Accepted Manuscript Can Trauma Surgeons Manage Mild Traumatic Brain Injuries? Tiffany L. Overton, MA, MPH Shahid Shafi, Md George F. Cravens, MD Rajesh R. Gandhi, MD, PhD PII:
S0002-9610(14)00179-2
DOI:
10.1016/j.amjsurg.2014.02.012
Reference:
AJS 11155
To appear in:
The American Journal of Surgery
Received Date: 13 September 2013 Revised Date:
29 January 2014
Accepted Date: 11 February 2014
Please cite this article as: Overton TL, Shafi S, Cravens GF, Gandhi RR, Can Trauma Surgeons Manage Mild Traumatic Brain Injuries?, The American Journal of Surgery (2014), doi: 10.1016/ j.amjsurg.2014.02.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 Can Trauma Surgeons Manage Mild Traumatic Brain Injuries?
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Running head: MANAGEMENT OF MILD TBI
Shahid Shafi, MD [email protected] JPS Health Network
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Rajesh R. Gandhi, MD, PhD [email protected]
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George F. Cravens, MD [email protected]
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Corresponding Author: Tiffany L. Overton, MA, MPH [email protected] O: 817-702-5913 F: 817-702-5162 Trauma Services JPS Health Network 1500 S. Main St. Fort Worth, Tx 76104
SC
Authors:
ACCEPTED MANUSCRIPT 2 BACKGROUND Traumatic brain injury (TBI) is an important public health concern and a leading cause of morbidity and mortality.(1) The vast majority of TBI are considered mild (70-85% ),(1, 2) and
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are defined as Glasgow Coma Scale (GCS) score of 13 to 15 and a temporary disruption of brain function after a traumatic injury.(3-6) Controversy surrounds the most appropriate management of mild TBI (MTBI).(7) The American College of Surgeons recommends neurosurgical
SC
evaluation of any patient with a GCS score less than 15 at two hours after injury and patients greater than 65 years of age(4) even though less than 1% of patients with MTBI require
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neurosurgical intervention.(8, 9) This requirement creates a burden on scarce neurosurgical resources, which is likely to become worse with shortage of neurosurgeons and aging of the population.(10) In fact, there is emerging evidence that patients with intracranial bleeds can be safely managed in trauma centers without neurosurgical services, except in the case of moderate
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to severe TBI.(11, 12)
To study this issue, we implemented a protocol of selective neurosurgical consultation in 2008 that enabled trauma surgeons to manage patients with MTBI without neurosurgical
EP
consultations. This study reports our initial experience with management of MTBI by trauma surgeons alone. We hypothesize patients with MTBI managed by trauma surgeons will be the
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same as outcomes for patients managed by neurosurgeons. METHOD
This is a retrospective analysis of patients treated at a major urban level 1 trauma center at a public institution over a period of 7 years (January 2006-June 2012). Patients were monitored before (2006 – 2008) and after (2008-2012) the implementation of the protocol mentioned above. The inclusion criteria consisted of patients with mild TBI defined as an
ACCEPTED MANUSCRIPT 3 intracranial hemorrhage less than or equal to 1 centimeter and a Glasgow Coma Score of 13 or greater at the time of arrival. Exclusion criteria consisted of patients with additional intracranial injuries (i.e. intraparenchymal hemorrhages, diffuse axonal injuries with white matter shearing),
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and patients transferred to another acute care facility or those who left against medical advice. Based on these criteria, 171 patients were included in the study. Patients were divided into two groups: those managed by trauma surgeons alone (n = 51, 30%) and those who were managed by
SC
neurosurgeons (n = 120, 70%). Management by a neurosurgeon was defined by whether or not a neurosurgeon was consulted. Neurosurgical consultations could occur at any point during the
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patients’ admission, so patients with a shift and neurosurgical consultation after initial exam were included in the neurosurgical management group. The need for neurosurgery consultation was at the discretion of the trauma surgeons.
