Evaluation and management of mild traumatic brain injury: an Eastern Association for the Surgery of Trauma practice management guideline

Consensus paper on the assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13-15 at the emergency department: A multidisciplinary overview

Traumatic brain injury (TBI) is a common reason for presenting to emergency departments (EDs). The assessment of these patients is frequently hampered by various confounders, and diagnostics is still often based on nonspecific clinical signs. Throughout Europe, there is wide variation in clinical practices, including the follow-up of those discharged from the ED. The objective is to present a practical recommendation for the assessment of adult patients with an acute TBI, focusing on milder cases not requiring in-hospital care. The aim is to advise on and harmonize practices for European settings. A multiprofessional expert panel, giving consensus recommendations based on recent scientific literature and clinical practices, is employed. The focus is on patients with a preserved consciousness (Glasgow Coma Scale 13-15) not requiring in-hospital care after ED assessment. The main results of this paper contain practical, clinically usable recommendations for acute clinical assessment, decision-making on acute head computerized tomography (CT), use of biomarkers, discharge options, and needs for follow-up, as well as a discussion of the main features and risk factors for prolonged recovery. In conclusion, this consensus paper provides a practical stepwise approach for the clinical assessment of patients with an acute TBI at the ED. Recommendations are given for the performance of acute head CT, use of brain biomarkers and disposition after ED care including careful patient information and organization of follow-up for those discharged.

Impact of Trauma Center Type on Outcomes in Pediatric Population Following Severe Isolated Blunt Traumatic Brain Injuries: A National Analysis

INTRODUCTION

This study aims to evaluate the association between trauma center type, verification level, and clinical outcomes in pediatric trauma patients with moderate and severe isolated blunt traumatic brain injury (TBI).

METHODS

This is a retrospective cohort study utilizing the American College of Surgeons (ACS) Trauma Quality Program (TQP) Participant Use File (PUF) database from 2017 to 2021. Severely injured pediatric (<18 years) trauma patients with isolated moderate and severe TBI (AIS head >2, all other body regions <3) were included. Outcomes included in-hospital mortality, discharge disposition, intensive care unit length-of-stay (ICU-LOS), and ventilator-free days (VFDs).

RESULTS

Patients treated at a level-I combined adult and pediatric trauma centers (CTCs) had significantly lower odds of in-hospital mortality than those treated at adult trauma centers (ATCs) (OR .495, 95% CI 0.291-.841, P = .009). Patients treated at level-I pediatric trauma centers (PTCs) (OR 2.726, 95% CI 2.059-3.609, P < .001) and level-II PTCs (OR 6.18, 95% CI 3.402-11.239, P < .001) were significantly more likely to be discharged home than equivalent-level ATCs.

CONCLUSION

Pediatric patients with isolated blunt moderate and severe TBI treated at level-I PTCs and CTCs had reduced odds of in-hospital mortality compared to level-I ATCs. Patients at level I and II PTCs had significantly higher odds of discharge home than those at equivalent-level CTCs and ATCs.

Defining Mild Traumatic Brain Injury: From Research Definition to Clinical Practice

INTRODUCTION

Approximately 75% of traumatic brain injuries (TBIs) qualify as mild. However, there exists no universally agreed upon definition for mild TBI (mTBI). Consequently, treatment guidelines for this group are lacking. The Center for Disease Control (CDC), American College of Rehabilitation Medicine (ACRM), Veterans Affairs and Department of Defense (VA/DoD), Eastern Association for the Surgery of Trauma (EAST), and the University of Arizona's Brain Injury Guidelines (BIG) have each published differing definitions for mTBI. The aim of this study was to compare the ability of these definitions to correctly classify mTBI patients in the acute care setting.

METHODS

A single-center, retrospective cohort study comparing the performance of the varying definitions of mTBI was performed at a Level I trauma center from August 2015 to December 2018. Definitions were compared by sensitivity, specificity, positive predictive value, negative predictive value, as well as overtriage and undertriage rates. Finally, a cost-savings analysis was performed.

RESULTS

We identified 596 patients suffering blunt TBI with Glasgow Coma Scale 13-15. The CDC/ACRM definitions demonstrated 100% sensitivity but 0% specificity along with the highest rate of undertriage and TBI-related mortality. BIG 1 included nearly twice as many patients than EAST and VA/DoD while achieving a superior positive predictive value and undertriage rate.

CONCLUSIONS

The BIG definition identified a larger number of patients compared to the VA/DoD and EAST definitions while having an acceptable and more accurate overtriage and undertriage rate compared to the CDC and ACRM. By eliminating undertriage and minimizing overtriage rates, the BIG maintains patient safety while enhancing the efficiency of healthcare systems. Using the BIG definition, a cost savings of $395,288.95-$401,263.95 per year could be obtained at our level 1 trauma facility without additional mortality.

Role of Occupational Therapy Cognitive Assessment in Mild Traumatic Brain Injury: Is Universal Consultation Required?

INTRODUCTION

Mild traumatic brain injury (mTBI) or concussion is prevalent among trauma patients, but symptoms vary. Assessing discharge safety is not standardized. At our institution, occupational therapy (OT) performs cognitive assessments for mTBI to determine discharge readiness, potentially increasing resource utilization. We aimed to describe characteristics and outcomes in mTBI trauma patients and hypothesized that OT consultation was associated with increased length of stay (LOS).

METHODS

This is a retrospective study at a level 1 trauma center over 17 mo. All patients with mTBI, without significant concomitant injuries, were included. We collected data regarding OT assessment, LOS, mechanism of injury, Glasgow coma score, injury severity score (ISS), concussion symptoms, and patient disposition. Statistical analysis was performed, and significance was determined when P < 0.05.

RESULTS

Two hundred thirty three patients were included. Median LOS was 1 d and ISS 5. Ninety percent were discharged home. The most common presenting symptom was loss of consciousness (85%). No symptoms were associated with differences in LOS or discharge disposition (P > 0.05). OT consult (n = 114, 49%) was associated with longer LOS and higher ISS (P < 0.01). Representation with concussive symptoms, discharge disposition, mechanism of injury, and patient demographics were no different regardless of OT consultation (P > 0.05).

CONCLUSIONS

mTBI is common and assessment for discharge safety is not standardized. OT cognitive assessment was associated with longer LOS and higher injury severity. Despite institutional culture, OT consultation was variable and not associated with improved concussion-related outcomes. Our data suggest that OT is not required for mTBI discharge readiness assessment. To improve resource utilization, more selective OT consultation should be considered. Further prospective data are needed to identify which patients would most benefit.

The prevalence of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants is very low: a retrospective cohort register study

BACKGROUND

Current guidelines from Scandinavian Neuro Committee mandate a 24-hour observation for head trauma patients on anticoagulants, even with normal initial head CT scans, as a means not to miss delayed intracranial hemorrhages. This study aimed to assess the prevalence, and time to diagnosis, of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants.

METHOD

Utilizing comprehensive two-year data from Region Skåne's emergency departments, which serve a population of 1.3 million inhabitants, this study focused on adult head trauma patients prescribed oral anticoagulants. We identified those with intracranial hemorrhage within 30 days, defining delayed intracranial hemorrhage as a bleeding not apparent on their initial CT head scan. These cases were further defined as clinically relevant if associated with mortality, any intensive care unit admission, or neurosurgery.

RESULTS

Out of the included 2,362 head injury cases (median age 84, 56% on a direct acting oral anticoagulant), five developed delayed intracranial hemorrhages. None of these five cases underwent neurosurgery nor were admitted to an intensive care unit. Only two cases (0.08%, 95% confidence interval [0.01-0.3%]) were classified as clinically relevant, involving subdural hematomas in patients aged 82 and 87 years, who both subsequently died. The diagnosis of these delayed intracranial hemorrhages was made at 4 and 7 days following initial presentation to the emergency department.

