Observational approach to subjects with mild-to-moderate head injury and initial non-neurosurgical lesions

The Influence of Serious Extracranial Injury on In-Hospital Mortality in Children with Severe Traumatic Brain Injury

(1) Background: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Serious extracranial injury (SEI) commonly coexists with sTBI after the high impact of trauma. Limited studies evaluate the influence of SEI on the prognosis of pediatric sTBI. We aimed to analyze SEI’s clinical characteristics and initial presentations and evaluate if SEI is predictive of higher in-hospital mortality in these sTBI children. (2) Methods: In this 11-year-observational cohort study, a total of 148 severe sTBI children were enrolled. We collected patients’ initial data in the emergency department, including gender, age, mechanism of injury, coexisting SEI, motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and intracranial Rotterdam computed tomography (CT) score of the first brain CT scan, as potential mortality predictors. (3) Results: Compared to sTBI children without SEI, children with SEI were older and more presented with initial hypotension and hypothermia; the initial lab showed more prolonged prothrombin time and a higher in-hospital mortality rate. Multivariate analysis showed that motor components of mGCS, fixed pupil reaction, prolonged prothrombin time, and higher Rotterdam CT score were independent predictors of in-hospital mortality in sTBI children. SEI was not an independent predictor of mortality. (4) Conclusions: sTBI children with SEI had significantly higher in-hospital mortality than those without. SEI was not an independent predictor of mortality in our study. Brain injury intensity and its presentations, including lower mGCS, fixed pupil reaction, higher Rotterdam CT score, and severe injury-induced systemic response, presented as initial prolonged prothrombin time, were independent predictors of in-hospital mortality in these sTBI children.

Predictors of In-Hospital Mortality for Road Traffic Accident-Related Severe Traumatic Brain Injury

(1) Background: Road traffic accidents (RTAs) are the leading cause of pediatric traumatic brain injury (TBI) and are associated with high mortality. Few studies have focused on RTA-related pediatric TBI. We conducted this study to analyze the clinical characteristics of RTA-related TBI in children and to identify early predictors of in-hospital mortality in children with severe TBI. (2) Methods: In this 15-year observational cohort study, a total of 618 children with RTA-related TBI were enrolled. We collected the patients' clinical characteristics at the initial presentations in the emergency department (ED), including gender, age, types of road user, the motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and the intracranial computed tomography (CT) Rotterdam score, as potential mortality predictors. (3) Results: Compared with children exhibiting mild/moderate RTA-related TBI, those with severe RTA-related TBI were older and had a higher mortality rate (p < 0.001). The in-hospital mortality rate for severe RTA-related TBI children was 15.6%. Compared to children who survived, those who died in hospital had a higher incidence of presenting with hypothermia (p = 0.011), a lower mGCS score (p < 0.001), a longer initial prothrombin time (p < 0.013), hyperglycemia (p = 0.017), and a higher Rotterdam CT score (p < 0.001). Multivariate analyses showed that the mGCS score (adjusted odds ratio (OR): 2.00, 95% CI: 1.28-3.14, p = 0.002) and the Rotterdam CT score (adjusted OR: 2.58, 95% CI: 1.31-5.06, p = 0.006) were independent predictors of in-hospital mortality. (4) Conclusions: Children with RTA-related severe TBI had a high mortality rate. Patients who initially presented with hypothermia, a lower mGCS score, a prolonged prothrombin time, hyperglycemia, and a higher Rotterdam CT score in brain CT analyses were associated with in-hospital mortality. The mGCS and the Rotterdam CT scores were predictive of in-hospital mortality independently.

Isolated subarachnoid hemorrhage in mild traumatic brain injury: is a repeat CT scan necessary? A single-institution retrospective study

BACKGROUND

Traumatic brain injury (TBI) with isolated subarachnoid hemorrhage (iSAH) is a common finding in the emergency department. In many centers, a repeat CT scan is routinely performed 24 to72 h following the trauma to rule out further radiological progression. The aim of this study is to assess the clinical utility of the repeat CT scan in clinical practice.

