Trauma Surgeons on Par With Neurosurgeons for Small ICHs

LAKE BUENA VISTA, Fla.– Score one for the trauma surgeons. Outcomes are no different for patients with small intracranial hemorrhages managed by a trauma surgeon rather than a neurosurgeon, a new study shows.

Investigators at the JPS Health Network in Fort Worth, Tex., compared trauma activations for 124 patients before and 199 patients after a protocol was instituted at the level 1 trauma center allowing trauma surgeons to manage patients with a traumatic brain injury due to a fall resulting in a 1-cm or less intracranial hemorrhage (ICH). Patients with penetrating wounds or who were transferred to other acute care facilities were excluded from the analysis.

After the protocol was initiated, neurosurgery consults significantly decreased from 93.5% to 83.4% (P less than .01), Ms. Tiffany Littleton, trauma services research associate, and her colleagues reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

No significant differences at discharge were observed pre- and postprotocol for patient age (61.5 years vs. 58 years), sex (71% male vs. 65%), race (69.4% white vs. 70.4%), Glasgow Coma Scale scores (median 14.5 vs. 15), or Injury Severity Score (both median 20).

Additionally, there were no differences in outcomes such as length of stay (median 4 days for both; P = .86), condition on discharge (P = .57), where patients were discharged to (P = .14), or Glasgow Outcome Scale (GOS) scores (P = .18), she reported.

At discharge, most patients pre- and postprotocol had moderate disability (70.2% vs. 50.3%), went home without the need for professional assistance (59.7% vs. 49.2%), and were GOS classified as "good recovery" (50% vs. 60%).

"Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons," the authors concluded.

The results are particularly relevant, as the literature is scant regarding the management of ICHs of 1 cm or less. Moreover, the number of trauma activations resulting from falls is expected to increase with the aging American population, the investigators noted.

Falls are the second leading cause of trauma activations, and half of fall fatalities and associated costs are related to traumatic brain injury. Falls also constitute 52% of emergency department visits for adults aged 75 years or older.

Despite the potential for turf wars when departmental duties are shifted, "neurosurgeons were delighted" with the new protocol, senior author and JPS medical director of trauma services Dr. Rajesh Gandhi said in an interview. In fact, it was two neurosurgeons who developed and initiated the protocol change.

The researchers are currently acquiring data from the National Trauma Bank to examine differences in ICH outcomes in a larger sample.

"Additionally, we want to look at the range in which trauma surgeons can effectively manage ICH, and determine the point at which neurosurgeon management results in significant differences in outcome," said Ms. Littleton. "This can also translate to rural health care in terms of transferring these types of patients to trauma centers."

Ms. Littleton and her coauthors reported no financial conflicts of interest. Dr. Gandhi serves as a speaker for LifeCell and KCI.

LAKE BUENA VISTA, Fla.– Score one for the trauma surgeons. Outcomes are no different for patients with small intracranial hemorrhages managed by a trauma surgeon rather than a neurosurgeon, a new study shows.

Investigators at the JPS Health Network in Fort Worth, Tex., compared trauma activations for 124 patients before and 199 patients after a protocol was instituted at the level 1 trauma center allowing trauma surgeons to manage patients with a traumatic brain injury due to a fall resulting in a 1-cm or less intracranial hemorrhage (ICH). Patients with penetrating wounds or who were transferred to other acute care facilities were excluded from the analysis.

After the protocol was initiated, neurosurgery consults significantly decreased from 93.5% to 83.4% (P less than .01), Ms. Tiffany Littleton, trauma services research associate, and her colleagues reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

No significant differences at discharge were observed pre- and postprotocol for patient age (61.5 years vs. 58 years), sex (71% male vs. 65%), race (69.4% white vs. 70.4%), Glasgow Coma Scale scores (median 14.5 vs. 15), or Injury Severity Score (both median 20).

Additionally, there were no differences in outcomes such as length of stay (median 4 days for both; P = .86), condition on discharge (P = .57), where patients were discharged to (P = .14), or Glasgow Outcome Scale (GOS) scores (P = .18), she reported.

