University of Minnesota Medical School, Minneapolis, Minnesota.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
J Surg Res. 2019 Oct;242:4-10. doi: 10.1016/j.jss.2019.04.006. Epub 2019 May 3.
Traumatic brain injury (TBI) is a leading cause of trauma-related death and disability. Computed tomography (CT) imaging of the head is essential for diagnosis of intracranial hemorrhage. This study aimed to identify optimal time to imaging and its impact on mortality for older patients with mild TBIs.
State-wide quality collaborative data were used from level I-II trauma centers. Inclusion criteria were ICD-9/10 codes for head trauma, age ≥50, admission/emergency department Glasgow Coma Scale ≥14, injury severity score ≤20, nonfull trauma activation, and head CT imaging time between 5 and 90 min of arrival. Locally weighted scatterplot smoothing plot data were used to dichotomize patients into early and late head CT imaging cohorts. Multivariable logistic regression and negative binomial models were used to evaluate the effect of early verses late head CT on clinical outcomes. The primary outcome was in-hospital mortality.
Mortality nadired at 35 min. Each 1-min delay in CT imaging resulted in a 2% increase in mortality (P = 0.002). Early patients had significantly reduced in-hospital mortality (P = 0.03), shorter emergency department length of stay (P < 0.001), and were more likely to receive fresh frozen plasma within 4 h if anticoagulated (P = 0.03). Teaching, high-volume, and level 2 trauma centers were all less likely to provide early head CTs (all P < 0.05).
Delay in head CT imaging in the setting of potential mild TBI was associated with an increase in mortality. A delay in diagnosis cascades into delays in delivery of therapeutic interventions. Head CT within 35 min should be evaluated as a quality metric for older patients with mild TBI.
颅脑损伤（TBI）是创伤相关死亡和残疾的主要原因。头部计算机断层扫描（CT）成像对于诊断颅内出血至关重要。本研究旨在确定最佳成像时间及其对轻度 TBI 老年患者死亡率的影响。
使用来自一级-二级创伤中心的全州质量协作数据。纳入标准为头部创伤 ICD-9/10 编码、年龄≥50 岁、入院/急诊格拉斯哥昏迷量表评分≥14、损伤严重程度评分≤20、非全创伤激活以及头部 CT 成像时间在到达后 5-90 分钟之间。使用局部加权散点平滑图数据将患者分为早期和晚期头部 CT 成像队列。多变量逻辑回归和负二项式模型用于评估早期与晚期头部 CT 对临床结果的影响。主要结局是住院死亡率。
死亡率在 35 分钟时达到峰值。CT 成像每延迟 1 分钟，死亡率增加 2%（P=0.002）。早期患者的住院死亡率显著降低（P=0.03），急诊停留时间更短（P<0.001），如果抗凝，在 4 小时内更有可能接受新鲜冷冻血浆（P=0.03）。教学、大容量和二级创伤中心均不太可能提供早期头部 CT（均 P<0.05）。
在可能发生轻度 TBI 的情况下，头部 CT 成像延迟与死亡率增加相关。诊断延迟会导致治疗干预的延迟。对于轻度 TBI 的老年患者，应将 35 分钟内进行头部 CT 评估作为质量指标。