METHODS

We reviewed the medical charts of all patients who presented to our institution with mild TBI (mTBI) and isolated SAH between January 2015 and October 2017. CT scan at admission and control after 24 to 72 h were examined for each patient in order to detect any possible change. Neurological deterioration, antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries, and length of stay in hospital were analyzed.

RESULTS

Of the 649 TBI patients, 106 patients met the inclusion criteria. Fifty-four patients were females and 52 were males with a mean age of 68.2 years. Radiological iSAH progression was found in 2 of 106 (1.89) patients, and one of them was under antiplatelet therapy. No neurological deterioration was observed. Ten of 106 (9.4%) patients were under anticoagulation therapy, and 28 of 106 (26.4%) were under antiplatelet therapy.

CONCLUSION

ISAH in mTBI seems to be a radiological stable entity over 72 h with no neurological deterioration. The clinical utility of a repeat head CT in such patients is questionable, considering its radiation exposure and cost. Regardless of anticoagulation/antiplatelet therapy, neurologic observation and symptomatic treatment solely could be a reasonable alternative.

The Financial and Radiation Burden of Early Reimaging in Neurosurgical Patients: An Original Study and Review of the Literature

The computed tomographic (CT) scanner has become ubiquitous in healthcare. When trauma patients are imaged at facilities not equipped to care for them, imaging is often repeated at the receiving institution. CTs have clinical, financial, and resource costs, and eliminating unnecessary imaging will benefit patients, providers, and institutions. This paper reviews patterns of repetition of CT scans for transferred trauma patients and motivations underlying such behaviors via analysis of our Trauma Registry database and literature published in this area. Neurosurgeons are fundamentally impactful in this decision-making process. The most commonly repeated scan is a CT head (CTH). More than ¼ of our patients receiving a clinically indicated repeat CTH also had a repeat scan of their cervical spine with no reason given for the cervical scan. Herein, we discuss our findings that both non-trauma center practitioners and non-neurosurgical staff at trauma centers cite a lower level of comfort with neuroradiology and fear of litigation as motivators in overzealous neuroimaging. As a result, inappropriate neurosurgical imaging is routinely ordered prior to transfer and again upon arrival at trauma centers. Education of non-neurosurgical staff is essential to prevent inappropriate neuroaxis imaging.

Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study

Background

Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients.

Methods

Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively.

Results

A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90).

Conclusions

Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00930-1.

Management of Minor Traumatic Brain Injury in an ED Observation Unit

Introduction

Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.

Methods

This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.

Results

There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.

Conclusion

Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Predictors of In-Hospital Mortality for School-Aged Children with Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of mortality in children. There are few studies focused on school-aged children with TBI. We conducted this study to identify the early predictors of in-hospital mortality in school-aged children with severe TBI. In this 10 year observational cohort study, a total of 550 children aged 7-18 years with TBI were enrolled. Compared with mild/moderate TBI, children with severe TBI were older; more commonly had injury mechanisms of traffic accidents; and more neuroimage findings of subarachnoid hemorrhage (SAH), subdural hemorrhage (SDH), parenchymal hemorrhage, cerebral edema, and less epidural hemorrhage (EDH). The in-hospital mortality rate of children with severe TBI in our study was 23%. Multivariate analysis showed that falls, being struck by objects, motor component of Glasgow coma scale (mGCS), early coagulopathy, and SAH were independent predictors of in-hospital mortality. We concluded that school-aged children with severe TBI had a high mortality rate. Clinical characteristics including injury mechanisms of falls and being struck, a lower initial mGCS, early coagulopathy, and SAH are predictive of in-hospital mortality.

Filled to the brim: The characteristics of over-triage at a level I trauma center

BACKGROUND

Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage.

METHODS

Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged <48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records.

RESULTS

Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in <48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home.

CONCLUSION

Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.

Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes

OBJECTIVE

Among the elderly, use of antithrombotics (ATs), antiplatelets (APs; aspirin, clopidogrel), and/or anticoagulants (ACs; warfarin, direct oral ACs [DOACs; dabigatran, rivaroxaban, apixaban]) to prevent thromboembolic events must be carefully weighed against the risk of intracranial hemorrhage (ICH) with trauma. The goal of this study was to assess the risk of sustaining a traumatic brain injury (TBI), ICH, and poorer outcomes in relation to AT use among all patients 65 years or older presenting to a single institution with head trauma.

METHODS

Data were collected from all head trauma patients 65 years or older presenting to the authors' supraregional tertiary trauma center over a 24-month period and included age, sex, injury mechanism, medical history, international normalized ratio, Glasgow Coma Scale (GCS) score, ICH presence and type, hospital admission, reversal therapy, surgery, discharge destination, Extended Glasgow Outcome Scale (GOSE) score at discharge, and mortality.

RESULTS

A total of 1365 head trauma patients 65 years or older were included; 724 were on AT therapy (413 on APs, 151 on ACs, 59 on DOACs, 48 on 2 APs, 38 on AP+AC, and 15 on AP+DOAC) and 641 were not. Among all head trauma patients, the risk of sustaining a TBI was associated with AP use after adjusting for covariates. Of the 731 TBI patients, those using ATs had higher rates of ICH (p <0.0001), functional dependency at discharge (GOSE score ≤ 4; p < 0.0001), and mortality (p < 0.0001). Elevated rates of ICH progression on follow-up CT scanning were observed in patients in the warfarin monotherapy (OR 5.30, p < 0.0001) and warfarin + AP (OR 6.15, p = 0.0011). Risk of mortality was not associated with single antiplatelet use but was notably high with 2 APs (OR 4.66, p = 0.0056), warfarin (OR 5.18, p = 0.0003), and DOAC use (OR 5.09, p = 0.0149).

CONCLUSIONS

Elderly trauma patients on ATs, especially combination therapy, are at elevated risk of ICH and poor outcomes compared with those not on AT therapy. While both AP and warfarin use alone and in combination were associated with significantly elevated odds of sustaining an ICH among TBI patients, only warfarin use was a predictor of hemorrhage progression on follow-up scans. The use of a single AP was not associated with mortality; however, the combination of both aspirin and clopidogrel was. Warfarin and DOAC users had comparable mortality rates; however, DOAC users had lower rates of ICH progression, and fewer survivors were functionally dependent at discharge than were warfarin users. DOACs are an overall safer alternative to warfarin for patients at high risk of falls.

Teleneurosurgery: Outcome of Mild Head Injury Patients Managed in Non-Neurosurgical Centre in the State of Johor

Background

With teleneurosurgery, more patients with head injury are managed in the primary hospital under the care of general surgical unit. Growing concerns regarding the safety and outcome of these patients are valid and need to be addressed.

Method

This study is to evaluate the outcome of patients with mild head injury which were managed in non-neurosurgical centres with the help of teleneurosurgery. The study recruits samples from five primary hospitals utilising teleneurosurgery for neurosurgical consultations in managing mild head injury cases in Johor state. Two main outcomes were noted; favourable and unfavourable, with a follow up review of the Glasgow Outcome Scale (GOS) at 3 and 6 months.

Results

Total of 359 samples were recruited with a total of 11 (3.06%) patients have an unfavourable. no significant difference in GOS at 3 and 6 months for patient in the unfavourable group (P = 0.368).

Conclusion

In this study we have found no significant factors affecting the outcome of mild head injury patients managed in non-neurosurgical centres in Johor state using the help of teleneurosurgery.

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

The authors looked at all of the pediatric patients with a head injury who were transferred from other hospitals to their own over 12 years and tried to identify factors that would allow patients to stay closer to home at their local hospitals and not be transferred. Many patients with isolated, nondisplaced skull fractures or negative CT imaging likely could have avoided transfer. While hospitals should be cautious, this may help families stay closer to home.

