Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
ORIGINAL RESEARCH
Open Access
Factors correlating with delayed trauma center
admission following traumatic brain injury
Rahul Raj1*, Jari Siironen1, Riku Kivisaari1, Markku Kuisma2, Tuomas Brinck3, Jaakko Lappalainen1
and Markus B Skrifvars2
Abstract
Background: Delayed admission to appropriate care has been shown increase mortality following traumatic brain
injury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in
a cohort of TBI patients in the intensive care unit (ICU).
Methods: A retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was
carried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed
admission. Patients in the delayed admission group were initially transported to a local hospital without
neurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized
to identify pre-hospital factors associated with delayed admission.
Results: Of 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed
admission groups (median time to admission 1:07h, IQR 0:52–1:28 vs. 4:06h, IQR 2:53–5:43, p <0.001). In multivariate
analysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13),
incident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital
physician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial
injury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38).
A significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion
when admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was
noted between the groups (p= 0.814).
Conclusion: Delayed trauma center admission following TBI is common. Factors increasing likelihood of this were:
male gender, incident at public place compared to home, low energy trauma, absence of pre-hospital physician
involvement, stable blood pressure, no major extra cranial injuries, normal pupillary light reflex and severe alcohol
intoxication. Focused educational efforts and access to physician consultation may help expedite access to appropriate
care in TBI patients.
Keywords: Traumatic brain injury, Pre-hospital, Transport, Triage, Outcome, Emergency medical service
Introduction
Traumatic brain injury (TBI) is the leading cause of
death and disability among the young around the world
[1]. The American College of Surgeons Committee on
Trauma and Centers for Disease and Prevention have
developed field triage guidelines for TBI patients, which
are in conjunction with the Brain Trauma Foundation’s
* Correspondence: rahul.raj@helsinki.fi
1
Department of Neurosurgery, Helsinki University Central Hospital, Helsinki,
Finland
Full list of author information is available at the end of the article
pre-hospital guidelines, internationally acknowledged cornerstones of pre-hospital TBI triaging and treatment [2,3].
The guidelines recommend direct transport of patients
with TBI to hospitals with availability of neurosurgical care
including computerized tomography (CT) scanning,
neurosurgical care, intracranial monitoring and treatment
[3]. Accordance with the guidelines has been shown to
improve outcome in TBI patients [4-6]. Despite this nearly
half of all TBI patients are initially transported to a hospital without neurosurgical expertise, before inter-transfer
© 2013 Raj et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
to a hospital with neurosurgical capability, which has been
shown to increase mortality [5,7].
Accordingly, we sought to assess pre-hospital factors
associated with an initial transport to a non-neurosurgical
hospital in a region where all TBI care is centralized to
one single trauma center.
Methods
Hospital and trauma system
Finland is divided into five major health care regions
each having a three-tier health care system: local district
hospitals (primary care), regional central hospitals
(secondary care) and university hospitals (tertiary care).
The Helsinki health care region is the largest health care
region in the country serving a population of nearly two
million people. There are over twenty different primary
and secondary level of care hospitals in the region but only
one tertiary level of care hospital providing neurosurgical
care (Töölö Hospital, Helsinki University Central Hospital,
referred to as “TC” in the text). Accordingly, all TBI care is
centralized to the designated TC. Pre-hospital emergency
medical service (EMS) protocol mandates transportation
of patients requiring neurosurgical and intensive care
directly to the designated hospital following injury.
The EMS routinely stabilizes the patients in the field
(such as controlling of the airway in unconscious patients,
correction of hypotension and hypoxia) enabling direct
transport throughout the region when indicated. The EMS
may always consult a pre-hospital physician and request
for assistance and/or transport instructions.
Patients and data collection
A retrospective analysis of all TBI patients (adults and
children) admitted to the Töölö Hospital (Helsinki
University Central Hospital) trauma intensive care units
(ICU) during a two-year period (1.1.2009 - 31.12.2010)
was conducted. Patients were categorized into two groups:
direct admission and delayed admission. Patients in the
delayed admission group were initially transported to a
local hospital without neurosurgical expertise before
inter-transfer to the TC.
