1
|
Wycech Knight J, Fokin AA, Menzione N, Rabinowitz SR, Viitaniemi SA, Puente I. Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study. Brain Inj 2024; 38:659-667. [PMID: 38568043 DOI: 10.1080/02699052.2024.2337904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/28/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To compare outcomes between geriatric and non-geriatric patients with traumatic brain injury (TBI) transferred to trauma center and effects of anticoagulants/antiplatelets (AC/AP) and reversal therapy. METHODS A retrospective review of 1,118 patients with TBI transferred from acute care facilities to level 1 trauma center compared in groups: geriatric versus non-geriatric, geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/AP reversal therapy versus without. RESULTS Patients with TBI constituted 54.4% of trauma transfers. Mean transfer time was 3.9 h. Propensity matched by Injury Severity Score and Abbreviated Injury Score (AIS) head geriatric compared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeat head computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions (57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients on AC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001). Patients with AC/AP reversals compared to without reversals had more AIS head 5 (32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs 57.1%), all p < 0.001. CONCLUSION TBI constituted half of trauma transfers and 10% required surgery. Based on higher ICU admissions, mortality, and prevalence of AC/AP therapy requiring reversal, geriatric patients with TBI on anticoagulants/antiplatelets should be considered for direct trauma center admission.
Collapse
Affiliation(s)
- Joanna Wycech Knight
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida, USA
| | - Alexander A Fokin
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Nicholas Menzione
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
| | - Sarah R Rabinowitz
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Sari A Viitaniemi
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
| | - Ivan Puente
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
- Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, Miami, Florida, USA
| |
Collapse
|
2
|
Seidenfaden SC, Pedersen CK, Juul N, Kirkegaard H, Bøtker MT. Patients suffering traumatic brain injury: patient characteristics, prehospital triage, primary referral and mortality - A population-based follow-up study. Scand J Trauma Resusc Emerg Med 2024; 32:58. [PMID: 38898534 PMCID: PMC11186223 DOI: 10.1186/s13049-024-01229-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a potential high-risk condition, but appropriate care pathways, including prehospital triage and primary referral to a specialised neurosurgical centre, can improve neurological outcome and survival. The care pathway starts with layman triage, wherein the patient or bystander decides whether to contact a general practitioner (GP) or emergency services (1-1-2 call) as an entryway into the health care system. The GP or 112-health care professional then decides on the level of urgency and dispatches emergency medical services (EMS) when needed. Finally, a decision is made regarding referral of the TBI patient to a specialised neurotrauma centre or a local hospital. Recent studies have shown that injuries are generally more severe in patients entering the health care system through EMS (112-calls) than through GPs; however, no information exists on whether mortality and morbidity outcomes differ depending on the referral choice. The aim of this study was to examine triage pathways, including the method of entry into the health care system, as well as patient characteristics and place of primary referral, to determine the associated 30-day and 1-year mortality rates in TBI patients with confirmed intracranial lesions. METHODS This retrospective observational population-based follow-up study was conducted in the Central Denmark Region from 1 February 2017 to 31 January 2019. We included all adult patients who contacted hospitals and were ascribed a predefined TBI ICD-10 diagnosis code in the Danish National Patient Register. The obtained TBI cohort was merged with prehospital data from the Prehospital Emergency Medical Services, Central Denmark Region, and vital status from the Danish Civil Registration System. Binary logistic regression analysis of mortality was conducted. In all patients with TBI (including concussions), the primary outcome was primary referral to a specialised centre based on mode of entry ('GP/HCP', '112-call' or 'Unreferred') into the health care system. In the subgroup of patients with confirmed intracranial lesions, the secondary outcomes were the relative risk of death at day 30 and 1 year based on the place of primary referral. RESULTS Of 5,257 first TBI hospital contacts of adult patients included in the cohort, 1,430 (27.2%) entered the health care system via 1-1-2 emergency medical calls. TBI patients triaged by 112-calls were more likely to receive the highest level of emergency response (15.6% vs. 50.3%; p < 0.001) and second-tier resources and were more frequently referred directly to a specialised centre than were patients entering through GPs or other health care personnel. In the subgroup of 1188/5257 (22.4%) patients with confirmed intracranial lesions, we found no difference in the risk ratio of 30 day (RR 1.04 (95%CI 0.65-1.63)) or 1 year (RR 0.96 (95%CI 0.72-1.25)) all-cause mortality between patients primarily referred to a regional hospital or to a specialised centre when adjusting for age, sex, comorbidities, antiplatelet/anticoagulant treatment and type of intracranial lesions. CONCLUSION TBI patients mainly enter the health system by contact with GPs or other health care professionals. However, patients entering through 112-calls are more frequently triaged directly to specialised centres. We were unable to demonstrate any significant difference in the adjusted 30-day and 1-year mortality based on e primary referral to a specialised centre. The inability to demonstrate an effect on mortality based on primary referral to a specialised centre may reflect a lack of clinical data in the registries used. Considerable differences may exist in nondocumented baseline characteristics (i.e., GCS, blood pressure and injury severity) between the groups and may limit conclusions about differences in mortality. Further research providing high-quality evidence on the effect of primary referral is needed to secure early neurosurgical interventions in TBI patients.
Collapse
Affiliation(s)
- Sophie-Charlott Seidenfaden
- Research & Development, Prehospital Emergency Medical Services, Central Denmark Region, Brendstrupgårdsvej 7, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, bld. 2, Palle Juul-Jensens Blvd. 82, Aarhus, Denmark.
- Department of Anaesthesiology, Randers Regional Hospital, Skovlyvej 15, Randers, Denmark.
| | - Claus Kjaer Pedersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, Aarhus, Denmark
| | - Niels Juul
- Department of Anaesthesiology and Intensive Care, Section North, Neurointensive Care Unit, Aarhus University Hospital, Palle Jull-Jensens Blvd.161, Aarhus, Denmark
| | - Hans Kirkegaard
- Research & Development, Prehospital Emergency Medical Services, Central Denmark Region, Brendstrupgårdsvej 7, Aarhus N, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital, and Aarhus University, Palle Juul-Jensens Blvd. 99, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, bld. 2, Palle Juul-Jensens Blvd. 82, Aarhus, Denmark
| | - Morten Thingemann Bøtker
- Research & Development, Prehospital Emergency Medical Services, Central Denmark Region, Brendstrupgårdsvej 7, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, bld. 2, Palle Juul-Jensens Blvd. 82, Aarhus, Denmark
- Department of Anaesthesiology, Randers Regional Hospital, Skovlyvej 15, Randers, Denmark
| |
Collapse
|
3
|
De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
Collapse
Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
| |
Collapse
|
4
|
Ambesi V, Miller C, Fitzgerald MC, Mitra B. The GCS-Pupils (GCS-P) score to assess outcomes after traumatic brain injury: a retrospective study. Br J Neurosurg 2024:1-4. [PMID: 38259200 DOI: 10.1080/02688697.2023.2301071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024]
Abstract
INTRODUCTION The Glasgow Coma Scale (GCS) and pupil response to light are commonly used to assess brain injury severity and predict outcomes. The aim of this study was to investigate whether the GCS combined with pupil response (GCS-P), compared to the GCS alone, could be a better predictor of hospital mortality for patients with traumatic brain injury (TBI). METHODS A retrospective cohort study was undertaken at an adult level one trauma centre including patients with isolated TBI of Abbreviated Injury Scale above three. The GCS and pupil response were combined to an arithmetic score (GCS score (range 3-15) minus the number of nonreacting pupils (0, 1, or 2)), or by treating each factor as separate categorical variables. The association of in-hospital mortality with GCS-P as a categorical variable was evaluated using Nagelkerke's R2 and compared using areas under the receiver operating characteristic (AUROC) curve. RESULTS There were 392 patients included over the study period of 1 July 2014 and 30 September 2017, with an overall mortality rate of 15.2%. Mortality was highest at GCS-P of 1 (79%), with lowest mortality at a GCS-P 15 (1.6%). Nagelkerke's R2 was 0.427 for GCS alone and 0.486 for GCS-P. The AUROC for GCS-P to predict mortality was 0.87 (95%CI: 0.82-0.72), higher than for GCS alone (0.85; 95%CI: 0.80-0.90; p < .001). DISCUSSION GCS-P provided a better predictor of mortality compared to the GCS. As both the GCS and pupillary response are routinely recorded on all patients, combination of these pieces of information into a single score can further simplify assessment of patients with TBI, with some improvement in performance.
Collapse
Affiliation(s)
- Vito Ambesi
- Office of Nursing & Midwifery, La Trobe University, Bundoora, Australia
| | - Charne Miller
- Office of Nursing & Midwifery, La Trobe University, Bundoora, Australia
| | - Mark C Fitzgerald
- Alfred Health, Trauma Service, Melbourne, Australia
- Central Clinical School, Monash University, Clayton, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- School of Public Health & Preventive Medicine, Monash University, Clayton, Australia
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| |
Collapse
|
5
|
Yadav K, Lampron J, Nadj R, Raichura R, Figueira S, Nemnom MJ, Taljaard M, Émond M, Benhamed A, Eagles D. Predictors of mortality among older major trauma patients. CAN J EMERG MED 2023; 25:865-872. [PMID: 37742324 DOI: 10.1007/s43678-023-00597-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Older trauma patients have a higher mortality yet are more likely to be under-triaged compared to younger patients. Studies have suggested that current trauma team activation criteria are suboptimal for older patients. OBJECTIVES The objective was to describe trauma care delivered, patient outcomes, and to identify variables independently associated with mortality. METHODS We performed a health records review from 2014 to 2020 of older (age ≥ 65 years) trauma patients presenting to a level one trauma centre with any of the following: injury severity score (ISS) > 12, and all trauma team activations or admission to the trauma ward. The primary outcome was 30-day all-cause mortality. Secondary outcomes included injury mechanism and trauma care delivered. Multivariable logistic regression was used to identify factors independently associated with 30-day all-cause mortality. Multiple imputation was used to deal with missing data. RESULTS We enrolled 1,380 patients (mean age 80 years, mean ISS 18); 26.8% had multimorbidity (≥ 2 chronic conditions) and 65.9% met criteria for polypharmacy (≥ 5 medications). The most common mechanism was fall from standing height (61.1%). Thirty-day all-cause mortality occurred in 239 (17.3%) patients. A Glasgow coma scale (GCS) < 15 (odds ratio [OR] = 5.55; 95% CI 3.73-8.24), ISS > 15 (OR = 3.75, 95% CI 2.35-6.01), age ≥ 85 years (OR = 2.04, 95% CI 1.29-3.22), anticoagulation with a direct oral anticoagulant (DOAC) or warfarin (OR = 1.59, 95% CI 1.08-2.35) and multimorbidity (OR = 1.53, 95% CI 1.06-2.22) were significantly associated with increased risk 30-day mortality (C-statistic = 0.82, 95% CI 0.79-0.85). Dementia (OR = 0.61, 95% CI 0.40-0.95) and time to CT scan > 60 min (OR = 0.50, 95% CI 0.34-0.74) were associated with decreased mortality risk. CONCLUSION We identified five factors associated with increased 30-day mortality in older trauma patients: GCS < 15, ISS > 15, age ≥ 85 years, anticoagulation, and multimorbidity. These factors should be considered when developing modified trauma team activation criteria for older adults.