The primary outcome of interest was Glasgow Outcome Score (GOS). GOS ranges from
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1 to 4, with higher scores reflecting better outcomes. Patients were classified into two categories based upon their GOS. Scores equal to or less than 3 suggest moderate to severe outcomes and scores greater than 3 suggest good outcomes. Severity of TBI was measured using the
EP
Abbreviated Injury Scale (AIS) and the Glasgow Coma Scale (GCS).(13, 14) Overall, injury severity was measured using the Injury Severity Score (ISS)(15) and systolic blood pressure
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(SBP) upon presentation to the emergency department. Chi-square and Fisher exact test were used as appropriate for categorical variables, whereas Student t test and ANOVA were used for continuous variables. Multivariate analysis was undertaken using backward stepwise binary logistic regression analyses to measure the association of trauma vs. neurosurgical management on outcome while controlling for confounding effects of age, gender, race/ethnicity, injury severity, insurance status, and GCS
ACCEPTED MANUSCRIPT 4 motor scores upon arrival to the emergency department. Results are presented as medians and interquartile range (IQR), proportions, and odds ratios (ORs) with 95% confidence interval (CI).
used for all statistical analyses, with p < .05 considered significant. RESULTS
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Statistical Package for the Social Sciences for Windows, Version 20 (SPSS Inc., Chicago) was
Neurosurgical consultations among MTBI patients significantly decreased from 94% to
SC
65% after implementation of the protocol in 2008 (Table I) even though the patients presenting after protocol implementation had significantly higher injury severity scores.
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Patients managed by trauma surgeons alone and those managed by neurosurgeons were similar in age, race/ethnicity, gender distribution, injury severity, length of stay, or mechanism of injury (Table II). Neurosurgeon consultations were called for in the majority of patients presenting with a GCS of 15 (x2 = 6.914, p < 0.032).
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Neurologic outcome of the patients in the two groups was also similar. GOS indicated good recovery for the majority of patients (Trauma Surgeons 82% vs. Neurosurgeons 78%, p = ns). Patients were primarily discharged home (Trauma Surgeons 82% vs. Neurosurgeons 79%, p
EP
= ns) with moderate disability (Trauma Surgeons, 77%; Neurosurgeons, 81%). There were no differences in patients’ hospital length of stay or ICU length of stay by management service
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(Table III).
Multivariate regression analysis yielded younger age, lower ISS, and higher GCS motor scores as significant predictors for better outcomes (Table IV). Neurosurgeon consultation was not associated with patient outcomes. The American College of Surgeons recommends obtaining neurosurgical consultation for patients older than 65 years of age with blunt TBI. Table V shows the multivariate analysis for
ACCEPTED MANUSCRIPT 5 patients younger and older than 65 years separately. Again, management by neurosurgeons was not associated with neurologic outcomes of the patients over or under 65 years of age. DISCUSSION
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There are two primary findings of this study. First, by implementing a policy of selective consultation, we were able to reduce neurosurgery consultations. Second, there was no difference in neurologic outcomes between the patients with MTBI managed by trauma surgeons versus
SC
neurosurgeons, suggesting that trauma surgeons can effectively manage such patients.
These findings are consistent with prior studies demonstrating the ability of trauma
M AN U
surgeons to effectively manage patients with small ICH. This is likely related to the fact that only 0.1% to 0.3% of MTBI patients with abnormal head CT require neurosurgical intervention or treatment.(8, 9, 16, 17) Non-operative management of TBI such as serial exams and imaging studies, neuropsychology evaluation for concussion, and rehabilitation can be managed
TE D
effectively by trauma surgeons.
The main implication of our findings is that not all patients with MTBI require neurosurgical consultation. This selective use of neurosurgical resources may be beneficial for
EP
trauma centers, particularly in locations with scarcity of neurosurgeons. Currently, the ratio of neurosurgeons to the population in the United States is approximately 1:61,000. With only
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approximately 3,689 practicing board certified neurosurgeons and increasing demands for neurosurgical services,(18) the availability of on-call neurosurgeons is a growing national issue in trauma and emergency care.(19) Neurosurgical workforce demands are usually estimated at one neurosurgeon per 100,000 population ratio,(20) but many states have zero to two neurosurgeons per 100,000 people.(21) Trauma center designation depends upon 24 hour on-call neurosurgical coverage, and due in part
ACCEPTED MANUSCRIPT 6 to this shortage, trauma centers in Pennsylvania, Tennessee, Missouri, Illinois, Texas, and Florida were closed.(22) Not surprisingly, in a national survey of emergency department directors, 75% reported inadequate neurosurgical coverage.(10) In addition, selective use of
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neurosurgical resources may allow for more appropriate allocation of scarce neurosurgical
resources to more severely injured patients or non-trauma patients. The American College of Surgeons needs to look more carefully at resource use on a larger scale, as frequent neurosurgical
SC
consultation may not be necessary, and a reduction of consultations can reduce costs.
