Comparison of Selected Outcomes for JPS Traumatic Brain Injury Resulting from Fall Patients with Intracranial Hemorrhage (<1 centimeter) Managed by JPS trauma Surgeon or Neurosurgeon
T. Littleton*, T. Rives, P. Cho, G. Cravens, R. Gandhi
John Peter Smith Health Network, Fort Worth, TX, 76104
* Corresponding Author: John Peter Smith Health Network, email: email@example.com
Falls are the second leading cause of trauma activations and often result in traumatic brain injury (TBI), a leading cause of morbidity and mortality. Guidelines for the diagnosis and management of TBI vary, but the literature is scant regarding the management of intracranial hemorrhages (ICH) <1 centimeter (cm). Current protocol at a Level I trauma center allows trauma surgeons to manage ICH <1 cm, but no evidence exists regarding the frequency of ICH management by trauma surgeons versus neurosurgeons or differences in patient outcomes. We hypothesize no difference in outcomes for patients managed by a trauma surgeon rather than a neurosurgeon. This is a retrospective chart review of data collected from the trauma registry maintained at JPS, which includes data from 1994 to 2011. Patients who presented to JPS between 2006 and 2011 with fall as the primary mechanism of injury and a TBI resulting in an ICH <1 cm were included. Patients sustaining penetrating wounds and patients transferred to other acute care facilities were excluded from analysis. Between 2006 and 2011, 343 patients presented with a TBI resulting from a fall. Patients ranged in age from 13 to 100 years, with a mean age of 58.05 (SD = 21.48). Sixty-six percent were male (n = 225), 70% were white (n = 239), 88% (n = 302) received a neurosurgeon consult, and 13% (n = 44) died. No significant differences exist between patients’ condition on discharge, χ2(2) = 1.28, ns, where patients were discharged to, χ2(4) = 1.47, ns, or length of stay, F(1,341) = 2.46, ns, between neurosurgeon management and trauma surgeon management. Although not all TBIs are a result of falls, this homogenous sample of patients enables us to draw conclusions regarding patient outcomes based on management services in the absence of comorbidities. With the expected increase of the aging population, we predict an increase in the number of trauma activations resulting from falls. Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons for ICH <1 cm.
Keywords: Traumatic brain injury, management, falls, intracranial hemorrhage
Traumatic brain injury (TBI) is an important public health concern and a leading cause of morbidity and mortality. Approximately 1.5 million emergency room visits in America are due to TBI. Although TBI-associated mortality rates have declined, an estimated 5.3 million Americans have TBI-related disabilities. The majority of patients with TBI are treated and released in the emergency department (ED), while approximately 235,000 (15.67%) patients with TBI are hospitalized.1-2 Public awareness of TBI is limited and the psychological effect of trauma appears to have a greater effect on patients who sustain a TBI than patients with multiple injuries without a TBI.3
Due in part to its prevalence, controversy surrounds the most appropriate management of TBI in trauma patients.4 In terms of severe TBI, a pair of articles were published regarding the management of patients in a neurocritical care unit versus nonspecialist centers. Researchers in favor of managing all patients in a neurocritical care unit argue that decreased mortality and improved outcomes are associated with specialized care, as well as better resource utilization.5-6 In contrast, it has been argued that patients can receive similar benefits from protocol-guided therapy regardless of treatment center specialization.7-8 Standardized treatment for severe TBI can be applied in settings without neurological services, reducing the potential to adversely affect outcome by transferring patients with acute brain injury9 while concurrently reducing the necessity for specialized neurocritical resources except in the most severe instances.10 Guideline-based TBI care has shown to reduce length of stay (LOS), decrease mortality rates, and increase the proportion of positive outcomes.11-12 Trauma center designation has been shown to effect functional outcomes for patients suffering from severe TBI. Patients with severe TBI are more likely to achieve functional independence (FI) at discharge when treated at an American College of Surgeons (ACS) verified Level I center than those treated at a center with Level II designation. However, for patients sustaining moderate TBI, no differences in achieving FI at discharge were seen when comparing treatment centers.13
“Mild” traumatic brain injuries (MTBI) constitute the majority of traumatic brain injuries that occur annually (70 – 85%).1,14 Diagnosis and management of MTBI is an important area of concern, and studies have shown no single diagnostic tool can adequately diagnose MTBI.4,15 Patients sustaining MTBI frequently recover without surgical intervention,16-17 but symptoms such as headache,18-19 attention and memory impairments, irritability and fatigue19 may persist for months,20-24 or up to a year post-injury,15,25 and quality of life may be significantly lower up to 10 years later.19
