Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients

Is There an Optimal Time Window of Placement of Intracranial Pressure (ICP) Monitor for Elderly Patients With Severe Traumatic Brain Injury? An 11-Year Institutional Cohort Study With Restricted Cubic Spline Analysis

Severe traumatic brain injury (sTBI) is a prominent contributor to both morbidity and mortality in the elderly population. The monitoring of intracranial pressure (ICP) is crucial in the management of sTBI patients. Nevertheless, the appropriate timing for the placement of ICP monitor in elderly sTBI patients remains uncertain. To determine the optimal timing for the placement of ICP monitor in elderly sTBI patients, in this retrospective cohort study, we collected data from elderly patients (> 65 years) who suffered sTBI and received ICP monitors at Tangdu Hospital, The Fourth Military Medical University, between January 2011 and December 2021. To examine the relationship between the time of ICP monitor placement and in-hospital mortality, we conducted a multi-variate-adjusted restricted cubic spline (RCS) analysis. Additionally, logistic regression analysis was applied to further analyze the influencing factors contributing to early or late ICP monitor placements. A total of 283 eligible elderly TBI patients were included in the current analysis. The in-hospital mortality rate was 73 out of 283 (26%). The RCS analysis demonstrated an inverted U-shaped curve in the relationship between the timing of ICP monitor placement and in-hospital mortality. For the elderly sTBI patient cohort, 6 h was identified as the crucial moment for the treatment strategy. In addition, the protective time window for ICP placement was less than 4.92 h for the GCS 3-5 group, and less than 8.26 h for the GCS 6-8 group. However, the clinical benefit of ICP placement decreased gradually over time. The relationship between ICP placement and in-hospital mortality was non-linear, exhibiting an inverted U-shaped curve in elderly patients with sTBI. For elderly patients with sTBI, early (≤ 6 h) ICP placement was associated with reduced in-hospital mortality. The clinical benefit of ICP placement decreased beyond the optimal time window.

Predictive value and interrater reliability of mental status and mobility assessment in the emergency department

AIM

To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team.

METHOD

Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team.

RESULTS

4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility.

CONCLUSION

Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.

Antithrombotic and risk of hemorrhagic complications in over-60-year-olds after mild-minimal traumatic brain injury

PRIMARY OBJECTIVE

to identify if antithombotics are risk factors for intracereral lesion in older adults with minimal-mild traumatic brain injury (m-mTBI).

RESEARCH DESING

prospective cohort study.

METHODS AND PROCEDURES

We included 2,303 patients over 60 years arriving at our Emergency Department within 24 hours of an mTBI with a Glasgow Coma Scale (GSC) of 14-15. Data were gathered on clinical history, cranial CT scans, blood analyses.

OUTCOMES AND RESULTS

91.1% had an admission GSC score of 15, and 23.6% developed intracranial complications. In bivariate analyses, statins were associated with a 1.28-fold lower risk of IC. Hemorrhagic progression was 29.76-fold higher in patients receiving anticoagulants, with no difference among anticoagulant types. Male sex, GSC of 14, alcohol consumption, and the presence of tumor were risk factors for IC. In multivariate analysis, GSC of 14, alcohol consumption, and malignancy emerged as risk factors for these complications, neurological disease and diabetes as protective factors. After exclusion of neurological disease and diabetes from the multivariate model, a GSC of 14 showed the highest predictive capacity.

CONCLUSIONS

Antithrombotics intake are not risks factor for intracranial injury in minimal-mild brain injury trauma. Further research is needed taking account of their fragility and comorbidities.

Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study

Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n  = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P  < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P  < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.

Comparisons of electrophysiological markers of impaired executive attention after traumatic brain injury and in healthy aging

Executive attention impairments are a persistent and debilitating consequence of traumatic brain injury (TBI). To make headway towards treating and predicting outcomes following heterogeneous TBI, cognitive impairment specific pathophysiology first needs to be characterized. In a prospective observational study, we measured EEG during the attention network test aimed at detecting alerting, orienting, executive attention and processing speed. The sample (N = 110) of subjects aged 18-86 included those with and without traumatic brain injury: n = 27, complicated mild TBI; n = 5, moderate TBI; n = 10, severe TBI; n = 63, non-brain-injured controls. Subjects with TBI had impairments in processing speed and executive attention. Electrophysiological markers of executive attention processing in the midline frontal regions reveal that, as a group, those with TBI and elderly non-brain-injured controls have reduced responses. We also note that those with TBI and elderly controls have responses that are similar for both low and high-demand trials. In subjects with moderate-severe TBI, reductions in frontal cortical activation and performance profiles are both similar to that of controls who are ∼4 to 7 years older. Our specific observations of frontal response reductions in subjects with TBI and in older adults is consistent with the suggested role of the anterior forebrain mesocircuit as underlying cognitive impairments. Our results provide novel correlative data linking specific pathophysiological mechanisms underlying domain-specific cognitive deficits following TBI and with normal aging. Collectively, our findings provide biomarkers that may serve to track therapeutic interventions and guide development of targeted therapeutics following brain injuries.

Expediting Treatment of Trauma Patients in the Emergency Department: Rapid Trauma Evaluation (RTE)

BACKGROUND

Criteria for trauma determination evolves. We developed/evaluated a Rapid Trauma Evaluation (RTE) process for a trauma patient subset not meeting preestablished trauma criteria.

METHODS

Retrospective study (July 2019 - May 2020) for patients either > 65 years with ground level fall within 24 hours or in a motorcycle collision (MCC) arriving by EMS not meeting ACS trauma-criteria. RTE process was immediate evaluation by nurse/EMT, room placement, physician notification, undressing/gowning, vital signs, head-to-toe assessment, upgrade trauma status. Number/type of admissions, discharges, trauma upgrades, LOS obtained via trauma-registry and chart-review. For comparison, historic controls (HC) were used [all patients meeting RTE criteria seen in the ED prior to RTE (Apr- June 2019)].

RESULTS

The RTE cohort (n=755) was 77% falls,23% MCCs, median age 82 [IQR 74-88] years; 42% male-Among falls, 3.2% required a modified-upgrade; 0.7% full-upgrade, 55% admitted [29.4% trauma). HC (n=575) was 92.3% falls, 7.7% MCCs, median age 81 (IQR: 67-88) years, 40.5% males-57.4% admitted (22% trauma). RTE MCC median age 42 (IQR:30-49) years, 84.4% male- 21.9% were upgraded [(6 modified-trauma; 1 full-trauma; 43.8% admitted (85.7% trauma)]. HC MCC median age 29 (IQR: 23-41) years, 95.5% male, 54.5% admitted (75% trauma]. No difference on demographics, admissions or discharges between groups (P>0.05) except HC MCC was younger (P<0.005). RTE median LOS was shorter than HC [203 (IQR: 147-278) minutes vs. 286 (IQR: 205-392) minutes, P<0.001].

CONCLUSIONS

Patients > 65 years with a ground level fall or in a MCC arriving via EMS not meeting ACS trauma criteria may benefit from RTE.

Configurations and outcomes of acute hospital care for frail and older patients with moderate to major trauma: a systematic review

OBJECTIVE

To systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma.

SETTING

Electronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched.

INCLUDED ARTICLES

Peer-reviewed articles of any study design, published in English, 1999-2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone.

METHODS

Screening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken.

OUTCOME MEASURES

Any outcomes reported for patients, staff or care system.

RESULTS

17 603 references were identified and 518 read in full; 22 were included-frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury.

CONCLUSIONS

This systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS PROSPERO: CRD42016032895.

