Patients with a head injury who "talk and die" in the 1990s

Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

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.

Intracranial pressure management and neurological outcome for patients with mild traumatic brain injury who required neurosurgical intervention: a Japanese database study

Purpose: Among mild traumatic brain injuries (mTBI; a Glasgow Coma Scale score ≥13 on arrival), few result in severe neurological deficit, especially when they needed neurosurgical intervention. We investigated the association of intracranial pressure (ICP) control management with neurological outcome in patients with mTBI who needed neurosurgical intervention. Methods: From 1,092 records of the Japan Neurotrauma Data Bank during 2009-2011, we retrospectively identified 195 patients with neurosurgical intervention for mTBI. Using the Glasgow Outcome Scale, we grouped records into two: favorable and poor outcome. We analyzed neurological outcomes using a logistic regression analysis adjusted for ICP control managements. Results: Seventy patients had a poor outcome. Logistic regression analysis revealed that sedatives, hyperosmotic agents, and hyperventilation therapy were significantly associated with poor outcome (odds ratio [OR]: 2.36, 95% confidence interval [CI]: 1.31-4.26; OR: 2.81, 95% CI: 1.17-6.75; OR: 9.36, 95% CI: 1.81-48.35). However, temperature management was significantly related with favorable outcome (OR: 0.26, 95% CI: 0.10-0.66). Conclusions: Our study, using a Japanese multicenter brain trauma registry, suggested that requirement of sedatives, hyperosmotic agents, and hyperventilation is associated with poor neurological outcome for patients with mTBI who underwent neurosurgical intervention, although temperature management was associated with favorable neurological outcome.

The natural history of brain contusion: an analysis of radiological and clinical progression

Object

Although brain contusions are a common neurosurgical condition, surprisingly little has been written about their natural history. The purpose of this study was to identify factors that predict radiological and clinically significant progression of this pattern of traumatic brain injury in patients who did not initially require surgery. On the basis of their results and the available literature, the authors suggest a management algorithm.

Methods

The authors performed a retrospective review of clinical and radiological records of consecutive patients with brain contusions who initially underwent conservative treatment. Significant radiological progression was defined as a 30% increase in contusion size on CT scans. Statistical analysis was performed to identify clinical and radiological predictors of CT contusion progression, the significance of progression, and predictors of clinical outcome.

Results

Of 98 patients identified with brain contusions who initially received conservative treatment, 44 (45%) had significant progression on CT, and 19 (19%) required surgical intervention. The initial size of the contusion and the presence of subdural hematoma were the only statistically significant predictors of CT progression in the multivariate analysis (p = 0.0212 and 0.05, respectively). Four patients required delayed contusion evacuation (3 had radiological progression on follow-up scans). Good Glasgow Coma Scale (GCS) scores on presentation and younger age were predictors of eventual discharge from the hospital (OR 1.471, CI 1.233–1.755, p < 0.001 and OR 0.949, CI 0.912–0.988, p = 0.011, respectively). No patients with an initial GCS score of 15 or an initial contusion size < 14 ml required delayed evacuation.

Conclusions

Contusion progression is a common phenomenon that is seen more commonly in larger contusions. Patients with large contusions and low initial GCS scores are at risk for delayed deterioration. A proposed management algorithm for patients with contusions initially treated conservatively may help practitioners identify the best course of treatment.

A critical comparison of clinical decision instruments for computed tomographic scanning in mild closed traumatic brain injury in adolescents and adults

STUDY OBJECTIVE

A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having surgical, nonsurgical, or no intracranial lesions.

METHODS

We performed a secondary analysis of prospectively collected database from 7,955 patients aged 10 years or older with mild traumatic brain injury to compare sensitivity and specificity of 6 common clinical decision strategies: the Canadian CT Head Rule, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the New Orleans, the National Emergency X-Radiography Utilization Study II (NEXUS-II), the National Institute of Clinical Excellence guideline, and the Scandinavian Neurotrauma Committee guideline. Excluded from the database were patients for whom the history of trauma was unclear, the initial Glasgow Coma Scale score was less than 14, the injury was penetrating, vital signs were unstable, or who refused diagnostic tests. Patients revisiting the emergency department within 7 days were counted only once.

RESULTS

The percentage of scans that would have been required by applying each of the 6 aids were Canadian CT head rule (high risk only) 53%, Canadian (medium & high risk) 56%, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies 56%, New Orleans 69%, NEXUS-II 56%, National Institute of Clinical Excellence 71%, and the Scandinavian 50%. The 6 decision aids' sensitivities for surgical hematomas could not be distinguished statistically (P>.05). Sensitivity was 100% (95% confidence interval [CI] 96% to 100%) for NEXUS-II, 98.1% (95% CI 93% to 100%) for National Institute of Clinical Excellence, and 99.1% (95% CI 94% to 100%) for the other 4 clinical decision instruments. Sensitivity for any intracranial lesion ranged from 95.7% (95% CI 93% to 97%) (Scandinavian) to 100% (95% CI 98% to 100%) (National Institute of Clinical Excellence). In contrast, specificities varied between 30.9% (95% CI 30% to 32%) (National Institute of Clinical Excellence) and 52.9% (95% CI 52% to 54) (Scandinavian).

CONCLUSION

NEXUS-II and the Scandinavian clinical decision aids displayed the best combination of sensitivity and specificity in this patient population. However, we cannot demonstrate that the higher sensitivity of NEXUS-II for surgical hematomas is statistically significant. Therefore, choosing which of the 2 clinical decision instruments to use must be based on decisionmakers' attitudes toward risk.