The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center

Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of <48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5–16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P < 0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089–34,087), whereas ED charges were ($40,440; IQR: $26,150–65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.

Evaluation of a Low-risk Mild Traumatic Brain Injury and Intracranial Hemorrhage Emergency Department Observation Protocol

OBJECTIVES

Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH.

METHODS

This retrospective cohort study was approved by the institutional review board. Study subjects were patients ≥ 18 years of age with an International Classification of Diseases code corresponding to a traumatic ICH and admitted to an ED observation unit (EDOU) of an urban, academic Level I trauma center between February 1, 2015, and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record, and imaging data, from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU before and after protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit, or operating room from the EDOU and the proportion of patients with worsening findings on repeat computed tomography (CT) head scan in the EDOU.

RESULTS

A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Inter-rater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the preprotocol period and 153 after protocol implementation. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR = 0.45, 95% confidence interval [CI] = 0.25-0.82, p = 0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission before implementation of the protocol and 13% (20/153) of patients required an inpatient admission after protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p = 0.34).

CONCLUSIONS

While there was no difference in EDOU LOS, implementing a low-risk mild TBI and ICH protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol-driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.

Cost-effectiveness of Access to Critical Cerebral Emergency Support Services (ACCESS): a neuro-emergent telemedicine consultation program

AIMS

Access to Critical Cerebral Emergency Support Services (ACCESS) was developed as a low-cost solution to providing neuro-emergent consultations to rural hospitals in New Mexico that do not offer comprehensive stroke care. ACCESS is a two-way audio-visual program linking remote emergency department physicians and their patients to stroke specialists. ACCESS also has an education component in which hospitals receive training from stroke specialists on the triage and treatment of patients. This study assessed the clinical and economic outcomes of the ACCESS program in providing services to rural New Mexico from a healthcare payer perspective.

METHODS

A decision tree model was constructed using findings from the ACCESS program and existing literature, the likelihood that a patient will receive a tissue plasminogen activator (tPA), cost of care, and resulting quality adjusted life years (QALYs). Data from the ACCESS program includes emergency room patients in rural New Mexico from May 2015 to August 2016. Outcomes and costs have been estimated for patients who were taken to a hospital providing neurological telecare and patients who were not.

RESULTS

The use of ACCESS decreased neuro-emergent stroke patient transfers from rural hospitals to urban settings from 85% to 5% (no tPA) and 90% to 23% (tPA), while stroke specialist reading of patient CT/MRI imaging within 3 h of onset of stroke symptoms increased from 2% to 22%. Results indicate that use of ACCESS has the potential to save $4,241 ($3,952-$4,438) per patient and increase QALYs by 0.20 (0.14-0.22). This increase in QALYs equates to ∼73 more days of life at full health. The cost savings and QALYs are expected to increase when moving from a 90-day model to a lifetime model.

CONCLUSION

The analysis demonstrates potential savings and improved quality-of-life associated with the use of ACCESS for patients presenting to rural hospitals with acute ischemic stroke (AIS).

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

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.

Italian guidelines on the assessment and management of pediatric head injury in the emergency department

OBJECTIVE

We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury.

METHODS

These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text.

CONCLUSIONS

Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.

A protocol for the development of a prediction model in mild traumatic brain injury with CT scan abnormality: which patients are safe for discharge?

BACKGROUND

Head injury is an extremely common clinical presentation to hospital emergency departments (EDs). Ninety-five percent of patients present with an initial Glasgow Coma Scale (GCS) score of 13-15, indicating a normal or near-normal conscious level. In this group, around 7% of patients have brain injuries identified by CT imaging but only 1% of patients have life-threatening brain injuries. It is unclear which brain injuries are clinically significant, so all patients with brain injuries identified by CT imaging are admitted for monitoring. If risk could be accurately determined in this group, admissions for low-risk patients could be avoided and resources could be focused on those with greater need.This study aims to (a) estimate the proportion of GCS13-15 patients with traumatic brain injury identified by CT imaging admitted to hospital who clinically deteriorate and (b) develop a prognostic model highly sensitive to clinical deterioration which could help inform discharge decision making in the ED.

