Systematic Review of Caregiver and Dyad Interventions After Adult Traumatic Brain Injury

Objective

To describe and synthesize the literature on adult traumatic brain injury (TBI) family caregiver and dyad intervention. TBI is a common injury that has a significant long-term impact, and is sometimes even characterized as a chronic condition. Informal (ie, unpaid) family caregivers of adults with TBI experience high rates of burnout, depression, fatigue, anxiety, lower subjective well-being, and poorer levels of physical health compared to noncaregivers. This study addresses the critical gap in the understanding of interventions designed to address the impact of TBI on adult patients and their family caregivers.

Longitudinal Examination of Resilience After Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

Objectives

To evaluate (1) the trajectory of resilience during the first year after a moderate-severe traumatic brain injury (TBI); (2) factors associated with resilience at 3, 6, and 12 months postinjury; and (3) changing relationships over time between resilience and other factors.

Severe Traumatic Brain Injury in Austria III: Prehospital status and treatment

Summary OBJECTIVES: The goal of this paper is to describe prehospital status and treatment of patients with severe TBI in Austria. PATIENTS AND METHODS: Data sets from 396 patients with severe TBI (Glasgow Coma Scale score < 9) included by 5 Austrian hospitals were available. The analysis focused on incidence and/or degree of severity of typical clinical signs, frequency of use of different management options, and association with outcomes for both. ICU mortality, 90-day mortality, final outcome (favorable = good recovery or moderate disability; unfavorable = severe disability, vegetative state, or death) after 6 or 12 months, and ratio of observed (90-day) to predicted mortality (O/E ratio) are reported for the selected parameters. Chi²-test, t-test, Fisher's exact test, and logistic regression were used to identify significant (p < 0.05) differences for association with survival and favorable outcome (both coded as 1). RESULTS: The majority of patients were male (72%), mean age was 49 ± 21 years, mean injury severity score (ISS) was 27 ± 17, mean first GCS score was 5.6 ± 2.9, and expected hospital survival was 63 ± 30%. ICU mortality was 32%, 90-day mortality was 37%, and final outcome was favorable in 35%, unfavorable in 53%, unknown in 12%. We found that age > 60 years, ISS > 50 points, GCS score < 4, bilateral changes in pupil size and reactivity, respiratory rate < 10/min, systolic blood pressure (SBP) < 90 mm Hg, and heart rate < 60/min were associated with significantly higher ICU and 90-day mortality rates, and lower rates of favorable outcome. With regard to prognostic value the GCS motor response score is identical to the full GCS score. Administration of > 1000 ml of fluid and helicopter transport were associated with better outcomes than expected, while endotracheal intubation in the field had neither a positive nor a negative effect on outcomes. Administration of no or < 500 ml of fluids was associated with worse outcomes than expected. Outcomes were better than expected in the few patients (5%) who received hypertonic saline. CONCLUSIONS: Age, ISS, and initial neuro status are the factors most closely associated with outcome. Hypotension must be avoided. Fluids should be given to restore and/or maintain SBP > 110 mm Hg. Helicopter transport should be arranged for more seriously injured patients.

---

Schweres Sch?delhirntrauma in ?sterreich III: Pr?klinischer Status und Erstversorgung