This study has a few limitations that should be recognized. This is a retrospective
M AN U
analysis with all its inherent limitations. An important limitation is the possibility of type II error due to a small sample size. Another limitation is the lack of follow-up data and patients’ longterm outcomes. More discriminatory outcomes, such as the Disability Rating Scale, was unavailable for these patients, so we were unable to evaluate more sensitive outcomes for
TE D
patients at discharge. Additionally, the protocol was voluntary and requesting neurosurgical consultations may be related to on-call trauma surgeon’s preference. In conclusion, implementation of a policy for selective neurosurgical consultation for
EP
patients with mild TBI significantly reduced the number of neurosurgical consultations without
TBI.
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any impact on patient outcomes. Trauma surgeons can effectively manage patients with mild
ACCEPTED MANUSCRIPT 7 REFERENCES 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:
2.
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Department of Health and Human Services, 2003.
Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury.
JAMA. 1999;282:954-7.
Alexander MP. Mild traumatic brain injury: Pathophysiology, natural history, and clinical
SC
3.
management. Neurology. 1995;45:1253-60.
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support
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4.
Student Course Manual. Ninth ed. Chicago, IL,: American College of Surgeons; 2012. Jennett B, MacMillan R. Epidemiology of head injury. Br Med J. 1981;282:101-4.
6.
Wasserberg J. Treating head injuries. BMJ. 2002;325:454-5.
7.
Blostein PA, Jones SJ. Identification and evaluation of patients with mild traumatic brain
TE D
5.
injury: Results of a national survey of Level I Trauma Centers. J Trauma. 2003;55:450-3. 8.
Jeret JS, Mandell M, Anziska B, et al. Clinical predictors of abnormality disclosed by
9.
EP
computed tomography after mild head trauma. Neurosurgery. 1993;32:9-16. Miller EC, Derlet RW, Kinser D. Minor head trauma: Is computed tomography always
10.
AC C
necessary? Neurosurgery. 1993;32:9-16. Rao MB, Lerro C, Gross CP. Shortage of on-call surgical specialist coverage: A national
survey of emergency department directors. Acad Emerg Med. 2010;17(12):1374-82. 11.
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;242:36470.
ACCEPTED MANUSCRIPT 8 12.
Klein Y, Donchik V, Jaffe D, Simon D, Kessel B, Levy L, et al. Management of patients
with traumatic intracranial injury in hospitals without neurosurgical service. J Trauma. 2010;69:544-8. Copes WS, Sacco WJ, Champion HR, Bain LW, editors. Progress in characterizing
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13.
anatomic injury. Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Automotive Medicine; 1998; Baltimore, Mass.
Teasdale G, Jennet B. Assessment of coma and impaired consciousness. Lancet.
SC
14.
1974;2:81-4.
Baker SP, O'Neill B, Haddon W, Long WB. The Injury Severity Score: a method for
M AN U
15.
describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187-96. 16.
Dunham CM, Coates S, Cooper C. Compelling evidence for discretionary brain
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computed tomographic imaging in those patients with mild cognitive impairment after blunt trauma. J Trauma. 1996;41:679-86. 17.
Huynh T, Jacobs DG, Dix S, Sing RF, Miles WS, Thomason MH. Utility of
2006;72:1162-7.
Harbrecht BG, Smith JW, Franklin GA, Miller FB, Richardson JD. Decreasing Regional
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18.
EP
Neurosurgical Consultation for Mild Traumatic Brain Injury. The American Surgeon.
Neurosurgical Workforce - A Blueprint for Disaster. J Trauma. 2010;68(6):1367-74. 19.
Center for Workforce Studies. 2012 Physician Specialty Data Book. Washington, DC:
Association of American Medical Colleges, 2012. 20.
Zuidema GD. The SOSSUS report and its impact on neurosurgery. J Neurosurg.
1977;46:135-44.
ACCEPTED MANUSCRIPT 9 21.
Institute HPR. The Surgical Workforce in the United States: Profile and Recent Trends.
American College of Surgeons and Association of American Medical Colleges, 2010. 22.
The Projected Physician Shortage and How Health Care Reforms Can Address the
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Problem: Hearing before the Small Business, United States House of Representatives, First
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EP
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SC
Session Sess. (July 8, 2009, 2009).
