Cipolle, Mark, MD

Patel, Puja, MD

Shah, Kamalesh T, MD

Stansbury, Tara

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works USF-LVHN SELECT Differentiating the Need for Neurosurgical Interventions at a Level 1 Trauma Center in Patients with a Mild Traumatic Brain Injury and a Positive CT Head Tara Stansbury Puja Patel MD Kamalesh T. Shah MD Mark Cipolle MD Follow this and additional works at: https://scholarlyworks.lvhn.org/select-program  Part of the Medical Education Commons This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. © 2018 Lehigh Valley Health NetworkLehigh Valley Health Network, Allentown, PennsylvaniaThe need for neurosurgical intervention was higher in patients with a midline shift >5mm, warfarin use (especially requiring reversal), convex SDH, worsening repeat CT scan, and hemiparesis. Defining factors that are at highest risk for leading to neurosurgical intervention can aid in determining which patients require transfer to higher level of care an early operative intervention. If a patient has these risk factors, transfer to a level 1 trauma center may be warranted. A complete dataset is needed to determine the existence of other factors that may indicate the need for neurosurgical intervention. Differentiating the Need for Neurosurgical Interventions at a Level 1 Trauma Center in Patients with a Mild Traumatic Brain Injury and a Positive CT Head REFERENCES• Among 352 patients with traumatic intracranial hemorrhage (mean age 77 [60-86], 53.4% male), 90.4% did not require neurosurgical intervention. • Of note, 82.6% repeat CT scans were the same or better than the initial scan.• Retrospective chart review of 1650 patients• This project represents a smaller subset (359 patients)• Inclusion criteria: – GCS 13-15– Intracranial bleed present on initial CT scan– Date of admission between Oct 1st 2015 to Sept 30th, 2019 to LVHN- Cedar Crest or transferred from another hospital• Patient charts were reviewed for the following: – GCS at initial hospital, on admission, within 24 hrs– Past medical history, history of brain ICH– Number of ICH, type of bleed, size of bleed– Time to and type of neurosurgical intervention– Neurological deficits on presentation( Including Pupil size and reactivity to light)– Anticoagulation therapy and need for reversal– INR at initial hospital and on admission– 60-day readmission, 60-day mortality, and in-hospital mortalityTara Stansbury, Puja Patel, DO, Kamaleshh Shah, MD, Mark Cipolle, MD1. Kim B., Park K., et al. Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head trauma. Acta Neurochir. 2014; 156: 1605-1613.2. Joseph B, Friese RS, Sadoun M, et al. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014;76(4):965-9.3. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery. 2006 Mar;58(3 Suppl):S16-24; discussion Si-iv. PMID: 16710968.4. Yun BJ, White BA, Benjamin Harvey H, et al. Opportunity to reduce transfer of patients with mild traumatic brain injury and intracranial hemorrhage to a Level 1 trauma center. Am J Emerg Med. 2017;35(9):1281-1284. doi:10.1016/j.ajem.2017.03.071Problem StatementTraumatic brain injuries (TBIs) are a leading cause of disability. These include mild traumatic brain injuries (mTBIs), which are defined as head trauma in patients with Glasgow Coma Scale (GCS) of 13 to 15. About 10-15% of mTBI patients will have an intracranial hemorrhage.1 While most are managed non-operatively2, a small portion require neurosurgical intervention and these patients are transferred to tertiary referral centers for higher level of care.3 There currently are no national guidelines to determine the need for transfer of patients with mTBIs from community to level 1 trauma centers.4 Identification of factors that place patients at high risk for neurosurgical intervention could determine which patients need to be transferred and decrease the number of unnecessary transfers in low-risk individuals.To determine risk factors leading to neurosurgical intervention and subsequent transfer to level I trauma center in patients with mTBI. • Risk factors with higher rate of neurosurgical intervention: – CT scan with midline shift >5mm– Warfarin use (esp with reversal)– SDH (esp convex)– Neurological deficit (esp hemiparesis) – Worsening repeat CT• Patients with multiple of these factors would most likely benefit from transfer to a higher level of care.• These factors could be used to establish protocol for transferring mTBIpatients. • Values based patient centered care: pttransfer is a burden on patients and their families. It would be better for patient care to admit them at the hospital that they regularly receive care.• Health Systems: reducing unnecessary transfers improves healthcare costs and utilization of resources. • Limitations include the incomplete dataset and lack of  applicablitiy to patients with adbanced directives. Number of patients Percent of patients Number of patients 352Mean age, years 77.0 GenderMale 190 53.4 %Female 166 46.6 %Medical HistoryCongestive heart failure 15 4.2 %Alzheimer’s 10 2.6 %Previous history of head trauma 35 9.8 % Cerebrovascular Accident (CVA) 35 9.8 %Transient Ischemic Attack (TIA) 10 2.8 %Myocardial infarction 12 3.4 %Hypertension 234 65.7 %Diabetes Mellitus 80 22.5 %Bleeding disorder 13 3.7 %Chronic aspirin use 63 17.7 %Anticoagulation therapy 116 32.6 %Dementia 59 16.6 %Obesity 48 13.5 % Chronic obstructive pulmonary disease (COPD)50 14.0 %Chronic ongoing alcohol abuse 29 8.1 %Substance use disorder 7 2.0 % Current smoker 56 15.7 % Advanced directive limiting care 115 32.3 %Functionally dependent health status 150 42.1 %Figure 1: Patient DemographicsNeurosurgical interventionmedical management p -value Mean age 67 78 0.02% on Warfarin 55.60% 25.20% 0.0066% with Neurological Deficit 87% 63% 0.0043% with CT with any midline shift 81.30% 12.30% <0.0001Avg size of midline shift 10.0 mm 4.0 mm <0.0001% with Worse second scan 42.30% 15.40% 0.0038% with SDH 97.00% 53.10% <0.0001Figure 2: highest risk factors for neurosurgical intervention vs. medical management only, of SDH 90.6% were convex (p=0.0090) and the most significant neurological deficit was hemiparesis at 24.1% (p=0.0006)

Differentiating the Need for Neurosurgical Interventions at a Level 1 Trauma Center in Patients with a Mild Traumatic Brain Injury and a Positive CT Head

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Differentiating the Need for Neurosurgical Interventions at a Level 1 Trauma Center in Patients with a Mild Traumatic Brain Injury and a Positive CT Head

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