CONCLUSION

In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation. This challenges the effectiveness of the 24-hour observation period recommended by the Scandinavian Neurotrauma Committee guidelines, suggesting a need to reassess these guidelines to optimise care and resource allocation.

TRIAL REGISTRATION

This is a retrospective cohort study, does not include any intervention, and has therefore not been registered.

Seizure-Related Head Injuries: A Narrative Review

Epilepsy is one of the most common neurological diseases. Epileptic seizures very often result in head injuries that may lead to many adverse consequences, both acute and chronic. They contribute to the need for hospitalization, modification of treatment, and a general decline in social productivity. The objective of our review is to characterize and assess management aspects of seizure-related head injuries (SRHIs) as an important and frequent clinical problem present in emergency department settings. PubMed and other relevant databases and websites were systematically searched for articles on traumatic brain injuries connected with the occurrence of seizures published from inception to 9 April 2024; then, we reviewed the available literature. Our review showed that SRHIs can lead to various acute complications, in some cases requiring hospitalization and neurosurgical intervention. Long-term complications and cognitive decline after injury might be present, eventually implying a negative impact on a patient's quality of life. Despite being frequent and clinically important, there are still no widely accepted, uniform recommendations for the management of patients with SRHIs. As such, a concise and standardized protocol for the management of seizure-related head injuries in emergency departments is worth consideration.

Higher risk of traumatic intracranial hemorrhage with antiplatelet therapy compared to oral anticoagulation-a single-center experience

PURPOSE

Traumatic brain injury is the main reason for the emergency department visit of up to 3% of the patients and a major worldwide cause for morbidity and mortality. Current emergency management guidelines recommend close attention to patients taking oral anticoagulation but not patients on antiplatelet therapy. Recent studies have begun to challenge this. The aim of this study was to determine the impact of antiplatelet therapy and oral anticoagulation on traumatic intracranial hemorrhage.

METHODS

Medical records of adult patients triaged with "head injury" as the main reason for emergency care were retrospectively reviewed from January 1, 2017, to December 31, 2017, and January 1, 2020, to December 31, 2021. Patients ≥ 18 years with head trauma were included. Odds ratio was calculated, and multiple logistic regression was performed.

RESULTS

A total of 4850 patients with a median age of 70 years were included. Traumatic intracranial hemorrhage was found in 6.2% of the patients. The risk ratio for traumatic intracranial hemorrhage in patients on antiplatelet therapy was 2.25 (p < 0.001, 95% confidence interval 1.73-2.94) and 1.38 (p = 0.002, 95% confidence interval 1.05-1.84) in patients on oral anticoagulation compared to patients without mediations that affect coagulation. In binary multiple regression, antiplatelet therapy was associated with intracranial hemorrhage, but oral anticoagulation was not.

CONCLUSION

This study shows that antiplatelet therapy is associated with a higher risk of traumatic intracranial hemorrhage compared to oral anticoagulation. Antiplatelet therapy should be given equal or greater consideration in the guidelines compared to anticoagulation therapy. Further studies on antiplatelet subtypes within the context of head trauma are recommended to improve the guidelines' diagnostic accuracy.

Association of Early Dexmedetomidine Utilization With Clinical Outcomes After Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study

BACKGROUND

Traumatic brain injury (TBI) is an expensive and common public health problem. Management of TBI oftentimes includes sedation to facilitate mechanical ventilation (MV) for airway protection. Dexmedetomidine has emerged as a potential candidate for improved patient outcomes when used for early sedation after TBI due to its potential modulation of autonomic dysfunction. We examined early sedation patterns, as well as the association of dexmedetomidine exposure with clinical and functional outcomes among mechanically ventilated patients with moderate-severe TBI (msTBI) in the United States.

METHODS

We conducted a retrospective cohort study using data from the Premier dataset and identified a cohort of critically ill adult patients with msTBI who required MV from January 2016 to June 2020. msTBI was defined by head-neck abbreviated injury scale (AIS) values of 3 (serious), 4 (severe), and 5 (critical). We described early continuous sedative utilization patterns. Using propensity-matched models, we examined the association of early dexmedetomidine exposure (within 2 days of intensive care unit [ICU] admission) with the primary outcome of hospital mortality and the following secondary outcomes: hospital length of stay (LOS), days on MV, vasopressor use after the first 2 days of admission, hemodialysis (HD) after the first 2 days of admission, hospital costs, and discharge disposition. All medications, treatments, and procedures were identified using date-stamped hospital charge codes.

RESULTS

The study population included 19,751 subjects who required MV within 2 days of ICU admission. The patients were majority male and white. From 2016 to 2020, the annual percent utilization of dexmedetomidine increased from 4.05% to 8.60%. After propensity score matching, early dexmedetomidine exposure was associated with reduced odds of hospital mortality (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.47-0.74; P < .0001), increased risk for liberation from MV (hazard ratio [HR], 1.20; 95% CI, 1.09-1.33; P = .0003), and reduced LOS (HR, 1.11; 95% CI, 1.01-1.22; P = .033). Exposure to early dexmedetomidine was not associated with odds of HD (OR, 1.14; 95% CI, 0.73-1.78; P = .56), vasopressor utilization (OR, 1.10; 95% CI, 0.78-1.55; P = .60), or increased hospital costs (relative cost ratio, 1.98; 95% CI, 0.93-1.03; P = .66).

CONCLUSIONS

Dexmedetomidine is being utilized increasingly as a sedative for mechanically ventilated patients with msTBI. Early dexmedetomidine exposure may lead to improved patient outcomes in this population.

Preliminary Evaluation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries with Glial Fibrillary Acidic Protein

Glial fibrillary acidic protein (GFAP) has become the most promising biomarker for detecting traumatic abnormalities on head computed tomography (CT) in patients with traumatic brain injury (TBI), but most studies have not addressed the potential added value of combining the biomarker with clinical variables that confer risk for intracranial injuries. The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults were the first clinical decision rules in the field with an incorporated biomarker, the S100 astroglial calcium-binding protein B (S100B), which is used in the Mild (Low Risk) group defined by the guidelines. Our aim was to evaluate the performance of the guidelines when S100B was substituted with GFAP. The sample (N = 296) was recruited from the Tampere University Hospital's emergency department between November 2015 and November 2016, and there were 49 patients with available GFAP results who were stratified in the Mild (Low Risk) group (thus patients undergoing biomarker triaging). A previously reported cutoff of plasma GFAP ≥140 pg/mL was used. Within the Mild (Low Risk) group (n = 49), GFAP sensitivity (with 95% confidence intervals in parentheses) for detecting traumatic CT abnormalities was 1.0 (0.40-1.00), specificity 0.34 (0.19-0.53), the negative predictive value (NPV) 1.0 (0.68-1.00), and the positive predictive value (PPV) 0.16 (0.05-0.37). The sensitivity and specificity of the modified guidelines with GFAP, when applied to all imaged patients (n = 197) in the whole sample, were 0.94 (0.77-0.99) and 0.20 (0.15-0.28), respectively. NPV was 0.94 (0.80-0.99) and PPV 0.18 (0.13-0.25). In the Mild (Low Risk) group, none of the patients with GFAP results below 140 pg/mL had traumatic abnormalities on their head CT. These findings were derived from a small patient subgroup. Future researchers should replicate these findings in larger samples and assess whether GFAP has added or comparable value to S100B in acute TBI management.

