Admission of patients with severe and moderate traumatic brain injury to specialized ICU facilities: a search for triage criteria

Factors Associated with Poor Outcomes in Patients with Mild or Moderate Acute Subdural Hematomas

The factors influencing the outcomes of mild/moderate acute subdural hematoma (ASDH) are still unclear. Retrospective analyses were performed to identify such factors. The medical records of all patients who were admitted to Saiseikai Shiga Hospital with mild (Glasgow Coma Scale [GCS] score of 14–15) or moderate (GCS score of 9–13) ASDH between April 2008 and March 2017 were reviewed. Comparisons between the patients who exhibited favorable and poor outcomes were performed. Then, independent factors that contributed to poor outcomes were identified via logistic regression analyses. A total of 266 patients with a mean age of 70.2 were included in this study. The most common concomitant injuries were subarachnoid hemorrhages (SAHs; 56.8%). The patients’ Injury Severity Scores (ISS) ranged from 16 to 75 (median: 21). The 66 moderate ASDH patients exhibited significantly higher frequencies of surgery and mortality (24.2% and 13.6%, respectively) than the 200 mild ASDH patients (8.0% and 4.5%, respectively). The factors associated with poor outcomes were age (odds ratio [OR]: 1.06) and the ISS (OR: 1.24) in the mild ASDH patients, and older age (OR: 1.09) and the higher ISS (OR: 1.15) in the moderate group, too.

Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis

OBJECTIVES

To summarise and compare the accuracy of physical examination, computed tomography (CT), sonography of the optic nerve sheath diameter (ONSD), and transcranial Doppler pulsatility index (TCD-PI) for the diagnosis of elevated intracranial pressure (ICP) in critically ill patients.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Six databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018.

STUDY SELECTION CRITERIA

English language studies investigating accuracy of physical examination, imaging, or non-invasive tests among critically ill patients. The reference standard was ICP of 20 mm Hg or more using invasive ICP monitoring, or intraoperative diagnosis of raised ICP.

DATA EXTRACTION

Two reviewers independently extracted data and assessed study quality using the quality assessment of diagnostic accuracy studies tool. Summary estimates were generated using a hierarchical summary receiver operating characteristic (ROC) model.

RESULTS

40 studies (n=5123) were included. Of physical examination signs, pooled sensitivity and specificity for increased ICP were 28.2% (95% confidence interval 16.0% to 44.8%) and 85.9% (74.9% to 92.5%) for pupillary dilation, respectively; 54.3% (36.6% to 71.0%) and 63.6% (46.5% to 77.8%) for posturing; and 75.8% (62.4% to 85.5%) and 39.9% (26.9% to 54.5%) for Glasgow coma scale of 8 or less. Among CT findings, sensitivity and specificity were 85.9% (58.0% to 96.4%) and 61.0% (29.1% to 85.6%) for compression of basal cisterns, respectively; 80.9% (64.3% to 90.9%) and 42.7% (24.0% to 63.7%) for any midline shift; and 20.7% (13.0% to 31.3%) and 89.2% (77.5% to 95.2%) for midline shift of at least 10 mm. The pooled area under the ROC (AUROC) curve for ONSD sonography was 0.94 (0.91 to 0.96). Patient level data from studies using TCD-PI showed poor performance for detecting raised ICP (AUROC for individual studies ranging from 0.55 to 0.72).

CONCLUSIONS

Absence of any one physical examination feature is not sufficient to rule out elevated ICP. Substantial midline shift could suggest elevated ICP, but the absence of shift cannot rule it out. ONSD sonography might have use, but further studies are needed. Suspicion of elevated ICP could necessitate treatment and transfer, regardless of individual non-invasive tests.

REGISTRATION

PROSPERO CRD42018105642.

Utility of clinical decision rule for intensive care unit admission in patients with traumatic intracranial hemorrhage

BACKGROUND

Recent literature suggests the majority of traumatic intracranial hemorrhage does not require intervention. One recently described clinical decision rule was sensitive in identifying patients requiring critical care interventions in an urban setting. We sought to validate its effectiveness in our predominately rural setting.

METHODS

A retrospective study was conducted of adult patients with traumatic intracranial hemorrhage. The rule, based on age, initial Glasgow coma scale score, and presence of a non-isolated head injury, was applied to externally validate the previously reported findings.

RESULTS

In our population, the rule displayed a sensitivity of 0.923, specificity of 0.251, positive predictive value of 0.393, and negative predictive value of 0.862. The area under curve was 0.587. While our population has a similar adjusted head injury severity score as that from which the rule was developed, significant differences in age and intracranial hemorrhage pattern were noted.