The hospital and EMS records were reviewed for data
regarding reason for dispatch urgency, injury details,
patient characteristics, time details, transport destination
and pre-hospital physician involvement. Time of injury was
defined as time of dispatch call unless other mentioned in
the EMS records. Dispatch urgency is ranging from A to D
(A being the most urgent and D the least urgent) and
categorized as urgent (A-B) and non-urgent (C-D).
Patient blood alcohol level (BAL) was measured in
the pre-hospital setting using an alcohol breath test and
categorized to: none (0.0‰), low (< 2.3‰), high ≥ 2.3‰
and not tested [8]. The blood alcohol breath test has
been shown to be a reliable test for measuring blood
Page 2 of 9
alcohol concentration [9]. Glasgow coma scale (GCS)
was measured in the field and upon trauma center
admission and categorized as moderate-to-severe (3–12)
and mild (13–15) [10]. High-energy injury was defined as
velocities over 25 km/h or head hitting the ground from
above two meters height. Hypoxia and hypotension are
defined according to the BTF guidelines: oxygen saturation <90% or systolic blood pressure <90 mmHg
at any time during the pre-hospital transport [3]. Major
extra cranial injury was collected from EMS forms, and
defined retrospectively as any extra cranial injury that
requires hospital admission within its own rights [11].
Patient head CT was classified by a radiologist and neurosurgeon (RK) unaware of EMS care according to the
Rotterdam CT-score [12]. Overall injury severity and TBI
severity were retrospectively evaluated using the injury
severity score (ISS) and the IMPACT-TBI model
[13,14]. Patient outcome was 6-month mortality.
Statistical analysis
For statistical analysis: “IBM Corp. Released 2011. IBM
SPSS Statistics for Windows, Version 20.0. Armonk, NY:
IBM Corp” was used. For univariate categorical analysis
the χ2 test (two-tailed) was used. Continuous variables were
analyzed for normality distribution. All continuous data
were highly skewed; the non-parametric Mann–Whitney U
test was used. Data is presented as median values with
interquartile range (IQR), unless other is mentioned.
Significant variables (p ≤ 0.05) from the univariate
analysis were used to build a logistic regression model
to identify variables present at scene of associated with
pre-hospital transport location. Only factors available at
the scene of the incident were included (with the exception
of penetrating head injuries as all penetrating head
injuries are automatically transported to the designated trauma center). Collinearity between variables
was tested for by assessing the variance inflation factor (VIF). Missing values were categorized separately
but included in the models.
Results
Baseline characteristics
A total 431 were included patients of whom 65%
were in the direct admission group and 35% in the
delayed admission group. Patient median age was 54
(32– 64) and 71% were male (Table 1). Median time
from injury to TC admission was 1:07h (0:52–1.28)
for the directly admitted patients versus 4:06h (2:54–
5:43) for the delayed patients (p<0.001). The two
most common causes of injury were ground level fall
accidents (GLF) and road traffic accidents (RTA)
(49%, 21%). Ground level falls were more frequent in
the delayed admission group (70%, 35%, p< 0.001)
and RTA more frequent in the direct admission
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
Page 3 of 9
Table 1 Patients baseline characteristics and injury details
Trauma center admission
All patients 431 (100%)
Direct 282 (65%)
Delayed 149 (35%)
p-Value
Age
54 (32–64)
49 (24–64)
59 (47–66)
< 0.001
Male gender
307 (71)
188 (67)
119 (80)
0.004
< 0.001
Location of the incident
Home
107 (25)
61 (22)
46 (31)
Public place inside
55 (13)
37 (13)
18 (12)
Public place outside
205 (48)
157 (56)
48 (32)
Other / Unknown
64 (14)
27 (9)
37 (25)
Weekday
279 (65)
