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Head trauma and nonsurvival—a sample survey
Neurol 1788;30:273-5
273
Surg
Head Trauma
and Nonsurvival-A
Eldon L. Foltz, M.D., and Jose Rodriquez, Division of Neurosurgery,
Foltz EL, Rodriquez survey. Surg Neurol
University
J. Head trauma 1988;30:273-5.
M.D.
of California, Irvine Medical Center, Orange, California
and nonsurvival-a
sample
A retrospective survivor study of 42 patients with severe brain and multisystem injury is presented. Al1 patients were treated with vigorous trauma/neurosurgical techniques. Thirty-seven patients in this series had a Glasgow Coma Score of 3 at the initial examination, and none survived. Since al1 37 patients at initial emergency room evaluation showed persistent apnea at 40-60 minutes after injury, a diagnosis of dead on arrival (DOA) might have been appropriate. Cost analysis shows that the direct tost for the 37 cases was $27,000 per patient, or $9!90,000 for the 37 patients with no survivors. A diagnosis of DOA would have been $200 per patient. Many implications can be derived from these figures. KEY WORDS: Head trauma; Emergency gency room diagnosis
medical care; Emer-
This study of head injuries was precipitated by the reported realization over several years that several factors in our trauma care system for Orange County, Calif. had become worrisome to experienced neurosurgeons: (a) the mortality rate for head injuries from motor vehicle accidents had not changed since extensive development and reorganization by the Emergency Medical Service (EMS) (Federal program) in Orange County concerning the emergency care system; (6) the diagnosis of dead on arrival (DOA) had virtually disappeared from the emergency room (ER) statistics compared to pre-1980 before the EMS was installed; (c) apparently al1 patients with severe head injury were admitted to the hospita1 irrespective of the degree of life or death present at the initial ER examination; (d) ER evaluation by the neurosurgery division for severe head injury had become a consultation request from the trauma service, and the neurosurgical advice was not Presented at the American Academy of Neurological Surgery Annual Meeting, San Antonio, Texas, October 9, 1987. Address reprint requests to; Eldon L. Fok, M.D., Division of Neurosurgery, University of California, Irvine Medical Center, 101 City Drive South, Orange, California 92668. Received February 23, 1988; accepted April 13, 1988. 0 1988 by Elsevier Science Publishing Co., lnc.
Sample Survey
necessarily followed; initial emergency action by the trauma team was fast and efficient-the unconscious head-injured patient was always paralyzed, intubated, and placed on a mechanica1 respirator after only limited centra1 nervous system (CNS) examination; (e) in cases of severe multiple system injury (including brain), emergency operations (such as on the abdomen) were performed on patients whom the neurosurgery division believed to be already dead or nonsurvivors, yet we felt forced to operate on the brain lesion to remove a cerebral blood clot as demonstrated by computed tomography scanning after having seen the patient first only in the operating room. Experienced neurosurgeons have a sense of futility when patients with a severe brain injury are admitted CO the hospita1 after an ER evaluation demonstrates that the patient: 1) has suffered severe brain trauma with persisting apnea within the preceding 60 minutes, 2) had a persisting Glasgow Coma Scale score of 3 or 4, 3) has been intubated and is on mechanica1 ventilation, and 4) has normal blood gases with a negative drug screen. A review of 42 such cases brought to the ER at University of California, Irvine Medical Center during 1986 has therefore been made, using only selection criteria as above. The goals were limited and twofold: 1) to assess survival under aggressive management and 2) to calculate the direct costs of these efforts.
Clinical
Material
and Methods
The selection criteria of these patients were (a) severe brain injury with or without multisystem injury, (6) persisting apnea or near apnea during 40 minutes after injury and requiring emergency intubation to protect the airway and prevent hypoxia; (c) stabilized blood pressure and negative drug screen. Al1 of the patients were designated as “trauma pa-
Table Category Male Female
1. Sex and Age of Victims in Sample No. of patients 35 7
Age range (years)
Mean age (years)
3-71 3-38
31 22
OOOO-3019/88/$3.50
274
Table
Surg Neurol 1988;30:273-5
2.
