The impact of delayed time to first CT head in traumatic brain injury

Hypotension and Adverse Outcomes in Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Importance

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Hypotension in patients with TBI is associated with poorer outcomes. A comprehensive review examining adverse outcomes of hypotension in patients with TBI is needed.

Objective

To investigate the mortality and incidence of hypotension in patients with TBI.

Data Sources

A search of studies published before April 2024 was conducted using MEDLINE, MEDLINE In Process, ePubs, Embase, Classic+Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for primary research articles in English, including randomized control trials, quasirandomized studies, prospective cohorts, retrospective studies, longitudinal studies, and cross-sectional surveys.

Study Selection

Inclusion criteria were patients aged at least 10 years with moderate to severe TBI with hypotension. The exclusion criteria were mild TBI (due to the differences in management principles from moderate to severe TBI). Data were screened using Covidence software with multiple reviewers.

Data Extraction and Synthesis

This meta-analysis conforms to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines for assessing data quality and validity. Primary outcomes (unadjusted and adjusted odds ratios [ORs]) were calculated using a random-effect model with 95% CIs. Incidence of hypotension was derived using logit transformation.

Main Outcomes and Measures

Main outcomes were association of hypotension with death and/or vegetative state within 6 months and incidence of hypotension. Vegetative state was not reported due to lack of data from included studies. Hypothesis testing occurred before data collection.

Results

The search strategy identified 17 676 unique articles. The final review included 51 studies (384 329 patients). Pooled analysis of found a significant increase in mortality in patients with hypotension and moderate to severe TBI (crude OR, 3.82; 95% CI, 3.04-4.81; P < .001; I2 = 96.98%; adjusted OR, 2.22; 95% CI, 1.96-2.51; P < .001; I2 = 92.21%). The overall hypotension incidence was 18% (95% CI, 12%-26%) (P < .001; I2 = 99.84%).

Conclusions and Relevance

This meta-analysis of nearly 400 000 patients with TBI found a significant association of greater than 2-fold odds of mortality in patients with hypotension and TBI. This comprehensive analysis can guide future management recommendations, specifically with respect to blood pressure threshold management to reduce deaths when treating patients with TBI.

Development of a Quality Indicator Set for the Optimal Acute Management of Moderate to Severe Traumatic Brain Injury in the Australian Context

BACKGROUND

The aim of this study was to develop a consensus-based set of indicators of high-quality acute moderate to severe traumatic brain injury (msTBI) clinical management that can be used to measure structure, process, and outcome factors that are likely to influence patient outcomes. This is the first stage of the PRECISION-TBI program, which is a prospective cohort study that aims to identify and promote optimal clinical management of msTBI in Australia.

METHODS

A preliminary set of 45 quality indicators was developed based on available evidence. An advisory committee of established experts in the field refined the initial indicator set in terms of content coverage, proportional representation, contamination, and supporting evidence. The refined indicator set was then distributed to a wider Delphi panel for assessment of each indicator in terms of validity, measurement feasibility, variability, and action feasibility. Inclusion in the final indicator set was contingent on prespecified inclusion scoring.

RESULTS

The indicator set was structured according to the care pathway of msTBI and included prehospital, emergency department, neurosurgical, intensive care, and rehabilitation indicators. Measurement domains included structure indicators, logistic indicators, and clinical management indicators. The Delphi panel consisted of 44 participants (84% physician, 12% nursing, and 4% primary research) with a median of 15 years of practice. Of the 47 indicators included in the second round of the Delphi, 32 indicators were approved by the Delphi group.

CONCLUSIONS

This study identified a set of 32 quality indicators that can be used to structure data collection to drive quality improvement in the clinical management of msTBI. They will also be used to guide feedback to PRECISION-TBI's participating sites.

