Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Provider Perceptions of Oxygenation Strategies for Critically Ill Trauma Patients With and Without Moderate-to-Severe Traumatic Brain Injury

BACKGROUND

Hypoxia and hyperoxia (pulse oximetry [SpO2] > 96%) are associated with increased mortality in critically ill patients. However, provider practices regarding oxygenation in traumatic brain injury (TBI) patients are unknown. This study assesses views on oxygenation of critically ill trauma patients with and without TBI and how this varies between Neurological ICU (NeuroICU) and Surgical-Trauma ICU (STICU) providers.

METHODS

This is a cross-sectional survey of Level I trauma center's NeuroICU and STICU providers. We used Likert scales, yes-no questions, and multiple-choice case-based scenarios to characterize provider views on oxygenation with descriptive statistics to characterize responses. Significant differences regarding TBI and non-TBI patients or NeuroICU and STICU providers were determined using Fisher's exact test and a P-value of .05.

RESULTS

A total of 83 providers initiated the survey, and 53 providers completed it. Most providers identified a threshold SpO2 < 92% for the administration of supplemental oxygen in critically ill TBI patients. A total of 9% of providers "somewhat or completely agreed" that they were more likely to give supplemental oxygen to a critically ill trauma patient with TBI than one without TBI and the same SpO2. A total of 48% of providers selected an SpO2 < 90% as the point at which supplemental oxygen should be initiated in patients without TBI, compared to 27% of providers in patients with TBI (P < .01). This threshold for supplemental oxygen use varied by provider type for non-TBI patients, but not for TBI patients (30% NeuroICU and 69% STICU providers selected SpO2 < 90% in non-TBI, P < .05; 30% NeuroICU and 35% STICU providers selected SpO2 < 90% in TBI, P = .85).

CONCLUSIONS

Critical care providers at UCHealth University of Colorado Hospital approach the oxygenation of critically ill trauma patients with and without TBI differently. Specifically, critical care respondents accepted a different lower oxygen saturation threshold for TBI and non-TBI patients. NeuroICU and STICU respondents differed in their threshold for the down-titration of supplemental oxygen. Targeted education for critical care providers may reduce these discrepancies and optimize oxygen use.

Traumatic Brain Injury in Cameroon: A Prospective Observational Study in a Level I Trauma Centre

Background and Objective: About 14 million people will likely suffer a traumatic brain injury (TBI) per year by 2050 in sub-Saharan Africa. Studying TBI characteristics and their relation to outcomes can identify initiatives to improve TBI prevention and care. The objective of this study was to define the features and outcomes of TBI patients seen over a 1-year period in a level-I trauma centre in Cameroon. Materials and Methods: Data on demographics, causes, clinical aspects, and discharge status were collected over a period of 12 months. The Glasgow Outcome Scale-Extended (GOSE) and the Quality-of-Life Questionnaire after Brain Injury (QoLIBRI) were used to evaluate outcomes six months after TBI. Comparisons between two categorical variables were done using Pearson's chi-square test. Results: A total of 160 TBI patients participated in the study. The age group 15-45 years was most represented (78%). Males were more affected (90%). A low educational level was seen in 122 (76%) cases. Road traffic incidents (RTI) (85%), assaults (7.5%), and falls (2.5%) were the main causes of TBI, with professional bike riders being frequently involved (27%). Only 15 patients were transported to the hospital by ambulance, and 14 of these were from a referring hospital. CT-imaging was performed in 78% of cases, and intracranial traumatic abnormalities were identified in 64% of cases. Financial constraints (93%) was the main reason for not performing a CT scan. Forty-six (33%) patients were discharged against medical advice (DAMA) due to financial constraints. Mortality was 14% (22/160) and high in patients with severe TBI (46%). DAMA had poor outcomes with QoLIBRI. Only four patients received post-injury physical therapy services. Conclusions: TBI in Cameroon mainly results from RTIs and commonly affects young adult males. Lack of pre-hospital care, financial constraints limiting both CT scanning and medical care, and a lack of acute physiotherapy services likely influenced care and outcomes adversely.