Foltz ad
Disposition of CU.IU
Treatment
No. of patients
Operation No operation DOA
1‘ 2s 0
NLlnSUrVi\,0rs
SllrVl\orS
13 ‘4
I
1
tients” in which our leve1 1 trauma facility assembled the full trauma team in the emergency room to await the arrival of the patient for evaluation and treatment. The standard of practice was to have emergency care initially directed by the trauma surgeon until the arrival of the neurosurgeon [4,1 l]. These 42 patients arrived in the emergency room with a Glasgow Coma Score (GCS) of 3 or 4. After stabilization of the airway and bloed pressure, the GCS has not improved. At 40-60 minutes, apnea persisted. The predominantly male population in this study does not differ from nationally reported statistics on mean age and sex in trauma victims (Table 1) [ 1.31. There were 37 deaths (88% ) and only live survivors. These five survivors had only CNS injury but two remained in a vegetative state, and two were left with severe cognitive deficits and permanently disabled. Among the deaths, 17 patients died in the emergency room, 17 had a neurosurgical operation, and 8 went to the surgical intensive care unit without requiring an operation. Only one patient had a good outcome after evacuation of an acute epidural hematoma; this patient had only CNS injury and a GCS of 4 (Table 2). The patients were divided into three groups, using both GCS [9,10] and the predictive trauma score [2,3,6,7). Groups 1 and 2 had lOOY+ mortality. Group 3 consisted of patients with brain injury only and showed no mortality. However, morbidity was significant with the exception of one patient who had an epidural hematoma evacuated. The most alarming results are in the first two groups who had lOO$Y mortaility (Table 3). A tost analysis on patient care was done for these patients similar to prior reports [7,13,14]. These direct tost data were obtained from hospita1 billing statistics and do not include indirect tost analysis (Table 4). Our findings of high mortaility for those patients who had severe head injury with a persisting GCS of less than 4 are similar to the high mortality (73f1 ) reported
Table Patient @OUP
3.
Rodriquez
Outcone Initial GCS
1 2
3 3
3
4
ofItzjuq Predictive trauma score 2 3-4
-5
5-day mortality
100’; 1ow; O’f
Na of paciencs
10 5
by others [2,5,8,12]. Stil1 others have reported 100c/( mortality no matter what medical or surgical intcrvention is given ET, 111. Fischer and his group [7] believed it was futile to continue resuscitative measures on patients with trauma scores less than 2, or if less than 4 associated with cardiovascular instability continuing for 1 hom; in their study 100% mortality occurred in such patients. We have not identifïed the specific group of patients who have 1OOyC mortality in al1 situations, but there is no doubt that a significant amount of unneeded intensive medical/surgical care was rendered in this study. This may be related to the medical-legal practice of a limited initial clinical evaluation, in which al1 patients with significant respiratory distress at ER entry are immediately paralyzediintubated and placed on a mechanica1 ventilator for “airway control.” The neurc‘surgical evaluation comes at a later phase. Under these conditions, a diagnosis of DOA is rarely made. The tost analysis compares the tost of the DOA diagnosis ($200 per patient) with the emergency head trauma care sequence ($27,000 per patient), with no survivors in 37 patients, groups 1 and 11. These facts must urge al1 concerned to improve initial head injury evaluations to the extent that the diagnosis of DOA reappears in our statistical summary of ER patients with head injury [4]. Taking al1 precaution to insure that apnea is due to the brain trauma, we would classify a patient who remains apneic at 40-60 minutes after severe multisystem neurotrauma as DOA. A physician wel1 trained in neurological trauma can substantiate such a diagnosis at the first evaluation and avoid an excessive treatment routine. Medicolegal consideration may favor practice as described in this series. However, if this situation as presented is widely prevalent, lawyers may condemn excessive treatment instead. If DOA can be clearly established by competent physicians, highly expensive, emotionally charged salvage routines can be avoided and should have only favorable medicolegal implications.