First steps toward a BIG change: A pilot study to implement the Brain Injury Guidelines across a 24-hospital system

INTRODUCTION

The modified Brain Injury Guidelines (mBIG) support a subset of low-risk patients to be managed without repeat head computed tomography (RHCT), neurosurgical consult (NSC), or hospital transfer/admission. This pilot aimed to assess mBIG implementation at a single facility to inform future systemwide implementation.

METHODS

Single cohort pilot trial at a level I trauma center, December 2021-August 2022. Adult patients included if tICH meeting BIG 1 or 2 criteria. BIG 3 patients excluded.

RESULTS

No patients required neurosurgical intervention. 72 RHCT and 83 NSC were prevented. 21 isolated BIG 1 were safely discharged home from the ED. No hospital readmissions for tICH. Protocol adherence rate was 92%.

CONCLUSION

Implementation of the mBIG at a single trauma center is feasible and optimizes resource utilization. This pilot study will inform an implementation trial of the mBIG across a 24-hospital integrated health system.

Navigating the Complexities of Traumatic Encephalopathy Syndrome (TES): Current State and Future Challenges

Chronic traumatic encephalopathy (CTE) is a unique neurodegenerative disease that is associated with repetitive head impacts (RHI) in both civilian and military settings. In 2014, the research criteria for the clinical manifestation of CTE, traumatic encephalopathy syndrome (TES), were proposed to improve the clinical identification and understanding of the complex neuropathological phenomena underlying CTE. This review provides a comprehensive overview of the current understanding of the neuropathological and clinical features of CTE, proposed biomarkers of traumatic brain injury (TBI) in both research and clinical settings, and a range of treatments based on previous preclinical and clinical research studies. Due to the heterogeneity of TBI, there is no universally agreed-upon serum, CSF, or neuroimaging marker for its diagnosis. However, as our understanding of this complex disease continues to evolve, it is likely that there will be more robust, early diagnostic methods and effective clinical treatments. This is especially important given the increasing evidence of a correlation between TBI and neurodegenerative conditions, such as Alzheimer's disease and CTE. As public awareness of these conditions grows, it is imperative to prioritize both basic and clinical research, as well as the implementation of necessary safe and preventative measures.

Delayed intracranial hemorrhage after head trauma seems rare and rarely needs intervention-even in antiplatelet or anticoagulation therapy

BACKGROUND

Traumatic brain injury causes morbidity, mortality, and at least 2,500,000 yearly emergency department visits in the USA. Computerized tomography of the head is the gold standard to detect traumatic intracranial hemorrhage. Some are not diagnosed at the first scan, and they are denoted "delayed intracranial hemorrhages. " To detect these delayed hemorrhages, current guidelines for head trauma recommend observation and/or rescanning for patients on anticoagulation therapy but not for patients on antiplatelet therapy. The aim of this study was to investigate the prevalence and need for interventions of delayed intracranial hemorrhage after head trauma.

METHODS

The study was a retrospective review of medical records of adult patients with isolated head trauma presenting at Helsingborg General Hospital between January 1, 2020, and December 31, 2020. Univariate statistical analyses were performed.

RESULTS

In total, 1627 patients were included and four (0.25%, 95% confidence interval 0.06-0.60%) patients had delayed intracranial hemorrhage. One of these patients was diagnosed within 24 h and three within 2-30 days. The patient was diagnosed within 24 h, and one of the patients diagnosed within 2-30 days was on antiplatelet therapy. None of these four patients was prescribed anticoagulation therapy, and no intensive care, no neurosurgical operations, or deaths were recorded.

CONCLUSION

Traumatic delayed intracranial hemorrhage is rare and consequences mild and antiplatelet and anticoagulation therapy might confer similar risk. Because serious complications appear rare, observing, and/or rescanning all patients with either of these medications can be debated. Risk stratification of these patients might have the potential to identify the patients at risk while safely reducing observation times and rescanning.

Applicability of machine learning technique in the screening of patients with mild traumatic brain injury

Even though the demand of head computed tomography (CT) in patients with mild traumatic brain injury (TBI) has progressively increased worldwide, only a small number of individuals have intracranial lesions that require neurosurgical intervention. As such, this study aims to evaluate the applicability of a machine learning (ML) technique in the screening of patients with mild TBI in the Regional University Hospital of Maringá, Paraná state, Brazil. This is an observational, descriptive, cross-sectional, and retrospective study using ML technique to develop a protocol that predicts which patients with an initial diagnosis of mild TBI should be recommended for a head CT. Among the tested models, he linear extreme gradient boosting was the best algorithm, with the highest sensitivity (0.70 ± 0.06). Our predictive model can assist in the screening of mild TBI patients, assisting health professionals to manage the resource utilization, and improve the quality and safety of patient care.

Cervical Collars and Dysphagia Among Geriatric TBIs and Cervical Spine Injuries: A Retrospective Cohort Study

INTRODUCTION

Dysphagia, a complication of traumatic brain injuries (TBIs), can lead to death. Cervical collar (c-collar) restriction may increase the risk for dysphagia. The objective was to determine how c-collars affect dysphagia rates.

METHODS

This retrospective cohort study included geriatric TBIs or cervical spine injuries (January 2016 to December 2018) at a Level 1 trauma center. Outcomes (dysphagia, aspiration, and respiratory failure) were compared by c-collar placement.

RESULTS

There were 684 patients: 21.5% had a c-collar and 78.5% did not. Demographics, injury severity score, and Glasgow Coma Scale were comparable. Dysphagia (53.7% vs. 39.3%, p = .002) and respiratory failure (17.0% vs. 6.9%, p = .0002) were more common among patients with c-collars. Aspiration rates (p = .11) were similar. After adjustment, patients with a c-collar had a significantly higher odds of dysphagia and respiratory failure. Among patients who did not receive swallow therapy, aspiration (p = .02) and respiratory failure (p < .0001) were more common for those with c-collars.

CONCLUSIONS

C-collar placement increased the risk for dysphagia and respiratory failure. There was evidence that swallow therapy may modify the effect of c-collar placement. For patients who did not receive swallow therapy, aspiration was more common among those with a c-collar. Dysphagia screening among patients with a c-collar may improve patient quality.

Biomarker S100B in plasma a screening tool for mild traumatic brain injury in an emergency department

INTRODUCTION

A computerized tomography (CT) scan is an effective test for detecting traumatic intracranial findings after mild traumatic brain injury (mTBI). However, a head CT is costly, and can only be performed in a hospital.

OBJECTIVE

To determine if the addition of plasma S100B to clinical guidelines could lead to a more selective scanning strategy without compromising safety.

METHODS

We conducted a single center prospective cohort study at the emergency department. Patients (≥16 years) who received head CT and had a blood draw were included. The primary outcome was the accuracy of plasma S100B to predict the presence of any traumatic intracranial lesion on head CT.

RESULTS

We included 495 patients, out of the 74 patients who had traumatic intracranial lesions, 5 patients had a plasma S100B level below the cutoff value of 0.105 ug/L. For the detection of traumatic intracranial injury, S100B had a sensitivity of 0.932 , a specificity of 0.157, a negative predictive value of 0.930, and a positive predictive value of 0.163.

CONCLUSIONS

Among patients undergoing guideline-based CT scan for mTBI, the use of S100B, would results in a further decrease (14.8%) of CT scans but at a cost of missed injury, without clinical consequence, on CT.

Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department

INTRODUCTION

Elderly patients on oral anticoagulation are commonly seen in emergency departments (EDs). Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. Data on delayed bleeds in anticoagulated patients are limited. The objective of this study was to examine risk of delayed intracranial hemorrhage in patients presenting to the ED with a head injury anticoagulated with warfarin or a direct oral anticoagulant, compared to patients not anticoagulated.

