Effect of alcohol in traumatic brain injury: is it really protective?

Background

Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI.

Methods

Version 7.2 of the National Trauma Data Bank (2007–2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications.

Results

A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1–2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1–2.8, P = 0.009) in patients with isolated severe TBI.

Conclusions

ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification.     

Correlating the blood alcohol concentration with outcome after traumatic brain injury: too much is not a bad thing

Although recent evidence suggests a beneficial effect of alcohol for patients with traumatic brain injury (TBI), the level of alcohol that confers the protective effect is unknown. Our objective was to investigate the relationship between admission blood alcohol concentration (BAC) and outcomes in patients with isolated moderate to severe TBI. From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients ≥14 years of age with isolated moderate to severe TBI and admission serum alcohol levels. Patients were then stratified into four levels based on admission BAC: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (≥230 mg/dL). Demographics, patient characteristics, and outcomes were compared across levels. In evaluating 3794 patients, the mortality rate decreased with increasing BAC levels (linear trend P < 0.0001). In determining the relationship between BAC and mortality, multivariable logistic regression analysis demonstrated a high BAC level was significantly protective (adjusted odds ratio 0.55; 95% confidence interval: 0.38-0.8; P = 0.002). In the largest study to date, a high (≥230 mg/dL) admission BAC was independently associated with improved survival in patients with isolated moderate to severe TBI. Additional research is warranted to investigate the potential therapeutic implications.     

Ethanol intoxication is associated with a lower incidence of admission coagulopathy in severe traumatic brain injury patients

The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury (sTBI)-associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. Patients admitted to the surgical intensive care unit from June 2005 through December 2008 following sTBI, defined as a head Abbreviated Injury Scale (AIS) score ≥3, were retrospectively identified. Patients with a chest, abdomen, or extremity AIS score >3 were excluded to minimize the impact of extracranial injuries. Criteria for sTBI-associated coagulopathy included thrombocytopenia and/or elevated International Normalized Ratio (INR) and/or prolonged activated partial thromboplastin time (aPTT). The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive [ETOH (+)] and ETOH negative [ETOH (-)]. During the study period, there were 439 patients with ETOH levels available for analysis. Overall, 46.5% (n=204) of these patients were ETOH (+), while 53.5% (n=235) were ETOH (-). Coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts (5.4% versus 15.3%; adjusted p<0.001). In the forward logistic regression analysis, a positive ETOH level proved to be an independent protective factor for admission coagulopathy [OR (95% CI)=0.24 (0.10,0.54; p=0.001]. ETOH (+) patients had a significantly lower in-hospital mortality rate than ETOH (-) patients [9.8% versus 16.6%; adjusted p=0.011; adjusted OR (95% CI)=0.39 (0.19,0.81)]. For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality. Further research to establish the pathophysiologic mechanisms underlying any potential beneficial effect of ETOH on the coagulation system following sTBI is warranted.     

The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury

BACKGROUND: Although early intubation to prevent the mortality that accompanies hypoxia is considered the standard of care for severe traumatic brain injury (TBI), the efficacy of this approach remains unproven. METHODS: Patients with moderate to severe TBI (Head/Neck Abbreviated Injury Scale [AIS] score 3+) were identified from our county trauma registry. Logistic regression was used to explore the impact of prehospital intubation on outcome, controlling for age, gender, mechanism, Glasgow Coma Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension. Neural network analysis was performed to identify patients predicted to benefit from prehospital intubation. RESULTS: A total of 13,625 patients from five trauma centers were included; overall mortality was 22.9%, and 19.3% underwent prehospital intubation. Logistic regression revealed an increase in mortality with prehospital intubation (odds ratio, 0.36; 95% confidence interval, 0.32-0.42; p < 0.001). This was true for all patients, for those with severe TBI (Head/Neck AIS score 4+ and/or Glasgow Coma Scale score of 3-8), and with exclusion of patients transported by aeromedical crews. Patients intubated in the field versus the emergency department had worse outcomes. Neural network analysis identified a subgroup of patients with more significant injuries as potentially benefiting from prehospital intubation. CONCLUSION: Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively.     

