Chen Jeffrey W, Yengo-Kahn Aaron, Chotai Silky, Bhamidipati Akshay, Smith Candice, Davis Philip, Reynolds Rebecca A, Boyd Mary Peyton, Barrett Tyler W, Compton Elizabeth S, Dennis Bradley M, Norris Michael S, Patel Mayur B, Schwarz Jacob P, Thomason Nicholas R, Thompson Reid C, Guillamondegui Oscar D
Vanderbilt University School of Medicine, Nashville, TN, United States.
Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States.
Injury. 2023 Jan;54(1):82-86. doi: 10.1016/j.injury.2022.08.009. Epub 2022 Aug 6.
Patients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile.
A non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation.
A total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001).
A protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.
轻度创伤性脑损伤（TBI）和颅内出血患者常接受神经外科会诊。然而，只有一小部分患者需要干预。我们的假设是，在没有立即进行神经外科会诊的情况下管理的低风险轻度TBI患者将有合理的安全性和有效性结果。
2018年11月，在一家一级创伤中心实施了一项针对成人轻度TBI的非神经外科管理方案，作为一项跨学科质量改进举措。轻度TBI定义为因钝性机制导致格拉斯哥昏迷量表（GCS）评分为15分，未接受抗凝或抗血小板治疗，且头部CT成像显示孤立性气颅和/或创伤性蛛网膜下腔出血。通过住院死亡率、神经外科干预以及出院后两周内的急诊复诊来评估安全性。通过神经外科会诊率和住院时间来评估有效性。比较方案实施前后8个月的结果。
共纳入97例患者，其中49例在方案实施前，48例在方案实施后。两个时期之间的住院死亡率[0（0%）对0（0%）]、神经外科手术[1（2.1%）对0（0%）]、手术[0（0%）对0（0%）]和急诊复诊率[1（2.0%）对2（4.2%），p = 0.985]没有差异。方案实施后神经外科会诊显著减少（92%对29%，p<0.001）。
针对轻度TBI患者的方案有效减少了神经外科会诊，且安全性未改变。这种针对低风险神经创伤的跨学科管理方案可以通过对神经功能稳定的TBI患者进行分层，有效利用神经外科会诊服务。
