Management of traumatic brain injury: first link in chain of survival

Evacuation Strategies for U.S. Casualties with Traumatic Brain Injury (TBI) with and without Polytrauma

INTRODUCTION

According to the Military Health System Traumatic Brain Injury (TBI) Center of Excellence, 51,261 service members suffered moderate to severe TBI in the last 21 years. Moderate to severe TBI in service members is usually related to blast injury in combat operations, which necessitates medical evacuation to higher levels of care. Prevention of secondary insult, and mitigation of the unique challenges associated with the transport of TBI patients in a combat setting are important in reducing the morbidity and mortality associated with this injury. The primary goal of this study was a secondary analysis comparing the impact of time to transport on clinical outcomes for TBI patients without polytrauma versus TBI patients with polytrauma transported out of the combat theater via Critical Care Air Transport Teams (CCATT). Our secondary objective was to describe the occurrence of in-flight events and interventions for TBI patients without polytrauma versus TBI with polytrauma to assist with mission planning for future transports.

MATERIALS AND METHODS

We performed a secondary analysis of a retrospective cohort of 438 patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Polytrauma was defined as abbreviated injury scale (AIS) of at least three to another region in addition to head/neck. Time to transport was defined as the time (in days) from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and examined the associations between time to transport and preflight characteristics, in-flight interventions and events, and clinical outcomes for TBI patients with and without polytrauma.

RESULTS

We categorized patients into two groups, those who had a TBI without polytrauma (n = 179) and those with polytrauma (n = 259). Within each group, we further divided those that were transported within 1 day of injury, in 2 days, and 3 or more days. Patients with TBI without polytrauma transported in 1 or 2 days were more likely to have a penetrating injury, an open head injury, a preflight Glascow Coma Score (GCS) of 8 or lower, and be mechanically ventilated compared to those transported later. Patients without polytrauma who were evacuated in 1 or 2 days required more in-flight interventions compared to patients without polytrauma evacuated later. Patients with polytrauma who were transported in 2 days were more likely to receive blood products, and patients with polytrauma who were evacuated within 1 day were more likely to have had at least one episode of hypotension en route. Polytrauma patients who were evacuated in 2-3 days had higher hospital days compared to polytrauma with earlier evacuations. There was no significant difference in mortality between any of the groups.

CONCLUSIONS

In patients with moderate to severe TBI transported via CCATT, early evacuation was associated with a higher rate of in-flight hypotension in polytrauma patients. Furthermore, those who had TBI without polytrauma that were evacuated in 1-2 days received more in-flight supplementary oxygen, blood products, sedatives, and paralytics. Given the importance of minimizing secondary insults in patients with TBI, recognizing this in this subset of the population may help systematize ways to minimize such events. Traumatic Brain Injury patients with polytrauma may benefit from further treatment and stabilization in theater prior to CCATT evacuation.

Influence of Time to Transport to a Higher Level Facility on the Clinical Outcomes of US Combat Casualties with TBI: A Multicenter 7-Year Study

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and is associated with mortality rates as high as 30%. Patients with TBI are at high risk for secondary injury and need to be transported to definitive care expeditiously. However, the physiologic effects of aeromedical evacuation are not well understood and may compound these risks. Combat TBI patients may benefit from delayed aeromedical evacuation. The goal of this study was to evaluate the impact of transport timing out of theater via Critical Care Air Transport Teams (CCATT) to a higher level facility on the clinical outcomes of combat casualties with TBI.

MATERIALS AND METHODS

We performed a retrospective review of patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Data abstractors collected flight information, vital signs, procedures, in-flight assessments, and outcomes. Time to transport was defined as the time from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and constructed regression models to determine the association between time to transport and clinical outcomes. This study was approved by the U.S. Air Force 59th Medical Wing Institutional Review Board.

RESULTS

We analyzed the records of 438 patients evacuated out of theater via CCATT and categorized them into three groups: patients who were transported in one day or less (n = 165), two days (n = 163), and three or more days (n = 110). We used logistic regression models to compare outcomes among patients who were evacuated in two days or three or more days to those who were transported within one day while adjusting for demographics, injury severity, and injury type. Patients who were evacuated in two days or three or more days had 50% lower odds of being discharged on a ventilator and were twice as likely to return to duty or be discharged home than those who were evacuated within one day. Additionally, patients transported in three or more days were 70% less likely to be ventilated at discharge with a GCS of 8 or lower and had 30% lower odds of mortality than those transported within one day.

