Moderate traumatic brain injury

(GCS 9–13) or loss of consciousness for between 15 minutes and 6 hours, or a period of post-traumatic amnesia of up to 24 hours.

The comprehensive expansion of the Trauma Register of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; TR-DGU) now enables, for the first time, studies on traumatic brain injury (TBI) with special attention to care processes, clinical course, and outcomes of treatment on discharge or transfer from the acute-care hospital. METHODS:

Retrospective analysis of patients documented in the TR-DGU in the period 2013-2017 who had moderate to severe head injury as defined by the Abbreviated Injury Scale (AIS).

In the period 2013-2017, 41 101 patients with moderate to severe TBI were treated in TR-DGU-associated hospitals in Germany (n = 605 hospitals), corresponding to 8220 cases per year and thus to a population-wide incidence of 10.1 cases per 100 000 persons per year. TBI was present as an isolated injury in 39.1% of cases. The mean age of the patients was 60 years (median; range 0-104 years), and the male-to-female ratio was 2:1. 97.5% of the patients had blunt trauma. Falls from a low height were the most common cause of TBI (38.7%). 43.6% of the patients were intubated before arriving at the hospital, and more than 95% underwent cranial tomographic imaging within 22 minutes of arrival (standard deviation [SD] = 17 minutes). 18.4% underwent an emergency neurosurgical procedure. The in-hospital mortality was 23.5%, corresponding to a population-wide mortality from TBI of 2.4 per 100 000 persons per year. More than half of the patients recovered well or with only mild disability; 14.9% had persistent severe disability or remained in a vegetative state.

Putting these figures in the appropriate international context requires the acquisition of comparable data in multiple countries and is the main task of international TBI consortia 1).

1. orders as for minor head injury except patient is kept NPO in case surgical intervention is needed (including intracranial pressure monitoring).

2. for GCS = 9–12 admit to ICU. For GCS=13, admit to ICU if CT shows any significant abnormality (hemorrhagic contusions unless very small, rim subdural…)

Patients with normal or near-normal CTs should improve within hours. Any patient who fails to reach a GCS of 14–15 within 12 hrs should have a repeat CT at that time 2).

For those with an abnormal initial CT, the CTscan is usually repeated prior to discharge

Patients with moderate head injury are likely to suffer from a number of residual symptoms.

The most commonly reported symptoms include tiredness, headaches and dizziness (physical effects) difficulties with thinking, attention, memory planning, organising, concentration and word-finding problems (cognitive effects) and irritability (an emotional and behavioural problem). These symptoms are accompanied by understandable worry and anxiety. This can be particularly pronounced if the patient has not been warned that these problems are likely to arise. If the patient expects to be perfectly well within a few days and symptoms are still prominent after a few weeks, they may worry or feel guilty. This has the effect of creating a vicious circle leading to more symptoms and so on. A large proportion of people find that when they return to work they have difficulties and feel that they are not functioning at their highest level. For the majority of people these residual symptoms gradually improve, although this can sometimes take 6 to 9 months.

Behavioral problems are serious consequences of moderate to severe traumatic brain injury (TBI) and have a negative impact on outcome.

Outcome prognostication in traumatic brain injury (TBI) is important, but challenging due to heterogeneity of the disease. The aim of a systematic review of Dijkland et al. was to present the current state-of-the-art on prognostic models for outcome after moderate and severe TBI and evidence on their validity. They searched for studies reporting on the development, validation or extension of prognostic models for functional outcome after TBI with Glasgow Coma Scale (GCS) ≤ 12 published between 2006-2018. Studies with patients aged ≥14 years and evaluating a multivariable prognostic model based on admission characteristics were included. Model discrimination was expressed with the area under the receiver operating characteristic curve (AUC), and model calibration with calibration slope and intercept. We included 58 studies describing 67 different prognostic models, comprising the development of 42 models, 149 external validations of 31 models and 12 model extensions. The most common predictors were GCS (motor) score (n=55), age (n=54) and pupillary reactivity (n=48). Model discrimination varied substantially between studies. The International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) models were developed on the largest cohorts (8,509 and 10,008 patients, respectively) and were most often externally validated (n=91), yielding AUCs ranging between 0.65-0.90 and 0.66-1.00, respectively. Model calibration was reported with a calibration intercept and slope for 7 models in 53 validations, and was highly variable. In conclusion, the discriminatory validity of the IMPACT and CRASH prognostic models is supported across a range of settings. The variation in calibration, reflecting heterogeneity in reliability of predictions, motivates continuous validation and updating if clinical implementation is pursued. PROSPERO registry number: CRD42016052100 3).

Results of a study highlight the importance of preinjury occupational status and level of education in returning to productive activity following moderate to severe TBI 4).

Maegele M, Lefering R, Sakowitz O, Kopp MA, Schwab JM, Steudel WI, Unterberg A, Hoffmann R, Uhl E, Marzi I. The Incidence and Management of Moderate to Severe Head Injury. Dtsch Arztebl Int. 2019 Mar 8;116(10):167-173. doi: 10.3238/arztebl.2019.0167. PubMed PMID: 30995953; PubMed Central PMCID: PMC6482369.
Stein SC, Ross SE. Moderate head injury: a guide to initial management. J Neurosurg. 1992 Oct;77(4):562-4. PubMed PMID: 1527615.
Dijkland SA, Foks KA, Polinder S, Dippel DWJ, Maas A, Lingsma H, Steyerberg EW. Prognosis in Moderate and Severe Traumatic Brain Injury: A Systematic Review of Contemporary Models and Validation Studies. J Neurotrauma. 2019 May 17. doi: 10.1089/neu.2019.6401. [Epub ahead of print] PubMed PMID: 31099301.
Pretz C, Kowalski RG, Cuthbert JP, Whiteneck GG, Miller AC, Ketchum JM, Dams-OʼConnor K. Return to Productivity Projections for Individuals With Moderate to Severe TBI Following Inpatient Rehabilitation: A NIDILRR TBIMS and CDC Interagency Collaboration. J Head Trauma Rehabil. 2019 Jul 29. doi: 10.1097/HTR.0000000000000506. [Epub ahead of print] PubMed PMID: 31365435.
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