ObjectiveTo describe visits and visit rates of adults presenting to emergency departments (EDs) with a diagnosis of traumatic brain injury (TBI). TBI is a major cause of death and disability in the USA; yet, current literature is limited because few studies examine longer-term ED revisits and hospital readmission patterns of TBI patients across a broad spectrum of injury severity, which can help inform potential unmet healthcare needs.DesignWe performed a retrospective cohort study.SettingWe analysed non-public patient-level data from California’s Office of Statewide Health Planning and Development for years 2005 to 2014.ParticipantsWe identified 1.2 million adult patients aged ≥18 years presenting to California EDs and hospitals with an index diagnosis of TBI.Primary and secondary outcome measuresOur main outcomes included revisits, readmissions and mortality over time. We also examined demographics, mechanism and severity of injury and disposition at discharge.ResultsWe found a 57.7% increase in the number of TBI ED visits, representing a 40.5% increase in TBI visit rates over the 10-year period (346–487 per 100 000 residents). During this time, there was also a 33.8% decrease in the proportion of patients admitted to the hospital. Older, publicly insured and black populations had the highest visit rates, and falls were the most common mechanism of injury (45.5% of visits). Of all patients with an index TBI visit, 40.5% of them had a revisit during the first year, with 46.7% of them seeking care at a different hospital from their initial hospital or ED visit. Additionally, of revisits within the first year, 13.4% of them resulted in hospital readmission.ConclusionsThe large proportion of patients with TBI who are discharged directly from the ED, along with the high rates of revisits and readmissions, suggest a role for an established system for follow-up, treatment and care of TBI.

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A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13–15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74–0.98)), prior psychiatric history (AOR = 3.75 (1.73–8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93–196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29–9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17–10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.

Objective: Intracranial pressure (ICP) over 20 mmHg is associated with poor neurologic prognosis, but measuring ICP directly requires an invasive procedure. Dilation of the optic nerve sheath on axial ultrasound of the eye has been correlated with elevated ICP, but optimal cutoffs have been inconsistent possibly related to the measurement technique. A coronal technique has been studied on healthy volunteers but not on patients with high ICP. We compared two measurement techniques (axial and coronal) in patients with suspected high ICP due to trauma, bleeding, tumor, or infection.Design: Prospective blinded observational study.Setting: Two tertiary referral center intensive care units.Patients: 20 adults admitted to the ICU at risk for increased ICP expected to receive invasive intracranial monitoring.Interventions: Ultrasound measurements of the optic nerve sheath in axial and coronal views either averaged between eyes or the highest in either eye. Measurements and Main Results:Coronal measurements showed less variability between each eye than axial measurements (mean difference 0.5mm vs. 1mm, p=0.03) and were associated with high ICP at first measurement and over 24 hours (AUROC range 0.7 to 0.8). Mean and highest axial measurements showed improved association with first (AUROC 0.87, 0.94) and highest ICP measurement (AUROC 0.89, 0.96) within 24 hours. A cutoff of highest axial measurement in either eye greater than 6.2mm or mean axial measurement between eyes of 5.6mm had a sensitivity of 100% in predicting high ICP over the following 24 hours.