METHODS

A retrospective case note review of 2000 patients with an initial GCS13-15 and traumatic brain injury identified by CT imaging (2007-2017) will be completed in two English major trauma centres. The prevalence of clinically significant deterioration including death, neurosurgery, intubation, seizures or drop in GCS by more than 1 point will be estimated. Candidate prognostic factors have been identified in a previous systematic review. Multivariable logistic regression will be used to derive a prognostic model, and its sensitivity and specificity to the outcome of deterioration will be explored.

DISCUSSION

This study will potentially derive a statistical model that predicts clinically relevant deterioration and could be used to develop a clinical risk tool guiding the need for hospital admission in this group.

Surgical Transfer Decision Making: How Regional Resources are Allocated in a Regional Transfer Network

BACKGROUND

Tertiary care centers often operate above capacity, limiting access to emergency surgical care for patients at nontertiary facilities. For nontraumatic surgical emergencies there are no guidelines to inform patient selection for transfer to another facility. Such decisions may be particularly difficult for gravely ill patients when the benefits of transfer are uncertain.

METHODS

To characterize surgeons' decision-making strategies for transfer, a qualitative analysis of semistructured interviews was conducted with 16 general surgeons who refer and accept patients within a regional transfer network. Interviews included case-based vignettes about surgical patients with high comorbidity, multisystem organ failure, and terminal conditions. An inductive coding strategy was used, followed by performance of a higher-level analysis to characterize important themes and trends.

RESULTS

Surgeons at outlying hospitals seek transfer when the resources to care for patients' surgical needs or comorbid conditions are unavailable locally. In contrast, surgeons at the tertiary center accept all patients regardless of outcome or resource considerations. Bed availability at the tertiary care center restricts transfer capacity, harming patients who cannot be transferred. Surgeons sometimes transfer dying patients in order to exhaust all treatment options or appease families, but they are conflicted about the value of transfer, which displaces patients from their local communities and limits access to tertiary care for others.

CONCLUSION

Decisions to transfer surgical patients are complex and require comprehensive understanding of local capacity and regional resources. Current decision-making strategies fail to optimize patient selection for transfer and can inappropriately allocate scarce tertiary care beds.

How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study

OBJECTIVE

To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system.

SETTING

ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million.

PARTICIPANTS

5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only.

RESULTS

A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit.

CONCLUSION

The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.

Satisfaction of patients' next of kin in a 'Hub & Spoke' ICU network

This study aimed to gauge the opinions of patients' next of kin regarding transfer of patients from the specialist 'Hub' intensive care unit, to 'Spoke' intensive care units near home. We included 213 consecutive patients with severe trauma or severe acute neurological conditions admitted to the Hub intensive care unit over a 21-month period, who were repatriated to Spoke intensive care units for ongoing intensive care. One year after admission to the Hub intensive care unit, two thirds of patients' next of kin said they would have preferred patients to have been treated only in the Hub intensive care unit, and not repatriated. They perceived Hub intensive care unit care to be important, and would have preferred that their relatives be hospitalised there until intensive treatment was completed. The next of kin's preference was associated with severe acute neurological conditions (p ≤ 0.0001). Although centralised Hub & Spoke intensive care unit networks are appropriate to ensure specialised care, repatriation to local hospitals may not be appropriate for patients with severe neurological conditions.

The cost-effectiveness of diagnostic management strategies for children with minor head injury

AIM

To estimate the cost-effectiveness of diagnostic management strategies for children with minor head injury and identify an optimal strategy.

METHODS

A probabilistic decision analysis model was developed to estimate the costs and quality-adjusted life years (QALYs) accrued by each of six potential management strategies for minor head injury, including a theoretical 'zero option' strategy of discharging all patients home without investigation. The model took a lifetime horizon and the perspective of the National Health Service.

