Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester

Leach, Philip; Childs, Charmaine; Evans, Julia; Johnston, Norman J.; Protheroe, Richard; King, Andrew

doi:10.1080/02688690701210562

Cited by 47 publications

(35 citation statements)

References 19 publications

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“…For the past 2 decades, studies have documented a substantial increase in patient mortality and morbidity associated with delays in transfer to an appropriate trauma center for definitive care. This detrimental outcome impact has been observed most significantly in patients who have sustained head injuries in comparison with other mechanisms of injury despite similar intergroup injury severity [8,9]. It would, therefore, seem reasonable to conclude that any further delay caused by obtaining CT examinations before transfer could potentially increase trauma-related morbidity and mortality.…”

Section: Discussionmentioning

confidence: 93%

Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure

Chwals

Robinson

Sivit

et al. 2008

Journal of Pediatric Surgery

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Section: Discussionmentioning

confidence: 93%

Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure

Chwals

Robinson

Sivit

et al. 2008

Journal of Pediatric Surgery

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“…Time from trauma until surgical decompression affects the mortality. Many authors have observed that the sooner surgery is performed in cases of acute head trauma, the better the final results are (6,12,14,16,21,41,46). Seelig et al (32) reported considerable decline in the rates of mortality and morbidity of the patients operated in the first four hours after the trauma compared to those operated upon later.…”

Section: █ Conclusionmentioning

confidence: 99%

The surgical outcome of traumatic extraaxial hematomas causing brain herniation

Gürer¹,

Kertmen²,

Yı́lmaz³

et al. 2015

Turkish Neurosurgery

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ABSTRACTcommon clinical entities encountered by any neurosurgical service.Brain herniation due to posttraumatic hematoma remains one of the most difficult situation faced by neurosurgeons, and causes significant mortality and morbidity. To our knowledge there were only few past studies focused especially into the herniated subgroup of traumatic extraaxial hematomas (31,37,43,44).The aim of this retrospective study was to assess the surgical outcome and the prognostic importance of clinical and █ INTRODUCTION A ccident is the leading cause of death among individuals younger than 45 years. Traumatic brain injury (TBI) accounts for approximately 70% of these traumatic deaths and most of the unfavorable outcomes (2). The most important complication of TBI is the development of intracranial hematomas. It is estimated that intracranial hematomas occur in 25-45% of severe TBI, 3-12% of moderate cases and approximately 1 in 500 patients with mild TBI (40). As a result, acute traumatic extraaxial hematomas (epidural hematoma (EDH) and subdural hematoma (SDH)), are among the most AIm: The aim of this study was to assess the surgical outcome and the prognostic importance of clinical and radiological data of patients operated emergently for an extraaxial hematoma causing brain herniation. mATERIAl and mEThODS:This retrospective study comprised 108 adult patients who were operated due to herniated traumatic extraaxial hematomas from January 2000 to January 2013. RESUlTS:Of 108 patients, 63 patients (58.3%) were diagnosed as subdural hematoma (SDH), and 45 patients (41.7%) as epidural hematoma (EDH). An unfavorable outcome was significantly increased for patients who were diagnosed as SDH (90.4%) compared with EDH patients (33.3%). Mortality rate for herniated SDH patients was 65.1%, and 26.6% for herniated EDH patients. High mortality and unfavorable outcome ratios were associated with Glasgow Coma Scale scores at admission, mean postoperative intracranial pressure (ICP) values, type of the brain herniation, interval from the time of trauma to the time of hematoma decompression, the duration of the brain herniation, intraoperative acute brain swelling, hematoma volume and thickness, degree of the midline shift and the obliteration of the basal cisterns. CONClUSION:Our data showed that, postoperative ICP values were one most important predictor of the mortality. We recommended postoperative ICP monitoring for all patients presenting with the brain herniation due to traumatic extraaxial hematoma.

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“…7 Within the latter, a case has been made for increasing the number of intensive care beds within SNCs to enable them to accept a higher proportion of the patients with TBI referred to them. However, even if this provision were made, the pre-trauma system patterns of carehighlighted in the recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report and other publications -would not have allowed patients with TBI injured nearest a NSAH to receive early neurosurgery (within 4 hours of injury 5,8 ).…”

Section: Initial Cost-benefit Estimate For Early Neurosurgerymentioning

confidence: 99%

“…The analysis showed that in 2005-7 patients with SDH/EDH who are taken first to a NSAH are transferred to the neurosurgical centre on average 5-7 hours after injury. 5 This is due to inherent delays of stabilisation for CT/transfer and referral/ acceptance communications. The only means of achieving early neurosurgery is to take all patients with TBI from scene to the nearest SNC, which -excluding the 10% of the UK's population who live in remote and rural areas -is commonly < 1 hour's journey time from the scene of injury.…”

Section: Initial Cost-benefit Estimate For Early Neurosurgerymentioning

confidence: 99%

“…4 The remaining two-thirds of patients were injured nearest to a NSAH, many undergoing later secondary transfer to SNCs, arriving between 5 and 7 hours later than if they had been transferred straight from the scene of injury. 5 Up to one-third were cared for entirely within acute hospitals. The reasons for restricted access to specialist care were found to be ambulance service (AS) pre-hospital protocols dictating that all injured patients are taken straight to the nearest ED and low numbers of critical care beds in SNCs causing requests for transfer from NSAH to be declined.…”

Section: Relevance Of Hits-ns To the Nhsmentioning

confidence: 99%

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The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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BackgroundReconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence – with regard to ‘early neurosurgery’ in this cohort – which we sought to address.MethodsPilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). Primary outcomes: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. ‘Open-label’ secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.ResultsOverall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%;p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.ConclusionsCurrent NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating ‘early neurosurgery through bypass’ and address the challenge of reliable TBI diagnosis at the scene of injury.Trial registrationCurrent Controlled Trials ISRCTN68087745.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

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Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester

Cited by 47 publications

References 19 publications

Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure

Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure

The surgical outcome of traumatic extraaxial hematomas causing brain herniation

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

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