METHODS

Cohort study using administrative data from Ontario of patients ≥ 65 years presenting to the ED with a complaint of head injury between 2016 and 2018. The primary outcome was delayed intracranial hemorrhage, defined as a new ICD-10 code for intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed. The main exposure variable was oral anticoagulation use, which was a three-level variable (warfarin, direct oral anticoagulants, or no oral anticoagulation). We used multivariable logistic regression to determine the odds of delayed intracranial hemorrhage based on anticoagulation status.

RESULTS

69,321 patients were included: 58,233 (84.0%) had not been prescribed oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant prescription. Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients not anticoagulated, 586 (1.0%) had a delayed intracranial hemorrhage, 54 (1.8%) patients on warfarin, and 78 (1.0%) patients on a direct oral anticoagulant had a delayed intracranial hemorrhage. There was an increased odds of delayed intracranial hemorrhage with warfarin use compared with no anticoagulation (OR 1.5, 95% CI 1.1-2.1). There was no association between delayed intracranial hemorrhage and direct oral anticoagulant use compared to no anticoagulation (OR 0.9, 95% CI 0.6-1.1).

CONCLUSIONS

There was an increased odds of delayed intracranial hemorrhage within 90 days in older ED head injured patients prescribed warfarin compared to patients not on anticoagulation. direct oral anticoagulant use was not associated with increased risk of delayed intracranial hemorrhage.

What are the demographic and clinical differences between those older adults with traumatic brain injury who receive a neurosurgical intervention to those that do not? A systematic literature review with narrative synthesis

OBJECTIVES

This review aimed to identify the demographic and clinical differences between those older adults admitted directly under neurosurgical care and those that were not, and whether EMS clinicians could use these differences to improve patient triage.

METHODS

The authors searched for papers that included older adults who had suffered a TBI and were either admitted directly under neurosurgical care or were not. Titles and abstracts were screened, shortlisting potentially eligible papers before performing a full-text review. The Newcastle-Ottawa Scale was used to assess the risk of bias.

RESULTS

A total of nine studies were eligible for inclusion. A high abbreviated injury score head, Marshall score or subdural hematoma greater than 10 mm were associated with neurosurgical care. There were few differences between those patients who did and did not receive neurosurgical intervention.

CONCLUSIONS

Absence of guidelines and clinician bias means that differences between those treated aggressively and conservatively observed in the literature are fraught with bias. Further work is required to understand which patients would benefit from an escalation of care and whether EMS can identify these patients so they are transported directly to a hospital with the appropriate services on-site.

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

BACKGROUND

Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls.

METHODS

This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included.

RESULTS

The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13-2.60) and 1.08 (p = 0.73), (95% CI 0.70-1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02-2.49), p = 0.041).

CONCLUSION

This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.

Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

Importance

The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators.

Objective

To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care.

Design, Setting, and Participants

This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners.

Main Outcomes and Measures

Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability.

Results

Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery).

Conclusions and Relevance

In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

Aldolase C Profiling in Serum after Mild Traumatic Brain Injury: A Prospective Cohort Study

BACKGROUND

After a traumatic brain injury (TBI), in addition to clinical indices, the serum level of neurological biomarkers may provide valuable diagnostic and prognostic information. The present study aimed to investigate the aldolase C (ALDOC) profile in serum for early diagnosis of brain damage in patients with mild TBI (mTBI) presented to the Emergency Department (ED).

METHODS

A single-center prospective cohort study was carried out in 2018-2019 at Imam Khomeini Hospital affiliated with Mazandaran University of Medical Sciences, Sari, Iran. A total of 89 patients with mTBI were enrolled in the study. Blood samples were taken within three hours after head trauma to measure ALDOC serum levels. Brain CT scan was used as the gold standard. Statistical analysis was performed using the Kruskal Wallis, Mann-Whitney U, and Chi square tests. The receiver-operating characteristic (ROC) curve plot was used to determine the optimal cutoff point for ALDOC. The sensitivity and specificity of the determined cutoff point were calculated. P values less than 0.05 were considered statistically significant.

RESULTS

Of the 89 patients, the CT scan findings showed a positive TBI in 30 (33.7%) of the patients and in 59 (66.3%) a negative TBI. The median ALDOC serum level in the patients with positive CT scan findings (8.35 ng/mL [IQR: 1.65]) was significantly higher than those with negative CT scan findings (5.3 ng/mL [IQR: 6.9]) (P<0.001). The optimal cutoff point for ALDOC serum level was 6.95 ng/mL, and the area under the curve was 99.6% (P<0.001). The sensitivity and specificity of the determined cutoff point were 100% and 98%, respectively.

CONCLUSION

The ALDOC serum level in patients with mTBI significantly correlates with the pathologic findings of the brain CT scan. This biomarker, with 100% sensitivity, is a suitable tool to detect brain structural abnormalities in mTBI patients.

What are the strongest indicators of intracerebral hemorrhage in mild traumatic brain injury?

Background

Although there are eight factors known to indicate a high risk of intracranial hemorrhage (ICH) in mild traumatic brain injury (TBI), identification of the strongest of these factors may optimize the utility of brain CT in clinical practice. This study aimed to evaluate the predictors of ICH based on baseline characteristics/mode of injury, indications for brain CT, and a combination of both to determine the strongest indicator.

Methods

This was a descriptive, retrospective, analytical study. The inclusion criteria were diagnosis of mild TBI, high risk of ICH, and having undergone a CT scan of the brain. The outcome of the study was any type of ICH. Stepwise logistic regression analysis was used to find the strongest predictors according to three models: (1) injury pattern and baseline characteristics, (2) indications for CT scan of the brain, and (3) a combination of models 1 and 2.

Results

There were 100 patients determined to be at risk of ICH based on indications for CT of the brain in patients with acute head injury. Of these, 24 (24.00%) had ICH. Model 1 found that injury due to motor vehicle crash was a significant predictor of ICH, with an adjusted OR (95% CI) of 11.53 (3.05 to 43.58). Models 2 and 3 showed Glasgow Coma Scale (GCS) score of 13 to 14 after 2 hours of observation and open skull or base of skull fracture to be independent predictors, with adjusted OR (95% CI) of 11.77 (1.32 to 104.96) and 5.88 (1.08 to 31.99) according to model 2.

Discussion

Open skull or base of skull fracture and GCS score of 13 to 14 after 2 hours of observation were the two strongest predictors of ICH in mild TBI.

Level of evidence

III.

Systematic review and cumulative meta-analysis of the diagnostic accuracy of glial fibrillary acidic protein vs. S100 calcium binding protein B as blood biomarkers in observational studies of patients with mild or moderate acute traumatic brain injury

Traumatic brain injuries (TBIs) and sports-related concussions (SRCs) are the leading causes of hospitalization and death in subjects <45 years old in the USA and Europe. Some biomarkers (BMs) have been used to reduce unnecessary cranial computed tomography (CCT). In recent years, the astroglial S100 calcium-binding B protein (S100B) has prevented approximately 30% of unnecessary CCTs. Glial fibrillary acidic protein (GFAP) has also been studied in direct comparison with S100B. The aim of our cumulative meta-analysis (cMA) is to compare - in the context of hospital emergency departments or SRC conditions - the differences in diagnostic accuracy (DA), sensitivity (Se) and specificity (Sp) of GFAP and S100B. The main cMA inclusion criterion was the assessment of both BMs in the included subjects since 2010, with blood samples drawn 1-30 h from the suspected TBI or SRC. The risk-of-bias (RoB) score was determined, and both the publication bias (with the Begg, Egger and Duval trim-and-fill tests) and sensitivity (with the box-and-whiskers plot) were analyzed for outliers. Seven studies with 899 subjects and nine observations (samples) were included. The diagnostic odds ratios (dORs) with their prediction intervals (PIs), Se and Sp (analyzed with a hierarchical model to respect the binomial data structure) were assessed, and a random-effects MA and a cMA of the difference in the BMs dOR natural logarithms (logOR(G-S)) between the BMs were performed. The cMA of dOR(G-S) was significant (5.78 (CI 2-16.6)) probably preventing approximately 50% of unnecessary CCTs. Further work is needed to standardize and harmonize GFAP laboratory methods.

