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van Dijck JTJM, Mostert CQB, Greeven APA, Kompanje EJO, Peul WC, de Ruiter GCW, Polinder S. Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study. Acta Neurochir (Wien) 2020; 162:1607-1618. [PMID: 32410121 PMCID: PMC7295836 DOI: 10.1007/s00701-020-04384-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI. METHODS We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation. RESULTS A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%). CONCLUSION In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.
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Affiliation(s)
- Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands.
- LUMC, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands.
| | - Cassidy Q B Mostert
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | | | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Weber E, Goverover Y, DeLuca J. Beyond cognitive dysfunction: Relevance of ecological validity of neuropsychological tests in multiple sclerosis. Mult Scler 2020; 25:1412-1419. [PMID: 31469351 DOI: 10.1177/1352458519860318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In neurological diseases such as multiple sclerosis (MS), a neuropsychological assessment is often requested to assist clinicians in evaluating the role of cognition in a patient's level of everyday functioning. To be effective in this charge, it is assumed that performance on neuropsychological tests is related to how a person may function in everyday life, and the question is often asked: "Are neuropsychological tests ecologically valid?" In this review, we synthesize the literature that examines the use of neuropsychological tests to assess functioning across a variety of everyday functioning domains in MS (i.e. driving, employment, instrumental activities of daily living (IADLs)). However, we critically examine the usefulness of asking this broad question regarding ecological validity, given the psychometric and conceptual pitfalls it may yield. While many neuropsychological tests may be generally considered "ecologically valid" in MS, it is much more helpful to specify for whom, under what circumstances, and to what degree.
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Affiliation(s)
- Erica Weber
- Kessler Foundation, East Hanover, NJ, USA/ Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Yael Goverover
- Kessler Foundation, East Hanover, NJ, USA/Department of Occupational Therapy, NYU Steinhardt, New York, NY, USA
| | - John DeLuca
- Kessler Foundation, West Orange, NJ, USA/Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA/ Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study. Brain Sci 2020; 10:brainsci10050269. [PMID: 32369967 PMCID: PMC7287871 DOI: 10.3390/brainsci10050269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 01/25/2023] Open
Abstract
A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13–15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74–0.98)), prior psychiatric history (AOR = 3.75 (1.73–8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93–196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29–9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17–10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.
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Coats TJ, Lecky FE. The CRASH3 study: prehospital TXA for every injured patient? Emerg Med J 2020; 37:392-394. [PMID: 32220860 DOI: 10.1136/emermed-2019-209264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/18/2020] [Accepted: 03/07/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Timothy J Coats
- Emergency Medicine Academic Group (EMAG), College of Medicine Biological Sciences and Psychology, University of Leicester, Leicester, UK
| | - Fiona E Lecky
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research, Unviersity of Sheffield, Sheffield, UK
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Rajwani KM, Lavrador JP, Ansaripour A, Tolias CM. Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network? Br J Neurosurg 2020; 34:271-275. [PMID: 32212864 DOI: 10.1080/02688697.2020.1742289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.
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Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis. Intensive Care Med 2020; 46:995-1004. [PMID: 32100061 PMCID: PMC7210239 DOI: 10.1007/s00134-020-05965-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/09/2020] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers. METHODS This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers. RESULTS A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13-15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01). CONCLUSIONS Half of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial between-center variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources.