External validation of the GCS-Pupils Score as an outcome predictor after traumatic brain injury in adults: a single-center experience

OBJECTIVE

The GCS-Pupils (GCS-P) score is a recently described scoring system to aid outcome prediction in patients with traumatic brain injury (TBI). The aim of this study was to provide the first external validation of the GCS-P score by identifying independent predictors of outcome in TBI patients.

METHODS

Review of prospective adult (≥ 16 years) TBI database at a tertiary neurosurgical center with a catchment population of 1.5 million over a 12-month period commencing October 2016. Multivariate logistic regression was used to identify predictors of discharge destination and 30-day mortality.

RESULTS

Three hundred and fifty-eight patients were included. The median age was 60 years with a male predominance of 64%. The median GCS-P was 14 (interquartile range 12-15) and the commonest GCS-P category was mild (13-15; 238/358, 66%). Discharge destination was home in 69% of patients and rehab services or equivalent in 31%. Multivariate analysis identified age (p = 0.01), CT findings of an acute subdural hematoma (p = 0.01) or diffuse axonal injury (p = 0.02), and a neurosurgical operation (p = 0.02) as independent predictors of discharge destination. The 30-day mortality rate was 11%. Within the category of severe TBI (GCS-P ≤ 8), GCS-P was able to identify patients with a very high likelihood of 30-day mortality (GCS-P ≤ 4; 16/31, 52%). Multivariate analysis revealed the Charlson comorbidity score (p = 0.01), GCS-P (p = 0.02), and traumatic subarachnoid hemorrhage (p = 0.05) as independent predictors of mortality.

CONCLUSION

The GCS-P is a useful predictor of 30-day mortality, although its usefulness for other clinical outcomes remains to be proven.

A Proof-of-Concept Electrochemical Skin Sensor for Simultaneous Measurement of Glial Fibrillary Acidic Protein (GFAP) and Interleukin-6 (IL-6) for Management of Traumatic Brain Injuries

This work demonstrates the use of a noninvasive, sweat-based dual biomarker electrochemical sensor for continuous, prognostic monitoring of a Traumatic Brain Injury (TBI) with the aim of enhancing patient outcomes and reducing the time to treatment after injury. A multiplexed SWEATSENSER was used for noninvasive continuous monitoring of glial fibrillary acidic protein (GFAP) and Interleukin-6 (IL-6) in a human sweat analog and in human sweat. Electrochemical impedance spectroscopy (EIS) and chronoamperometry (CA) were used to measure the sensor response. The assay chemistry was characterized using Fourier Transform Infrared Spectroscopy (FTIR). The SWEATSENSER was able to detect GFAP and IL-6 in sweat over a dynamic range of 3 log orders for GFAP and 2 log orders for IL-6. The limit of detection (LOD) for GFAP detection in the sweat analog was estimated to be 14 pg/mL using EIS and the LOD for IL-6 was estimated to be 10 pg/mL using EIS. An interference study was performed where the specific signal was significantly higher than the non-specific signal. Finally, the SWEATSENSER was able to distinguish between GFAP and IL-6 in simulated conditions of a TBI in human sweat. This work demonstrates the first proof-of-feasibility of a multiplexed TBI marker combined with cytokine and inflammatory marker detection in passively expressed sweat in a wearable form-factor that can be utilized toward better management of TBIs. This is the first step toward demonstrating a noninvasive enabling technology that can enable baseline tracking of an inflammatory response.

Poor outcome in frail elderly patient after severe TBI

OBJECTIVE

To investigate the influence of frailty in elderly with severe TBI on mortality and functional outcome.

METHOD

126 patients with TBI aged 60 years or older and with a presenting Glasgow Coma Scale score of 8 or lower were retrospectively included. To investigate frailty, we used the CSHA Clinical Frailty Scale. The primary outcome measures were mortality, and the secondary outcome measures were Glasgow Outcome Scale Extended (GOSE) at discharge and GOSE at 6 months after trauma.

RESULTS

High frailty was a significant predictor for mortality (OR 2.38, p 0.047), if adjusted for the injury severity scale. High frailty was also a significant predictor for poor functional outcome after 6 months (OR 4.35, p 0.03). After 6 months, the GOSE of the low frailty group was significantly higher than in the high frailty group (p 0.019). Also, the improvement of the GOSE was significant in the low frailty group (p 0.007), while in the high frailty group there was no significant improvement of the GOSE (p 0.546) after 6 months.

CONCLUSION

Frailty has a significant impact on outcome in elderly with severe TBI. There is a higher mortality in the frail elderly and there is less recovery after TBI.

Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study

Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.

What are the demographic and clinical differences between those older adults with traumatic brain injury who receive a neurosurgical intervention to those that do not? A systematic literature review with narrative synthesis

OBJECTIVES

This review aimed to identify the demographic and clinical differences between those older adults admitted directly under neurosurgical care and those that were not, and whether EMS clinicians could use these differences to improve patient triage.

METHODS

The authors searched for papers that included older adults who had suffered a TBI and were either admitted directly under neurosurgical care or were not. Titles and abstracts were screened, shortlisting potentially eligible papers before performing a full-text review. The Newcastle-Ottawa Scale was used to assess the risk of bias.

RESULTS

A total of nine studies were eligible for inclusion. A high abbreviated injury score head, Marshall score or subdural hematoma greater than 10 mm were associated with neurosurgical care. There were few differences between those patients who did and did not receive neurosurgical intervention.

CONCLUSIONS

Absence of guidelines and clinician bias means that differences between those treated aggressively and conservatively observed in the literature are fraught with bias. Further work is required to understand which patients would benefit from an escalation of care and whether EMS can identify these patients so they are transported directly to a hospital with the appropriate services on-site.

A Prehospital Triage System to Detect Traumatic Intracranial Hemorrhage Using Machine Learning Algorithms

IMPORTANCE

An adequate system for triaging patients with head trauma in prehospital settings and choosing optimal medical institutions is essential for improving the prognosis of these patients. To our knowledge, there has been no established way to stratify these patients based on their head trauma severity that can be used by ambulance crews at an injury site.

OBJECTIVES

To develop a prehospital triage system to stratify patients with head trauma according to trauma severity by using several machine learning techniques and to evaluate the predictive accuracy of these techniques.

DESIGN, SETTING, AND PARTICIPANTS

This single-center retrospective cohort study was conducted by reviewing the electronic medical records of consecutive patients who were transported to Tokyo Medical and Dental University Hospital in Japan from April 1, 2018, to March 31, 2021. Patients younger than 16 years with cardiopulmonary arrest on arrival or with a significant amount of missing data were excluded.

MAIN OUTCOMES AND MEASURES

Machine learning-based prediction models to detect the presence of traumatic intracranial hemorrhage were constructed. The predictive accuracy of the models was evaluated with the area under the receiver operating curve (ROC-AUC), area under the precision recall curve (PR-AUC), sensitivity, specificity, and other representative statistics.

RESULTS

A total of 2123 patients (1527 male patients [71.9%]; mean [SD] age, 57.6 [19.8] years) with head trauma were enrolled in this study. Traumatic intracranial hemorrhage was detected in 258 patients (12.2%). Among several machine learning algorithms, extreme gradient boosting (XGBoost) achieved the mean (SD) highest ROC-AUC (0.78 [0.02]) and PR-AUC (0.46 [0.01]) in cross-validation studies. In the testing set, the ROC-AUC was 0.80, the sensitivity was 74.0% (95% CI, 59.7%-85.4%), and the specificity was 74.9% (95% CI, 70.2%-79.3%). The prediction model using the National Institute for Health and Care Excellence (NICE) guidelines, which was calculated after consultation with physicians, had a sensitivity of 72.0% (95% CI, 57.5%-83.8%) and a specificity of 73.3% (95% CI, 68.7%-77.7%). The McNemar test revealed no statistically significant differences between the XGBoost algorithm and the NICE guidelines for sensitivity or specificity (P = .80 and P = .55, respectively).

