Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80 years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80 years of age. Data were derived from the TraumaRegister DGU® from 2002 to 2016. Inclusion criteria were ≥ 80 years of age, an Abbreviated Injury ScaleHead (AIS) ≥ 3, and an AISNon-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AISHead of 5/6 (p = 0.03). Patients 80 years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.

OBJECTIVE:Severe traumatic brain injury (TBI) has a major influence on polytrauma outcome. The aim of this study was to evaluate the impact of body mass index (BMI) on mortality and early neurologic outcome in patients suffering from severe TBI with a special focus on obesity classes II and III (BMI ≥35). METHODS:A retrospective cohort analysis of patients suffering from a leading, at least severe TBI and registered in the TraumaRegister DGU was conducted. Patients alive on admission with full status documentation on Glasgow Coma Scale, height, and weight were classified into 4 BMI subgroups. Early neurologic outcome was classified using the Glasgow Outcome Scale. RESULTS:A total of 1634 patients met the inclusion criteria. Lowest mortality was documented for BMI group 1 (15.2%, BMI 25.0-29.9918.5). Highest mortality was found in BMI group 5 (25.6%, BMI ≥35). BMI ≥35 was an independent predictor of mortality with an odds ratio of 3.15 (95% confidence interval [1.06-9.36], P = 0.039). Further independent mortality predictors were >65 years of age, a Glasgow Coma Scale of ≤13, an Abbreviated Injury Scalehead ≥5, prehospital cardiopulmonary resuscitation, and a prehospital blood pressure of <90 mm Hg. In terms of good early neurologic outcomes, no differences were recorded between the BMI groups (range 59.0%-62.6%, P = 0.087). CONCLUSIONS:In this study a BMI ≥35 is an independent predictor of mortality and is associated with an inferior early functional neurologic outcome.

BACKGROUND:Although unconsciousness (Glasgow Coma Scale [GCS] 3 to 8) necessitates intubation according national guidelines, there is a notable lack of evidence to support this approach. This study evaluates the impact on outcome of prehospital intubation with and without sedation in trauma patients with a GCS of ≤8. METHODS:A retrospective cohort analysis of severely injured trauma patients registered in the TraumaRegister DGU of the German Trauma Society (DGU) from 2002 to 2013 was conducted. Only directly admitted patients alive on admission and with a GCS of ≤8 at the scene were included. The observed outcome was matched with the expected outcome deriving from the Revised Injury Severity Classification, version II (RISC-II). Furthermore, a Standardized Mortality Ratio (SMR) was calculated for various subgroups. Early neurological outcome was classified using the Glasgow Outcome Scale. RESULTS:A total of 21,242 patients fulfilled the study inclusion criteria. A total of 18,975 patients (89.3%) received prehospital intubation. Intubation rates were continuously increasing with decreasing GCS score values. Difference between observed and expected mortality was lower in intubated patients (42.2% [95% confidence interval (CI), 41.5%-42.9%]; RISC-II prognosis 41.4%; SMR 1.020 [95% CI, 1.003-1.037]) compared with nonintubated (30.0% [95% CI, 28.1-31.9%] RISC-II prognosis 26.6% and SMR 1.128 [95% CI, 1.057-1.199]). Patients being sedated before intubation presented significant (P<0.001) lower observed mortality (37.7% [95% CI, 36.7-38.7%], RISC-II prognosis 39.0%, SMR 0.967 [95% CI, 0.951-0.983]) associated with a less poor early neurological outcome compared with those being intubated without sedation. CONCLUSIONS:Observed outcome of prehospital intubated patients with a GCS of ≤8 seems less poor than predicted compared with nonintubated patients. Sedation before intubation might potentially decrease mortality and improve early neurological outcome. Further studies are required to clarify this issue.