ACCEPTED MANUSCRIPT
Background: Current practices suggest patients with mild traumatic brain injuries (MTBI) receive neurosurgical consultations, while fewer than 1% require neurosurgical intervention. We implemented a policy of selective neurosurgical consultation with the hypothesis that trauma
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surgeons alone may manage such patients with no impact on patient outcomes. Methods: Data from a Level I trauma registry was analyzed. Patients with MTBI resulting in an intracranial hemorrhage less than or equal to 1 centimeter and a Glasgow Coma Score of 13 or greater were
SC
included. Patients with additional intracranial injuries were excluded. Multivariate regression was used to determine the relationship between neurosurgical management and good neurologic
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outcomes, while controlling for injury severity, demographics, and comorbidities. Results: Implementation of the neurosurgical policy significantly reduced the number of such consults (94% before vs. 65% after, p < 0.002). Multivariate analysis revealed that neurosurgical consultation was not associated with neurologic outcomes of patients. Conclusions:
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Implementation of a selective neurosurgical consultation policy for patients with MTBI reduced neurosurgical consultations without any impact on patient outcomes, suggesting trauma surgeons
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can effectively manage these patients.
ACCEPTED MANUSCRIPT
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Summary: Current practices suggest patients with mild traumatic brain injuries receive neurosurgical consultations, while less than 1% require neurosurgical intervention. We implemented a policy of selective neurosurgical consultation with the hypothesis that trauma surgeons alone may manage such patients with no impact on patient outcomes. Implementation of the neurosurgical policy significantly reduced the number of such consults, while neurosurgical consultation was not associated with neurologic outcomes of patients. This suggests that trauma surgeons can effectively manage patients with mild traumatic brain injuries.
ACCEPTED MANUSCRIPT
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Keywords: mild traumatic brain injury; neurosurgical management; neurosurgeon consultation; policy implementation; mild TBI management
ACCEPTED MANUSCRIPT 1 Table I. Neurosurgical Consultations Before and After Protocol Implementation
Neurosurgical Consultation Age (yr, median, IQR)
After Implementation
(n = 31)
(n = 140)
2 (6%)
49 (35%)
29 (94%)
91 (65%)
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No Neurosurgical Consultation
Before Implementation
42 (24 72)
Gender (% male)
23 (74%)
Race/Ethnicity (% White, Non
21 (68%)
50.5 (31.5 69.8) 95 (68%) 86 (61%)
ISS (median, IQR)*
16 (16 20)
First ED Systolic Blood Pressure
137 (122
159)
GCS 1 (3%)
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13
SC
Hispanic)
14 15 GCS Motor (median, IQR)
134 (120.5
154)
9 (6%) 28 (20%)
25 (81%)
103 (74%)
6)
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ISS, Injury Severity Scale; GCS, Glasgow Coma Scale. *significant difference between groups, p < 0.05
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24)
5 (16%)
6 (6
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17 (16
6 (6
6)
ACCEPTED MANUSCRIPT 2 Table II. Patient Demographics and Injury Severity Neurosurgeon
(n = 51)
(n = 120)
48 (34
64)
Gender, % male
71%
Race/Ethnicity (%White, Non
58%
49 (29 71) 68%
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Age (yr, median, IQR)
Trauma Surgeon
65%
Hispanic) ISS (median, IQR)
17 (16
First ED Systolic Blood
25)
132 (122
154)
134 (120 156)
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Pressure (mm Hg, median, IQR) GCS (%)* 6%
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13
17 (16 21)
14 15 GCS Motor (median, IQR)
31%
14%
63%
80%
6 (6
Mechanism of Injury Fall Motor vehicle
Motorcycle Auto-Pedestrian Other
6)
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6)
48%
31%
23%
15%
13%
10%
4%
0%
3%
2%
8%
ISS Injury Severity Scale; GCS, Glasgow Coma Scale.
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6 (6
42%
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Assault
6%
ACCEPTED MANUSCRIPT 3 Table III. Crude Outcomes by Management Service
Discharge Location
Neurosurgeon
(n = 51, 30%)
(n = 120, 70%)
Good Recovery
42 (82%)
93 (78%)
Moderate Disability
7 (14%)
17 (14%)
Severe Disability
2 (4%)
Death
0 (0%)
Home
42 (82%)
Facility
9 (18%) 0%
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Other Length of stay (days, median, IQR)
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median, IQR)
2 (2%) 8 (7%)
95 (79%)
16 (13%) 1 (1%)
2 (1 5)
3 (2 6)
1 (1 3)
2 (1
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ICU length of stay (days,
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Glasgow Outcome Score
Trauma Surgeon
5)
ACCEPTED MANUSCRIPT 4 Table IV. Association between Neurosurgical Management and Good Neurologic Outcomes – Multivariate analysis Odds Ratio
95% CI
P value
Trauma Surgeon
1.74
0.61-4.92
0.300
Age
0.94
0.91-0.96
Injury Severity Score
0.87
0.81-0.94
Glasgow Coma Scale -
13.96
2.23-87.3
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Motor
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Variable
0.000
0.000
0.005
ACCEPTED MANUSCRIPT 5 Table V. Association between Neurosurgical Management and Good Neurologic Outcomes
Odds Ratio
95% CI
P value
Trauma Surgeon
5.22
0.74-37.06
0.1
Injury Severity
0.89
0.81-0.97
0.010
10.06
1.27-79.54
0.03
Trauma Surgeon
1.43
0.26-0.6
0.68
Injury Severity
0.8
0.01
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65 years
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Score
0.67-0.95
S0002-9610(14)00179-2
DOI:
10.1016/j.amjsurg.2014.02.012
Reference:
AJS 11155
To appear in:
The American Journal of Surgery
Received Date: 13 September 2013 Revised Date:
29 January 2014
Accepted Date: 11 February 2014
Please cite this article as: Overton TL, Shafi S, Cravens GF, Gandhi RR, Can Trauma Surgeons Manage Mild Traumatic Brain Injuries?, The American Journal of Surgery (2014), doi: 10.1016/ j.amjsurg.2014.02.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 Can Trauma Surgeons Manage Mild Traumatic Brain Injuries?
