|Year : 2018 | Volume
| Issue : 3 | Page : 95-100
Time-related outcome in patients with traumatic brain injury admitted to neurosurgical care in a tertiary centre
David O Udoh, Oduwa O Aghahowa, Emmanuel C Obeta
Division of Neurological Surgery, Department of Surgery, University of Benin Teaching Hospital, P.M.B.1111, Benin City, Edo State, Nigeria
|Date of Web Publication||27-Sep-2019|
Dr. David O Udoh
Division of Neurological Surgery, Department of Surgery, University of Benin Teaching Hospital, PMB 1111, Benin City, Edo State 300283
Source of Support: None, Conflict of Interest: None
Background: The decreased mortality and improved outcomes associated with constantly metamorphosing trauma systems is particularly relevant in traumatic brain injuries (TBI) in which the duration from injury to neurosurgical intervention is an important determinant of outcome. With defective organization of trauma systems comes reduced access to quick and effective neurosurgical care which impact inexorably on outcomes. Using a time honoured scale, we took a critical look at TBI outcomes on the background of time of arrival to specialist neurosurgical care. We sought the association of various demographic factors with outcomes of traumatic brain injury in patients who arrived at our neurosurgical facility at various time intervals following injury.
Patients and Method: A retrospective study of 385 of 483 patients with TBI admitted to neurosurgical care from 2009 to 2011 at our teaching hospital. Data was obtained from a computerized log of all TBI patients, case files and intensive care unit records, and analyzed using STATA software version 12.
Results: Seventy percent (70%) of the patients arrived within 24 hours, especially between 12 to 24 hours i.e. 27.01%. However, only 5.71%, comprising those with mean age 22.59(±12.31) years arrived within the first hour Young patients arrived significantly earlier to specialized care than those ≥40 years. Regardless of injury duration, most patients had severe TBI (p value 0.012). Most, 77.69%, outcomes were favourable (Glasgow outcome scores, GOS, 4 and 5); 16.54% died (GOS 1). The middle strata of GOS 2 and 3 were almost absent. Injury duration did not influence duration of intensive care or overall hospital stay. Mortality was highest after 24hours.
Conclusion: There is a dearth, in this region, of any auditing of the relationship between time of arrival of patients with TBI to specialized care, recovery characteristics (post-neurosurgical care) and eventual outcome using the Glasgow outcome scale.
Keywords: Glasgow outcome scale, mortality, outcome, time interval, traumatic brain injuryDecreased mortality, Glasgow outcome scale, improved outcomes, interval from injury to neurosurgical care, traumatic brain injury
|How to cite this article:|
Udoh DO, Aghahowa OO, Obeta EC. Time-related outcome in patients with traumatic brain injury admitted to neurosurgical care in a tertiary centre. Arch Int Surg 2018;8:95-100
|How to cite this URL:|
Udoh DO, Aghahowa OO, Obeta EC. Time-related outcome in patients with traumatic brain injury admitted to neurosurgical care in a tertiary centre. Arch Int Surg [serial online] 2018 [cited 2019 Oct 19];8:95-100. Available from: http://www.archintsurg.org/text.asp?2018/8/3/95/268123
| Introduction|| |
Traumatic brain injury (TBI) is a significant cause of death in young adults, contributing largely to the burden of morbidity arising from accidents and expenditure on health care, particularly in those living with disabilities., Due to insufficient accurate data, the global incidence of TBI is underestimated resulting from substandard records, poor reporting from countries with inadequately organized trauma system, and notable discrepancies in defining TBI between health care systems of various countries. The other reasons are absence of any data on patients with mild TBI, who never sought medical care and who died before reaching hospital (especially in rural areas). The Glasgow coma scale (GCS) issued at accident scenes and emergency rooms, and Glasgow outcome score (GOS) issued at discharge; are neurological scales widely utilized in the management of patients with TBI. The GCS assesses three criteria including eye-opening response (maximum score of four), verbal response (maximum score of five), and motor response (maximum score of six); summed-up to a total minimum score of three in patients in coma and unresponsive patients and a maximum score of 15 for patients with full alertness.,
The GOS assesses the level of disability or recovery after TBI with scores ranging from 1-5; for death, persistent vegetative state, severe disability, moderate disability, and good recovery, respectively.
In low-income countries, trauma systems are less organized; coupled with lean access to neurosurgical care and lack of central electronic database of traumatic brain injuries, and accounts for the dearth of verifiable evidence on the burden of TBI in these regions. In addition, socio-economic inequalities, dissimilarity in cultural practices and disease perception, as well as, slowly developing healthcare systems, contribute to eventual outcome in patients with TBI.