Distinct Serum Glial Fibrillary Acidic Protein and Neurofilament Light Time-Courses After Rapid Head Rotations

Traumatic brain injury (TBI) causes significant neurophysiological deficits and is typically associated with rapid head accelerations common in sports-related incidents and automobile accidents. There are over 1.5 million TBIs in the United States each year, with children aged 0-4 being particularly vulnerable. TBI diagnosis is currently achieved through interpretation of clinical signs and symptoms and neuroimaging; however, there is increasing interest in minimally invasive fluid biomarkers to detect TBI objectively across all ages. Pre-clinical porcine models offer controlled conditions to evaluate TBI with known biomechanical conditions and without comorbidities. The objective of the current study was to establish pediatric porcine healthy reference ranges (RRs) of common human serum TBI biomarkers and to report their acute time-course after nonimpact rotational head injury. A retrospective analysis was completed to quantify biomarker concentrations in porcine serum samples collected from 4-week-old female (n = 215) and uncastrated male (n = 6) Yorkshire piglets. Subjects were assigned to one of three experimental groups (sham, sagittal-single, sagittal-multiple) or to a baseline only group. A rapid nonimpact rotational head injury model was used to produce mild-to-moderate TBI in piglets following a single rotation and moderate-to-severe TBI following multiple rotations. The Quanterix Simoa Human Neurology 4-Plex A assay was used to quantify glial fibrillary acidic protein (GFAP), neurofilament light (Nf-L), tau, and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1). The 95% healthy RRs for females were calculated and validated for GFAP (6.3-69.4 pg/mL), Nf-L (9.5-67.2 pg/mL), and UCH-L1 (3.8-533.7 pg/mL). Rising early, GFAP increased significantly above the healthy RRs for sagittal-single (to 164 and 243 pg/mL) and increased significantly higher in sagittal-multiple (to 494 and 413 pg/mL) groups at 30 min and 1 h postinjury, respectively, returning to healthy RRs by 1-week postinjury. Rising later, Nf-L increased significantly above the healthy RRs by 1 day in sagittal-single (to 69 pg/mL) and sagittal-multiple groups (to 140 pg/mL) and rising further at 1 week (single = 231 pg/mL, multiple = 481 pg/mL). Sagittal-single and sagittal-multiple UCH-L1 serum samples did not differ from shams or the healthy RRs. Sex differences were observed but inconsistent. Serum GFAP and Nf-L levels had distinct time-courses following head rotations in piglets, and both corresponded to load exposure. We conclude that serum GFAP and Nf-L offer promise for early TBI diagnosis and intervention decisions for TBI and other neurological trauma.

Time to traumatic intracranial hematoma evacuation: contemporary standard and room for improvement

PURPOSE

Traumatic intracranial hematoma (TICH) is a neurosurgical emergency with high mortality and morbidity. The time to operative decompression is a modifiable but inconsistently reported risk factor for TICH patients?

OUTCOMES

We aimed to provide contemporary time to evacuation data and long-term trends in timing of TICH evacuation in a trauma system.

METHODS

A 13-year retrospective cohort study ending in 2021 at a trauma system with one level-1 trauma center included all patients undergoing urgent craniotomy or craniectomy for evacuation of TICH. Demographics, injury severity and key timeframes of care were collected. Subgroups analyzed were polytrauma versus isolated head injury, direct admissions versus transfers and those who survived versus those who died. Linear regression of times from injury to operating room was performed.

RESULTS

Seventy-eight TICH patients (Age: 35 (22-56); 58 (74%) males; ISS: 25(25-41); AIS head: 5 (4-5); mortality: 21 (27%) patients) were identified. Initial GCS was 8 (3.25-14) which decreased to 3 (3-7) by arrival in the trauma center. There were 46 (59%) patients intubated prior to arrival. Median time from injury to operation was 4.88 (3.63-6.80) hours. Linear regression of injury to OR showed increasing times to operative intervention for direct admissions to the trauma center over the study period (p=0.04). There was no associated change in mortality or Glasgow outcome score over the same time.