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Running head: MANAGEMENT OF MILD TBI
Shahid Shafi, MD [email protected] JPS Health Network
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Rajesh R. Gandhi, MD, PhD [email protected]
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George F. Cravens, MD [email protected]
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Corresponding Author: Tiffany L. Overton, MA, MPH [email protected] O: 817-702-5913 F: 817-702-5162 Trauma Services JPS Health Network 1500 S. Main St. Fort Worth, Tx 76104
SC
Authors:
ACCEPTED MANUSCRIPT 2 BACKGROUND Traumatic brain injury (TBI) is an important public health concern and a leading cause of morbidity and mortality.(1) The vast majority of TBI are considered mild (70-85% ),(1, 2) and
RI PT
are defined as Glasgow Coma Scale (GCS) score of 13 to 15 and a temporary disruption of brain function after a traumatic injury.(3-6) Controversy surrounds the most appropriate management of mild TBI (MTBI).(7) The American College of Surgeons recommends neurosurgical
SC
evaluation of any patient with a GCS score less than 15 at two hours after injury and patients greater than 65 years of age(4) even though less than 1% of patients with MTBI require
M AN U
neurosurgical intervention.(8, 9) This requirement creates a burden on scarce neurosurgical resources, which is likely to become worse with shortage of neurosurgeons and aging of the population.(10) In fact, there is emerging evidence that patients with intracranial bleeds can be safely managed in trauma centers without neurosurgical services, except in the case of moderate
TE D
to severe TBI.(11, 12)
To study this issue, we implemented a protocol of selective neurosurgical consultation in 2008 that enabled trauma surgeons to manage patients with MTBI without neurosurgical
EP
consultations. This study reports our initial experience with management of MTBI by trauma surgeons alone. We hypothesize patients with MTBI managed by trauma surgeons will be the
AC C
same as outcomes for patients managed by neurosurgeons. METHOD
This is a retrospective analysis of patients treated at a major urban level 1 trauma center at a public institution over a period of 7 years (January 2006-June 2012). Patients were monitored before (2006 – 2008) and after (2008-2012) the implementation of the protocol mentioned above. The inclusion criteria consisted of patients with mild TBI defined as an
ACCEPTED MANUSCRIPT 3 intracranial hemorrhage less than or equal to 1 centimeter and a Glasgow Coma Score of 13 or greater at the time of arrival. Exclusion criteria consisted of patients with additional intracranial injuries (i.e. intraparenchymal hemorrhages, diffuse axonal injuries with white matter shearing),
RI PT
and patients transferred to another acute care facility or those who left against medical advice. Based on these criteria, 171 patients were included in the study. Patients were divided into two groups: those managed by trauma surgeons alone (n = 51, 30%) and those who were managed by
SC
neurosurgeons (n = 120, 70%). Management by a neurosurgeon was defined by whether or not a neurosurgeon was consulted. Neurosurgical consultations could occur at any point during the
M AN U
patients’ admission, so patients with a shift and neurosurgical consultation after initial exam were included in the neurosurgical management group. The need for neurosurgery consultation was at the discretion of the trauma surgeons.
