The impact of anemia in moderate to severe traumatic brain injury

Purpose

The impact of anemia and restrictive transfusion strategies in traumatic brain injury (TBI) is unclear. The purpose of this study was to examine the outcome of varying degrees of anemia in patients who have sustained a TBI.

Methods

We performed a retrospective study of all adult patients with isolated blunt TBI admitted between January 2003 and June 2010. The impact of increasing severity of anemia (Hb ≤8, ≤9, or ≤10 g/dl measured on three consecutive draws within the first 7 days of admission) and transfusions on complications, length of stay, and mortality was examined using univariate and multivariate analysis.

Results

Of the 31,648 patients with blunt trauma admitted to the trauma service during the study period, 812 had an isolated TBI, among which 196 (24.1 %) met at least one of the anemia thresholds within the first 7 days [78 % male, mean age 47 ± 23 years, Injury Severity Score 16 ± 8, and head Abbreviated Injury Scale 3.3 ± 1.0]. Using a logistic regression model, anemia even as low as 8 g/dl was not associated with an increase in mortality [AOR₈ = 0.8 (0.2, 3.2), p = 0.771; AOR₉ = 0.8 (0.4, 1.6), p = 0.531; AOR₁₀ = 0.6 (0.3, 1.3), p = 0.233] or complications. However, for all patients, the transfusion of packed red blood cells was associated with a significant increase in septic complications [AOR = 3.2 (1.5, 13.7), p = 0.030].

Conclusion

The presence of anemia in patients with TBI as low as 8 g/dl was not associated with increased mortality or complications, while the transfusion of red blood cells was associated with a significant increase in septic complications. Prospective evaluation of an optimal transfusion trigger in head-injured patients is warranted.     

The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury

BACKGROUND: Several studies have demonstrated that the success rate of prehospital intubation is improved by the use of neuromuscular blocking agents (NMBAs). However, a recent study has reported that prehospital intubation with NMBAs worsens outcome after traumatic brain injury (TBI). We sought to determine the effect of the use of NMBAs to facilitate prehospital intubation on outcome after TBI. METHODS: All patients admitted to our Level I trauma center with a head Abbreviated Injury Scale score >/= 3 were identified by the trauma registry (January 1998-June 2003). Patient records were matched with prehospital databases. Patients were further stratified on the basis of prehospital Glasgow Coma Scale (GCS) score into mild (GCS score of 14/15), moderate (GCS score of 9-13), and severe (GCS score < 9) TBI. Outcome included mortality and good outcome (survival to discharge with a GCS score of 14/15). RESULTS: There were 3,052 patients who were identified as having been transported directly from the field. Complete prehospital data were available for 2,012 patients (66%). Of these, 920 were mild TBI (intubation rate, 17.4%), 293 moderate TBI (intubation rate, 57.7%), and 799 severe TBI (intubation rate, 95%). Overall, 72% of intubated patients received NMBAs. There were no significant differences in demographics or injury severity between the groups. Patients not receiving NMBAs were more likely to be hypotensive and have prehospital cardiopulmonary resuscitation (p = 0.001). The unadjusted mortality for the patients intubated with NMBAs was 25% versus 37% for those not receiving NMBAs (p < 0.001). When adjusted for confounding variables, patients intubated with NMBAs were more likely to survive (odds ratio, 0.63; 95% confidence interval, 0.41-0.97; p = 0.04) and have a good outcome (odds ratio, 1.7; 95% confidence interval, 1.2-2.6; p = 0.006) than those in the no-NMBA group. CONCLUSION: The use of NMBAs to facilitate prehospital intubation improves outcome for patients with TBI. The value of prehospital intubation for TBI remains to be determined; however, any trial evaluating nonintubation for TBI must be compared with NMBA-facilitated intubation to be valid.     

Cognitive and psychosocial outcome following moderate or severe traumatic brain injury

The outcome of 96 consecutive adult patients with moderate to severe head injury was sequentially measured at 6, 12 and 24 months post-injury. In addition to global outcome using the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests of cognitive function, the Head Injury Symptom Checklist (HISC) and Relative's Questionnaire (RQ) were used. Although poorer GOS scores and severe cognitive impairments were typically associated with greater severity of initial injury, relatives reported similar functional problems irrespective of injury severity. This illustrates the legacy of moderate head injury in influencing many aspects of everyday life, supporting the argument that the needs of this group should not be overlooked.     