References 1. Alberico
AM, Ward JD, Choi SC, et al. Outcome afcer severe head injury: relacionship to mass Iesions, diffuse injury, and ICP course in pediatrie and adult patients. J Neurosurg 1987;h’:G485(X
Head Trauma
Surg Neurol 1988:30:273-5
and Nonsurvival
2. Becker DP, Miller JD, Ward JD, et al. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 1977;47:491-502. 3. Braakman R, Gelpke GJ, Habbeman JDF, et al. Systematic selection of prognostic features in patients with severe head injury. Neurosurgery 1980;6:362-70. 4. Cales R. Trauma mortality in Orange County: the effect of implementation of a regional trauma system. Ann Emerg Med 1985;13:1-24. 5. Carlsson CA, von Essen C, Lofgren J. Factors affecting the clinical course of patients with severe head injuries. 1. Influence of biological factors. 2. Significante of posttraumatic coma. J Neurosurg 1968;29:242-5 1. 6. Champion
H. Trauma
score.
Crit Care Med 1981;9:672-75.
7. Fischer R, Flynn T, Miller P, et al. The economics dollars and sense. J Trauma 1985;25:746-50.
of fatal injury:
8. Gennarelli TA, Spielman GM, Langfitt TW, et al. Influence of the type of intracranial Iesion on outcome from severe head injury:
a multicenter 1982;56:26-32.
study
using
a new
9. Jennett B, Bond M. Assessment damage: a practica1 scale. Lancet
classification.
of outcome 1975;1:480-4.
275
J Neurosurg
after severe
brain
10. Jennett B, Teasdale G, Braakman R, et al. Predicting outcome in individual patients after severe head injury. Lancet 1976;1:103111. Laws D. Trauma operation room in conjunction with an air ambulance system: Indications, interventions, and outcomes. J Trauma 1982;22:759-65. 12. Miller JD, Butterworth in the management 1981;54:289-99. 13. Munoz Trauma
of
JF, Gudeman SK. Furcher severe head injury. J
E. Economie costs 1984;24:237-44.
of trauma,
United
experience Neurosurg
States,
1982. J
14. Oakes D, Holcomb S, Sherck J, Patterns of trauma care costs and reimbursements: the burden of uninsured motorists. J Trauma 1985;25:740-5.
273
Surg
Head Trauma
and Nonsurvival-A
Eldon L. Foltz, M.D., and Jose Rodriquez, Division of Neurosurgery,
Foltz EL, Rodriquez survey. Surg Neurol
University
J. Head trauma 1988;30:273-5.
M.D.
of California, Irvine Medical Center, Orange, California
and nonsurvival-a
sample
A retrospective survivor study of 42 patients with severe brain and multisystem injury is presented. Al1 patients were treated with vigorous trauma/neurosurgical techniques. Thirty-seven patients in this series had a Glasgow Coma Score of 3 at the initial examination, and none survived. Since al1 37 patients at initial emergency room evaluation showed persistent apnea at 40-60 minutes after injury, a diagnosis of dead on arrival (DOA) might have been appropriate. Cost analysis shows that the direct tost for the 37 cases was $27,000 per patient, or $9!90,000 for the 37 patients with no survivors. A diagnosis of DOA would have been $200 per patient. Many implications can be derived from these figures. KEY WORDS: Head trauma; Emergency gency room diagnosis
medical care; Emer-
This study of head injuries was precipitated by the reported realization over several years that several factors in our trauma care system for Orange County, Calif. had become worrisome to experienced neurosurgeons: (a) the mortality rate for head injuries from motor vehicle accidents had not changed since extensive development and reorganization by the Emergency Medical Service (EMS) (Federal program) in Orange County concerning the emergency care system; (6) the diagnosis of dead on arrival (DOA) had virtually disappeared from the emergency room (ER) statistics compared to pre-1980 before the EMS was installed; (c) apparently al1 patients with severe head injury were admitted to the hospita1 irrespective of the degree of life or death present at the initial ER examination; (d) ER evaluation by the neurosurgery division for severe head injury had become a consultation request from the trauma service, and the neurosurgical advice was not Presented at the American Academy of Neurological Surgery Annual Meeting, San Antonio, Texas, October 9, 1987. Address reprint requests to; Eldon L. Fok, M.D., Division of Neurosurgery, University of California, Irvine Medical Center, 101 City Drive South, Orange, California 92668. Received February 23, 1988; accepted April 13, 1988. 0 1988 by Elsevier Science Publishing Co., lnc.