Incidence and Predictors of Mortality Among Patients with Traumatic Brain Injury at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study

Background

Traumatic brain injury is a major list of health and socioeconomic problems especially in low- and middle-income countries which influences productive age groups. Differences in patient characteristics, socioeconomic status, intensive care unit admission thresholds, health-care systems, and the availability of varying numbers of intensive care unit (ICU) beds among hospitals had shown to be the causes for the variation on the incidence in mortality following traumatic brain injury across different continents. The aim of this study was to assess the incidence and predictors of mortality among patients with traumatic brain injury at University of Gondar Comprehensive Specialized Hospital.

Methods

A retrospective follow-up study was conducted based on chart review and selected patient charts admitted from January, 2017 to January, 2022. Participants in the study were chosen using a simple random sample procedure that was computer generated. Data was entered with epi-data version 4.6 and analyzed using SPSS version 26. Both bivariate and multivariate logistic regression analyses were used, and in multivariate logistic regression analysis, P-value <0.05 with 95% CI was considered statistically significant.

Results

The magnitude of mortality was 28.8%. Most of the injuries were caused by assault followed by road traffic accident (RTA). About 30% of the subjects presented with severe head injuries and epidural hematoma (EDH) followed by skull fracture were the most common diagnoses on admission. The independent predictors of mortality were male sex (AOR: 6.12, CI: 1.82, 20.5), severe class injury with Glasco coma scale (GCS <9) (AOR: 5.96, CI: 2.07, 17.12), intraoperative hypoxia episode (AOR: 10.5, CI: 2.6-42.1), hyperthermia (AOR: 25, CI: 5.54, 115.16), lack of pre-hospital care (AOR: 2.64 CI: 1.6-4.2), abnormal appearance on both eyes (AOR: 13.4, CI: 5.1-34.6), in-hospital hypoxia episode and having extra-cranial concomitant injury were positively associated with mortality, while on admission, systolic blood pressure (SBP) of 100-149 (AOR: 0.086, CI: 0.016-0.46) was negatively associated with mortality.

Conclusion

The overall mortality rate was considerably high. As a result, traumatic brain injury management should be focused on modifiable factors that increase patient mortality, such as on-admission hypotension, a lack of pre-hospital care, post-operative complications, an intraoperative hypoxia episode, and hyperthermia.

Towards exploring current challenges and future opportunities relating to the prehospital triage of patients with traumatic brain injury: a mixed-methods study protocol

INTRODUCTION

Traumatic brain injury (TBI) is a major global health burden that results in disability and loss of health. Identifying those patients who require specialist neuroscience care can be challenging due to the low accuracy of existing prehospital trauma triage tools. Despite the widespread use of decision aids to 'rule out' TBI in hospitals, they are not widely used in the prehospital environment. We aim to provide a snapshot of current prehospital practices in the UK, and to explore facilitators and challenges that may be encountered when adopting new tools for decision support.

METHODS AND ANALYSIS

A mixed-methods study will be conducted using a convergent design approach. In the first phase, we will conduct a national survey of current practice in which every participating ambulance service in the UK will receive an online questionnaire, and only one response is required. In the second phase, semistructured interviews will be conducted to explore the perceptions of ambulance service personnel regarding the implementation of new triage methods that may enhance triage decisions. The survey questions and the interview topic guide were piloted and externally reviewed. Quantitative data will be summarised using descriptive statistics; qualitative data will be analysed thematically.

ETHICS AND DISSEMINATION

This study has been approved by the Health Research Authority (REC reference 22/HRA/2035). Our findings may inform the design of future care pathways and research as well as identify challenges and opportunities for future development of prehospital triage tools for patients with suspected TBI. Our findings will be published in peer-reviewed journals, relevant national and international conferences, and will be included in a PhD thesis.