In order to determine the presence of intracranial hemorrhage (ICH), CT scan of the brain is standard of care for patients with mild TBI and the presence of at least one of the following: loss of consciousness, post-traumatic amnesia, confusion or impaired alertness, or evidence of skull fracture.26 Consequences associated with MTBI have been shown to be more severe in patients with intracranial injuries (ICI), but controversies exist surrounding the long term impact. Patients with ICI may be more likely to develop anosmia up to 10 years post-injury, but have shown improved long-term outcome over patients without ICI.19 However, headache and memory deficits were more frequently reported by patients suffering ICI than patients without ICI one year after injury.27 The presence of intracranial lesions does not always constitute neurosurgical intervention, and research suggests patients with a Glasgow Coma Score of 15 can be safely managed without neurosurgical consultation unless significant deterioration occurs.16,28-29
Looking specifically at intracranial hemorrhage (ICH), a specific type of ICI, the literature regarding the effect of physician specialty on outcomes is conflicting. Research regarding admitting physician specialty on patient outcomes for non-traumatic intracerebral hemorrhage found that physician affected hospital length of stay (LOS), but not in-hospital mortality or disability at discharge.30 Similarly, when adjusted for age and comorbidities, patients admitted to neurology services with ischemic stroke have similar outcomes to patients admitted to other services.31 However, other research has shown neurologist care significantly predicted improved outcome32 and lower rates of mortality at discharge.33 The effect of specialist care on LOS is conflicting, with some research suggesting no effect of specialist care,32 neurosurgical specialty associated with decreased LOS,30 and others finding greater LOS for patients in neurological intensive care units.33 No clear explanation exists for the inconsistency in results regarding length of stay. The need for neurosurgical intervention in an emergency is rare,34 and literature suggests patients with intracranial bleeds can be safely managed in trauma centers without neurosurgical services, except in severe circumstances.35
Falls are second only to motor vehicle collisions (MVC) as the leading cause of trauma activations, but surpass MVCs as the leading cause of TBI. While falls do not result in the greatest number of TBI-related deaths and hospitalizations, they constitute 28% ED visits, particularly for children under 4 years (39%) and adults 75 years and older (52%).2,36-37 Older adults who sustain a fall related head injury are susceptible to ICH, particularly adults on anticoagulant medications.38 Additionally, half of fall fatalities and associated costs are TBI related.39-40
Current protocol at our hospital allows trauma surgeons to manage ICH equal to or less than 1 cm, but no evidence exists regarding the frequency of ICH management by trauma surgeons or differences in patient outcomes. We hypothesize no difference in patient outcomes when TBI resulting in an intracranial hemorrhage ≤1 cm is managed by a trauma surgeon rather than a neurosurgeon at our Level I Trauma Center.
We retrospectively reviewed data collected from the trauma registry maintained at an urban Level I Trauma Center, which includes data from 1994 to 2011. Protocol allowing trauma surgeons to manage patients with TBI resulting in an ICH <1 cm was instituted in January 2008. Patients who presented from 2006 through 2010 with fall as the primary mechanism of injury with no TBI or a TBI resulting in an ICH <1 cm were included. Demographic and clinical data including age, gender, race, services consulted, Glasgow Coma Score (GCS) on arrival, and complications were abstracted. In addition, all neurological injuries and procedures were identified using the International Classification for Diseases – 9th Edition medical procedure codes 850.0 – 850.9. Injury Severity Score (ISS) was assessed. The primary outcomes were condition at discharge, where patients were discharged to, Glasgow Outcome Score (GOS), and length of stay (LOS). Patients with incomplete data, patients sustaining penetrating or burn injuries, or patients transferred to another acute care facility were excluded from analysis. Management by a neurosurgeon was defined by whether or not the attending trauma surgeon requested a neurological consult. This study was approved by our hospital’s Institutional Review Board.
Data analysis was conducted using SPSS version 17. Descriptive statistics were performed to characterize demographic information. Independent t-tests and χ2 tests were used to test for differences between continuous and categorical variables, respectively. Fisher’s exact was used when expected values from categorical analysis did not reach 5. Kolmogorov-Smirnov tests were used to test for normality. Mann-Whitney U tests were performed for non-normally distributed data with medians reported for comparison. A p value of ≤ 0.05 was considered statistically significant.
The following results are for patients who presented to JPS, between 2006 and 2011, with a fall as the primary mechanism of injury and a TBI resulting in an ICH <1 cm.