Collapse
Affiliation(s)
- Krishan Yadav
- Department of Emergency Medicine, Clinical Epidemiology Unit F660b, University of Ottawa, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Jacinthe Lampron
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Richard Nadj
- Undergraduate Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rikesh Raichura
- Undergraduate Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Marcel Émond
- Département de Médecine de Famille Et de Médecine d'urgence, Université Laval, Québec, QC, Canada
| | - Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Benard, Lyon, France
| | - Debra Eagles
- Department of Emergency Medicine, Clinical Epidemiology Unit F660b, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
6
|
Barrett JW, Williams J, Skene SS, Griggs JE, Bootland D, Leung J, Da Costa A, Ballantyne K, Davies R, Lyon RM. Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case-control study. Scand J Trauma Resusc Emerg Med 2023; 31:65. [PMID: 37908011 PMCID: PMC10619243 DOI: 10.1186/s13049-023-01138-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury. METHODS This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician. RESULTS In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms. CONCLUSION This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.
Collapse
Affiliation(s)
- J W Barrett
- South East Coast Ambulance Service NHS FT, Crawley, UK.
- University of Surrey, Guildford, UK.
| | - J Williams
- South East Coast Ambulance Service NHS FT, Crawley, UK
- Paramedic Clinical Research Unit, University of Hatfield, Hatfield, UK
| | | | - J E Griggs
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| | - D Bootland
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - J Leung
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - A Da Costa
- Medway Maritime Hospital NHS FT, Gillingham, UK
| | - K Ballantyne
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - R Davies
- South East Coast Ambulance Service NHS FT, Crawley, UK
| | - R M Lyon
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| |
Collapse
|
7
|
Benhamed A, Isaac CJ, Boucher V, Yadav K, Mercier E, Moore L, D'Astous M, Bernard F, Dubucs X, Gossiome A, Emond M. Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study. Eur J Emerg Med 2023; 30:271-279. [PMID: 37161755 DOI: 10.1097/mej.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.
Collapse
Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | | | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Krishan Yadav
- Department of Emergency Medicine-University of Ottawa
- Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Eric Mercier
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec
| | | | - Francis Bernard
- Services de soins intensifs, Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM)-Université de Montréal, Montréal, Québec, Canada
| | - Xavier Dubucs
- Service d'urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Marcel Emond
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
| |
Collapse
|
8
|
Kim N, Jamison K, Jaywant A, Garetti J, Blunt E, RoyChoudhury A, Butler T, Dams-O'Connor K, Khedr S, Chen CC, Shetty T, Winchell R, Hill NJ, Schiff ND, Kuceyeski A, Shah SA. Comparisons of electrophysiological markers of impaired executive attention after traumatic brain injury and in healthy aging. Neuroimage 2023; 274:120126. [PMID: 37191655 PMCID: PMC10286242 DOI: 10.1016/j.neuroimage.2023.120126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/10/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023] Open
Abstract
Executive attention impairments are a persistent and debilitating consequence of traumatic brain injury (TBI). To make headway towards treating and predicting outcomes following heterogeneous TBI, cognitive impairment specific pathophysiology first needs to be characterized. In a prospective observational study, we measured EEG during the attention network test aimed at detecting alerting, orienting, executive attention and processing speed. The sample (N = 110) of subjects aged 18-86 included those with and without traumatic brain injury: n = 27, complicated mild TBI; n = 5, moderate TBI; n = 10, severe TBI; n = 63, non-brain-injured controls. Subjects with TBI had impairments in processing speed and executive attention. Electrophysiological markers of executive attention processing in the midline frontal regions reveal that, as a group, those with TBI and elderly non-brain-injured controls have reduced responses. We also note that those with TBI and elderly controls have responses that are similar for both low and high-demand trials. In subjects with moderate-severe TBI, reductions in frontal cortical activation and performance profiles are both similar to that of controls who are ∼4 to 7 years older. Our specific observations of frontal response reductions in subjects with TBI and in older adults is consistent with the suggested role of the anterior forebrain mesocircuit as underlying cognitive impairments. Our results provide novel correlative data linking specific pathophysiological mechanisms underlying domain-specific cognitive deficits following TBI and with normal aging. Collectively, our findings provide biomarkers that may serve to track therapeutic interventions and guide development of targeted therapeutics following brain injuries.
Collapse
Affiliation(s)
- Nayoung Kim
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Keith Jamison
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Abhishek Jaywant
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065, United States; Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, NY 10065, United States; NewYork-Presbyterian Hospital, New York, NY 10065, United States
| | - Jacob Garetti
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Emily Blunt
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Arindam RoyChoudhury
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
| | - Tracy Butler
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Shahenda Khedr
- Department of Surgery, NewYork-Presbyterian Queens Hospital, Queens, NY 11355, United States
| | - Chun-Cheng Chen
- Department of Surgery, NewYork-Presbyterian Queens Hospital, Queens, NY 11355, United States; Department of Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - Teena Shetty
- Department of Neurology, Hospital for Special Surgery, New York, NY, 10021 United States
| | - Robert Winchell
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - N Jeremy Hill
- National Center for Adaptive Neurotechnologies, Stratton VA Medical Center, Albany, NY 12208, United States; Electrical & Computer Engineering Department, State University of New York at Albany, NY 12226, United States
| | - Nicholas D Schiff
- Department of BMRI & Neurology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Amy Kuceyeski
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Sudhin A Shah
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States; Department of BMRI & Neurology, Weill Cornell Medicine, New York, NY 10065, United States.
| |
Collapse
|
9
|
Cuevas-Østrem M, Thorsen K, Wisborg T, Røise O, Helseth E, Jeppesen E. Care pathways and factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe traumatic brain injury: a population-based study from the Norwegian trauma registry. Scand J Trauma Resusc Emerg Med 2023; 31:34. [PMID: 37365649 DOI: 10.1186/s13049-023-01097-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals. METHODS A population-based cohort study from the national Norwegian Trauma Registry (2015-2020) of adult patients (≥ 16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head ≥ 3, AIS Body < 3 and maximum 1 AIS Body = 2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability. RESULTS The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P < 0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P < 0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤ 13: 55% vs. 27, P < 0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients < 77 years, and increasing NISSs until the effect was inverted at higher scores. Decreased transfer probability was significantly associated with increasing age and comorbidity, and distance between the acute care trauma hospital and the nearest neurotrauma center, except for extreme NISSs. CONCLUSIONS Acute care trauma hospitals managed a substantial burden of isolated moderate-to-severe TBI patients primarily and definitively, highlighting the importance of high-quality neurotrauma care in non-neurosurgical hospitals. The transfer probability declined with increasing age and comorbidity, suggesting that older patients were carefully selected for transfer to specialized care.
Collapse
Affiliation(s)
- Mathias Cuevas-Østrem
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.
- C/O Norwegian Air Ambulance Foundation, Postboks 414 Sentrum, Oslo, 0103, Norway.
| | - Kjetil Thorsen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Torben Wisborg
- INTEREST: Interprofessional Rural Research Team-Finnmark, Faculty of Health Sciences, University of Tromsø-the Arctic University of Norway, Hammerfest, Norway
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Hammerfest Hospital, Department of Anaesthesiology and Intensive Care, Finnmark Health Trust, Hammerfest, Norway
| | - Olav Røise
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eirik Helseth
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Elisabeth Jeppesen
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| |
Collapse
|
10
|
Jiang D, Chen T, Yuan X, Shen Y, Huang Z. Predictive value of the Trauma Rating Index in Age, Glasgow Coma Scale, Respiratory rate and Systolic blood pressure score (TRIAGES) and Revised Trauma Score (RTS) for the short-term mortality of patients with isolated traumatic brain injury: A retrospective study. Am J Emerg Med 2023; 71:175-181. [PMID: 37421814 DOI: 10.1016/j.ajem.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/23/2023] [Accepted: 06/17/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Ensuring rapid and precise mortality prediction in patients with traumatic brain injury (TBI) at the emergency department (ED) is paramount in patient triage and enhancing their outcomes. We aimed to estimate and compare the predictive power of the Trauma Rating Index in Age, Glasgow Coma Scale, Respiratory rate, and Systolic blood pressure score (TRIAGES) and Revised Trauma Score (RTS) for 24-h in-hospital mortality in patients with isolated TBI. METHODS We conducted a retrospective single-center study analyzing clinical data from 1156 patients with isolated acute TBI treated in the ED of the Affiliated Hospital of Nantong University from January 1, 2020, to December 31, 2020. We calculated each patient's TRIAGES and RTS scores and estimated their predictive value for short-term mortality using receiver operating characteristic (ROC) curves. RESULTS 87 patients (7.53%) died within 24 h of admission. The non-survival group had higher TRIAGES and lower RTS than the survival group. Compared to non-survivors, survivors exhibited higher Glasgow Coma Scale scores (GCS) with a median score of 15 (12, 15) compared to a median score of 4.0 (3.0, 6.0). The crude and adjusted odds ratios (ORs) for TRIAGES were 1.79, 95% CI (1.62 to 1.98) and 1.79, 95% CI (1.60 to 2.00), respectively. The crude and adjusted ORs for RTS were 0.39, 95% CI (0.33 to 0.45) and 0.40, 95% CI (0.34 to 0.47), respectively. The area under the ROC (AUROC) curve of TRIAGES, RTS, and GCS was 0.865 (0.844 to 0.884), 0.863 (0.842 to 0.882), and 0.869 (0.830 to 0.909), respectively. The optimal cut-off values for predicting 24-h in-hospital mortality were 3 for TRIAGES, 6.08 for RTS, and 8 for GCS. The subgroup analysis showed a higher AUROC in TRIAGES (0.845) compared to GCS (0.836) and RTS (0.829) among patients aged 65 and above, although the difference was not statistically significant. CONCLUSIONS TRIAGES and RTS have shown promising efficacy in predicting 24-h in-hospital mortality in patients with isolated TBI, with comparable performance to GCS. However, improving the comprehensiveness of assessment does not necessarily translate into an overall increase in predictive ability.
