Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma

BACKGROUND: A large population of patients on oral anticoagulants is exposed to the risk of traumatic brain injury (TBI). Effects of age and anticoagulation on TBI outcomes need to be assessed separately. METHODS: Retrospective analysis of consecutive series of TBI patients (age 18 years and older) in a suburban teaching hospital. RESULTS: A total of 1,493 adult blunt head trauma patients between January 2001 and May 2005 were analyzed. Of these, 159 patients were warfarin-anticoagulated at the time of trauma. The mortality in anticoagulated patients was statistically significantly higher than in the control group (38/159, 23.9% vs. 66/1,334, 4.9%; p < 0.001; odds ratio 6.0). Mortality of patients over 70 years of age was significantly higher than in the younger population (p < 0.001). Both mortality and the occurrence of intracranial hemorrhage (ICH) after head trauma were significantly increased with higher INR (Cochran's linear trend p < 0.001), especially with INR over 4.0 (mortality 50%, risk of ICH 75%). Preinjury warfarin anticoagulation and age were found to be predictive of survival in a binary logistic regression model (92.5% correct prediction, p = 0.027). Addition of Injury Severity Score and initial Glasgow Coma Score to this model only modestly improved its predictive performance (95.4% correct prediction, p < 0.001). CONCLUSIONS: Both age and warfarin anticoagulation are independent predictors of mortality after blunt TBI. Warfarin anticoagulation carries a six-fold increase in TBI mortality. Age over 70 years and excessive anticoagulation are associated with higher mortality, as well.     

Low-dose aspirin prophylaxis and risk of intracranial hemorrhage in patients older than 60 years of age with mild or moderate head injury: a prospective study

OBJECT: The goal of this paper was to investigate a possible relationship between the consumption of low-dose aspirin (LDA) and traumatic intracranial hemorrhage in an attempt to determine whether older patients receiving prophylactic LDA require special treatment following an incidence of mild-to-moderate head trauma. METHODS: Two hundred thirty-one patients older than 60 years of age, who arrived at the emergency department with a mild or moderate head injury (Glasgow Coma Scale [GCS] Scores 13-15 and 9-12, respectively), were included in the study. One hundred ten patients were receiving prophylactic LDA (100 mg/day) and these formed the aspirin-treated group. One hundred twenty-one patients were receiving no aspirin, and these formed the control group. There was no statistically significant difference between the two groups with respect to age, sex, mechanism of trauma, or GCS score on arrival at the emergency department. Most of the patients sustained the head injury from falls (88.2% of patients in the aspirin-treated group and 85.1% of patients in the control group), and had external signs of head trauma such as bruising or scalp laceration (80.9% of patients in the aspirin-treated group and 86.8% of patients in the control group). All patients underwent similar neurological examinations and computerized tomography (CT) scanning of the head. The CT scans revealed evidence of traumatic intracranial hemorrhage in 27 (24.5%) patients in the aspirin-treated group and in 31 patients (25.6%) in the control group. Surgical intervention was required for five patients in each group (4.5% of patients in the aspirin-treated group and 4.1% of patients in the control group). A surprising number of the patients who arrived with GCS Score 15 were found to have traumatic intracranial hemorrhage, as revealed by CT scanning (11.5% of patients in the aspirin-treated group and 16.5% of patients in the control group). Surgery, however, was not necessary for any of these patients. CONCLUSIONS: There was no statistically significant difference in the frequency or types of traumatic intracranial hemorrhage between patients who had received aspirin prophylaxis and those who had not. The authors conclude that LDA does not increase surgically relevant parenchymal or meningeal bleeding following moderate and minor head injury in patients older than 60 years of age.     

