The impact of delayed time to first CT head in traumatic brain injury

• Authors: Morgan Schellenberg, University of Southern California; Elizabeth Benjamin, Emory University; Natthida Owattanapanich, University of Southern California; Kenji Inaba, University of Southern California; Demetrios Demetriades, University of Southern California
• Journal Title: EUROPEAN JOURNAL OF TRAUMA AND EMERGENCY SURGERY
• Publisher: SPRINGER HEIDELBERG | 2020-06-25
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1007/s00068-020-01421-1
• Subjects: Biology, Neuroscience; Health Sciences, Health Care Management; Health Sciences, Medicine and Surgery
• Keywords: Science & Technology; Life Sciences & Biomedicine; Emergency Medicine; Traumatic brain injury; Computed tomography of the head; Undertriage; Time to intervention; Trauma; MORTALITY; WOUNDS

Abstract

Purpose: Trauma team activation (TTA) criteria trigger early mobilization of resources for the sickest trauma patients. Patients with moderately depressed GCS who do not trigger the highest level activation are at risk for adverse outcomes, potentially from delayed time to intervention. The study objective was to define the impact of time to first CT Head (CTH) on outcomes among blunt trauma patients with moderately depressed GCS. Methods: Patients from the Trauma Quality Improvement Program (TQIP) databank (2013–2016) with first ED GCS 9–12 were included. Transfers, penetrating mechanisms, death < 24 h, AIS = 6 in any body region, and patients with severe associated injuries were excluded. Study groups were defined by time to first CTH after ED arrival: immediate (≤ 1 h) vs. delayed (1–6 h). Primary outcomes were time to neurosurgical intervention and time to ED discharge. Results: After exclusions, 4997 patients were identified. Of these, 79% (n = 3,954) underwent immediate CTH and 21% (n = 1,043) had delayed CTH. Median GCS was 11 [10–12] in both groups and there was no difference in median Head AIS (4 [3–4] vs. 4 [3–4], p = 0.586). Time to craniotomy and ICP monitor insertion were longer in the delayed group (4.2 h [3.0–7.6] vs. 3.1 h [2.1–8.7], p = 0.001; and 5.7 h [3.8–13.0] vs. 4.4 h [2.6–12.0], p = 0.008), as was time in the ED (4.3 h [2.7–6.5] vs. 2.1 h [1.2–3.7], p < 0.001). There was no difference in need for craniotomy (11% vs. 10%, p = 0.287), need for ICP monitor (12% vs. 12%, p = 0.899), or mortality (11% vs. 9%, p = 0.160). On multivariate analysis, age > 65 (OR 2.813, p < 0.001), SBP < 90 mmHg (OR 2.934, p < 0.001), ED intubation (OR 1.486, p = 0.001), and Head AIS scores of 4 (OR 1.884, p < 0.001) and 5 (OR 6.729, p < 0.001) were independently associated with death. Conclusions: Immediate CTH for blunt trauma patients with moderately depressed GCS decreases time to intervention and reduces ED time. A protocol to shorten time to CTH may be beneficial for both patients and hospitals.