Collapse
Affiliation(s)
- Daishan Jiang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong City 226001, Jiangsu Province, China
| | - Tianxi Chen
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong City 226001, Jiangsu Province, China
| | - Xiaoyu Yuan
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong City 226001, Jiangsu Province, China
| | - Yanbo Shen
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong City 226001, Jiangsu Province, China.
| | - Zhongwei Huang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong City 226001, Jiangsu Province, China.
| |
Collapse
|
11
|
Aslani-Amoli B, Griffen M, Bauman K, Newcomb A, Kuo E, Stepanova M, Henry L, Howell JM. Expediting Treatment of Trauma Patients in the Emergency Department: Rapid Trauma Evaluation (RTE). J Emerg Med 2023; 64:429-438. [PMID: 36958994 DOI: 10.1016/j.jemermed.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 03/25/2023]
Abstract
BACKGROUND Criteria for trauma determination evolves. We developed/evaluated a Rapid Trauma Evaluation (RTE) process for a trauma patient subset not meeting preestablished trauma criteria. METHODS Retrospective study (July 2019 - May 2020) for patients either > 65 years with ground level fall within 24 hours or in a motorcycle collision (MCC) arriving by EMS not meeting ACS trauma-criteria. RTE process was immediate evaluation by nurse/EMT, room placement, physician notification, undressing/gowning, vital signs, head-to-toe assessment, upgrade trauma status. Number/type of admissions, discharges, trauma upgrades, LOS obtained via trauma-registry and chart-review. For comparison, historic controls (HC) were used [all patients meeting RTE criteria seen in the ED prior to RTE (Apr- June 2019)]. RESULTS The RTE cohort (n=755) was 77% falls,23% MCCs, median age 82 [IQR 74-88] years; 42% male-Among falls, 3.2% required a modified-upgrade; 0.7% full-upgrade, 55% admitted [29.4% trauma). HC (n=575) was 92.3% falls, 7.7% MCCs, median age 81 (IQR: 67-88) years, 40.5% males-57.4% admitted (22% trauma). RTE MCC median age 42 (IQR:30-49) years, 84.4% male- 21.9% were upgraded [(6 modified-trauma; 1 full-trauma; 43.8% admitted (85.7% trauma)]. HC MCC median age 29 (IQR: 23-41) years, 95.5% male, 54.5% admitted (75% trauma]. No difference on demographics, admissions or discharges between groups (P>0.05) except HC MCC was younger (P<0.005). RTE median LOS was shorter than HC [203 (IQR: 147-278) minutes vs. 286 (IQR: 205-392) minutes, P<0.001]. CONCLUSIONS Patients > 65 years with a ground level fall or in a MCC arriving via EMS not meeting ACS trauma criteria may benefit from RTE.
Collapse
Affiliation(s)
- Bahareh Aslani-Amoli
- Department of Emergency Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Margaret Griffen
- Department of Surgery, Inova Fairfax Hospital, Falls Church, Virginia
| | - Kara Bauman
- Department of Emergency Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Anna Newcomb
- Department of Surgery, Inova Fairfax Hospital, Falls Church, Virginia
| | - Elyse Kuo
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Maria Stepanova
- Inova Medicine Service Live, Inova Health Systems, Falls Church, Virginia
| | - Linda Henry
- Inova Medicine Service Live, Inova Health Systems, Falls Church, Virginia
| | - John M Howell
- Department of Emergency Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| |
Collapse
|
12
|
Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 278] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
Collapse
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
| | | |
Collapse
|
13
|
Barrett JW, Williams J, Griggs J, Skene S, Lyon R. 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. Brain Inj 2022; 36:841-849. [PMID: 35767716 DOI: 10.1080/02699052.2022.2093398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jack W Barrett
- Department of Research and Development, South East Coast Ambulance Service NHS Foundation Trust, Nexus House, Crawley, UK.,Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - Julia Williams
- Department of Research and Development, South East Coast Ambulance Service NHS Foundation Trust, Nexus House, Crawley, UK.,School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Joanna Griggs
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK.,Department of Research and Innovation, Air Ambulance Kent, Surrey, Sussex, Surrey, UK
| | - Simon Skene
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - Richard Lyon
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK.,Department of Research and Innovation, Air Ambulance Kent, Surrey, Sussex, Surrey, UK
| |
Collapse
|
14
|
Park N, Turcato G, Zaboli A, Santini M, Cipriano A. The state of the art of the management of anticoagulated patients with mild traumatic brain injury in the Emergency Department. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The effects of Oral Anticoagulation Therapy (OAT) in older patients who suffered a mild Traumatic Brain Injury (mTBI) are widely debated but still strong guidelines are lacking and clinical approaches and management are sometimes heterogeneous. Different predictors of adverse outcomes were identified in the literature but their use in the decision-making process is unclear. Moreover, there is no consensus on the appropriate length of stay in the Observation Unit nor on the continuation of OAT, even if the diagnosis of life-threatening delayed post-traumatic Intracranial Hemorrhage is rare. The recurrence of a control CT scan is often needless. This review aims to summarize recent scientific literature focusing on patients with mTBI taking OAT and to identify crucial questions on the topic to suggest a best clinical practice.
Collapse
|
15
|
Alqurashi N, Alotaibi A, Bell S, Lecky F, Body R. The diagnostic accuracy of prehospital triage tools in identifying patients with traumatic brain injury: A systematic review. Injury 2022; 53:2060-2068. [PMID: 35190184 DOI: 10.1016/j.injury.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/04/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prehospital care providers are usually the first responders for patients with traumatic brain injury (TBI). Early identification of patients with TBI enables them to receive trauma centre care, which improves outcomes. Two recent systematic reviews concluded that prehospital triage tools for undifferentiated major trauma have low accuracy. However, neither review focused specifically on patients with suspected TBI. Therefore, we aimed to systematically review the existing evidence on the diagnostic performance of prehospital triage tools for patients with suspected TBI. METHODS A comprehensive search of the current literature was conducted using Medline, EMBASE, CINAHL Plus and the Cochrane library (inception to 1st June 2021). We also searched Google Scholar, OpenGrey, pre-prints (MedRxiv) and dissertation databases. We included all studies published in English language evaluating the accuracy of prehospital triage tools for TBI. We assessed methodological quality and risk of bias using a modified Quality Assessment of Diagnostic Studies (QUADAS-2) tool. Two reviewers independently performed searches, screened titles and abstracts and undertook methodological quality assessments. Due to the heterogeneity in the population of interest and prehospital triage tools used, a narrative synthesis was undertaken. RESULTS The initial search identified 1787 articles, of which 8 unique eligible studies met the inclusion criteria (5 retrospective, 2 prospective, 1 mixed). Overall, sensitivity of triage tools studied ranged from 19.8% to 87.9% for TBI identification. Specificity ranged from 41.4% to 94.4%. Two decision tools have been validated more than once: HITS-NS (2 studies, sensitivity 28.3-32.6%, specificity 89.1-94.4%) and the Field Triage Decision Scheme (4 studies, sensitivity 19.8-64.5%, specificity 77.4%-93.1%). Existing tools appear to systematically under-triage older patients. CONCLUSION Further efforts are needed to improve and optimise prehospital triage tools. Consideration of additional predictors (e.g., biomarkers, clinical decision aids and paramedic judgement) may be required to improve diagnostic accuracy.
Collapse
Affiliation(s)
- Naif Alqurashi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK; Department of Accidents and Trauma, Prince Sultan bin Abdelaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia.
| | - Ahmed Alotaibi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Trust, Bolton, BL1 5DD, UK.
| | - Fiona Lecky
- University of Sheffield, School of Health and Related Research, Sheffield, UK.
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK; Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK.
| |
Collapse
|
16
|
Laic RAG, Vander Sloten J, Depreitere B. Traumatic brain injury in the elderly population: a 20-year experience in a tertiary neurosurgery center in Belgium. Acta Neurochir (Wien) 2022; 164:1407-1419. [PMID: 35267099 DOI: 10.1007/s00701-022-05159-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) rates in the elderly population are rapidly increasing worldwide. However, there are no clinical guidelines for the treatment of elderly TBI to date. This study aims at describing injury patterns and severity, clinical management, and outcomes in elderly TBI patients, which may contribute to specific prognostic tools and clinical guidelines in the future. METHODS Clinical records of 2999 TBI patients ≥ 65 years old admitted in the University Hospital Leuven (Belgium) between 1999 and 2019 were manually screened and 1480 cases could be included. Records were scrutinized for relevant clinical data. RESULTS The median age in the cohort was 78.0 years (IQR = 12). Falls represented the main accident mechanism (79.7%). The median Glasgow Coma Score on admission was 15 (range 3-15). Subdural hematomas were the most common lesion (28.4%). 90.1% of all patients were hospitalized and 27.0% were admitted to intensive care. 16.4% underwent a neurosurgical intervention. 11.0% of all patients died within 30 days post-TBI. Among the 521 patients with mild TBI, 28.6% were admitted to ICU and 13.1% had a neurosurgical intervention and 30-day mortality was 6.9%. CONCLUSION Over the 20-year study period, an increase of age and comorbidities and a reduction in neurosurgical interventions and ICU admissions were observed, along with a trend to less severe injuries but a higher proportion of treatment withdrawals, while at the same time mortality rates decreased. TBI is a life-changing event, leading to severe consequences in the elderly population, especially at higher ages. Even mild TBI is associated with substantial rates of hospitalization, surgery, and mortality in elderly. The characteristics of the elderly population with TBI are subject to changes over time.
Collapse
|
17
|
Young AA, Cooper E, Yaxley P, Habing G. Evaluation of geriatric trauma in dogs with moderate to severe injury (6169 cases): A VetCOT registry study. J Vet Emerg Crit Care (San Antonio) 2022; 32:386-396. [DOI: 10.1111/vec.13165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/17/2020] [Accepted: 07/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Anda A. Young
- Department of Veterinary Clinical Sciences The Ohio State University Columbus Ohio USA
| | - Edward Cooper
- Department of Veterinary Clinical Sciences The Ohio State University Columbus Ohio USA
| | - Page Yaxley
- Department of Veterinary Clinical Sciences The Ohio State University Columbus Ohio USA
| | - Greg Habing
- Department of Veterinary Clinical Sciences The Ohio State University Columbus Ohio USA
| |
Collapse
|
18
|
Bick H, Wasfie T, Labond V, Hella JR, Pearson E, Barber KR. Traumatic brain injury in the elderly with high Glasgow coma scale and low injury severity scores: Factors influencing outcomes. Am J Emerg Med 2021; 51:354-357. [PMID: 34808458 DOI: 10.1016/j.ajem.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Current trauma activation guidelines do not clearly address age as a risk factor when leveling trauma patients. Glasgow coma scale (GCS) and mode of injury play a major role in leveling trauma patients. We studied the above relationship in our elderly patients presenting with traumatic head injury. METHODS This study was a retrospective analysis of patients who presented to the emergency department with traumatic brain injuries. We classified the 270 patients into two groups. Group A was 64 years and younger, and group B was 65 years and older. Their GCS, ISS, age, sex, comorbidities, and anticoagulant use were abstracted. The primary outcome was mortality and length of stay. The groups were compared using an independent student's t-test and Chi-square analysis. The Cox regression analysis was used to analyze differences in the outcome while adjusting for the above factors. RESULTS There were 140 patients in group A, and 130 patients in group B who presented to the ED with a GCS of 14-15 and an ISS of below 15. The mean ISS significantly differed between group A (6.2 ± 6.8) vs (7.9 ± 3.2) in group B (p < 0.0001). The most common diagnosis in group A was concussion (57.3%), while in group B was subdural and subarachnoid hemorrhage (55%). In group B, 13.8% presented as a level one or level two trauma activation. The mean hospital and intensive care stay for group A was 2.1 (±1.9) days and 0.9 (±1.32) days, respectively, versus 4.2 (±3.04) days and 2.4 (±2.02 days) for the elderly group B. Mortality in group A was zero and in group B was 3.8%. Cox regression analysis showed age as an independent predictor of death as well as length of stay. CONCLUSION Elderly traumatic brain injury patients presenting to the ED with minor trauma and high GCS should be triaged at a higher level in most cases.
