Siegel J H, Gens D R, Mamantov T, Geisler F H, Goodarzi S, MacKenzie E J
Department of Surgery, University of Maryland School of Medicine, Baltimore.
Crit Care Med. 1991 Oct;19(10):1252-65. doi: 10.1097/00003246-199110000-00007.
To examine the effects of associated injuries on death, disability, rehabilitation needs, and cost in patients with blunt traumatic brain injury.
A retrospective case series analysis of 1,709 patients with blunt traumatic brain injury, or 37.2% of 4,590 consecutive blunt trauma patients, was combined with a prospective study of a subset of 202 of the 1,709 brain-injured patients obtained during the same time period with regard to need for rehabilitation services, residual disability, and costs at 1 yr after discharge from the acute trauma center.
A level I regional trauma center that is also the statewide neurotrauma and multiple trauma unit serving a population of more than 3 million persons.
Contingency table analysis showed the Glasgow Coma Scale to be highly predictive (p less than .0001) of likelihood of mortality, need for postacute inpatient rehabilitation, or discharge home. Of the blunt traumatic brain injury patients, 40.4% (691) had an isolated brain injury and 59.6% (1,018) had brain plus at least one other systemic injury. The mortality rate of the isolated brain injury group was 11.1% compared with 21.8% in all brain plus systemic injury groups (p less than .0001). Spine, lung, visceral, pelvis, or extremity injuries in blunt traumatic brain injury all increased mortality rate to greater than 25% (all simultaneously significant, p less than .0001). Analysis of the interaction of brain injury (quantified by Glasgow Coma Scale) with blood replacement in the initial 24 hrs showed that at any Glasgow Coma Scale range, percent mortality increased as the volume of blood increased. Hypovolemic shock increased the mortality rate from 12.8% to 62.1% (p less than .0001). The need for postacute inpatient rehabilitation in survivors also increased as blood replacement increased, and shock increased the percent of patients requiring post-acute inpatient rehabilitation from 39.7% to 60.3%. In 202 consecutive surviving brain trauma patients followed for 1 yr, isolated brain-injured patients with moderate brain injuries had a 4% need for posttrauma, postacute inpatient rehabilitation with a total cost per case of $12,489 compared with the brain plus extremity injury group, who had a 23% postacute inpatient rehabilitation rate and a total cost per case of $36,177 at 1 yr. With severe brain injury, isolated brain injury increased postacute inpatient rehabilitation to 29% and 1-yr cost to $59,274, but with the brain plus extremity injury group, postacute inpatient rehabilitation increased to 49% and cost to $84,950.
In blunt traumatic brain injury, the addition of major visceral or extremity injuries, with need for blood replacement or shock, increases the risk of death, the need for rehabilitation, and the costs of disability.
探讨钝性颅脑损伤患者合并伤对死亡、残疾、康复需求及费用的影响。
对1709例钝性颅脑损伤患者（占4590例连续钝性创伤患者的37.2%）进行回顾性病例系列分析，并对同期获得的1709例脑损伤患者中的202例进行前瞻性研究，观察其康复服务需求、残留残疾情况及急性创伤中心出院后1年的费用。
一所一级区域创伤中心，也是全州神经创伤和多发伤治疗单位，服务人口超过300万。
列联表分析显示，格拉斯哥昏迷量表对死亡率、急性后期住院康复需求或出院回家的可能性具有高度预测性（p<0.0001）。在钝性颅脑损伤患者中，40.4%（691例）为单纯脑损伤，59.6%（1018例）为脑损伤合并至少一种其他全身损伤。单纯脑损伤组的死亡率为11.1%，而所有脑损伤合并全身损伤组的死亡率为21.8%（p<0.0001）。钝性颅脑损伤患者的脊柱、肺、内脏、骨盆或四肢损伤均使死亡率增加至25%以上（均具有统计学意义，p<0.0001）。对脑损伤（以格拉斯哥昏迷量表量化）与最初24小时内输血情况的相互作用分析表明，在任何格拉斯哥昏迷量表范围内，死亡率百分比随输血量增加而升高。低血容量性休克使死亡率从12.8%升至62.1%（p<0.0001）。幸存者对急性后期住院康复的需求也随输血量增加而增加，休克使需要急性后期住院康复的患者百分比从39.7%升至60.3%。在连续随访1年的202例存活脑外伤患者中，中度脑损伤的单纯脑损伤患者有4%需要创伤后急性后期住院康复，每例总费用为12489美元，而脑损伤合并四肢损伤组在1年时急性后期住院康复率为23%，每例总费用为36177美元。重度脑损伤时，单纯脑损伤使急性后期住院康复率增至29%，1年费用增至59274美元，但脑损伤合并四肢损伤组急性后期住院康复率增至49%，费用增至84950美元。
在钝性颅脑损伤中，合并主要内脏或四肢损伤且需要输血或发生休克，会增加死亡风险、康复需求及残疾费用。