CONCLUSIONS AND RELEVANCE

In this cohort study, the prediction model achieved a comparatively accurate performance in detecting traumatic intracranial hemorrhage using only the simple pretransportation information from the patient. Further validation with a prospective multicenter data set is needed.

Traumatic brain injury in the elderly population: a 20-year experience in a tertiary neurosurgery center in Belgium

PURPOSE

Traumatic brain injury (TBI) rates in the elderly population are rapidly increasing worldwide. However, there are no clinical guidelines for the treatment of elderly TBI to date. This study aims at describing injury patterns and severity, clinical management, and outcomes in elderly TBI patients, which may contribute to specific prognostic tools and clinical guidelines in the future.

METHODS

Clinical records of 2999 TBI patients ≥ 65 years old admitted in the University Hospital Leuven (Belgium) between 1999 and 2019 were manually screened and 1480 cases could be included. Records were scrutinized for relevant clinical data.

RESULTS

The median age in the cohort was 78.0 years (IQR = 12). Falls represented the main accident mechanism (79.7%). The median Glasgow Coma Score on admission was 15 (range 3-15). Subdural hematomas were the most common lesion (28.4%). 90.1% of all patients were hospitalized and 27.0% were admitted to intensive care. 16.4% underwent a neurosurgical intervention. 11.0% of all patients died within 30 days post-TBI. Among the 521 patients with mild TBI, 28.6% were admitted to ICU and 13.1% had a neurosurgical intervention and 30-day mortality was 6.9%.

CONCLUSION

Over the 20-year study period, an increase of age and comorbidities and a reduction in neurosurgical interventions and ICU admissions were observed, along with a trend to less severe injuries but a higher proportion of treatment withdrawals, while at the same time mortality rates decreased. TBI is a life-changing event, leading to severe consequences in the elderly population, especially at higher ages. Even mild TBI is associated with substantial rates of hospitalization, surgery, and mortality in elderly. The characteristics of the elderly population with TBI are subject to changes over time.

Validation of the Elderly Traumatic Brain Injury Score: an observational case-control study

INTRODUCTION

Traumatic brain injury (TBI) poses a particular health risk for the elderly. The recently developed Elderly Traumatic Brain Injury Score (eTBI Score) combines the prognostic information of the risk factors characteristic of the geriatric population. We aimed to determine its validity and reliability on an independent sample.

METHODS

We present a retrospective analysis of 506 consecutive patients after TBI aged ≥65 years. The previously described nomogram and the eTBI Score were used. The primary outcome measure was mortality or vegetative state at 30 days after hospital admission.

RESULTS

Mortality or vegetative state rate was 21.3%. The nomogram and eTBI Score showed similar predictive performance with accuracy of 83.8% (95%CI 80.2%-87%) and 84.4% (95%CI 80.8%-87.6%), respectively. Based on the Youden index and C4.5 algorithm we divided patients according to the 3-tier pattern into low, high and medium risk groups. The outcome prediction in the first two groups was correct in 93.1% (survival in the low risk group) and 94.4% (mortality in the high risk group). Patients included in the medium risk group usually required surgical treatment (85.3%), and characterized for increased mortality or vegetative state (55%). Among patients with eTBI≥5 (n=221), there was no difference in outcome between those treated conservatively and surgically.

CONCLUSIONS

This is the first study confirming the validity of the eTBI Score and its close association with outcome of geriatric population after TBI. The novel 3-tier risk stratification scheme was applicable to both conservatively and surgically treated patients.

Evaluation of Pediatric Early Warning System and Drooling Reluctance Oropharynx Others Leukocytosis scores as prognostic tools for pediatric caustic ingestion: a two-center, cross-sectional study

Caustic chemicals are widely distributed in our environment. Exposure to caustic agents is a lifelong problem associated with severe tissue and mucous membrane injuries. In pediatrics, corrosive exposure is the most common cause of nonpharmaceutical exposure presenting to poison control centers. Therefore, this study evaluated the role of the Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) scores as early in-hospital outcome predictors following corrosive ingestion. The current study was a two-center, retrospective, cross-sectional study carried out among pediatric patients diagnosed with acute caustic ingestion during the past 4 years. Most exposure occurred accidentally among boys (59.4%) living in rural areas (51.9%) of preschool age (50% were 2-4 years old). Residence, body temperature, respiratory rate, vomiting, skin and mucosal burns, retrosternal pain, respiratory distress, Oxygen (O2) saturation, Glasgow Coma Scale score, HCO₃ level, total bilirubin level, anemia, leukocytosis, and presence of free peritoneal fluid were significant predictors of esophageal injuries (p < 0.05). DROOL and PEWS scoring were the most significant predictors of esophageal injuries with worthy predictive power, where odds ratio (95% confidence interval (CI)) was 1.76 (0.97-3.17) and 0.47 (0.21-0.99) for PEWS and DROOL, respectively. At a cutoff of < 6.5, the DROOL score could predict esophageal injuries excellently, with AUC = 0.931; sensitivity, 91.7%; specificity, 72.5%; and overall accuracy, 91.3%. At a cutoff of > 6.5, PEWS could significantly predict unfavorable outcomes, with AUC = 0.893; sensitivity, 94.4%; specificity, 71.9%; and overall accuracy, 89.3%. However, PEWS better predicted the need for admittance to the intensive care unit (ICU). Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) are potentially useful accurate scorings that could predict the esophageal injuries and ICU admission following corrosive ingestion in pediatrics.

Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters

BACKGROUND

Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits.

AIMS

We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR.

METHODS

We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018-07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED.

RESULTS

A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%).

DISCUSSION

Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary.

CONCLUSION

Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.

Severity of Traumatic Brain Injury in Older Adults and Risk of Ischemic Stroke and Depression

OBJECTIVE

Risk of ischemic stroke and depression is elevated among older adults following traumatic brain injury (TBI), yet little is known about how the severity of TBI influences risk. Thus, our objective was to assess the association between severity of the index TBI and risk of ischemic stroke and depression in a sample of older adults treated for TBI.

DESIGN

Retrospective cohort study.

SETTING

R Adams Cowley Shock Trauma Center.

PARTICIPANTS

Adults 65 years and older treated for TBI between 2006 and 2010 who survived to hospital discharge and could be linked to their Medicare administrative claims data with continuous enrollment for at least 6 months pre-TBI and 12 months post-TBI.

MAIN MEASURES

First dates of ischemic stroke and depression available in Medicare claims were used to exclude individuals with a history. Next, we separately assessed the association between TBI severity and time to first stroke and depression using Cox proportional hazards models.

RESULTS

Among 132 patients without preexisting history of stroke, high TBI severity was associated with increased risk of stroke compared with low TBI severity (adjusted hazard ratio 6.68, 95% confidence interval 2.49-17.94). Among 163 patients without preexisting history of depression, high TBI severity was not significantly associated with increased risk of depression compared with low TBI severity (adjusted hazard ratio 1.90, 95% confidence interval 0.94-3.84).

CONCLUSION

In this group of older adults with TBI, higher TBI severity was associated with increased risk of ischemic stroke, but not depression. These results suggest that increased monitoring of older adults with moderate-severe TBI for stroke may be warranted.

Trauma Response for Elderly Anticoagulated Patients: An Initiative to Reduce Trauma Resource Utilization in the Emergency Department

BACKGROUND

Trauma centers are challenged to have appropriate criteria to identify injured patients needing a trauma activation; one population that is difficult to triage is injured elderly patients taking anticoagulation or antiplatelet (ACAP) medications with suspected head injury.

