Factors associated with adverse outcomes in patients with traumatic intracranial hemorrhage and Glasgow Coma Scale of 15

Hyperosmolar therapies for neurological deterioration in mild and moderate traumatic brain injury: A scoping review

OBJECTIVE

To explore the available evidence on hyperosmolar therapies(HT) in mild and moderate traumatic brain injury(TBI) and to evaluate the effects on outcomes.A scoping review was conducted according to the Joanna Briggs Institute methodology. Inclusion criteria: (a)randomized controlled trials(RCTs), prospective and retrospective cohort studies and case-control studies; (b)all-ages mild and moderate TBIs; (c)HT administration; (d)functional outcomes recorded; (e)comparator group.

RESULTS

From 4424 records, only 3 respected the inclusion criteria. In a retrospective cohort study of adult moderate TBIs, the Glasgow Coma Scale(GCS) remained the same at 48 hours in those treated with hypertonic saline(HTS) while it worsened in the non-treated. A trend toward increased pulmonary infections and length of stay was found. In an RCT of adult severe and moderate TBIs, moderate TBIs treated with HTS showed a trend toward better secondary outcomes than standard care alone, with similar odds of adverse effects. An RCT enrolling children with mild TBI found a significant improvement in concussive pain immediately after HTS administration and after 2-3 days. No adverse events occurred.

CONCLUSIONS

A gap in the literature about HTs' role in mild and moderate TBI was found. Some benefits may exist with limited side effects and further studies are desirable.

Prognostic Value of Initial Diagnostic Imaging Findings for Patient Outcomes in Adult Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

INTRODUCTION

Termed the "silent epidemic," traumatic brain injury (TBI) is one of the greatest global contributors not only to post-traumatic death but also to post-traumatic long-term disability. This systematic review and meta-analysis aims to specifically evaluate the prognostic value of features on initial imaging completed within 24 h of arrival in adult patients with TBI.

METHOD

The authors followed the PRISMA 2020 checklist for systematic review and meta-analysis design and reporting. Comprehensive searches of the Medline and Embase databases were carried out. Two independent readers extracted the following demographic, clinical and imaging information using a predetermined data abstraction form. Statistics were performed using Revman 5.4.1 and R version 4.2.0. For pooled data in meta-analysis, forest plots for sensitivity and specificity were created to calculate the diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) curves were generated using a bivariate model, and diagnostic accuracy was determined using pooled sensitivity and specificity as well as the area under the receiver operator characteristic curve (AUC).

RESULTS

There were 10,733 patients over the 19 studies. Overall, most of the studies included had high levels of bias in multiple, particularly when it came to selection bias in patient sampling, bias in controlling for confounders, and reporting bias, such as in reporting missing data. Only subdural hematoma (SDH) and mortality in all TBI patients had both an AUC with 95% CI not crossing 0.5 and a DOR with 95% CI not crossing 1, at 0.593 (95% CI: 0.556-0.725) and 2.755 (95% CI: 1.474-5.148), respectively.

CONCLUSION

In meta-analysis, only SDH with mortality in all TBI patients had a moderate but significant association. Given the small number of studies, additional research focused on initial imaging, particularly for imaging modalities other than NECT, is required in order to confirm the findings of our meta-analysis and to further evaluate the association of imaging findings and outcome.

External validation of the updated Brain Injury Guidelines for complicated mild traumatic brain injuries: a retrospective cohort study

OBJECTIVE

Approximately 10% of patients with mild traumatic brain injury (mTBI) have intracranial bleeding (complicated mTBI) and 3.5% eventually require neurosurgical intervention, which is mostly available at centers with a higher level of trauma care designation and often requires interhospital transfer. In 2018, the Brain Injury Guidelines (BIG) were updated in the United States to guide emergency department care and patient disposition for complicated mild to moderate TBI. The aim of this study was to validate the sensitivity and specificity of the updated BIG (uBIG) for predicting the need for interhospital transfer in Canadian patients with complicated mTBI.

METHODS

This study took place at three level I trauma centers. Consecutive medical records of patients with complicated mTBI (Glasgow Coma Scale score 13-15) who were aged ≥ 16 years and presented between September 2016 and December 2017 were retrospectively reviewed. Patients with a penetrating trauma and those who had a documented cerebral tumor or aneurysm were excluded. The primary outcome was a combination of neurosurgical intervention and/or mTBI-related death. Sensitivity and specificity analyses were performed.