Mortality in polytrauma patients with moderate to severe TBI on par with isolated TBI patients: TBI as last frontier in polytrauma patients

BackgroundMortality caused by Traumatic Brain Injury (TBI) remains high, despite improvements in trauma and critical care. Polytrauma is naturally associated with high mortality. This study compared mortality rates between isolated TBI (_ITBI) patients and polytrauma patients with TBI (_PTBI) admitted to ICU to investigate if concomitant injuries lead to higher mortality amongst TBI patients.MethodsA 3-year cohort study compared polytrauma patients with TBI (_PTBI) with AIS head ≥3 (and AIS of other body regions ≥3) from a prospective collected database to isolated TBI (_ITBI) patients from a retrospective collected database with AIS head ≥3 (AIS of other body regions ≤2), both admitted to a single level-I trauma center ICU. Patients <16 years of age, injury caused by asphyxiation, drowning, burns and ICU transfers from and to other hospitals were excluded. Patient demographics, shock and resuscitation parameters, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and mortality data were collected and analyzed for group differences.Results259 patients were included; 111 _PTBI and 148 _ITBI patients. The median age was 54 [33-67] years, 177 (68%) patients were male, median ISS was 26 [20-33]. Seventy-nine (31%) patients died. Patients with _PTBI developed more ARDS (7% vs. 1%, p = 0.041) but had similar MODS rates (18% vs. 10%, p = 0.066). They also stayed longer on the ventilator (7 vs. 3 days, p=<0.001), longer in ICU (9 vs. 4 days, p=<0.001) and longer in hospital (24 vs. 11 days, p=<0.001). TBI was the most prevalent cause of death in polytrauma patients. Patients with _PTBI showed no higher in-hospital mortality rate. Moreover, mortality rates were skewed towards _ITBI patients (24% vs. 35%, p = 0.06).DiscussionThere was no difference in mortality rates between _PTBI and _ITBI patients, suggesting TBI-severity as the predominant factor for ICU mortality in an era of ever improving acute trauma care.     

The presence of the adult respiratory distress syndrome does not worsen mortality or discharge disability in blunt trauma patients with severe traumatic brain injury

PURPOSE: To evaluate the prevalence of the acute respiratory distress syndrome (ARDS) among blunt trauma patients with severe traumatic brain injury (TBI) and to determine if ARDS is associated with higher mortality, morbidity and worse discharge outcome. METHODS: Blunt trauma patients with TBI (head abbreviated injury score (AIS)> or =4) who developed predefined ARDS criteria between January 2000 and December 2004 were prospectively collected as part of an ongoing ARDS database. Each patient in the TBI+ARDS group was matched with two control TBI patients based on age, injury severity score (ISS) and head AIS. Outcomes including complications, mortality and discharge disability were compared between the two groups. RESULTS: Among 362 TBI patients, 28 (7.7%) developed ARDS. There were no differences between the two groups with respect to age, sex, ISS, Glasgow coma score (GCS), head, abdomen and extremity AIS. The TBI+ARDS group had significantly more patients with chest AIS> or =3 (57.1% versus 32.1%, p=0.03). There was no difference with respect to overall mortality between the TBI+ARDS group (50.0%) and the TBI group (51.8%) (OR 0.79: 95% CI 0.31-2.03, p=0.63). There was no significant difference with respect to discharge functional capacity between the two groups. There were significantly more overall complications in the TBI+ARDS group (42.9%) compared to the TBI group (16.1%) (OR 3.66: 95% CI 1.19-11.24, p=0.02). The TBI+ARDS group had an overall mean intensive care unit (ICU) length of stay of 15.6 days, versus 8.4 days in the TBI group (p<0.01). The TBI+ARDS group had significantly higher hospital charges than the TBI group ($210,097 versus $115,342, p<0.01). CONCLUSION: The presence of ARDS was not associated with higher mortality or worse discharge disability. It was, however, associated with higher hospital morbidity, longer ICU and hospital length of stay.     