CONCLUSION

This contemporary data shows timing from injury to evacuation is approaching 5 hours. Over the 13-year study period the time to operative intervention significantly increased for direct admissions. This study will guide our institutions response to TICH presentations in the future. Other trauma systems should critically appraise their results with the same reporting standard.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Current trauma team activation processes at Canadian trauma centres: A national survey

BACKGROUND

Trauma team activation (TTA) allows the provision of specialized and timely care to improve outcomes for severely injured patients. Limited information is available on the current state of TTA in Canadian trauma centres (TC). Study objectives were to describe TTA processes, data and reports, along with the challenges and successes from a national perspective.

METHODS

A mixed-methods, cross-sectional survey was undertaken with Canadian trauma leadership, utilizing a total population sampling strategy. The questionnaire, containing 108-items, was administered online between February-April 2022, utilizing a modified Dillman technique. Descriptive statistics and thematic analyses were performed.

RESULTS

Trauma leaders from 9 out of 10 provinces responded for a response rate of 68% (32/47). Two-thirds (67%) of respondents worked in adult TC; 63% in a level I center. A higher proportion of pediatric TC had a two-tiered TT response (60% pediatric; 35% adult). The most common criteria were neurologic compromise (100% one-level TTA) and hypotension (pediatric: 100% one-level, 100% tier 1; adult: 92% one-level, 86% tier 1). All one-level TTA included penetrating trauma criteria. One-third of respondents reported using TTA subgroup criteria for pediatric, pregnant, and/or geriatric patients. There was variability with disciplines responding to TTA, with largest, most comprehensive teams for tier 1. Two-thirds of TC review activation compliance (under/overtriage), while 55% focus on non-compliance and reasons for missed TTA. The most frequent challenges related to TTA practices were reliable data collection (60%) while successes included were the establishment of TTA guidelines to improve team compliance (33%) and RN initiated TTA.

CONCLUSIONS

Some TTA practices were similar among Canadian TC, while others showed variability. Findings provide opportunities for improvement, including a two-tier system, geriatric-specific criteria, and RN initiated TTA, and could help establish national standards and best practices. Compliance with standards has the potential to improve Canadian TTA practices and patient outcomes.

Undertriage of Severely Injured Trauma Patients

INTRODUCTION

The American College of Surgeons (ACS) delineates trauma team activation (TTA) criteria to identify seriously injured trauma patients in the field. Patients are deemed to be severely undertriaged (SU), placing them at risk for adverse outcomes, when they do not meet TTA criteria but nonetheless sustain significant injuries (Injury Severity Score [ISS] ≥25).

OBJECTIVES

Delineate patient demographics, injuries, and outcomes after SU.

PARTICIPANTS

Trauma patients presenting to our ACS-verified Level 1 trauma center with ISS ≥25 were included (11/2015-03/2022). Transfers and private vehicle transports were excluded. Patients were dichotomized and compared by trauma arrival level: TTA (Appropriately Triaged, AT) vs routine consults (SU).

RESULTS

Study criteria were satisfied by 1653 patients: 1375 (83%) AT and 278 (17%) SU. Severely undertriaged patients were older than AT patients (47 vs 36 years, P < .001). Severely undertriaged occurred almost exclusively following blunt trauma (96% vs 71%, P < .001). Injury Severity Score was lower following SU than AT (29 vs 32, P < .001). The most common severe injuries (Abbreviated Injury Scale score [AIS] ≥3) among the SU group were in the Chest (n = 179, 64%). Severely undertriaged patients necessitated emergent intubation (n = 34, 12%), surgery (n = 59, 21%), and angioembolization (n = 22, 8%) at high rates. Severely undertriaged mortality was n = 40, 14%.

CONCLUSION

Severely undertriaged occurred among a substantial proportion of ISS ≥25 patients, predominately following blunt trauma. Severe chest injuries were most likely to evade capture. Rates of intubation, emergent intervention, and in-hospital mortality were high after SU. Efforts should be made to identify such patients in the field as they may benefit from TTA.

