A. T. Abid1,2, A. A. Fokin1,2, J. Wycech Knight1,3, H. M. Jackson1,5, I. Puente1,2,3,4 1Delray Medical Center, Trauma Services, DELRAY BEACH, FL, USA 2Florida Atlantic University, Charles E Schmidt College Of Medicine, Boca Raton, FL, USA 3Broward Health Medical Center, Trauma Services, Fort Lauderdale, FL, USA 4Florida International University, Herbert Wertheim College Of Medicine, Miami, FL, USA 5Larkin Community Hospital, Miami, FL, USA
Introduction: Among the inter-facility transfers to Trauma Center (TC), traumatic brain injury (TBI) patients are the most common. Studies have shown that among all transfers, repeat computed tomography (CT) is the most frequent in patients with head injuries. Our goal was to characterize TBI patients transferred to an urban level 1 TC from Acute Care Facility (ACF) who required immediate repeat head CT and to find predictors for emergent repeat CT.
Methods: This IRB approved study included 1017 TBI patients who were transferred from ACF to TC between 2016 and 2019 with CT available for review and who received a repeat head CT at TC. Analyzed variables included: age, sex, comorbidities, Injury Severity Score (ISS), Abbreviated Injury Score (AIS) head, Glasgow Coma Scale (GCS), pre-injury anticoagulation/antiplatelet (ACAP) therapy and reversal therapy, head CT timing, brain surgery rates, transfer time, intensive care unit (ICU) stay and mortality. Multivariable regression was used to determine predictors for emergent repeat CT.
Results: The distribution of CT time after TC admission showed that 82 (8.1%) patients received a repeat head CT within one hour of admission to TC (emergent), 141 (13.9%) within two hours, 169 (16.6%) within three hours, and 277 (27.2%) within the first six hours. The 82 patients who had the emergent repeat CT within the first hour of TC admission compared to the rest 935 patients who had the CT done later during the hospital stay, had significantly higher ISS (16.5 vs 14.0, p=0.004), lower GCS (12.5 vs 14.3, p<0.001), higher AIS head (3.7 vs 3.4, p=0.01), required more brain surgeries (18.3% vs 9.9%, p=0.02), stayed in ICU longer (4.2 vs 2.9 days, p=0.03) and had higher mortality (26.8% vs 7.4%, p<0.001). Subdural hematoma was present in 43.9% of the 82 patients, subarachnoid hemorrhage in 19.5% and both in 23.5%. Mean transfer time was similar between two groups (3.6 vs 3.7 hours, p=0.7), and was evenly divided between the time from ACF admission to TC consultation and the transportation time from ACF to TC. Age (69.2 vs 72.3 years), pre-injury ACAP use (37.8% vs 45.0%), or reversal therapy (18.3% vs 20.1%) did not affect the repeat CT timing (all p>0.1). The lower the GCS the more often emergent CTs were performed (Figure). Multivariable analysis showed GCS as a statistically significant (p<0.001) predictor of an emergent repeat CT at the TC. The Receiver Operator Characteristics area under the curve showed threshold value at GCS<9.
Conclusion: Emergent repeat head CT within 1 hour of admission was done in 8.1 % of TBI patients transferred to TC. These patients required brain surgery significantly more often and had a higher mortality. A strong predictor of an urgent repeat CT is a GCS<9.