The primary outcome of interest was Glasgow Outcome Score (GOS). GOS ranges from
TE D
1 to 4, with higher scores reflecting better outcomes. Patients were classified into two categories based upon their GOS. Scores equal to or less than 3 suggest moderate to severe outcomes and scores greater than 3 suggest good outcomes. Severity of TBI was measured using the
EP
Abbreviated Injury Scale (AIS) and the Glasgow Coma Scale (GCS).(13, 14) Overall, injury severity was measured using the Injury Severity Score (ISS)(15) and systolic blood pressure
AC C
(SBP) upon presentation to the emergency department. Chi-square and Fisher exact test were used as appropriate for categorical variables, whereas Student t test and ANOVA were used for continuous variables. Multivariate analysis was undertaken using backward stepwise binary logistic regression analyses to measure the association of trauma vs. neurosurgical management on outcome while controlling for confounding effects of age, gender, race/ethnicity, injury severity, insurance status, and GCS
ACCEPTED MANUSCRIPT 4 motor scores upon arrival to the emergency department. Results are presented as medians and interquartile range (IQR), proportions, and odds ratios (ORs) with 95% confidence interval (CI).
used for all statistical analyses, with p < .05 considered significant. RESULTS
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Statistical Package for the Social Sciences for Windows, Version 20 (SPSS Inc., Chicago) was
Neurosurgical consultations among MTBI patients significantly decreased from 94% to
SC
65% after implementation of the protocol in 2008 (Table I) even though the patients presenting after protocol implementation had significantly higher injury severity scores.
M AN U
Patients managed by trauma surgeons alone and those managed by neurosurgeons were similar in age, race/ethnicity, gender distribution, injury severity, length of stay, or mechanism of injury (Table II). Neurosurgeon consultations were called for in the majority of patients presenting with a GCS of 15 (x2 = 6.914, p < 0.032).
TE D
Neurologic outcome of the patients in the two groups was also similar. GOS indicated good recovery for the majority of patients (Trauma Surgeons 82% vs. Neurosurgeons 78%, p = ns). Patients were primarily discharged home (Trauma Surgeons 82% vs. Neurosurgeons 79%, p
EP
= ns) with moderate disability (Trauma Surgeons, 77%; Neurosurgeons, 81%). There were no differences in patients’ hospital length of stay or ICU length of stay by management service
AC C
(Table III).
Multivariate regression analysis yielded younger age, lower ISS, and higher GCS motor scores as significant predictors for better outcomes (Table IV). Neurosurgeon consultation was not associated with patient outcomes. The American College of Surgeons recommends obtaining neurosurgical consultation for patients older than 65 years of age with blunt TBI. Table V shows the multivariate analysis for
ACCEPTED MANUSCRIPT 5 patients younger and older than 65 years separately. Again, management by neurosurgeons was not associated with neurologic outcomes of the patients over or under 65 years of age. DISCUSSION
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There are two primary findings of this study. First, by implementing a policy of selective consultation, we were able to reduce neurosurgery consultations. Second, there was no difference in neurologic outcomes between the patients with MTBI managed by trauma surgeons versus
SC
neurosurgeons, suggesting that trauma surgeons can effectively manage such patients.
These findings are consistent with prior studies demonstrating the ability of trauma
M AN U
surgeons to effectively manage patients with small ICH. This is likely related to the fact that only 0.1% to 0.3% of MTBI patients with abnormal head CT require neurosurgical intervention or treatment.(8, 9, 16, 17) Non-operative management of TBI such as serial exams and imaging studies, neuropsychology evaluation for concussion, and rehabilitation can be managed
TE D
effectively by trauma surgeons.
The main implication of our findings is that not all patients with MTBI require neurosurgical consultation. This selective use of neurosurgical resources may be beneficial for
EP
trauma centers, particularly in locations with scarcity of neurosurgeons. Currently, the ratio of neurosurgeons to the population in the United States is approximately 1:61,000. With only
AC C
approximately 3,689 practicing board certified neurosurgeons and increasing demands for neurosurgical services,(18) the availability of on-call neurosurgeons is a growing national issue in trauma and emergency care.(19) Neurosurgical workforce demands are usually estimated at one neurosurgeon per 100,000 population ratio,(20) but many states have zero to two neurosurgeons per 100,000 people.(21) Trauma center designation depends upon 24 hour on-call neurosurgical coverage, and due in part
ACCEPTED MANUSCRIPT 6 to this shortage, trauma centers in Pennsylvania, Tennessee, Missouri, Illinois, Texas, and Florida were closed.(22) Not surprisingly, in a national survey of emergency department directors, 75% reported inadequate neurosurgical coverage.(10) In addition, selective use of
RI PT
neurosurgical resources may allow for more appropriate allocation of scarce neurosurgical
resources to more severely injured patients or non-trauma patients. The American College of Surgeons needs to look more carefully at resource use on a larger scale, as frequent neurosurgical
SC
consultation may not be necessary, and a reduction of consultations can reduce costs.