Management of trauma in the geriatric patient

PURPOSE OF REVIEW

The purpose of this review is to examine recent evidence on the role and significance of anesthesiologists in caring for elderly patients suffering from severe trauma.

RECENT FINDINGS

Recent findings suggest that early aggressive resuscitation and medical management interventions may lead to improved outcomes in elderly trauma patients.

SUMMARY

Data suggest that anesthesiologists should actively participate in the resuscitation and critical care management of patients soon after they have suffered significant trauma. Further research is needed to delineate specific areas of focus and intervention to allow for optimal care and outcomes.

Head-Injured Patients Who “Talk and Die”: The San Diego Perspective

BACKGROUND

Head-injured patients who "talk and die" are potentially salvageable, making their early identification important. This study uses a large, comprehensive database to explore risk factors for head-injured patients who deteriorate after their initial presentation.

METHODS

Patients with a head Abbreviated Injury Score (AIS) score of 3+ and a preadmission verbal Glasgow Coma Scale (GCS) score of 3+ were identified from our county trauma registry during a 16-year period. Survivors and nonsurvivors were compared with regard to demographics, initial clinical presentation, and various risk factors. Logistic regression was used to explore the impact of multiple factors on outcome, including the significance of a change in GCS score from field to arrival. In addition, patients were stratified by injury severity and hospital day of death to further define the relationship between outcome and multiple clinical variables.

RESULTS

A total of 7,443 patients were identified with head AIS 3+ and verbal GCS score 3+. Overall mortality was 6.1%. About one-third of deaths occurred on the first hospital day, with more than one-third occurring after hospital day 5. Logistic regression revealed an association between mortality and older age, more violent mechanisms of injury (fall, gunshot wound, pedestrian versus automobile), greater injury severity (higher head AIS and Injury Severity Score), lower GCS score, and hypotension. In addition, mortality was associated with a decrease in GCS score from field to arrival, the use of anticoagulants, and a diagnosis of pulmonary embolus. Two important groups of "talk-and-die" patients were identified. Early deaths occurred in younger patients with more critical extracranial injuries. Anticoagulant use was also an independent risk factor in these early deaths. Later deaths occurred in older patients with less significant extracranial injuries. Pulmonary embolus also appeared to be an important contributor to late mortality.

CONCLUSIONS

More severe injuries and use of anticoagulants are independent risk factors for early death in potentially salvageable traumatic brain injury patients, whereas older age and pulmonary embolus are associated with later deaths.

An audit of clinical practice in the management of head injured patients following the introduction of the Scottish Intercollegiate Guidelines Network (SIGN) recommendations

A prospective study was conducted by the Scottish Trauma Audit Group (STAG) in A&E of Edinburgh Royal Infirmary to examine clinical practices in the management of head injured patients pre- and post-inception of the SIGN guidelines published in August 2000.1607 patients attended the department in two separate one month periods at equal intervals pre- and post-guidelines publication. The majority of patients with a SIGN indication for admission were admitted (93% pre- and 92% post-guidelines). For skull x ray (SXR) requests, in the pre-guidelines group, 92% of admitted patients with a SIGN indication for x ray had a SXR: this figure dropped to 79% post-guidelines. 36% of patients with a SIGN indication for CT actually had a scan pre-guidelines: this figure increased to 64% post-guidelines.57% of patients pre-guidelines and 44% of patients post-guidelines were discharged from A&E in accordance with the SIGN recommendations. Of patients admitted for neurological observations, this increased from 50% pre- to 88% post-guidelines. Of patients who were discharged "inappropriately", only one re-presented and was subsequently admitted but required no neurosurgical intervention. Despite publication of the SIGN guidelines and positive reinforcement in A&E and at ward level, practice has not changed significantly. Where our practice did not adhere to SIGN recommendations, there was no untoward sequelae. For published national guidelines to be effective, a formal audit structure with regular feedback is necessary to ensure a continued change in clinical practices.

Mild head injury: reliability of early computed tomographic findings in triage for admission

OBJECTIVE

To search the literature for case reports on adverse outcomes in patients with mild head injury where acute computed tomography (CT) findings had been normal.

METHODS

Mild head injury was defined as head trauma involving amnesia or loss of consciousness, but where neurological findings are normal on arrival at hospital (GCS 15). The scientific literature was systematically searched for case reports where an early CT was normal and the patient deteriorated within two days. In these cases, early discharge despite a normal CT head scan would have been hazardous.

RESULTS

Two prospective studies were found that investigated the safety of early CT in 3300 patients with mild head injury, as were 39 reports on adverse outcomes describing 821 patients. In addition, 52 studies containing over 62 000 patients with mild head injury were reviewed. In total, only three cases were deemed to have experienced an early adverse outcome despite a normal CT and GCS 15 on initial presentation. In another eight cases with incomplete descriptions, the interpretation was doubtful. Many reports of complications were not relevant to our question and excluded. These reports included cases with more severe head injury/not GCS 15 at presentation, complications that occurred after more than two days, or initial CT findings that were not fully normal.

CONCLUSION

Very few cases were found where an early adverse event occurred after normal acute CT in patients with mild head injury. The strongest scientific evidence available at this time shows that a CT strategy is a safe way to triage patients for admission.