OBJECTIVE

The study purpose was to evaluate a hospital initiative to improve the trauma triage response for this population.

METHODS

A retrospective study at a Level I trauma center evaluated revised trauma response criteria. In Phase 1 (June 2017 to April 2018; n = 91), a limited activation occurred in the trauma bay for injured patients 55 years and older, taking ACAP medications with evidence of head injury. In Phase 2 (June 2018 to April 2019; n = 142), patients taking ACAP medications with evidence of head injury received a rapid emergency department (ED) response. Primary outcomes were timeliness of ED interventions and hospital admission rates. Differences between phases were assessed with Kruskal-Wallis tests.

RESULTS

An ED rapid response significantly reduced trauma team involvement (100%-13%, p < .001). Compared with Phase 1, patients in Phase 2 were more frequently discharged from the ED (48% vs. 68%, p = .003), and ED disposition decision was made more quickly (147 vs. 120 min, p = .01). In Phase 2, time to ED disposition decision was longer for patients who required hospital admission (108 vs. 179 min, p < .001); however, there were no significant differences between phases in reversal intervention (6% vs. 11%, p = .39) or timeliness of reversal intervention (49 vs. 118 min, p = .51).

CONCLUSION

The ED rapid response delivered safe, timely evaluation to injured elderly patients without overutilizing trauma team activations.

Evaluation of elderly specific pre-hospital trauma triage criteria: a systematic review

BACKGROUND

Pre-hospital identification of major trauma in elderly patients is key for delivery of optimal care, however triage of this group is challenging. Elderly-specific triage criteria may be valuable. This systematic review aimed to summarise the published pre-hospital elderly-specific trauma triage tools and evaluate their sensitivity and specificity and associated clinical outcomes.

METHODS

MEDLINE and EMBASE databases were searched using predetermined criteria (PROSPERO: CRD42019140879). Two authors independently assessed search results, performed data extraction, risk of bias and quality assessments following the Grading of Recommendations, Assessment, Development and Evaluation system.

RESULTS

801 articles were screened and 11 studies met eligibility criteria, including 1,332,300 patients from exclusively USA populations. There were eight unique elderly-specific triage criteria reported. Most studies retrospectively applied criteria to trauma databases, with few reporting real-world application. The Ohio Geriatric Triage Criteria was reported in three studies. Age cut-off ranged from 55 to 70 years with ≥ 65 most frequently reported. All reported existing adult criteria with modified physiological parameters using higher thresholds for systolic blood pressure and Glasgow coma scale, although the values used varied. Three criteria added co-morbidity or anti-coagulant/anti-platelet use considerations. Modifications to anatomical or mechanism of injury factors were used by only one triage criteria. Criteria sensitivity ranged from 44 to 93%, with a median of 86.3%, whilst specificity was generally poor (median 54%). Scant real-world data showed an increase in patients meeting triage criteria, but minimal changes to patient transport destination and mortality. All studies were at risk of bias and assessed of "very low" or "low" quality.

CONCLUSIONS

There are several published elderly-specific pre-hospital trauma triage tools in clinical practice, all developed and employed in the USA. Consensus exists for higher thresholds for physiological parameters, however there was variability in age-cut offs, triage criteria content, and tool sensitivity and specificity. Although sensitivity was improved over corresponding 'adult' criteria, specificity remained poor. There is a paucity of published real-world data examining the effect on patient care and clinical outcomes of elderly-specific triage criteria. There is uncertainty over the optimal elderly triage tool and further study is required to better inform practice and improve patient outcomes.

Prognostic Value of Circadian Rhythm of Brain Temperature in Traumatic Brain Injury

Hypothermia has been used in postoperative management of traumatic brain injury (TBI); however, the rhythmic variation and prognostic value of brain temperature after TBI have never been studied. This study describes diurnal brain temperature patterns in comatose patients with TBI. Mesors of brain temperature, amplitude, and acrophase were estimated from recorded temperature measurements using cosinor analysis. The association of these patterns with clinical parameters, mortality, and functional outcomes in a 12-month follow-up was examined. According to the cosinor analysis, 59.3% of patients presented with circadian rhythms of brain temperature in the first 72 h postoperatively. The rhythm-adjusted mesor of brain temperature was 37.39 ± 1.21 °C, with a diminished mean amplitude of 0.28 (±0.25) °C; a shift of temperature acrophase was also observed. Multivariate logistic regression analysis revealed that initial Glasgow coma scale score, age, elevated blood glucose level, and circadian rhythm of brain temperature seemed to be predictive and prognostic factors of patients' functional outcomes. For the prediction of survival status, younger patients or those patients with mesor within the middle 50% of brain temperature were more likely to survive. The analysis of brain temperature rhythms in patients with moderate and severe TBI provided additional predictive information related to mortality and functional outcomes.

Functional motor improvement during inpatient rehabilitation among older adults with traumatic brain injury

BACKGROUND

Older adults comprise an increasingly large proportion of patients with traumatic brain injury (TBI) receiving care in inpatient rehabilitation facilities (IRF). However, high rates of comorbidities and evidence of declining preinjury health among older adults who sustain TBI raise questions about their ability to benefit from IRF care.

OBJECTIVES

To describe the proportion of older adults with TBI who exhibited minimal detectable change (MDC) and a minimally clinically important difference (MCID) in motor function from IRF admission to discharge; and to identify characteristics associated with clinically meaningful improvement in motor function and better discharge functional status.

DESIGN

This retrospective cohort study used Medicare administrative data probabilistically linked to the National Trauma Data Bank to estimate the proportion of patients whose motor function improved during inpatient rehabilitation and identify factors associated with meaningful improvement in motor function and motor function at discharge.

SETTING

Inpatient rehabilitation facilities in the United States.

PATIENTS

Fee-for-service Medicare beneficiaries with TBI.

MAIN OUTCOME MEASURES

Minimal Detectable Change (MDC) and Minimally Clinically Important Difference (MCID) in the Functional Independence Measure motor (FIM-M) score from admission to discharge, and FIM-M score at IRF discharge.

RESULTS

From IRF admission to discharge 84% of patients achieved the MDC threshold, and 68% of patients achieved the MCID threshold for FIM-M scores. Factors associated with a higher probability of achieving the MCID for FIM-M scores included better admission motor and cognitive function, lower comorbidity burden, and a length of stay longer than 10 days but only among individuals with lower admission motor function. Older age was associated with a lower FIM-M discharge score, but not the probability of achieving the MCID in FIM-M score.

CONCLUSION

Older adults with TBI have the potential to improve their motor function with IRF care. Baseline functional status and comorbidity burden, rather than acute injury severity, should be used to guide care planning.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury in Skilled Nursing Facilities

OBJECTIVE

To identify patient, injury, and functional status characteristics associated with successful discharge to the community following a skilled nursing facility (SNF) stay among older adults hospitalized following traumatic brain injury (TBI).

SETTING

Skilled nursing facilities.

PARTICIPANTS

Medicare fee-for-service beneficiaries admitted to an SNF after hospitalization for TBI.

DESIGN

Retrospective cohort study using Medicare administrative data merged with the National Trauma Data Bank using a multilayered Bayesian record linkage approach.

MAIN OUTCOME MEASURE

Successful community discharge: discharged alive within 100 days of SNF admission and remaining in the community for 30 days or more without dying or admission to a healthcare facility.

RESULTS

Medicaid enrollment, incontinence, decreased independence with activities of daily living, and cognitive impairment were associated with lower odds of successful discharge, whereas race "other" was associated with higher odds of successful discharge. Injury factors including worse injury severity (Glasgow Coma Scale and Abbreviated Injury Scale scores) and fall-related injury mechanism were not associated with successful discharge.