Diagnostic value of the Glasgow Coma Scale for traumatic brain injury in 18,002 patients with severe multiple injuries

Although patients with severe multiple injuries may have other reasons for unconsciousness, traumatic brain injury (TBI) in these patients is frequently defined by the Glasgow Coma Scale (GCS). Nevertheless, the diagnostic value of GCS for severe TBI in the multiple-injured patient is unknown. Therefore, we investigated the diagnostic value of GCS to identify severe TBI in multiple-injured patients. The records of 18,002 severely injured adult (ISS >16) patients from the Trauma Register of the German Society for Trauma Surgery were analyzed and initial GCS and Abbreviated Injury Scale (head) (AIS(head)) were recorded. A severe TBI was defined by an AIS(head) ≥ 3. On the other hand, unconsciousness was defined by an initial GCS ≤ 8. By these criteria, 6546 patients (36.3%) were unconscious, and 8746 patients (48.6%) had severe TBI. Nine percent of all cases (n=1643) had a GCS ≤ 8 without severe TBI. Only 56.1% of patients with severe TBI (n=4903) had been unconscious. Decreasing levels of unconsciousness (as defined by GCS) showed consistent rising prevalence of severe TBI (correlation coefficient r=-0.52). Approximately 20% of all multiple-injured patients arriving in the emergency department with an initial GCS of 15 had severe TBI (AIS(head) ≥ 3). The diagnostic value of GCS ≤ 8 for severe TBI in patients with multiple injuries has low sensitivity (56.1%) but higher specificity (82.2%). Our study indicates that the GCS (as defined ≤ 8) in unconsciousness patients with multiple injuries shows only a moderate correlation with the diagnosis of severe TBI. Nevertheless, the main reason for unconsciousness in patients with multiple injuries is TBI, since only 9% of these patients had another reason for unconsciousness. However, due to the poor sensitivity of GCS, we suggest the use of the anatomical scoring system with AIS(head) ≥ 3 to define severe TBI in patients with multiple injuries.     

Severe traumatic brain injuries in children: Does the type of trauma center matter?

Background

Traumatic brain injury (TBI) is the leading cause of death among injured children. Depending on geographic location, and trauma resources, pediatric patients may be treated at pediatric (PTC), adult (ATC), or mixed trauma centers (MTC). The effect of the type of trauma center on outcomes in severe TBI is not known.

Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios

IntroductionHigher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients.MethodsRetrospective observational study. Patients with isolated severe blunt TBI (AIS head ≥ 3, AIS extracranial < 3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution’s trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis.ResultsA total of 385 patients were included. Median age was 32 years (IQR 2–50), 71.4% were male, and 76.6% had an ISS ≥ 16. Plasma:PRBC transfusion ratios ≥ 1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22–0.81]). PLT:PRBC transfusion ratios ≥ 1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08–1.92]).ConclusionThis study revealed plasma to PRBC transfusion ratios ≥ 1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.     

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.     

The effects of admission alcohol level on cerebral blood flow and outcomes after severe traumatic brain injury

This study examined the relationship between admission serum alcohol level (ETOH) and cerebral blood flow (CBF) and outcomes in the adult traumatic brain injured (TBI) population. We hypothesized that individuals with ETOH > 100 mg/dL will have decreased blood flow on admission and poorer outcomes. Eighty subjects, age 16-65, with severe TBI (Glasgow Coma Score [GCS] 100 mg/dL at the time of admission after a TBI were associated with a decrease in global CBF. Elevated serum ETOH level at time of injury did not, however, impact outcomes.     

