Traumatic Brain Injury is a leading cause of death and disability in adults worldwide. The investigators want to find the best way to predict which patients with head injuries are going to deteriorate in order to get medical treatment promptly. Pupil examination is an essential part of a neurological assessment, providing a window in to the brain. Abnormalities in measurement of pupil size and response to light indicates rising pressure inside the rigid skull (intracranial pressure (ICP)), which results in significant death and disability.
Traumatic brain injury (TBI) is a leading cause of death and disability in adults worldwide. Severe TBI, defined as a Glasgow Coma Score (GCS) 8, is associated with mortality as high as 30-40%. It is established that the major determinant of outcome following TBI and target of medical interventions is secondary brain injury, primarily cerebral ischaemia. It is due to a combination of intracranial hypertension (ICH), systemic hypotension, hypoxia, hyperpyrexia, hypercapnia and hypoglycaemia, all have been shown to independently worsen survival after TBI. ICH refers to rise in pressure inside the rigid skull (intracranial pressure (ICP)), which reduces blood flow and oxygen to the brain. ICP values over 20-25mmHg are indicative of ICH. Accordingly, treatment of these patients centres on controlling ICP, improving cerebral blood flow (CBF) and oxygenation. Monitoring pupil size and its light reflex mechanism is an integral part of non-invasive clinical monitoring in patients with severe brain injury in NCCUs globally. Abnormalities in pupillary response or size asymmetry are associated with neurological deterioration and poor outcome. In addition, studies have shown a strong correlation with brainstem oxygenation and blood flow. A study evaluating pupil response and ICP showed that changes in pupils were detected even in patients with normal ICP. Crucially, they suggested that abnormalities in posterior frontal and temporal regions of the brain may occur even when the ICP is normal. Given the indispensable role of these parameters, there is considerable impetus to ensure they are measured accurately. The invetigator's study aims to compare the use of standard pen torch versus quantitative pupillometer for pupil assessment in severely brain injured patients in NCCU. This data could establish whether currently practised pen torch assessment is inadequate for clinical practice. The investigators also propose to study whether pupil response (NPi) changes with rising ICP. This group of patients have invasive monitoring in place as standard care and provides an important opportunity to study this relationship. This has the potential to allow early, non-invasive detection of neurological deterioration and as such, indication for timely intervention in the first instance. It also allows scope for development of this tool across emergency departments and even pre-hospital care settings. The primary aims of this study are twofold. First, to compare the accuracy and reliability of the pupillometer device (NPi 200) versus the conventional pen-torch technique in measuring pupil response in patients with severe TBI in NCCU. Second, to evaluate the relationship between the important measures of neurological deterioration in TBI patients: ICP, CPP, and NPi. This will be achieved by simultaneous recording of NPi and ICP (a standard invasive clinical monitoring tool) to assess for any correlation. The investigator will also be noting the measurement displayed by the ICP monitor at the time of pupil measurement or conversely note the NPi at the time of any significant ICP rise. This observational study will recruit patients who are admitted to NCCU within 48 hours of brain injury. The end point of the study will be when ICP monitors are removed which is normally 7-10 days, unless the patient recovers earlier or passes away. Data collection will cease in periods requiring surgical treatment. Patient recruitment will cease after 6 months
Study Type
OBSERVATIONAL
Enrollment
9
Hourly Pupil response
Time frame: Recorded hourly from when patient is admitted to Walton Critical Care Unit (CCU) and is undergoing ICP monitoring in situ. Collection of outcome measure will end once ICP monitors are removed; this normally occurs after 7-10 days unless patients recovers
Hourly NPi Value and corresponding ICP value
Time frame: Recorded hourly from when patient is admitted to Walton Critical Care Unit (CCU) and is undergoing ICP monitoring in situ. Collection of outcome measure will end once ICP monitors are removed; this normally occurs after 7-10 days unless patients recovers
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