Collapse
Affiliation(s)
- Heather Bick
- Ascension Genesys Hospital, Emergency Department, Grand Blanc, MI, United States of America
| | - Tarik Wasfie
- Ascension Genesys Hospital, Department of Trauma Services, Grand Blanc, MI, United States of America.
| | - Virginia Labond
- Ascension Genesys Hospital, Emergency Department, Grand Blanc, MI, United States of America
| | - Jennifer R Hella
- Ascension Genesys Hospital, Department of Clinical & Academic Research, Grand Blanc, MI, United States of America
| | - Eric Pearson
- Ascension Genesys Hospital, Emergency Department, Grand Blanc, MI, United States of America
| | - Kimberly R Barber
- Ascension Genesys Hospital, Department of Clinical & Academic Research, Grand Blanc, MI, United States of America
| |
Collapse
|
19
|
Beck S, Kinnear FB, Maree Kelly A, Chu KH, Sen Kuan W, Keijzers G, Body R, Karamercan MA, Klim S, Wijeratne T, Kamona S, Graham CA, Roberts T, Horner D, Laribi S. Clinical presentation and assessment of older patients presenting with headache to emergency departments: A multicentre observational study. Australas J Ageing 2021; 41:126-137. [PMID: 34570422 DOI: 10.1111/ajag.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSION Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.
Collapse
Affiliation(s)
- Sierra Beck
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Emergency Department, Dunedin Hospital, Dunedin, New Zealand
| | - Frances B Kinnear
- Emergency & Children's Services, The Prince Charles Hospital, Chermside, Qld, Australia.,Department of Medicine, University of Queensland, St Lucia, Qld, Australia
| | - Anne Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health, Sunshine, Melbourne, Vic., Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Parkville, Vic., Australia
| | - Kevin H Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Qld, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Qld, Australia
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Qld, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia.,School of Medicine, Griffith University, Gold Coast, Qld, Australia
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mehmet A Karamercan
- Faculty of Medicine Department of Emergency Medicine, Gazi University, Ankara, Turkey
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health, Sunshine, Melbourne, Vic., Australia
| | - Tissa Wijeratne
- The University of Melbourne, Parkville, Australia.,Department of Neurology, Western Health, St Albans, Vic., Australia.,Public Health School, La Trobe University, Bundoora, Vic., Australia
| | - Sinan Kamona
- School of Medicine, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Colin A Graham
- Emergency Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR
| | - Tom Roberts
- Trainee Emergency Research Network (TERN), North Bristol NHS Trust, Bristol, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford, UK
| | - Said Laribi
- Emergency Medicine Department, Tours University Hospital, Tours, France.,EUSEM Research Network, Aartselaar, Belgium
| | | |
Collapse
|
20
|
Mehmood A, Rowther AA, Kobusingye O, Ssenyonjo H, Zia N, Hyder AA. Delays in emergency department intervention for patients with traumatic brain injury in Uganda. Trauma Surg Acute Care Open 2021; 6:e000674. [PMID: 34527810 PMCID: PMC8395360 DOI: 10.1136/tsaco-2021-000674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/20/2021] [Indexed: 11/03/2022] Open
Abstract
Background In Sub-Saharan African countries, the incidence of traumatic brain injury (TBI) is estimated to be many folds higher than the global average and outcome is hugely impacted by access to healthcare services and quality of care. We conducted an analysis of the TBI registry data to determine the disparities and delays in treatment for patients presenting at a tertiary care hospital in Uganda and to identify factors predictive of delayed treatment initiation. Methods The study was conducted at the Mulago National Referral Hospital, Kampala. The study included all patients presenting to the emergency department (ED) with suspected or documented TBI. Early treatment was defined as first intervention within 4 hours of ED presentation-a cut-off determined using sensitivity analysis to injury severity. Descriptive statistics were generated and Pearson's χ2 test was used to assess the sample distribution between treatment time categories. Univariable and multivariable logistic regression models with <0.05 level of significance were used to derive the associations between patient characteristics and early intervention for TBI. Results Of 3944 patients, only 4.6% (n=182) received an intervention for TBI management within 1 hour of ED presentation, whereas 17.4% of patients (n=708) received some treatment within 4 hours of presentation. 19% of those with one or more serious injuries and 18% of those with moderate to severe head injury received care within 4 hours of arrival. Factors independently associated with early treatment included young age, severe head injury, and no known pre-existing conditions, whereas older or female patients had significantly less odds of receiving early treatment. Discussion With the increasing number of patients with TBI, ensuring early and appropriate management must be a priority for Ugandan hospitals. Delay in initiation of treatment may impact survival and functional outcome. Gender-related and age-related disparities in care should receive attention and targeted interventions. Level of evidence Prognostic and epidemiological study; level II evidence.
Collapse
Affiliation(s)
- Amber Mehmood
- College of Public Health, University of South Florida, Tampa, Florida, USA.,International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Armaan Ahmed Rowther
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Olive Kobusingye
- Trauma, Injury, & Disability Unit, Makerere University's School of Public Health, Kampala, Uganda
| | | | - Nukhba Zia
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Adnan A Hyder
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA
| |
Collapse
|
21
|
Trauma Response for Elderly Anticoagulated Patients: An Initiative to Reduce Trauma Resource Utilization in the Emergency Department. J Trauma Nurs 2021; 28:159-165. [PMID: 33949350 DOI: 10.1097/jtn.0000000000000577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma centers are challenged to have appropriate criteria to identify injured patients needing a trauma activation; one population that is difficult to triage is injured elderly patients taking anticoagulation or antiplatelet (ACAP) medications with suspected head injury. OBJECTIVE The study purpose was to evaluate a hospital initiative to improve the trauma triage response for this population. METHODS A retrospective study at a Level I trauma center evaluated revised trauma response criteria. In Phase 1 (June 2017 to April 2018; n = 91), a limited activation occurred in the trauma bay for injured patients 55 years and older, taking ACAP medications with evidence of head injury. In Phase 2 (June 2018 to April 2019; n = 142), patients taking ACAP medications with evidence of head injury received a rapid emergency department (ED) response. Primary outcomes were timeliness of ED interventions and hospital admission rates. Differences between phases were assessed with Kruskal-Wallis tests. RESULTS An ED rapid response significantly reduced trauma team involvement (100%-13%, p < .001). Compared with Phase 1, patients in Phase 2 were more frequently discharged from the ED (48% vs. 68%, p = .003), and ED disposition decision was made more quickly (147 vs. 120 min, p = .01). In Phase 2, time to ED disposition decision was longer for patients who required hospital admission (108 vs. 179 min, p < .001); however, there were no significant differences between phases in reversal intervention (6% vs. 11%, p = .39) or timeliness of reversal intervention (49 vs. 118 min, p = .51). CONCLUSION The ED rapid response delivered safe, timely evaluation to injured elderly patients without overutilizing trauma team activations.
Collapse
|
22
|
Recalibrating the Glasgow Coma Score as an Age-Adjusted Risk Metric for Neurosurgical Intervention. J Surg Res 2021; 268:696-704. [PMID: 34487962 DOI: 10.1016/j.jss.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 07/15/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) score is the most frequently used neurologic assessment in traumatic brain injury (TBI). The risk for neurosurgical intervention based on GCS is heavily modified by age. The objective is to create a recalibrated Glasgow Coma Scale (GCS) score that accounts for an interaction by age and determine the predictive performance of the recalibrated GCS (rGCS) compared to the standard GCS for predicting neurosurgical intervention. METHODS This retrospective cohort study utilized the National Trauma Data Bank and included all patients admitted from 2010-2015 with TBI (ICD9 diagnosis code 850-854.19). The study population was divided into 2 subsets: a model development dataset (75% of patients) and a model validation dataset (remaining 25%). In the development dataset, logistic regression models were used to calculate conditional probabilities of having a neurosurgical intervention for each combination of age and GCS score, to develop a point-based risk score termed the rGCS. Model performance was examined in the validation dataset using area under the receiver operating characteristic (AUROC) curves and calibration plots. RESULTS There were 472,824 patients with TBI. The rGCS ranged from 1-15, where rGCS 15 denotes the baseline risk for neurosurgical intervention (4.4%) and rGCS 1 represents the greatest risk (62.6%). In the validation dataset there was a statistically significant improvement in predictive performance for neurosurgical intervention for the rGCS compared to the standard GCS (AUROC: 0.71 versus 0.67, difference, -0.04, P<0.001), overall and by trauma level designation. The rGCS was better calibrated than the standard GCS score. CONCLUSIONS The relationship between GCS score and neurosurgical intervention is significantly modified by age. A revision to the GCS that incorporates age, the rGCS, provides risk of neurosurgical intervention that has better predictive performance than the standard ED GCS score.