Characterizing Blunt Cerebrovascular Injuries and Stroke: A Single Center Retrospective Study

OBJECTIVE

To highlight the occurrence of ischemic stroke after blunt cerebrovascular injuries and discuss the neurologist's role in preventing and managing ischemic strokes in this trauma population.

METHODS

A retrospective chart review was performed and included data from 2016 to 2019 from a Level I trauma center. Demographics, injury mechanism, ischemic stroke occurrence, interventions, and neurology consultations were examined and descriptive statistics were utilized to characterize the nature of ischemic strokes and their management.

RESULTS

A total of forty patients (81% male, average age 44) presented with blunt cerebrovascular injury, nine of whom later developed ischemic stroke. Eighteen patients had a carotid artery injury with six developing ischemic stroke. Twenty-seven patients had a vertebral artery injury with three developing ischemic stroke. Six of the nine ischemic strokes occurred on hospital day two, whereas neurology was generally consulted on hospital day four.

CONCLUSIONS

A considerable portion of patients may go on to develop ischemic stroke following blunt cerebrovascular injuries. Polytrauma may interfere with prompt diagnosis which may contribute to delayed anti-thrombotic therapy for ischemic stroke prevention. Neurologists have the opportunity to reduce ischemic stroke burden in this trauma population and patients may benefit from earlier neurology consultation.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Glucagon-like peptide-1 receptor agonist Exendin-4 improves neurological outcomes by attenuating TBI- induced inflammatory responses and MAPK activation in rats

Traumatic brain injury (TBI) can be exacerbated and prolonged for months or even years by chronic inflammatory processes with long-term consequences on neurodegeneration and neurological impairment. However, there are no clear pharmacological therapies of benefit to manage neurological dysfunctions, which, relating to the molecular mechanisms underlying the behavioral deficits after TBI, have yet to be fully identified. Recently, a glucagon-like peptide 1 (GLP-1) agonist, Exendin-4, was approved not only for the treatment of type 2 diabetes mellitus, but it also played a neurotrophic role in various CNS neurological diseases. In this study, we evaluated the neuroprotective effects of Exendin-4 on neurological outcome, cerebral blood flow, neurodegeneration, and inflammatory responses by utilizing a cortical contusion impact injury (CCI) model in rats. We found that TBI rats displayed neurological impairments, neurodegeneration, reduction of cerebral blood flow, and inflammatory responses, while Exendin-4 promoted neurological, cognitive, and cerebral blood flow recovery and attenuated neural degeneration and inflammatory cytokines after TBI. Furthermore, Exendin-4 treatment significantly diminished the TBI-induced overexpression of TNFα and IL-1β, as well as phosphorylation of p38 and ERK1/2. These data suggest a strong beneficial action of the glucagon-like peptide-1 receptor agonist Exendin-4 in improving neurological outcomes by attenuating inflammatory responses induced by traumatic brain injury, which is of therapeutic potential for TBI.

Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study

A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13–15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74–0.98)), prior psychiatric history (AOR = 3.75 (1.73–8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93–196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29–9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17–10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low-Energy Falls

BACKGROUND/OBJECTIVES

To determine the prevalence and severity of traumatic intracranial hemorrhage (tICH) in a large cohort of older adults presenting with low-energy falls and the association with anticoagulation or antiplatelet medication.

DESIGN

Bicentric retrospective cohort analysis.

SETTING

Two level 1 trauma centers in Switzerland and Germany.

PARTICIPANTS

Consecutive sample of older adults (aged ≥65 y) presenting to the emergency department (ED) over a 1-year period with low-energy falls who received cranial computed tomography (cCT) within 48 hours of ED presentation.

MEASUREMENTS

The prevalence and severity of tICHs was assessed and the outcomes (in-hospital mortality, admission to intensive care unit [ICU], or neurosurgical intervention) were specified. We used multivariate regression models to measure the association between anticoagulation/antiplatelet therapy and the risk for tICH after adjustment for known predictors.

RESULTS

The overall prevalence for tICH detected by cCT was 176 of 2567 (6.9%). Neurosurgical intervention was performed in 15 of 176 (8.5%) patients with tICH, 28 of 176 (15.9%) patients were admitted to the ICU, and 14 of 176 (8.0%) died in the hospital. CT-detected skull fracture and signs of injury above the clavicles were the strongest predictors for the presence of tICH (odds ratio [OR] = 4.28; 95% confidence interval [CI] = 2.79-6.51; OR = 1.88; 95% CI = 1.3-2.73, respectively). Among 2567 included patients, 1424 (55%) were on anticoagulation/antiplatelet therapy. Multivariate regression models showed no differences for the risk of tICH (OR = 1.05; 95% CI = .76-1.47; P = .76) or association with the head-specific Injury Severity Scale (incident rate ratio = 1.08; 95% CI = .97-1.19; P = .15) with or without anticoagulation/antiplatelet therapy.

CONCLUSION

Medication with anticoagulants or antiplatelet agents was not associated with higher prevalence and severity of tICH in older patients with low-energy falls undergoing cCT examination. In addition to cCT-detected skull fractures, visible injuries above the clavicles were the strongest clinical predictors for tICH. Our findings merit prospective validation. J Am Geriatr Soc 68:977-982, 2020.

Detecting delayed intracranial hemorrhage with repeat head imaging in trauma patients on antithrombotics with no hemorrhage on the initial image: A retrospective chart review and meta-analysis

BACKGROUND

There is debate regarding routine repeat head computed tomography (CT) in blunt trauma patients on a pre-injury antithrombotic when the initial CT is negative for intracranial hemorrhage (ICH).

DATA SOURCES

Retrospective chart review and systematic literature review with meta-analysis.

CONCLUSIONS

In the chart review, 32.1% did not have a repeat head CT and 67.9% did. The delayed ICH incidence between those with and without a repeat head CT was similar (1.7% vs 0, p = .3101). The current study was combined with the identified 24 studies. Delayed ICH with or without routine repeat CT was similar between antiplatelet and anticoagulant categories (1.4% vs. 1.3%, p = .5322). Delayed ICH was lower for patients without routine repeat CT compared to those with routine repeat CT (0.8% vs 1.7%, p = .0008). For this patient population, repeat scans should be discretionary. Routine repeat CT may identify a larger proportion of minor delayed ICH.

Beta-adrenergic blockade for attenuation of catecholamine surge after traumatic brain injury: a randomized pilot trial

Background

Beta-blockers have been proven in multiple studies to be beneficial in patients with traumatic brain injury. Few prospective studies have verified this and no randomized controlled trials. Additionally, most studies do not titrate the dose of beta-blockers to therapeutic effect. We hypothesize that propranolol titrated to effect will confer a survival benefit in patients with traumatic brain injury.

Methods

A randomized controlled pilot trial was performed during a 24-month period. Patients with traumatic brain injury were randomized to propranolol or control group for a 14-day study period. Variables collected included demographics, injury severity, physiologic parameters, urinary catecholamines, and outcomes. Patients receiving propranolol were compared with the control group.

