Isolated traumatic brain injury: Routine intubation for Glasgow Coma Scale 7 or 8 may be harmful!

Intubation and In-Hospital Mortality After Trauma With Glasgow Coma Scale Score Eight or Less-A Cohort Study

INTRODUCTION

Most trauma societies recommend intubating trauma patients with Glasgow Coma Scale (GCS) scores ≤8 without robust supporting evidence. We examined the association between intubation and 30-d in-hospital mortality in trauma patients arriving with a GCS score ≤8 in an Indian trauma registry.

METHODS

Outcomes of patients with a GCS score ≤8 who were intubated within 1 h of arrival (intubation group) were compared with those who were intubated later or not at all (nonintubation group) using various analytical approaches. The association was assessed in various subgroup and sensitivity analyses to identify any variability of the effect.

RESULTS

Of 3476 patients who arrived with a GCS score ≤8, 1671 (48.1%) were intubated within 1 h. Overall, 1957 (56.3%) patients died, 947 (56.7%) in the intubation group and 1010 (56.0%) in the nonintubation group, with no significant difference in mortality (odds ratio = 1.2 [confidence interval, 0.8-1.8], P value = 0.467) in multivariable regression and propensity score-matched analysis. This result persisted across subgroup and sensitivity analyses. Patients intubated within an hour of arrival had longer durations of ventilation, intensive care unit stay, and hospital stay (P < 0.001).

CONCLUSIONS

Intubation within an hour of arrival with a GCS score ≤8 after major trauma was not associated with differences in-hospital mortality. The indications and benefits of early intubation in these severely injured patients should be revisited to promote optimal resource utilization in LMICs.

The Neurocritical Care Examination and Workup

OBJECTIVE

This article provides an overview of the evaluation of patients in neurocritical care settings and a structured approach to recognizing and localizing acute neurologic emergencies, performing a focused examination, and pursuing workup to identify critical findings requiring urgent management.

LATEST DEVELOPMENTS

After identifying and stabilizing imminent threats to survival, including respiratory and hemodynamic compromise, the initial differential diagnosis for patients in neurocritical care is built on a focused history and clinical examination, always keeping in mind critical "must-not-miss" pathologies. A key priority is to identify processes warranting time-sensitive therapeutic interventions, including signs of elevated intracranial pressure and herniation, acute neurovascular emergencies, clinical or subclinical seizures, infections of the central nervous system, spinal cord compression, and acute neuromuscular respiratory failure. Prompt neuroimaging to identify structural abnormalities should be obtained, complemented by laboratory findings to assess for underlying systemic causes. The indication for EEG and lumbar puncture should be considered early based on clinical suspicion.

ESSENTIAL POINTS

In neurocritical care, the initial evaluation is often fast paced, requiring assessment and management to happen in parallel. History, clinical examination, and workup should be obtained while considering therapeutic implications and the need for lifesaving interventions.

Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation?

BACKGROUND

Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS).

METHODS

The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head.

RESULTS

From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13).

DISCUSSION

Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.

Acute Respiratory Failure in Severe Acute Brain Injury

Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.

Injury patterns and outcomes in motorcycle driver crashes in the United States: The effect of helmet use

BACKGROUND

Motorcycle crashes pose a persistent public health problem with disproportionate rates of severe injuries and mortality. This study aims to analyze injury patterns and outcomes with regard to helmet use. We hypothesized that helmet use is associated with fewer head injuries and does not increase the risk of cervical spine injuries.

METHODS

The National Trauma Data Bank was queried for all motorcycle driver crashes between 2007-2017. Univariable analysis was used to compare demographics, clinical data, injury patterns using abbreviated injury scale, and outcomes between helmeted motorcycle drivers and non-helmeted motorcycle drivers who were injured in traffic crashes. Independent factors associated with mortality were determined by regression analysis after adjustment for potential confounders.