The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury

OBJECTIVE: To evaluate the effect of paramedic rapid sequence intubation (RSI) on outcome in patients with severe traumatic brain injury. METHODS: Adult major trauma victims were prospectively enrolled over two years using the following inclusion criteria: Glasgow Coma Scale (GCS) 3-8, suspected head injury by mechanism or physical examination, transport time > 10," and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using physical examination, capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. For this analysis, trial patients were excluded for absence of a head injury (Head/Neck AIS score < 2), failure to fulfill major trauma outcome study criteria, unsuccessful intubation or Combitube insertion, or death in the field or in the resuscitation suite within 30" of arrival. Each study patient was hand matched to three nonintubated historical controls from our trauma registry using the following parameters: age, sex, mechanism of injury, trauma center, and AIS score for each body system. Controls were excluded for Head/Neck AIS defined by a c-spine injury or death in the field or in the resuscitation suite within 30" of arrival. chi 2, odds ratios, and logistic regression were used to investigate the impact of RSI on the primary outcome measures of mortality and incidence of a "good outcome," defined as discharge to home, rehabilitation, psychiatric facility, jail, or signing out against medical advice. RESULTS: A total of 209 trial patients were hand matched to 627 controls. The groups were similar with regard to all matching parameters, admission vital signs, frequency of specific head injury diagnoses, and incidence of invasive procedures. Mortality was significantly increased in the trial cohort versus controls for all patients (33.0% versus 24.2%, p < 0.05) and in those with Head/Neck AIS scores of 3 or greater (41.1% versus 30.3%, p < 0.05). The incidence of a "good outcome" was lower in the trial cohort versus controls (45.5% versus 57.9%, p < 0.01). Factors that may have contributed to the increase in mortality include transient hypoxia, inadvertent hyperventilation, and longer scene times associated with the RSI procedure. CONCLUSION: Paramedic RSI protocols to facilitate intubation of head-injured patients were associated with an increase in mortality and decrease in good outcomes versus matched historical controls.     

Effect of traumatic subarachnoid haemorrhage on neuropsychological profiles and vocational outcome following moderate or severe traumatic brain injury

OBJECTIVE: Traumatic subarachnoid haemorrhage (tSAH) frequently occurs in moderate or severe traumatic brain injury (TBI) and is related to worse outcome at time of discharge from the acute hospitalization. The current study compared neuropsychological impairment and vocational outcome at 1-year post-injury in patients with and without tSAH. DESIGN: Acute injury, neuroradiological, neuropsychological and vocational data were collected for 100 patients admitted for neurorehabilitation following TBI. RESULTS: Patients with tSAH had significantly worse vocational outcome than patients without tSAH. On neuropsychological measures, patients with tSAH generally performed worse than patients without tSAH across most neurocognitive domains. However, differences in neuropsychological test performance between patients with and without tSAH reached statistical significance on measures of visuospatial processing, verbal reasoning and mood only. CONCLUSION: The presence of tSAH appears to be associated with worse vocational outcome in survivors of moderate or severe TBI. As such, the presence of tSAH appears to have predictive value with respect to outcome following TBI.     

Mortality and morbidity from moderate to severe traumatic brain injury in Argentina

After adopting the Guidelines for the Management of Severe Head Injury, critical care physicians in Argentina reduced the mortality rate of patients with traumatic brain injury (TBI). However, there is no in-hospital or postdischarge rehabilitation services for persons with TBI in Argentina. Thus, severely disabled survivors were being discharged to home without follow-up or long-term care. OBJECTIVES: The objectives of this project were to establish a structure for conducting research about TBI in Argentina, and to conduct a prospective, observational study of outcomes from TBI in hospitals that had adopted the acute care guidelines. The goal was to document outcomes for people treated in a medical system that does not provide TBI rehabilitation. The focus of this report is mortality and morbidity during the acute care and hospital ward treatment of TBI in Argentina. METHODS: We established a data-collection system in 5 hospitals in Argentina, using instruments and protocols developed by the NIDRR-funded TBI Model System program. Data-collection intervals were established to be comparable with intervals used in the TBI Model System program. The Argentine team consists of 11 neurocritical care physicians and 1 project manager/translator. All patient evaluation, data collection and entry, quality control, and local administration were conducted by this group. RESULTS: Over 31 months, 278 patients were entered into the study. Approximately 61% were discharged from acute care directly to home. The in-hospital mortality rate was 31%. Seventy-six percent of expired patients died from secondary complications such as sepsis and pneumonia, and 93% while in the hospital. DISCUSSION: TBI is a major public health concern in Argentina. However, rehabilitation for TBI is not a part of this country's medical system. The greatest proportion of expired patients in the Argentine sample died of secondary complications such as pneumonia or sepsis, which may have been avoided employing basic medical rehabilitation. The next research questions to be addressed in this population should be designed to identify solutions to the immediate need for rehabilitation, including treatment efficacy questions as well as questions about systems for delivering treatments.     

Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury

BACKGROUND: The role of pre-hospital trauma care and the effect of pre-hospital rapid sequence intubation (RSI) on patient outcome are still not clear. This study evaluated the impact of pre-hospital trauma care by emergency physicians (EP) on mortality from severe traumatic brain injury (TBI) and a 180-day Glasgow Outcome Scale (GOS). METHODS: A 48-month parallel non-controlled cohort study compared a group of 64 patients with severe TBI [Glasgow Coma Scale (GCS) < 9; Injury Severity Score (ISS) > 15] who received pre-hospital advanced life support (ALS) with RSI and were transported to the hospital by EPs (EP group), with a group of 60 patients who did not receive pre-hospital ALS with RSI [emergency medical technicians (EMT) group]. RESULTS: There were no significant statistical differences between the groups in age (P= 0.79), mechanism of injury (P= 0.68), gender (P= 0.82), initial GCS (P= 0.63), initial SaO(2) in the field (P= 0.63), initial systolic blood pressure in the field (P= 0.47) and on-scene time (P= 0.41). In the EP group, there was significantly better first hour survival (97% vs. 79%, P= 0.02), first day survival (90% vs. 72%, P= 0.02), better functional outcome (GOS 4-5: 53% vs. 33%, P < 0.01; GOS 2-3: 8% vs. 20%, P < 0.01) and shortened hospitalization time in intensive care unit (ICU) (P= 0.03) and other departments (P= 0.04). In total hospital mortality, we detected no differences between both groups [EP group: 40% (95% CI: 34-45%) vs. EMT group 42% (95% CI: 36-47%, P= 0.76], except in a subgroup of patients with GCS 6-8 where there was significantly lower total hospital mortality in the EP group (24% vs. 78%, P < 0.01). CONCLUSION: After starting the trauma care system with emergency physicians in our region, there was a decrease in the number of deaths on hospital admission, a reduction in hospital mortality in the GCS group 6-8, a change in the temporal distribution of deaths, an improvement in functional neurological outcome and shortened hospitalization time.     

The impact of early flow and brain oxygen crisis on the outcome of patients with severe traumatic brain injury

Background

Multimodality monitoring and goal-directed therapy may not prevent blood flow and brain oxygen (Flow/BrOx) crisis. We sought to determine the impact of these events on outcome in patients with severe traumatic brain injury (sTBI).

Methods

Twenty-four patients with sTBI were treated to maintain intracranial pressure (ICP) less than or equal to 20 mm Hg, cerebral perfusion pressure (CPP) greater than or equal to 60 mm Hg, brain oxygen greater than or equal to 20 mm Hg, and near infrared spectroscopy greater than or equal to 60%. Flow/BrOx crisis events were recorded. The 14-day predicted mortality was compared with actual mortality.

Results

Nonsurvivors had a significantly higher number of crisis events nonresponsive to treatment (P < .05). Mortality was 87.5% in patients with greater than or equal to 20 events versus 6.3% in patients with less than 20 events. The predicted mortality was 58%, whereas actual mortality was 33.3% (8/24), yielding a 42% reduction in mortality.

Conclusions

A multimodality monitoring and goal-directed therapy may decrease mortality in sTBI. However, Flow/BrOx crisis events still occur and predict a poor outcome.     