RESULTS

The optimal strategy was based on the Children's Head injury Algorithm for the prediction of Important Clinical Events (CHALICE) rule, although the costs and outcomes associated with each strategy were broadly similar.

CONCLUSIONS

Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost saving, with the CHALICE rule being the optimal strategy, although there is some uncertainty in the results. Incremental changes in the costs and QALYs are very small when all selective CT strategies are compared. The estimated cost of caring for patients with brain injury worsened by delayed treatment is very high compared with the cost of CT scanning. This analysis suggests that all hospitals receiving children with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence-based guidelines.

Outcomes of a nontransfer protocol for mild traumatic brain injury with abnormal head computed tomography in a rural hospital setting

OBJECTIVE

This study sought to investigate outcomes after a novel nontransfer protocol for mild traumatic brain injuries patients with small intracranial hemorrhage (ICH) in a rural trauma center without neurosurgical capabilities.

METHODS

This was a retrospective cohort study. In 2007, a nontransfer protocol was implemented at a Level III Trauma Center. It included adult patients from April 2007 through December 2012 with mild traumatic brain injury (mTBI) (Glasgow Coma Scale score 13 to 15) and computed tomography (CT) showing small ICH and no coagulopathy. The following ICHs were allowed: 1) minimal or small traumatic subarachnoid hemorrhage, 2) punctuate or minimal superficial cerebral contusion, 3) punctuate or minimal intraparenchymal hemorrhage, or 4) very small subdural hemorrhage (SDH) without mass effect (a very thin smear SDH along the tentorium or falx). CT scans were reviewed by the on-call neurosurgeon at an affiliated Level I Trauma Center, and consensus was obtained on the suitability for nontransfer.

RESULTS

A total of 76 patients were included. The median hospital length of stay was 1 day (interquartile range = 1 day). No patient required a neurosurgical intervention or postadmission transfer to a Level I facility. There were no in-hospital deaths, and all patients were discharged with stable head CTs and in good neurologic condition. Two patients were readmitted for nonprotocol-related reasons: 1 acute-on-chronic SDH 6 weeks postdischarge, and 1 visual eye change with normal CT 2 days postdischarge.

CONCLUSIONS

Our 6-year study corroborates the low neurosurgical rate reported in the literature for mTBI with small ICH. Nontransfer protocols may lead to a more efficient use of hospital resources while providing safe, effective and economical health care.

Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study

INTRODUCTION

Pre-injury antithrombotic therapy might influence the outcome of subjects with head injuries and positive computed tomography (CT) scans. We aimed to determine the potential risk of pre-injury antiplatelet drug use on short- and long-term outcome of head injured subjects admitted to emergency departments (EDs) in Italy for extended observation.

METHODS

A total of 1,558 adult subjects with mild, moderate and severe head injury admitted to Italian EDs were studied. In multivariable logistic regression analyses, the short-term outcome was assessed by an evaluation of head CT scan at 6 to 24 hours after trauma and the long-term outcome by the Glasgow outcome scale (GOS) at six months.

RESULTS

Head CT scan comparisons showed that 201 subjects (12.9%) worsened. The risk of worsening was increased two fold by the use of antiplatelet drugs (106, 19.7% treated versus 95, 9.3% untreated; relative risk (RR) 2.09, 95% CI 1.63 to 2.71). The risk was particularly high in subjects on clopidogrel (RR 5.76, 95% CI 3.88 to 8.54), independent of the association with aspirin. By logistic regression, 5 of 14 items were independently associated with worsening (Glasgow coma scale (GCS), Marshall category, antiplatelet therapy, intraventricular hemorrhage, number of lesions). After six months, only 4 of 14 items were predictors of unfavorable outcome (GOS 1 to 3) (GCS score, Marshall category, age in decades, intracerebral hemorrhage/contusion). The risk increased by 50% in the group treated with antiplatelet therapy (RR 1.58, 95% CI 1.28 to 1.95; P<0.001).