Collapse
|
23
|
Lecky FE, Otesile O, Marincowitz C, Majdan M, Nieboer D, Lingsma HF, Maegele M, Citerio G, Stocchetti N, Steyerberg EW, Menon DK, Maas AIR. The burden of traumatic brain injury from low-energy falls among patients from 18 countries in the CENTER-TBI Registry: A comparative cohort study. PLoS Med 2021; 18:e1003761. [PMID: 34520460 PMCID: PMC8509890 DOI: 10.1371/journal.pmed.1003761] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 10/12/2021] [Accepted: 08/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is an important global public health burden, where those injured by high-energy transfer (e.g., road traffic collisions) are assumed to have more severe injury and are prioritised by emergency medical service trauma triage tools. However recent studies suggest an increasing TBI disease burden in older people injured through low-energy falls. We aimed to assess the prevalence of low-energy falls among patients presenting to hospital with TBI, and to compare their characteristics, care pathways, and outcomes to TBI caused by high-energy trauma. METHODS AND FINDINGS We conducted a comparative cohort study utilising the CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) Registry, which recorded patient demographics, injury, care pathway, and acute care outcome data in 56 acute trauma receiving hospitals across 18 countries (17 countries in Europe and Israel). Patients presenting with TBI and indications for computed tomography (CT) brain scan between 2014 to 2018 were purposively sampled. The main study outcomes were (i) the prevalence of low-energy falls causing TBI within the overall cohort and (ii) comparisons of TBI patients injured by low-energy falls to TBI patients injured by high-energy transfer-in terms of demographic and injury characteristics, care pathways, and hospital mortality. In total, 22,782 eligible patients were enrolled, and study outcomes were analysed for 21,681 TBI patients with known injury mechanism; 40% (95% CI 39% to 41%) (8,622/21,681) of patients with TBI were injured by low-energy falls. Compared to 13,059 patients injured by high-energy transfer (HE cohort), the those injured through low-energy falls (LE cohort) were older (LE cohort, median 74 [IQR 56 to 84] years, versus HE cohort, median 42 [IQR 25 to 60] years; p < 0.001), more often female (LE cohort, 50% [95% CI 48% to 51%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001), more frequently taking pre-injury anticoagulants or/and platelet aggregation inhibitors (LE cohort, 44% [95% CI 42% to 45%], versus HE cohort, 13% [95% CI 11% to 14%]; p < 0.001), and less often presenting with moderately or severely impaired conscious level (LE cohort, 7.8% [95% CI 5.6% to 9.8%], versus HE cohort, 10% [95% CI 8.7% to 12%]; p < 0.001), but had similar in-hospital mortality (LE cohort, 6.3% [95% CI 4.2% to 8.3%], versus HE cohort, 7.0% [95% CI 5.3% to 8.6%]; p = 0.83). The CT brain scan traumatic abnormality rate was 3% lower in the LE cohort (LE cohort, 29% [95% CI 27% to 31%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001); individuals in the LE cohort were 50% less likely to receive critical care (LE cohort, 12% [95% CI 9.5% to 13%], versus HE cohort, 24% [95% CI 23% to 26%]; p < 0.001) or emergency interventions (LE cohort, 7.5% [95% CI 5.4% to 9.5%], versus HE cohort, 13% [95% CI 12% to 15%]; p < 0.001) than patients injured by high-energy transfer. The purposive sampling strategy and censorship of patient outcomes beyond hospital discharge are the main study limitations. CONCLUSIONS We observed that patients sustaining TBI from low-energy falls are an important component of the TBI disease burden and a distinct demographic cohort; further, our findings suggest that energy transfer may not predict intracranial injury or acute care mortality in patients with TBI presenting to hospital. This suggests that factors beyond energy transfer level may be more relevant to prehospital and emergency department TBI triage in older people. A specific focus to improve prevention and care for patients sustaining TBI from low-energy falls is required.
Collapse
Affiliation(s)
- Fiona E. Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Emergency Department, Salford Royal Hospital, Salford, United Kingdom
- * E-mail:
| | - Olubukola Otesile
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Carl Marincowitz
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Marek Majdan
- Department of Public Health, University of Trnava, Trnava, Slovakia
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marc Maegele
- Institute for Research in Operative Medicine, Witten/Herdecke University, Köln, Germany
| | - Giuseppe Citerio
- Neurointensive Care, Azienda Socio Sanitaria Territoriale di Monza, Monza, Italy
- School of Medicine and Surgery, Università degli Studi di Milano–Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - David K. Menon
- University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, Edegem, Belgium
| | | |
Collapse
|
24
|
Yadav K, Boucher V, Le Sage N, Malo C, Mercier É, Voyer P, Clément J, Émond M. A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults. Can J Surg 2021; 64:E339-E345. [PMID: 34085511 PMCID: PMC8327996 DOI: 10.1503/cjs.021519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 01/05/2023] Open
Abstract
Background Older patients (age ≥ 65 yr) with trauma have increased morbidity and mortality compared to younger patients; this is partly explained by undertriage of older patients with trauma, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. The objective of this study was to identify modifiers to the prehospital and emergency department phases of major trauma care for older adults based on expert consensus. Methods We conducted a modified Delphi study between May and September 2019 to identify major trauma care modifiers for older adults based on national expert consensus. The panel consisted of 24 trauma care professionals from across Canada from the prehospital and emergency department phases of care. The survey consisted of 16 trauma care modifiers. Three online survey rounds were distributed. Consensus was defined a priori as a disagreement index score less than 1. Results There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panellists. The panel achieved consensus agreement for 17 of the 19 trauma care modifiers. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate less than 10 or greater than 20 breaths/min or need for ventilatory support. The emergency department modifier with the strongest level of agreement was obtaining 12-lead electrocardiography following the primary and secondary survey. Conclusion Using a modified Delphi process, an expert panel agreed on 17 trauma care modifiers for older adults in the prehospital and emergency department settings. These modifiers may improve the delivery of trauma care for older adults and should be considered when developing local and national trauma guidelines.
Collapse
Affiliation(s)
- Krishan Yadav
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| | - Valérie Boucher
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| | - Natalie Le Sage
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| | - Christian Malo
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| | - Éric Mercier
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| | - Philippe Voyer
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| | - Julien Clément
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| | - Marcel Émond
- From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo)
| |
Collapse
|
25
|
Kim DK, Lee DH, Lee BK, Cho YS, Ryu SJ, Jung YH, Lee JH, Han JH. Performance of Modified Early Warning Score (MEWS) for Predicting In-Hospital Mortality in Traumatic Brain Injury Patients. J Clin Med 2021; 10:jcm10091915. [PMID: 33925023 PMCID: PMC8124302 DOI: 10.3390/jcm10091915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/19/2021] [Accepted: 04/22/2021] [Indexed: 11/25/2022] Open
Abstract
The present study aimed to analyze and compare the prognostic performances of the Revised Trauma Score (RTS), Injury Severity Score (ISS), Shock Index (SI), and Modified Early Warning Score (MEWS) for in-hospital mortality in patients with traumatic brain injury (TBI). This retrospective observational study included severe trauma patients with TBI who visited the emergency department between January 2018 and December 2020. TBI was considered when the Abbreviated Injury Scale was 3 or higher. The primary outcome was in-hospital mortality. In total, 1108 patients were included, and the in-hospital mortality was 183 patients (16.3% of the cohort). Receiver operating characteristic curve analyses were performed for the ISS, RTS, SI, and MEWS with respect to the prediction of in-hospital mortality. The area under the curves (AUCs) of the ISS, RTS, SI, and MEWS were 0.638 (95% confidence interval (CI), 0.603–0.672), 0.742 (95% CI, 0.709–0.772), 0.524 (95% CI, 0.489–0.560), and 0.799 (95% CI, 0.769–0.827), respectively. The AUC of MEWS was significantly different from the AUCs of ISS, RTS, and SI. In multivariate analysis, age (odds ratio (OR), 1.012; 95% CI, 1.000–1.023), the ISS (OR, 1.040; 95% CI, 1.013–1.069), the Glasgow Coma Scale (GCS) score (OR, 0.793; 95% CI, 0.761–0.826), and body temperature (BT) (OR, 0.465; 95% CI, 0.329–0.655) were independently associated with in-hospital mortality after adjustment for confounders. In the present study, the MEWS showed fair performance for predicting in-hospital mortality in patients with TBI. The GCS score and BT seemed to have a significant role in the discrimination ability of the MEWS. The MEWS may be a useful tool for predicting in-hospital mortality in patients with TBI.
Collapse
|
26
|
The features of the typical traumatic brain injury patient in the ICU are changing: what will this mean for the intensivist? Curr Opin Crit Care 2021; 27:80-86. [PMID: 33534257 DOI: 10.1097/mcc.0000000000000814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe the key features and epidemiology of traumatic brain injury (TBI) and how they may be changing, with an emphasis on how this may affect care in the intensive care unit. RECENT FINDINGS TBI has been traditionally perceived as occurring mainly in a younger, predominantly male population injured in high velocity motor vehicle crashes or assaults. However, there are an increasing number of patients over 65 years who have sustained a TBI secondary to low velocity falls. Considering the effects of frailty, comorbidities and extracranial injuries is important when making management decisions. Mild TBI comprises a third of those admitted and as a significant proportion may have poor outcomes secondary to their TBI they should be assessed to ensure appropriate follow-up. Multimodal monitoring may offer a way in the future to offer more personalised management to this very complex and heterogeneous patient group. SUMMARY This review highlights the urgent need to develop more age-inclusive TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing TBI population. Being elderly does not necessarily portend a poor outcome, and more research is needed to better triage, guide management and prognosticate on these patients.
Collapse
|
27
|
Salottolo K, Panchal R, Madayag RM, Dhakal L, Rosenberg W, Banton KL, Hamilton D, Bar-Or D. Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000641. [PMID: 33634212 PMCID: PMC7880096 DOI: 10.1136/tsaco-2020-000641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/05/2021] [Accepted: 01/29/2021] [Indexed: 12/19/2022] Open
Abstract
Background The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories. Methods The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves. Results The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients. Discussion We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury. Level of evidence III epidemiologic/prognostic.
Collapse
Affiliation(s)
| | - Ripul Panchal
- Neurosurgery, Medical Center of Plano, Plano, Texas, USA
| | - Robert M Madayag
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Laxmi Dhakal
- Neurosurgery, Wesley Medical Center, Wichita, Kansas, USA
| | | | - Kaysie L Banton
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - David Hamilton
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado, USA
| | - David Bar-Or
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
| |
Collapse
|
28
|
Fuller G, Pandor A, Essat M, Sabir L, Buckley-Woods H, Chatha H, Holt C, Keating S, Turner J. Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review. J Trauma Acute Care Surg 2021; 90:403-412. [PMID: 33502151 DOI: 10.1097/ta.0000000000003039] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care. METHODS Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings. RESULTS Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting. CONCLUSION Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds. LEVEL OF EVIDENCE Systematic review, level III.
Collapse
Affiliation(s)
- Gordon Fuller
- From the School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, South Yorkshire, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Alshibani A, Singler B, Conroy S. Towards improving prehospital triage for older trauma patients. Z Gerontol Geriatr 2021; 54:125-129. [PMID: 33507358 DOI: 10.1007/s00391-021-01844-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/05/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The proportion of older adults with major trauma is increasing. High-quality care for this population requires accurate and effective prehospital trauma triage decisions. OBJECTIVE Anatomical and physiological changes with age, comorbidities, and medication use for older adults may affect the accuracy of prehospital trauma triage. MATERIAL AND METHODS This narrative review focusses on age-related anatomical and physiological changes, comorbidities, and medication use for older adults with an emphasis on their impact on the accuracy of prehospital trauma triage tools. It also addresses the efforts to develop alternative triage criteria to reduce undertriage. RESULTS Age-related anatomical and physiological changes, comorbidities, and medication use were shown to affect physiological responses to injury and mechanism of injury for older people. Current triage tools poorly predicted injury severity. Geriatric-specific physiological measures and comorbidities significantly improved sensitivity with much lower specificity. Assessing anticoagulant or antiplatelet use in head injury notably improved sensitivity to identify traumatic intracranial hemorrhage, neurosurgery or death with modest decrease in specificity. CONCLUSION Improving prehospital providers' knowledge about the challenges of assessing older people with trauma may reduce undertriage. Assessing frailty could help in improving prehospital providers' judgments. Future research is needed to improve triage decisions for this population.