The effect of delay in rehabilitation on outcome of severe traumatic brain injury

Background

Expeditious care within minutes of severe injury improves outcome and is the driving force for development of trauma care systems. Transition from hospital care to rehabilitation is an important step in recovery after trauma-related injury. We hypothesize that delay in the transition from acute care to rehabilitation adversely affects outcome and diminishes recovery after traumatic brain injury (TBI).

Methods

After institutional review board approval, the trauma registry of our regional level I pediatric trauma center was queried for all children with severe blunt TBI (initial Glasgow Coma Scale score ≤8) that required inpatient rehabilitation. Records were stratified as severe TBI (Glasgow Coma Scale [GCS] scores 3, 4, 5) and moderate TBI (GSC scores 6, 7, 8). Intensity of acute care was defined by need for mechanical ventilation and length of intensive care unit stay. Outcome was defined by functional independence measurement (FIM) scores at time of transfer to inpatient rehabilitation. Linear regression was used to compare time in days between discharge from intensive care and admission to inpatient rehabilitation (delay) to rehabilitation efficiency (RE), defined as the ratio of FIM score improvement to length of stay for inpatient rehabilitation. Functional improvement was determined by analysis of FIM score improvement (ΔFIM) between initiation and completion of inpatient rehabilitation.

Results

Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Mean length of stay in the intensive care unit was 11.1 ± 7.4 days. Fifty-two children required an average of 9.4 ± 6.8 ventilator days. Delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with RE and ΔFIM (correlation coefficient = −0.346, P = .0068). For children with the highest potential for salvage (GCS scores 6, 7, 8), RE correlation increased to −0.457 (P = .011), whereas those with most severe injury (GCS scores 3, 4, 5) demonstrated a weaker correlation that was not significant. For children with most severe injury (GCS scores 3,4,5), the correlation of ΔFIM was significant (−0.38; P = .035); however, RE was not.

Conclusions

These data demonstrate the price of delay of comprehensive rehabilitation, especially for the most vulnerable TBI children with best potential for salvage. The “golden hour,” which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to the “golden day,” during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation to effect the greatest functional recovery.     

Balance abilities in individuals with moderate and severe traumatic brain injury

Balance characteristics, latency, amplitude, and symmetry were measured in 23 moderate and 23 severe traumatic brain-injured (TBI) patients. Patients received two graded forward and two graded backward linear perturbations. Although within normal limits, latency was high. Patients were able to appropriately grade force in relation to the size of the perturbation. Standing posture prior to and during perturbation was recorded by the amount of force generation through each lower extremity. Some individuals used an asymmetrical balance response following perturbations, whereas others shifted to a more symmetrical weight-bearing balance response. TBI patients may be prone to instability due to a combination of long latency of onset of the balance response coupled with asymmetrical stance patterns during recovery from an unexpected linear perturbation.     

Hybrid outcome prediction model for severe traumatic brain injury

Numerous studies addressing different methods of head injury prognostication have been published. Unfortunately, these studies often incorporate different head injury prognostication models and study populations, thus making direct comparison difficult, if not impossible. Furthermore, newer artificial intelligence tools such as machine learning methods have evolved in the field of data analysis, alongside more traditional methods of analysis. This study targets the development of a set of integrated prognostication model combining different classes of outcome and prognostic factors. Methodologies such as discriminant analysis, logistic regression, decision tree, Bayesian network, and neural network were employed in the study. Several prognostication models were developed using prospectively collected data from 513 severe closed head-injured patients admitted to the Neurocritical Unit at National Neuroscience Institute of Singapore, from April 1999 to February 2003. The correlation between prognostic factors at admission and outcome at 6 months following injury was studied. Overfitting error, which may falsely distinguish different outcomes, was compared graphically. Tenfold cross-validation technique, which reduces overfitting error, was used to validate outcome prediction accuracy. The overall prediction accuracy achieved ranged from 49.79% to 81.49%. Consistently high outcome prediction accuracy was seen with logistic regression and decision tree. Combining both logistic regression and decision tree models, a hybrid prediction model was then developed. This hybrid model would more accurately predict the 6-month post-severe head injury outcome using baseline admission parameters.     

The impact of acute care medications on rehabilitation outcome after traumatic brain injury

Objectives: To examine the impact of medications with known central nervous system (CNS) mechanisms of action, given during the acute care stages after traumatic brain injury (TBI), on the extent of cognitive and motor recovery during inpatient rehabilitation.