RESULTS

A total of 315,258 patients were included for analysis, 66 % of these patients were helmeted. The sample was 92.5 % male and the median age was 41 years. Non-helmeted motorcycle drivers were more likely to sustain severe head trauma (head abbreviated injury scale ≥ 3: 28.5 % vs. 13.3 %, p < 0.001), had higher intensive care unit-admission (38 % vs. 30.2 %, p<0.001), mechanical ventilation (20.1 % vs. 13 %, p<0.001) and overall mortality rates (6.2 % vs. 3.9 %, p<0.001). Cervical spine injuries occurred in 10.6 % of non-helmeted motorcycle drivers and in 9.5 % of helmeted motorcycle drivers (p<0.001). Helmet use was identified as an independent factor associated with lower mortality [OR 0.849 (0.809-0.891), p<0.001].

CONCLUSION

Helmet use is protective for severe head injuries and associated with decreased mortality. Helmet use was not associated with increased rates of cervical spine injuries. On the contrary, fewer injuries were observed in helmeted motorcycle drivers. Public health initiatives should be aimed at enforcement of universal helmet laws within the United States and across the world.

Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines

INTRODUCTION

This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines.

METHODS

We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10.

RESULTS

In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score.

CONCLUSION

A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.

Mild traumatic brain injury: not always a mild injury

PURPOSE

In general, risk of mortality after trauma correlates with injury severity. Despite arriving in relatively stable clinical condition, however, some patients are at risk of death following mild traumatic brain injury (TBI). The study objective was delineation of patients who die in-hospital following mild isolated TBI in order to inform Emergency Department (ED) disposition and care discussions with patients and families.

METHODS

In this retrospective cohort study, patients from the National Trauma Data Bank (NTDB) (2007-2018) were included if they were injured by blunt trauma and sustained a mild TBI (defined as Head Abbreviated Injury Scale [AIS] score of 1 or 2 and arrival Glasgow Coma Scale [GCS] score of 13-15). Exclusions were severe associated injuries (extracranial AIS > 2); transfers; and missing data. Patients were defined by in-hospital mortality: Survivors vs. Mortalities. Demographics, clinical/injury data, and the outcomes were collected and compared with univariate analysis. Multivariate analysis established independent factors associated with in-hospital mortality following mild TBI.

RESULTS

In total, 932,107 patients (10% of NTDB population) met study criteria: 928,542 (99.6%) Survivors and 3,565 (0.4%) Mortalities. In general, comorbidities (including home anticoagulation, cardiac disease, and diabetes mellitus) were significantly more common among patients who died (p < 0.001), although drug and alcohol intoxication on arrival were more common among Survivors (16% vs. 7%, p < 0.001; 13% vs. 10%, p < 0.001). In terms of insurance status, Private/Commercial insurance was more common among Survivors (39% vs. 20%, p < 0.001) while Governmental Insurance was more common among Mortalities (55% vs. 36%, p < 0.001). On multivariate analysis, age ≥ 65 was most strongly associated with death (OR 26.43, p < 0.001), followed by ED intubation (OR 10.08, p < 0.001), admission hypotension (OR 4.55, p < 0.001), and comorbidities, particularly end-stage renal disease (ESRD) (OR 3.03, p < 0.001) and immunosuppression (OR 2.18, p < 0.001).

CONCLUSIONS

Survivors differed substantially from Mortalities after mild TBI in terms of comorbidities, intoxicants, and insurance status. Independent variables most strongly associated with in-hospital death following mild head injury included age ≥ 65, intubation in the ED, admission hypotension, and comorbidities (particularly ESRD and immunosuppression). Increased clinical vigilance, including a mandatory period of clinical observation, for patients with these risk factors should be considered to optimize outcomes and potentially mitigate death after mild TBI.

Pre-injury stimulant use in isolated severe traumatic brain injury: effect on outcomes

PURPOSE

The aim of this study was to assess the impact of pre-injury stimulant use (amphetamine, cocaine, methamphetamine and/or ecstasy) on outcomes after isolated severe traumatic brain injury (TBI).

METHODS

Retrospective 2017 TQIP study, including adult trauma patients (≥16 years old) who underwent drug and alcohol screening on admission and sustained an isolated severe TBI (head AIS ≥3). Patients with significant extracranial trauma (AIS ≥3) were excluded. Epidemiological and clinical characteristics, procedures and outcome variables were collected. Patients with isolated stimulant use were matched 1:1 for age, gender, mechanism of injury, head AIS and overall comorbidities, with patients with negative toxicology and alcohol screen. Outcomes in the two groups were compared with univariable and multivariable regression analysis.

