M. C. Spalding1,2, D. E. Leshikar1,3, C. Hester1, C. T. Minshall1 1Parkland, UT Southwestern,Burn/Trauma/Critical Care Surgery,Dallas, TEXAS, USA 2Grant Medical Center, Ohio University College Of Osteopathic Medicine,Trauma And Acute Care Surgery,Columbus, OHIO, USA 3UC Davis,Trauma, Acute Care Surgery And Surgical Critical Care,Sacramento, CA, USA
Introduction: There are over 1.7 million traumatic brain injuries annually. Thirty percent of these patients present with associated skull fractures and maxillofacial fractures (SMXFX). Despite a paucity of evidence, consulting services ENT, OMFS, Plastic Surgery and Neurosurgery will restrict pulmonary recruitment techniques: incentive spirometer or bi-level positive airway pressure (BiPAP) secondary to the alleged risk of post-traumatic meningitis. These imposed limitations are not evidence-based and are potentially dangerous in patients with marginal pulmonary effort. We initiated an aggressive noninvasive respiratory protocol (NRP) to improve pulmonary recruitment for all patients with SMXFX and minimal pulmonary reserve. We prospectively evaluated the effect of therapy on the incidence of meningitis, pneumothorax, pneumocephalus or need for re-intubation on patients with SMXFX.
Methods: This is a prospective evaluation of all trauma patients with SMXFX admitted to the SICU of a Level I Trauma Center from 1/2015 to 12/2015. Patients with SMXFX were required to perform incentive spirometer (IS) every 4hrs under direction of respiratory therapy after 48 hours from time of injury. Patients that were not capable of achieving > 30% of predicted volume (PV) using IS were also started on BiPAP treatment every 4 hrs. Liberation from BiPAP therapy occurred when patients achieved > 50% PV on IS for two consecutive treatment sessions. We tracked the incidence of new or worsening pneumocephalus, worsening pulmonary failure, pneumothorax, SICU readmission, meningitis, and deviations from protocol.
Results:Seventy five patients with complex SMXFX were admitted to the SICU during the study period. Eighty two percent of these patients received IS therapy every 4 hours with a mean start time of 48 hours from admission. The mean inspiratory capacity for patients who progressed to BIPAP was 32% of PV. The average number of BIPAP treatments per patient in this group was 39 and these treatments achieved a mean volume of 1345 ml. One patient was intubated after initiation of the NRP for progressive respiratory failure. There were no cases of meningitis, pneumothorax, need for re-intubation or pneumocephalus
Conclusion:Early implementation of the proposed NRP is safe for patients with complex SMXFX within 48 hour injury or closure of a CSF leak. Since these results we have advanced our volume recruitment strategies for complex SMXFX patients to be implemented in the first 24 hours after admission for those without a cerebral spinal fluid (CSF) leak, or 24 hours after documented closure of the CSF leak.