CONCLUSION

Among older adults with TBI who discharge to an SNF, sociodemographic and functional status characteristics are associated with successful discharge and may be useful to clinicians for discharge planning. Acute injury severity indices may have limited utility in predicting discharge disposition once a patient is admitted to an SNF for post-acute care.

Epidemiology of geriatric trauma patients in Norway: A nationwide analysis of Norwegian Trauma Registry data, 2015-2018. A retrospective cohort study

INTRODUCTION

Geriatric patients have a high risk of poor outcomes after trauma and is a rapid-increasing group within the trauma population. Given the need to ensure that the trauma system is targeted, efficient, accessible, safe and responsive to all age groups the aim of the present study was to explore the epidemiology and characteristics of the Norwegian geriatric trauma population and assess differences between age groups within a national trauma system.

MATERIALS AND METHODS

This retrospective analysis is based on data from the Norwegian Trauma Registry (2015-2018). Injury severity was scaled using the Abbreviated Injury Scale (AIS), and the New Injury Severity Score (NISS). Trauma patients 16 years or older with NISS ≥9 were included, dichotomized into age groups 16-64 years (Group 1, G1) and ≥65 years (Group 2, G2). The groups were compared with respect to differences in demographics, injury characteristics, management and outcome. Descriptive statistics and relevant parametric and non-parametric tests were used.

RESULTS

Geriatric patients proved to be at risk of sustaining severe injuries. Low-energy falls predominated in G2, and the AIS body regions 'Head' and 'Pelvis and lower extremities' were most frequently injured. Crude 30-day mortality was higher in G2 compared to G1 (G1: 2.9 vs. G2: 13.6%, P<0.01) and the trauma team activation (TTA) rate was lower (G1: 90 vs. G2: 73%, P<0.01). A lower proportion of geriatric patients were treated by a physician prehospitally (G1: 30 vs. G2: 18%, [NISS 15-24], P<0.01) and transported by air-ambulance (G1: 24 vs. G2: 14%, [NISS 15-24], P<0.01). Median time from alarm to hospital admission was longer for geriatric patients (G1: 71 vs. G2: 78 min [NISS 15-24], P<0.01), except for the most severely injured patients (NISS≥25).

CONCLUSION

In this nationwide study comparing adult and geriatric trauma patients, geriatric patients were found to have a higher mortality, receive less frequently advanced prehospital treatment and transportation, and a lower TTA rate. This is surprising in the setting of a Nordic country with free access to publicly funded emergency services, a nationally implemented trauma system with requirements to pre- and in-hospital services and a national trauma registry with high individual level coverage from all trauma-receiving hospitals. Further exploration and a deeper understanding of these differences is warranted.

Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury

Background

The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories.

Methods

The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves.

Results

The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients.

Discussion

We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury.

Level of evidence

III epidemiologic/prognostic.

The Whole is Greater Than the Sum of its Parts: GCS Versus GCS-Motor for Triage in Geriatric Trauma

BACKGROUND

Trauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations.

MATERIALS AND METHODS

We conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007-2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared.

RESULTS

In total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non-motor-only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm.

CONCLUSIONS

Geriatric patients more frequently present with non-motor-only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.

Validity and reliability of the triage scale in older people in a regional emergency department in Hong Kong

Background:

Older people (⩾65 years) present a unique challenge in emergency department triage. Hong Kong’s Hospital Authority adopts a five-level emergency department triage system, with no special considerations for older people. We evaluated the validity and reliability of this triage scale in older people in a regional Hong Kong emergency department.

Methods:

In total, 295 cases stratified by triage category were randomly selected for review from November 2016 to January 2017. Validity was established by comparing the real emergency department patients’ triage category against (1) that of an expert panel and (2) the need for life-saving intervention. Triage notes were extracted to make case scenarios to evaluate inter- and intra-rater reliabilities. Emergency department nurses (n = 8) were randomly selected and grouped into <5 and ⩾5 years emergency department experience. All nurses independently rated all 295 scenarios, blinded to clinical outcomes.

Results:

The percentage agreement between the real emergency department patients’ triage category and the expert panel’s assignment was 68.5%, with 16.3% and 15.3% over-triage and under-triage, respectively. Quadratic weighting kappa for agreement with the expert panel was 0.72 (95% confidence interval: 0.53–0.91). The sensitivity, specificity and positive likelihood ratio for the need for life-saving interventions were 75.0% (95% confidence interval: 47.6%–92.7%), 97.1% (95% confidence interval: 94.4%–98.8%) and 26.2 (95% confidence interval: 12.5%–54.8%), respectively. The Fleiss kappa value for inter-rater reliability was 0.50 (95% confidence interval: 0.47–0.54) for junior and senior nurse groups, respectively.

Conclusion:

The current triage scale demonstrates reasonable validity and reliability for use in our older people. Considerations highlighting the unique characteristics of older people emergency department presentations are recommended.

Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury

Background

For the prehospital diagnosis of raised intracranial pressure (ICP), clinicians are reliant on clinical signs such as the Glasgow Coma Score (GCS), pupillary response and/or Cushing’s triad (hypertension, bradycardia and an irregular breathing pattern). This study aimed to explore the diagnostic accuracy of these signs as indicators of a raised ICP.

Methods

We performed a retrospective cohort study of adult patients attended by a Helicopter Emergency Medical Service (Air Ambulance Kent, Surrey Sussex), who had sustained a traumatic brain injury (TBI), requiring prehospital anaesthesia between 1 January 2016 and 1 January 2018. We established optimal cut-off values for clinical signs to identify patients with a raised ICP and investigated diagnostic accuracy for combinations of these values.

Results

Outcome data for 249 patients with TBI were available, of which 87 (35%) had a raised ICP. Optimal cut-off points for systolic blood pressure (SBP), heart rate (HR) and pupil diameter to discriminate patients with a raised ICP were, respectively, >160 mm Hg,<60 bpm and >5 mm. Cushing criteria (SBP >160 mm Hg and HR <60 bpm) and pupillary response and size were complimentary in their ability to detect patients with a raised ICP. The presence of a fixed blown pupil or a Cushing’s response had a specificity of 93.2 (88.2–96.6)%, and a positive likelihood ratio (LR+) of 5.4 (2.9–10.2), whereas sensitivity and LR− were only 36.8 (26.7–47.8)% and 0.7 (0.6–0.8), respectively, (Area Under the Curve (AUC) 0.65 (0.57–0.73)). Sensitivity analysis revealed that optimal cut-off values and resultant accuracy were dependent on injury pattern.

Conclusion

Traditional clinical signs of raised ICP may under triage patients to prehospital treatment with hyperosmolar drugs. Further research should identify more accurate clinical signs or alternative non-invasive diagnostic aids in the prehospital environment.

Undertriage of the elderly major trauma patient continues in major trauma centre care: a retrospective cohort review

BACKGROUND

Major trauma (Injury Severity Score (ISS) ≥16) in older people is increasing, but concerns persist that major trauma is not always recognised in older patients on triage. This study compared undertriage of older and younger adult major trauma patients in the major trauma centre (MTC) setting to investigate this concern.

METHODS

A retrospective review of Trauma Audit and Research Network data was conducted for three MTCs in the UK for 3 months in 2014. Age, ISS, injury mechanism and injured areas were examined for all severely injured patients (ISS ≥16) and appropriate major trauma triage rates measured via the surrogate markers of trauma team activation and the presence of a consultant first attender, as per standards for major trauma care set by National Confidential Enquiry into Patient Outcomes and Deaths, Royal College of Surgeons of England and the British Orthopaedic Association. Trends in older (age ≥65) and younger (ages 18-64) adult major trauma presentation, triage and reception were reviewed.