Sample Survey
necessarily followed; initial emergency action by the trauma team was fast and efficient-the unconscious head-injured patient was always paralyzed, intubated, and placed on a mechanica1 respirator after only limited centra1 nervous system (CNS) examination; (e) in cases of severe multiple system injury (including brain), emergency operations (such as on the abdomen) were performed on patients whom the neurosurgery division believed to be already dead or nonsurvivors, yet we felt forced to operate on the brain lesion to remove a cerebral blood clot as demonstrated by computed tomography scanning after having seen the patient first only in the operating room. Experienced neurosurgeons have a sense of futility when patients with a severe brain injury are admitted CO the hospita1 after an ER evaluation demonstrates that the patient: 1) has suffered severe brain trauma with persisting apnea within the preceding 60 minutes, 2) had a persisting Glasgow Coma Scale score of 3 or 4, 3) has been intubated and is on mechanica1 ventilation, and 4) has normal blood gases with a negative drug screen. A review of 42 such cases brought to the ER at University of California, Irvine Medical Center during 1986 has therefore been made, using only selection criteria as above. The goals were limited and twofold: 1) to assess survival under aggressive management and 2) to calculate the direct costs of these efforts.
Clinical
Material
and Methods
The selection criteria of these patients were (a) severe brain injury with or without multisystem injury, (6) persisting apnea or near apnea during 40 minutes after injury and requiring emergency intubation to protect the airway and prevent hypoxia; (c) stabilized blood pressure and negative drug screen. Al1 of the patients were designated as “trauma pa-
Table Category Male Female
1. Sex and Age of Victims in Sample No. of patients 35 7
Age range (years)
Mean age (years)
3-71 3-38
31 22
OOOO-3019/88/$3.50
274
Table
Surg Neurol 1988;30:273-5
2.
Foltz ad
Disposition of CU.IU
Treatment
No. of patients
Operation No operation DOA
1‘ 2s 0
NLlnSUrVi\,0rs
SllrVl\orS
13 ‘4
I
1
tients” in which our leve1 1 trauma facility assembled the full trauma team in the emergency room to await the arrival of the patient for evaluation and treatment. The standard of practice was to have emergency care initially directed by the trauma surgeon until the arrival of the neurosurgeon [4,1 l]. These 42 patients arrived in the emergency room with a Glasgow Coma Score (GCS) of 3 or 4. After stabilization of the airway and bloed pressure, the GCS has not improved. At 40-60 minutes, apnea persisted. The predominantly male population in this study does not differ from nationally reported statistics on mean age and sex in trauma victims (Table 1) [ 1.31. There were 37 deaths (88% ) and only live survivors. These five survivors had only CNS injury but two remained in a vegetative state, and two were left with severe cognitive deficits and permanently disabled. Among the deaths, 17 patients died in the emergency room, 17 had a neurosurgical operation, and 8 went to the surgical intensive care unit without requiring an operation. Only one patient had a good outcome after evacuation of an acute epidural hematoma; this patient had only CNS injury and a GCS of 4 (Table 2). The patients were divided into three groups, using both GCS [9,10] and the predictive trauma score [2,3,6,7). Groups 1 and 2 had lOOY+ mortality. Group 3 consisted of patients with brain injury only and showed no mortality. However, morbidity was significant with the exception of one patient who had an epidural hematoma evacuated. The most alarming results are in the first two groups who had lOO$Y mortaility (Table 3). A tost analysis on patient care was done for these patients similar to prior reports [7,13,14]. These direct tost data were obtained from hospita1 billing statistics and do not include indirect tost analysis (Table 4). Our findings of high mortaility for those patients who had severe head injury with a persisting GCS of less than 4 are similar to the high mortality (73f1 ) reported
Table Patient @OUP
3.