This study has a few limitations that should be recognized. This is a retrospective
M AN U
analysis with all its inherent limitations. An important limitation is the possibility of type II error due to a small sample size. Another limitation is the lack of follow-up data and patients’ longterm outcomes. More discriminatory outcomes, such as the Disability Rating Scale, was unavailable for these patients, so we were unable to evaluate more sensitive outcomes for
TE D
patients at discharge. Additionally, the protocol was voluntary and requesting neurosurgical consultations may be related to on-call trauma surgeon’s preference. In conclusion, implementation of a policy for selective neurosurgical consultation for
EP
patients with mild TBI significantly reduced the number of neurosurgical consultations without
TBI.
AC C
any impact on patient outcomes. Trauma surgeons can effectively manage patients with mild
ACCEPTED MANUSCRIPT 7 REFERENCES 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:
2.
RI PT
Department of Health and Human Services, 2003.
Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury.
JAMA. 1999;282:954-7.
Alexander MP. Mild traumatic brain injury: Pathophysiology, natural history, and clinical
SC
3.
management. Neurology. 1995;45:1253-60.
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support
M AN U
4.
Student Course Manual. Ninth ed. Chicago, IL,: American College of Surgeons; 2012. Jennett B, MacMillan R. Epidemiology of head injury. Br Med J. 1981;282:101-4.
6.
Wasserberg J. Treating head injuries. BMJ. 2002;325:454-5.
7.
Blostein PA, Jones SJ. Identification and evaluation of patients with mild traumatic brain
TE D
5.
injury: Results of a national survey of Level I Trauma Centers. J Trauma. 2003;55:450-3. 8.
Jeret JS, Mandell M, Anziska B, et al. Clinical predictors of abnormality disclosed by
9.
EP
computed tomography after mild head trauma. Neurosurgery. 1993;32:9-16. Miller EC, Derlet RW, Kinser D. Minor head trauma: Is computed tomography always
10.
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necessary? Neurosurgery. 1993;32:9-16. Rao MB, Lerro C, Gross CP. Shortage of on-call surgical specialist coverage: A national
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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;242:36470.
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Klein Y, Donchik V, Jaffe D, Simon D, Kessel B, Levy L, et al. Management of patients
with traumatic intracranial injury in hospitals without neurosurgical service. J Trauma. 2010;69:544-8. Copes WS, Sacco WJ, Champion HR, Bain LW, editors. Progress in characterizing
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13.
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14.
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Baker SP, O'Neill B, Haddon W, Long WB. The Injury Severity Score: a method for
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15.
describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187-96. 16.
Dunham CM, Coates S, Cooper C. Compelling evidence for discretionary brain
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computed tomographic imaging in those patients with mild cognitive impairment after blunt trauma. J Trauma. 1996;41:679-86. 17.
Huynh T, Jacobs DG, Dix S, Sing RF, Miles WS, Thomason MH. Utility of
2006;72:1162-7.
Harbrecht BG, Smith JW, Franklin GA, Miller FB, Richardson JD. Decreasing Regional
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18.
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Neurosurgical Consultation for Mild Traumatic Brain Injury. The American Surgeon.
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Association of American Medical Colleges, 2012. 20.
Zuidema GD. The SOSSUS report and its impact on neurosurgery. J Neurosurg.
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Institute HPR. The Surgical Workforce in the United States: Profile and Recent Trends.
American College of Surgeons and Association of American Medical Colleges, 2010. 22.
The Projected Physician Shortage and How Health Care Reforms Can Address the
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Problem: Hearing before the Small Business, United States House of Representatives, First
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Session Sess. (July 8, 2009, 2009).
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Background: Current practices suggest patients with mild traumatic brain injuries (MTBI) receive neurosurgical consultations, while fewer than 1% require neurosurgical intervention. We implemented a policy of selective neurosurgical consultation with the hypothesis that trauma
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surgeons alone may manage such patients with no impact on patient outcomes. Methods: Data from a Level I trauma registry was analyzed. Patients with MTBI resulting in an intracranial hemorrhage less than or equal to 1 centimeter and a Glasgow Coma Score of 13 or greater were
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included. Patients with additional intracranial injuries were excluded. Multivariate regression was used to determine the relationship between neurosurgical management and good neurologic
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outcomes, while controlling for injury severity, demographics, and comorbidities. Results: Implementation of the neurosurgical policy significantly reduced the number of such consults (94% before vs. 65% after, p < 0.002). Multivariate analysis revealed that neurosurgical consultation was not associated with neurologic outcomes of patients. Conclusions:
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Implementation of a selective neurosurgical consultation policy for patients with MTBI reduced neurosurgical consultations without any impact on patient outcomes, suggesting trauma surgeons
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can effectively manage these patients.
