Author summary Why was this study done? Traumatic brain injury (TBI) poses a huge global disease burden, considered to mainly result from high-energy transfer mechanisms such as road traffic... Show moreAuthor summary Why was this study done? Traumatic brain injury (TBI) poses a huge global disease burden, considered to mainly result from high-energy transfer mechanisms such as road traffic collisions, sports, falls from a height, and interpersonal violence.People injured through low-energy transfer (ground- or low-level falls) are considered less likely to sustain significant TBI, so can be given lower priority for acute specialist care within emergency medical services (triage decisions).Recent multinational studies challenge these assumptions by identifying falls as an important TBI causal mechanism-but these studies seldom describe fall height.The lack of clarity concerning the low-energy TBI disease burden hampers effective prevention and clinical management. What did the researchers do and find? We studied 21,681 patients with TBI presenting to 56 hospital emergency departments across Europe and Israel using an efficient registry methodology enabling a real-world approach.We found that the 40% of patients with TBI who were injured through low-energy falls were significantly older, more likely to be female, and more likely to be taking pre-injury drugs that prevent blood clotting than patients with TBI sustained through high-energy transfer.Despite similar rates of significant injury on the CT brain scan and of dying in hospital, patients injured through low-energy falls were half as likely to receive critical care or emergency intervention compared to those injured by high-energy transfer. What do these findings mean? Low-energy falls contribute to a significant portion of the TBI disease burden, which will increase as the global population ages.In older people, the assumption that energy transfer predicts brain injury severity and threat to life appears to lack validity.Factors beyond energy transfer level may be more relevant to prehospital and emergency department TBI triage in older people. The appropriateness of providing less intensive acute hospital care after low-energy TBI requires further study.Reduction of TBI disease burden requires specific prevention and therapy initiatives targeted at low-energy TBI.BackgroundTraumatic brain injury (TBI) is an important global public health burden, where those injured by high-energy transfer (e.g., road traffic collisions) are assumed to have more severe injury and are prioritised by emergency medical service trauma triage tools. However recent studies suggest an increasing TBI disease burden in older people injured through low-energy falls. We aimed to assess the prevalence of low-energy falls among patients presenting to hospital with TBI, and to compare their characteristics, care pathways, and outcomes to TBI caused by high-energy trauma. Methods and findingsWe conducted a comparative cohort study utilising the CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) Registry, which recorded patient demographics, injury, care pathway, and acute care outcome data in 56 acute trauma receiving hospitals across 18 countries (17 countries in Europe and Israel). Patients presenting with TBI and indications for computed tomography (CT) brain scan between 2014 to 2018 were purposively sampled. The main study outcomes were (i) the prevalence of low-energy falls causing TBI within the overall cohort and (ii) comparisons of TBI patients injured by low-energy falls to TBI patients injured by high-energy transfer-in terms of demographic and injury characteristics, care pathways, and hospital mortality. In total, 22,782 eligible patients were enrolled, and study outcomes were analysed for 21,681 TBI patients with known injury mechanism; 40% (95% CI 39% to 41%) (8,622/21,681) of patients with TBI were injured by low-energy falls. Compared to 13,059 patients injured by high-energy transfer (HE cohort), the those injured through low-energy falls (LE cohort) were older (LE cohort, median 74 [IQR 56 to 84] years, versus HE cohort, median 42 [IQR 25 to 60] years; p < 0.001), more often female (LE cohort, 50% [95% CI 48% to 51%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001), more frequently taking pre-injury anticoagulants or/and platelet aggregation inhibitors (LE cohort, 44% [95% CI 42% to 45%], versus HE cohort, 13% [95% CI 11% to 14%]; p < 0.001), and less often presenting with moderately or severely impaired conscious level (LE cohort, 7.8% [95% CI 5.6% to 9.8%], versus HE cohort, 10% [95% CI 8.7% to 12%]; p < 0.001), but had similar in-hospital mortality (LE cohort, 6.3% [95% CI 4.2% to 8.3%], versus HE cohort, 7.0% [95% CI 5.3% to 8.6%]; p = 0.83). The CT brain scan traumatic abnormality rate was 3% lower in the LE cohort (LE cohort, 29% [95% CI 27% to 31%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001); individuals in the LE cohort were 50% less likely to receive critical care (LE cohort, 12% [95% CI 9.5% to 13%], versus HE cohort, 24% [95% CI 23% to 26%]; p < 0.001) or emergency interventions (LE cohort, 7.5% [95% CI 5.4% to 9.5%], versus HE cohort, 13% [95% CI 12% to 15%]; p < 0.001) than patients injured by high-energy transfer. The purposive sampling strategy and censorship of patient outcomes beyond hospital discharge are the main study limitations. ConclusionsWe observed that patients sustaining TBI from low-energy falls are an important component of the TBI disease burden and a distinct demographic cohort; further, our findings suggest that energy transfer may not predict intracranial injury or acute care mortality in patients with TBI presenting to hospital. This suggests that factors beyond energy transfer level may be more relevant to prehospital and emergency department TBI triage in older people.A specific focus to improve prevention and care for patients sustaining TBI from low-energy falls is required. Show less
Background There is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require... Show moreBackground There is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require neurosurgical intervention, while many guidelines recommend routine admission of all patients. We aim to validate the Hull Salford Cambridge Decision Rule (HSC DR) and the Brain Injury Guidelines (BIG) criteria to select low-risk patients for discharge from the emergency department. Method A cohort from 18 countries of Glasgow Coma Scale 13-15 patients with injuries on CT imaging was identified from the multicentre Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Study (conducted from 2014 to 2017) for secondary analysis. A composite outcome measure encompassing need for ongoing hospital admission was used, including seizure activity, death, intubation, neurosurgical intervention and neurological deterioration. We assessed the performance of our previously derived prognostic model, the HSC DR and the BIG criteria at predicting deterioration in this validation cohort. Results Among 1047 patients meeting the inclusion criteria, 267 (26%) deteriorated. Our prognostic model achieved a C-statistic of 0.81 (95% CI: 0.78 to 0.84). The HSC DR achieved a sensitivity of 100% (95% CI: 97% to 100%) and specificity of only 4.7% (95% CI: 3.3% to 6.5%) for deterioration. Using the BIG criteria for discharge from the ED achieved a higher specificity (13.3%, 95% CI: 10.9% to 16.1%) and lower sensitivity (94.6%, 95% CI: 90.5% to 97%), with 12/105 patients recommended for discharge subsequently deteriorating, compared with 0/34 with the HSC DR. Conclusion Our decision rule would have allowed 3.5% of patients to be discharged, none of whom would have deteriorated. Use of the BIG criteria may select patients for discharge who have too high a risk of subsequent deterioration to be used clinically. Further validation and implementation studies are required to support use in clinical practice. Show less