181 (64)
98 (66)
Weekend
152 (35)
101 (36)
51 (34)
8-17 (office hours)
206 (48)
126 (45)
80 (54)
17-8 (outside office hours)
225 (52)
156 (55)
69 (46)
High
130 (30)
127 (45)
3 (2)
Low
301 (70)
155 (55)
146 (98)
Penetrating injury
6 (1)
6 (2)
0 (0)
0.073
Physician consulted
86 (20)
59 (21)
27 (18)
< 0.001
Physician present
208 (48)
184 (65)
24 (16)
< 0.001
< 0.001
Time of incident
0.743
Injury energy*
< 0.001
EMS risk category
A-B
304 (71)
230 (82)
74 (50)
C-D
74 (17)
32 (11)
42 (28)
Missing
53 (12)
20 (7)
33 (22)
Injury to EMS arrival
0:10 (0:07–0:16)
0:10 (0:07–0:17)
0:10 (0:07–0:16)
0.750
Injury to first hospital
1:05 (0:49–1:27)
1:07 (0:52–1:28)
1:03 (0:43–1:24)
0.177
1:23 (0:58–2:51)
1:07 (0:52–1:28)
Time intervals (hh:min)
Time spent at other hospital
Injury to trauma center
3:03 (1:51–4:50)
4:05 (2:53–5:43)
< 0.001
Categorical variables are presented as N (%) and continuous variables as median (IQR).
Abbreviations: TBI= Traumatic Brain Injury, EMS= Emergency Service Personnel.
*High-energy traumas are defined as velocities over 25 km/h or falls from over two meters height.
group (32%, 3%, p< 0.001). High-energy traumas
weresignificantly more often noted among the directly
admitted patients (45%, 2%, p< 0.001). Also, prehospital physician involvement was significantly more
noted in the direct admission group (p< 0.001).
Pre trauma center clinical features
Patients in the direct admission group had a significantly
lower field GCS than patients in the delayed admission
group (p< 0.001) (Table 2). However, there were no
differences in GCS when admitted to the TC (p= 0.063)
(Table 3). In univariate analysis direct admission showed
significant association with: documented unconsciousness
(p< 0.001), major extra cranial injury (p< 0.001), hypoxia
(p< 0.001), hypotension (p< 0.001) and abnormal pupillary
light reflex (p< 0.001).
Furthermore, patient BAL was significantly associated
with indirect transport in univariate analysis as 61% of
patients with a high BAL were indirectly transported to
the trauma center, compared to 36% and 24% for patients with low and negative BAL (p= 0.017). Median
time from injury to TC admission for patients with a high
BAL was 2:53h (1:17–7.27), which was significantly longer than for patients with a low BAL (1:20h, 0:58–2:55),
negative BAL (1:23h, 1:07–1:43) and not tested (1:19h,
0:56–2:25) (p= 0.006). As only 23% of patients were
tested for BAL in the pre-hospital setting we tested the
correlation between the pre-hospital BAL and the blood
alcohol level measured in the trauma center. Following
trauma center admission, 48% of all patients were tested
for blood alcohol levels. The BAL measured in the
pre-hospital setting correlated extremely well with the
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
Page 4 of 9
Table 2 Differences in initial pre-hospital clinical features made by the emergency medical service between patients
transported directly and indirectly to the trauma center
Trauma center admission
All patients 431(100%)
Direct 282 (65%)
Delayed 149 (35%)
p-Value
3-12
258 (60)
13-15
155 (36)
204 (72)
54 (36)
< 0.001
74 (27)
80 (54)
Missing
Major extra cranial injury
18 (4)
3 (1)
15 (10)
118 (27)
107 (38)
11 (7)
< 0.001
Unconsciousness
260 (60)
198 (70)
62 (42)
< 0.001
< 0.001
Field GCS
Pupillary light reaction
Normal
284 (66)
181 (64)
103 (69)
Abnormal
87 (20)
76 (27)
11 (7)
Missing
60 (14)
25 (9)
35 (24)
Hypoxia
87 (20)
72 (26)
15 (10)
< 0.001
Hypotension
49 (11)
47 (17)
2 (1)
< 0.001
0.004
Field blood alcohol level (‰)
0.0
17 (4)
13 (5)
4 (3)
< 2.3
44 (10)
28 (10)
16 (11)
≥ 2.3
38 (9)
15 (5)
23 (15)
Not tested
332 (77)
226 (80)
106 (70)
Median
2.0 (0.9-2.8)
1.7 (0.6-2.4)
2.3 (1.6-2.9)
0.008
Glucose (mmol/l)
7.2 (6.0-8.8)
7.2 (6.0-8.9)
7.1 (5.9-8.8)
0.773
Focal neurological sign
37 (9)
24 (9)
13 (9)
0.904
Categorical variables are presented as N (%) and continuous as median (IQR).