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Summary: Current practices suggest patients with mild traumatic brain injuries receive neurosurgical consultations, while less than 1% require neurosurgical intervention. We implemented a policy of selective neurosurgical consultation with the hypothesis that trauma surgeons alone may manage such patients with no impact on patient outcomes. Implementation of the neurosurgical policy significantly reduced the number of such consults, while neurosurgical consultation was not associated with neurologic outcomes of patients. This suggests that trauma surgeons can effectively manage patients with mild traumatic brain injuries.
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Keywords: mild traumatic brain injury; neurosurgical management; neurosurgeon consultation; policy implementation; mild TBI management
ACCEPTED MANUSCRIPT 1 Table I. Neurosurgical Consultations Before and After Protocol Implementation
Neurosurgical Consultation Age (yr, median, IQR)
After Implementation
(n = 31)
(n = 140)
2 (6%)
49 (35%)
29 (94%)
91 (65%)
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No Neurosurgical Consultation
Before Implementation
42 (24 72)
Gender (% male)
23 (74%)
Race/Ethnicity (% White, Non
21 (68%)
50.5 (31.5 69.8) 95 (68%) 86 (61%)
ISS (median, IQR)*
16 (16 20)
First ED Systolic Blood Pressure
137 (122
159)
GCS 1 (3%)
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Hispanic)
14 15 GCS Motor (median, IQR)
134 (120.5
154)
9 (6%) 28 (20%)
25 (81%)
103 (74%)
6)
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ISS, Injury Severity Scale; GCS, Glasgow Coma Scale. *significant difference between groups, p < 0.05
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5 (16%)
6 (6
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17 (16
6 (6
6)
ACCEPTED MANUSCRIPT 2 Table II. Patient Demographics and Injury Severity Neurosurgeon
(n = 51)
(n = 120)
48 (34
64)
Gender, % male
71%
Race/Ethnicity (%White, Non
58%
49 (29 71) 68%
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Age (yr, median, IQR)
Trauma Surgeon
65%
Hispanic) ISS (median, IQR)
17 (16
First ED Systolic Blood
25)
132 (122
154)
134 (120 156)
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Pressure (mm Hg, median, IQR) GCS (%)* 6%
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13
17 (16 21)
14 15 GCS Motor (median, IQR)
31%
14%
63%
80%
6 (6
Mechanism of Injury Fall Motor vehicle
Motorcycle Auto-Pedestrian Other
6)
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48%
31%
23%
15%
13%
10%
4%
0%
3%
2%
8%
ISS Injury Severity Scale; GCS, Glasgow Coma Scale.
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6 (6
42%
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Assault
6%
ACCEPTED MANUSCRIPT 3 Table III. Crude Outcomes by Management Service
Discharge Location
Neurosurgeon
(n = 51, 30%)
(n = 120, 70%)
Good Recovery
42 (82%)
93 (78%)
Moderate Disability
7 (14%)
17 (14%)
Severe Disability
2 (4%)
Death
0 (0%)
Home
42 (82%)
Facility
9 (18%) 0%
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Other Length of stay (days, median, IQR)
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median, IQR)
2 (2%) 8 (7%)
95 (79%)
16 (13%) 1 (1%)
2 (1 5)
3 (2 6)
1 (1 3)
2 (1
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ICU length of stay (days,
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Glasgow Outcome Score
Trauma Surgeon
5)
ACCEPTED MANUSCRIPT 4 Table IV. Association between Neurosurgical Management and Good Neurologic Outcomes – Multivariate analysis Odds Ratio
95% CI
P value
Trauma Surgeon
1.74
0.61-4.92
0.300
Age
0.94
0.91-0.96
Injury Severity Score
0.87
0.81-0.94
Glasgow Coma Scale -
13.96
2.23-87.3
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Motor
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Variable
0.000
0.000
0.005
ACCEPTED MANUSCRIPT 5 Table V. Association between Neurosurgical Management and Good Neurologic Outcomes
Odds Ratio
95% CI
P value
Trauma Surgeon
5.22
0.74-37.06
0.1
Injury Severity
0.89
0.81-0.97
0.010
10.06
1.27-79.54
0.03
Trauma Surgeon
1.43
0.26-0.6
0.68
Injury Severity
0.8
0.01
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65 years
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Score
0.67-0.95