At discharge, most patients pre- and postprotocol had moderate disability (70.2% vs. 50.3%), went home without the need for professional assistance (59.7% vs. 49.2%), and were GOS classified as "good recovery" (50% vs. 60%).

"Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons," the authors concluded.

The results are particularly relevant, as the literature is scant regarding the management of ICHs of 1 cm or less. Moreover, the number of trauma activations resulting from falls is expected to increase with the aging American population, the investigators noted.

Falls are the second leading cause of trauma activations, and half of fall fatalities and associated costs are related to traumatic brain injury. Falls also constitute 52% of emergency department visits for adults aged 75 years or older.

Despite the potential for turf wars when departmental duties are shifted, "neurosurgeons were delighted" with the new protocol, senior author and JPS medical director of trauma services Dr. Rajesh Gandhi said in an interview. In fact, it was two neurosurgeons who developed and initiated the protocol change.

The researchers are currently acquiring data from the National Trauma Bank to examine differences in ICH outcomes in a larger sample.

"Additionally, we want to look at the range in which trauma surgeons can effectively manage ICH, and determine the point at which neurosurgeon management results in significant differences in outcome," said Ms. Littleton. "This can also translate to rural health care in terms of transferring these types of patients to trauma centers."

Ms. Littleton and her coauthors reported no financial conflicts of interest. Dr. Gandhi serves as a speaker for LifeCell and KCI.

LAKE BUENA VISTA, Fla.– Score one for the trauma surgeons. Outcomes are no different for patients with small intracranial hemorrhages managed by a trauma surgeon rather than a neurosurgeon, a new study shows.

Investigators at the JPS Health Network in Fort Worth, Tex., compared trauma activations for 124 patients before and 199 patients after a protocol was instituted at the level 1 trauma center allowing trauma surgeons to manage patients with a traumatic brain injury due to a fall resulting in a 1-cm or less intracranial hemorrhage (ICH). Patients with penetrating wounds or who were transferred to other acute care facilities were excluded from the analysis.

After the protocol was initiated, neurosurgery consults significantly decreased from 93.5% to 83.4% (P less than .01), Ms. Tiffany Littleton, trauma services research associate, and her colleagues reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

No significant differences at discharge were observed pre- and postprotocol for patient age (61.5 years vs. 58 years), sex (71% male vs. 65%), race (69.4% white vs. 70.4%), Glasgow Coma Scale scores (median 14.5 vs. 15), or Injury Severity Score (both median 20).

Additionally, there were no differences in outcomes such as length of stay (median 4 days for both; P = .86), condition on discharge (P = .57), where patients were discharged to (P = .14), or Glasgow Outcome Scale (GOS) scores (P = .18), she reported.

At discharge, most patients pre- and postprotocol had moderate disability (70.2% vs. 50.3%), went home without the need for professional assistance (59.7% vs. 49.2%), and were GOS classified as "good recovery" (50% vs. 60%).

"Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons," the authors concluded.

The results are particularly relevant, as the literature is scant regarding the management of ICHs of 1 cm or less. Moreover, the number of trauma activations resulting from falls is expected to increase with the aging American population, the investigators noted.

Falls are the second leading cause of trauma activations, and half of fall fatalities and associated costs are related to traumatic brain injury. Falls also constitute 52% of emergency department visits for adults aged 75 years or older.

Despite the potential for turf wars when departmental duties are shifted, "neurosurgeons were delighted" with the new protocol, senior author and JPS medical director of trauma services Dr. Rajesh Gandhi said in an interview. In fact, it was two neurosurgeons who developed and initiated the protocol change.

The researchers are currently acquiring data from the National Trauma Bank to examine differences in ICH outcomes in a larger sample.

"Additionally, we want to look at the range in which trauma surgeons can effectively manage ICH, and determine the point at which neurosurgeon management results in significant differences in outcome," said Ms. Littleton. "This can also translate to rural health care in terms of transferring these types of patients to trauma centers."

Ms. Littleton and her coauthors reported no financial conflicts of interest. Dr. Gandhi serves as a speaker for LifeCell and KCI.