CONCLUSIONS

In patients with moderate to severe TBI, a delay in aeromedical evacuation out of the combat theater was associated with improved mortality rates and a higher likelihood of discharge to home and return to duty dispositions. This study is correlational in nature and focused on CCATT transports from Role III to Role IV facilities; as such, care must be taken in interpreting our findings and future studies are needed to establish a causal link between delayed evacuation and improved discharge disposition. Our study suggests that delaying aeromedical evacuation of TBI patients when feasible may confer benefit.

Pediatric emergency department visits for pedestrian and bicyclist injuries in the US

Background

Despite reductions in youth pedestrian and bicyclist deaths over the past two decades, these injuries remain a substantial cause of morbidity and mortality for children and adolescents. There is a need for additional information on non-fatal pediatric pedestrian injuries and the role of traumatic brain injury (TBI), a leading cause of acquired disability.

Methods

Using a multi-year national sample of emergency department (ED) records, we estimated annual motorized-vehicle related pediatric pedestrian and bicyclist (i.e. pedalcyclist) injury rates by age and region. We modeled in-hospital fatality risk controlling for age, gender, injury severity, TBI, and trauma center status.

Results

ED visits for pediatric pedestrian injuries declined 19.3% (95% CI 16.8, 21.8) from 2006 to 2012, with the largest decreases in 5-to-9 year olds and 10-to-14 year olds. Case fatality rates also declined 14.0%. There was no significant change in bicyclist injury rates.

TBI was implicated in 6.7% (95% CI 6.3, 7.1) of all pedestrian and bicyclist injuries and 55.5% (95% CI 27.9, 83.1) of fatalities. Pedestrian ED visits were more likely to be fatal than bicyclist injuries (aOR = 2.4, 95% CI 2.3, 2.6), with significant additive interaction between pedestrian status and TBI.

Conclusions

TBI in young pedestrian ED patients was associated with a higher risk of mortality compared to cyclists. There is a role for concurrent clinical focus on TBI recovery alongside ongoing efforts to mitigate and prevent motor vehicle crashes with pedestrians and bicyclists. Differences between youth pedestrian and cycling injury trends merit further exploration and localized analyses, with respect to behavior patterns and interventions. ED data captures a substantially larger number of pediatric pedestrian injuries compared to crash reports and can play a role in those analyses.

Electronic supplementary material

The online version of this article (10.1186/s40621-017-0128-5) contains supplementary material, which is available to authorized users.

Epidemiology, clinical characteristics and outcomes of head injured patients in an Ethiopian emergency centre

INTRODUCTION

Head injury is a leading cause of mortality in Africa. We characterise the epidemiology and outcomes of head injury at an Ethiopian emergency centre.

METHODS

We conducted a prospective cohort study of all head injured patients presenting to the Emergency Centre of Tikur Anbessa Specialised Hospital, Addis Ababa. Data was collected via a standardised form from the patient's chart, radiology reports and operative reports. Patients were followed until discharge, facility transfer, death, or 7 days in hospital. Consent was obtained from the patient or substitute decision maker.

RESULTS

Among 204 head injured patients enrolled, the majority were <30 years old (51.0%) and male (86.8%). Forty-one percent of injuries occurred from road traffic accidents (RTAs). A significant number of patients had at least one indicator of severe injury on presentation: 51 (25.0%) had a GCS < 9, 53 (26.0%) had multi-system trauma, 95 (46.6%) had ≥1 abnormal vital sign and of the 133 patients with data available, 37 (27.8%) had a Revised Trauma Score (RTS) < 6. Patients injured by RTA were more likely to have indicators of severe injury than other mechanisms, including multi-system trauma (OR 3.2, 95% CI 1.7-6.2, p = 0.00), GCS < 9 (OR 3.7, 95% CI 1.8-7.4, p = 0.00), ≥1 abnormal vital sign (OR 2.5, 95% CI 1.4-4.6, p = 0.00) or an RTS score < 6 (OR 3.6, 95% CI 1.6-8.1, p = 0.00). Overall, 149 (73.0%) patients were discharged from hospital, 34 (16.7%) were transferred to another hospital, and 21 patients died (10.3%). In multivariable analysis, death was significantly associated with age over 60 years (aOR 68.8, 95% CI 2.0-2329.0, p = 0.02), GCS < 9 (aOR 14.8, 95% CI 2.2-99.5, p = 0.01), fixed bilateral pupils (aOR 39.1, 95% CI 4.2-362.8, p < 0.01) and hypoxia (oxygen saturation <90%; aOR 14.2%, 95% CI 2.6-123.9, p = 0.01).

