J Neurocrit Care.  2020 Dec;13(2):80-85. 10.18700/jnc.200011.

Minimal-risk traumatic brain injury management without neurosurgical consultation

• Compton ES
• Smallheer BA
• Thomason NR
• Norris MS
• Nordness MF
• Smith MD
• Patel MB

• KMID: 2509936
• DOI: http://doi.org/10.18700/jnc.200011

Abstract

Background
Traumatic brain injury (TBI) with intracranial hemorrhage management results in clinical practice variability, complexity, and/or limitations in acute care surgical and radiological workflow, which can prompt neurosurgical consultation, even when unnecessary. To facilitate an interdisciplinary practice for minimal-risk TBI, our objective was to create and sustain a neurotrauma protocol change that we hypothesized would not result in outcome differences.
Methods
A retrospective pre-post cohort study was conducted over an eight-month period to evaluate the protocol change toward trauma team management of TBI with isolated pneumocephalus and/or subarachnoid hemorrhage (SAH) given a normal neurologic exam (i.e., minimal-risk TBI) without neurosurgery consultation. Demographics of age and Glasgow coma scale (GCS) were collected and expressed in means. Target outcomes consisted of protocol compliance, management compliance (e.g., nursing neurologic checks, thromboembolism prophylaxis, seizure prophylaxis, speech-cognitive testing, follow-up), neurological worsening, increasing therapeutic intensity levels, and TBI-related 30-day readmission.
Results
Of the 49 patients included, 21 were in the pre-group (age, 54.19 years; GCS, 15) and 28 were in the post-group (age, 52.25 years; GCS, 15). There was 5% and 36% non-compliance with pre- and post-protocol practices in terms of neurosurgery consultation rates. In both pre- and post-periods, management compliance was similar, and none of the TBI patients experienced a worsening neurologic exam, increased therapeutic intensity level, or re-admission.
Conclusion
Minimal TBI-risk protocol compliance was weaker after the practice change although management compliance and outcomes remained unchanged. This work supports that minimal-risk TBI patients with SAH and normal neurologic exams can be safely managed by trauma teams without neurosurgery consultation.

Keyword

Traumatic brain injury; Quality improvement; Neurotrauma; Trauma surgery; Neurosurgery

Figure

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  Fig. 1. Minimal-risk traumatic brain injury without neurosurgery. ED, emergency department; CT, computed tomography; GCS, Glasgow coma scale; SAH, subarachnoid hemorrhage; IPH, intraparenchymal hemorrhage; EDH, epidural hemorrhage; SDH, subdural hemorrhage; Q4h, every 4 hours; Surgery OK 12 hr post-injury, surgery authorized on/after 12 hours post-injury; Q2h, every 2 hours; TBI, traumatic brain injury; DVT, deep-venous thrombosis.

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