Zusammenfassung ZIELE: Das Ziel der vorliegenden Arbeit ist es, pr?klinischen Status und pr?klinisches Management von Patienten mit schwerem Sch?del-Hirn-Trauma (SHT) darzustellen. PATIENTEN UND METHODEN: Es standen Datens?tze von 396 Patienten mit schwerem SHT (Glasgow Coma Scale < 9) zur Verfügung, die von 5 ?sterreichischen Zentren in die Studie inkludiert worden waren. Analysiert wurden Inzidenz und Schweregrad typischer klinischer Symptome und die H?ufigkeit der Verwendung verschiedener Behandlungsoptionen, und der Zusammenhang mit dem Behandlungsergebnis. Für Symptome und Behandlungsoptionen wurden ICU- und 90-Tage-Mortalit?t, Endzustand nach 6 oder 12 Monaten (gut = Normalzustand oder leichte Behinderung, schlecht = schwere Behinderung, vegetativer Zustand oder Tod), und die O/E ratio (Verh?ltnis von beobachteter zu erwarteter Mortalit?t) erhoben. Statistik: Es kamen Chi²-test, t-test, Fisher's exact test, und logistische Regression zur Anwendung; ein p < 0,05 wurde als signifikant angesehen. ERGEBNISSE: Die Mehrzahl (72%) der Patienten war m?nnlich, das Alter betrug 49 ± 21 Jahre, der mittlere injury severity score (ISS) war 27 ± 17, die mittlere GCS betrug 5,6 ± 2,9, und die erwartete überlebensrate lag bei 63 ± 30%. Die ICU-Mortalit?t lag bei 32%, und die 90-Tage-Mortalit?t bei 37%. Das Ergebnis war "gut" bei 35%, "schlecht" bei 53%, und unbekannt bei 12% der Patienten. Es fand sich, dass Alter > 60 a, ISS > 50, GCS score < 4, bilaterale Pupillenver?nderungen, Atemfrequenz < 10/min, SBP < 90 mm Hg, und Herzfrequenz < 60/min mit signifikant erh?hter ICU- und 90-Tage-Mortalit?t und schlechtem Ergebnisses einhergingen. Zur Klassifikation von Patienten mit SHT k?nnen anstelle der gesamten Punktezahl der GCS auch nur die Punkte für die motorische Antwort verwendet werden. Die Gabe von > 1000 ml Volumen sowie Hubschraubertransport waren mit besserem Ergebnis als erwartet assoziiert, w?hrend die endotracheale Intubation weder einen positiven noch einen negativen Effekt hatte. Unterlassen der Volumentherapie oder Gabe von < 500 ml Volumen hatte ein schlechteres Ergebnis als erwartet zur Folge. Das Ergebnis war besser als erwartet bei den wenigen Patienten (5%) die hypertones NaCl erhalten hatten. SCHLUSSFOLGERUNGEN: Für das Behandlungsergebnisse dürften vor allem Alter, ISS und initialer neurologischer Zustand wesentlich sein. Hypotension muss vermieden werden. Es sollte rasch ausreichend Volumen gegeben werden, um einen SBP > 110 mm Hg zu erreichen oder zu halten. Für schwer verletzte Patienten mit SHT sollte ein Hubschraubertransport arrangiert werden.

     

Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study

Objective

To prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions.

The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review

BackgroundThe use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications.ObjectiveOur aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI.MethodsWe conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs.ResultsThere were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH.ConclusionsThis systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.     

Self-Report of Outpatient Therapy Dose at 6 and 12 Months After Severe Traumatic Brain Injury

Objective

Determine agreement between self-reported dose and dose reflected in administrative records of outpatient physical, occupational, and speech therapies at 6 and 12 months after severe traumatic brain injury (TBI), for the purpose of examining accuracy and predictors of accuracy of self-reported health care utilization in this population.

Cognitive and Behavioral Impairment in Traumatic Brain Injury Related to Outcome and Return to Work

Benedictus MR, Spikman JM, van der Naalt J. Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work.

Objective

To evaluate the cognitive and behavioral disturbances related to return to work (RTW) in patients with traumatic brain injury (TBI) with the application of a differentiated outcome scale.

Design

Longitudinal cohort study.

Setting

Level I trauma center.

Participants

Adults (N=434) with TBI of various severity.

Interventions

Not applicable.

Main Outcome Measures

Extended Glasgow Outcome Scale (GOS-E), Differentiated Outcome Scale (DOS), and RTW.

Results

Patients encountered problems in the physical (40%), cognitive (62%), behavioral (55%), and social domains (49%) of the DOS, with higher frequency related to severity of injury. Even those with mild TBI experienced cognitive (43%) and behavioral problems (33%). Patients with good recovery (58%) according to the GOS-E experienced problems in 1 or more domains of the DOS. Half the patients were able to resume previous vocational activities completely, although 1 in 3 experienced cognitive or behavioral problems. Using multivariate logistic regression analysis, the cognitive (odds ratio [OR], 10.548; confidence interval [CI], 5.99-18.67), behavioral (OR, 2.648; CI, 1.63-4.29), and physical domains (OR, 2.763; CI, 1.60-4.78) were significant (P<.01) predictors of RTW. For subcategories of TBI, the cognitive domain was predictive for RTW in those with moderate and severe TBI, whereas both the cognitive and behavioral domains were predictive for RTW in those with mild TBI.

