Can trauma surgeons manage mild traumatic brain injuries?

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 SurgeonsManage Mild Traumatic Brain Injuries?, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.02.012.

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http://dx.doi.org/10.1016/j.amjsurg.2014.02.012

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Can Trauma Surgeons Manage Mild Traumatic Brain Injuries?

Running head: MANAGEMENT OF MILD TBI Authors: 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 Shahid Shafi, MD [email protected] JPS Health Network George F. Cravens, MD [email protected] Rajesh R. Gandhi, MD, PhD [email protected]

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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

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

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

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

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

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

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

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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),

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

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

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

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

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

(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

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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).

Statistical Package for the Social Sciences for Windows, Version 20 (SPSS Inc., Chicago) was

used for all statistical analyses, with p < .05 considered significant.

RESULTS

Neurosurgical consultations among MTBI patients significantly decreased from 94% to

65% after implementation of the protocol in 2008 (Table I) even though the patients presenting

after protocol implementation had significantly higher injury severity scores.

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).

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

= 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

(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

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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

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

neurosurgeons, suggesting that trauma surgeons can effectively manage such patients.

These findings are consistent with prior studies demonstrating the ability of trauma

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

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

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

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

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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

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

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

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’ long-

term 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

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

patients with mild TBI significantly reduced the number of neurosurgical consultations without

any impact on patient outcomes. Trauma surgeons can effectively manage patients with mild

TBI.

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REFERENCES

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3. Alexander MP. Mild traumatic brain injury: Pathophysiology, natural history, and clinical

management. Neurology. 1995;45:1253-60.

4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support

Student Course Manual. Ninth ed. Chicago, IL,: American College of Surgeons; 2012.

5. 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

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8. Jeret JS, Mandell M, Anziska B, et al. Clinical predictors of abnormality disclosed by

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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,

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12. Klein Y, Donchik V, Jaffe D, Simon D, Kessel B, Levy L, et al. Management of patients

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15. Baker SP, O'Neill B, Haddon W, Long WB. The Injury Severity Score: a method for

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17. Huynh T, Jacobs DG, Dix S, Sing RF, Miles WS, Thomason MH. Utility of

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18. Harbrecht BG, Smith JW, Franklin GA, Miller FB, Richardson JD. Decreasing Regional

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21. Institute HPR. The Surgical Workforce in the United States: Profile and Recent Trends.

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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

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

included. Patients with additional intracranial injuries were excluded. Multivariate regression

was used to determine the relationship between neurosurgical management and good neurologic

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:

Implementation of a selective neurosurgical consultation policy for patients with MTBI reduced

neurosurgical consultations without any impact on patient outcomes, suggesting trauma surgeons

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

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Table I. Neurosurgical Consultations Before and After Protocol Implementation

Before Implementation

(n = 31)

After Implementation

(n = 140)

No Neurosurgical Consultation 2 (6%) 49 (35%)

Neurosurgical Consultation 29 (94%) 91 (65%)

Age (yr, median, IQR) 42 (24 72) 50.5 (31.5 69.8)

Gender (% male) 23 (74%) 95 (68%)

Race/Ethnicity (% White, Non

Hispanic)

21 (68%) 86 (61%)

ISS (median, IQR)* 16 (16 20) 17 (16 24)

First ED Systolic Blood Pressure 137 (122 159) 134 (120.5 154)

GCS

13 1 (3%) 9 (6%)

14 5 (16%) 28 (20%)

15 25 (81%) 103 (74%)

GCS Motor (median, IQR) 6 (6 6) 6 (6 6)

ISS, Injury Severity Scale; GCS, Glasgow Coma Scale. *significant difference between groups, p < 0.05

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Table II. Patient Demographics and Injury Severity

Trauma Surgeon

(n = 51)

Neurosurgeon

(n = 120)

Age (yr, median, IQR) 48 (34 64) 49 (29 71)

Gender, % male 71% 68%

Race/Ethnicity (%White, Non

Hispanic)

58% 65%

ISS (median, IQR) 17 (16 25) 17 (16 21)

First ED Systolic Blood

Pressure (mm Hg, median,

IQR)

132 (122 154) 134 (120 156)

GCS (%)*

13 6% 6%

14 31% 14%

15 63% 80%

GCS Motor (median, IQR) 6 (6 6) 6 (6 6)

Mechanism of Injury

Fall 42% 48%

Motor vehicle 31% 23%

Assault 15% 13%

Motorcycle 10% 4%

Auto-Pedestrian 0% 3%

Other 2% 8%

ISS Injury Severity Scale; GCS, Glasgow Coma Scale.

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Table III. Crude Outcomes by Management Service

Trauma Surgeon

(n = 51, 30%)

Neurosurgeon

(n = 120, 70%)

Glasgow Outcome Score Good Recovery 42 (82%) 93 (78%)

Moderate Disability 7 (14%) 17 (14%)

Severe Disability 2 (4%) 2 (2%)

Death 0 (0%) 8 (7%)

Discharge Location Home 42 (82%) 95 (79%)

Facility 9 (18%) 16 (13%)

Other 0% 1 (1%)

Length of stay (days,

median, IQR)

2 (1 5) 3 (2 6)

ICU length of stay (days,

median, IQR)

1 (1 3) 2 (1 5)

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Table IV. Association between Neurosurgical Management and Good Neurologic Outcomes

– Multivariate analysis

Variable Odds Ratio 95% CI P value

Trauma Surgeon 1.74 0.61-4.92 0.300

Age 0.94 0.91-0.96 0.000

Injury Severity Score 0.87 0.81-0.94 0.000

Glasgow Coma Scale -

Motor

13.96 2.23-87.3 0.005

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Table V. Association between Neurosurgical Management and Good Neurologic Outcomes

– Multivariate analysis by Age Group

Variable Odds Ratio 95% CI P value

<65 years Trauma Surgeon 5.22 0.74-37.06 0.1

Injury Severity

Score

0.89 0.81-0.97 0.010

Glasgow Coma

Scale - Motor

10.06 1.27-79.54 0.03

>65 years Trauma Surgeon 1.43 0.26-0.6 0.68

Injury Severity

Score

0.8 0.67-0.95 0.01

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Can trauma surgeons manage mild traumatic brain injuries?