Randy Chesnut

[Randy Chesnut @Randy_Chesnut]

@Matt_Pinner It's a coin purse. Squeeze it longitudinally and it opens.

[Randy Chesnut @Randy_Chesnut]

The second sTBI management algorithm from the Seattle Brain Injury Consensus Conference is now available ahead of print in Intensive Care Medicine @yourICM at https://t.co/rIpLfYsC6t

[Randy Chesnut @Randy_Chesnut]

The consensus-based treatment algorithm for ICP-only monitored sTBI patients has now been downloaded over 15,000 times!!! Amazing interest for the generally under-appreciated area of traumatic brain injury! It is open access at https://t.co/uA9wHqcIr9. #brain

[Randy Chesnut @Randy_Chesnut]

The second consensus based algorithm (for patients with both ICP and PbtO2 monitors) has been accepted by @yourICM and should be available PAP (published ahead of print) on their webpage soon.

[Randy Chesnut @Randy_Chesnut]

The consensus-based treatment algorithm for ICP-only monitored sTBI patients has now been downloaded over 15,000 times!!! Amazing interest for the generally under-appreciated area of traumatic brain injury! It is open access at https://t.co/uA9wHqcIr9.

[Randy Chesnut @Randy_Chesnut]

My interpretation of the BEST TRIP trial is that we simply have ICP-based-monitoring wrong, which is fixable. The fix is targeted treatment based on multi modality monitoring, tailoring the treatment to each individual injury, or at least to each individual injury class. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

Perhaps that should not be surprising, in that we currently treat all types of severe traumatic brain injury the same, using a single algorithm and a single monitor, treating them all at the same ICP threshold. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

What it did show is that our current method of managing severe traumatic brain injury patients with elevated intracranial pressure was not independently better than managing them without an ICP monitor. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

The study did not show that ICP monitoring per se is of no value or that knowing the intracranial pressure is not useful.

[Randy Chesnut @Randy_Chesnut]

The BEST TRIP trial did not study the value of knowing the ICP. It studied the protocol we use to manage monitored ICP, comparing it to the management of suspected intracranial hypertension based on imaging and clinical examination. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

The Cremer and Safi studies were confounded by being retrospective, with no control of who was monitored at monitoring centres, treatment intensity, management approaches, etc. It is hard to support much more than centre differences in any detail. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

What would you rather have, a CT or an ICP monitor? #ICPTBI

[Randy Chesnut @Randy_Chesnut]

ICP is primarily an indicator of disease severity (Miller, Marmarou, etc). There is a subset of patients with intracranial hypertension for whom lowering the elevated ICP will improve their outcome. Nevertheless, the primary importance is a severity indicator in TBI. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

The individual contribution of treating managed ICP to the change in mortality was highly confounded by other concomitant events (the #1 being the new availability of CT imaging, but also better prehospital and ICU care in general. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

#ICPTBI

[Randy Chesnut @Randy_Chesnut]

Monitoring ICP changed the paradigm of managing TBI from a surgical disease (anatomical injury) to an intensive care disease (physiologic injury). That is probably the majour benefit from monitoring. #ICPTBI

[Randy Chesnut @Randy_Chesnut]

@bgross27 @SNACCNeuro The placement of an ICP monitor did do one particular thing: it changed the paradigm of TBI from a surgical disease to a physiological disease. That probably is the main benefit from monitoring

[Randy Chesnut @Randy_Chesnut]

@bgross27 @SNACCNeuro Can't be claimed as casual without an RCT, A LOT of things occurred at this time, including better critical care, better pre-hospital care, the ready availability of CT (#1 confounder in my book), improvements in trauma surgery service, etc.

[Randy Chesnut @Randy_Chesnut]

How many clinical errors should result from unsupervised feeding frenzies on new data sets? #NEJMDataSummit

[Randy Chesnut @Randy_Chesnut]

McMurray is right on in stressing the importance of being careful and scientific in writing and reading papers #NEJMDataSummit