The edition · Emergency & Critical Care
The Brain Injury Guidelines rule out deterioration well in mild head injury, and dapagliflozin in sepsis is still a hypothesis
A meta-analysis of the Brain Injury Guidelines for traumatic brain injury, French intensive care recommendations on withholding or withdrawing life-sustaining treatment, a 136-patient trial of dapagliflozin in sepsis, and a small trial of open against closed suctioning in ARDS.
The edition in brief
A systematic review and meta-analysis of 23 studies of the original Brain Injury Guidelines (BIG) found that the lowest-risk category (BIG1) had pooled sensitivity of about 98% for ruling out neurological deterioration (98.3%, 95% CI 95.7 to 99.4), neurosurgical intervention (98.7%, 97.4 to 99.4) and death (98.2%, 96.6 to 99.1), with low specificity of about 13%. This supports using BIG to identify patients for discharge or observation without routine neurosurgical consultation, but it is based on observational studies. French intensive care and rehabilitation societies published nine recommendations on decisions to withhold or withdraw life-sustaining treatment in adult ICU, mostly expert opinion rather than high-grade evidence. A single-centre trial of 136 patients with sepsis found dapagliflozin 10 mg for 5 days did not change SOFA score; left ventricular ejection fraction was higher on day 5 and 28-day mortality was 26% against 36%, not significant. A 60-patient trial of open versus closed suctioning in ARDS found closed suctioning preserved lung volume better in the first minutes, with no difference in oxygenation index at 30 minutes, extubation or survival. The pearl covers anticoagulants in head injury.
French intensive care societies set out nine recommendations on withholding and withdrawing life-sustaining treatment
Consider reading the full French guideline when reviewing your unit's process for limiting treatment, and adapt it to local law and practice.
Dapagliflozin in sepsis improved ejection fraction but not organ failure scores in a small trial
Treat dapagliflozin in sepsis as experimental; hold SGLT2 inhibitors during acute illness as usual.
Closed suctioning protected lung volume briefly in ARDS, without changing outcomes
Closed suctioning limits the short-term fall in lung volume in ARDS, but outcome benefit is unproven.
Ask about anticoagulants and antiplatelets in every head injury
Ask about blood-thinning drugs in every head injury and follow your imaging and observation protocol.
The Brain Injury Guidelines rule out deterioration with about 98% sensitivity in the lowest-risk group
Consider BIG as support for deciding who can avoid neurosurgical transfer in CT-positive mild head injury, within local protocol and clinical judgement.
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