Pupillary light reflex measured with quantitative pupillometry has low sensitivity and high specificity for predicting neuroworsening after traumatic brain injury

BACKGROUND

Triage and neurological assessment of the 1.7 million traumatic brain injuries occurring annually is often done by nurse practitioners and physician assistants in the emergency department. Subjective assessments, such as the neurological examination that includes evaluation of the pupillary light reflex (PLR), can contain bias. Quantitative pupillometry (QP) standardizes and objectifies the PLR examination. Additional data are needed to determine whether QP can predict neurological changes in a traumatic brain injury (TBI) patient.

PURPOSE

This study examines the effectiveness of QP in predicting neurological decline within 24 hours of admission following acute TBI.

METHODOLOGY

This prospective, observational, clinical trial used pragmatic sampling to assess PLR in TBI patients using QP within 24 hours of ED admission. Chi-square analysis was used to determine change in patient status, through Glasgow Coma Scale (GCS), at baseline and within 24 hours of admission, to the QP.

RESULTS

There were 95 participants included in the analysis; of whom 35 experienced neuroworsening, defined by change in GCS of >2 within the first 24 hours of admission. There was a significant association between an abnormal Neurological Pupil index (NPi), defined as NPi of <3, and neuroworsening (p < .0001). The sensitivity (51.43%) and specificity (91.67%) of abnormal NPi in predicting neuroworsening were varied.

CONCLUSION

There is a strong association between abnormal NPi and neuroworsening in the sample of TBI patients with high specificity and moderate sensitivity.

IMPLICATIONS

NPi may be an early indicator of neurological changes within 24 hours of ED admission in patients with TBI.

Impact of a sensory stimulation program conducted by family members on the consciousness and pain levels of ICU patients: A mixed method study

Background

The results of several studies show the different effects of a balanced sensory stimulation program (SSP) on patients with brain injury admitted to the intensive care unit (ICU), but these effects have been less studied based on mixed and comprehensive methods.

Method

This mixed-method study involved 66 patients with brain injury admitted to the ICU who were allocated into intervention (n = 33) and control (n = 33) groups using random stratified sampling. Patients in the intervention group received a sensory stimulation program from family members for 1 h daily during ICU hospitalization, while the control group received only routine care. Patients' level of consciousness and pain intensity were measured immediately before and after the intervention using Glasgow Coma Scale (GCS) and Behavioral Pain Scale (BPS), respectively. In-depth unstructured interviews were conducted with the patients in the intervention group 3 months after discharge from the ICU. These interviews were analyzed following Graneheim and Lundman (2004) conventional content analysis method.

Results

A significant difference was found between the study groups in terms of the mean difference of GCS (P =0.001) and BPS score (P = 0.001) before and after intervention. Patients in the intervention group had a higher mean GCS and a lower mean BPS than did patients in the control group. The main themes extracted from the qualitative analysis confirmed the results obtained from the quantitative phase of the study.

Conclusion

The combination of the quantitative and qualitative findings suggested that amidst the many hardships and sufferings brain injury patients go through in the ICU, a sensory stimulation program offered by family members may have many benefits such as increased level of consciousness and reduced pain for these patients. Therefore, it is necessary to formulate a framework for this program and provide the needed facilities in order to benefit more from the capacity of such programs for ICU patients.

Development and validation of a prehospital-stage prediction tool for traumatic brain injury: a multicentre retrospective cohort study in Korea

OBJECTIVES

Predicting diagnosis and prognosis of traumatic brain injury (TBI) at the prehospital stage is challenging; however, using comprehensive prehospital information and machine learning may improve the performance of the predictive model. We developed and tested predictive models for TBI that use machine learning algorithms using information that can be obtained in the prehospital stage.

DESIGN

This was a multicentre retrospective study.

SETTING AND PARTICIPANTS

This study was conducted at three tertiary academic emergency departments (EDs) located in an urban area of South Korea. The data from adult patients with severe trauma who were assessed by emergency medical service providers and transported to three participating hospitals between 2014 to 2018 were analysed.