Beta-blockers in isolated blunt head injury

BACKGROUND: The purpose of this study was to evaluate the effect of beta-blockers on patients sustaining acute traumatic brain injury. Our hypothesis was that beta-blocker exposure is associated with improved survival. STUDY DESIGN: The trauma registry and the surgical ICU databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2005. Patients sustaining major associated injuries (Abbreviated Injury Score > or = 4 in any body region other than the head) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcomes measure evaluated was in-hospital mortality. RESULTS: During the 90-month study period, 1,156 patients with isolated head injury were admitted to the ICU. Of these, 203 (18%) received beta-blockers and 953 (82%) did not. Patients receiving beta-blockers were older (50 +/- 21 years versus 38 +/- 20 years, p < 0.001), had more frequent severe (Abbreviated Injury Score > or = 4) head injury (54% versus 43%, p < 0.01), Glasgow Coma Scale < or = 8 less often (37% versus 47%, p = 0.01), more skull fractures (20% versus 12%, p < 0.01), and underwent craniectomy more frequently (23% versus 4%, p < 0.001). Stepwise logistic regression identified beta-blocker use as an independent protective factor for mortality (adjusted odds ratio: 0.54; 95% CI, 0.33 to 0.91; p = 0.01). On subgroup analysis, elderly patients (55 years or older) with severe head injury (Abbreviated Injury Score > or = 4) had a mortality of 28% on beta-blockers as compared with 60% when they did not receive them (odds ratio: 0.3; 96% CI, 0.1 to 0.6; p = 0.001). CONCLUSIONS: Beta-blockade in patients with traumatic brain injury was independently associated with improved survival. Older patients with severe head injuries demonstrated the largest reduction in mortality with beta-blockade.     

Management and hospital outcome of the severely head injured elderly patient

Introduction: Severe traumatic head injury in the elderly has been associated with poor outcomes. However, there is currently no consensus to direct management in these patients. This study outlines the demographics, injury characteristics, management and outcome of the elderly trauma patients with severe head injury across a defined population. Materials and Methods: A retrospective review of all elderly patients (age >64 years) with a Glasgow Coma Scale (GCS) score of 8 or less, and confirmed intracranial pathology or fractured skull, was undertaken over a period of 40 months from July 2001 to September 2005. Data on patient demographics, injury cause, presenting clinical features and interventions were collected. In‐hospital mortality was used as the primary outcome. Results: There were 96 patients who met the inclusion criteria. One‐third of the patients were managed palliatively, one‐third supportively without surgery and another third underwent surgery. Overall mortality was 70.8% (n = 68). Older age and brainstem injuries were identified as independent predictors of mortality. Mortality was reported in all patients aged 85 years or older. Conclusions: Although overall outcomes were poor, careful consideration should be given to active treatment as favourable outcomes were possible even in the presence of extremely low GCS scores. Prediction of outcome on the basis of age and anatomical diagnoses may help in this decision‐making.     

Intensive care unit outcome of vehicle-related injury in elderly trauma patients

Vehicle-related trauma is a common mechanism of injury in elderly (age > or = 65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.     

Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity

OBJECTIVE: The purpose of this study was to compare data obtained from a statewide data set for elderly patients (age > 64 years) that presented with traumatic brain injury with data from nonelderly patients (age > 15 and < 65 years) with similar injuries. METHODS: The New York State Trauma Registry from January 1994 through December 1995, from trauma centers and community hospitals excluding New York City (45,982 patients), was examined. Head-injured patients were identified by International Classification of Diseases, Ninth Revision diagnosis codes. A relative head injury severity scale (RHISS) was constructed on the basis of groups of these codes (range, 0 = none to 3 = severe). Comparisons were made with nonelderly patients for mortality, Glasgow Coma Scale (GCS) score at admission and discharge, Injury Severity Score, New Injury Severity Score, and RHISS. Outcome was assessed by a Functional Independence Measure score in three major domains: expression, locomotion, and feeding. Data were analyzed by the chi2 test and Mann-Whitney U test, with p < 0.05 considered significant. RESULTS: There were 11,772 patients with International Classification of Diseases, Ninth Revision diagnosis of head injury, of which 3,244 (27%) were elderly. There were more male subjects in the nonelderly population (78% male subjects) compared with the elderly population (50% men). Mortality was 24.0% in the elderly population compared with 12.8% in the nonelderly population (risk ratio, 2.2; 95% confidence interval, 1.99-2.43). The elderly nonsurvivors were statistically older, and mortality rate increased with age. Stratified by GCS score, there was a higher percentage of nonsurvivors in the elderly population, even in the group with only moderately depressed GCS score (GCS score of 13-15; risk ratio, 7.8; 95% confidence interval, 6.1-9.9 for elderly vs. nonelderly). Functional outcome in all three domains was significantly worse in the elderly survivors compared with the nonelderly survivors. CONCLUSION: Elderly traumatic brain injury patients have a worse mortality and functional outcome than nonelderly patients who present with head injury even though their head injury and overall injuries are seemingly less severe.     