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Silverberg ND, Iaccarino MA, Panenka WJ, Iverson GL, McCulloch KL, Dams-O’Connor K, Reed N, McCrea M, Cogan AM, Park Graf MJ, Kajankova M, McKinney G, Weyer Jamora C. Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Arch Phys Med Rehabil 2020; 101:382-393. [DOI: 10.1016/j.apmr.2019.10.179] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/13/2019] [Accepted: 10/09/2019] [Indexed: 12/14/2022]
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Marincowitz C, Lecky FE, Allgar V, Hutchinson P, Elbeltagi H, Johnson F, Quinn E, Tarantino S, Townend W, Kolias AG, Sheldon TA. Development of a Clinical Decision Rule for the Early Safe Discharge of Patients with Mild Traumatic Brain Injury and Findings on Computed Tomography Brain Scan: A Retrospective Cohort Study. J Neurotrauma 2020; 37:324-333. [PMID: 31588845 PMCID: PMC6964807 DOI: 10.1089/neu.2019.6652] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
International guidelines recommend routine hospital admission for all patients with mild traumatic brain injury (TBI) who have injuries on computed tomography (CT) brain scan. Only a small proportion of these patients require neurosurgical or critical care intervention. We aimed to develop an accurate clinical decision rule to identify low-risk patients safe for discharge from the emergency department (ED) and facilitate earlier referral of those requiring intervention. A retrospective cohort study of case notes of patients admitted with initial Glasgow Coma Scale 13-15 and injuries identified by CT was completed. Data on a primary outcome measure of clinically important deterioration (indicating need for hospital admission) and secondary outcome of neurosurgery, intensive care unit admission, or intubation (indicating need for neurosurgical admission) were collected. Multi-variable logistic regression was used to derive models and a risk score predicting deterioration using routinely reported clinical and radiological candidate variables identified in a systematic review. We compared the performance of this new risk score with the Brain Injury Guideline (BIG) criteria, derived in the United States. A total of 1699 patients were included from three English major trauma centers. A total of 27.7% (95% confidence interval [CI], 25.5-29.9) met the primary and 13.1% (95% CI, 11.6-14.8) met the secondary outcomes of deterioration. The derived clinical decision rule suggests that patients with simple skull fractures or intracranial bleeding <5 mm in diameter who are fully conscious could be safely discharged from the ED. The decision rule achieved a sensitivity of 99.5% (95% CI, 98.1-99.9) and specificity of 7.4% (95% CI, 6.0-9.1) to the primary outcome. The BIG criteria achieved the same sensitivity, but lower specificity (5%). Our empirical models showed good predictive performance and outperformed the BIG criteria. This would potentially allow ED discharge of 1 in 20 patients currently admitted for observation. However, prospective external validation and economic evaluation are required.
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Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Fiona E. Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Victoria Allgar
- Hull York Medical School, John Hughlings Jackson Building, University of York, Heslington, United Kingdom
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Hadir Elbeltagi
- Emergency Department, Salford Royal Hospital, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Faye Johnson
- Salford Royal Hospital, Acute Research Delivery Team, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Eimhear Quinn
- Emergency Department, Salford Royal Hospital, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Silvia Tarantino
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Will Townend
- Emergency Department, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Trevor A. Sheldon
- Department of Health Sciences, University of York, Alcuin Research Resource Centre, Heslington, United Kingdom
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Gillespie CS, Mcleavy CM, Islim AI, Prescott S, McMahon CJ. Rationalising neurosurgical head injury referrals: development and validation of the Liverpool Head Injury Tomography Score (Liverpool HITS) for mild TBI. Br J Neurosurg 2020; 34:127-134. [DOI: 10.1080/02688697.2019.1710825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Conor S. Gillespie
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Abdurrahman I. Islim
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
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Newsome H. Use of CT in children with minor head injuries with isolated vomiting. Arch Dis Child 2019; 104:1231-1233. [PMID: 31473602 DOI: 10.1136/archdischild-2019-317949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/06/2019] [Accepted: 08/19/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Helen Newsome
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
