‘Talk and Die’ patients presenting to a major trauma centre over a 10 year period: A critical review

Secondary Neurologic Deterioration After Moderate Traumatic Brain Injury: Development of a Multivariable Prediction Model and Proposition of a Simple Triage Score

BACKGROUND

Identifying patients at risk of secondary neurologic deterioration (SND) after moderate traumatic brain injury (moTBI) is a challenge, as such patients will need specific care. No simple scoring system has been evaluated to date. This study aimed to determine clinical and radiological factors associated with SND after moTBI and to propose a triage score.

METHODS

All adults admitted in our academic trauma center between January 2016 and January 2019 for moTBI (Glasgow Coma Scale [GCS] score, 9-13) were eligible. SND during the first week was defined either by a decrease in GCS score of >2 points from the admission GCS in the absence of pharmacologic sedation or by a deterioration in neurologic status associated with an intervention, such as mechanical ventilation, sedation, osmotherapy, transfer to the intensive care unit (ICU), or neurosurgical intervention (for intracranial mass lesions or depressed skull fracture). Clinical, biological, and radiological independent predictors of SND were identified by logistic regression (LR). An internal validation was performed using a bootstrap technique. A weighted score was defined based on beta (β) coefficients of the LR.

RESULTS

A total of 142 patients were included. Forty-six patients (32%) showed SND, and 14-day mortality rate was 18.4%. Independent variables associated with SND were age above 60 years (odds ratio [OR], 3.45 [95% confidence interval {CI}, 1.45-8.48]; P = .005), brain frontal contusion (OR, 3.22 [95% CI, 1.31-8.49]; P = .01), prehospital or admission arterial hypotension (OR, 4.86 [95% CI, 2.03-12.60]; P = .006), and a Marshall computed tomography (CT) score of 6 (OR, 3.25 [95% CI, 1.31-8.20]; P = .01). The SND score was defined with a range from 0 to 10. The score included the following variables: age >60 years (3 points), prehospital or admission arterial hypotension (3 points), frontal contusion (2 points), and Marshall CT score of 6 (2 points). The score was able to detect patients at risk of SND, with an area under the receiver operating characteristic curve (AUC) of 0.73 (95% CI, 0.65-0.82). A score of 3 had a sensitivity of 85%, a specificity of 50%, a VPN of 87%, and a VPP of 44 % to predict SND.

CONCLUSIONS

In this study, we demonstrate that moTBI patients have a significant risk of SND. A simple weighted score at hospital admission could be able to detect patients at risk of SND. The use of the score may enable optimization of care resources for these patients.

Cushing Index Based on Cushing Signs to Predict In-Hospital Death and Early Intervention for Minor Head Injury

A considerable number of patients with mild traumatic brain injury have been known to "talk and die." Serial neurological examinations, however, have been the only method of determining the necessity of repeat computed tomography (CT), and no validated method has been available to predict early deterioration of minor head injury. This study aimed to evaluate the association between hypertension and bradycardia, a classic sign of raised intracranial pressure (Cushing reflex) on hospital arrival and determine the clinical consequences of minor head injury after blunt trauma. We created a new Cushing Index (CI) by dividing the systolic blood pressure by the heart rate (equaling the inverse number of the Shock Index, a score for hemodynamic stability) and hypothesized that a high CI would predict surgical intervention for deterioration and in-hospital death among patients with minor head injury. To test our hypothesis, a retrospective observational study was conducted using a nationwide trauma database. Accordingly, adult blunt trauma with minor head injury (defined as a Glasgow Coma Scale of 13-15 and Abbreviated Injury Scale score of ≥2 in the head) who were transported directly from the scene by ambulances were included. Among the 338,744 trauma patients identified in the database, 38,844 were eligible for inclusion. A restricted cubic spline regression curve for risks of in-hospital death was created using the CI. Thereafter, the thresholds were determined based on inflection points of the curve, and patients were divided into low-, intermediate-, and high-CI groups. Patients with high CI showed significantly higher in-hospital mortality rates compared with those with intermediate CI (351 [3.0%] vs. 373 [2.3%]; odds ratio [OR] = 1.32 [1.14-1.53]; p < 0.001). Patients with high index also had a higher incidence of emergency cranial surgery within 24h after arrival than those with an intermediate CI (746 [6.4%] vs. 879 [5.4%]; OR = 1.20 [1.08-1.33]; p < 0.001). In addition, patients with low CI (equal to high Shock Index, meaning hemodynamically unstable) showed higher in-hospital death compared with those with intermediate CI (360 [3.3%] vs. 373 [2.3%]; p < 0.001). In conclusion, a high CI (high systolic blood pressure and low heart rate) on hospital arrival would be helpful in identifying patients with minor head injury who might experience deterioration and need close observation.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients

INTRODUCTION

"Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma.

METHODS

We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018.

RESULTS

Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively.

CONCLUSIONS

Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

Coagulopathy and Traumatic Brain Injury: Overview of New Diagnostic and Therapeutic Strategies

Coagulopathy is a common sequela of traumatic brain injury. Consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability. In addition, fibrinolytic pathways are hyperactivated as a result of vascular endothelial cell damage in the injured brain. Coagulation and fibrinolytic parameters change dynamically to reflect these pathologies. Fibrinogen is consumed and degraded after injury, with fibrinogen concentrations at their lowest 3-6 h after injury. Hypercoagulability causes increased fibrinolytic activity, and plasma levels of D-dimer increase immediately after traumatic brain injury, reaching a maximum at 3 h. Owing to disseminated intravascular coagulation in the presence of fibrinolysis, the bleeding tendency is highest within the first 3 h after injury, and often a condition called “talk and deteriorate” occurs. In neurointensive care, it is necessary to measure coagulation and fibrinolytic parameters such as fibrinogen and D-dimer routinely to predict and prevent the development of coagulopathy and its negative outcomes. Currently, the only evidence-based treatment for traumatic brain injury with coagulopathy is tranexamic acid in the subset of patients with mild-to-moderate traumatic brain injury. Coagulation and fibrinolytic parameters should be closely monitored, and treatment should be considered on a patient-by-patient basis.

Ability of neutrophil-to-lymphocyte ratio to predict secondary neurological impairment in patients with mild to moderate head injury. A retrospective study

BACKGROUND

The main objective was to assess the performance of the neutrophil-lymphocyte ratio (NLR) for early prediction of delayed neurological impairment and cerebral contusion worsening in patients with mild-to-moderate traumatic brain injury (TBI).

METHODS

Over a 3-year period, every adult patient triaged to our level 1 trauma center with brain contusion and Glasgow Coma Scale (GCS) of 10 or greater were retrospectively included. The main study outcome was the occurrence of delayed clinical deterioration, defined as a GCS < 10 and/or a secondary need for mechanical ventilation, within 5 days after TBI. The performance of NLR for prediction of delayed clinical deterioration was assessed by receiver operating characteristic (ROC) curve.

RESULTS

Overall, 115 patients were included and 16 (14%) presented a delayed clinical deterioration. Overall, the NLR at ED admission was higher in patients who developed a delayed clinical deterioration (18 [12-29] vs 8 [5-13], p = 0.0003). The area under the ROC curves for NLR at ED admission in predicting delayed clinical deterioration was 0.79 [0.65-0.93] and NLR > 15 was found to be independently associated with the occurrence of delayed clinical deterioration (adjusted OR = 10.1 [95%CI: 2.3-45.6]).

CONCLUSION

The NLR at ED admission was independently associated with the occurrence of delayed clinical deterioration, although limited by a poor discriminative value by itself. Further studies are needed to test the predictive value of composite scoring systems including NLR for prevention of under-triage of patients with mild-to-moderate TBI.

Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series

BACKGROUND

Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on.

METHODS

This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed.