RESULTS

Of 153 severely injured patients, 46 were aged ≥65. Older patients were significantly less likely to receive the attention of a consultant first attender or trauma team. Similar trends were also seen on subgroup analysis by mechanism of injury or number of injured body areas. Older major trauma patients exhibit a higher mortality, despite a lower median ISS (older patient ISS=20 (IQR 16-25), younger patient ISS=25 (IQR 18-29)).

CONCLUSION

Older major trauma patients are at greater risk of undertriage, even in the MTC environment. Existing hospital trauma triage practices should be further investigated to explain and reduce undertriage of elderly trauma patients.

Collision of Priorities in Posttraumatic Coma and Suspected Multiple Injuries: A Prospective Multicenter Trial

OBJECTIVE

 The presence of multiple injuries in addition to a traumatic brain injury (TBI) is initially uncertain in most patients with posttraumatic coma. The interdisciplinary team of physicians in charge of initial treatment after hospital admission may face a collision of vital priorities. The purpose of this study was to analyze which diagnostic and surgical measures were given priority over others in comatose patients after injury and to draw conclusions from these data.

METHODS

 In this prospective multicenter cohort study, the outcomes of 1,003 comatose patients with suspected multiple injuries were studied. The analysis was divided into an early and a late stage. Diagnostic and surgical measures were analyzed for a 6-month period. The prognostic value of the Glasgow Coma Scale (GCS) and the World Federation of Neurosurgical Societies grading scale were investigated.

RESULTS

 Removal of intracranial hematomas and decompressive craniotomies were the most frequent procedures within the first 48 hours after admission to the hospital. Prognosis depends on the location and the combination of injuries. Outcome is significantly correlated to initial signs of brainstem dysfunction. The GCS did not adequately predict clinical outcome.

CONCLUSION

 Comatose patients with suspected multiple injuries should only be admitted to hospitals with a continuous neurosurgical service because intracranial operations are more frequent in the first 48 hours than extracranial operations. Depending on the neurologic status of the patient, an urgent surgical decompression may be essential for a good outcome. The GCS alone is not a sufficient tool for the neurologic assessment and the prognosis of patients with multiple injuries. The onset of clinical signs of brainstem dysfunction indicates a critical deterioration of the functioning of the central nervous system. The priority of surgical measures should be tailored accordingly.

Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study

Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.

The reliability of the Glasgow Coma Scale in detecting traumatic brain injury: The continuous effect of age

Background: Recent studies noted the limited applicability of Glasgow Coma Scale (GCS) for elderly patients with Traumatic Brain Injury (TBI). However, the dichotomic distinction between "elderly" and "non-elderly" does not cover the full span of influence of age on GCS presentation.Objective: To analyze the influence of age on GCS scores of patients with isolated TBI.Methods: A retrospective study of 18,534 patients hospitalized due to isolated TBI recorded in the Israeli National Trauma Registry in 1997-2017. The GCS scores were compared between four age-groups: 20-44, 45-64, 65-74 and 75+ years old. Additional factors included patient's sex, Abbreviated Injury Scores (AIS) and injury circumstances.Results: GCS scores increased continuously with age at all AIS levels. The trend was significant even after adjustment for patient's sex and injury circumstances. The angle of the trend was different in various injury circumstances, with GCS scores of victims of Road Traffic Accidents sharply increasing after age of 44 and that of the patients hospitalized after falling from own height surging after age of 64.Conclusions: Screening procedures for patients with TBI should give a greater weight to the actual age of adults, as well as to the circumstances of their injury.

Age differences in outcome after mild traumatic brain injury: results from the HeadSMART study

This study longitudinally examined age differences across multiple outcome domains in individuals diagnosed with acute mild traumatic brain injury (mTBI). A sample of 447 adults meeting VA/DoD criteria for mTBI was dichotomized by age into older (≥65 years; n = 88) and younger (<65 years; n = 359) sub-groups. All participants presented to the emergency department within 24 hours of sustaining a head injury, and outcomes were assessed at 1-, 3-, and 6-month intervals. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), post-concussive symptoms (PCS) were ascertained with the Rivermead Post-Concussion Questionnaire (RPQ), and functional recovery from the Extended Glasgow Outcome Scale (GOSE). Mixed effects logistic regression models showed that the rate of change over time in odds of functional improvement and symptom alleviation did not significantly differ between age groups (p = 0.200-0.088). Contrary to expectation, older adults showed equivalent outcome trajectories to younger persons across time. This is a compelling finding when viewed in light of the majority opinion that older adults are at risk for significantly worse outcomes. Future work is needed to identify the protective factors inherent to sub-groups of older individuals such as this.

Is medical urgency of elderly patients with traumatic brain injury underestimated by emergency department triage?

Background: Mortality is high among elderly patients with traumatic brain injury (TBI). Recent data suggest that early surgical intervention and aggressive rehabilitation may reduce mortality rates even in elderly patients. Our aim was therefore to study the Rapid Emergency Triage and Treatment System-Adult (RETTS-A) triage of patients with isolated TBI and examine the differences in acute management according to age.Methods: We included 306 adult patients with isolated severe TBI and an abbreviated injury scale (AIS) score ≥3. Using a cut-off of 60 years of age, differences in triage priority according to RETTS-A, time to first computed tomography (CT) scan, length of hospital stay (LOS), and 30-day survival were studied.Results: In patients with an AIS score of 3 and 4, we observed that elderly patients had a longer time from admission to first CT scan. In addition, we observed that elderly patients were less often triaged with the highest priority level, despite similar AIS scores. LOS was significantly higher in elderly patients (median 9 days compared with 3 days for younger patients, p < 0.001). Finally, age, triage priority, and AIS score were independent risk factors for mortality.Conclusion: Elderly patients with isolated TBI are managed differently than younger patients, which could be due to an under-triage of elderly patients by RETTS-A.

Auricular Electroacupuncture for Late Posttraumatic Epilepsy after Severe Brain Injury: A Retrospective Study

Background

Posttraumatic epilepsy (PTE) is a common complication of traumatic brain injury (TBI), which seriously affects patients' survival and recovery. Vagus nerve stimulation (VNS) is a nonpharmacological therapy for epilepsy. The auricular branch of the vagus nerve (ABVN) is the only peripheral branch and has antiepileptic effects, but the efficacy of ABVN stimulation as treatment of late PTE is uncertain. We retrospectively analyzed the clinical efficacy of ABVN stimulation by auricular electroacupuncture for the treatment of late PTE, and investigated the influence of sodium valproate and edaravone on the anti-PTE effects of auricular electroacupuncture.

Method

Univariate and multivariate logistic regression analyses were used to investigate the relationship of age, cause of PTE, use of auricular electroacupuncture, sodium valproate, and edaravone with the incidence of late PTE. To compare the curative effects of auricular electroacupuncture, 89 cases of late PTE were divided into an auricular electroacupuncture and a control group according to whether they were treated with auricular electroacupuncture. We further analyzed the influence of sodium valproate and edaravone on the effects of the treatment of PTE with auricular electroacupuncture.

Results

Among age, cause, use of auricular electroacupuncture, sodium valproate, and edaravone, the use of auricular electroacupuncture was associated with significantly reduced incidence of late PTE (P < 0.05). Compared with the control group, there were more seizure-free cases in the auricular electroacupuncture group (P < 0.01). The total effective rate of the auricular electroacupuncture group was 90%. The seizure-free rate among patients treated with auricular electroacupuncture was significantly reduced, regardless of the use of sodium valproate or edaravone (P < 0.05).

Conclusion

Auricular electroacupuncture can reduce the incidence of late PTE and is a safe and economical therapy for late PTE.