Low-dose aspirin therapy is not a reason for repeating head computed tomographic scans in traumatic brain injury: a prospective study

Background

Most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate the utility of repeat head computed tomography (RHCT) and outcomes in patients on low-dose aspirin (acetylsalicylic acid; ASA) therapy.

Methods

Patients with traumatic brain injury with intracranial hemorrhage on initial head computed tomography (CT) were prospectively enrolled. Patients on prehospital low-dose (81 mg) aspirin therapy were matched with patients exclusive of antiplatelet and anticoagulation therapy using propensity score matching in a 1:1 ratio for age, Glasgow Coma Scale, head Abbreviated Injury Scale score, Injury Severity Score, and neurological examination. Outcome measures were progression on RHCT and subsequent neurosurgical intervention.

Results

A total of 144 patients who had intracranial hemorrhage on initial CT scan (ASA group: 72; No-ASA group: 72) were enrolled. The mean age was 72.8 ± 11.7 years, 59.7% were male, and median head Abbreviated Injury Scale was 3 (2–3). There was no difference in progression on RHCT (25% in ASA versus 16.6% in no-ASA), change in management as a result of RHCT (1.4% versus 1.4%), RHCT as a result of neurological decline (0 versus 1.4%), discharge Glasgow Coma Scale (15 [14–15] versus 15 [14–15]), and mortality (0 versus 1.4%) between the two groups.

Conclusions

Low-dose aspirin therapy is not associated with progression of initial insult on RHCT or clinical deterioration. Prehospital low-dose aspirin therapy as a sole criterion should not warrant a routine repeat head CT in traumatic brain injury.     

Traumatic head injury in the anticoagulated elderly patient: a lethal combination.

Warfarin is the most common oral anticoagulant used for chronic anticoagulation therapy. Even without any antecedent trauma overanticoagulation can result in intracranial hemorrhage. The triad of anticoagulation with warfarin, age greater than 65 years, and traumatic head injury frequently produces a lethal brain hemorrhage. A retrospective review of more than 2000 patients admitted to the Trauma Service between September 1998 and May 2000 produced 278 patients with head injury and CT-documented intracranial hemorrhage. Of these patients 21 were admitted with an elevated prothrombin time (PT) due to anticoagulation with warfarin. Eighteen patients (86%) were above the age of 70. The most common indications for anticoagulation were atrial fibrillation (71%), deep venous thrombosis (19%), aortic valve replacement (9%), and ischemic cerebral infarcts (9%). Fourteen injuries were the result of a fall, one resulted from a gunshot wound, and one resulted from an assault. The remaining five patients were excluded as their history, workup, and evaluation by neurosurgery suggested a spontaneous bleed leading to fall rather than a fall causing a traumatic bleed. The average Glasgow Coma Score on admission was 11. The average PT and International Normalized Ratio (INR) on admission were 19.2 and 2.99 respectively. Eight of the 16 patients analyzed died. The risk of intracranial hemorrhage with relatively minor head injury is increased dramatically in the anticoagulated patient. A mortality rate of 50 per cent far exceeds the mortality rate in patients with similar head injuries who are not anticoagulated. In addition the risk/benefit equation of anticoagulation for the elderly is more complex and differs from that for younger patients. Perhaps more frequent and judicious monitoring of prothrombin time levels with lower therapeutic ranges (INR 1.5-2) is necessary.     

