Incidence, causes and consequences of moderate and severe traumatic brain injury as determined by Abbreviated Injury Score in the Netherlands

Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals

BACKGROUND

Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population.

METHODS

We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses.

FINDINGS

We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality.

CONCLUSIONS

In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population.

REVIEW REGISTRATION

PROSPERO CRD42022323231.

A Mobile Health Transitional Care Intervention Delivered by Nurses Improves Postdischarge Outcomes of Caregivers of Patients with Traumatic Brain Injury: A Randomized Controlled Trial

OBJECTIVE

Caring for patients with traumatic brain injury (TBI) during the transition from hospital to home can be psychologically challenging to caregivers. This study aimed to assess the effectiveness of a novel mobile health (m-health) transitional care intervention to reduce stress and burden of caregivers of patients with TBI and to reduce readmissions.

METHODS

A randomized controlled trial was conducted with 74 caregivers of adult patients with moderate or severe TBI admitted to a referral hospital in Indonesia. An m-health application for Android mobile phones was designed including education and information for caregivers. The application included an online chat feature with weekly monitoring. The m-health transitional care intervention also included face-to-face education before hospital discharge. Primary outcomes were caregivers' stress and burden. Outcomes were measured at 3 time points: at hospital discharge, 2 weeks postdischarge, and 4 weeks postdischarge. Random Allocation Software was used for randomization of study participants.

RESULTS

Final analysis included data of 37 caregivers in the intervention group and 37 caregivers in the control group. Stress within the intervention group decreased over time (P < 0.001, mean difference = 11.05). Between both groups, stress was significantly different at 2 weeks and 4 weeks postdischarge (P < 0.001). Caregiver burden showed similar results (2 weeks postdischarge P < 0.001 and 4 weeks postdischarge P < 0.001). Only 1 patient in the control group was readmitted to the hospital.

CONCLUSIONS

The m-health transitional care intervention reduced stress and burden of caregivers of patients with moderate or severe TBI. Nurses should consider using m-health technologies to support caregivers in the transition from the hospital into the community.

Characteristics of victims of trauma requiring invasive mechanical ventilation with a short stay in critical care

BACKGROUND

Many patients who are admitted to the intensive care unit (ICU) have needs which rapidly resolve and are discharged alive within 24 h. We sought to characterize the outcomes of critically ill trauma victims at our institution with a short stay in the ICU.

METHODS

We conducted a retrospective cohort study of all critically ill adult trauma victims presenting to our ED between January 1st, 2011 and December 31st, 2019. We included patients who were endotracheally intubated in either the prehospital setting or the ED and were admitted either to the operating room (OR), angiography suite, or ICU. Our primary outcome was the proportion of patients who were discharged alive from the ICU within 24 h.

RESULTS

We included 3869 patients meeting the criteria above who were alive at 24 h. This population was 78% male with a median age of 40 and 76% of patients suffered from blunt trauma. The median injury severity score (ISS) of the group was 21 [inter-quartile range (IQR) 11-30]. In-hospital mortality amongst the group was 12%. 17% of the group were discharged alive from the ICU within 24 h. Thirty-four percent of the group had an ISS ≤ 15. Of the group which left the ICU alive within 24 h, six patients (0.9%) died in the hospital, 2 % of patients were re-admitted to an ICU, and 0.6% of patients required re-intubation.

CONCLUSIONS

We found that 17% of patients who were intubated in the prehospital setting or emergency department and subsequently hospitalized were discharged alive from the ICU within 24 h.

Empowering Support for Family Members of Brain Injury Patients in the Acute Phase of Hospital Care: A Mixed-Methods Systematic Review

This review aimed to identify and synthesize empowering support for the family members of patients in the acute phase of traumatic brain injury hospital treatment. CINAHL, PubMed, Scopus, and Medic databases were searched from 2010 to 2021. Twenty studies met the inclusion criteria. Each article was critically appraised using the Joanna Briggs Institute Critical Appraisals Tools. Following a thematic analysis, four main themes were identified about the process of empowering traumatic brain injury patients' family members in the acute phases of hospital care: (a) needs-based informational, (b) participatory, (c) competent and interprofessional, and (d) community support. This review of findings may be utilized in future studies focusing on designing, implementing, and evaluating an empowerment support model for the traumatic brain injury patient's family members in the acute care hospitalization to strengthen the current knowledge and develop nursing practices.

Epidemiology and management of traumatic brain injury in a regional Queensland Emergency Department

BACKGROUND

There is a paucity of traumatic brain injury (TBI) data in Australia in the regional and rural context. This study aimed to investigate the epidemiology, severity, causes, and management of TBI in a regional north Queensland population to plan acute care, follow up, and prevention strategies.