Table 1. Patient Demographics.
n = 343
Age (years) 58.05 (± 21.48)
Male (%) 225 (65.6)
Caucasian (%) 239 (69.7)
African American (%) 24 (7)
Hispanic (%) 68 (19.8)
Other (%) 12 (3.5)
Neurosurgeon Consultation (%) 302 (88)
Condition on Discharge
Good (%) 19 (5.5)
Moderate Disability (%) 231 (67.3)
Severe Disability (%) 49 (14.3)
Dead (%) 44 (12.8)
Home, No Assistance (%) 181 (52.8)
Home, Prof. Assistance (%) 19 (5.5)
Nursing/Rehab/Residential Facility (%) 92 (26.8)
In order to determine if patient outcomes differed by management service, we analyzed outcomes for patients managed by a trauma surgeon versus a neurosurgeon. All distributions were significantly different from normal. Of the 323 patients with brain injury, 41 were managed by a trauma surgeon and 282 were managed by a neurosurgeon. There was no significant difference between patients’ condition on discharge, χ2(2) = 1.28, ns, or to where patients were discharged, χ2(4) = 1.47, ns, between neurosurgeon management and trauma surgeon management. Additionally, there was no significant effect of management service on the length of stay, F(1, 341) = 2.46, ns. Table 2 summarizes patient demographics by management service.
Table 2. Patient Demographics by TBI Management Service.
Trauma Surgeon n = 41 Neurosurgeon n = 302
Age (years) 58.05 (± 21.48)
Male (%) 31 (75.6) 194 (64.2)
Caucasian (%) 22 (53.7) 217 (71.9)
African American (%) 7 (17.1) 17 (5.6)
Hispanic (%) 11 (26.8) 57 (18.9)
Other (%) 1 (2.4) 11 (3.6)
Condition on Discharge
Good (%) 8 (19.5) 11 (3.6)
Moderate Disability (%) 24 (58.5) 207 (68.5)
Severe Disability (%) 6 (14.6) 43 (14.2)
Dead (%) 3 (7.3) 41 (13.6)
Home, No Assistance (%) 24 (52.5) 157 (52)
Home, Prof. Assistance (%) 2 (4.9) 17 (5.6)
Nursing/Rehab Facility (%) 11 (26.8) 81 (26.8)
Although not all TBIs are a result of falls, this homogenous sample of patients enabled the researchers of this present study to draw conclusions regarding patient outcomes based on management services in the absence of comorbidities. Although the JPS hospital currently has guidelines in place allowing trauma surgeons to manage TBIs resulting in an ICH <1 cm, the trauma surgeons only manage a small number of these patients even though the outcomes do not differ from the outcomes of the cases managed by neurosurgeons. The researchers of the present study predict an increase in the number of trauma activations resulting from falls. Due to the demand placed on neurosurgeons for more severe brain injuries, the data suggests that patients needing to be managed for ICH <1 cm. could have comparable outcomes whether managed by trauma surgeons, or neurosurgeons. Future studies should investigate the extent to which implementation of new brain injury protocol affects physician practice and patient outcomes; not only for patients directly affected by changes in practice, but also for patients who may receive improved care as a byproduct of the appropriate management of other patients.
1. Centers for Disease Control and Prevention. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta (GA): Department of Health and Human Services (US), CDC, National Center of Injury Prevention and Control; 2003.
2. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.
3. Steel J, Youssef M, Pfeifer R, Ramirez JM, Probst C, Sellei R, Zelle BA, Sittaro NA, Khalifa F, Pape HC. Health-related quality of life in patients with multiple injuries and traumatic brain injury 10+ years post injury. J Trauma. 2010; 69:523-531.
4. Blostein PA, Jones, SJ. Identifications and evaluation of patients with mild traumatic brain injury: Results of a national survey of Level I Trauma Centers. J Trauma. 2003;55:450-453.
5. Mirski MA, Chang CW, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosug Anesthesiol. 2001;13:83-92.
6. Teig M, Smith M. Where should patients with severe traumatic brain injury be managed? All patients should be managed in a neurocritical care unit. J Neurosurg Anesthesiol. 2010;22:357-359.
7. Clayton T, Nelson R, Manara A. Reduction in mortality from severe head injury following introduction of a protocol for intensive care management. Br J Anaesth. 2004;93:761-767.
8. Patel H, Menon D, Tebbs S, et al. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28:547-553.
9. Price SJ, Suttner N, Aspoas AR. Have ATLS and National Transfer Guidelines improved the quality of resuscitation and transfer of head-injured patients? A prospective survey from a Regional Neurosurgical Unit. Injury. 2003;34:834-838.
10. Petsas A, Waldmann C. Where should patients with severe traumatic brain injury be managed? Patients can be safely managed in a nonspecialist center. J Neurosurg Anesthesiol. 2010;22:354-356.
11. Fakhry SM, Trask AL, Waller MA, Watts DD. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma. 2004;56:492-499.
12. Sekula RF, Wilberger JE. The management of traumatic brain injury: The development of guidelines and their influence. Clin Neurosurg. 2005;52:306-310.