Increased serum sFas and TNFalpha following isolated severe head injury in males

OBJECTIVES: Severe traumatic brain injury (TBI) is associated with a 30-70% mortality rate. Nevertheless, controversy has been raised concerning the prognostic value of biomarkers following severe TBI. Therefore, our aim was to determine whether sFas or TNFalpha serum levels correlate with primary outcome following isolated severe TBI. METHODS: Seventeen consecutive male patients, victims of isolated severe TBI (Glasgow Coma Scale score 3-8) and a control group consisting of 6 healthy male volunteers were enrolled in this prospective study. Clinical outcome variables of severe TBI comprised: survival, time for intensive care unit (ICU) discharge, and neurological assessment by Glasgow Outcome Scale at ICU discharge. Venous blood samples were taken at admission in the ICU. Serum sFas and TNFalpha concentrations were measured by ELISA assays. RESULTS: At admission in the ICU (mean time 10.2 h after injury), mean sFas and TNFalpha concentrations were significantly increased in the TBI (0.105 and 24.275 rhog/l, respectively) compared with the control group (0.047 and 15.475 rhog/l, respectively). However, no significant correlation was found between higher serum sFas or TNFalpha concentrations and fatal outcome. CONCLUSIONS: Increased serum sFas and TNFalpha levels following isolated severe TBI did not predict fatal outcome.     

Outcomes and costs of acute treatment of traumatic brain injury

BACKGROUND: Although there are nearly a quarter of a million hospitalizations for traumatic brain injury (TBI) in the United States each year, data on the outcomes and costs of TBI treatment in the acute-care setting are limited. METHODS: Using a large, geographically diverse, multihospital database, we examined inpatient records for persons aged 16 years or older who were hospitalized for TBI between January 1, 1997, and June 30, 1999. Patients were stratified by TBI severity using an adaptation of the Abbreviated Injury Scale for administrative data (ICD/AIS), as follows: 2 = "moderate"; 3 = "serious"; 4 = "severe"; and 5 = "critical." Patient characteristics, patterns of treatment, and outcomes and costs were examined by injury severity and mechanism of injury. RESULTS: Of 8,717 study subjects identified, 12.5% had moderate, 44.8% had serious, 29.6% had severe, and 13.2% had critical TBI. Falls were the most common reported cause of injury (40.8%), followed by motor vehicle crashes (39.3%), blows to the head (11.3%), and gunshot wounds (2.4%). Average length of stay in hospital ranged from 6.7 days for moderate TBI to 17.5 days for critical TBI. The overall rate of death in hospital was relatively low among patients with moderate (1.3%), serious (5.7%), and severe (8.7%) TBIs, but much higher among the most critically injured patients (52.0%). Costs of hospitalization averaged 8,189 dollars for moderate, 14,603 dollars for serious, 16,788 dollars for severe, and 33,537 dollars for critical TBI. Costs also varied by injury type, averaging 20,084 dollars for gunshot wounds, 20,522 dollars for motor vehicle crashes, 15,860 dollars for falls, and 19,949 dollars for blows to the head. CONCLUSION: The economic burden of TBI in the acute-care setting is substantial; treatment outcomes and costs vary considerably by TBI severity and mechanism of injury.     

Serum Hsp70 as an early predictor of fatal outcome after severe traumatic brain injury in males

Severe traumatic brain injury (TBI) is associated with a 35-70% mortality rate. Biochemical markers of cellular stress/injury have been proposed to indicate outcome after head injury. Therefore, our aim was to determine whether Hsp70 could be detected in the serum of patients after severe TBI and whether serum levels of Hsp70 correlate with primary outcome in severe TBI. Twenty consecutive male patients, victims of severe TBI (GCS 3-8), were enrolled in this prospective study. Clinical outcome variables of severe TBI comprised: survival, time for ICU discharge, and neurological assessment using the Glasgow Outcome Scale (GOS) at the ICU discharge. Venous blood samples were taken at admission in the ICU (study entry), 24 h later, and 7 days later. A control group consisting of eight healthy male volunteers was also included. Serum Hsp70 levels were measured by an enzyme-linked immunosorbent assay. Mean serum Hsp70 concentrations were significantly increased in the TBI (97.6, 48.1, and 39.2 ng/mL, at study entry, 24 h later, and 7 days later, respectively) compared with the control group (12.2 ng/mL). Severe TBI was associated with a 50% mortality rate. On study entry (mean time 10.8 h after injury), a higher proportion of patients with fatal outcome had elevated serum Hsp70 (mean 143.5 ng/mL) concentrations when compared with survivors (mean 51.6 ng/mL). There was a significant correlation between higher initial serum Hsp70 concentrations and fatal outcome. The sensitivity of serum Hsp70 predicting mortality according to the cutoff of 62 ng/mL is 70% within 20 h after injury. Increased serum Hsp70 levels may constitute an early predictor of unfavorable outcome in severe TBI in males.     