METHODS

This retrospective study analysed TBI patients presenting to Mackay Base Hospital Emergency Department (ED) in 2021. We identified patients using head injury SNOMED codes, and analysed patient characteristics with descriptive and multivariable regression analysis.

RESULTS

There were 1120 head injury presentations, with an overall incidence of 909 per 100,000 people per year. The median (IQR) age was 18 (6-46) years. Falls were the most common injury mechanism (52.4% of presentations). 41.1% of patients had a Computed Tomography (CT) scan, while 16.5% of patients who met criteria had post traumatic amnesia (PTA) testing. Age, being male and Indigenous status were associated with higher odds of moderate to severe TBI.

CONCLUSION

TBI incidence in this regional population was higher than metropolitan locations. CT scan was undertaken less frequently than in comparative literature, and low rates of PTA testing were undertaken. These data provide insight to assist in planning prevention and TBI-care services.

Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury

Objective

Many patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy.

Methods

The neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups.

Results

All patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101.

Conclusion

GCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.

Concepts, utilization, and perspectives on the Dutch Nationwide Trauma registry: a position paper

Over the last decades, the Dutch trauma care have seen major improvements. To assess the performance of the Dutch trauma system, in 2007, the Dutch Nationwide Trauma Registry (DNTR) was established, which developed into rich source of information for quality assessment, quality improvement of the trauma system, and for research purposes. The DNTR is one of the most comprehensive trauma registries in the world as it includes 100% of all trauma patients admitted to the hospital through the emergency department. This inclusive trauma registry has shown its benefit over less inclusive systems; however, it comes with a high workload for high-quality data collection and thus more expenses. The comprehensive prospectively collected data in the DNTR allows multiple types of studies to be performed. Recent changes in legislation allow the DNTR to include the citizen service numbers, which enables new possibilities and eases patient follow-up. However, in order to maximally exploit the possibilities of the DNTR, further development is required, for example, regarding data quality improvement and routine incorporation of health-related quality of life questionnaires. This would improve the quality assessment and scientific output from the DNTR. Finally, the DNTR and all other (European) trauma registries should strive to ensure that the trauma registries are eligible for comparisons between countries and healthcare systems, with the goal to improve trauma patient care worldwide.

Power Drill Craniostomy for Bedside Intracranial Access in Traumatic Brain Injury Patients

Invasive neuromonitoring is a bedrock procedure in neurosurgery and neurocritical care. Intracranial hypertension is a recognized emergency that can potentially lead to herniation, ischemia, and neurological decline. Over 50,000 external ventricular drains (EVDs) are performed in the United States annually for traumatic brain injuries (TBI), tumors, cerebrovascular hemorrhaging, and other causes. The technical challenge of a bedside ventriculostomy and/or parenchymal monitor placement may be increased by complex craniofacial trauma or brain swelling, which will decrease the tolerance of brain parenchyma to applied procedural force during a craniostomy. Herein, we report on the implementation and safety of a disposable power drill for bedside neurosurgical practices compared with the manual twist drill that is the current gold standard. Mechanical testing of the drill's stop extension (n = 8) was conducted through a calibrated tensile tester, simulating an axial plunging of 22.68 kilogram (kg) or 50 pounds of force (lbf) and measuring the strength-responsive displacement. The mean displacement following compression was 0.18 ± 0.11 mm (range of 0.03 mm to 0.34 mm). An overall cost analysis was calculated based on the annual institutional pricing, with an estimated $64.90 per unit increase in the cost of the disposable electric drill. Power drill craniostomies were utilized in a total of 34 adult patients, with a median Glasgow Coma Scale (GCS) score of six. Twenty-seven patients were male, with a mean age of 50.7 years old. The two most common injury mechanisms were falls and motor vehicle/motorcycle accidents. EVDs were placed in all subjects, and additional quad-lumen neuromonitoring was applied to 23 patients, with no incidents of plunging events or malfunctions. One patient developed an intracranial infection and another had intraparenchymal tract hemorrhaging. Two illustrative TBI cases with concomitant craniofacial trauma were provided. The disposable power drill was successfully implemented as an option for bedside ventriculostomies and had an acceptable safety profile.

Increasing incidence of ED-visits and admissions due to traumatic brain injury among elderly patients in the Netherlands, 2011-2020

BACKGROUND AND IMPORTANCE

Traumatic brain injury (TBI) is a leading cause of disability and mortality worldwide. Nowadays the highest combined incidence of TBI-related emergency department (ED) visits, hospitalizations and deaths occurs in older adults. Knowledge of the changing patterns of epidemiology is essential to identify targets to enhance prevention and management of TBI.