Does health care insurance affect outcomes after traumatic brain injury? Analysis of the National Trauma Databank

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 +/- 22.4 vs. 37.3 +/- 16.3 years, P < 0.0001), more severely injured (ISS > or =16: 78.4% vs. 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 +/- 9.4 vs. 5.1 +/- 7.6, P < 0.0001) and had higher mortality (9.3% vs. 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.     

Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome

BACKGROUND: Geriatric trauma patients have a worse outcome than the young with comparable injuries. The contribution of traumatic brain injury (TBI) to this increased mortality is unknown and has been confounded by the presence of other injuries. The purpose of this study was to investigate the role of age in the mortality and early outcome from isolated TBI. METHODS: This was a retrospective analysis of all adult patients with isolated TBI (Abbreviated Injury Scale score > or = 3) admitted during a 5-year period to two Level I trauma centers. Mortality, Glasgow Outcome Scale score at discharge, therapy, and complications were compared for elderly (age > or = 65 years) and younger patients. RESULTS: Of 694 patients, 22% were defined as elderly. The mortality for the elderly group was twice that of their younger counterparts (30% vs. 14%, p < 0.001), even for those with mild to moderate TBI (Glasgow Coma Scale score of 9-15). Thirteen percent of elderly survivors had a poor functional outcome (Glasgow Outcome Scale score of 2 or 3) at hospital discharge versus 5% in the young group (p < 0.01). Independent factors associated with a high mortality were age and Glasgow Coma Scale score. CONCLUSION: The mortality from TBI is higher in the geriatric population at all levels of head injury. In addition, functional outcome at hospital discharge is worse. Although some of this increased mortality may be explained by complications or type of head injury, age itself is an independent predictor for mortality in TBI.     

Effective management of severe traumatic brain injury in a district hospital

Abstract The authors investigated how effectively adults with severe traumatic brain injury (TBI) can be managed in a district general hospital intensive care unit offering intracranial pressure monitoring (ICPM) receiving advice from a neurosurgical unit. A single-centre case series with retrospective review of prospectively collected information was undertaken of 44 consecutive patients presenting over seven years from January 2003 to January 2010 with severe traumatic brain injury to a single district general hospital intensive care unit serving a population of 500,000 adults. A prospectively entered clinical database was used to obtain information including patient demographics, Glasgow Coma Score (GCS) on admission, ICPM insertion, ICPM-related complications, inpatient mortality and neurosurgical advice. Case notes were used to ratify information and obtain neurorehabilitation clinic functional outcome scores. Forty-four patients were identified (40 male, age range 16-77 years). Mortality in intensive care was 30%. Twenty-eight patients received frontal twist drill ICPM following neurosurgical advice. ICPM had 2 (7%) device malfunctions but no other complications. Twelve additional patients were transferred to tertiary centres. Patients (23 of 31) who survived ICU stay (74%) were referred to neurorehabilitation. Mean clinic follow-up was 14 months. All patients had a Glasgow Outcome Score (GOS) of 3 or 4 at initial clinic assessment. Twenty-two improved to GOS to 4 or 5 at clinic discharge. One patient died prior to clinic discharge. Carefully selected patients with severe TBI can be managed safely and effectively in a district general hospital offering ICPM insertion if transfer to a neurosurgical centre is not possible. Neurosurgical advice regarding patient selection and on-going management is fundamental to provid a good service. Protocol driven therapies provide a useful systematic approach to doctors who do not deal with severe TBI on a routine basis.     

Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly.