Rodriquez
Outcone Initial GCS
1 2
3 3
3
4
ofItzjuq Predictive trauma score 2 3-4
-5
5-day mortality
100’; 1ow; O’f
Na of paciencs
10 5
by others [2,5,8,12]. Stil1 others have reported 100c/( mortality no matter what medical or surgical intcrvention is given ET, 111. Fischer and his group [7] believed it was futile to continue resuscitative measures on patients with trauma scores less than 2, or if less than 4 associated with cardiovascular instability continuing for 1 hom; in their study 100% mortality occurred in such patients. We have not identifïed the specific group of patients who have 1OOyC mortality in al1 situations, but there is no doubt that a significant amount of unneeded intensive medical/surgical care was rendered in this study. This may be related to the medical-legal practice of a limited initial clinical evaluation, in which al1 patients with significant respiratory distress at ER entry are immediately paralyzediintubated and placed on a mechanica1 ventilator for “airway control.” The neurc‘surgical evaluation comes at a later phase. Under these conditions, a diagnosis of DOA is rarely made. The tost analysis compares the tost of the DOA diagnosis ($200 per patient) with the emergency head trauma care sequence ($27,000 per patient), with no survivors in 37 patients, groups 1 and 11. These facts must urge al1 concerned to improve initial head injury evaluations to the extent that the diagnosis of DOA reappears in our statistical summary of ER patients with head injury [4]. Taking al1 precaution to insure that apnea is due to the brain trauma, we would classify a patient who remains apneic at 40-60 minutes after severe multisystem neurotrauma as DOA. A physician wel1 trained in neurological trauma can substantiate such a diagnosis at the first evaluation and avoid an excessive treatment routine. Medicolegal consideration may favor practice as described in this series. However, if this situation as presented is widely prevalent, lawyers may condemn excessive treatment instead. If DOA can be clearly established by competent physicians, highly expensive, emotionally charged salvage routines can be avoided and should have only favorable medicolegal implications.
References 1. Alberico
AM, Ward JD, Choi SC, et al. Outcome afcer severe head injury: relacionship to mass Iesions, diffuse injury, and ICP course in pediatrie and adult patients. J Neurosurg 1987;h’:G485(X
Head Trauma
Surg Neurol 1988:30:273-5
and Nonsurvival
2. Becker DP, Miller JD, Ward JD, et al. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 1977;47:491-502. 3. Braakman R, Gelpke GJ, Habbeman JDF, et al. Systematic selection of prognostic features in patients with severe head injury. Neurosurgery 1980;6:362-70. 4. Cales R. Trauma mortality in Orange County: the effect of implementation of a regional trauma system. Ann Emerg Med 1985;13:1-24. 5. Carlsson CA, von Essen C, Lofgren J. Factors affecting the clinical course of patients with severe head injuries. 1. Influence of biological factors. 2. Significante of posttraumatic coma. J Neurosurg 1968;29:242-5 1. 6. Champion
H. Trauma
score.
Crit Care Med 1981;9:672-75.
7. Fischer R, Flynn T, Miller P, et al. The economics dollars and sense. J Trauma 1985;25:746-50.
of fatal injury:
8. Gennarelli TA, Spielman GM, Langfitt TW, et al. Influence of the type of intracranial Iesion on outcome from severe head injury:
a multicenter 1982;56:26-32.
study
using
a new
9. Jennett B, Bond M. Assessment damage: a practica1 scale. Lancet
classification.
of outcome 1975;1:480-4.
275
J Neurosurg
after severe
brain
10. Jennett B, Teasdale G, Braakman R, et al. Predicting outcome in individual patients after severe head injury. Lancet 1976;1:103111. Laws D. Trauma operation room in conjunction with an air ambulance system: Indications, interventions, and outcomes. J Trauma 1982;22:759-65. 12. Miller JD, Butterworth in the management 1981;54:289-99. 13. Munoz Trauma
of
JF, Gudeman SK. Furcher severe head injury. J
E. Economie costs 1984;24:237-44.
of trauma,
United
experience Neurosurg
States,
1982. J
14. Oakes D, Holcomb S, Sherck J, Patterns of trauma care costs and reimbursements: the burden of uninsured motorists. J Trauma 1985;25:740-5.