RESULTS

We developed and tested five machine learning algorithms-logistic regression analyses, extreme gradient boosting, support vector machine, random forest and elastic net (EN)-to predict TBI, TBI with intracranial haemorrhage or injury (TBI-I), TBI with ED or admission result of admission or transferred (TBI with non-discharge (TBI-ND)) and TBI with ED or admission result of death (TBI-D). A total of 1169 patients were included in the final analysis, and the proportions of TBI, TBI-I, TBI-ND and TBI-D were 24.0%, 21.5%, 21.3% and 3.7%, respectively. The EN model yielded an area under receiver-operator curve of 0.799 for TBI, 0.844 for TBI-I, 0.811 for TBI-ND and 0.871 for TBI-D. The EN model also yielded the highest specificity and significant reclassification improvement. Variables related to loss of consciousness, Glasgow Coma Scale and light reflex were the three most important variables to predict all outcomes.

CONCLUSION

Our results inform the diagnosis and prognosis of TBI. Machine learning models resulted in significant performance improvement over that with logistic regression analyses, and the best performing model was EN.

Prospective observational cohort study on epidemiology, treatment and outcome of patients with traumatic brain injury (TBI) in German BG hospitals

OBJECTIVES

Since 2000/2001, no large-scale prospective studies addressing traumatic brain injury (TBI) epidemiology in Germany have been published. Our aim was to look for a possible shift in TBI epidemiology described in other European countries, to look for possible changes in TBI management and to identify predictors of 1-year outcome especially in patients with mild TBI.

DESIGN

Observational cohort study.

SETTING

All patients suffering from a TBI of any degree between 1 October 2014 and 30 September 2015, and who arrived in one of the seven participating BG hospitals within 24 hours after trauma, were included.

PARTICIPANTS

In total, 3514 patients were included.

OUTCOME MEASURES

Initial care, acute hospital care and rehabilitation were documented using standardised documentation forms. A standardised telephone interview was conducted 3 and 12 months after TBI in order to obtain information on outcome.

RESULTS

Peaks were identified in males in the early 20s and mid-50s, and in both sexes in the late 70s, with 25% of all patients aged 75 or older. A fall was the most frequent cause of TBI, followed by traffic accidents (especially bicyclists). The number of head CT scans increased, and the number of conventional X-rays of the skull decreased compared with 2000/2001. Besides, more patients were offered rehabilitation than before. Though most TBI were classified as mild, one-third of the patients participating in the telephone interview after 12 months still reported troubles attributed to TBI. Negative predictors in mild TBI were female gender, intracranial bleeding and Glasgow Coma Scale (GCS) 13/14.

CONCLUSION

The observed epidemiologic shift in TBI (ie, elderly patients, more falls, more bicyclists) calls for targeted preventive measures. The heterogeneity behind the diagnosis 'mild TBI' emphasises the need for defining subgroups not only based on GCS.

Identification of Serious Adverse Events in Patients with Traumatic Brain Injuries, from Prehospital Care to Intensive-Care Unit, Using Early Warning Scores

Traumatic brain injuries are complex situations in which the emergency medical services must quickly determine the risk of deterioration using minimal diagnostic methods. The aim of this study is to analyze whether the use of early warning scores can help with decision-making in these dynamic situations by determining the patients who need the intensive care unit. A prospective, multicentric cohort study without intervention was carried out on traumatic brain injury patients aged over 18 given advanced life support and taken to the hospital. Our study included a total of 209 cases. The total number of intensive-care unit admissions was 50 cases (23.9%). Of the scores analyzed, the National Early Warning Score2 was the best result presented with an area under the curve of 0.888 (0.81–0.94; p < 0.001) and an odds ratio of 25.4 (95% confidence interval (CI):11.2–57.5). The use of early warning scores (and specifically National Early Warning Score2) can help the emergency medical services to differentiate traumatic brain injury patients with a high risk of deterioration. The emergency medical services should use the early warning scores routinely in all cases for the early detection of high-risk situations.