Collapse
Affiliation(s)
- Abdullah Alshibani
- Department of Health Sciences, College of Life Sciences, University of Leicester, LE1 7HA, Leicester, UK.
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Boris Singler
- Zweckverband für Rettungsdienst und Feuerwehralarmierung, Hauptmarkt 16, 90403, Nürnberg, Germany
- Klinik Hallerwiese/Cnopfsche Kinderklinik, Sankt-Johannis-Mühlgasse 19, 90419, Nürnberg, Germany
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, LE1 7HA, Leicester, UK
| |
Collapse
|
30
|
Moyron RB, Vallejos PA, Fuller RN, Dean N, Wall NR. Neuroimaging and advanced research techniques may lead to improved outcomes in military members suffering from traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000608. [PMID: 33490604 PMCID: PMC7797256 DOI: 10.1136/tsaco-2020-000608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/07/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Recent military conflicts in Iraq and Afghanistan have resulted in the significant increase in blast-related traumatic brain injury (TBI), leading to increased Department of Defense interest in its potential long-term effects ranging from the mildest head injuries termed subconcussive trauma to the most debilitating termed chronic traumatic encephalopathy (CTE). Most patients with mild TBI will recover quickly while others report persistent symptoms called postconcussive syndrome. Repeated concussive and subconcussive head injuries result in neurodegenerative conditions that may hinder the injured for years. Fundamental questions about the nature of these injuries and recovery remain unanswered. Clinically, patients with CTE present with either affective changes or cognitive impairment. Genetically, there have been no clear risk factors identified. The discovery that microglia of the cerebral cortex discharged small extracellular vesicles in the injured and adjacent regions to a TBI may soon shed light on the immediate impact injury mechanisms. The combination of neuroimaging and advanced research techniques may, one day, fill critical knowledge gaps and lead to significant TBI research and treatment advancements.
Collapse
Affiliation(s)
- Ron B Moyron
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Paul A Vallejos
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Ryan N Fuller
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Natasha Dean
- Department of Biology, La Sierra University, Riverside, California, USA
| | - Nathan R Wall
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| |
Collapse
|
31
|
Razik MA, Alslimah FA, Alghamdi KS, Altamimi MA, Alzhrani AA, Alqahtani NM, Alshalawi SM. The severity of fall injuries in Saudi Arabia: a cross-sectional study. Pan Afr Med J 2020; 36:152. [PMID: 32874416 PMCID: PMC7436634 DOI: 10.11604/pamj.2020.36.152.23944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction fall injuries constitute a major public health concern worldwide, contributing to over 646,000 deaths every year. The aim of this study was to determine the nature and severity of fall injuries at a tertiary hospital in the Kingdom of Saudi Arabia (KSA). Methods we conducted a cross-sectional study at the King Khalid Hospital and Prince Sultan Centre for Health Care in Al Kharj. We recruited the patients and followed them through the triage, admission and discharge processes. We analyzed the participant´s clinical notes on the electronic health record (EHR) to obtain information relevant to the study, including the nature, cause, mechanism of injury, demographic characteristics and prognostic factors captured through the injury severity score (ISS), the Glasgow coma scale (GCS) and the presence or absence of shock. Results of 264 patients, most of the patients were children under the age of ten (25.7%), followed by young adults between the ages of twenty-one and thirty (18.2%). The ISS was associated with severe head, chest, skull, brain, scalp, rib, abdominal, pelvic and lower limb injuries. The GCS was associated with severe the head, chest, skull, brain and rib injuries (p<0.005). The degree of shock was also significantly associated with pelvic, head, chest, skull, brain, scalp, abdominal and upper limb injuries (p<0.05). Conclusion: fall injuries in our setting are severe. Training of staff should prioritize head, chest, skull, brain, abdominal and rib injury management. As a reference hospital, minor injuries are more likely to be managed at lower levels of care.
Collapse
Affiliation(s)
- Mohamed Abdel Razik
- General Surgery Department, College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | | | | | - Adel Ahmed Alzhrani
- College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | | |
Collapse
|
32
|
Cuevas-Østrem M, Røise O, Wisborg T, Jeppesen E. Geriatric Trauma - A Rising Tide. Assessing Patient Safety Challenges in a Vulnerable Population Using Norwegian Trauma Registry Data and Focus Group Interviews: Protocol for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e15722. [PMID: 32352386 PMCID: PMC7226039 DOI: 10.2196/15722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 12/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level. OBJECTIVE The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system. METHODS This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes. RESULTS The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020. CONCLUSIONS By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/15722.
Collapse
Affiliation(s)
- Mathias Cuevas-Østrem
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Olav Røise
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Torben Wisborg
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Elisabeth Jeppesen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| |
Collapse
|
33
|
Lampart A, Kuster T, Nickel CH, Bingisser R, Pedersen V. Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low-Energy Falls. J Am Geriatr Soc 2020; 68:977-982. [PMID: 32142155 DOI: 10.1111/jgs.16400] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 01/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Alina Lampart
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Kuster
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Roland Bingisser
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Vera Pedersen
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland.,Department for General, Trauma and Reconstructive Surgery, Ludwig Maximilian University Munich, Munich, Germany
| |
Collapse
|
34
|
Dixon JR, Lecky F, Bouamra O, Dixon P, Wilson F, Edwards A, Eardley W. Age and the distribution of major injury across a national trauma system. Age Ageing 2020; 49:218-226. [PMID: 31763677 PMCID: PMC7047820 DOI: 10.1093/ageing/afz151] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/30/2019] [Indexed: 12/29/2022] Open
Abstract
Background Trauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution. Objectives There is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between. Methods The TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England. Results About 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs. Conclusions Within adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.
Collapse
Affiliation(s)
- Jan Robert Dixon
- Newcastle University School of Medicine, Newcastle University, Cookson Building, Newcastle Upon Tyne NE2 4HH, UK
| | - Fiona Lecky
- Trauma Audit and Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | - Omar Bouamra
- Trauma Audit and Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Paul Dixon
- Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Faye Wilson
- Department for Care of the Elderly, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Will Eardley
- Department of Trauma and Orthopaedics, James Cook University Hospital, Marton Road Middlesbrough, TS4 3BW, UK
- York Clinical Trials Unit, Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York YO105 DD, UK
| |
Collapse
|
35
|
Ruge T, Carlsson AC, Hellstrom M, Wihlborg P, Undén J. Is medical urgency of elderly patients with traumatic brain injury underestimated by emergency department triage? Ups J Med Sci 2020; 125:58-63. [PMID: 31986958 PMCID: PMC7054978 DOI: 10.1080/03009734.2019.1706674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: Mortality is high among elderly patients with traumatic brain injury (TBI). Recent data suggest that early surgical intervention and aggressive rehabilitation may reduce mortality rates even in elderly patients. Our aim was therefore to study the Rapid Emergency Triage and Treatment System-Adult (RETTS-A) triage of patients with isolated TBI and examine the differences in acute management according to age.Methods: We included 306 adult patients with isolated severe TBI and an abbreviated injury scale (AIS) score ≥3. Using a cut-off of 60 years of age, differences in triage priority according to RETTS-A, time to first computed tomography (CT) scan, length of hospital stay (LOS), and 30-day survival were studied.Results: In patients with an AIS score of 3 and 4, we observed that elderly patients had a longer time from admission to first CT scan. In addition, we observed that elderly patients were less often triaged with the highest priority level, despite similar AIS scores. LOS was significantly higher in elderly patients (median 9 days compared with 3 days for younger patients, p < 0.001). Finally, age, triage priority, and AIS score were independent risk factors for mortality.Conclusion: Elderly patients with isolated TBI are managed differently than younger patients, which could be due to an under-triage of elderly patients by RETTS-A.
Collapse
Affiliation(s)
- Toralph Ruge
- Department of Clinical Sciences Malmö, University Hospital of Skåne, Sweden
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- CONTACT Toralph Ruge Department of Emergency Medicine, Karolinska University Hospital, Huddinge, 171 76 Stockholm, Sweden
| | - Axel C. Carlsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden
| | - Magnus Hellstrom
- Department of Surgical and Perioperative Science, Umeå University, Umeå, Sweden
| | - Per Wihlborg
- Department of Clinical Sciences Malmö, University Hospital of Skåne, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Halmstad Hospital, Halmstad, Sweden
- Anaesthesiology and Intensive Care Medicine, Lund University, Lund, Sweden
| |
Collapse
|
36
|
Beck B, Cameron PA, Braaf S, Nunn A, Fitzgerald MC, Judson RT, Teague WJ, Lennox A, Middleton JW, Harrison JE, Gabbe BJ. Traumatic spinal cord injury in Victoria, 2007-2016. Med J Aust 2020; 210:360-366. [PMID: 31055854 DOI: 10.5694/mja2.50143] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/26/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10-year period. DESIGN, SETTING, PARTICIPANTS Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007-2016. MAIN OUTCOMES AND MEASURES Temporal trends in population-based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more). RESULTS There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17-1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99-1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4-15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in-hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths). CONCLUSIONS Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post-discharge care, and support.
