Abstract
IntroductionWorldwide, severe traumatic brain injury is a frequent pathology and is associated with high morbidity and mortality. Mannitol and hypertonic saline are therapeutic options for intracranial hypertension occurring in the acute phase of care. However, current practices of emergency physicians are unknown.MethodsWe conducted a self-administered survey of emergency physicians in the province of Québec, Canada, to understand their attitudes surrounding the use of hyperosmolar solutions in patients with severe traumatic brain injury. Using information from a systematic review of hypertonic saline solutions and experts' opinion, we developed a questionnaire following a systematic approach (items generation and reduction). We tested the questionnaire for face and content validity, and test-retest reliability. Physicians were identified through the department head of each eligible level I and II trauma centers. We administered the survey using a web-based interface and planned email reminders.ResultsWe received 210 questionnaires out of 429 potentials respondents (response rate 49%). Most respondents worked in level II trauma centers (69%). Fifty-three percent (53%) of emergency physicians stated using hypertonic saline to treat severe traumatic brain injury. Most reported using hyperosmolar therapy in the presence of severe traumatic brain injury and unilateral reactive mydriasis, midline shift or cistern compression on brain computed tomography.ConclusionHyperosmolar therapy is believed being broadly used by emergency physicians in Quebec following severe traumatic brain injury. Despite the absence of clinical practice guidelines promoting the use of hypertonic saline, a majority of them said to use these solutions in specific clinical situations.
Highlights
Worldwide, severe traumatic brain injury is a frequent pathology and is associated with high morbidity and mortality
Emergency physicians working in level I and II trauma centers in the province of Quebec where an estimated mean of at least one adult patient with severe traumatic brain injury per month consulting in the emergency room were considered eligible, since we wanted to survey emergency physicians with a minimum of experience in treating severe head injury patients
In our study, we observed practice variation regarding the use of hyperosmolar solutions in adult patients with severe traumatic brain injury by emergency physicians working in level I and level II trauma centers of the province of Quebec, Canada
Summary
Severe traumatic brain injury is a frequent pathology and is associated with high morbidity and mortality. As part of the recommendations of the Brain Trauma Foundation guidelines for the management of patients with severe traumatic brain injury, mannitol is often used by emergency physicians to treat presumed increased intracranial pressure [8,9]. Used in a military setting to minimize weight carriage of resuscitation fluids, it was suggested in patients with severe traumatic brain injury as hyperosmolar therapy especially in presence of hemodynamic instability [16,17]. Very little information is currently available on the use hypertonic saline solutions among emergency physicians. Considering the expanding use of these solutions in Canada [13] despite limited evidence of clinical benefit, along with current guidelines suggesting minimizing the use of hyperosmolar therapies prior to monitoring intracranial pressure, a better understanding of their utilization is needed
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