OBJECTIVE

To examine time trends of ED visits, admissions, and mortality for TBI comparing non-elderly and elderly people (aged ≥ 65 years) in the Netherlands from 2011 to 2020.

DESIGN

We conducted a retrospective observational, longitudinal study of TBI using data from the Dutch Injury Surveillance System (DISS) and Statistics Netherlands from 2011 to 2020.

OUTCOME MEASURE AND ANALYSIS

The main outcome measures were TBI-related ED visits, hospitalizations, and mortality. Temporal trends in population-based incidence rates were evaluated using Poisson regression. We compared patients under 65 years and patients aged 65 years or older.

MAIN RESULTS

From 2011 to 2020, absolute numbers of TBI related ED visits increased by 244%, and hospital admissions and mortality showed an almost twofold increase in patients aged 65 years and older. The incidence of TBI-related ED visits and hospital admission increased also in elderly adults, with 156% and 51% respectively, whereas the mortality remained stable. In contrast, overall rates of ED visits, admissions, and mortality, and causes for TBI did not change in patients younger than 65 years during the study period.

CONCLUSION

This trend analysis shows a significant increase of ED-visits and hospital admission for TBI in elderly adults from 2011 to 2020, whereas the mortality remained stable. This increase cannot be explained by the aging of the Dutch population alone, but might be related to comorbidities, causes of injury, and referral policy. These findings strengthen the development of strategies to prevent TBI and improve the organization of acute care necessary to reduce the impact and burden of TBI in elderly adults and on healthcare and society.

Polytrauma patients with severe cervical spine injuries are different than with severe TBI despite similar AIS scores

Traumatic cervical spine injuries (TCSI) are rare injuries. With increasing age the incidence of TCSI is on the rise. TCSI and traumatic brain injury (TBI) are often associated. Both TCSI and TBI are allocated to the Abbreviated Injury Scale (AIS) head region. However, the nature and outcome of these injuries are potentially different. Therefore, the aim of this study was to investigate the epidemiology, demographics and outcome of severely injured patients with severe TCSI, and compare them with polytrauma patients with severe TBI in the strict sense. Consecutive polytrauma patients aged ≥ 15 years with AIShead ≥ 3 who were admitted to a level-1 trauma center Intensive Care Unit (ICU) from 2013 to 2021 were included. Demographics, treatment, and outcome parameters were analyzed for patients who had AIShead ≥ 3 based on TCSI and compared to patients with AIShead ≥ 3 based on proper TBI. Data on follow-up were collected for TCSI patients. Two hundred eighty-four polytrauma patients (68% male, Injury Severity Score (ISS) 33) with AIShead ≥ 3 were included; Thirty-one patients (11%) had AIShead ≥ 3 based on TCSI whereas 253 (89%) had AIShead ≥ 3 based on TBI. TCSI patients had lower systolic blood pressure in the Emergency Department (ED) and stayed longer in ICU than TBI patients. There was no difference in morbidity and mortality rates. TCSI patients died due to high cervical spine injuries or respiratory insufficiency, whereas TBI patients died primarily due to TBI. TCSI was mainly located at C2, and 58% had associated spinal cord injury. Median follow-up time was 22 months. Twenty-two percent had improvement of the spinal cord injury, and 10% died during follow-up. In this study the incidence of severe TCSI in polytrauma was much lower than TBI. Cause of death in TCSI was different compared to TBI demonstrating that AIShead based on TCSI is a different entity than based on TBI. In order to avoid data misinterpretation injuries to the cervical spine should be distinguished from TBI in morbidity and mortality analysis.

Effect of drug therapy on nerve repair of moderate-severe traumatic brain injury: A network meta-analysis

Objective: This network meta-analysis aimed to explore the effect of different drugs on mortality and neurological improvement in patients with traumatic brain injury (TBI), and to clarify which drug might be used as a more promising intervention for treating such patients by ranking.

Methods: We conducted a comprehensive search from PubMed, Medline, Embase, and Cochrane Library databases from the establishment of the database to 31 January 2022. Data were extracted from the included studies, and the quality was assessed using the Cochrane risk-of-bias tool. The primary outcome measure was mortality in patients with TBI. The secondary outcome measures were the proportion of favorable outcomes and the occurrence of drug treatment–related side effects in patients with TBI in each drug treatment group. Statistical analyses were performed using Stata v16.0 and RevMan v5.3.0.