CONCLUSIONS

The rule displayed decreased performance in our population, most likely secondary to differences in age and intracranial hemorrhage patterns. Prospective evaluation and cost-savings analysis are appropriate subsequent steps for the rule.

Intracranial pressure monitoring: fundamental considerations and rationale for monitoring

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. In large part critical care for TBI is focused on the identification and management of secondary brain injury. This requires effective neuromonitoring that traditionally has centered on intracranial pressure (ICP). The purpose of this paper is to review the fundamental literature relative to the clinical application of ICP monitoring in TBI critical care and to provide recommendations on how the technique maybe applied to help patient management and enhance outcome. A PubMed search between 1980 and September 2013 identified 2,253 articles; 244 of which were reviewed in detail to prepare this report and the evidentiary tables. Several important concepts emerge from this review. ICP monitoring is safe and is best performed using a parenchymal monitor or ventricular catheter. While the indications for ICP monitoring are well established, there remains great variability in its use. Increased ICP, particularly the pattern of the increase and ICP refractory to treatment is associated with increased mortality. Class I evidence is lacking on how monitoring and management of ICP influences outcome. However, a large body of observational data suggests that ICP management has the potential to influence outcome, particularly when care is targeted and individualized and supplemented with data from other monitors including the clinical examination and imaging.

Midline shift in relation to thickness of traumatic acute subdural hematoma predicts mortality

BACKGROUND

Traumatic acute subdural hematoma has a high mortality despite intensive treatment. Despite the existence of several prediction models, it is very hard to predict an outcome. We investigated whether a specific combination of initial head CT-scan findings is a factor in predicting outcome, especially non-survival.

METHODS

We retrospectively studied admission head CT scans of all adult patients referred for a traumatic acute subdural hematoma between April 2009 and April 2013. Chart review was performed for every included patient. Midline shift and thickness of the hematoma were measured by two independent observers. The difference between midline shift and thickness of the hematoma was calculated. These differences were correlated with outcome. IRB has approved the study.

RESULTS

A total of 59 patients were included, of whom 29 died. We found a strong correlation between a midline shift exceeding the thickness of the hematoma by 3 mm or more, and subsequent mortality. For each evaluation, specificity was 1.0 (95 % CI: 0.85-1 for all evaluations), positive predictive value 1.0 (95 % CI between 0.31-1 and 0.56-1), while sensitivity ranged from 0.1 to 0.23 (95 % CI between 0.08-0.39 and 0.17-0.43), and negative predictive value varied from 0.52 to 0.56 (95 % CI between 0.38-0.65 and 0.41-0.69).

CONCLUSIONS

In case of a traumatic acute subdural hematoma, a difference between the midline shift and the thickness of the hematoma ≥ 3 mm at the initial CT predicted mortality in all cases. This is the first time that such a strong correlation was reported. Especially for the future development of prediction models, the relation between midline shift and thickness of the hematoma could be included as a separate factor.

Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank

Introduction

Patients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14–15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI.

Methods

The National Trauma Databank (2007–2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14–15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables.

Results

The study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention.

Conclusions

We found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.

Derivation of a clinical decision instrument to identify adult patients with mild traumatic intracranial hemorrhage at low risk for requiring ICU admission

STUDY OBJECTIVE

The objective of this study is to derive a clinical decision instrument with a sensitivity of at least 95% (with upper and lower bounds of the 95% confidence intervals [CIs] within a 5% range) to identify adult emergency department patients with mild traumatic intracranial hemorrhage who are at low risk for requiring critical care resources during hospitalization and thus may not need admission to the ICU.

METHODS

This was a prospective, observational study of adult patients with mild traumatic intracranial hemorrhage (initial Glasgow Coma Scale [GCS] score 13 to 15, with traumatic intracranial hemorrhage) presenting to a Level I trauma center from July 2009 to February 2013. The need for ICU admission was defined as the presence of an acute critical care intervention (intubation, neurosurgical intervention, blood product transfusion, vasopressor or inotrope administration, invasive monitoring for hemodynamic instability, urgent treatment for arrhythmia or cardiopulmonary resuscitation, and therapeutic angiography). We derived the clinical decision instrument with binary recursive partitioning (with a misclassification cost of 20 to 1). The accuracy of the decision instrument was compared with the treating physician's (emergency medicine faculty) clinical impression.