Collapse
Affiliation(s)
- Ben Beck
- Monash University, Melbourne, VIC
| | - Peter A Cameron
- Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | | | - Andrew Nunn
- Monash University, Melbourne, VIC.,Victorian Spinal Cord Service, Austin Hospital, Melbourne, VIC
| | - Mark C Fitzgerald
- The Alfred Hospital, Melbourne, VIC.,National Trauma Research Institute, Melbourne, VIC
| | - Rodney T Judson
- Royal Melbourne Hospital, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Warwick J Teague
- University of Melbourne, Melbourne, VIC.,Royal Children's Hospital, Melbourne, VIC.,Murdoch Children's Research Institute, Melbourne, VIC
| | | | - James W Middleton
- Kolling Institute, University of Sydney, Sydney, NSW.,Agency for Clinical Innovation, Sydney, NSW
| | - James E Harrison
- Research Centre for Injury Studies, Flinders University, Adelaide, SA
| | - Belinda J Gabbe
- Monash University, Melbourne, VIC.,Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, United Kingdom
| |
Collapse
|
37
|
Ţolescu RŞ, Zorilă MV, Şerbănescu MS, Kamal KC, Zorilă GL, Dumitru I, Florou C, Mogoantă L, Văduva IA, Stanca L, Zăvoi RE. Severe traumatic brain injury (TBI) - a seven-year comparative study in a Department of Forensic Medicine. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2020; 61:95-103. [PMID: 32747899 PMCID: PMC7728107 DOI: 10.47162/rjme.61.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/24/2020] [Indexed: 11/08/2022]
Abstract
Deaths caused by traumatic brain injury (TBI) increase in incidence every year worldwidely, mainly in developing countries. Thus, World Health Organization (WHO) estimates that in 2020, TBI will become the third main cause of death. In our study, we evaluated the deaths caused by TBI recorded within the Institute of Forensic Medicine of Craiova, Romania, between 2011 and 2017. Therefore, according to age, the cases were divided into two groups: people aged 0-18 years old (including 18 years old) and people aged over 18 years old (a total of 1005 cases, of which 971 were adults and 34 included in the age group 0-18 years old). In both groups, most patients were males from the rural area. In adults, falling was the main legal entity of the cases, followed by car accidents (which were the most common in children). In both groups, in car accidents, most of them were pedestrians and car occupants. Various aggressions (human, animal, self-injury) were found in 94 (9.68%) of the adult cases and in four (11.76%) cases of children. Another parameter under study was the blood alcohol concentration, being observed that most of the subjects with positive blood alcohol content died from car accidents. By evaluating the Glasgow Coma Scale (GCS) score as a prognostic factor, most of the subjects presented third and fourth degree coma at admission; still, 5.14% of the adult patients who deceased had GCS score 15 at admission, death occurring probably by developing some intracranial hematomas in time. Regarding the morphology of the lesions, most patients presented various forms of cranial fractures, 185 (19.05%) adults in association with extradural hemorrhages∕hematomas, but also there were four cases with extradural hematomas without any cranial fractures. In children, there was highlighted a single case of extradural hemorrhage under the fracture line. Seventy-eight percent of the adults and 44.12% of children presented subdural hematomas associated with other meningo-cerebral lesions. Also, 83.63% of the adults and 97% of children presented brain contusions. In both groups, brain laceration was observed in approximately 50% of the cases.
Collapse
Affiliation(s)
- Răzvan Ştefan Ţolescu
- PhD Student, Department of Histology, University of Medicine and Pharmacy of Craiova, Romania
| | - Marian Valentin Zorilă
- Department of Forensic Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Mircea-Sebastian Şerbănescu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy of Craiova, Romania
| | | | - George Lucian Zorilă
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
| | - Ilie Dumitru
- Department of Road Vehicles, Transportation and Industrial Engineering, Faculty of Mechanics, University of Craiova, Romania
| | - Charoula Florou
- Department of Forensic Pathology, Faculty of Medicine, University of Thessaly, Greece
| | - Laurenţiu Mogoantă
- Department of Histology, University of Medicine and Pharmacy of Craiova, Romania
| | - Ion Alexandru Văduva
- PhD Student, Department of Histology, University of Medicine and Pharmacy of Craiova, Romania
| | - Liliana Stanca
- Department of Forensic Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Roxana Eugenia Zăvoi
- Department of Forensic Medicine, University of Medicine and Pharmacy of Craiova, Romania
| |
Collapse
|
38
|
Zhang W, Qin Z, Xian K, Tang S. Assessment of plasma homocysteine levels in patients with craniocerebral injury and prognosis. J Int Med Res 2019; 48:300060519882202. [PMID: 31852292 PMCID: PMC7607269 DOI: 10.1177/0300060519882202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To investigate the effect of plasma homocysteine (Hcy) and C-reactive protein
(CRP) levels in patients with craniocerebral injury. Methods A retrospective analysis of data from patients with craniocerebral injury who
underwent surgery. Patients were stratified according to the extent of the
craniocerebral injury into severe, moderate and mild craniocerebral injury
groups. Serum Hcy and CRP levels were determined at admission, at 7 days
after treatment and at 3 months after injury. Univariate and multivariate
Cox regression analyses were undertaken to identify prognostic factors. Results The study enrolled 96 patients: 29 patients with mild injury; 33 patients
with moderate injury; and 34 patients with severe injury. Serum Hcy and CRP
levels at admission were significantly higher in the severe craniocerebral
injury group than in the other two groups; and they were significantly
higher the moderate craniocerebral injury group compared with the mild
craniocerebral injury group. Serum Hcy and CRP levels of the three groups of
patients were significantly lower after 7 days of treatment than those
before treatment. The levels of Hcy and CRP were positively correlated in
all three groups. Conclusion Serum Hcy and CRP levels in patients could be used to monitor the condition
and prognosis of patients with craniocerebral injury.
Collapse
Affiliation(s)
- Wenjia Zhang
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
| | - Zhongqiao Qin
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
| | - Kecong Xian
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
| | - Shuhong Tang
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
| |
Collapse
|
39
|
Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. Older age is associated with a reduced likelihood of ambulance transport to a trauma centre after major trauma in Perth. Emerg Med Australas 2019; 31:763-771. [PMID: 30827060 DOI: 10.1111/1742-6723.13244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 11/28/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the characteristics and outcomes of older adult (≥65 years) major trauma patients in comparison with younger adults (16-64 years). To determine whether older age is associated with a reduced likelihood of transport (directly or indirectly) to a major trauma centre and whether this is associated with in-hospital mortality. METHODS A retrospective cohort study of major trauma patients transported to hospital by St John Ambulance paramedics in Perth, Western Australia, between 1 January 2013 and 31 December 2016. Multivariate logistic regression was used to test the relationship between age and major trauma centre transport. Multivariate logistic regression analysis using inverse probability of treatment weighting was used to determine if major trauma centre transport was associated with in-hospital mortality in older adults. RESULTS One thousand six hundred and twenty-five patients were included; of these 576 (35%) were ≥65 years. In comparison with younger adults, older adults had more falls as their mechanism of injury (n = 358 [62%] versus n = 102 [10%], P ≤ 0.001) and more major head injuries (n = 472 [82%] versus n = 609 [58%], P ≤ 0.001). Older adults had lower odds (adjusted odds ratio 0.52, 95% confidence interval [CI] 0.35-0.78) of major trauma centre transport and this was associated with 1.7 times the likelihood of in-hospital mortality (95% CI 1.04-2.7). CONCLUSIONS Older adults who were not transported to the trauma centre had an increased odds of in-hospital mortality. However, older age was associated with a significantly reduced likelihood of trauma centre transport. With the aging population, the development of specific prehospital triage criteria to enable the complexities of this higher-risk population to be identified is important.
Collapse
Affiliation(s)
- Elizabeth Brown
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul Bailey
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia.,Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia
| | - Daniel Fatovich
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Gavin Pereira
- School of Public Health, Curtin University, Perth, Western Australia, Australia.,Telethon Kids Institute, Perth, Western Australia, Australia
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
40
|
Barrett JW. A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England. Br Paramed J 2019; 3:1-7. [PMID: 33328810 PMCID: PMC7706740 DOI: 10.29045/14784726.2019.03.3.4.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU). METHOD All patients with a primary injury of TBI who were transported to hospital by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) from 1 January 2016 to 31 December 2016 and entered into the Trauma Audit & Research Network (TARN) registry were reviewed. Patients were stratified by hospital designation (MTC or TU). Severity of TBI was categorised using the patients' pre-hospital Glasgow Coma Scale (GCS) and Abbreviated Injury Score (AIS) Head. The outcomes of interest were 30-day mortality and Glasgow Outcome Score (GOS) at discharge. RESULTS Between 1 January and 31 December 2016, 549 TBI patients were identified in the TARN database as being transported by SECAmb to either an MTC or a TU. The majority of patients were transported to a TU (77.96%), and the median age of the TU cohort was older than the MTC group (TU 82.15 IQR 16.73 vs. MTC 62.1 IQR 42.6). The median Injury Severity Score (ISS) was greater in the MTC cohort (22 IQR 10 vs. 17 IQR 9), where falls from height and road traffic collisions (RTCs) contributed to 50.51% of all injuries. Within the TU cohort, falls from less than 2 metres (standing height) were the main mechanism of injury (MOI) (77.62%). The median length of hospital stay (LOS) was longer in the MTC cohort compared to the TU cohort (10 IQR 13.25 vs. 8 IQR 14). CONCLUSION The high proportion of mild TBI and absence of reliable triage guidelines make it difficult for ambulance clinicians to identify patients who will benefit from transport to an MTC. Future research should focus on how TBI triage influences outcomes and how ambulance services can better identify patients with a TBI and who would benefit from specialist care.
Collapse
|
41
|
Stocker RA. Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection. Med Sci (Basel) 2019; 7:medsci7030037. [PMID: 30813644 PMCID: PMC6473302 DOI: 10.3390/medsci7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.
Collapse
Affiliation(s)
- Reto A Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, CH-8032 Zurich, Switzerland.
| |
Collapse
|
42
|
Pélieu I, Kull C, Walder B. Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury. Med Sci (Basel) 2019; 7:E12. [PMID: 30669658 PMCID: PMC6359668 DOI: 10.3390/medsci7010012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/12/2019] [Accepted: 01/19/2019] [Indexed: 02/06/2023] Open
Abstract
Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.
Collapse
Affiliation(s)
- Iris Pélieu
- Division of Anaesthesiology, University Hospitals of Geneva, 12011 Geneva, Switzerland.
| | - Corey Kull
- Division of Anaesthesiology, University Hospitals of Geneva, 12011 Geneva, Switzerland.
| | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva, 12011 Geneva, Switzerland.
| |
Collapse
|
43
|
Van den Brand CL, Karger LB, Nijman STM, Hunink MGM, Patka P, Jellema K. Traumatic brain injury in the Netherlands, trends in emergency department visits, hospitalization and mortality between 1998 and 2012. Eur J Emerg Med 2019; 25:355-361. [PMID: 28266943 DOI: 10.1097/mej.0000000000000457] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. The effects of epidemiological changes such as ageing of the population and increased traffic safety on the incidence of TBI are unknown. OBJECTIVE The objective of this study was to evaluate trends in TBI-related emergency department (ED) visits, hospitalization and mortality in the Netherlands between 1998 and 2012. DESIGN This was a retrospective observational, longitudinal study. MAIN OUTCOME MEASURES The main outcome measures were TBI-related ED visits, hospitalization and mortality. RESULTS Between 1998 and 2012, there were 500 000 TBI-related ED visits in the Netherlands. In the same period, there were 222 000 TBI-related admissions and 17 000 TBI-related deaths. During this period, there was a 75% increase in ED visits for TBI and a 95% increase for TBI-related hospitalization; overall mortality because of TBI did not change significantly. Despite the overall increase in TBI-related ED visits, this increase was not evenly distributed among age groups or trauma mechanisms. In patients younger than 65 years, a declining trend in ED visits for TBI caused by road traffic accidents was observed. Among patients 65 years or older, ED visits for TBI caused by a fall increased markedly. TBI-related mortality shifted from mainly young (67%) and middle-aged individuals (<65 years) to mainly elderly (63%) individuals (≥65 years) between 1998 and 2012. The conclusions of this study did not change when adjusting for changes in age, sex and overall population growth. CONCLUSION The incidence of TBI-related ED visits and hospitalization increased markedly between 1998 and 2012 in the Netherlands. TBI-related mortality occurred at an older age. These observations are probably the result of a change in aetiology of TBI, specifically a decrease in traffic accidents and an increase in falls in the ageing population. This hypothesis is supported by our data. However, ageing of the population is not the only cause of the changes observed; the observed changes remained significant when correcting for age and sex. The higher incidence of TBI with a relatively stable mortality rate highlights the importance of clinical decision rules to identify patients with a high risk of poor outcome after TBI.