CONCLUSION

Head injury represents a significant risk for morbidity and mortality in Ethiopia, of which RTA's increase injury severity. Targeted approaches to improving care of the injured may improve outcomes.

Prehospital management of severe traumatic brain injury: concepts and ongoing controversies

PURPOSE OF REVIEW

Prehospital management affects long-term outcome of patients with severe traumatic brain injury (TBI). This article reviews the current concepts and ongoing controversies of prehospital treatment of severe TBI.

RECENT FINDINGS

Prehospital management focuses on the prevention of secondary brain injury and rapid transport to a neurotrauma center for definitive diagnosis and life- as well as brain-saving emergency treatment such as decompressive craniotomy. There is a broad consensus that adequate airway management, prevention of hypoxia, hypocapnia or hypercapnia, prevention of hypotension and control of hemorrhage represent preclinical therapeutic modalities that may contribute to improved survival in severe TBI. The precise role of prehospital endotracheal intubation, osmotic agents and early therapeutic hypothermia needs to be clarified in the context of time required for transportation, local infrastructure, geographical factors and availability of experienced emergency teams.

SUMMARY

Prehospital management of TBI remains challenging. There are no universal objectives suitable to all patients. Randomized, controlled clinical trials are necessary for developing optimal protocols for paramedic and physician emergency medical teams.

Clinical review: Respiratory monitoring in the ICU - a consensus of 16

Monitoring plays an important role in the current management of patients with acute respiratory failure but sometimes lacks definition regarding which 'signals' and 'derived variables' should be prioritized as well as specifics related to timing (continuous versus intermittent) and modality (static versus dynamic). Many new techniques of respiratory monitoring have been made available for clinical use recently, but their place is not always well defined. Appropriate use of available monitoring techniques and correct interpretation of the data provided can help improve our understanding of the disease processes involved and the effects of clinical interventions. In this consensus paper, we provide an overview of the important parameters that can and should be monitored in the critically ill patient with respiratory failure and discuss how the data provided can impact on clinical management.

The impact of arterial hypertension on polytrauma and traumatic brain injury

BACKGROUND

Pre-hospital hypotension in trauma patients is associated with high mortality. Especially for patients with severe traumatic brain injury (TBI), arterial normotension or even hypertension (AHT) is considered an important mechanism for sustaining adequate cerebral perfusion pressure. The effect of pre-hospital arterial hypertension (pAHT) on in-hospital mortality after trauma has not been studied to date.

METHODS

We retrospectively analyzed data in the trauma registry of the German Society for Trauma Surgery (DGU) on all trauma patients in Germany from 1993 to 2008 who were 16 to 80 years old at the time of the trauma and had an injury severity score (ISS) of 9 or above (total, 42 500 patient data sets). For the analysis, we divided the patients into two groups: those with and those without TBI. We further divided the TBI patients into five subgroups depending on the course of their systolic blood pressure up to the moment of their arrival at the hospital. We also analyzed the patients' demographic data, patterns of injury, and accident mechanisms.

RESULTS

Trauma patients with TBI and pAHT (142 of 561 patients) had a significantly higher mortality than normotensive TBI patients (25.3% vs. 13.5%, p<0.001). Arterial hypertension that either rises or falls before the patient reaches the hospital is associated with higher in-hospital mortality. A logistical regression analysis of 5384 patients revealed that patients with pAHT (n = 561) had an odds ratio of 1.9 (95% confidence interval, 1.4 to 1.6) for death in the hospital compared to normotensive patients (n = 6020).

CONCLUSION

Systolic blood pressure values above 160 mm Hg before arrival in the hospital worsen the outcome of trauma patients with TBI.

A review of traumatic brain injury trauma center visits meeting physiologic criteria from The American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention Field Triage Guidelines

BACKGROUND

Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient.

OBJECTIVES

This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population.

METHODS

The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling.

RESULTS

The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7-28.3). Other physiologic criteria also demonstrated significant odds of death.

CONCLUSIONS

These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.