13. Brown, JB, Stassen NA, Cheng JD, Sangosanya AT, Bankey PE, Gestring ML. Trauma center designation correlates with function independence after severe but notmoderate traumatic brain injury. J Trauma. 2010;69:263-269.
14. Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury. JAMA. 1999;282:954-957.
15. Dutton RP, Prior K, Cohen R, Wade, C, Sewell J, Fouche Y, Stein D, Aarabi B, Scalea TM. Diagnosing mild traumatic brain injury: Where are we now? J Trauma. 2011;70:554-559.
16. Jeret JS, Mandell M, Anziska B, et al. Clinical predictors of abnormality disclosed by computed tomography after mild head trauma. Neurosurgery. 1993;32:9-16.
17. Miller EC, Derlet RW, Kinser D. Minor head trauma: is computed tomography always necessary? Neurosurgery. 1993;32:9-16.
18. Nampiaparampil DE. Prevalence of chronic pain after traumatic brain injury: a systematic review. JAMA. 2008;300:711-719.
19. Zumstein MA, Moser M, Mottini M, Ott SR, Sadowski-Cron C, Radanov BP, Zimmermann H, Exadaktylos A. Long-term outcomes in patients with mild traumatic brain injury: A prospective observational study. J Trauma. 2010.
20. Bohnen N, Jolles J, Twijnstra A. Neuropsychological deficits in patients with persistent symptoms six months after mild head injury. Neurosurgery. 1992;30:692-696.
21. Chambers J, Cohen SS, Hemminger L, Prall JA, Nichols JS. Mild traumatic brain injuries in low-risk trauma patients. J Trauma. 1996;41:976-980.
22. Cushman JG, Nikhilesh A, Fabian TC, et al. Practice management guidelines for the management of mild traumatic brain injury: the EAST practice management guidelines work group. J Trauma. 2001;51:1016-1026.
23. Hugenholtz H, Stuss DT, Stethem LL, Richard MT. How long does it take to recover from a mild concussion? Neurosurgery. 1988;22:853-858.
24. Van der Naalt J. Prediction of outcomes in mild to moderate head injury: a review. J Clin Exp Neuropsychol. 2001;23:837-851.
25. Alves W, Macciocchi S, Barth J. Postconcussive symptoms after uncomplicated mild head injury. J Head Trauma Rehabil. 1993;8:48-59.
26. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with Minor Head Injury. N Engl J Med. 2000;343:100-105.
27. Sadowski-Cron C, Schneider J, Senn P, Radanov BP, Ballinari P, Zimmermann H. Patients with mild traumatic brain injury: immediate and long-term outcome compared to intra-cranial injuries on CT scan. Brain Inj. 2006;20:1131-1137.
28. Huynh T, Jacobs DG, Dix S, Sing RF, Miles WS, Thomason MH. Utility of neurosurgical consultation for mild traumatic brain injury. The Amer Surg. 2006;72:1162- 1167.
29. Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med. 1997;15:453-457.
30. Bhattacharya P, Shankar L, Manjila S, Chaturvedi S, Madhavan R. Comparison of outcomes of nonsurgical spontaneous intracerebral hemorrhage based on risk factors and physician specialty. J Stroke and Cerebrovasc Dis. 2010;19:340-346.
31. Horner RD, Matchar DB, Divine GW, et al. Relationship between physician specialty and the selection and outcome of ischemic stroke patients. Health Serv Res. 1995;30:275- 287.
32. Goldstein LB, Matchar DB, Hoff-Lindquist J, et al. VA stroke study: Neurologist care is associated with increased testing but improved outcomes. Neurology. 2003;61:792-96.
33. Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med. 2001;29:635-640.
34. Esposito TJ, Reed RL II, Gamelli RL, Luchette FA. Neurosurgical coverage: essential, desired, or irrelevant for good patient care and trauma center status. Ann Surg. 2005;242:364-370.
35. Klein Y, Donchik V, Jaffe D, Simon D, Kessel B, Levy L, Kashtan H, Peleg, K. Management of patients with traumatic intracranial injury in hospitals without neurosurgical service. J Trauma. 2010;69:544-548.
36. Centers for Disease Control and Prevention. Public health and aging: nonfatal fall-related traumatic brain injury among older adults – California, 1996 – 1999. MMWR Morb Mortal Wkly Rep. 2003;53:276-278.
37. Jager TE, Weiss HB, Coben JH, et al. Traumatic brain injuries evaluated in U.S. emergency departments, 1992-1994. Acad Emerg Med. 2000;7:134-140.
38. Karni A, Holtzman R, Bass T, et al. Traumatic head injury in the anticoagulated elderly patient: a lethal combination. Am Surg. 2001;67:1098-1100.
39. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health. 1992;82:1020-1023.
40. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Injury Prev. 2006;12:290-295.