Conclusions

With application of a more detailed outcome scale, cognitive and behavioral impairments interfering with RTW were present in a substantial part of patients with TBI in the chronic phase after injury. More research is needed exploring the cognitive and behavioral outcome in different categories of injury severity separately.     

Prolonged Emergency Department Length of Stay is Not Associated with Worse Outcomes in Traumatic Brain Injury

Background

Data suggest that prolonged Emergency Department length of stay (EDLOS) has a detrimental effect on outcomes in some critically ill patients. However, the relationship between EDLOS and outcomes in traumatic brain injury (TBI) has not been examined.

Objective

Our objective was to determine the effect of EDLOS on neurologic outcomes in TBI patients.

Methods

We performed a retrospective analysis of a prospectively identified cohort of patients with moderate (Glasgow Coma Scale [GCS] score 9–13) and severe (GCS ≤ 8) TBI who presented to a Level 1 trauma center (2006–2010). Inclusion criteria were transfer to the intensive care unit (ICU) or operating room (OR) from the ED. Primary outcome was Glasgow Outcome Scale (GOS) score, a measure of neurologic function, at discharge. We used a proportional odds model to control for significant predictors of GOS in univariate analysis.

Results

Two hundred and twenty-four patients were included in the analysis, 77 (34%) of which were transferred to the OR. Median EDLOS was 3.3 h and 81.2% of patients had a GOS score ≤3 (e.g., severe disability, vegetative, or deceased). In multivariable analyses, EDLOS was not associated with GOS score in either ICU bound (p = 0.57) or OR bound (p = 0.11) patients. Younger age, pupil reactivity, and absence of intubation were independent predictors of good outcomes in the ICU group. In OR patients, predictors of higher GOS score included presence of an epidural hemorrhage, absence of midline shift, and pupil reactivity.

Conclusions

Our study demonstrates that EDLOS was not associated with poor outcomes in patients with moderate to severe TBI who required intensive care or early operative intervention in an academic Level 1 trauma center.     

A Comparison of Five Simplified Scales to the Out-of-hospital Glasgow Coma Scale for the Prediction of Traumatic Brain Injury Outcomes

Background: The 15-point Glasgow Coma Scale (GCS) frequently is used in the initial evaluation of traumatic brain injury (TBI) in out-of-hospital settings. We hypothesized that the GCS might be unnecessarily complex for out-of-hospital use.
Objectives: To assess whether a simpler scoring system might demonstrate similar accuracy in the prediction of TBI outcomes.
Methods: We performed a retrospective analysis of a trauma registry consisting of patients evaluated at our Level 1 trauma center from 1990 to 2002. The ability of out-of-hospital GCS scores to predict four clinically relevant TBI outcomes (emergency intubation, neurosurgical intervention, brain injury, and mortality) by using areas under receiver operating characteristic curves (AUROCs) was calculated. The same analyses for five simplified scales were performed, and compared with the predictive accuracies of the total GCS score.
Results: In this evaluation of 7,233 trauma patients over a 12-year period of time, the AUROCs for the total GCS score were 0.83 (95% confidence interval [CI] = 0.81 to 0.84) for emergency intubation, 0.86 (95% CI = 0.85 to 0.88) for neurosurgical intervention, 0.83 (95% CI = 0.82 to 0.84) for brain injury, and 0.89 (95% CI = 0.88 to 0.90) for mortality. The five simplified scales approached the performance of the total GCS score for all clinical outcomes.
Conclusions: In the evaluation of injured patients, five simplified neurological scales approached the performance of the total GCS score for the prediction of four clinically relevant TBI outcomes.     

Longitudinal Description of the Glasgow Outcome Scale-Extended for Individuals in the Traumatic Brain Injury Model Systems National Database: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study

Objective

To comprehensively describe the temporal patterns of global outcome after traumatic brain injury (TBI) in the Traumatic Brain Injury Model Systems National Database (TBIMS NDB).

Design

Longitudinal prospective cohort study.

Setting

TBI Model Systems centers.