RESULTS

A total of 600 patients with mild traumatic intracranial hemorrhage were enrolled; 116 patients (19%) had a critical care intervention. The derived instrument consisted of 4 predictor variables: admission GCS score less than 15, nonisolated head injury, aged 65 years or older, and evidence of swelling or shift on initial cranial computed tomography scan. The decision instrument identified 114 of 116 patients requiring an acute critical care intervention (sensitivity 98.3%; 95% CI 93.9% to 99.5%) if at least 1 variable was present and 192 of 484 patients who did not have an acute critical care intervention (specificity 39.7%; 95% CI 35.4% to 44.1%) if no variables were present. Physician clinical impression was slightly less sensitive (90.1%; 95% CI 83.1% to 94.4%) but overall similar to the clinical decision instrument.

CONCLUSION

We derived a clinical decision instrument that identifies a subset of patients with mild traumatic intracranial hemorrhage who are at low risk for acute critical care intervention and thus may not require ICU admission. Physician clinical impression had test characteristics similar to those of the decision instrument. Because the results are based on single-center data without a validation cohort, external validation is required.

A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission

OBJECTIVE

To derive a clinical decision rule to identify adult emergency department (ED) patients with traumatic intracranial haemorrhage (tICH) who are at low risk for requiring critical care resources during hospitalization.

METHODS

This is a retrospective cohort study of patients (≥ 18 years) with tICH presenting to the ED. The need for intensive care unit (ICU) admission was defined as the presence of a critical care intervention including: intubation, neurosurgical intervention, blood product transfusion, vasopressor or inotrope administration, invasive monitoring for haemodynamic instability, emergent treatment for arrhythmia, therapeutic angiography, and cardiopulmonary resuscitation. The decision rule was derived using binary recursive partitioning.

RESULTS

A total of 432 patients were identified (median age 48 years) of which 174 patients (40%) had a critical care intervention. We performed binary recursive partitioning with Classification and Regression Trees (CART) software to develop the clinical decision rule. Patients with a normal mental status (Glasgow Coma Score=15), isolated head injury, and age<65 were considered low risk for a critical care intervention. The derived rule had a sensitivity of 98% (95% confidence interval [CI] 94-99), a specificity of 50% (95% CI 44-56), a positive predictive value of 57% (95% CI 51-62), and a negative predictive value of 97% (95% CI 93-99). The area under the curve for the decision rule was 0.74 (95% CI 0.70-0.77).

CONCLUSIONS

This clinical decision rule identifies low risk adult ED patients with tICH who do not need ICU admission. Further validation and refinement of these findings would allow for more appropriate ICU resource utilisation.

Variability of ICU use in adult patients with minor traumatic intracranial hemorrhage

STUDY OBJECTIVE

Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.

METHODS

A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.

RESULTS

Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P<.001).

CONCLUSION

Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.

Are initial radiographic and clinical scales associated with subsequent intracranial pressure and brain oxygen levels after severe traumatic brain injury?

BACKGROUND

Prediction of clinical course and outcome after severe traumatic brain injury (TBI) is important.

OBJECTIVE

To examine whether clinical scales (Glasgow Coma Scale [GCS], Injury Severity Score [ISS], and Acute Physiology and Chronic Health Evaluation II [APACHE II]) or radiographic scales based on admission computed tomography (Marshall and Rotterdam) were associated with intensive care unit (ICU) physiology (intracranial pressure [ICP], brain tissue oxygen tension [PbtO2]), and clinical outcome after severe TBI.

METHODS

One hundred one patients (median age, 41.0 years; interquartile range [26-55]) with severe TBI who had ICP and PbtO2 monitoring were identified. The relationship between admission GCS, ISS, APACHE II, Marshall and Rotterdam scores and ICP, PbtO2, and outcome was examined by using mixed-effects models and logistic regression.

RESULTS

Median (25%-75% interquartile range) admission GCS and APACHE II without GCS scores were 3.0 (3-7) and 11.0 (8-13), respectively. Marshall and Rotterdam scores were 3.0 (3-5) and 4.0 (4-5). Mean ICP and PbtO2 during the patients' ICU course were 15.5 ± 10.7 mm Hg and 29.9 ± 10.8 mm Hg, respectively. Three-month mortality was 37.6%. Admission GCS was not associated with mortality. APACHE II (P = .003), APACHE-non-GCS (P = .004), Marshall (P < .001), and Rotterdam scores (P < .001) were associated with mortality. No relationship between GCS, ISS, Marshall, or Rotterdam scores and subsequent ICP or PbtO2 was observed. The APACHE II score was inversely associated with median PbtO2 (P = .03) and minimum PbtO2 (P = .008) and had a stronger correlation with amount of time of reduced PbtO2.

