Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, NC, USA.
Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, NC, USA.
Injury. 2022 May;53(5):1645-1651. doi: 10.1016/j.injury.2022.02.007. Epub 2022 Feb 12.
Computerized tomography (CT) imaging is a standard part of traumatic brain injury (TBI) evaluation but not all patients require it after mild head injury. Given the increasing incidence of TBI in the United States, there is an urgent need to better characterize CT head imaging utilization in evaluating trauma patients, especially patients at low risk of requiring intervention, such as those presenting with a normal GCS.
We analyzed the 2017-2019 National Trauma Databank using ICD-10 codes to identify patients who received a head CT. We used Abbreviated Injury Scale (AIS) scores to identify patients with a moderate to severe head injury defined as an AIS severity ≥ 3. Procedural TBI management was defined as having an intracranial monitor or operative decompression. We used a modified Poisson modeling to identify risk factors for a moderate/severe TBI and risk factors for undergoing procedural management among patients with head CT and GCS 15.
Of 2,850,036 patients, 1,502,039 (52.7%) had a head CT. Among patients who had a head CT, 1,078,093 patients (74.9%) had a GCS 15 on arrival. Of this group, only 16.6% (n = 176,431) had a moderate/severe head injury. For those with moderate/severe head injury, 6.0% (n = 10,544/176,431) of patients underwent procedural head injury management. Risk factors for undergoing procedural head injury management included: isolated head injury (RR 2.43, 95% CI 2.34, 2.53), male sex (RR 1.73, 95% CI 1.67, 1.80), age > 50 years (RR 1.39 95% CI 1.32, 1.47), falls (RR 1.28, 95% CI 1.22, 1.35), and the use of anti-coagulation (RR 1.16, 95% CI 1.11, 1.21).
Few patients had moderate/severe head injury when presenting with a GCS 15. However, patients ≥ 50 years, men, and those who suffered falls were at higher risk. Anti-coagulation use was not associated with moderate/severe head injury but did increase the risk of procedural TBI management. Given the cost and associated radiation, reducing CT utilization for younger patients while using a more liberal head CT strategy for high-risk patients may provide substantial patient value.
计算机断层扫描（CT）成像已成为创伤性脑损伤（TBI）评估的标准部分，但并非所有轻度头部受伤的患者都需要进行 CT 检查。鉴于美国 TBI 的发病率不断上升，我们急需更好地描述 CT 头部成像在评估创伤患者中的应用，尤其是在那些受伤风险较低、如格拉斯哥昏迷量表（GCS）评分 15 分的患者。
我们使用国际疾病分类第 10 版（ICD-10）代码分析了 2017 年至 2019 年国家创伤数据库，以确定接受头部 CT 检查的患者。我们使用损伤严重程度评分（AIS）来识别中度至重度头部损伤的患者，定义为 AIS 严重程度≥3。手术性 TBI 管理定义为颅内监测或手术减压。我们使用修正泊松模型来确定中度/重度 TBI 的风险因素以及头部 CT 检查且 GCS 评分 15 的患者中接受手术性管理的风险因素。
在 285 万例患者中，150.2 万例（52.7%）接受了头部 CT 检查。在接受头部 CT 检查的患者中，107.8 万例（74.9%）在到达时 GCS 评分为 15 分。在这一组中，只有 16.6%（n=176431）有中度/重度头部损伤。对于那些有中度/重度头部损伤的患者，6.0%（n=10544/176431）接受了手术性头部损伤管理。接受手术性头部损伤管理的风险因素包括：孤立性头部损伤（RR 2.43，95%CI 2.34，2.53）、男性（RR 1.73，95%CI 1.67，1.80）、年龄>50 岁（RR 1.39，95%CI 1.32，1.47）、跌倒（RR 1.28，95%CI 1.22，1.35）和抗凝治疗（RR 1.16，95%CI 1.11，1.21）。
当 GCS 评分为 15 分时，很少有患者有中度/重度头部损伤。然而，≥50 岁的患者、男性和那些跌倒的患者风险更高。抗凝治疗与中度/重度头部损伤无关，但会增加手术性 TBI 管理的风险。鉴于成本和相关辐射，减少年轻患者的 CT 使用率，同时对高风险患者采用更宽松的头部 CT 策略，可能会为患者带来显著价值。