Abbreviations: GCS= Glasgow Coma Scale, EMS= Emergency Medical Service, EMS risk category A= highest risk and D= lowest risk. * Any injury that requires
hospital admission within its own right.
† Hypoxic insult is defined as documented 02 saturation < 90% at any time during the pre-hospital transfer.
‡ Hypotensive insult is defined as systole < 90 mmHg at any time during the pre-hospital transfer.
Table 3 Differences in injury severity after trauma center admission
Trauma center admission
All patients 431 (100%)
Direct 282 (65%)
Delayed 149 (35%)
p-Value
26 (14–47)
26 (12–50)
25 (16–41)
0.619
3-12
295 (68)
203 (72)
92 (62)
0.063
13-15
136 (31)
79 (28)
57 (38)
1-2
93 (21)
59 (21)
34 (23)
3-4
251 (59)
163 (57)
88 (59)
5-6
87 (20)
60 (22)
27 (18)
ISS > 15
372 (86)
235 (83)
137 (92)
0.013
ISS > 25
160 (37)
111 (39)
49 (33)
0.186
Acute craniotomy
144 (33)
59 (21)
85 (57)
< 0.001
IMPACT-TBI score
Trauma center GCS
Rotterdam CT-score
0.584
Categorical variables are presented as N (%) and continuous variables as median (IQR). Abbreviations: CT= computer tomography, ISS= injury severity score,
IMPACT= international mission for prognosis and clinical trials on TBI.
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
blood alcohol levels measured in the trauma center
(Spearman’s correlation coefficient: 0.844, p< 0.001).
Patients in the direct admission group were significantly more often intubated in the field compared to patients in the delayed admission group (N= 158/282, 56%;
N= 7/149, 5%; p< 0.001); a pre-hospital physician was
present in 84% (N= 133/158) of cases in the direct admission group and in 43% (N= 3/7) of cases in the delayed admission group. Additionally 58 patients in the
delayed admission group were intubated at the local hospital before transfer to the TC. Thus, on TC admission
44% (N= 65/149) of patients in the delayed admission
group were intubated compared to 56% (N= 160/282) of
patients in the direct admission group (p= 0.010). Furthermore, of the 149 patients in the delayed admission group
6% (N= 8) had a documented episode of hypoxia (O2<
90%) and 1% (N= 2) a documented episode of hypotension
(systolic blood pressure< 90 mmHg) at the local hospital
before TC transfer. Mean time to TC admission for patients initially transported to a local hospital where
they were intubated before transfer to the TC was
4:30h (IQR 3:19–6:08), which did not significantly differ from those not intubated at the local hospital
before transfer to the TC (median 4:02h, IQR 2:50–
5:38) (p= 0.389).
Pre-hospital transport
In a multivariate logistic regression analysis factors
increasing likelihood of delayed admission were: male
gender (OR: 3.82, 95% CI: 1.60-9.13, p= 0.003), incident at public place compared to home (OR: 0.26,
95% CI: 0.11-0.61, p= 0.002), high energy trauma
(OR: 0.05, 95% CI: 0.01-0.28, p= 0.001), pre-hospital physician consultation (OR: 0.15, 95% CI: 0.06-0.39, p< 0.001)
or presence (OR: 0.08, 95% CI: 0.03-0.22, p< 0.001),
hypotension (OR: 0.09, 95% CI: 0.01-0.93, p= 0.044), major
extra cranial injury (OR: 0.17, 95% CI: 0.05-0.55, p= 0.003),
abnormal pupillary light reflex (OR: 0.26, 95% CI:
0.09-0.73, p= 0.010) and severe alcohol intoxication
(OR: 12.44, 95% CI: 2.14-72.38, p= 0.005) (Table 4). No
collinearity in the final model was noted (VIFmax= 2.1).
