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More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes Quoc Dang, DO,a,b,* Joshua Simon, DO,a,b Joe Catino, MD,b,c Ivan Puente, MD,b,c Fahim Habib, MD,b,c Lloyd Zucker, MD,b and Marko Bukur, MDb,c a

Department of Surgery, Larkin Community Hospital, South Miami, Florida Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida c Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida b

article info

abstract

Article history:

Background: In an expanding elderly population, traumatic brain injury (TBI) remains a

Received 5 January 2015

significant cause of death and disability. Guidelines for management of TBI, according to

Received in revised form

the Brain Trauma Foundation (BTF), include intracranial pressure (ICP) monitoring.

16 March 2015

Whether ICP monitoring contributes to outcomes in the elderly patients with TBI has not

Accepted 27 March 2015

been explored.

Available online xxx

Methods: This is a retrospective study extracted from the National Trauma Database 2007e2008 research datasets. Patients were included if aged >55 y and they met BTF in-

Keywords:

dications for ICP monitoring. Patients that had nonsurvivable injuries (any body region,

Traumatic brain injury

abbreviated injury score ¼ 6), were dead on arrival, had withdrawal of care, or length of

Elderly

stay 65 y) is the fastest growing age group in the United States and will encompass 20% of the population in this country over the ensuing decade [1]. Traumatic injury continues to be a significant cause of death and disability in the elderly population, and the incidence of trauma in this population will only continue to rise. A large part of injuries suffered by these patients include traumatic brain injury (TBI). Over the past decade, the incidence of TBI in elderly patients increased from 373.1 per 100,000 to 603.3 per 100,000. Eighty-two percent were caused by falls, followed by pedestrian struck, motor vehicle accidents, and other causes [2]. Mortality rates for elderly TBI patients are nearly double than those seen in the younger population, even for mild injuries. This is likely due to unique factors in the elderly TBI patient that accelerate the ongoing senescent process of neuronal loss. These factors include atrophy of brain tissues leading to increased susceptibility to immediate vascular damage [3], increased blood vessel permeability [4], and diminished ability to autoregulate cerebral blood flow [5]. Furthermore, long-term psychological and physical disabilities are frequently observed and are likely secondary to decreased neuronal plasticity [6]. One of the most important and controversial aspects of managing trauma patients with TBI is the utilization of intracranial pressure (ICP) monitors. Sustained elevations of ICP have been associated with increased mortality and poorer outcomes [7e9]. According to the Brain Trauma Foundation (BTF), ICP monitoring is indicated in patients with severe TBI (Glasgow coma scale [GCS] 3e8) with an abnormal computed tomography (CT) scan of the brain or those with a normal brain CT if any two of the following conditions are met: age is >40 y, motor posturing is present, or systolic blood pressure (SBP) after resuscitation is 55 y. As the NTDB does not have CT scan

results available as a data field, the head abbreviated injury score (AIS) was used as a proxy. A value of three or higher is indicative of an intracranial bleed, and in all practicality, was most likely to be identified on CT imaging because it is exceedingly rare for patients with TBI to be taken directly to the operating room on clinical examination alone. Patients were excluded if the AIS in any body region was equal to 6 (i.e., a nonsurvivable injury), died in the emergency department (ED), underwent withdrawal of care, or had a hospital a length of stay (LOS) of 25 (%) ISS AIS, median, (IQR) Isolated head injury (%) Immediate OR (%) Craniotomy (%) ICU admission (%)

6.5 150.46  38.1 (148.5) 65.9 1 (1e1) 1 (1e1) 1 (1e3) 3 (3e6] 9.3 93.7 4 (4e5) 0 (0e3) 0 (0e0) 0 (0e0) 58.2 26 (25e35) 70.0 32.5 23.2 94.7

9.9 145.66  39.38 (145) 66.1 1 (1e1) 1 (1e1) 1 (1e2) 3 (3e6) 8.9 81.1 4 (4e5) 0 (0e2) 0 (0e0) 0 (0e0) 40.6 25 (17e29) 72.2 17.9 9.0 87.6

9.5 146.2  39.3 (145) 66.1 1 (1e1) 1 (1e1) 1 (1e2) 3 (3e6) 9.0 82.6 4 (4e5) 0 (0e2) 0 (0e0) 0 (0e0) 42.6 25 (17e29) 72.0 19.5 10.6 88.2

0.015 0.01 0.912 0.09 0.095 0.332 0.952 0.79

More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes.

In an expanding elderly population, traumatic brain injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI...
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