In order to determine the factors influencing outcome following craniotomy for trauma in patients over the age of 65 and to establish criteria for surgical intervention, the authors carried out a retrospective analysis of the hospital and general practice records of all head injury patients over the age of 65 who underwent a craniotomy for evacuation of a post-traumatic haematoma within 7 days of injury at Frenchay Hospital during a 10-year period (1980-89). Outcome was measured using the Glasgow Outcome Scale and patients were allotted to a good outcome group (good recovery or moderate disability but independent) or a poor outcome group (severe disability, vegetative state of death). There were 35 men and 31 women with a mean age of 72.5 years (range 65-85 years). The mortality rate was 61% and 9% of patients survived in a severely disabled or vegetative state. All 20 (30%) patients with a good outcome had a Glasgow Coma Score (GCS) of 5 or more immediately before surgery. All 18 (27%) patients with a GCS of 4 or less and all 22 (33%) patients with unilateral or bilateral pupillary dilatation had a poor outcome. Outcome was significantly worse in the older patients (75-85 years) compared with the younger patients (65-74 years) and in those patients requiring craniotomy within 24 hours of injury, but the mechanism of injury (fall or road traffic accident), the presence or absence of skull fractures and limb fractures and the pre-operative CT scan appearances did not influence outcome. This study confirms the high probability of poor outcome following surgical evacuation of traumatic intracranial haematomas for elderly head-injured patients with pupillary dilatation or extensor motor responses. Craniotomy under these circumstances is not justified.     

Acute diabetes insipidus in severe head injury: a prospective study

BACKGROUND: The incidence and risk factors for acute diabetes insipidus after severe head injury and the effect of this complication on outcomes have not been evaluated in any large prospective studies. STUDY DESIGN: We conducted a prospective study of all patients admitted to the surgical ICU of a Level I trauma center with severe head injury (head Abbreviated Injury Score [AIS] >or= 3). The following potential risk factors with p < 0.2 on bivariate analysis were included in a stepwise logistic regression to identify independent risk factors for diabetes insipidus and its association with mortality: age, mechanism of injury (blunt or penetrating), blood pressure, Glasgow Coma Scale, Injury Severity Score, head and other body area AIS, skull fracture, cerebral edema and shift, intracranial hemorrhage, and pneumocephaly. RESULTS: There were 436 patients (blunt injuries, 392; penetrating injuries, 44); 387 patients had isolated head injury. Diabetes insipidus occurred in 15.4% of all patients (blunt, 12.5%; penetrating, 40.9%; p < 0.0001) and in 14.7% of patients with isolated head injury (blunt, 11.8%; penetrating, 39.5%; p < 0.0001). The presence of major extracranial injuries did not influence the incidence of diabetes insipidus. Independent risk factors for diabetes insipidus in isolated head injury were Glasgow Coma Scale3. Diabetes insipidus was an independent risk factor for death (adjusted odds ratio, 3.96; 95% CI [1.65, 9.72]; adjusted p value = 0.002). CONCLUSIONS: The incidence of acute diabetes insipidus in severe head injury is high, especially in penetrating injuries. Independent risk factors for diabetes insipidus include a Glasgow Coma Scale3. Acute diabetes insipidus was associated with significantly increased mortality.     