Objectives Early diagnosis of traumatic brain injury and reliable prediction of outcome are essential for determining treatment strategies and allocating resources. This study re-evaluates the Eppendorf–Cologne Scale (ECS) and its predictive accuracy for outcome compared with the Glasgow Coma Scale (GCS). Methods A prospective cohort analysis of severely injured trauma patients registered in the Trauma Registry of the German Society for Trauma Surgery from 2012–2013 was carried out. Only directly admitted patients alive on admission with complete data on GCS, ECS and outcome in terms of survival to hospital discharge or death were included. The predictive accuracy in terms of the outcome of the ECS and the GCS was modelled using area under the receiver operating characteristic (AUROC) curve analysis. Results A total of 17 616 patients fulfilled the study inclusion criteria. The ECS outmatched the predictive accuracy of the GCS for outcome (AUROC, 0.853, 95% confidence interval, 0.831–0.854; and AUROC 0.836; 95% confidence interval, 0.825–0.848, respectively; P =0.062). An ECS score of 8 was associated with a 25-fold higher mortality compared with an ECS score of 0. Patients who had an ECS score of 8 had a 1.5-fold higher mortality compared with patients allocated a GCS score of 3. Conclusion The ECS shows a higher accuracy for prediction of outcome compared with the GCS and enables further differentiation within the critical GCS 3 collective.

OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIShead) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIShead score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.

BACKGROUND:Early diagnosis of traumatic brain injury (TBI) and reliable prediction of outcome are essential for determining treatment strategies and allocating resources. This study introduces the Eppendorf-Cologne Scale (ECS) and evaluated its predictive accuracy for outcome and TBI presence compared with those of the Glasgow Coma Scale (GCS). METHODS:A retrospective cohort analysis of severely injured trauma patients registered in the Trauma Registry of the German Society for Trauma Surgery from 1993 to 2010 was conducted. Only directly admitted patients alive on admission and with complete data on GCS, pupil reactivity, and size were included. The ECS was modeled using pupil reactivity, size, and a modified GCS motor component. The unadjusted predictive role of each component was evaluated using multivariable regression analysis. The predictive power regarding the presence of TBI and outcome of the ECS and the GCS was modeled using area under the receiver operating characteristic (AUROC) curve analyses. RESULTS:A total of 28,305 patients fulfilled the study inclusion criteria. The ECS outmatched the predictive accuracy of the GCS for outcome (AUROC, 0.824; 95% confidence interval [95% CI], 0.817-0.831; and AUROC, 0.811; 95% CI, 0.804-0.818, respectively; rs = 0.887, p < 0.001) and TBI presence (AUROC, 0.813; 95% CI, 0.805-0.822; and AUROC, 0.777; 95% CI, 0.768-0.786, respectively; rs = 0.889, p < 0.001). Patients with TBI were five times more often unconscious at the scene and showed a 3.5-fold increased in-hospital mortality. An ECS score of 8 was associated with a 20-fold higher mortality compared with an ECS score of 0. The ECS differentiates patients with a fourfold higher mortality within the GCS 3 collective. CONCLUSION:The ECS shows a significantly higher accuracy for prediction of outcome and TBI presence compared with the GCS and provides a simple, yet reliable, stratification tool for early decision making. LEVEL OF EVIDENCE:Prognostic study, level III.

BACKGROUND:Varying results have been reported concerning the effect of body mass index (BMI) on polytrauma outcome. Although most studies focus on obesity and its associated preexisting medical diseases as a predictor for increased mortality rates, there is evidence that polytrauma patients with underweight also face an inferior outcome. METHODS:Records of 5766 trauma patients (minimum 18 years of age, Injury Severity Score ≥ 16, treated from 2004 to 2008) documented in the Trauma Registry of the German Society for Trauma Surgery were subclassified into 4 BMI groups and analysed to assess the impact of BMI on polytrauma outcome. RESULTS:Underweight (BMI Group I) as well as obesity (BMI Group IV) in polytraumatized patients are associated with significantly increased mortality by multivariate logistic regression analysis with hospital mortality as the target variable (adjusted odds ratio for BMI Group I, 2.1 (95% CI 1.2-3.8, p = 0.015); for BMI Group IV, 1.6 (95% CI 1.1-2.3, p = 0.009)). Simple overweight (BMI Group III) does not qualify as a predictor for increased mortality (odds ratio 1.0; 95% CI 0.8-1.3). CONCLUSIONS:There is a significant correlation between obesity, underweight, and increased mortality in polytraumatized patients. Efforts to promote optimal body weight may reduce not only the risk of chronic diseases but also the risk of polytrauma mortality amongst obese and underweight individuals.