Results: We included 30 randomized controlled trials that included 13 interventions (TXA, EPO, progesterone, progesterone + vitamin D, atorvastatin, beta-blocker therapy, Bradycor, Enoxaparin, Tracoprodi, dexanabinol, selenium, simvastatin, and placebo). The analysis revealed that these drugs significantly reduced mortality in patients with TBI and increased the proportion of patients with favorable outcomes after TBI compared with placebo. In terms of mortality after drug treatment, the order from the lowest to the highest was progesterone + vitamin D, beta-blocker therapy, EPO, simvastatin, Enoxaparin, Bradycor, Tracoprodi, selenium, atorvastatin, TXA, progesterone, dexanabinol, and placebo. In terms of the proportion of patients with favorable outcomes after drug treatment, the order from the highest to the lowest was as follows: Enoxaparin, progesterone + vitamin D, atorvastatin, simvastatin, Bradycor, EPO, beta-blocker therapy, progesterone, Tracoprodi, TXA, selenium, dexanabinol, and placebo. In addition, based on the classification of Glasgow Outcome Scale (GOS) scores after each drug treatment, this study also analyzed the three aspects of good recovery, moderate disability, and severe disability. It involved 10 interventions and revealed that compared with placebo treatment, a higher proportion of patients had a good recovery and moderate disability after treatment with progesterone + vitamin D, Bradycor, EPO, and progesterone. Meanwhile, the proportion of patients with a severe disability after treatment with progesterone + vitamin D and Bradycor was also low.

Conclusion: The analysis of this study revealed that in patients with TBI, TXA, EPO, progesterone, progesterone + vitamin D, atorvastatin, beta-blocker therapy, Bradycor, Enoxaparin, Tracoprodi, dexanabinol, selenium, and simvastatin all reduced mortality and increased the proportion of patients with favorable outcomes in such patients compared with placebo. Among these, the progesterone + vitamin D had not only a higher proportion of patients with good recovery and moderate disability but also a lower proportion of patients with severe disability and mortality. However, whether this intervention can be used for clinical promotion still needs further exploration.

Management of traumatic brain injury: practical development of a recent proposal

A recent article identified weaknesses in the management of patients with traumatic brain injury (TBI). The authors suggested some reasons but overlooked two of the reasons for the low quality of services: a lack of resources and a systemic failure to organise rehabilitation services. They suggested early involvement of a condition-specific service with a new 'neuroscience clinician' and additional neuro-navigators, but the evidence shows this approach does not work. Their proposal failed to acknowledge the neuroscience skills of existing rehabilitation medicine consultants and teams, and ignored the many non-TBI problems patients will have and the consequent need for expert rehabilitation input. We revise and develop their proposal, suggesting an alternative way to improve services. Rehabilitation teams should work in parallel with acute services and remain responsible for the rehabilitation of patients as they move through different settings. This suggested development of rehabilitation mirrors the development followed by geriatric medicine from 40 years ago.

Prognostic Factors for Stage 3 Acute Kidney Injury in Isolated Serious Traumatic Brain Injury

BACKGROUND

Stage 3 acute kidney injury (AKI) has been observed to develop following serious traumatic brain injury (TBI) and is associated with worse outcomes, though its incidence is not consistently established. This study aims to report the incidence of stage 3 AKI in serious isolated TBI in a large, national trauma database, and explore associated predictive factors.

METHODS

This was a retrospective cohort study using 2015-2018 data from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP), a national database of trauma patients. Adult trauma patients admitted to the hospital with isolated serious TBI were included. Variables relating to demographics, comorbidities, vitals, hospital presentation, and course of stay were assessed. Imputed multivariable logistic regression assessed factors predictive of stage 3 AKI development.

RESULTS

A total of 342,675 patients with isolated serious TBI were included, 1,585 (0.5%) of whom developed stage 3 AKI. Variables associated with stage 3 AKI in multivariable analysis were older age, male sex, Black race, higher BMI, history of hypertension, diabetes, peripheral artery disease, chronic kidney disease, higher injury severity score, higher heart rate on arrival, lower oxygen saturation and motor Glasgow coma scale (GCS), admission to the intensive care unit (ICU) or operating room, development of catheter-associated urinary tract infections (CAUTI) or acute respiratory distress syndrome (ARDS), longer ICU stay and ventilation duration.

CONCLUSIONS

Stage 3 AKI occurred in 0.5% of serious TBI cases. Complications of ARDS and CAUTI are more likely to co-occur with stage 3 AKI in serious TBI patients.