Collapse
Affiliation(s)
| | | | | | - Myriam G M Hunink
- Radiology, Erasmus MC, Rotterdam, The Netherlands.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | |
Collapse
|
44
|
Lindfors M, Vehviläinen J, Siironen J, Kivisaari R, Skrifvars MB, Raj R. Temporal changes in outcome following intensive care unit treatment after traumatic brain injury: a 17-year experience in a large academic neurosurgical centre. Acta Neurochir (Wien) 2018; 160:2107-2115. [PMID: 30191364 DOI: 10.1007/s00701-018-3670-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/31/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of morbidity and mortality. However, it remains undetermined whether long-term outcomes after TBI have improved over the past two decades. METHODS We conducted a retrospective analysis of consecutive TBI patients admitted to an academic neurosurgical ICU during 1999-2015. Primary outcomes of interest were 6-month all-cause mortality (available for all patients) and 6-month Glasgow Outcome Scale (GOS, available from 2005 onwards). GOS was dichotomized to favourable and unfavourable functional outcome. Temporal changes in outcome were assessed using multivariate logistic regression analysis, adjusting for age, sex, GCS motor score, pupillary light responsiveness, Marshall CT classification and major extracranial injury. RESULTS Altogether, 3193 patients were included. During the study period, patient age and admission Glasgow Coma Scale score increased, while the overall TBI severity did not change. Overall unadjusted 6-month mortality was 25% and overall unadjusted unfavourable outcome (2005-2015) was 44%. There was no reduction in the adjusted odds of 6-month mortality (OR 0.98; 95% CI 0.96-1.00), but the adjusted odds of favourable functional outcome significantly increased (OR 1.08; 95% CI 1.04-1.11). Subgroup analysis showed outcome improvements only in specific subgroups (conservatively treated patients, moderate-to-severe TBI patients, middle-aged patients). CONCLUSIONS During the past two decades, mortality after significant TBI has remained largely unchanged, but the odds of favourable functional outcome have increased significantly in specific subgroups, implying an improvement in quality of care. These developments have been paralleled by notable changes in patient characteristics, emphasizing the importance of continuous epidemiological monitoring.
Collapse
|
45
|
One-year outcome following brain injury: a comparison of younger versus elderly major trauma patients. Arch Orthop Trauma Surg 2018; 138:1375-1387. [PMID: 29948226 DOI: 10.1007/s00402-018-2974-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Indexed: 10/14/2022]
Abstract
INTRODUCTION The increasing number of older trauma patients has provoked a debate on the need for subsequent rehabilitative therapy for the elderly. Our findings revealed a lack of detailed data on this topic so we became interested in the effective differences in the longer-term outcomes for older and younger major trauma patients with TBI. As validation studies on the recently published specific Quality of Life after Brain Injury (QOLIBRI) have only involved patients under the age of 68 years, we focused on testing this score in comparison to other outcome measures. MATERIALS AND METHODS Prospective cohort study of the differences in 1-year functional or health-related quality of life (HRQoL) outcomes, such as the Glasgow Outcome Score (GOS), the Quality of Life after Brain Injury (QOLIBRI) score or the medical outcomes study Short Form-36 (SF-36) between younger (16-64 years) and elderly (> 65 years) adults following major trauma (New Injury Severity Score, NISS ≥ 8) with TBI (Abbreviated Injury Scale, AIS head > 0). RESULTS Out of 326 TBI patients with a mean NISS of 20.6 ± 9.4 34% (n = 110 (33.7%)) were aged 65 or older versus n = 216 (66.3%) who were younger. Comparison of 1-year outcomes revealed no differences between younger versus elderly patients with regard to functional or HRQoL scores (e.g. total QOLIBRI 77.4 ± 20.0 and 75.6 ± 18.1, resp.). Univariate analysis showed no correlation of the total QOLIBRI with age (Pearson r = - 0.09) or trauma severity (AIS) of the head (r = - 0.05). Multivariate analysis confirmed an association of age 80 or older (R2 = 0.026, p = 0.029), but not of overall age (R2 = 0.004, p = 0.218) with 1-year outcome scores on the total QOLIBRI. CONCLUSIONS Given the rising rehabilitation demands of the elderly these pilot findings call for the utilisation of specific outcome scores such as the QOLIBRI in this age group as well, at least up to an age of 80 years and independently of the severity of TBI sustained.
Collapse
|
46
|
Moradi Moghadam O, Nematollahi N, Shiri Malek Abad E, Hasani V, Tabibkhooei A, Sheikhvatan M, Niakan Lahiji M. Effect of Modafinil Administration on the Level of Consciousness in Patients with Brain Injuries of Moderate Severity. Trauma Mon 2018; 24. [DOI: 10.5812/traumamon.61505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 12/24/2017] [Accepted: 01/09/2018] [Indexed: 07/04/2024] Open
|
47
|
Born K, Amsler F, Gross T. Prospective evaluation of the Quality of Life after Brain Injury (QOLIBRI) score: minor differences in patients with major versus no or mild traumatic brain injury at one-year follow up. Health Qual Life Outcomes 2018; 16:136. [PMID: 29986710 PMCID: PMC6038178 DOI: 10.1186/s12955-018-0966-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/02/2018] [Indexed: 02/02/2023] Open
Abstract
Background The Quality of Life after Brain Injury (QOLIBRI) score was developed to assess disease-specific health-related quality of life (HRQoL) after traumatic brain injury (TBI). So far, validation studies on the QOLIBRI were only conducted in cohorts with traumatic brain injury. This study investigated the longer-term residuals in severely injured patients, focusing specifically on the possible impact of major TBI. Methods In a prospective questionnaire investigation, 199 survivors with an injury severity score (ISS) > 15 participated in one-year follow-up. Patients who had sustained major TBI (abbreviated injury scale, AIS head > 2) were compared with patients who had no or only mild TBI (AIS head ≤ 2). Univariate analysis (ANOVA, Cohen’s kappa, Pearson’s r) and stepwise linear regression analysis (B with 95% CI, R, R2) were used. Results The total QOLIBRI revealed no differences in one-year outcomes between patients with versus without major TBI (75 and 76, resp.; p = 0.68). With regard to the cognitive subscore, the group with major TBI demonstrated significantly more limitations than the one with no or mild TBI (p < 0.05). The AIS head correlated significantly with the cognitive dimension of the QOLIBRI (r = − 0.16; p < 0.05), but not with the mental components of the SF-36 or the TOP. In multivariate analysis, the influence of the severity of head injury (AIS head) on total QOLIBRI was weaker than that of injured extremities (R2 = 0.02; p < 0.05 vs. R2 = 0.04; p = 0.001) and equal to the QOLIBRI cognitive subscore (R2 = 0.03, p < 0.01 each). Conclusions Given the unexpected result of similar mean QOLIBRI total score values and only minor differences in cognitive deficits following major trauma independently of whether patients sustained major brain injury or not, further studies should investigate whether the QOLIBRI actually has the discriminative capacity to detect specific residuals of major TBI. In effect, the score appears to indicate mental deficits following different types of severe trauma, which should be evaluated in more detail. Trial registration NCT02165137; retrospectively registered 11 June 2014.
Collapse
Affiliation(s)
- Konstantin Born
- Department of Traumatology, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland
| | | | - Thomas Gross
- Department of Traumatology, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland.
| |
Collapse
|
48
|
Beck B, Cameron P, Lowthian J, Fitzgerald M, Judson R, Gabbe BJ. Major trauma in older persons. BJS Open 2018; 2:310-318. [PMID: 30263982 PMCID: PMC6156159 DOI: 10.1002/bjs5.80] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/11/2018] [Indexed: 11/06/2022] Open
Abstract
Background Globally, populations are ageing, creating challenges for trauma system design. Despite this, little is known about causes of injury and long-term outcomes in older injured patients. This study aims to describe temporal trends in the incidence, causes and functional outcomes of major trauma in older adults. Methods The population-based Victorian State Trauma Registry was used to identify patients with major trauma aged 65 years and older with a date of injury between 1 January 2007 and 31 December 2016. Temporal trends in population-based incidence rates were evaluated. Functional outcome was measured using the Glasgow Outcome Scale - Extended. Results There were 9250 older adults with major trauma during the study period. Low falls were the most common mechanism of injury (62·5 per cent), followed by transport-related events (22·2 per cent) and high falls (9·5 per cent). The number of patients with major trauma aged 65 years and older more than doubled from 2007 to 2016, and the incidence increased by 4·3 per cent per year (incidence rate ratio 1·043, 95 per cent c.i. 1·035 to 1·050; P < 0·001). At 12 months after injury, 41·8 per cent of older adults with major trauma had died, and 52·2 per cent of those who survived to hospital discharge were not living independently. Conclusions The number and proportion of older adults with major trauma are increasing rapidly and this will impact on trauma system design. Given the poor long-term outcomes, there needs to be greater emphasis on ensuring that appropriate interventions are targeted to the right patients and enhanced efforts in primary prevention.
Collapse
Affiliation(s)
- B Beck
- Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Victoria Australia
| | - P Cameron
- Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Victoria Australia.,Emergency and Trauma Centre The Alfred Melbourne, Victoria Australia
| | - J Lowthian
- Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Victoria Australia.,Bolton Clarke Research Institute, Bolton Clarke Melbourne, Victoria Australia
| | - M Fitzgerald
- Trauma Service The Alfred Melbourne, Victoria Australia.,National Trauma Research Institute, Royal Melbourne Hospital Melbourne, Victoria Australia
| | - R Judson
- Department of General Surgery, Royal Melbourne Hospital Melbourne, Victoria Australia.,Department of Surgery University of Melbourne Melbourne, Victoria Australia
| | - B J Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Victoria Australia.,Farr Institute Swansea University Medical School Swansea UK
| |
Collapse
|
49
|
Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis. J Neurotrauma 2018; 35:703-718. [PMID: 29324173 PMCID: PMC5831640 DOI: 10.1089/neu.2017.5259] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.
Collapse
Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Fiona E. Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - William Townend
- Emergency Department, Hull and East Yorkshire NHS Trust, Hull, United Kingdom
| | - Aditya Borakati
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Andrea Fabbri
- Emergency Unit, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, Forlì, Italy
| | - Trevor A. Sheldon
- Department of Health Sciences, University of York, Alcuin Research Resource Center, Heslington, York, United Kingdom
| |
Collapse
|
50
|
Perioperative Management of Adult Patients with Severe Head Injury. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|