Immediate, but not delayed, microsurgical skull reconstruction exacerbates brain damage in experimental traumatic brain injury model

Moderate to severe traumatic brain injury (TBI) often results in malformations to the skull. Aesthetic surgical maneuvers may offer normalized skull structure, but inconsistent surgical closure of the skull area accompanies TBI. We examined whether wound closure by replacement of skull flap and bone wax would allow aesthetic reconstruction of the TBI-induced skull damage without causing any detrimental effects to the cortical tissue. Adult male Sprague-Dawley rats were subjected to TBI using the controlled cortical impact (CCI) injury model. Immediately after the TBI surgery, animals were randomly assigned to skull flap replacement with or without bone wax or no bone reconstruction, then were euthanized at five days post-TBI for pathological analyses. The skull reconstruction provided normalized gross bone architecture, but 2,3,5-triphenyltetrazolium chloride and hematoxylin and eosin staining results revealed larger cortical damage in these animals compared to those that underwent no surgical maneuver at all. Brain swelling accompanied TBI, especially the severe model, that could have relieved the intracranial pressure in those animals with no skull reconstruction. In contrast, the immediate skull reconstruction produced an upregulation of the edema marker aquaporin-4 staining, which likely prevented the therapeutic benefits of brain swelling and resulted in larger cortical infarcts. Interestingly, TBI animals introduced to a delay in skull reconstruction (i.e., 2 days post-TBI) showed significantly reduced edema and infarcts compared to those exposed to immediate skull reconstruction. That immediate, but not delayed, skull reconstruction may exacerbate TBI-induced cortical tissue damage warrants a careful consideration of aesthetic repair of the skull in TBI.

Management and outcome of mechanically ventilated neurologic patients

OBJECTIVE

To describe and compare characteristics, ventilatory practices, and associated outcomes among mechanically ventilated patients with different types of brain injury and between neurologic and nonneurologic patients.

DESIGN

Secondary analysis of a prospective, observational, and multicenter study on mechanical ventilation.

SETTING

Three hundred forty-nine intensive care units from 23 countries.

PATIENTS

We included 552 mechanically ventilated neurologic patients (362 patients with stroke and 190 patients with brain trauma). For comparison we used a control group of 4,030 mixed patients who were ventilated for nonneurologic reasons.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We collected demographics, ventilatory settings, organ failures, and complications arising during ventilation and outcomes. Multivariate logistic regression analysis was performed with intensive care unit mortality as the dependent variable. At admission, a Glasgow Coma Scale score ≤8 was observed in 68% of the stroke, 77% of the brain trauma, and 29% of the nonneurologic patients. Modes of ventilation and use of a lung-protective strategy within the first week of mechanical ventilation were similar between groups. In comparison with nonneurologic patients, patients with neurologic disease developed fewer complications over the course of mechanical ventilation with the exception of a higher rate of ventilator-associated pneumonia in the brain trauma cohort. Neurologic patients showed higher rates of tracheotomy and longer duration of mechanical ventilation. Mortality in the intensive care unit was significantly (p < .001) higher in patients with stroke (45%) than in brain trauma (29%) and nonneurologic disease (30%). Factors associated with mortality were: stroke (in comparison to brain trauma), Glasgow Coma Scale score on day 1, and severity at admission in the intensive care unit.

CONCLUSIONS

In our study, one of every five mechanically ventilated patients received this therapy as a result of a neurologic disease. This cohort of patients showed a higher mortality rate than nonneurologic patients despite a lower incidence of extracerebral organ dysfunction.

Cognitive rehabilitation in traumatic brain injury

OPINION STATEMENT

Traumatic brain injury (TBI) is a major public health problem with neurobehavioral sequelae contributing to the long-term disability that is often associated with the moderate to severe levels of injury. Rehabilitation of cognitive skills is central to encouraging the full participation of the individual in home, vocational, and social roles. The review of available evidence points to four major recommendations for the rehabilitation of cognition following brain injury: 1) Access to subacute rehabilitation that is holistic in nature and involves a multidisciplinary or transdisciplinary team to work in an integrated fashion to support physical, cognitive, and social skill retraining is vital to support positive outcome following TBI. The collaborative effort of these individuals allows for continual reinforcement and evaluation of treatment goals and will often involve the family and/or important others in the individual's life to prepare for community re-entry. 2) Trials of medication, especially methylphenidate, to assist individuals with significant attention and memory impairment appear well supported by the available evidence. Though some data suggest that the use of cholinesterase inhibitors may be of use for individuals with memory impairments, there is less support for this practice and there are indications that it may worsen the behavioral sequelae of the injury. 3) Randomized controlled trials demonstrate the utility of specific rehabilitation approaches to attention retraining and retraining of executive functioning skills. Future research is needed on rehabilitation techniques in other domains of cognition. 4) Training in the use of supportive devices (either a memory book or more technologically enhanced compensatory devices) to support the individual's daily activities remains central to the independent function of the individual in the community. Though emerging treatments (eg, virtual reality environments) show relative degrees of promise for inclusion in the rehabilitation of the individual with TBI, these need further evaluation in systematic trials.