Trends in Hospitalization Associated with TBI in an Urban Level 1 Trauma Centre

Acute Traumatic Subdural Hematoma and Anticoagulation Risk

BACKGROUND

Anticoagulation is used to prevent thromboembolic events. It is a common practice to hold anticoagulation in the first few days following a traumatic brain injury (TBI) with intracranial hemorrhage. However, traumatic subdural hematomas (SDH) are prone to re-hemorrhage long after the trauma. Data are scarce in the literature on the best timing to resume anticoagulation following a TBI.

METHODS

Review of 95 consecutive patients admitted to a level 1 trauma center with a diagnosis of traumatic SDH and requiring anticoagulation. The reasons for anticoagulation, the amount of time without anticoagulation, CT characteristics, and the incidence of thromboembolic events or SDH re-hemorrhage were collected.

RESULTS

41.3% used anticoagulation for coronary artery disease and peripheral vascular disease, 24% for atrial fibrillation, 12% for cardiac valve replacement, and 12% for venous thromboembolic events. Anticoagulation was held a median of 67 days. For most patients (82.1%), anticoagulation was re-introduced once the SDH had completely resolved. For 17.9%, anticoagulation was restarted while the SDH had not completely resolved. One (1.1%) patient suffered from an atrial clot while anticoagulation was held. For those with residual SDH, 41.2% suffered from a SDH re-hemorrhage and 17.6% required surgery. The risk of re-hemorrhage climbed to 62.5% if the SDH remnant was large.

CONCLUSION

Anticoagulation while there is a residual SDH was associated with a significant risk of re-hemorrhage. This risk should be weighed against the risk of holding anticoagulation.

The burden of geriatric traumatic brain injury on trauma systems: Analysis of 348,800 Medicare inpatient claims

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability in older adults. The aim of this study was to characterize the burden of TBI in older adults by describing demographics, care location, diagnoses, outcomes, and payments in this high-risk group.

METHODS

Using 2016-2019 Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files (IPSAF), patients >65 years with TBI (>1 injury ICD-10 starting with "S06") were selected. Trauma center levels were linked to the IPSAF file via American Hospital Association Hospital Provider ID and fuzzy-string matching. Patient variables were compared across trauma center levels.

RESULTS

Three hundred forty-eight thousand eight hundred inpatients (50.4% female; 87.1% white) from 2963 US hospitals were included. Level I/II trauma centers treated 66.9% of patients; non-trauma centers treated 21.5%. Overall inter-facility transfer rate was 19.2%; in Level I/II trauma centers transfers-in represented 23.3% of admissions. Significant TBI (Head AIS ≥3) was present in 70.0%. Most frequent diagnoses were subdural hemorrhage (56.6%) and subarachnoid hemorrhage (30.6%). Neurosurgical operations were performed in 10.9% of patients and operative rates were similar regardless of center level. Total unadjusted mortality for the sample was 13.9%, with a mortality of 8.1% for those who expired in-hospital, and an additional 5.8% for those discharged to hospice. Medicare payments totaled $4.91B, with the majority (73.4%) going to Level I/II trauma centers.

CONCLUSIONS

This study fills a gap in TBI research by demonstrating that although the majority of older adult TBI patients in the United States receive care at Level I/II trauma centers, a substantial percentage are managed at other facilities, despite 1 in 10 requiring neurosurgical operation regardless of level of trauma center. This analysis provides preliminary data on the function of regionalized trauma care for older adult TBI care. Future studies assessing the efficacy of early care guidelines in this population are warranted.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

A multi-decade joinpoint analysis of firearm injury severity

BACKGROUND

Non-fatal firearm injuries constitute approximately 70% of all firearm trauma injuries in the United States. Patterns of severity of these injuries are poorly understood. We analyzed the overall, age-, sex- and intent-specific temporal trends in the injury severity of firearm hospitalizations from 1993 to 2014.

METHODS

We assessed temporal trends in the severity of patients hospitalized for firearm using Nationwide Inpatient Sample (NIS) data over a 22 year period. Firearm hospitalization was identified using assault (E965x), unintentional (E922x), intentional self-harm (E955x), legal (E970) and undetermined (E985x) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9) codes. Injury severity was measured using the computed New Injury Severity Score (NISS). We used survey weighted means, SD and annual percent change (APC), and joinpoint regression to analyze temporal trends.

RESULTS

A weighted total of 648 662 inpatient admissions for firearm injury were analyzed. Firearm injury severity demonstrated a significant annual increase of 1.4% (95% CI=1.3 to 1.6), and was driven by annual increases among young adults (APC=1.4%, 95% CI=1.3 to 1.5), older adults (APC=1.5%, 95% CI=1.3 to 1.6), female (APC=1.5%, 95% CI=1.3 to 1.6) and male (APC=1.4%, 95% CI=1.3 to 1.6) hospitalizations. The annual increase among assault/legal injuries was 1.4% (95% CI=1.3 to 1.5), similar to unintentional (APC=1.4%, 95% CI=1.3 to 1.6), intentional self-harm (APC=1.5%, 95% CI=1.4 to 1.6) and undetermined (APC=1.4%, 95% CI=1.3 to 1.6).

CONCLUSIONS

The severity of hospitalized firearm injuries increased significantly from 1993 to 2014. This annual increase reflects a move towards hospitalization of more serious injuries, and outpatient management of less serious injuries across the board, suggesting a mounting burden on the US healthcare system.

LEVEL OF EVIDENCE

Level IV.

Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review

PURPOSE OF REVIEW

Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond.

RECENT FINDINGS

The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.