Tucker Brian, Aston Jill, Dines Megan, Caraman Elena, Yacyshyn Marianne, McCarthy Mary, Olson James E
Department of Emergency Medicine, Wright State University, Boonshoft School of Medicine, Dayton, Ohio.
Department of Surgery, Wright State University, Boonshoft School of Medicine, Dayton, Ohio.
J Emerg Med. 2017 Jul;53(1):18-29. doi: 10.1016/j.jemermed.2017.02.010. Epub 2017 Mar 23.
Identifying patients who may progress to a poor clinical outcome will encourage earlier appropriate therapeutic interventions. Brain edema may contribute to secondary injury in traumatic brain injury (TBI) and thus, may be a useful prognostic indicator.
We determined whether the presence of brain edema on the initial computed tomography (CT) scan of TBI patients would predict poor in-hospital outcome.
We performed a retrospective review of all trauma patients with nonpenetrating head trauma at a Level I Trauma Center. International Classification of Diseases, Ninth Revision codes indicated the presence of brain edema and we evaluated the validity of this pragmatic assessment quantitatively in a random subset of patients. In-hospital mortality was the primary outcome variable. Univariate analysis and logistic regression identified predictors of mortality in all TBI patients and those with mild TBI.
Over 7200 patients were included in the study, including 6225 with mild TBI. Measurements of gray and white matter CT density verified radiological assessments of brain edema. Patients with documented brain edema had a mortality rate over 10 times that of the entire study population. With logistic regression accounting for Injury Severity Score, Glasgow Coma Scale score, other CT findings, and clinical variables, brain edema predicted an eightfold greater mortality rate in all patients (odds ratio 8.0, 95% confidence interval 4.6-14.0) and fivefold greater mortality rate for mild TBI patients (odds ratio 4.9, 95% confidence interval 2.0-11.7).
Brain edema is an independent prognostic variable across all categories of TBI severity. By alerting emergency physicians to patients with poor predicted clinical outcomes, this finding will drive better resource allocation, earlier intervention, and reduced patient mortality.
识别可能进展为不良临床结局的患者将促使更早地采取适当的治疗干预措施。脑水肿可能导致创伤性脑损伤（TBI）的继发性损伤，因此可能是一个有用的预后指标。
我们确定TBI患者初次计算机断层扫描（CT）上是否存在脑水肿可预测住院期间的不良结局。
我们对一级创伤中心所有非穿透性头部创伤的创伤患者进行了回顾性研究。国际疾病分类第九版编码表明存在脑水肿，我们在随机抽取的患者子集中定量评估了这种实用评估的有效性。住院死亡率是主要结局变量。单因素分析和逻辑回归确定了所有TBI患者以及轻度TBI患者的死亡预测因素。
该研究纳入了7200多名患者，其中6225例为轻度TBI。灰质和白质CT密度测量验证了脑水肿的影像学评估。有记录的脑水肿患者的死亡率是整个研究人群的10倍以上。在考虑损伤严重程度评分、格拉斯哥昏迷量表评分、其他CT表现和临床变量的逻辑回归分析中，脑水肿预测所有患者的死亡率高出八倍（优势比8.0，95%置信区间4.——14.0），轻度TBI患者的死亡率高出五倍（优势比4.9，95%置信区间2.0——11.7）。
脑水肿是所有TBI严重程度类别中的独立预后变量。通过提醒急诊医生注意预测临床结局不良的患者，这一发现将推动更好的资源分配、更早的干预并降低患者死亡率。