RESULTS

A total of 477 patients were included, of whom 8.4% received neurosurgical intervention and 3% died as a result of their mTBI. Forty patients (8%) were classified as uBIG-1, 168 (35%) as uBIG-2, and 269 (56%) as uBIG-3. No patients in uBIG-1 underwent neurosurgical intervention or died as a result of their injury. This translates into a sensitivity for predicting the need for a transfer of 100% (95% CI 93.2%-100%) and a specificity of 9.4% (95% CI 6.8%-12.6%). Using the uBIG could potentially reduce the number of transfers by 6% to 25%.

CONCLUSIONS

The patients in uBIG-1 could be safely managed at their initial center without the need for transfer to a center with a higher level of neurotrauma care. Although the uBIG could decrease the number of transfers, further refinement of the criteria could improve its specificity.

Utility and Predictive Value of CHIIDA Score in Pediatric Traumatic Brain Injury: A Prospective Observational Study

BACKGROUND

The Children's Intracranial Injury Decision Aid (CHIIDA) is a tool designed to stratify children with mild traumatic brain injury (mTBI). The aim of this study was to assess the utility and predictive value of CHIIDA in the assessment of the need for intensive care unit (ICU) admission in pediatric patients with mTBI.

METHODS

This prospective observational study included 425 children below 18 years of age admitted to the ICU of a tertiary care hospital with mTBI (Glasgow Coma Scale 13 to 15). The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Sensitivity, specificity, predictive values and likelihood ratios were calculated at CHIIDA scores 0 and 2.

RESULTS

Among 425 children with mTBI, 210 (49%) had a CHIIDA score 0, 16 (4%) scored 2 points, and 199 (47%) scored more than 2 points. Thirty-six (8.47%) patients experienced the primary outcome, and there were 3 deaths. A cutoff CHIIDA >0 to admit to ICU had a sensitivity of 97.22% (95% confidence interval [CI], 97.05%-97.39%) and a negative predictive value of 99.54% (95% CI, 99.50%-99.56%). A cutoff of score >2 had a sensitivity of 97.22% (95% CI, 97.05%-97.39%), and negative predictive value of 99.56% (95% CI, 99.54%-99.59%). The post-test probability at cutoff score of 0 and 2 was 16.65% and 16.27%, respectively.

CONCLUSIONS

CHIIDA score does not serve as reliable triage tool for identifying children with TBI who do not require ICU admission.

Minor Traumatic Intracranial Hemorrhage: Identifying Prognostic Factors and Comparing Patients with Favorable and Unfavorable Outcomes

BACKGROUND

Whether patients with minor traumatic intracranial hemorrhage (MTICH) require intensive care remains uncertain. This study aimed to identify the factors affecting the postinjury neurologic outcomes of patients with MTICH to determine optimal care.

METHODS

We retrospectively reviewed the data of all patients with trauma discharged from a tertiary trauma center during a 2-year period and included adult patients with isolated MTICH. Patient Glasgow Outcome Scale (GOS) score at discharge was the primary outcome measurement. A GOS score of 4 or 5 was defined as a favorable outcome, and a score of 1-3 was considered an unfavorable outcome. We compared the clinical data between favorable and unfavorable outcome groups to determine the differences between groups.

RESULTS

Of the 11,814 patients considered, we identified 534 patients who met the inclusion criteria. Older adults accounted for 35.4% of the study cohort. Only 4 complications (0.7%) and 1 mortality (0.2%) were observed during hospitalization. The number of patients who requiring brain surgery, transfusion, mechanical ventilation, pressor, or invasive monitor was 5 (0.9%), 5 (0.9%), 3 (5.6%), 0 (0%), and 0 (0%), respectively. After multivariate analysis, we discovered that comorbidities, brain surgery requirement, respiratory rate, and Trauma Injury Severity Score were strongly associated with patient GOS score at discharge.

CONCLUSIONS

MTICH rarely resulted in permanent morbidity and mortality. Older patients exhibited higher incidences of MTICH and were at a higher risk for unfavorable outcomes.

Secondary Overtriage in Patients with Complicated Mild Traumatic Brain Injury: An Observational Study and Socioeconomic Analysis of 1447 Hospitalizations

BACKGROUND

Secondary overtriage is a problematic phenomenon because it creates unnecessary expense and potentially results in the mismanagement of healthcare resources. The rates of secondary overtriage among patients with complicated mild traumatic brain injury (cmTBI) are unknown.