Some descriptive studies from this region have evaluated the common mechanisms of injury and population at risk of TBI, using data from accident and emergency departments of some tertiary hospitals, including pediatric populations, but none documented the clinical characteristics and outcome (using GOS) of patients after neurosurgical intervention.,,,,,,,,
Hence, this study sought the outcomes in patients with TBI arriving at various time intervals (or injury duration) in a tertiary center with specialist neurosurgical care.
| Patients and Methods|| |
This was a retrospective study of patients with traumatic brain injury admitted into our Neurosurgical service from September 2006 till August 2012.
The Neurosurgical unit of University of Benin Teaching Hospital was established in June 2006. The U.B.T.H, Benin City is situated at the confluence of several interstate highways which provide access to the Northern, Southern, Eastern and Western parts of Nigeria. Since inception, it has served as a population of approximately 15 million people in at least eight states.
All patients were admitted through the Accidents and Emergency department arriving from the scene of the accident or through referrals from primary and secondary health centers. Resuscitation, on arrival, was instituted by the emergency unit and trauma team followed by the neurosurgical referral. Admission protocol included detailed neurosurgical evaluation as well as radiological and laboratory investigations. The radiological assessment included cranial computerized tomographic (CT) scan and cervical spine radiographs to determine the type and extent of brain injury and to rule out cervical spine injury, respectively. Relevant laboratory investigations included complete blood counts; serum electrolyte; urea, creatinine, and blood sugar estimation; which were potential indicators for the presence of risk of secondary brain injury.
The patients who had severe traumatic brain injury (i.e. Glasgow coma score (GCS) 3 to 8) and/or acute respiratory insufficiency were admitted into the intensive care unit (ICU). Those who had mild (GCS 13 to 15) and moderate (GCS 9 to 12) TBI were admitted to the neurosurgical ward.
Around 98 patients, for whom complete data could not be obtained, were excluded from the study.
Data were analyzed using STATA software package (version 12). Categorical variables were analyzed using Chi-square test while continuous variables (age, duration of ICU care and length of hospital stay), in mean ± standard deviation, were compared using one-way analysis of variance (ANOVA).
| Results|| |
Out of a total of 483 patients with TBI, 385 patients had complete data.
Majority of the patients (69.6%) arrived within 24 hours from the time of injury while others arrived >1 to 7 days (19.74%) and >7 days (10.65%) after injury [Table 1], [Figure 1]. Around 27.01% patients arrived within the time interval of 12 to 24 hours after injury while only 5.71% arrived within the first six hours [Table 1], [Figure 1].
|Table 1: Distribution of six time categories of arrival at emergency room by patient characteristics and outcome|
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|Figure 1: Distribution of patients with traumatic brain injury by time interval to neurosurgical care|
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Age of patients
The young patients (22.59 ± 12.31 to 32.46 ± 17.35 years) arrived at the specialist care significantly earlier than the older patients. (P-value 0.0006). Notably, those with a mean age 22.59 (±12.31) years arrived within the first hour of injury while those with a mean age of 40.29 (±21.48) years arrived after 7 days (P-value 0.0006) [Table 1].
In the study population, there were more males (80.78%) in ratio of 4:1 for all the patients who arrived at various time intervals. There was no statistical significance with respect to gender and duration of injury before arrival. (P-value 0.106) [Table 1].
Although 77.02% of injuries were due to road traffic accidents and 11.5% were due to civil violence, there was no significant relationship between etiology and time before arrival at the specialist care [Table 1].
Severity of injury and Glasgow outcome score (GOS)
Irrespective of duration of injury before arrival, most patients (40.67%) had severe TBI (P-value 0.012) while others had mild (35.49%) and moderate (23.83%) TBI [Table 1].
GOS showed that almost all the patients either had favorable outcomes (77.69%) with GOS 4 and 5 or died (16.54%). The middle strata of outcome scores (GOS 2 and 3) were almost absent for all time intervals following injury (P-value < 0.001) [Table 1].
Mortality was highest in patients arriving between 24 hours and one week of injury.
Duration of intensive care and length of hospital stay
The duration of injury before arrival did not significantly influence the duration of intensive care unit (ICU) care and overall period of hospital stay (P-values 0.8834 and 0.0928, respectively) [Table 1].
| Discussion|| |
The advantages of expeditious neurosurgical care of TBI are well documented and have influenced the development of practical clinical guidelines in the management of patients with TBI, as well as, the evolution of sturdy trauma systems in more developed countries.,, Seelig et al. observed that the most relevant predictor of survival was the time to neurosurgical intervention in patients with traumatic acute subdural hematoma, with the outcome being better in patients who had neurosurgical intervention within 4 hours from the time of injury.
Both, crude and adjusted odd ratios revealed that, lower post-resuscitation GCS, presence of post-resuscitation pupil abnormality, hypotension, and increasing age were significant predictors for ICU mortality., No significant difference was found in demographic profile, mechanism of injury, type of injuries or severity, duration of ICU stay and mechanical ventilation among the patients admitted during weekdays, weeknights or weekends. Moreover, this stresses the importance of a specialized neurosurgical intensive care unit (NICU), with adequate staffing and requisite diagnostic and therapeutic modalities.