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Krueger EM, Putty M, Young M, Gaynor B, Omi E, Farhat H. Neurosurgical Outcomes of Isolated Hemorrhagic Mild Traumatic Brain Injury. Cureus 2019; 11:e5982. [PMID: 31808447 PMCID: PMC6876901 DOI: 10.7759/cureus.5982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/24/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Mild traumatic brain injury (TBI) is common but its management is variable. Objectives To describe the acute natural history of isolated hemorrhagic mild TBI. Methods This was a single-center, retrospective chart review of 661 patients. Inclusion criteria were consecutive patients with hemorrhagic mild TBI. Exclusion criteria were any other acute traumatic injury and significant comorbidities. Variables recorded included neurosurgical intervention and timing, mortality, emergency room disposition, intensive care unit (ICU) length of stay (LOS), discharge disposition, repeat computed tomography head (CTH) indications and results, neurologic exam, age, sex, Glasgow Coma Scale (GCS) score, and hemorrhage type. Results Overall intervention and unexpected delayed intervention rates were 9.4% and 1.5%, respectively. The mortality rate was 2.4%. A 10-year age increase had 26% greater odds of intervention (95% CI, 9.6-45%; P<.001) and 53% greater odds of mortality (95% CI, 11-110%; P=.009). A one-point GCS increase had 49% lower odds of intervention (95% CI, 25-66%; P<.001) and 50% lower odds of mortality (95% CI, 1-75%; P=.047). Subdural and epidural hemorrhages were more likely to require intervention (P=.02). ICU admission was associated with discharge to an acute care facility (OR, 2.9; 95% CI, 1.4-6.0; P=.003). Neurologic exam changes were associated with a worsened CTH scan (OR, 12.3; 95% CI, 7.0-21.4; P<.001) and intervention (OR, 15.1; 95% CI, 8.4-27.2; P<.001). Conclusions Isolated hemorrhagic mild TBI patients are at a low, but not clinically insignificant, risk of intervention and mortality.
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Affiliation(s)
| | | | - Michael Young
- Neurosurgery, Advocate Bromenn Medical Center, Normal, USA
| | - Brandon Gaynor
- Neurosurgery, Advocate Christ Medical Center, Oak Lawn, USA
| | - Ellen Omi
- Trauma Surgery, Advocate Health Care, Oak Lawn, USA
| | - Hamad Farhat
- Neurosurgery, Advocate Christ Medical Center, Oak Lawn, USA
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Kavi T, Abdelhady A, DeChiara J, Lubas E, Abdelhady K, Daci R, San Roman J, Patel UK. Association of Patterns of Mild Traumatic Brain Injury with Neurologic Deterioration: Experience at a Level I Trauma Center. Cureus 2019; 11:e5677. [PMID: 31723486 PMCID: PMC6825415 DOI: 10.7759/cureus.5677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/17/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION There are about 2.5 million emergency room visits for traumatic brain injury (TBI) every year and 75%-95% of all TBI patients have mild TBI. Previous studies have suggested that a large proportion of mild TBI patients can be treated in a non-aggressive manner, but they have not differentiated mild TBI as per radiological patterns to help in the selection of these patients. Our study aimed to identify different patterns of mild TBI to determine if certain injuries make patients more prone to neurologic worsening than others, and thus require more intensive monitoring. We also studied the factors associated with neurologic deterioration. METHODS We conducted a retrospective study using an institutional trauma database to identify TBI patients between the years of 2015 and 2016 with admission Glasgow Coma Score (GCS) of 13 to 15, through chart review by the investigators. Radiological and neurological worsening was determined through computed tomography (CT) scan results, GCS scores, and the requirement for neurosurgical intervention. We identified the prevalence of demographic characteristics, radiological patterns, and risk factors. We studied neurologic deterioration (decline in GCS to less than 13 at 48 hours or earlier after admission) and surgical intervention among patients with different radiological patterns of TBI. We further studied the cohort of isolated subdural hematoma (SDH) patients requiring surgery to evaluate the associated risk factors. RESULTS Out of 374 patients with mild TBI (mean age was 63 years), 59% were male, 77% were Caucasian, the median GCS was 15, majority of patients had isolated SDH (45%), and mixed pattern of hemorrhage (39%); the use of antiplatelet (33%) was the most commonly identified risk factors. Overall 7% of patients were found to have neurologic deterioration (GCS to less than 13) and 9% required surgical intervention at 48 hours or earlier after admission. The most common pattern of TBI requiring surgical intervention was isolated SDH (85%). Among the cohort of patients with isolated SDH, 17% required surgical intervention and 69% of those isolated SDH patients requiring surgery had neurologic deterioration. The most common risk factor in isolated SDH patients requiring surgery was antiplatelet use (34%), anticoagulant use (20%), alcohol abuse (17%), severe renal failure (17%), and thrombocytopenia (7%). Mean size of SDH in patients requiring surgery was 1.6 cm with 0.8 cm of midline shift. CONCLUSION This study identified the pattern of mild TBI associated with neurological worsening at our Level I Trauma Center. Among patients with mild TBI, SDH patients seem to be at highest risk for deterioration and requirement for surgery. If these results can be externally validated through a multi-center study, these patients could be selectively identified for aggressive monitoring in the intensive care unit (ICU) and repeat CT scans.
