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Neuro, trauma, or med/surg intensive care unit: Does it matter where multiple injuries patients with traumatic brain injury are admitted? Secondary analysis of the American Association for the Surgery of Trauma Multi-Institutional Trials Committee decompressive craniectomy study

Lombardo, Sarah MD; Scalea, Thomas MD; Sperry, Jason MD; Coimbra, Raul MD; Vercruysse, Gary MD; Enniss, Toby MD; Jurkovich, Gregory J. MD; Nirula, Raminder MD, MPH

Journal of Trauma and Acute Care Surgery: March 2017 - Volume 82 - Issue 3 - p 489–496
doi: 10.1097/TA.0000000000001361
AAST 2016 Plenary Papers

INTRODUCTION Patients with nontraumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without traumatic brain injury (TBI) fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU.

METHODS This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head computed tomography (CT) scans of patients with Glasgow Coma Scale score of 13 or less and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU type and survival and calculate the probability of death for increasing Injury Severity Score (ISS). Multiple injuries patients (ISS > 15) with TBI and isolated TBI patients (other Abbreviated Injury Scale score < 3) were analyzed separately.

RESULTS There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Before adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit type, age, and ISS remained independent predictors of death. Unit type modified the effect of ISS on mortality. TBI multiple injuries patients admitted to a TICU had improved survival across increasing ISS. Survival for isolated TBI patients was similar between TICU and NICU. Med/surg ICU carried the greatest probability of death.

CONCLUSION Multiple injuries patients with TBI have lower mortality risk when admitted to a trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a neuro ICU compared with a trauma ICU. Med/surg ICU admission carries the highest mortality risk.

LEVEL OF EVIDENCE Therapeutic study, level IV.

Department of Surgery (S.L.), University of Utah, Salt Lake City, Utah; Baltimore Shock Trauma, (T.S.) University of Maryland, Baltimore, Maryland; Department of Surgery, Division of Trauma and General Surgery (J.S.) University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery, Division of Trauma, Surgical Critical Care, Burns, and Acute Cares Surgery (R.C.), University of California, San Diego, California; Department of Surgery (G.V.), The University of Arizona Medical Center, Tucson, Arizona; Department of Surgery (T.E.), University of Utah, Salt Lake City, Utah; Department of Surgery (G.J.J.), UC Davis Health System, Sacramento, California; and Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah.

Submitted: August 4, 2016, Revised: November 7, 2016, Accepted: December 9, 2016, Published online: December 28, 2016.

This study was presented at the 75th annual meeting of the American Association for the Surgery of Trauma, September 14–17, 2016, in Waikoloa, Hawaii.

Financial Support: This was a secondary analysis of data that was obtained from an NIH funded study (NIH National Institute of Neurological Disorders and Stroke 1RC1NS069066-01 and 5RC1NS069066-02) which was completed and published (article PMID: 24662856). The analysis for this article was not directly funded by this grant only the acquisition of the data on which it is based.

Address for reprints: Sarah Lombardo, MD, Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132; email: sarah.lombardo@hsc.utah.edu.

© 2017 Lippincott Williams & Wilkins, Inc.