The use of head computerized tomography in patients with GCS 15 following trauma: Less is more

IntroductionComputerized tomography (CT) imaging is a standard part of traumatic brain injury (TBI) evaluation but not all patients require it after mild head injury. Given the increasing incidence of TBI in the United States, there is an urgent need to better characterize CT head imaging utilization in evaluating trauma patients, especially patients at low risk of requiring intervention, such as those presenting with a normal GCS.MethodsWe analyzed the 2017–2019 National Trauma Databank using ICD-10 codes to identify patients who received a head CT. We used Abbreviated Injury Scale (AIS) scores to identify patients with a moderate to severe head injury defined as an AIS severity ≥ 3. Procedural TBI management was defined as having an intracranial monitor or operative decompression. We used a modified Poisson modeling to identify risk factors for a moderate/severe TBI and risk factors for undergoing procedural management among patients with head CT and GCS 15.ResultsOf 2,850,036 patients, 1,502,039 (52.7%) had a head CT. Among patients who had a head CT, 1,078,093 patients (74.9%) had a GCS 15 on arrival. Of this group, only 16.6% (n = 176,431) had a moderate/severe head injury. For those with moderate/severe head injury, 6.0% (n = 10,544/176,431) of patients underwent procedural head injury management. Risk factors for undergoing procedural head injury management included: isolated head injury (RR 2.43, 95% CI 2.34, 2.53), male sex (RR 1.73, 95% CI 1.67, 1.80), age > 50 years (RR 1.39 95% CI 1.32, 1.47), falls (RR 1.28, 95% CI 1.22, 1.35), and the use of anti-coagulation (RR 1.16, 95% CI 1.11, 1.21).ConclusionFew patients had moderate/severe head injury when presenting with a GCS 15. However, patients ≥ 50 years, men, and those who suffered falls were at higher risk. Anti-coagulation use was not associated with moderate/severe head injury but did increase the risk of procedural TBI management. Given the cost and associated radiation, reducing CT utilization for younger patients while using a more liberal head CT strategy for high-risk patients may provide substantial patient value.     

Traumatic brain injury outcomes in pre- and post- menopausal females versus age-matched males

Gender differences in outcomes from major trauma have been described previously, and exogenous female hormone administration appears to be neuroprotective following traumatic brain injury (TBI). This analysis explored outcomes in pre- and post-menopausal females versus age-matched males. A total of 13,437 patients (n = 3,178 females, n = 10,259 males) with moderate-to-severe TBI (head AIS > or = 3) were identified from our county trauma registry. Overall mortality was similar between males and females (22% for both). Logistic regression was used to compare gender outcome differences, with a separate analysis performed for premenopausal (< 50 years) versus postmenopausal (> or = 50 years) patients, and after stratification by decade of life. No statistically significant difference in outcomes was observed for pre-menopausal females versus males (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.83, 1.35; p = 0.633), but outcomes were significantly better in postmenopausal females versus males (OR 0.63, 95% CI 0.48-0.81, p < 0.001) after adjusting for age, mechanism of injury, Glasgow Coma Scale (GCS), hypotension (SBP < or = 90 mm Hg), head Abbreviated Injury Score (AIS), and Injury Severity Score (ISS). Stratification by decade of life revealed the gender survival differential inflection point to occur between ages 40-49 (OR 1.06, 95% CI 0.66-1.71, p = 0.798) and ages 50-59 (OR 0.38, 95% CI 0.20-0.74, p = 0.005). In addition, Revised Trauma Score and Injury Severity Score (TRISS) was used to calculate probability of survival (PS); all patients were then stratified by decade of life, and males and females were compared with regard to mean survival differential (outcome - PS). The identical pattern of improved outcomes in post-menopausal but not pre-menopausal females versus age-matched males was observed. These data suggest that endogenous female sex hormone production is not neuroprotective.     