A Novel Risk Score to Predict Post-Trauma Mortality in Nonagenarians

Background:

Nonagenarians represent a rapidly growing age group who often have functional limitations and multiple comorbidities, predisposing them to trauma.

Aims:

The purpose of this study was to identify patient characteristics, hospital complications, and comorbidities that predict in-hospital mortality in the nonagenarian population following trauma. We also sought to create a scoring system using these variables.

Settings and Design:

This study was a retrospective chart review.

Methods:

We reviewed the medical records of 548 nonagenarian trauma patients admitted to two Level I trauma centers from 2006 to 2015. Statistical analysis was performed using logistic regression and a machine learning model, which calculated significant variables and computed a scoring system.

Results:

The in-hospital mortality rate was 7.1% (n = 39). Significant predictors of mortality were cardiac comorbidity, neuro-concussion, New Injury Severity Score (ISS) 16+, striking an object, ISS 25–75, and pulmonary and cardiac complications. Significant variables were assigned a numeric value. A score of 5+ carried a 41.1% mortality risk, 79% sensitivity, and 91% specificity. A score of 10+ had an associated 81.8% mortality risk with 31% specificity and 99% sensitivity.

Conclusions:

Our findings identified reliable predictors of mortality in nonagenarian population posttrauma. The scoring system performs with good specificity and sensitivity and incrementally correlates with mortality risk.

Craniocervical trauma above the age of 90: are current prognostic scores sufficient?

Clinical data following head or spine trauma in patients over 90 years is rare. The aim of this study was to analyze this patient cohort, assessing clinical characteristics, outcomes, and survival rates and to identify variables that may predict early mortality. A retrospective analysis of all patients over the age of 90 that were treated between January 2006 and December 2016 at our department was performed. Patient characteristics, type of injury, and comorbidities were analyzed with regard to the 30-day mortality rate as the primary outcome. One hundred seventy-nine patients were identified. Mean age was 93 (range 90-102); 105 (59%) patients were female. One hundred thirty-two (74%) and 34 (19%) of patients presented with head and spinal trauma, respectively. Fourteen patients (8%) had a combined head and spine injury. One hundred (56%) patients were treated operatively. Mean Charlson comorbidity index was 4.1 (range 0-18), mean diagnosis count was 6.2 (range 0-12), mean geriatric index of comorbidity (GIC) was 3.3 (range 1-4), and mean Barthel index was 28 (range 0-100). The 30-day mortality rate was 31%. Multivariate cox regression analysis showed that head trauma had a 1.66 hazard ratio (p = 0.036) of dying within 30 days of admission, whereas a higher Glasgow coma score and surgical treatment had a hazard ratio of 0.88 (p = 0.0001) and 0.72 (p = 0.05) to reach the primary outcome. None of the standard geriatric scores reached any significant correlation with the primary outcome. Standard geriatric prognostic scores seem less reliable to predict mortality for patients above the age of 90. Higher Glasgow coma score and surgical treatment were associated with a higher survival probability.

Geriatric patients on antithrombotic therapy as a criterion for trauma team activation leads to over triage

BACKGROUND

Our institution amended its trauma activation criteria to require a Level II activation for patients ≥65 years old on antithrombotic medication presenting with suspected head trauma.

METHODS

Our institutional trauma registry was queried for geriatric patients on antithrombotic medication in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups.

RESULTS

After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, P < 0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, P < 0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, P < 0.001; 70.7% vs. 27.3%, P < 0.001). There was no change in mortality (4.3 vs. 2.0%, P = 0.21).

CONCLUSIONS

Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality.

Incretin Mimetics as Rational Candidates for the Treatment of Traumatic Brain Injury

Traumatic brain injury (TBI) is becoming an increasing public health issue. With an annually estimated 1.7 million TBIs in the United States (U.S) and nearly 70 million worldwide, the injury, isolated or compounded with others, is a major cause of short- and long-term disability and mortality. This, along with no specific treatment, has made exploration of TBI therapies a priority of the health system. Age and sex differences create a spectrum of vulnerability to TBI, with highest prevalence among younger and older populations. Increased public interest in the long-term effects and prevention of TBI have recently reached peaks, with media attention bringing heightened awareness to sport and war related head injuries. Along with short-term issues, TBI can increase the likelihood for development of long-term neurodegenerative disorders. A growing body of literature supports the use of glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide (GIP), and glucagon (Gcg) receptor (R) agonists, along with unimolecular combinations of these therapies, for their potent neurotrophic/neuroprotective activities across a variety of cellular and animal models of chronic neurodegenerative diseases (Alzheimer's and Parkinson's diseases) and acute cerebrovascular disorders (stroke). Mild or moderate TBI shares many of the hallmarks of these conditions; recent work provides evidence that use of these compounds is an effective strategy for its treatment. Safety and efficacy of many incretin-based therapies (GLP-1 and GIP) have been demonstrated in humans for the treatment of type 2 diabetes mellitus (T2DM), making these compounds ideal for rapid evaluation in clinical trials of mild and moderate TBI.

A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England

Introduction:

Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU).

Method:

All patients with a primary injury of TBI who were transported to hospital by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) from 1 January 2016 to 31 December 2016 and entered into the Trauma Audit & Research Network (TARN) registry were reviewed. Patients were stratified by hospital designation (MTC or TU). Severity of TBI was categorised using the patients’ pre-hospital Glasgow Coma Scale (GCS) and Abbreviated Injury Score (AIS) Head. The outcomes of interest were 30-day mortality and Glasgow Outcome Score (GOS) at discharge.

Results:

Between 1 January and 31 December 2016, 549 TBI patients were identified in the TARN database as being transported by SECAmb to either an MTC or a TU. The majority of patients were transported to a TU (77.96%), and the median age of the TU cohort was older than the MTC group (TU 82.15 IQR 16.73 vs. MTC 62.1 IQR 42.6). The median Injury Severity Score (ISS) was greater in the MTC cohort (22 IQR 10 vs. 17 IQR 9), where falls from height and road traffic collisions (RTCs) contributed to 50.51% of all injuries. Within the TU cohort, falls from less than 2 metres (standing height) were the main mechanism of injury (MOI) (77.62%). The median length of hospital stay (LOS) was longer in the MTC cohort compared to the TU cohort (10 IQR 13.25 vs. 8 IQR 14).

Conclusion:

The high proportion of mild TBI and absence of reliable triage guidelines make it difficult for ambulance clinicians to identify patients who will benefit from transport to an MTC. Future research should focus on how TBI triage influences outcomes and how ambulance services can better identify patients with a TBI and who would benefit from specialist care.

Comparison of two simple models for prediction of short term mortality in patients after severe traumatic brain injury

INTRODUCTION

The subscale motor score of Glasgow Coma Scale (msGCS) and the Abbreviated Injury Score of head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim was to compare the prognostic performance of a HAIS-based prediction model including HAIS, pupil reactivity and age, and the reference prediction model including msGCS in emergency department (ED), pupil reactivity and age.

METHODS

Secondary analysis of a prospective epidemiological study including patients after severe TBI (HAIS > 3) with follow-up from the time of accident until 14 days or earlier death was performed in Switzerland. Performance of prediction, based on accuracy of discrimination [area under the receiver-operating curve (AUROC)], calibration (Hosmer-Lemeshow test) and validity (bootstrapping with 2000 repetitions to correct) for optimism of the two prediction models were investigated. A non-inferiority approach was performed and an a priori threshold for important differences was established.