CONCLUSIONS

Antithrombotic therapy (in particular clopidogrel) is a risk factor for both short-term and long-term unfavorable outcome in subjects with head injury, increasing the risk of progression and death, permanent vegetative state and severe disability.

The cost-effectiveness of diagnostic management strategies for adults with minor head injury

STUDY OBJECTIVE

To estimate the cost-effectiveness of diagnostic management strategies for adults with minor head injury.

METHODS

A mathematical model was constructed to evaluate the incremental costs and effectiveness (Quality Adjusted Life years Gained, QALYs) of ten diagnostic management strategies for adults with minor head injuries. Secondary analyses were undertaken to determine the cost-effectiveness of hospital admission compared to discharge home and to explore the cost-effectiveness of strategies when no responsible adult was available to observe the patient after discharge.

RESULTS

The apparent optimal strategy was based on the high and medium risk Canadian CT Head Rule (CCHRhm), although the costs and outcomes associated with each strategy were broadly similar. Hospital admission for patients with non-neurosurgical injury on CT dominated discharge home, whilst hospital admission for clinically normal patients with a normal CT was not cost-effective compared to discharge home with or without a responsible adult at £39 and £2.5 million per QALY, respectively. A selective CT strategy with discharge home if the CT scan was normal remained optimal compared to not investigating or CT scanning all patients when there was no responsible adult available to observe them after discharge.

CONCLUSION

Our economic analysis confirms that the recent extension of access to CT scanning for minor head injury is appropriate. Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost-saving. The cost of CT scanning is very small compared to the estimated cost of caring for patients with brain injury worsened by delayed treatment. It is recommended therefore that all hospitals receiving patients with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence based guidelines. Provisionally the CCHRhm decision rule appears to be the best strategy although there is considerable uncertainty around the optimal decision rule. However, the CCHRhm rule appears to be the most widely validated and it therefore seems appropriate to conclude that the CCHRhm rule has the best evidence to support its use.

Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13

BACKGROUND

The Glasgow Coma Scale (GCS) classifies traumatic brain injuries (TBIs) as mild (14-15), moderate (9-13), or severe (3-8). The Advanced Trauma Life Support modified this classification so that a GCS score of 13 is categorized as mild TBI. We investigated the effect of this modification on mortality prediction, comparing patients with a GCS score of 13 classified as moderate TBI (classic model) to patients with GCS score of 13 classified as mild TBI (modified model).

METHODS

We selected adult TBI patients from the Pennsylvania Outcome Study database. Logistic regressions adjusting for age, sex, cause, severity, trauma center level, comorbidities, and isolated TBI were performed. A second evaluation included the time trend of mortality. A third evaluation also included hypothermia, hypotension, mechanical ventilation, screening for drugs, and severity of TBI. Discrimination of the models was evaluated using the area under receiver operating characteristic curve (AUC). Calibration was evaluated using the Hosmer-Lemershow goodness of fit test.

RESULTS

In the first evaluation, the AUCs were 0.922 (95% CI, 0.917-0.926) and 0.908 (95% CI, 0.903-0.912) for classic and modified models, respectively. Both models showed poor calibration (p < 0.001). In the third evaluation, the AUCs were 0.946 (95% CI, 0.943-0.949) and 0.938 (95% CI, 0.934-0.940) for the classic and modified models, respectively, with improvements in calibration (p = 0.30 and p = 0.02 for the classic and modified models, respectively).

CONCLUSION

The lack of overlap between receiver operating characteristic curves of both models reveals a statistically significant difference in their ability to predict mortality. The classic model demonstrated better goodness of fit than the modified model. A GCS score of 13 classified as moderate TBI in a multivariate logistic regression model performed better than a GCS score of 13 classified as mild.

Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury

OBJECT

Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need.

METHODS

The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded.

RESULTS

During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6-131.8; OR 9.7 for SDH, 95% CI 2.4-39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15.

CONCLUSIONS

Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.