Results

Over the study period, 525 patients were screened, 26 were randomized, and 25 were analyzed. Overall, the mean age was 51.3 years and the majority were male with blunt mechanism. The mean Injury Severity Score was 21.8 and median head Abbreviated Injury Scale score was 4. Overall mortality was 20.0%. Mean arterial pressure was higher in the treatment arm as compared with control (p=0.021), but no other differences were found between the groups in demographics, severity of injury, severity of illness, physiologic parameters, or mortality (7.7% vs. 33%; p=0.109). No difference was detected over time in any variables with respect to treatment, urinary catecholamines, or physiologic parameters. Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation scores all improved over time. GCS at study end was significantly higher in the treatment arm (11.7 vs. 8.9; p=0.044). Finally, no difference was detected with survival analysis over time between groups.

Conclusions

Despite not being powered to show statistical differences between groups, GCS at study end was significantly improved in the treatment arm and mortality was improved although not at a traditional level of significance. The study protocol was safe and feasible to apply to an appropriately powered larger multicenter study.

Level of evidence

Level 2—therapeutic.

The “Headstrike” Protocol: A Retrospective Review of a Single Trauma Center's Operational Change in the Management of Anticoagulated Ground-Level Falls

Anticoagulated older adults suffering ground-level falls are a specialty trauma population at risk for intracranial hemorrhage (ICH). Delays in diagnosis or initiation of anticoagulation reversal can lead to increased morbidity/mortality. A novel “Headstrike” protocol was implemented to improve the treatment efficacy and disposition of these patients. The study objective was to determine effectiveness of the “Headstrike” protocol in providing these patients with timely treatment and disposition, while maintaining positive outcomes. A trauma performance improvement database was queried for all “Headstrike” activations for a 12-month period after implementation. Demographics, patient care, and health data were collected. Descriptive statistics were used for cohort analysis. Five hundred fifteen patients were activated as a “Headstrike” during the study period. Thirty eight patients were diagnosed with ICH (7.4%), 35 of whom were identified on initial imaging. Anticoagulation reversal was ordered for 84.6 per cent of these patients. Of the patients with negative initial CT, only three patients (0.8%) were found to have a delayed ICH on routine follow-up imaging. No anticoagulant/antiplatelet agent was associated with a significantly higher risk of ICH. Implementation of the “Headstrike” protocol resulted in trauma service line resources being used more efficiently, while ensuring high-quality, expeditious care to this population.

Clinical practice guidelines for rehabilitation in traumatic brain injury: a critical appraisal

This review aim to provide an overview of recommendations and quality of existing clinical practice guidelines (CPGs) for the management of traumatic brain injury (TBI) from the rehabilitation perspective. Comprehensive literature search, including health databases, CPG clearinghouse/developer websites, and grey literature using Internet search engines up to September 2017. All TBI CPGs published in the last decade were selected if their scope included management of TBI, systematic methods for evidence search, clear defined recommendations, and supporting evidence for rehabilitation interventions. Three authors independently critically appraised the quality of included CPGs using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument. Four of 13 potential CPGs met the inclusion criteria. Despite variation in scope, target population, size, and guideline development processes, all four CPGs assessed were good quality (AGREE score of 5-7/7). Key rehabilitation recommendations included education, physical rehabilitation, integrated computer-based management, repetitive task-specific practice in daily living activities, safe equipment usage, cognitive/behavioral feedback, compensatory memory/visual strategies, swallowing/communication, and psychological input for TBI survivors. In conclusion, although rehabilitation is an integral component in TBI management, many published CPGs do not include rehabilitation. These CPGs, however, recommend comprehensive, flexible coordinated multidisciplinary care and appropriate follow-up, education, and support for patients with TBI (and carers).

Using Lean Six Sigma to Improve Delayed Intracranial Hemorrhage Screening in a Geriatric Trauma Population

PURPOSE

Geriatric trauma patients taking preinjury anticoagulant or antiplatelet (ACAP) medications are at greater risk for delayed intracranial hemorrhage (DICH), a rare but potentially life-threatening condition. Routine repeat head computed tomography (RRHCT) scans can identify DICH. Our objective was to decrease the rate of missed RRHCT in a level 1 Midwest trauma center geriatric minor trauma population on preinjury ACAP medications.

OBJECTIVE

The objective of the quality improvement project was to identify the root cause of the missed RRHCTs and to implement a comprehensive solution to reduce rates of missed RRHCTs.

METHODS

Medical records from before and after the intervention were evaluated. Frequencies and percentages were calculated. In addition, χ and logistic regression were utilized. The Lean Six Sigma (LSS) DMAIC (Define, Measure, Analyze, Improve, and Control) process was used to drive process improvement.

RESULTS

At baseline, 15% (41 of 267) of RRHCTs were missed. After solution implementation, missed RRHCTs dropped to 4% (2 of 50). Of the 2 that were missed, zero were clinically inappropriate misses, making the postimplementation rate effectively 0%.

CONCLUSION

The LSS DMAIC process helped health care professional to facilitate improved adherence to the department's practice guideline with respect to RRHCT. Adherence with this guideline can help providers identify patients with DICH, a potentially life-threatening condition.

Why Does Brain Trauma Research Fail?

Traumatic brain injury (TBI) represents a major health care problem and a significant social and economic issue worldwide. Considering the generalized failure in introducing effective drugs and clinical protocols, there is an urgent need for efficient treatment modalities, able to improve devastating posttraumatic morbidity and mortality. In this work, the status of brain trauma research is analyzed in all its aspects, including basic and translational science and clinical trials. Implicit and explicit challenges to different lines of research are discussed and clinical trial structures and outcomes are scrutinized, along with possible explanations for systematic therapeutic failures and their implications for future development of drug and clinical trials. Despite significant advances in basic and clinical research in recent years, no specific therapeutic protocols for TBI have been shown to be effective. New potential therapeutic targets have been identified, following a better understanding of pathophysiologic mechanisms underlying TBI, although with disappointing results. Several reasons can be pinpointed at different levels, from inaccurate animal models of disease to faulty preclinical and clinical trials, with poor design and subjective outcome measures. Distinct strategies can be delineated to overcome specific shortcomings of research studies. Identifying and contextualizing the failures that have dominated TBI research is mandatory. This review analyzes current approaches and discusses possible strategies for improving outcomes.

Cerebral Autoregulation-Guided Optimal Blood Pressure in Sepsis-Associated Encephalopathy: A Case Series

BACKGROUND

Impaired cerebral autoregulation and cerebral hypoperfusion may play a critical role in the high morbidity and mortality in patients with sepsis-associated encephalopathy (SAE). Bedside assessment of cerebral autoregulation may help individualize hemodynamic targets that optimize brain perfusion. We hypothesize that near-infrared spectroscopy (NIRS)-derived cerebral oximetry can identify blood pressure ranges that enhance autoregulation in patients with SAE and that disturbances in autoregulation are associated with severity of encephalopathy.

METHODS

Adult patients with acute encephalopathy directly attributable to sepsis were followed using NIRS-based multimodal monitoring for 12 consecutive hours. We used the correlation in time between regional cerebral oxygen saturation and mean arterial pressure (MAP) to determine the cerebral oximetry index (COx) as a measure of cerebral autoregulation. Autoregulation curves were constructed for each patient with averaged COx values sorted by MAP in 3 sequential 4-hour periods; the optimal pressure (MAP_OPT), defined as the MAP associated with most robust autoregulation (lowest COx), was identified in each period. Severity of encephalopathy was measured with Glasgow coma scale (GCS).

RESULTS

Six patients with extracranial sepsis met the stringent criteria specified, including no pharmacological sedation or neurologic premorbidity. Optimal MAP was identified in all patients and ranged from 55 to 115 mmHg. Additionally, MAP_OPT varied within individual patients over time during monitoring. Disturbed autoregulation, based on COx, was associated with worse neurologic status (GCS < 13) both with and without controlling for age and severity of sepsis (adjusted odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.77-2.52; P < .001; OR: 2.97; 95% CI: 1.63-5.43; P < .001).