RESULTS

At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5.

CONCLUSIONS

The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.

[Interface between preclinical and clinical trauma care: Analysis of the processes in a trauma network]

INTRODUCTION

In the initial treatment of severely injured patients a good cooperation of the emergency medical service (EMS) with the hospital team is mandatory. The aim of this investigation was to evaluate the quality of cooperation between hospitals working within a trauma network and the rescue service and to develop a tool allowing assessment of the preclinical and clinical interface.

METHODS

Specific surveys concerning preclinical management and transfer to the target hospital were developed within a modified Delphi process. Injured trauma patients were included if the EMS involved was participating in the network and they were transferred to one of the participating hospitals.

RESULTS

Over an 11-month period a total of 360 patients were included in the study. The notification of transferring injured patients to the target hospital was carried out in a regular manner. Transport accompanied by an emergency physician occurred in 97% of the cases and no emergency physician was available although needed in only 1% of cases. Correct choice of target hospital was documented in 98.2%. The average waiting time for transferring the patient to the hospital team was 0.15 min. In 95.7% of cases a hospital physician was available to directly receive the patient in the emergency room. On a scale ranging from 1 (poor) to 10 (very good) clinical personnel as well as rescue teams rated the cooperation between both with a median of 10 points (IQR 8;10). From the clinicians point of view airway and circulation problems and external bleeding were correctly treated in the preclinical setting (airway 93.9%, circulation 97.3% and external bleeding 95.3%); however, for extremity injuries only in 78.5% of the cases.

CONCLUSION

This survey presents an adequate tool to identify weak spots within the primary management and to point out elements for improvement.

Surgical Treatment of Traumatic Bifrontal Contusions: When and How?

OBJECTIVE

The study aimed to investigate optimal surgical timing, methods, and clinical efficacy of bifrontal decompression craniotomy (BDC) on traumatic bifrontal contusions (TBC).

METHODS

A retrospective analysis was performed of 98 patients with TBC who underwent BDC of 2510 patients with traumatic brain injury. The operation-timing score was used to determine surgical timing.

RESULTS

Ninety-eight cases (19%) underwent amended BDC. Initial Glasgow Coma Score was 13-15 in 52 cases (61%). Initial computed tomography showed hematoma volumes of 15.1 ± 5.2 mL in 73 cases (74%). Preoperative hematoma (80.2 ± 20.5 mL; P < 0.05) was significantly enlarged. Fluctuation in the surgery-timing curve is timing for surgery. Average operation time was 4.5 ± 3.4 days after admission. Hematoma was totally evacuated and Glasgow Coma Score significantly increased (P < 0.05) in all cases. In the follow-up Glasgow Outcome Score, 79 patients (81%) recovered well.

CONCLUSIONS

TBC progressed gradually and deteriorated rapidly; this should be strictly and dynamically observed, and patients should be operated on in a timely manner. Changing the operation-timing score is the gold standard for surgery. Amended BDC can significantly improve the prognosis of patients.

Routine Head Computed Tomography for Patients in the Emergency Room with Trauma Requires Both Thick- and Thin-Slice Images

Background. Images of head CT for the supratentorial compartment are sometimes recommended to be reconstructed with a thickness of 8–10 mm to achieve lesion conspicuity. However, additional images of a thin slice may not be routinely provided for patients with trauma in the emergency room (ER). We investigated the diagnostic sensitivity of a head CT, where axial images were 10 mm thick slices, in cases of linear skull fractures. Methods. Two trauma surgeons retrospectively reviewed head CT with 10 mm slices and skull X-rays of patients admitted to the ER that were diagnosed with a linear skull fracture. All patients had undergone both head CT and skull X-rays (n = 410). Result. The diagnostic sensitivity of head CT with a thickness of sequential 10 mm was 89% for all linear skull fractures but only 56% for horizontal fractures. This CT technique with 10 mm slices missed 6% of patients with linear skull fractures. False-negative diagnoses were significantly more frequent for older (≥55 years) than for young (<15 years) individuals (p = 0.048). Conclusions. A routine head CT of the supratentorial region for patients in the ER with head injuries requires both thick-slice images to visualize cerebral hemispheres and thin-slice images to detect skull fractures of the cranial vault.

Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) has long been associated with coagulopathy; however, the time course of coagulation/fibrinolytic parameters in the acute phase of TBI remains unclear. The purpose of the study was to analyze the time course of coagulation/fibrinolytic parameters in the acute phase of TBI and to elucidate parameter relationships to prognosis. We retrospectively evaluated 234 patients with severe isolated TBI with initial blood samples obtained no more than 1 h after injury. Platelet count, prothrombin time, activated partial thromboplastin time (aPTT), plasma levels of fibrinogen, and D-dimer were measured on arrival in the emergency department and 3, 6, and 12 h after injury. Multivariate logistic regression analysis was performed to identify risk factors for poor prognosis at each time point. From hospital admission to 12 h after injury, an elevated D-dimer level was a significant negative prognostic indicator (admission: p < 0.0001; 3 h after injury: p = 0.0005; 6 h after injury: p = 0.005; 12 h after injury: p = 0.0009). An upward trend of aPTT on admission and 3 h after injury was also a significant negative prognostic indicator (admission: p = 0.0011; 3 h after injury: p = 0.013). On multivariate logistic regression analysis, which included all initial variables, independent risk factors for poor prognosis included older age (p = 0.0005), low Glasgow Coma Scale score (p < 0.0001), high Abbreviated Injury Score (p = 0.015), aPTT >30.2 sec (p = 0.019), and elevated D-dimer level (p = 0.0005). We concluded that D-dimer is the best coagulation/fibrinolytic parameter to monitor for prediction of outcome.

Early CT findings to predict early death in patients with traumatic brain injury: Marshall and Rotterdam CT scoring systems compared in the major academic tertiary care hospital in northeastern Japan

RATIONALE AND OBJECTIVES

Computed tomography (CT) plays a crucial role in early assessment of patients with traumatic brain injury (TBI). Marshall and Rotterdam are the mostly used scoring systems, in which CT findings are grouped differently. We sought to determine the scoring system and initial CT findings predicting the death at hospital discharge (early death) in patients with TBI.

MATERIALS AND METHODS

We included 245 consecutive adult patients with mild-to-severe TBI. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score was related to early death; compared the two scoring systems' performance in predicting early death, and identified the CT findings that are independent predictors of early death.

RESULTS

More deaths occurred among patients with higher Marshall and Rotterdam scores (both P < .05, Mann-Whitney U test). The areas under the receiver operating characteristic curve (AUCs) indicated that both scoring systems had similarly good discriminative power in predicting early death (Marshall, AUC = 0. 85 vs. Rotterdam, AUC = 0.85). Basal cistern absence (odds ratio [OR] = 771.5, P < .0001), positive midline shift (OR = 56.2, P = .0011), hemorrhagic mass volume ≥25 mL (OR = 12.9, P = .0065), and intraventricular or subarachnoid hemorrhage (OR = 3.8, P = .0395) were independent predictors of early death.

CONCLUSIONS

Both Marshall and Rotterdam scoring systems can be used to predict early death in patients with TBI. The performance of the Marshall score is at least equal to that of the Rotterdam score. Thus, although older, the Marshall score remains useful in predicting patients' prognosis.

Factors correlating with delayed trauma center admission following traumatic brain injury

BACKGROUND

Delayed admission to appropriate care has been shown increase mortality following traumatic brain injury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in a cohort of TBI patients in the intensive care unit (ICU).

METHODS

A retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was carried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed admission. Patients in the delayed admission group were initially transported to a local hospital without neurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized to identify pre-hospital factors associated with delayed admission.