The presence of a trauma system has been associated with decreased mortality and improved outcomes, by potentially speeding up the transfer of trauma patients to major trauma centers.[,,, This is particularly relevant in patients with a head injury, where time to neurosurgical intervention from the time of significant TBI is important in determining the outcome. North American guidelines recommend a maximum of four hours from the time of injury to neurosurgical attention for patients requiring the evacuation of an intracranial hematoma.,,,
Similarly, Kejriwal and Civil. also showed that patients who were transferred from another hospital arrived well outside the recommended guidelines or took significantly longer than four hours to arrive at the neurosurgical care while patients transported from the scene of injury arrived and underwent surgery within a mean of 3.50 hours. However, there was no difference in mortality rate, length of ICU stay and length of hospital stay between patients admitted directly and patients transferred from other hospitals; mainly because expedite resuscitation and stabilization, urgent computed tomography brain scan, and electronic review by a neurosurgeon and intensivists were made possible. On contrary, in our setting patients are received from facilities where a little resuscitation is possible.
Due to the heterogeneity of patient presentations; practice variations and the potential for secondary brain injury, the importance of early neurosurgical intervention on survival remains controversial, however studies show that the odds for in-hospital death are substantially less with early neurosurgical intervention.
Studies of trauma systems have identified TBI as a frequent cause of death or disability and survival of the brain injured trauma patient increased with trauma system development and timely transfer to a Level 1 trauma center.,,, The deterioration associated with delay in neurosurgical intervention was linked with secondary brain injuries resulting from swelling and compression of brain tissue, hypotension (systolic blood pressure <90 mmHg), and hypoxia (blood oxygen saturation <90%).
In view of these findings, the outcome of patients with TBI in any trauma is highly influenced by early identification, triage and monitoring of patients, and differences in practice variations of neurosurgical interventions. For ensuring best practices, different trauma systems have adopted severity in classification scores to facilitate early triage of patients from the scene of injury to Level 1 trauma centers. In addition, disability at the discharge of patients is also assessed while planning for the return of survival in society.
The guidelines for the management of patients with TBI are largely based upon the ability to improve physiological variables such as intracranial pressure (ICP) or cerebral perfusion pressure (CPP) and upon the known prognostic measure of these variables.,,,
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ghajar J. Traumatic brain injury. Lancet 2000;356:923-9.
Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol 2008;7:728-41.
Roozenbeek B, Maas AI, Menon DK. Changing patterns in the epidemiology of traumatic brain injury. Nat Rev Neurol 2013;9:231-6.
Teasdale G, Jennett B (Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.
Jennett B, Bond M. Assessment of Outcome after Severe Brain Damage. A Practical Scale. Lancet 1975;305:480-4.
Marmort M. Social determinants of health inequalities. Lancet 2005;365:1099-104.
Adogu POU, Egenti NB, Ubajaka CF, Anakwue JC, Ugezu AI. Epidemiological pattern and outcome of head injuries during festive and non-festive periods in a tertiary hospital, Nnewi, Nigeria. Int J Res Med Sci 2015;3:2718-24.
Oyedele EA, Andy E, Solomon GM, Rifkatu L, Nanbur S. The prevalence of traumatic head injury seen in a tertiary health facility in North-Central Nigeria. Int J Public Health Res 2015;3:127-9.
Adoga AA, Ozoilo KN. The epidemiology and type of injuries seen at the accident and emergency unit of a Nigerian referral center. J Emerg Trauma Shock 2014;7:77-82.
] [Full text]
Emejulu JKC, Isiguzo CM, Agbasoga CE, Ogbuagu CN. Traumatic brain injury in the accident and emergency department of a tertiary hospital in Nigeria. East Central J Surg 2010;15:28-38.
Yusuf AS, Odebode TO, Adeniran JO, Salaudeen AG, Adeleke NA, Alimi MF. Pattern and outcome of motorcyclists head injury in Ilorin, Nigeria. Niger J Basic Clin Sci 2014;11:80-4. [Full text]
Nnadi MO, Bankole OB, Fente BG. Epidemiology and treatment outcome of head injury in children: A prospective study. J Pediatr Neurosci 2014;9:237-41.
] [Full text]
Udoh DO, Adeyemo AA. Traumatic brain injuries in children: A hospital-based study in Nigeria. Afr J Paed Surg ;10:154-9.
Udoh DO, Nwajei C, Ogbomo OR. Acute traumatic brain injuries: Epidemiology, outcomes and prognostic criteria. Nigerian J Surg Sci 2009;19:48-53.