CONCLUSION

Following severe TBI, factors associated with outcome may not always predict a patient's ICU course and, in particular, intracranial physiology.

Identification of low-risk patients with traumatic brain injury and intracranial hemorrhage who do not need intensive care unit admission

BACKGROUND

Patients with traumatic brain injury (TBI) and traumatic intracranial hemorrhage are frequently admitted to the intensive care unit (ICU) but never require critical care interventions. Improved ICU triage in this patient population can improve resource utilization and decrease health care costs. We sought to identify a low-risk group of patients with TBI who do not require admission to an ICU.

METHODS

This is a retrospective cohort study of adult patients with TBI and traumatic intracranial hemorrhage. The need for ICU admission was defined as the presence of a critical care intervention. Patients were considered low risk if there was no critical care intervention before hospital admission. Measured outcomes included delayed critical care interventions at 48 hours and during hospitalization, mortality, and emergency surgery.

RESULTS

A total of 187 of 320 patients were considered low risk. In the low-risk group, two patients (1.1%; 95% confidence interval [CI], 0.1-3.8) had a delayed critical care intervention within 48 hours of admission and four patients (2.1%; 95% CI, 0.6-5.4) after 48 hours of admission. Two patients (1.1%; 95% CI, 0-3.8) in the low-risk group died. No patients in the low-risk group required neurosurgical intervention.

CONCLUSION

Patients with TBI without a critical care intervention before admission are at low risk for requiring future critical care interventions. Future studies are required to validate if this low-risk criteria can serve as a safe, cost-effective triage tool for ICU admission.

Admission blood glucose is an independent predictive factor for hospital mortality in polytraumatised patients

PURPOSE

The goal of this study was to analyse a possible association of admission blood glucose with hospital mortality of polytraumatised patients and to develop an outcome prediction model for this patient group.

METHODS

The outcome of adult polytraumatised patients admitted to the University Hospital of Berne, Switzerland, between 2002 and 2004 with an ISS > or = 17, and more than one severely injured organ system was retrospectively analysed.

RESULTS

The inclusion criteria were met by 555 patients, of which 108 (19.5%) died. Hyperglycaemia proved to be an independent predictor for hospital mortality (P < 0.0001), following multiple regression analysis. After inclusion of admission blood glucose, the calculated mortality prediction model performed better than currently described models (P < 0.0001, AUC 0.924).

CONCLUSION

In this retrospective, single-centre study in polytraumatised patients, admission blood glucose proved to be an independent predictor of hospital mortality following regression analysis controlling for age, gender, injury severity and other laboratory parameters. A reliable admission blood glucose-based mortality prediction model for polytraumatised patients could be established. This observation may be helpful in improving the precision of future outcome prediction models for polytraumatised patients. These observations warrant further prospective evaluation.

Systematic review of prognostic models in traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability world-wide. The ability to accurately predict patient outcome after TBI has an important role in clinical practice and research. Prognostic models are statistical models that combine two or more items of patient data to predict clinical outcome. They may improve predictions in TBI patients. Multiple prognostic models for TBI have accumulated for decades but none of them is widely used in clinical practice. The objective of this systematic review is to critically assess existing prognostic models for TBI METHODS: Studies that combine at least two variables to predict any outcome in patients with TBI were searched in PUBMED and EMBASE. Two reviewers independently examined titles, abstracts and assessed whether each met the pre-defined inclusion criteria.

RESULTS

A total of 53 reports including 102 models were identified. Almost half (47%) were derived from adult patients. Three quarters of the models included less than 500 patients. Most of the models (93%) were from high income countries populations. Logistic regression was the most common analytical strategy to derived models (47%). In relation to the quality of the derivation models (n:66), only 15% reported less than 10% pf loss to follow-up, 68% did not justify the rationale to include the predictors, 11% conducted an external validation and only 19% of the logistic models presented the results in a clinically user-friendly way

CONCLUSION

Prognostic models are frequently published but they are developed from small samples of patients, their methodological quality is poor and they are rarely validated on external populations. Furthermore, they are not clinically practical as they are not presented to physicians in a user-friendly way. Finally because only a few are developed using populations from low and middle income countries, where most of trauma occurs, the generalizability to these setting is limited.