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Affiliation(s)
- Tapan Kavi
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Ahmed Abdelhady
- Neurology, Cooper Medical School of Rowan University, Camden, USA
| | - James DeChiara
- Neurology, Cooper Medical School of Rowan University, Camden, USA
| | - Emily Lubas
- Neurology, Cooper Medical School of Rowan University, Camden, USA
| | - Khodeja Abdelhady
- Internal Medicine, Washington University of Health and Science, San Pedro, BLZ
| | - Rrita Daci
- Neurosurgery, University of Massachusetts, Worcester, USA
| | | | - Urvish K Patel
- Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
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Vedin T, Karlsson M, Edelhamre M, Clausen L, Svensson S, Bergenheim M, Larsson PA. A proposed amendment to the current guidelines for mild traumatic brain injury: reducing computerized tomographies while maintaining safety. Eur J Trauma Emerg Surg 2019; 47:1451-1459. [PMID: 31089789 PMCID: PMC8476398 DOI: 10.1007/s00068-019-01145-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Head trauma is a common complaint in emergency departments. Identifying patients with serious injuries can be difficult and generates many computerized tomographies. Reducing the number of computerized tomographies decreases both cost and radiation exposure. The aim of this study was to evaluate whether the current Scandinavian Neurotrauma Committee guidelines could be revised in such a way that would enable hospitals to perform fewer computerized tomographies while maintaining the ability to identify all patients requiring neurological intervention. METHODS A retrospective study of the medical records of adult patients suffering a traumatic brain injury was performed. A total of 1671 patients over a period of 365 days were included, and 25 parameters were extracted. Multitrauma patients managed with ATLS™ were excluded. The Scandinavian Neurotrauma Committee guidelines were amended with the previously derived "low-risk proposal" and applied retrospectively to the cohort. RESULTS Incidence of intracranial hemorrhage was 5.6% (93/1671). Application of the current Scandinavian Neurotrauma Committee guidelines would have resulted in 860 computerized tomographies and would have missed 11 intracranial hemorrhages. The proposed amendment with the low-risk proposal would have resulted in 748 CT scans and would have missed 19 intracranial hemorrhages (a relative reduction of 13%). None of the missed intracranial hemorrhages required neurological intervention. CONCLUSION For patients with mild and moderate traumatic brain injuries, application of the Scandinavian Neurotrauma Committee guidelines amended with the low-risk proposal may result in a significant reduction of computerized tomographies without missing any patients in need of neurological intervention.
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Affiliation(s)
- Tomas Vedin
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden.