Udoh DO, Obeta EC. Management of traumatic brain injuries in Benin City, Nigeria: Epidemiology, outcomes and prognostic criteria. J Med Biomed Res 2011;10:67-76.
Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Cho SC. Traumatic acute subdural haematoma: Major mortality reduction in comatose patients treated within four hours. N Engl J Med 1981;304:1511-8.
Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: Effect of delayed treatment. Br Med J 1979;1:1240-2.
Kejriwal R, Civil I. Time to definitive care for patients with moderate and severe traumatic brain injury-Does a trauma system matter? N Z Med J 2009;122:40-6.
Lee KK, Ng I, Ang BT. Outcome of severe head injured patients admitted to intensive care during weekday shifts compared to nights and weekends. Ann Acad Med Singapore 2008;37:390-6.
Schreiber MA, Aoki N, Scott BG, Beck Jr. Determinants of mortality in patients with severe blunt head injury. Arch Surg 2002;137:285-90.
Harrington DT, Conolly M, Biffl WL, Majercik SD, Cioffi WG. Transfer times to definitive care facilities are too long: A consequence of immature trauma system. Ann Surg 2005;241:961-6.
Mullins RJ, Mann NC, Hedge JR, Worrall W, Jurkovich GJ. Preferential benefit of implementation of a statewide trauma system in one of two adajacent states. J Trauma 1998;44:609-17.
Scottish Intercollegiate Guideline Network Guideline Development Group. Early management of patients with head injury. A national clinical guideline. Scottish intercollegiate guideines Network 2000 (online). Available from: https://www.sign.ac.uk/assets/sign110.pdf
. [Last accessed on 2019 Feb 21].
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors, Student Course Manual. 6th
ed. Chicago: American College of Surgeons; 1997.
Gabriel EJ, Ghajar J, Jagoda A, Pons PT, Scalea T, Walters BC; Brain Trauma Foundation. Guidelines for prehospital management of traumatic brain injury. J Neurotrauma 2002;19:111-74.
Hedges JR, Newgard CD, Veum-Stone J, Selden NR, Adams AL, Diggs BS, et al
. Early neurosurgical procedures enhance survival in blunt head injury: Propensity score analysis. J Emer Med 2009;37:115-23.
Mullins RJ, Veum-Stone J, Hedges JR, Zimmer-Gembeck MJ, Mann NC, Southard PA, et al
. Influence of a state-wide trauma system on location of hospitalization and outcome of injured patients. J Trauma 1996;40:536-46.
Pasquale MD, Peitzman AB, Bednarski J, Wasser TE. Outcome analysis of Pennsylvania trauma centres: Factors predictive of non survival in seriously injured patients. J Trauma 2000;50:465-74.
McConnell KJ, Newgard CD, Hedges JR, Arthur M, Mullins RJ. Mortality benefit of transfer to level 1 vs level 2 trauma centres for head injured patients: Analysis using instrumental variables. Health Serv Res 2005;40:435-57.
Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al
. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-22.
Bullock R, Chesnut RM, Clifton G et al
. Guidelines for the management of severe head injury. Brain Trauma Foundation. Eur J Emerg Med 1996 Jun;3:109-27.
Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, et al
. American Association For Surgery of Trauma; Child Neurology Society; International Society for Paediatric Neurosurgery; International Trauma Anaesthesia and Critical Care Societies; Society of Critical Care Medicine; World Federation of Paediatrics Intensive and Critical Care Societies. Guidelines for the acute management of severe traumatic brain injury in infants, children and adolescents. Chapter 5. Indication for intracranial pressure monitoring in paediatric patients with severe traumatic brain injury. Paediatric Crit Care Med 2003;4 (3 Suppl):S19-24.
Adelson PD, Bratton SL Carney NA, Chesnut RM, du Coudray HE, Goldstein B, et al
. American Association For Surgery of Trauma; Child Neurology Society; International Society for Paediatric Neurosurgery; International Trauma Anaesthesia and Critical Care Societies; Society of Critical Care Medicine; World Federation of Paediatrics Intensive and Critical Care Societies. Guidelines for the acute management of severe traumatic brain injury in infants, children and adolescents. Chapter 17. Critical pathway for the treatment of established intracranial hypertension in paediatric traumatic brain injury. Paediatr Crit Care Med 2003;4 (3 Suppl):S65-7.
Adelson PD, Bratton SL Carney NA, Chesnut RM, du Coudray HE, Goldstein B, et al
. American Association For Surgery of Trauma; Child Neurology Society; International Society for Paediatric Neurosurgery; International Trauma Anaesthesia and Critical Care Societies; Society of Critical Care Medicine; World Federation of Paediatrics Intensive and Critical Care Societies. Guidelines for the acute management of severe traumatic brain injury in infants, children and adolescents. Chapter 15. Surgical treatment of paediatric intracranial hypertension. Paediatr Crit Med 2003;4 (3 Suppl): S56-9.