Hypotension, hypoxia, and head injury: frequency, duration, and consequences

BACKGROUND: Retrospective studies have suggested an association between systemic hypotension and hypoxia and worsened outcome from traumatic brain injury. Little is known, however, about the frequency and duration of these potentially preventable causes of secondary brain injury. HYPOTHESIS: Early episodes of hypoxia and hypotension occurring during initial resuscitation will have a significant impact on outcome following traumatic brain injury. DESIGN: Prospective cohort study. SETTING: Urban level I trauma center. PATIENTS: Patients with a traumatic brain injury who had a Glasgow Coma Score of 12 or less within the first 24 hours of admission to the hospital and computed tomographic scan results demonstrating intracranial pathologic features. Patients who died in the emergency department were excluded from the study. MAIN OUTCOME MEASURES: Automated blood pressure and pulse oximetry readings were collected prospectively from the time of arrival through initial resuscitation. The number and duration of hypotensive (systolic blood pressure, < or =90 mm Hg) and hypoxic (oxygen saturation, < or =92%) events were analyzed for their association with mortality and neurological outcome. RESULTS: One hundred seven patients met the enrollment criteria (median Glasgow Coma Score, 7). Overall mortality was 43%. Twenty-six patients (24%) had hypotension while in the emergency department, with an average of 1.5 episodes per patient (mean duration, 9.1 minutes). Of these 26 patients with hypotension, 17 (65%) died (P =.01). When the number of hypotensive episodes increased from 1 to 2 or more, the odds ratio for death increased from 2.1 to 8.1. Forty-one patients (38%) had hypoxia, with an average of 2.1 episodes per patient (mean duration, 8.7 minutes). Of these 41 patients with hypoxia, 18 (44%) died (P =.68). CONCLUSIONS: Hypotension, but not hypoxia, occurring in the initial phase of resuscitation is significantly (P =.009) associated with increased mortality following brain injury, even when episodes are relatively short. These prospective data reinforce the need for early continuous monitoring and improved treatment of hypotension in brain-injured patients.     

Prognosis of traumatic head injury in South Tunisia: a multivariate analysis of 437 cases

BACKGROUND: This study aimed to determine predictive factors of mortality after posttraumatic brain injury. METHODS: A retrospective study conducted over a 3-year period (1997-1999) involved 437 adult patients with head injury admitted to the intensive care unit of a university hospital in Sfax, Tunisia. Basic demographic, clinical, biologic, and radiologic data were recorded at admission and during the intensive care unit stay. RESULTS: This study included 393 men (90%) and 44 women with a mean age of 36 +/- 17 years. Traffic accidents were the main cause of trauma (85.6%). In 58% of the cases, the injury was serious (Glasgow Coma Score, <8). The mean simplified acute physiology score was 39 +/- 15, and the mean Injury Severity Score was 34.5 +/- 17. Of the 437 patients, 127 (29.1%) died. According to multivariate analysis, the factors that correlated with a poor prognosis were age older than 40 years (p < 0.01), simplified acute physiology score exceeding 40 (p < 0.001), Glasgow Coma Score lower than 7 (p = 0.03), intracranial mass lesion (p = 0.02), a cerebral herniation (p < 0.001), diabetes insipidus (p < 0.001), and blood sugar level higher than 10 mmol/L (p < 0. 001). CONCLUSIONS: In Tunisia, head injury is a frequent cause of hospitalization, comprising 14.4% of all adult admissions. It is observed most often among young patients involved in traffic accidents. The short-term prognosis is poor, with a high (29%) mortality rate, and determined by demographic, clinical, radiologic, and biologic factors. Prevention is highly advised.     

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury

OBJECTIVES: There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS: Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.     

Acute subdural hematoma: Outcome and outcome prediction

Patients with traumatic acute subdural hematoma were studied to determine the factors influencing outcome.Between January 1986 and August 1995, we collected 113 patients who underwent craniotomy for traumatic acute subdural hematoma. The relationship between initial clinical signs and the outcome 3 months after admission was studied retrospectively.Functional recovery was achieved in 38% of patients and the mortality was 60%. 91% of patients with a high Glasgow Coma Scale (GCS) score (9–15) and 23% of patients with a low GCS score (3–8) achieved functional recovery. All of 14 patients with a GCS score of 3 died. The mortality of patients with GCS scores of 4 and 5 was 95% to 75%, respectively. Patients over 61 years old had a mortality of 73% compared to 64% mortality for those aged 21–40 years. 97% of patients with bilateral unreactive pupil and 81% of patients with unilateral unreactive pupil died. The mortality rates of associated intracranial lesions were 91% in intracerebral hematoma, 87% in subarachnoid hemorrhage, 75% in contusion.Time from injury to surgical evacuation and type of surgical intervention did not affect mortality. Age and associated intracranial lesions were related to outcome. Severity of injury and pupillary response were the most important factors for predicting outcome.     