| | - Mathias Karlsson
- Department of Clinical Chemistry, Center for Clinical Research, Centralsjukhuset, Karlstad, Sweden
| | - Marcus Edelhamre
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Linus Clausen
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Sebastian Svensson
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Mikael Bergenheim
- Centralsjukhuset i Karlstad, Rosenborgsgatan 9, 652 30, Karlstad, Sweden
| | - Per-Anders Larsson
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 699] [Impact Index Per Article: 139.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Abstract
BACKGROUND Patients with mild traumatic brain injury (TBI) are frequently admitted to an intensive care unit (ICU), but routine ICU use may be unnecessary. It is not clear to what extent this practice varies between hospitals. METHODS We conducted a retrospective cohort study using the National Trauma Data Bank. Patients with at least one TBI ICD-9-CM diagnosis code, a head abbreviated injury score (AIS) ≤ 4, and Glasgow coma scale (GCS) ≥ 13 were included; individuals with only a concussion and those with a non-head AIS > 2 were excluded. Primary outcomes were ICU admission and "overtriage" to the ICU, defined by: ICU stay ≤ 1 day; hospital stay ≤ 2 days; no intubation; no neurosurgery; and discharged to home. Mixed effects multivariable models were used to identify patient and facility characteristics associated with these outcomes. RESULTS A total of 595,171 patients were included, 44.7% of whom were admitted to an ICU; 17.3% of these met the criteria for overtriage. Compared with adults, children < 2 years were more likely to be admitted to an ICU (RR 1.21, 95% CI 1.16-1.26) and to be overtriaged (RR 2.06, 95% CI 1.88-2.25). Similarly, patients with isolated subarachnoid hemorrhage were at greater risk of both ICU admission (RR 2.36, 95% CI 2.31-2.41) and overtriage (RR 1.22, 95% CI 1.17-1.28). The probabilities of ICU admission and overtriage varied as much as 16- and 11-fold across hospitals, respectively; median risk ratios were 1.67 and 1.53, respectively. The likelihood of these outcomes did not vary substantially with the characteristics of the treating facility. CONCLUSIONS There is considerable variability in ICU admission practices for mild TBI across the USA, and some of these patients may not require ICU-level care. Refined ICU use in mild TBI may allow for reduced resource utilization without jeopardizing patient outcomes.
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Should Adults With Mild Head Injury Who Are Receiving Direct Oral Anticoagulants Undergo Computed Tomography Scanning? A Systematic Review. Ann Emerg Med 2019; 73:66-75. [DOI: 10.1016/j.annemergmed.2018.07.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 12/18/2022]
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Foks KA, van den Brand CL, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MGM, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Jellema K, Dippel DWJ. External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands. BMJ 2018; 362:k3527. [PMID: 30143521 PMCID: PMC6108278 DOI: 10.1136/bmj.k3527] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To externally validate four commonly used rules in computed tomography (CT) for minor head injury. DESIGN Prospective, multicentre cohort study. SETTING Three university and six non-university hospitals in the Netherlands. PARTICIPANTS Consecutive adult patients aged 16 years and over who presented with minor head injury at the emergency department with a Glasgow coma scale score of 13-15 between March 2015 and December 2016. MAIN OUTCOME MEASURES The primary outcome was any intracranial traumatic finding on CT; the secondary outcome was a potential neurosurgical lesion on CT, which was defined as an intracranial traumatic finding on CT that could lead to a neurosurgical intervention or death. The sensitivity, specificity, and clinical usefulness (defined as net proportional benefit, a weighted sum of true positive classifications) of the four CT decision rules. The rules included the CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and National Institute for Health and Care Excellence (NICE) guideline for head injury. RESULTS For the primary analysis, only six centres that included patients with and without CT were selected. Of 4557 eligible patients who presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for performing CT scanning: the NOC rule was preferable at a low threshold, the NICE rule was preferable at a higher threshold, whereas the CHIP rule was preferable for an intermediate threshold. CONCLUSIONS Application of the CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT scanning among patients with minor head injury, resulting in many unnecessary CT scans and some missed intracranial traumatic findings. Until an existing decision rule has been updated, any of the four rules can be used for patients presenting minor head injuries at the emergency department. Use of the CHIP rule is recommended because it leads to a substantial reduction in CT scans while missing few potential neurosurgical lesions.