CONCLUSIONS

In this high-fidelity group of patients with SAE, continuous, NIRS-based monitoring can identify blood pressure ranges that improve autoregulation. This is important given the association between cerebral autoregulatory function and severity of encephalopathy. Individualizing blood pressure goals using bedside autoregulation monitoring may better preserve cerebral perfusion in SAE than current practice.

Development of the CIDSS2 Score for Children with Mild Head Trauma without Intracranial Injury

While most children with mild traumatic brain injury (mTBI) without intracranial injury (ICI) can be safely discharged home from the emergency department, many are admitted to the hospital. To support evidence-based practice, we developed a decision tool to help guide hospital admission decisions. This study was a secondary analysis of a prospective study conducted in 25 emergency departments. We included children under 18 years who had Glasgow Coma Scale score 13-15 head injuries and normal computed tomography scans or skull fractures without significant depression. We developed a multi-variable model that identified risk factors for extended inpatient management (EIM; defined as hospitalization for 2 or more nights) for TBI, and used this model to create a clinical risk score. Among 14,323 children with mTBI without ICI, 20% were admitted to the hospital but only 0.76% required EIM for TBI. Key risk factors for EIM included Glasgow Coma Scale score less than 15 (odds ratio [OR] = 8.1; 95% confidence interval [CI] 4.0-16.4 for 13 vs. 15), drug/alcohol Intoxication (OR = 5.1; 95% CI 2.4-10.7), neurological Deficit (OR = 3.1; 95% CI 1.4-6.9), Seizure (OR = 3.7; 95% CI 1.8-7.8), and Skull fracture (odds ratio [OR] 24.5; 95% CI 16.0-37.3). Based on these results, the CIDSS₂ risk score was created. The model C-statistic was 0.86 and performed similarly in children less than (C = 0.86) and greater than or equal to 2 years (C = 0.86). The CIDSS₂ score is a novel tool to help physicians identify the minority of children with mTBI without ICI at increased risk for EIM, thereby potentially aiding hospital admission decisions.

Near-Term Decrease in Brain Volume following Mild Traumatic Injury Is Detectible in the Context of Preinjury Volumetric Stability: Neurobiologic Insights from Analysis of Historical Imaging Examinations

BACKGROUND AND PURPOSE

Neurodegeneration after mild traumatic brain injury may manifest as decreasing regional brain volume that evolves from months to years following mild traumatic brain injury and is associated with worse clinical outcomes. We hypothesized that quantitative brain volume derived from CT of the head, performed for clinical indications during routine care, would change with time and provide insights into the putative neuroinflammatory response to mild traumatic brain injury.

MATERIALS AND METHODS

We searched the electronic medical record of our institution for NCCTs of the head performed in patients with mild traumatic brain injury and included those who also underwent NCCTs of the head 1 month to 1 year before and after mild traumatic brain injury for an indication unrelated to trauma. Controls underwent 3 sequential NCCTs of the head with indications unrelated to trauma. The whole-brain and intracranial volume groups were computed using ITK-SNAP. Brain volumes normalized to intracranial volumes were compared across time points using the Wilcoxon signed-rank test.

RESULTS

We identified 48 patients from 2005 to 2015 who underwent NCCTs of the head in the emergency department for mild traumatic brain injury and had NCCTs of the head performed both before and after mild traumatic brain injury. Median normalized brain volumes significantly decreased on the follow-up study post-mild traumatic brain injury (0.86 versus 0.84, P < .001) and were similar compared with pre-mild traumatic brain injury studies (0.87 versus 0.86, P = .927). There was no significant difference between normalized brain volumes in the 48 controls.

CONCLUSIONS

A decrease in brain volume following mild traumatic brain injury is detectable on CT and is not seen in similar patients with non-mild traumatic brain injury during a similar timeframe. Given the stability of brain volume before mild traumatic brain injury, CT volume loss may represent the subtle effects of neurodegeneration.

Serum GFAP and UCH-L1 for prediction of absence of intracranial injuries on head CT (ALERT-TBI): a multicentre observational study

BACKGROUND

More than 50 million people worldwide sustain a traumatic brain injury (TBI) annually. Detection of intracranial injuries relies on head CT, which is overused and resource intensive. Blood-based brain biomarkers hold the potential to predict absence of intracranial injury and thus reduce unnecessary head CT scanning. We sought to validate a test combining ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), at predetermined cutoff values, to predict traumatic intracranial injuries on head CT scan acutely after TBI.

METHODS

This prospective, multicentre observational trial included adults (≥18 years) presenting to participating emergency departments with suspected, non-penetrating TBI and a Glasgow Coma Scale score of 9-15. Patients were eligible if they had undergone head CT as part of standard emergency care and blood collection within 12 h of injury. UCH-L1 and GFAP were measured in serum and analysed using prespecified cutoff values of 327 pg/mL and 22 pg/mL, respectively. UCH-L1 and GFAP assay results were combined into a single test result that was compared with head CT results. The primary study outcomes were the sensitivity and the negative predictive value (NPV) of the test result for the detection of traumatic intracranial injury on head CT.

FINDINGS

Between Dec 6, 2012, and March 20, 2014, 1977 patients were recruited, of whom 1959 had analysable data. 125 (6%) patients had CT-detected intracranial injuries and eight (<1%) had neurosurgically manageable injuries. 1288 (66%) patients had a positive UCH-L1 and GFAP test result and 671 (34%) had a negative test result. For detection of intracranial injury, the test had a sensitivity of 0·976 (95% CI 0·931-0·995) and an NPV of 0·996 (0·987-0·999). In three (<1%) of 1959 patients, the CT scan was positive when the test was negative.

INTERPRETATION

These results show the high sensitivity and NPV of the UCH-L1 and GFAP test. This supports its potential clinical role for ruling out the need for a CT scan among patients with TBI presenting at emergency departments in whom a head CT is felt to be clinically indicated. Future studies to determine the value added by this biomarker test to head CT clinical decision rules could be warranted.

FUNDING

Banyan Biomarkers and US Army Medical Research and Materiel Command.

Emergency Department Time Course for Mild Traumatic Brain Injury Workup

Introduction

Mild traumatic brain injury (mTBI) is a common cause for visits to the emergency department (ED). The actual time required for an ED workup of a patient with mTBI in the United States is not well known. National emergency medicine organizations have recommended reducing unnecessary testing, including head computed tomography (CT) for these patients.10.

Methods

To examine this issue, we developed a care map that included each step of evaluation of mTBI (Glasgow Coma Scale Score 13-15) - from initial presentation to the ED to discharge. Time spent at each step was estimated by a panel of United States emergency physicians and nurses. We subsequently validated time estimates using retrospectively collected, real-time data at two EDs. Length of stay (LOS) time differences between admission and discharged patients were calculated for patients being evaluated for mTBI.

Results

Evaluation for mTBI was estimated at 401 minutes (6.6 hours) in EDs. Time related to head CT comprised about one-half of the total LOS. Real-time data from two sites corroborated the estimate of median time difference between ED admission and discharge, at 6.3 hours for mTBI.

Conclusion

Limiting use of head CT as part of the workup of mTBI to more serious cases may reduce time spent in the ED and potentially improve overall ED throughput.