Post trauma center admission
Following TC emergency department admission and
resuscitation 82% patients in the direct admission group
were intubated compared to 81% in the delayed admission group (p= 0.870). There was no significant difference in admission Rotterdam CT-score between
the groups (p= 0.584) (Table 3). Although, subdural
hematoma and midline shift was more frequent in
the delayed admission groups (p< 0.001) and traumatic
subarachnoid hemorrhage more frequent in the direct admission group (p= 0.003). A significant higher proportion
of patients in the delayed admission group underwent
Page 5 of 9
Table 4 Multivariate analysis showing pre-hospital factors
associated with direct trauma center admission
Variable
OR (95% CI)
p-Value
Age
1.02 (1.00-1.04)
0.098
Male
3.82 (1.60-9.13)
0.003
EMS dispatch urgency
Urgent (A-B)
1.0
Non-urgent (C-D)
0.75 (0.33-1.71)
0.500
Incident location
Home
1.0
Public place
0.26 (0.11-0.61)
0.002
Other/Unknown
2.15 (0.70-6.59)
0.181
Injury energy
Low
1.0
High
0.05 (0.01-0.28)
0.001
Consulted
0.15 (0.06-0.39)
< 0.001
Present (called to the scene)
0.08 (0.03-0.22)
< 0.001
Documented unconsciousness
0.62 (0.27-1.41)
0.256
Hypoxia
1.02 (0.42-2.44)
0.972
Hypotension
0.09 (0.01-0.93)
0.044
Major extra cranial injury
0.17 (0.05-0.55)
0.003
Abnormal pupillary light reflex
0.26 (0.09-0.73)
0.010
Pre-hospital physician
Field GCS
3-12
1.0
13-15
1.64 (0.72-3.76)
0.240
Blood alcohol level (‰)
0.0
1.0
< 2.3
0.99 (0.19-5.33)
0.995
> 2.3
12.44 (2.14-72.38)
0.005
Odds ratios over one indicating an increased likelihood of direct admission
and odds ratios under one indicating a decreased likelihood of direct
admission (i.e. increased likelihood of delayed admission). Abbreviations:
OR= odds ratio, CI= confidence interval, GCS= glasgow coma scale,
EMS= emergency medical service.
acute craniotomy when admitted to the trauma center
(57%, 21%, p < 0.001). Also, an ISS > 15 were more frequently among patients in the delayed admission group
compared to the direct admission group (92%, 83%, p=
0.013). However, no differences ISS > 25 were noted between the groups (p= 0.186). According to the IMPACTTBI model, no significant difference in median TBI severity score was noted between the direct admission group
(24, IQR: 12–50) and delayed admission group (25, IQR:
16–41) (p= 0.657). Univariate analysis showed no significant difference in 6-month mortality between the groups
(24%, 25%, p= 0.814). There was no significant difference
in time from injury to TC admission between survivors
and non-survivors (p= 0.331).
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
Discussion
The centralization of TBI care to specialized trauma
centers have improved outcome [15,16]. Direct transport
of patients, from the scene of injury, to such specialized
trauma centers has been shown to significantly increase
survival [5,6,15]. Thus, initial pre-hospital triage and
subsequent transport is of major role in the handling of
TBI patients. The purpose of this study was to investigate
pre-hospital factors associated with an inappropriate transport of TBI patients in a region where all TBI care is centralized to one single trauma center. Our study showed
that despite a regional trauma care protocol, mandating
direct transport of TBI patients that are likely to specialized care to the TC, over one third are initially transported
to a hospital without the capacity of handling these
patients. We identified several factors associated with
transport to another hospital than the designated
trauma center, i.e. male gender, low energy of trauma,
lack of pre-hospital physician involvement, absence of
major extra cranial injuries, normal pupillary light
reflex and severe alcohol intoxication. Our re-transfer
rate is somewhat lower than previously described,
indicating a well-organized system in the region [7,17]. A
probable major factor influencing this is the availability
of pre-hospital physicians in the study region.