Predictors and Time-Based Hospital Mortality in Patients with Isolated and Polytrauma Brain Injuries

Background

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. We studied the predictors and time-based mortality in patients with isolated and polytrauma brain injuries in a rapidly developing country. We hypothesized that TBI-related 30-day mortality is decreasing over time.

Methods

A retrospective analysis was conducted for all patients with moderate-to-severe TBI who were admitted directly to a level 1 trauma center between 2010 and 2014. Patient’s data were analyzed and compared according to survival (survived vs. not survived), time (early death [2 days], intermediate [3–7 days] versus late [>7 days]) post-injury, and type (polytrauma vs. isolated TBI). Cox proportional hazards models were performed for the predictors of mortality.

Results

A total of 810 patients were admitted with moderate-to-severe TBI with a median age of 27 years. Traffic-related injury was the main mechanism of TBI (65%). Isolated TBIs represented 22.6% of cases and 56% had head AIS >3. The overall mortality rate was 27%, and most of deaths occurred in the intermediate (40%) and early period (38%). The incidence of TBI was greater in patients aged 21–30 years but the mortality was proportionately higher among elderly. The average annual incidence was 8.43 per 100,000 population with an overall mortality of 2.28 per 100,000 population. Kaplan–Meier curves showed that polytrauma had greater mortality than isolated TBI. However, Cox survival analysis showed that age [Hazard ratio (HR) 1.02], scene GCS (HR 0.86),subarachnoid hemorrhage (HR 1.7), and blood transfusion amount (HR 1.03) were the predictors of mortality regardless of being polytrauma or isolated TBI after controlling for 14 relevant covariates.

Conclusions

The 30-day survival in patients with TBI is improving over the years in Qatar; however, the mortality remains high in the elderly males. The majority of deaths occurred within a week after the injury. Further studies are needed to assess the long-term survival in patients with moderate-to-severe TBI.

     

Do pregnant women have improved outcomes after traumatic brain injury?

Background

Pregnant women, who have significantly elevated levels of estrogen and progesterone, might benefit from the neuroprotective effect of steroid hormones.

Methods

Pregnant patients were identified and compared with their nonpregnant counterparts with respect to demographics and outcome.

Results

Of the 18,800 female, moderate to severe TBI patients, 71 were pregnant. Similar mortalities were noted in pregnant and nonpregnant TBI patients (9.9% vs 9.3%, P = .84). Adjusting for confounding variables, pregnant TBI patients had a trend toward increased mortality (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI], .9–5.1; P = .07). In patients aged 15 to 47 years (n = 8,854), similar mortalities were noted in pregnant and nonpregnant TBI patients (9.9% vs 6.8%, P = .34). After adjusting for risk factors, again there was a trend toward increased mortality in the pregnant TBI group (AOR = 2.0; 95% CI, .8–4.6; P = .12).

Conclusions

Pregnant patients with moderate to severe TBI show no statistically significant difference in mortality compared with their nonpregnant counterparts.     