RESULTS

Of 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed admission groups (median time to admission 1:07h, IQR 0:52-1:28 vs. 4:06h, IQR 2:53-5:43, p <0.001). In multivariate analysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13), incident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital physician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial injury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38). A significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion when admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was noted between the groups (p= 0.814).

CONCLUSION

Delayed trauma center admission following TBI is common. Factors increasing likelihood of this were: male gender, incident at public place compared to home, low energy trauma, absence of pre-hospital physician involvement, stable blood pressure, no major extra cranial injuries, normal pupillary light reflex and severe alcohol intoxication. Focused educational efforts and access to physician consultation may help expedite access to appropriate care in TBI patients.

Preventable trauma deaths

OBJECTIVE

To describe methods of estimation and assess preventable deaths and types of errors related to health care.

METHODS

A systematic review of articles on preventable trauma deaths published between 2000 and 2009 was conducted. Lilacs, SciELO and Medline databases were searched using the keywords "trauma," "avoidable," "preventable," "interventions" and "complications" and the health sciences descriptors "death," "cause of death," and "hospitals."

RESULTS

A total of 29 articles published during the study period were selected. Most were retrospective studies (96.5%). The most common methods used to define avoidability of death were expert panel and injury severity scores. Deaths were categorized as follows: preventable; potentially preventable; and not preventable. The mean preventable death rate was 10.7% (SD 11.5%). The most commonly reported errors were inadequate care management of injured patients and evaluation and treatment errors.

CONCLUSIONS

Inconsistent terms were used to categorize deaths and related noncompliances. It is suggested to standardize the terminology for the classification of deaths and types of errors.

[Validation of the prehospital mSTaRT triage algorithm. A pilot study for the development of a multicenter evaluation]

INTRODUCTION

Successful management of a mass casualty incident requires integrated operating procedures. A common division of victims into descriptive needs-based groups and the corresponding decision processes is the key to ensuring a successful operational response. The mSTaRT ("modified simple triage and rapid treatment") algorithm should enable emergency medical technicians to conduct triage, perform appropriate medical interventions, and coordinate transportation to adequate care facilities. The aim of this study was to design a concept to validate the mSTaRT algorithm.

METHODS

Standardized evaluation sheets were distributed to emergency medical services (EMS) staff to prospectively classify trauma patients according to the mSTaRT algorithm: red (immediate: critically injured patients who can be helped by immediate transport), yellow (urgent: severely injured patients whose transport can be delayed), or green (delayed: patients with minor injuries who need help less urgently). The patients were then reevaluated in the emergency department, and the results were compared. The main points of the comparison were consistency of triage category and rates of overtriage and undertriage.

RESULTS

The study included 151 trauma patients. Of these, 62.3% were triaged correctly, 10.6% were overtriaged (2.6% critical overtriage), and 27.1% were undertriaged (4.0% critical undertriage). In the critically injured (immediate) category, the positive likelihood ratio (LR+) was 17.3 (95% CI 3.8-795), and the negative likelihood ratio (LR-) was 0.51 (95% CI 0.22-0.83). The probability of identifying a critically injured (immediate) patient was 17.3 times higher than the probability of identifying a severely (urgent) or minor (delayed) injured patient as immediate. Therefore, the rate of overtriage was very low. But every second patient who should have been classified as immediate was undertriaged by the EMS personnel. This undertriage was due to patients' suffering from head trauma, a well-known problem in the clinical context but a new problem in the triage context.

CONCLUSION

The results of our pilot study show that by using mSTaRT, patients designated as yellow (urgent) and green (delayed) will be accurately distinguished from red (immediate) patients; therefore, only a small number of patients will be overtriaged as red. However, some patients with severe head injury may not be initially assigned to the red category as required, resulting in undertriage. Consequently, modification of the mSTaRT procedures should be considered. A further identifier in the algorithm or checkpoint in the process should act as a safety net for catching severe head injury. A larger data set is required to further validate the mSTaRT algorithm. This will be acquired by means of a multicenter study.