Investigating gender differences in outcome following severe traumatic brain injury in a predominantly Asian population

The objective of this study was to investigate if there are possible gender differences in relation to outcome following closed severe traumatic brain injury (TBI) in a predominantly Asian population. A study was conducted using our prospectively maintained TBI database of 672 patients with severe TBI admitted into our neurosurgical intensive care unit. All patients were managed on a standardized protocol in accordance with the Guidelines to the management of severe traumatic brain injury. Glasgow Outcome Score was used to measure the outcome of patients 6 months postinjury. There were 525 males and 147 females, with the latter significantly older than their counterpart. Females had a significantly higher mortality and poorer outcome compared with males. However, this difference was no longer significant when variables (presence of multiple injuries, postresuscitation pupil abnormalities and Glasgow Coma Score) are controlled for. However, both crude and adjusted odd ratios revealed that females aged 60 and below were significantly more likely to have a poorer outcome.     

Determinants of hospital costs associated with traumatic brain injury in England and Wales

Using data from the Trauma Audit Research Network, we investigated the costs of acute care in patients > or = 18 years of age hospitalised for traumatic brain injury between January 2000 and December 2005 in England and Wales. Traumatic brain injury patients were defined and stratified using the Abbreviated Injury Scale. A total of 6484 traumatic brain injury patients were identified; 22.3% had an Abbreviated Injury Scale score of three, 38.0% of four and 39.7% of five. Median age (IQR) was 42 years (28-59) and 76.7% were men. Primary cause of injury was motor vehicle collisions (42.4%) followed by falls (38.0%). In total 23.7% of the patients died before discharge. Hospitalisation costs averaged 15,462 pounds sterling (SD 16,844 pounds sterling). Costs varied significantly by age, Glasgow Coma Score, Injury Severity Score, coexisting injuries of the thorax, spine and lower limb, hospital mortality, availability of neurosurgical services, and specialty of attendants seen in the Accident and Emergency department.     

Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3

HYPOTHESIS: To identify significant risk factors associated with mortality in patients with a Glasgow Coma Scale score of 3. DESIGN: Trauma registry study. SETTING: Level I urban trauma center. PATIENTS: A total of 760 patients with head injury with an admission Glasgow Coma Scale score of 3. Analysis was performed in all patients and in only patients who reached the hospital alive and had no major extracranial injuries (exclusion of patients with a chest or abdominal Abbreviated Injury Score [AIS] >3). MAIN OUTCOME MEASURES: Stepwise logistic regression analysis was used to identify independent risk factors associated with mortality. RESULTS: Blunt trauma accounted for 477 (63%) and penetrating trauma for 283 (37%) of the 760 head injuries. Penetrating trauma was significantly more likely to be associated with a lack of vital signs on admission (15% vs 9%; P = .03). Overall mortality was 76% (94% for penetrating injuries and 65% for blunt injuries; P<.001). Overall, 79% of patients had a head AIS of 4 or greater. Mortality in the subgroup was 64% (320/497) and was significantly higher in penetrating vs blunt trauma (89% vs 52%; P<.001). Penetrating trauma, high head AIS, hypotension on admission, and age older than 55 years were independent significant risk factors associated with mortality. Only 10% of the 177 survivors had good functional outcome at hospital discharge. Eighty-six patients (17% of those with vital signs on admission) became organ donors. CONCLUSIONS: Patients with head injury with an admission Glasgow Coma Scale score of 3 have a poor prognosis. Mechanism of injury, head AIS, hypotension on admission, and age play a critical role in outcome. These patients are an important source of organ donation and should be evaluated and resuscitated aggressively.