A retrospective review of patients who sustained traumatic brain injury in Ireland 2014–2019

IntroductionTraumatic brain injury (TBI) is the most significant cause of death and disability resulting from major trauma. The aim of this study is to describe the demographics of TBI patients, the current pathways of care and outcomes in the Republic of Ireland from 2014 to 2019.MethodsWe performed a retrospective review of all TBI patients meeting inclusion criteria in Ireland's Major Trauma Audit (MTA) from 2014 to 2019. Severe TBI was defined as an abbreviated injury scale (AIS) ≥3 and GCS ≤8.ResultsDuring the study period, 30,891 patients sustained major trauma meeting inclusion criteria for MTA, of which 7,393 (23.9%) patients met the inclusion criteria for TBI; 1,025 (13.9%) were classified as severe. The median age was 60.6 years (IQR 36.9–78.0), 54.3 years (32.8–73.4) for males and 71.7 years (50.0–83.0) for females (p<0.001). Of patients with severe TBI, 185 (18.0%) were brought direct to a neurosurgical centre, 389 (37.9%) were transferred to a neurosurgical centre and 321 (31.3%) had a neurosurgical intervention performed. In patients sustaining severe TBI, older patients (Adjusted OR, 0.96,95% CI 0.95–0.97) and patients requiring another surgery (OR 0.31, 95%CI 0.18–0.53) were less likely to be secondarily transferred to a neurosurgical centre. There were 47 (4.6%) patients with severe TBI discharged to rehabilitation. The 30-day mortality in Ireland was 11.6% in all TBI patients and 45.5% in severe TBI patients. Older patients and patients with higher ISS had a higher chance of death. Male patients, patients treated in neurosurgical centre, patients who had neurosurgery or non-neurosurgical surgery had a higher chance of survival.ConclusionThis population-based study bench marks the ‘as is’ for patients with TBI in Ireland. We found that presently in Ireland, the mortality rate from severe TBI appears to be higher than that reported in international literature, and only a minority of severe TBI patients are brought directly from the incident to a neurosurgical centre. The new major trauma system should focus on providing effective and efficient access to neurosurgical, neuro-critical and neuro-rehabilitative care for patients who sustain TBI.     

Effect of alcohol on Glasgow Coma Scale in head-injured patients

OBJECTIVE: Almost 50% of traumatic brain-injured (TBI) patients are alcohol intoxicated. The Glasgow Coma Scale (GCS) is frequently used to direct diagnostic and therapeutic decisions in these patients. It is commonly assumed that alcohol intoxication reduces GCS, thus limiting its utility in intoxicated patients. The purpose of this study was to test the hypothesis that the presence of blood alcohol has a clinically significant impact on GCS in TBI patients. METHODS: The National Trauma Data Bank of the American College of Surgeons was queried (1994-2003). Patients 18 to 45 years of age with blunt injury mechanism, whose GCS in the emergency department, survival status, anatomic severity of TBI (Head Abbreviated Injury Score [AIS]), and blood alcohol testing status were known, were included. GCS of patients who tested positive for alcohol (n = 55,732) was compared with GCS of patients who tested negative (n = 53,197), stratified by head AIS. RESULTS: Groups were similar in age (31 +/- 8 vs. 30 +/- 8 years), Injury Severity Score (ISS; 12 +/- 11 vs. 12 +/- 11), systolic blood pressure in the ED (131 +/- 25 vs. 134 +/- 25 mm Hg), TRISS (Trauma Injury Severity Score; probability of survival (94% +/- 16% vs. 95% +/- 15%), and actual survival (96% vs. 96%). When stratified by anatomic severity of TBI, the presence of alcohol did not lower GCS by more than 1 point in any head AIS group (GCS in alcohol-positive vs. alcohol-negative patients; AIS 1 = 13.9 +/- 2.8 vs. 14.3 +/- 2.3; AIS 2 = 13.4 +/- 3.2 vs. 14.1 +/- 2.4; AIS 3 = 11.1 +/- 4.7 vs. 11.6 +/- 4.6; AIS 4 = 9.8 +/- 4.9 vs. 10.4 +/- 4.9; AIS 5 = 5.5 +/- 3.8 vs. 5.9 +/- 4.1, AIS 6: 3.4 +/- 1.1 vs. 3.8 +/- 2.8). CONCLUSION: Alcohol use does not result in a clinically significant reduction in GCS in trauma patients. Attributing low GCS to alcohol intoxication in TBI patients may delay necessary diagnostic and therapeutic interventions.