The burden of traumatic brain injury from low-energy falls among patients from 18 countries in the CENTER-TBI Registry: A comparative cohort study

Abstract

Background Traumatic 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 findings We 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. Conclusions We 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.

The changing major trauma disease burden from low falls in the first two decades of the 21st Century – a longitudinal analysis from the largest European Trauma Registry

“…This study is based on data from almost a quarter of a million patients with ISS >15 from Europe’s largest trauma registry and explores the potential drivers of the changing face of major trauma (3,18). TARN data is subject to multiple checks for accuracy and completeness supporting the internal validity of our findings.…”

Acute traumatic brain injury in frail patients: the next pandemic

“…Although the global burden and prevalence of frailty are not well known, some general patterns have emerged: it is more frequent in women than men, increases with aging (even though it is present in all age groups), and is more common in lower socio-economic groups and ethnic minorities [ 1 , 2 ]. Evidence is growing around the impact of frailty in the ICU [ 3 – 6 ] and after severe brain damage [ 7 ▪ , 8 , 9 ▪ , 10 , 11 , 12 ▪ ]. Frailty is associated with higher mortality in older patients and is related to a broad spectrum of ‘geriatric conditions’ such as dementia, cognitive decline, disability, falls, fractures, loneliness, worsening mobility, lower quality of life, hospitalization, and dependence on home nursing [ 13 ].…”

“…In a retrospective review, postfall hospital readmission of octogenarian patients correlated directly with mortality at 6 months. Anticoagulation drugs showed no effect on mortality, corroborating frailty as the stronger predictor of readmission and mortality [ 9 ▪ ].…”

“…Overall mortality was similar following low-energy and high-energy accidents, but four times greater in the LE patients admitted to the ward. Moreover, patients suffering low-energy falls were half as likely as high-energy TBI patients to receive intensive care or emergency intervention [ 9 ▪ ]. Since energy transfer does not seem to be predictive of TBI severity in older people, further studies are needed to evaluate the appropriateness of choosing less intensive care in geriatric trauma patients [ 27 ].…”

Health and Well-Being of Persons of Working Age up to Seven Years after Severe Traumatic Brain Injury in Northern Sweden: A Mixed Method Study

“…However, severe cognitive impairment and impaired self-awareness are STBI consequences [ 30 , 31 ] that are commonly associated with disability and reduced health and well-being [ 32 , 33 ]. High energy trauma is prioritised in trauma triage because it is known such trauma causes more severe injury, but it is also important to be aware of low energy falls [ 34 ]. Repeated TBI is known as a risk factor for outcome [ 35 ].…”