B. Davis3, M. Darya1, 2, R. Stalder1, 2, J. W. Knight1, 3, J. Lozada3, 4, A. A. Fokin1, 2, I. Puente1, 2, 3, 4 1Delray Medical Center, Trauma And Critical Care Services, Delray Beach, FL, USA 2Florida Atlantic University, Charles E. Schmidt College Of Medicine, Department Of Surgery, Boca Raton, FL, USA 3Broward Health Medical Center, Trauma And Critical Care Services, Fort Lauderdale, FL, USA 4Florida International University, Herbert Wertheim College Of Medicine, Department Of Surgery, Miami, FL, USA
Introduction: There is a subset of traumatic brain injury (TBI) patients who experience low energy trauma that results in head surgery. The aim was to analyze these patient’s characteristics and to present management recommendations.
Methods: This IRB approved, retrospective study included 249 patients admitted to two level 1 Trauma Centers with TBI from low energy trauma who had at least one emergency head surgery (craniotomy, craniectomy, burr hole). Low energy trauma was defined as a ground-level fall. Two groups were compared. Group 1, had 157 patients who had only one surgery. Group 2, had 92 patients: 32 (35%) who had a 2nd head surgery and 60 who had indications but did not get the intervention due to advanced directives or excessive bleeding. Analyzed variables included: age, gender, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Abbreviated Injury Scale for Head (AISH), Marshall score, American Society of Anesthesiologists (ASA) score, CT findings and timing, neurological examination dynamic, mechanical ventilation requirements, complications, intensive care unit and hospital lengths of stay (ICULOS, HLOS).
Results: Patients in two groups were of similar age (68 vs 72), majority were male (62% in both), and prevalence of geriatric patients (≥65 y.o.) was comparable (64 vs 71%), all p>0.1. Group 1 compared to Group 2 had significantly higher GCS (13 vs 10), lower ISS (23 vs 26), AISH (4.6 vs 4.9), Marshall score (3 vs 4), and ASA (3 vs 4) at admission, all p<0.001 [Figure 1]. The predominant surgery type in both groups was a craniotomy, but significantly more burr holes were done in Group 1 than Group 2 (13% vs 1%, p=0.001). Mean time to first CT after first surgery was 5 hours in Group 1 and 4 hours in Group 2 (p=0.09). Negative changes on postoperative CT within 24 hours of first surgery were significantly more common in Group 2 than Group 1 (67% vs 26%), and so was negative postoperative neurological dynamic (49% vs 19%), both p<0.001. Significantly more patients in Group 2 than Group 1 required mechanical ventilation (77% vs 33%), ICU admission (100% vs 95%), and had more complications (57% vs 30%), all p<0.001. ICULOS and HLOS were not different between groups. Multivariable and Receiver Operator Characteristics analyses showed GCS, Marshall and ASA Scores as significant independent predictors for 2nd surgery with threshold values of 12; 3; and 4 respectively.
Conclusion: Low energy head trauma is common, especially in the growing geriatric population. GCS, Marshall, and ASA scores were significant predictors of second head surgery. We recommend that low energy TBI patients with GCS <12, Marshall Score ≥3, and ASA Score ≥4 undergo mandatory postoperative CT within 4 hours after surgery.
