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Old Patients Present with High GCS in traumatic brain injury

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Old Patients Present with High GCS in traumatic brain injury

  1. 1. Amber Z Jafferi Resident EM
  2. 2. A Kehoe, J E Smith, O Bouamra, A Edwards, D Yates, F Lecky
  3. 3. ABSTRACT The aim of this study was to confirm these observations using a national trauma database and to test explanatory hypotheses.
  4. 4. Methods  interrogated the Trauma Audit Research Network (TARN) database in England  isolated TBI between 1988 and 2013  Data included age, gender, mechanism of injury, abbreviated injury score (AIS) head, outcome, type of TBI (extradural, subdural, subarachnoid hemorrhage, parenchymal contusion) and GCS on arrival at hospital.
  5. 5.  Divided in 2 groups  65 years and older  young (<65 years)
  6. 6. INCLUSION/EXCLUSION CRITERIA  were >16 years of age at the time of injury  isolated, blunt head injury  any AIS head code with a severity of 3–5  TARN eligibility includes trauma patients who are admitted to hospital for ≥72 h, are admitted to a critical care unit, die in hospital or are transferred to another hospital for specialist care.
  7. 7. AIS  The Abbreviated Injury Scale (AIS) is an anatomical scoring system first introduced in 1969. Since this time it has been revised and updated against survival so that it now provides a reasonably accurate was of ranking the severity of injury. The latest incarnation of the AIS score is the 1990 revision
  8. 8.  The AIS is a simple numerical method for grading and comparing injuries by severity AIS Score Injury 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Survivable
  9. 9. RESULTS  25 082 patients with isolated TBI met the inclusion criteria  14 146 – younger group (<65 years)  10 936 – older group (65 years and older)  Older cohort was on average 44 (81 vs. 37) years older than the younger cohort  Older adults were effected with most severe form of TBI (40% vs. 30% of cases with AIS 5 severity) as compared to younger adults
  10. 10.  Older patients with TBI (70%) were injured by a low- energy fall this was very low (20%) in young population  Mortality was almost three times higher in older patients (28.4% vs. 10.5%)  Median presenting GCS in older group was higher (14 vs. 13)
  11. 11. DISCUSSION  Elderly patients are less likely to present with a low GCS (3–8) for a given TBI severity  GCS is used in most field triage guidelines to identify patients likely to need care in a specialist neurosurgical facility or MTC  Decrease in the sensitivity of their field triage guidelines for recognizing major trauma with each decade of life beyond 60 years.
  12. 12.  Ohio, Caterino et al found that Increasing the GCS threshold to 14 in the elderly improved sensitivity to 42.7% from previous 27%  This study suggests that trauma systems may need to be adapted to ensure early recognition of significant TBI in the elderly population
  13. 13. Comparison of initial GCS between young and older patients by severity of traumatic brain injury AIS and mechanism of injury Mechanism of Injury AIS Head N <65 Median GCS N >65 Median GCS Fall <2m 2 695 13 (13-15) 1136 15 (14-15) 4 1205 14 (12-15) 3328 15 (14-15) 5 965 13 (7-15) 3155 14(14-15) Fall >2m 3 738 14 (11-15) 385 14 (12-15) 4 966 13 (8-15) 734 14 (11-15) 5 781 8 (3-13) 700 10 (5-14) Overall 3 4611 14 (11-15) 1881 15 (13-15) 4 5365 14 (9-15) 4640 14 (13-15) 5 4170 9 (4-14) 4415 14 (8-15)
  14. 14. CONCLUSION  This is the largest study to date confirming that for a given anatomical severity of TBI, older patients present with a higher GCS than younger patients.  To identify significant TBI in older patients, trauma triage guidelines may need adaptation to ensure that elderly patients are managed appropriately.
  15. 15.  Thresholds for neurosurgical intervention in the elderly may need to be reconsidered.  These findings may partly explain the poorer outcomes previously observed in elderly patients with TBI since elderly patients with the same GCS as younger patients are likely to have sustained a more severe anatomical injury.

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