Impact of nonphysician, technology-guided alert level selection on rates of appropriate trauma triage in the United States: a before and after study

Purpose

Overtriage and undertriage rates are critical metrics in trauma, influenced by both trauma team activation (TTA) criteria and compliance with these criteria. Analysis of undertriaged patients at a level I trauma center revealed suboptimal compliance with existing criteria. This study assessed triage patterns after implementing compliance-focused process interventions.

Methods

A physician-driven, free-text alert system was modified to a nonphysician, hospital dispatcher-guided system. The latter employed dropdown menus to maximize compliance with criteria. The preintervention period included patients who presented between May 12, 2020, and December 31, 2020. The postintervention period incorporated patients who presented from May 12, 2021, through December 31, 2021. We evaluated appropriate triage, overtriage, and undertriage using the Standardized Trauma Assessment Tool. Statistical analyses were conducted with an α level of 0.05.

Results

The new system was associated with improved compliance with existing TTA criteria (from 70.3% to 79.3%, P=0.023) and decreased undertriage (from 6.0% to 3.2%, P=0.002) at the expense of increasing overtriage (from 46.6% to 57.4%, P<0.001), ultimately decreasing the appropriate triage rate (from 78.4% to 74.6%, P=0.007).

Conclusions

This study assessed a workflow change designed to improve compliance with TTA criteria. Improved compliance decreased undertriage to below the target threshold of 5%, albeit at the expense of increased overtriage. The decrease in appropriate triage despite compliance improvements suggests that the current criteria at this institution are not adequately tailored to optimally balance the minimization of undertriage and overtriage. This finding underscores the importance of improved compliance in evaluating the efficacy of TTA criteria.

Effect of trauma center operation on emergency care and clinical outcomes in patients with traumatic brain injury

Purpose

Traumatic brain injury (TBI) directly affects the survival of patients and can cause long-term sequelae. The purpose of our study was to investigate whether the operation of a trauma center in a single tertiary general hospital has improved emergency care and clinical outcomes for patients with TBI.

Methods

The participants of this study were all TBI patients, patients with isolated TBI, and patients with TBI who underwent surgery within 24 hours, who visited our level 1 trauma center from March 1, 2012 to February 28, 2020. Patients were divided into two groups: patients who visited before and after the operation of the trauma center. A comparative analysis was conducted. Differences in detailed emergency care time, hospital stay, and clinical outcomes were investigated in this study.

Results

On comparing the entire TBI patient population via dividing them into the aforementioned two groups, the following results were found in the group of patients who visited the hospital after the operation of the trauma center: an increased number of patients with a good functional prognosis (P<0.001 and P=0.002, respectively), an increased number of surviving discharges (P<0.001 and P<0.001, respectively), and a reduction in overall emergency care time (P<0.05, for all item values). However, no significant differences existed in the length of intensive care unit stay, ventilator days, and total length of stay for TBI patients who visited the hospital before and after the operation of the trauma center.

Conclusions

The findings confirmed that overall TBI patients and patients with isolated brain injury had improved treatment results and emergency care through the operation of a trauma center in a tertiary general hospital.

Impact of easing COVID-19 safety measures on trauma computed tomography imaging volumes

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has led to substantial disruptions in healthcare staffing and operations. Stay-at-home (SAH) orders and limitations in social gathering implemented in spring 2020 were followed by initial decreases in healthcare and imaging utilization. This study aims to evaluate the impact of subsequent easing of SAH on trauma volumes, demand for, and turnaround times for trauma computed tomography (CT) exams, hypothesizing that after initial decreases, trauma volumes have increased as COVID safety measures have been reduced.

METHODS

Patient characteristics, CT imaging volumes, and turnaround time were analyzed for all adult activated emergency department trauma patients requiring CT imaging at a single Level-I trauma center (1/2018-2/2022) located in the sixth most populous county in the USA. Based on COVID safety measures in place in the state of California, three time periods were compared: baseline (PRE, 1/1/2018-3/19/2020), COVID safety measures (COVID, 3/20/2020-1/25/2021), and POST (1/26/2021-2/28/2022).