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Affiliation(s)
- Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Myriam G M Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Centre for Health Decision Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Eef Reijners
- Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Meriam Braaksma
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
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Development of Delayed Posttraumatic Acute Subdural Hematoma. World Neurosurg 2018; 117:353-356. [PMID: 29959076 DOI: 10.1016/j.wneu.2018.06.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prior studies have shown that most patients with mild traumatic brain injury or negative computed tomography (CT) scans of the head rarely decline or require neurosurgical interventions. One common reason for a delayed decline is an intracranial hemorrhage that presents within 24-48 hours. This is typically seen in elderly patients and/or patients on antiplatelet or anticoagulation agents. We describe a case of a delayed subdural hemorrhage presenting in a young adult not on any antiplatelet or anticoagulation therapy. CASE DESCRIPTION A 19-year-old male presented to the emergency department after being involved in a motor vehicle accident. He had a Glasgow Coma Scale of 15, and an initial CT was negative for any intracranial hemorrhage or pathology, so he was then admitted to the intensive care unit for further care. The patient received 1 dose of aspirin 325 mg the following day for treatment of blunt cerebrovascular injury. Six hours later he reported a severe headache and had an episode of emesis with a subsequent rapid neurologic decline. Repeat CT showed an acute right subdural hematoma, and he underwent an emergent right decompressive hemicraniectomy. CONCLUSIONS In rare cases, patients with negative initial head CT scans neurologically deteriorate as a result of a delayed acute subdural hematoma. We present an unusual case of a young patient on no medications with no CT findings of an intracranial injury who neurologically declined due to a delayed acute subdural hematoma.
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Marincowitz C, Lecky FE, Townend W, Allgar V, Fabbri A, Sheldon TA. A protocol for the development of a prediction model in mild traumatic brain injury with CT scan abnormality: which patients are safe for discharge? Diagn Progn Res 2018; 2:6. [PMID: 31093556 PMCID: PMC6460841 DOI: 10.1186/s41512-018-0027-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 04/10/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Head injury is an extremely common clinical presentation to hospital emergency departments (EDs). Ninety-five percent of patients present with an initial Glasgow Coma Scale (GCS) score of 13-15, indicating a normal or near-normal conscious level. In this group, around 7% of patients have brain injuries identified by CT imaging but only 1% of patients have life-threatening brain injuries. It is unclear which brain injuries are clinically significant, so all patients with brain injuries identified by CT imaging are admitted for monitoring. If risk could be accurately determined in this group, admissions for low-risk patients could be avoided and resources could be focused on those with greater need.This study aims to (a) estimate the proportion of GCS13-15 patients with traumatic brain injury identified by CT imaging admitted to hospital who clinically deteriorate and (b) develop a prognostic model highly sensitive to clinical deterioration which could help inform discharge decision making in the ED. METHODS A retrospective case note review of 2000 patients with an initial GCS13-15 and traumatic brain injury identified by CT imaging (2007-2017) will be completed in two English major trauma centres. The prevalence of clinically significant deterioration including death, neurosurgery, intubation, seizures or drop in GCS by more than 1 point will be estimated. Candidate prognostic factors have been identified in a previous systematic review. Multivariable logistic regression will be used to derive a prognostic model, and its sensitivity and specificity to the outcome of deterioration will be explored. DISCUSSION This study will potentially derive a statistical model that predicts clinically relevant deterioration and could be used to develop a clinical risk tool guiding the need for hospital admission in this group.
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Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, University of Hull, Allam Medical Building, Hull, HU6 7RX UK
| | - Fiona E. Lecky
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - William Townend
- Emergency Department, Hull and East Yorkshire NHS Trust, Anlaby Road, Hull, HU3 2JZ UK
| | - Victoria Allgar
- Hull York Medical School, University of York, John Hughlings Jackson Building, Heslington, York, YO10 5DD UK
| | - Andrea Fabbri
- Emergency Unit, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, via Forlanini 34, 47121 Forlì, FC Italy
| | - Trevor A. Sheldon
- Department of Health Sciences, Alcuin Research Resource Centre, University of York, Heslington, York, YO10 5DD UK
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