三级创伤中心脑损伤指南的安全性和有效性。
Safety and efficacy of brain injury guidelines at a Level III trauma center.
机构信息
From the Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio (G.E.M., D.A.M., T.A.P., A.T.M., M.D.G.), Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio (C.P.C., Z.J.P., L.B.N.); and Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona (B.A.J.).
出版信息
J Trauma Acute Care Surg. 2018 Mar;84(3):483-489. doi: 10.1097/TA.0000000000001767.
BACKGROUND
Patients with mild to moderate traumatic brain injury (TBI) are often primarily managed by emergency medicine and trauma/acute care physicians. The Brain Injury Guidelines (BIG) were developed at an American College of Surgeons-accredited Level 1 trauma center to triage mild to moderate TBI patients and help identify patients who warrant neurosurgical consultation. The BIG have not been validated at a Level III trauma center. We hypothesized that BIG criteria can be safely adapted to an American College of Surgeons-accredited Level III trauma center to guide transfers to a higher echelon of care.
METHODS
We reviewed the trauma registry at a Level III trauma center to identify TBI patients who presented with an Abbreviated Injury Severity-Head score greater than zero. Demographic data, injury details, and clinical outcomes were abstracted with primary outcome measures of worsening on second computed tomography of the head, neurosurgical intervention, transfer to a Level I trauma center, and in-hospital mortality. Patients were classified using the BIG criteria. After validating the BIG in our cohort, we reclassified patients using updated BIG criteria. Updated criteria included mechanism of injury, reclassification of anticoagulation or antiplatelet use, and replacement of the neurologic examination component with stratification by admission Glasgow Coma Scale (GCS) score.
RESULTS
From July 2013 to June 2016, 332 TBI patients were identified: 115 BIG-1, 25 BIG-2, and 192 BIG-3. Patients requiring neurosurgical intervention (n = 30) or who died (n = 29) were BIG-3 with one exception. Patients with GCS score of less than 12 had worse outcomes than those with a GCS score of 12 or greater, regardless of BIG classification. Anticoagulant or antiplatelet use was not associated with worsened outcomes in patients not meeting other BIG-3 criteria. The updated BIG resulted in more patients in BIG-1 (n = 109) and BIG-2 (n = 100) without negatively affecting outcomes.
CONCLUSION
The BIG can be applied in the Level III trauma center setting. Updated BIG criteria can aid triage of mild to moderate TBI patients to a Level I trauma center and may reduce secondary overtriage.
LEVEL OF EVIDENCE
Care management, level IV.
背景
轻度至中度创伤性脑损伤（TBI）患者通常主要由急诊医学和创伤/急症护理医生进行管理。《脑损伤指南》（BIG）是在美国外科医师学院认可的一级创伤中心制定的，用于对轻度至中度 TBI 患者进行分诊，并帮助确定需要神经外科咨询的患者。这些 BIG 尚未在三级创伤中心得到验证。我们假设，BIG 标准可以安全地适用于美国外科医师学院认可的三级创伤中心，以指导向更高层次的护理机构转移。
方法
我们回顾了三级创伤中心的创伤登记处，以确定 Abbreviated Injury Severity-Head 评分大于零的 TBI 患者。提取人口统计学数据、损伤细节和临床结果，主要观察指标为头部第二次计算机断层扫描恶化、神经外科干预、转至一级创伤中心和院内死亡率。患者根据 BIG 标准进行分类。在我们的队列中验证 BIG 后，我们使用更新的 BIG 标准重新分类患者。更新的标准包括损伤机制、抗凝或抗血小板使用的重新分类以及用入院格拉斯哥昏迷量表（GCS）评分分层替代神经检查部分。
结果
2013 年 7 月至 2016 年 6 月，共确定了 332 例 TBI 患者：115 例 BIG-1、25 例 BIG-2 和 192 例 BIG-3。需要神经外科干预（n=30）或死亡（n=29）的患者均为 BIG-3，只有 1 例例外。GCS 评分低于 12 的患者的预后比 GCS 评分大于或等于 12 的患者差，无论 BIG 分类如何。不符合其他 BIG-3 标准的抗凝或抗血小板使用与预后恶化无关。更新的 BIG 导致更多的患者进入 BIG-1（n=109）和 BIG-2（n=100），而不会对结果产生负面影响。
结论
BIG 可应用于三级创伤中心。更新的 BIG 标准可以帮助将轻度至中度 TBI 患者分诊至一级创伤中心，并可能减少二次过度分诊。
证据水平
管理护理，IV 级。
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