Participants

Patients (N=3870) ≥16 years of age with moderate or severe TBI enrolled in the TBIMS NDB.

Interventions

None.

Main Outcome Measure

Glasgow Outcome Scale-Extended (GOS-E).

Results

The trajectory of the GOS-E scores is best described with a model of quadratic change, in which scores initially increase and peak approximately 10 years after the first GOS-E assessment, and then decrease. Change occurs most rapidly in the initial and final years of the timeline. There was significant variability in each growth parameter (P<.05). A reduced multilevel model was built, including all covariates (age at first GOS-E assessment, FIM, race, sex, rehabilitation length of stay) that related significantly to the growth parameters. An interactive tool was created to generate individual level trajectories based on various combinations of covariate values. Results provide an individual level account of the chronological progression of TBI outcomes, as measured by the GOS-E.

Conclusions

Individual growth curve analysis is a statistically rigorous approach to describe temporal change with respect to the GOS-E at the individual level for participants within the TBIMS NDB. Results indicated that, for individuals in the TBIMS NDB as a group, functional status as measured by the GOS-E initially improves, plateaus, and then begins to decline. Factors such as age at first GOS-E assessment, race, FIM score at rehabilitation admission, and rehabilitation length of stay were found to influence baseline GOS-E scores, as well as the rate and extent of both improvement and decline over time. Additional research may be required to determine the generalizability of these findings and the usefulness of this tool for clinical applications.     

Health-Related Quality of Life 3 Years After Moderate to Severe Traumatic Brain Injury: A Prospective Cohort Study

Objectives

To evaluate the time course of health-related quality of life (HRQoL) after moderate to severe traumatic brain injury (TBI) and to identify its predictors.

Design

Prospective cohort study with follow-up measurements at 3, 6, 12, 18, 24, and 36 months after TBI.

Setting

Patients with moderate to severe TBI discharged from 3 level-1 trauma centers.

Participants

Patients (N=97, 72% men) with a mean age ± SD of 32.8±13.0 years (range, 18–65y), hospitalized with moderate (23%) or severe (77%) TBI.

Interventions

Not applicable.

Main Outcome Measures

HRQoL was measured with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), functional outcomes with the Glasgow Outcome Scale (GOS), Barthel Index, FIM, and Functional Assessment Measure, and mood with the Wimbledon Self-Report Scale.

Results

The SF-36 domains showed significant improvement over time for Physical Functioning (P<.001), Role Physical (P<.001), Bodily Pain (P<.001), Social Functioning (P<.001), and Role Emotional (P=.024), but not for General Health (P=.263), Vitality (P=.530), and Mental Health (P=.138). Over time there was significant improvement in the Physical Component Summary (PCS) score, whereas the Mental Component Summary (MCS) score remained stable. At 3-year follow-up, HRQoL of patients with TBI was the same as that in the Dutch normative population. Time after TBI, hospital length of stay (LOS), FIM, and GOS were independent predictors of the PCS, whereas LOS and mood were predictors of the MCS.

Conclusions

After TBI, the physical component of HRQoL showed significant improvement over time, whereas the mental component remained stable. Problems of disease awareness seem to play a role in self-reported mental HRQoL. After TBI, mood status is a better predictor of the mental component of HRQoL than functional outcome, implying that mood should be closely monitored during and after rehabilitation.     

Racial Differences in Discharge Location After a Traumatic Brain Injury Among Older Adults

ObjectiveTo determine if there were racial differences in discharge location among older adults treated for traumatic brain injury (TBI) at a level 1 trauma center.DesignRetrospective cohort study.SettingR Adams Cowley Shock Trauma Center.ParticipantsBlack and white adults aged ≥65 years treated for TBI between 1998 and 2012 and discharged to home without services or inpatient rehabilitation (N=2902).Main Outcome MeasuresWe assessed the association between race and discharge location via logistic regression. Covariates included age, sex, Abbreviated Injury Scale-Head score, insurance type, Glasgow Coma Scale score, and comorbidities.ResultsThere were 2487 (86%) whites and 415 blacks (14%) in the sample. A total of 1513 (52%) were discharged to inpatient rehabilitation and 1389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval, 1.06-1.70).ConclusionsIn this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.