Design: Retrospective extraction of data utilizing an inception cohort of moderate and severe TBI survivors.

Methods: The records of 182 consecutive moderate and severe TBI survivors admitted to a single, large, Midwestern level I trauma centre and subsequently transferred for acute inpatient rehabilitation were abstracted for the presence of 11 categories of medication, three measures of injury severity (worst 24 hour Glasgow Coma Scale, worst pupillary response, intra-cranial hypertension), three measures of outcome (Function Independence Measure (FIM) Motor and Cognitive scores at both rehabilitation admission and discharge and duration of post-traumatic amnesia (PTA)).

Main outcome and results: The narcotics, benzodiazepines and neuroleptics were the most common categories of CNS active medications (92%, 67% and 43%, respectively). The three categories of medications appeared to have no significant outcome on the FIM outcome variables. The neuroleptics affected cognitive recovery with almost 7 more days required to clear PTA in the neuroleptic treated group. The presence of benzodiazepines did tend to obscure the impact of neuroleptics on PTA duration but the negative impact of neuroleptics on PTA duration remained significant.

Conclusions: The results suggest that the use of neuroleptics during the acute care stage of recovery has a negative impact on recovery of cognitive function at discharge from inpatient rehabilitation. Due to the paucity of subjects with hemiplegia in this cohort, conclusions could not be drawn as to the impact of acute care medications on motor recovery.     

The impact of intracranial pressure monitoring on mortality after severe traumatic brain injury

Background

The effect of intracranial pressure (ICP) monitoring on mortality after severe traumatic brain injury (sTBI) remains unclear. We hypothesized that ICP monitoring would not be associated with improved survival in patients with sTBI.

Methods

A retrospective analysis was performed on sTBI patients, defined as admission Glasgow Coma Scale score of 8 or less with intracranial hemorrhage. Patients who underwent ICP monitoring were compared with patients who did not. The primary outcome measure was inhospital mortality.

Results

Of 123 sTBI patients meeting inclusion criteria, 40 (32.5%) underwent ICP monitoring. On bivariate and multivariate regression analyses, ICP monitoring was associated with decreased mortality (odds ratio = .32, 95% confidence interval = .10 to .99, P = .049). This finding persisted on propensity-adjusted analysis.

Conclusions

ICP monitoring is associated with improved survival in adult patients with sTBI. In addition, significant variability exists in the use of ICP monitoring among patients with sTBI.     

The impact of prophylactic treatment on post-traumatic epilepsy after severe traumatic brain injury

AIM: To assess the incidence of late post-traumatic epilepsy (PTE) in patients with very severe traumatic brain injury (TBI) who either received or did not receive anti-epileptic prophylactic treatment. METHODS: Two populations were studied: 55 patients retrospectively and 82 subjects prospectively. RESULTS: Ten patients (18%) in the first population showed late PTE. Although the incidence was lower in patients who did not receive prophylactic treatment, the difference between the treated and the non-treated group was not statistically significant. Sixty-nine patients in the second group (84%) had prophylactic treatment. Twenty-seven patients (39%) suffered from late PTE during the 2-year follow-up period and 17 of them (63%) showed EEG epileptic abnormalities. No patient who did not receive preventive therapy suffered from late PTE during the observation period. CONCLUSIONS: Due to the negative cognitive effects of anti-epileptic drugs, the preliminary results are of considerable interest for the rehabilitation of patients with very severe TBI.     

Vocational outcome of aphasic patients following severe traumatic brain injury

The incidence and course of aphasia, and its impact on vocational outcome, were determined in a group of 351 patients with severe traumatic brain injury TBI . Aphasia was found in 111 , the common forms being amnestic 56 , 22 39 , expressive 10 3 , 4 39 and receptive 10 5 , 8 39 , as found on the first language assessment. No age difference was found between the aphasic and nonaphasic patients. Coma was more common in the aphasics than the non-aphasics 95 and 82 , respectively , although its mean duration was shorter. Aphasics had more severe locomotor deficits p 0 01, Fisher test and tended towards more severe cognitive disorders p 0 07, Fisher test . There was no difference between the groups in incidence of behavioural disturbances or occupational outcome. Most of the aphasic patients improved after therapy, and two recovered completely. The presence of aphasia did not have negative prognostic implications for occupational outcome.