RESULTS

There were 16,984 trauma patients across the study (PRE = 8289, COVID = 3139, POST = 5556). The average daily trauma patient volumes increased significantly in the POST period compared to the PRE and COVID periods (13.9 vs. 10.3 vs. 10.1, p < 0.001), with increases in both blunt (p < 0.001) and penetrating (p = 0.002) trauma. The average daily number of trauma CT examinations performed increased significantly in the POST period compared to the PRE and COVID periods (56.7 vs. 48.3 vs. 47.6, p < 0.001), with significant increases in average turnaround time (47 min vs. 31 and 37, p < 0.001).

CONCLUSION

After initial decreases in trauma radiology volumes following stay-at-home orders, subsequent easing of safety measures has coincided with increases in trauma imaging volumes above pre-pandemic levels and longer exam turnaround times.

50th anniversary of computed tomography: past and future applications in clinical neuroscience

Purpose: It has been 50 years since computed tomography was introduced to the worldwide neurologic medical and surgical community. In that time, tremendous advances in computer software and hardware, as well as creative changes in computerized tomographic (CT) hardware and tube technology, have dramatically improved the temporal and spatial resolution of CT. In this paper, I address what I feel are some of the most important impacts of CT in the field of clinical neuroscience over the last 50 years, as well as potential applications of CT that are on the horizon.

Approach: I have recounted from literature, colleagues, and personal recollection the historical impact of CT on neuroradiology practice and what appear to be near-term future applications.

Conclusions: Therapeutic applications beyond diagnosis, such as image-guided procedures, radiation, and surgical planning, and development of the field of theranostics have emerged and further increased the need for faster and more precise CT imaging. The integration of machine learning into the acquisition chain and radiologist tool kit has great implications for standardization, analysis, and diagnosis worldwide.

The impact of delayed time to first CT head on functional outcomes after blunt head trauma with moderately depressed GCS

Purpose

Recent work suggests patients with moderately depressed Glasgow Coma Scale (GCS) score in the Emergency Department (ED) who do not undergo immediate head CT (CTH) have delayed neurosurgical intervention and longer ED stay. The present study objective was to determine the impact of time to first CTH on functional neurologic outcomes in this patient population.

Methods

Blunt trauma patients presenting to our Level I trauma center (11/2015–10/2019) with first ED GCS 9–12 were retrospectively identified and included. Transfers and those with extracranial AIS ≥ 3 were excluded. The study population was stratified into Immediate (≤ 1 h) and Delayed (1–6 h) CTH groups based on time from ED arrival to first CTH. Outcomes included functional outcomes at hospital discharge based on the Modified Rankin Scale (mRS).

Results

After exclusions, 564 patients were included: 414 (73%) with Immediate CTH and 150 (27%) Delayed CTH. Both groups arrived with median GCS 11 and alcohol/drug intoxication did not differ (p > 0.05). AIS Head/Neck was comparable (3[3–4] vs. 3[3–3], p = 0.349). Time to ED disposition decision and ED exit were significantly shorter after Immediate CTH (2.8[1.5–5.3] vs. 5.2[3.6–7.5]h, p < 0.001 and 5.5[3.3–8.9] vs. 8.1[5.2–11.7]h, p < 0.001). Functional outcomes were slightly worse after Immediate CTH (mRS 2[1–4] vs. 2[1–3], p = 0.002). Subgroup analysis of patients requiring neurosurgical intervention demonstrated a greater proportion of moderately disabled patients with a lower proportion of severely disabled or dead patients after Immediate CTH as compared to Delayed CTH (51 vs. 20%, p = 0.063 and 35 vs. 60%, p = 0.122).

Conclusions

Immediate CTH shortened time to disposition decision out of the ED and ED exit. Patients requiring neurosurgical intervention after Immediate CTH had improved functional outcomes when compared to those undergoing Delayed CTH. These differences did not reach statistical significance in this single-center study and, therefore, a large, multicenter study is the next step in demonstrating the potential functional outcomes benefit of Immediate CTH after blunt head trauma.