RESULTS

681 patients with isolated TBI and stimulant use were matched with 681 patients with negative toxicology and alcohol screen. The incidence of hypotension and CGS <9 was similar in the two groups. In multivariable regression analysis, stimulant use was not independently associated with mortality (OR 0.95, 95% CI 0.61-1.49). However, stimulant use was associated with longer hospital length of stay (HLOS) (RC 1.13, 95%CI 1.03-1.24).

CONCLUSION

Pre-injury stimulant use is common in patients admitted for severe TBI, but was not independently associated with mortality when compared to patients with negative toxicology. However, stimulant use was associated with a significant longer HLOS.

Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit

BACKGROUND

We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI).

METHODS

From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients' demographic, clinical, and laboratory features.

RESULTS

EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81).

CONCLUSIONS

A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.

Indications for prehospital intubation among severely injured children and the prevalence of significant traumatic brain injury among those intubated due to impaired level of consciousness

BACKGROUND

Prehospital endotracheal intubation (PEI) of head injured children with impaired level of consciousness (LOC) aims to minimize secondary brain injury. However, PEI is controversial in otherwise stable children. We aimed to investigate the indications for PEI among pediatric trauma patients and the prevalence of clinically significant traumatic brain injury (csTBI) among those intubated solely due to impaired consciousness.

METHODS

This is a multicenter retrospective cohort study of children who underwent PEI in northern Israel between January 2014 and December 2020 by six EMS agencies and were transported to two trauma centers in the area. We extracted data from EMS records and trauma registries.

RESULTS

PEI was attempted in 179/986 (18.2%) patients and was successful in 92.2% of cases. Common indications for PEI were hypoxemia not corrected by supplemental oxygen (n = 30), traumatic cardiac arrest (n = 16), and facial injury compromising the airway (n = 13). 112 patients (62.6%) were intubated solely due to impaired or deteriorating LOC. Among these patients, 68 (62.4%) suffered csTBI. The prevalence of csTBI among those with field Glasgow Coma Scale (GCS) of 3, 4-8, and > 8 was 81.4%, 55.8%, and 28.6%, respectively (p < 0.001). Among children ≤ 10 years old intubated due to impaired LOC, 50% had csTBI.

CONCLUSION

Impaired LOC is a major indication for PEI. However, a significant proportion of these patients do not suffer csTBI. Older age and lower pre-intubation GCS are associated with more accurate field classification. Our data indicate that further investigation and better characterization of patients who may benefit from PEI is necessary.

Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs

Traumatic brain injury (TBI) accounts for around 30% of all trauma-related deaths. Over the past 40 years, TBI has remained a major cause of mortality after trauma. The primary injury caused by the injurious mechanical force leads to irreversible damage to brain tissue. The potentially preventable secondary injury can be accentuated by addressing systemic insults. Early recognition and prompt intervention are integral to achieve better outcomes. Consequently, surgeons still need to be aware of the basic yet integral emergency management strategies for severe TBI (sTBI). In this narrative review, we outlined some of the controversies in the early care of sTBI that have not been settled by the publication of the Brain Trauma Foundation’s 4th edition guidelines in 2017. The topics covered included the following: mode of prehospital transport, maintaining airway patency while securing the cervical spine, achieving adequate ventilation, and optimizing circulatory physiology. We discuss fluid resuscitation and blood product transfusion as components of improving circulatory mechanics and oxygen delivery to injured brain tissue. An outline of evidence-based antiplatelet and anticoagulant reversal strategies is discussed in the review. In addition, the current evidence as well as the evidence gaps for using tranexamic acid in sTBI are briefly reviewed. A brief note on the controversial emergency surgical interventions for sTBI is included. Clinicians should be aware of the latest evidence for sTBI. Periods between different editions of guidelines can have an abundance of new literature that can influence patient care. The recent advances included in this review should be considered both for formulating future guidelines for the management of sTBI and for designing future clinical studies in domains with clinical equipoise.

Higher pre-hospital anaesthesia case volumes result in lower mortality rates: implications for mass casualty care

Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior physician's skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient), circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills may be required to care for patients requiring pre-hospital airway management especially in hazardous environments, such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport decisions.