RESULTS

The cohort included 808 patients [median age 56 {inter-quartile range (IQR) 33-71}, median motor part of GCS in ED 1 (1-6), abnormal pupil reactivity 29.0%] with a death rate of 29.7% at 14 days. The accuracy of discrimination was similar (AUROC HAIS-based prediction model: 0.839; AUROC msGCS-based prediction model: 0.826, difference of the 2 AUROC 0.013 (-0.007 to 0.037). A similar calibration was observed (Hosmer-Lemeshow X² 11.64, p = 0.168 vs. Hosmer-Lemeshow X² 8.66, p = 0.372). Internal validity of HAIS-based prediction model was high (optimism corrected AUROC: 0.837).

CONCLUSIONS

Performance of prediction for short-term mortality after severe TBI with HAIS-based prediction model was non-inferior to reference prediction model using msGCS as predictor.

Comparison of two prehospital predictive models for mortality and impaired consciousness after severe traumatic brain injury

BACKGROUND

The primary aim was to investigate the performance of a National Advisory Committee for Aeronautics based predictive model (NACA-BM) for mortality at 14 days and a reference model using motor GCS (GCS-RM). The secondary aim was to compare the models for impaired consciousness of survivors at 14 days (IC-14; GCS ≤ 13).

METHODS

Patients ≥16 years having sustained TBI with an abbreviated injury scale score of head region (HAIS) of >3 were included. Multivariate logistic regression models were used to test models for death and IC-14. The discrimination was assessed using area under the receiver-operating curves (AUROCs); noninferiority margin was -5% between the AUROCs. Calibration was assessed using the Hosmer Lemeshow goodness-of-fit test.

RESULTS

Six hundred and seventy seven patients were included. The median age was 54 (IQR 32-71). The mortality rate was 31.6%; 99 of 438 surviving patients (22.6%) had an IC-14. Discrimination of mortality was 0.835 (95%CI 0.803-0.867) for the NACA-BM and 0.839 (0.807-0.872) for the GCS-RM; the difference of the discriminative ability was -0.4% (-2.3% to +1.7%). Calibration was appropriate for the NACA-BM (χ² 8.42; P = 0. 393) and for the GCS-RM (χ² 3.90; P = 0. 866). Discrimination of IC-14 was 0.757 (0.706-0.808) for the NACA-BM and 0.784 (0.734-0.835) for the GCS-RM; the difference of the discriminative ability was -2.5% (-7.8% to +2.6%). Calibration was appropriate for the NACA-BM (χ² 10.61; P = 0.225) and for the GCS-RM (χ² 6.26; P = 0.618).

CONCLUSIONS

Prehospital prediction of mortality after TBI was good with both models, and the NACA-BM was not inferior to the GCS-RM. Prediction of IC-14 was moderate in both models.

The global challenge of ageing population – Part I: Definitions, epidemiology and physiological changes

Background & Objectives Over the past 50 years, epidemiological data from the World Health Organisation has demonstrated a trend towards population ageing throughout the world. While this is widely recognised in the developed world, the phenomenon has been largely overlooked in the developing world, despite the fact that the rate of ageing in developing countries far outstrips that of developed countries. This global trend towards an increasingly older society has significant implications for healthcare. This article aims to review the definitions of ageing, its epidemiological characteristics and physiological changes associated with ageing. Methods A narrative review of the literature was undertaken using Medline, CINAHL and the Cochrane Database, supplemented by manual searches of the literature, and guided by the reference lists of relevant papers identified in the electronic search. No restriction was placed on the type of paper to be included in the study. Results The initial electronic search of the three databases included 239 papers, of which 60 were found to be relevant and included in this review. These articles discussed the epidemiology and definition of ageing, the physiology of ageing and its impact on health and illness, and the implications for health services. The overall findings of the studies implicate the clear differences in the physiology of older people, which do create specific challenges for health service provision. Conclusion Population ageing is a significant global phenomenon, affecting both developed and developing regions of the world. More work is needed, particularly in the developing world, to better understand the impact of ageing on our population.

Undertriage of major trauma patients at a university hospital: a retrospective cohort study

Background

Studies show increased mortality among severely injured patients not met by trauma team. Proper triage is important to ensure that all severely injured patients receive vital trauma care. In 2017 a new national trauma plan was implemented in Norway, which recommended the use of a modified version of “Guidelines for Field Triage of Injured Patients” to identify severely injured patients.

Methods

A retrospective study of 30,444 patients admitted to Haukeland University Hospital in 2013, with ICD-10 injury codes upon discharge. The exclusion criteria were department affiliation considered irrelevant when identifying trauma, patients with injuries that resulted in Injury Severity Score < 15, patients that did receive trauma team, and patients admitted > 24 h after time of injury. Information from patient records of every severely injured patient admitted in 2013 was obtained in order to investigate the sensitivity of the new guidelines.

Results

Trauma team activation was performed in 369 admissions and 85 patients were identified as major trauma. Ten severely injured patients did not receive trauma team resuscitation, resulting in an undertriage of 10.5%. Nine out of ten patients were men, median age 54 years. Five patients were 60 years or older. All of the undertriaged patients experienced fall from low height (< 4 m). Traumatic brain injury was seen in six patients. Six patients had a Glasgow Coma Scale score ≤ 13. The new trauma activation guidelines had a sensitivity of 95.0% in our 2013 trauma population. The degree of undertriage could have been reduced to 4.0% had the guidelines been implemented and correctly applied.

Conclusions

The rate of undertriage at Haukeland University Hospital in 2013 was above the recommendations of less than 5%. Use of the new trauma guidelines showed increased triage precision in the present trauma population.

Direct oral anticoagulants do not worsen traumatic brain injury after low-level falls in the elderly

BACKGROUND

Falls are now the leading cause of trauma and represent the most common type of trauma in the elderly. The use of anticoagulants is increasing in older patients, but there are little data on outcomes after traumatic brain injury while anticoagulated with direct oral anticoagulants compared with warfarin. We hypothesized that anticoagulated patients would have a greater mortality and complications than nonanticoagulated patients, and patients on direct oral anticoagulants would have more fatal outcomes after low-level falls because of lack of reversal agents.

METHODS

Patients 65 years or older admitted to level 1-3 trauma centers with 24-hour neurosurgical care were identified through the administrative database of 19 Trinity Health hospitals. Patients with International Classification of Diseases, Ninth Revision, codes consistent with low-level fall and traumatic brain injury from May 2013 through October 2015 were included. Preadmission warfarin or direct oral anticoagulant use was extracted from admission reconciliation of medications in the database.

RESULTS

A total of 700 patients met inclusion criteria with 177 on anticoagulants before admission. Anticoagulated patients had more cardiac (P < .001), pulmonary (P < .001), and clotting (P < .02) comorbidities. Warfarin patients had the greatest neurosurgical intervention rate at 18% compared with direct oral anticoagulants (2.8%, P < .02) or nonanticoagulation (11%, P < .02). No difference was identified in overall mortality and mortality after neurosurgical intervention between the nonanticoagulated, warfarin, or direct oral anticoagulant groups. Warfarin patients received more plasma (P < .001) and red cell transfusions (P = .035) with greater intensive care unit stays (P < .001) compared with direct oral anticoagulant or nonanticoagulated patients. With logistic regression, only advancing age (P < .05) and a lesser Glasgow Coma Scale score (P < .01) were associated with greater mortality.

CONCLUSION

Older direct oral anticoagulant patients with traumatic brain injury after low-level fall did not have increased morbidity or mortality compared with those treated with warfarin or who were not treated with anticoagulants. Concerns over the use of direct oral anticoagulant agents in this population may be overstated and deserve more scrutiny.

Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population

BACKGROUND

Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury.

OBJECTIVES

The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients.

METHODS

A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests.

RESULTS

More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle.

CONCLUSION

Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.