OBJECTIVE

To determine the rate of secondary overtriage among patients with cmTBI using the institutional trauma registry.

METHODS

An observational study using retrospective analysis of 1447 hospitalizations including all consecutive patients with cmTBI between 2004 and 2013. Data on age, sex, race/ethnicity, insurance status, GCS, Injury Severity Score (ISS), Trauma Injury Severity Score, transfer mode, overall length of stay (LOS), LOS within intensive care unit, and total charges were collected and analyzed.

RESULTS

Overall, the rate of secondary overtriage among patients with cmTBI was 17.2%. These patients tended to be younger (median: 41 vs 60.5 yr; P < .001), have a lower ISS (9 vs 16; P < .001), and were more likely to be discharged home or leave against medical advice.

CONCLUSION

Our findings provide evidence to the growing body of literature suggesting that not all patients with cmTBI need to be transferred to a tertiary care center. In our study, these transfers ultimately incurred a total cost of $13 294 ($1337 transfer cost) per patient.

Glial Fibrillary Acidic Protein (GFAP) Outperforms S100 Calcium-Binding Protein B (S100B) and Ubiquitin C-Terminal Hydrolase L1 (UCH-L1) as Predictor for Positive Computed Tomography of the Head in Trauma Subjects

OBJECTIVE

Traumatic brain injuries (TBIs) are largely underdiagnosed and may have persistent refractory consequences. Current assessments for acute TBI are limited to physical examination and imaging. Biomarkers such as glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase L1 (UCH-L1), and S100 calcium-binding protein B (S100B) have shown predictive value as indicators of TBI and potential screening tools.

METHODS

In total, 37 controls and 118 unique trauma subjects who received a clinically ordered head computed tomography (CT) in the emergency department of a level 1 trauma center were evaluated. Blood samples collected at 0-8 hours (initial) and 12-32 hours (delayed) postinjury were analyzed for GFAP, UCH-L1, and S100B concentrations. These were then compared in CT-negative and CT-positive subjects.

RESULTS

Median GFAP, UCH-L1, and S100B concentrations were greater in CT-positive subjects at both timepoints compared with CT-negative subjects. In addition, median UCH-L1 and S100B concentrations were lower at the delayed timepoint, whereas median GFAP concentrations were increased. As predictors of a positive CT of the head, GFAP outperformed UCH-L1 and S100B at both timepoints (initial: 0.89 sensitivity, 0.62 specificity; delayed: 0.94 sensitivity, 0.67 specificity). GFAP alone also outperformed all possible combinations of biomarkers.

CONCLUSIONS

GFAP, UCH-L1, and S100B demonstrated utility for rapid prediction of a CT-positive TBI within 0-8 hours of injury. GFAP exhibited the greatest predictive power at 12-32 hours. Furthermore, these results suggest that GFAP alone has greater utility for predicting a positive CT of the head than UCH-L1, S100B, or any combination of the 3.

Traumatic brain injured patients: primum non nocere

PURPOSE OF REVIEW

Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI.

RECENT FINDINGS

Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired.

SUMMARY

Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population.

[Mild head injury]

INTRODUCTION

Mild traumatic brain injury (TBI) represents a major health concern, because a sizeable number of patients with mild TBI will develop potentially life-threatening complications. The target of this study was to describe a large series of adult patients suffering from mild TBI, treated at University Hospital of Getafe, between 2010 and 2015 (n = 2480). We examined the patients' epidemiological and baseline clinical profile, diagnosis, treatment and ultimate outcomes, to identify major prognostic factors that influence the final result.

METHODS

We retrospectively extracted patient data from medical records and performed both bivariate and multivariate statistics.

RESULTS

In our sample, mild TBI was more common in men, and the most common causative mechanism was a traffic accident. We proposed a model for classifying patients according to risk, dividing them into low, intermediate and high risk, based upon their baseline clinical picture. This classification scheme correlated well with final outcomes. We investigated indications for skull radiography and computed tomography (CT), as well as for hospital admission for clinical observation.

CONCLUSIONS

In this study, the presence of a neurological focus on clinical examination, the existence of a fracture on plain radiographs, advanced age and the presence of a coagulation disorder were associated with the increased likelihood of intracranial complications and a poor prognosis. The Glasgow Coma Scale was deficient predicting patient outcomes, because it failed to account for concussion-related symptoms like amnesia and loss of consciousness, both very common in patients with mild TBI.