An update on diagnostic and prognostic biomarkers for traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) is a major worldwide neurological disorder of epidemic proportions. To date, there are still no FDA-approved therapies to treat any forms of TBI. Encouragingly, there are emerging data showing that biofluid-based TBI biomarker tests have the potential to diagnose the presence of TBI of different severities including concussion, and to predict outcome. Areas covered: The authors provide an update on the current knowledge of TBI biomarkers, including protein biomarkers for neuronal cell body injury (UCH-L1, NSE), astroglial injury (GFAP, S100B), neuronal cell death (αII-spectrin breakdown products), axonal injury (NF proteins), white matter injury (MBP), post-injury neurodegeneration (total Tau and phospho-Tau), post-injury autoimmune response (brain antigen-targeting autoantibodies), and other emerging non-protein biomarkers. The authors discuss biomarker evidence in TBI diagnosis, outcome prognosis and possible identification of post-TBI neurodegernative diseases (e.g. chronic traumatic encephalopathy and Alzheimer's disease), and as theranostic tools in pre-clinical and clinical settings. Expert commentary: A spectrum of biomarkers is now at or near the stage of formal clinical validation of their diagnostic and prognostic utilities in the management of TBI of varied severities including concussions. TBI biomarkers could serve as a theranostic tool in facilitating drug development and treatment monitoring.

Use of general practice before and after mild traumatic brain injury: a nationwide population-based cohort study in Denmark

OBJECTIVES

Traumatic brain injury (TBI) is commonly seen in the emergency department (ED). Approximately 85%-90% of TBIs are mild (mTBI). Some cause symptoms such as headache, dizziness, anxiety, blurred vision, insomnia and concentration difficulties, collectively known as postconcussion syndrome (PCS). Some studies suggest that recovery from mTBI is complete. Others find that symptoms persist for months, even years. The aim of this study was to describe the use of general practice, before and after mTBI, as a proxy for symptoms in a large cohort.

DESIGN

Nationwide population-based matched cohort study.

SETTING

Danish EDs and general practice.

PARTICIPANTS

All patients (aged ≥18 years), first-time diagnosed with mTBI in a Danish ED between 1 January 1998 and 31 December 2010 (n=93 517). Ten reference persons per patient with mTBI were randomly matched on gender, age and general practice (n=935 170).

PRIMARY OUTCOME

Overall use of general practice; consultations relating to mental and physical health.

RESULTS

We found higher use of general practice during the first year after mTBI for all ages, both genders and all types of contacts. Age 18-40 years: women, incidence rate ratio (IRR) 1.59 (95% CI 1.57 to 1.61); men, IRR 1.82 (95% CI 1.80 to 1.85). Age 41-65 years: women, IRR 1.75 (95% CI 1.72 to 1.78); men, IRR 1.85(95% CI 1.82 to 1.89). Age 66+ years: women, IRR 1.55 (95% CI 1.52 to 1.58); men, IRR 1.55 (95% CI 1.51 to 1.59). After the first year, the use decreased to the level before mTBI. Individuals with mTBI and higher use of general practice before mTBI had lower socioeconomic status and more comorbidities (P<0.001).

CONCLUSIONS

The use of general practice was higher in the first year after mTBI, specifically in the first 3 months. Patients with mTBI had different healthcare-seeking behaviour several years before diagnosis than their matched reference persons. Pretraumatic morbidity should be considered in the evaluation of PCS.

Evidence-Based Care of Geriatric Trauma Patients

The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.

Acute Management of Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of death and disability in patients with trauma. Management strategies must focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow. CPP can be maintained by increasing mean arterial pressure, decreasing intracranial pressure, or both. The goal should be euvolemia and avoidance of hypotension. Other factors that deserve important consideration in the acute management of patients with TBI are venous thromboembolism, stress ulcer, and seizure prophylaxis, as well as nutritional and metabolic optimization.

Mild brain injury and anticoagulants: Less is enough

BACKGROUND

Despite the higher theoretical risk of traumatic intracranial hemorrhage (ICH) in anticoagulated patients with mild head injury, the value of sequential head CT scans to identify bleeding remains controversial. This study evaluated the utility of 2 sequential CT scans at a 48-hour interval (CT1 and CT2) in patients with mild head trauma (Glasgow Coma Scale 13-15) taking oral anticoagulants.

METHODS

We retrospectively evaluated the clinical records of all patients on chronic anticoagulation treatment admitted to the emergency department for mild head injury.

RESULTS

A total of 344 patients were included, and 337 (97.9%) had a negative CT1. CT2 was performed on 284 of the 337 patients with a negative CT1 and was positive in 4 patients (1.4%), but none of the patients developed concomitant neurologic worsening or required neurosurgery.

CONCLUSIONS

Systematic routine use of a second CT scan in mild head trauma in patients taking anticoagulants is expensive and clinically unnecessary.

H-FABP: A new biomarker to differentiate between CT-positive and CT-negative patients with mild traumatic brain injury

The majority of patients with mild traumatic brain injury (mTBI) will have normal Glasgow coma scale (GCS) of 15. Furthermore, only 5%-8% of them will be CT-positive for an mTBI. Having a useful biomarker would help clinicians evaluate a patient's risk of developing intracranial lesions. The S100B protein is currently the most studied and promising biomarker for this purpose. Heart fatty-acid binding protein (H-FABP) has been highlighted in brain injury models and investigated as a biomarker for stroke and severe TBI, for example. Here, we evaluate the performances of S100B and H-FABP for differentiating between CT-positive and CT-negative patients. A total of 261 patients with a GCS score of 15 and at least one clinical symptom of mTBI were recruited at three different European sites. Blood samples from 172 of them were collected ≤ 6 h after trauma. Patients underwent a CT scan and were dichotomised into CT-positive and CT-negative groups for statistical analyses. H-FABP and S100B levels were measured using commercial kits, and their capacities to detect all CT-positive scans were evaluated, with sensitivity set to 100%. For patients recruited ≤ 6 h after trauma, the CT-positive group demonstrated significantly higher levels of both H-FABP (p = 0.004) and S100B (p = 0.003) than the CT-negative group. At 100% sensitivity, specificity reached 6% (95% CI 2.8-10.7) for S100B and 29% (95% CI 21.4-37.1) for H-FABP. Similar results were obtained when including all the patients recruited, i.e. hospital arrival within 24 h of trauma onset. H-FABP out-performed S100B and thus seems to be an interesting protein for detecting all CT-positive mTBI patients with a GCS score of 15 and at least one clinical symptom.

Modeling the Kinetics of Serum Glial Fibrillary Acidic Protein, Ubiquitin Carboxyl-Terminal Hydrolase-L1, and S100B Concentrations in Patients with Traumatic Brain Injury

Glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1), and S100B have been shown to be predictive of patients with brain injury. Kinetics of these biomarkers in injured humans have not been extensively examined. This prospective multi-center study included patients with mild-to-moderate traumatic brain injury. Blood samples obtained at enrollment and every 6 h up to 24 h post-injury were assayed for GFAP, UCH-L1, and S100B. Random effects models examined changes in the biomarkers' level over time. A total of 167 patients were enrolled; mean age was 46.0 ± 17.8, 61.1% were male, 143 (85.6%) had a Glasgow Coma Scale score of 15, and 33 (19.8%) had a positive head computed tomography (CT) scan. Baseline median biomarker concentrations for all three were higher among CT-positive patients (p < 0.0001) but GFAP was the only biomarker that significantly increased over time among CT-positive patients relative to CT-negative patients (log transformed values 0.037; 95% confidence interval 0.02, 0.05; p < 0.001), indicating a 3.7% per hour rise in GFAP concentration. There was no significant increase in either UCH-L1 or S100B in CT-positive patients (p = 0.15 and p = 0.47, respectively). GFAP concentrations increased 3.7% per hour among CT-positive patients whereas neither UCH-L1 nor S100B increased, compared with CT-negative patients. The kinetics and temporal profile of GFAP suggest it may be a more robust biomarker to detect patients with positive CT findings, particularly at later post-injury times. Further study is needed to determine if GFAP is a useful test to follow throughout a patient's clinical course.