Several studies have showed an improved outcome
after direct admission to a neurosurgical trauma center,
although there is no class I evidence to back this up.
Härtl et al. showed that patients transported indirectly
to a neurosurgical trauma center, via a lower level of
care hospital, had a 50% higher risk of death than patients
transported directly to a trauma center with neurosurgical
expertise [5]. Hannan et al. reported an almost twice as
low risk for in patients with TBI treated in a regional
trauma center compared to local non-trauma centers [19].
In our study, we did not find any association between
initial transport destination and outcome. Despite the fact
that patients who were initially transported to a local
hospital (delayed admission) were more severely injured
than the patients in the direct admission groups. Further
sub-group analysis showed that patients in the delayed
admission group more often required acute craniotomy
than patients in the direct admission group. As such one
might expect a higher mortality among these patients, as
it has been shown in numerous studies before [20-23].
However, this as well was not evident in our study. The
reason why we could not find any correlation between
initial transport destination and outcome is probable due
to lack of power. Another possible reason might be that
even though the indirectly transported patients had a significantly longer time delay to trauma center admission
than the directly transported patients the delay wasn’t
long enough to affect outcome. This is supported by the
fact that the majority of patients in both the direct and
Page 6 of 9
delayed admission group undergoing acute craniotomy
was operated on well within acknowledged time limits
[18,24]. Moreover, we found no significant difference in
time to trauma center admission between survivors and
non-survivors. This supports the earlier statement regarding a well working trauma system in the region. Another
factor and major strength to the present study that has to
be considered is that we used 6-month mortality as outcome measure whereas most other studies have used inhospital mortality. In-hospital mortality is not an optimal
marker for measuring TBI as it severely underestimates the
number of deaths [11]. Thus, it may simply be that indirect
transport increases the risk of short-term but not long-term
mortality. However, no statistical significant difference in
14-day mortality was noted between the direct and delayed
admission groups in univariate analysis.
Not surprisingly a high field GCS and the absence of
major extra cranial injuries associated with delayed
trauma center admission. However, field assessment of
injury severity was proven not to be a reliable marker of
injury severity as post-admission investigations revealed
that patients in the delayed admission group had higher
injury severity scores and that there were no differences
in TBI severity, despite contrary signs in the pre-hospital
setting. The GCS has been shown to be of limited value
in determining TBI severity in the field [25]. Fourteen
percent of patients with an initial GCS of 14 develops an
intracranial lesion [26]. Intracranial lesions in patients
with an initial GCS of 15 are uncommon unless risk factors are present, such as high age, use of anti-coagulants,
focal neurological symptoms and alcohol-intoxication
[27,28]. Approximately 3-6% of all TBI patients who die
have an field GCS of 13 to 15 [29,30]. This is of significance in pre-hospital care as lucid patients with a high
initial GCS easily can be under triaged and the possibility of an intracranial lesion overlooked. This problem was noted in our study as 31% of all patients
with a field GCS of 13 to 15 required acute craniotomy. Furthermore, 15% of all patients with a field
GCS of 13 to 15 died (compared to 32% of those
with a field GCS of 3 to 12). It should however be
noted that field GCS was measured by a paramedic if a
pre-hospital physician was not present (direct admission
35%, delayed admission 84%) but TC GCS was always
measured by an emergency department physician (trauma
surgeon, anesthesiologist or neurosurgeon). This potential
confounding factor in determining accurately determining
the GCS should be the focus of future studies.
Systemic hypotension and hypoxia in the pre-hospital
setting are associated with poor outcome in TBI patients
[3]. Twenty percent of all patients had a hypoxic insult
(SO2< 90%) and eleven percent a hypotensive insult
(< 90 mmHg) during the pre-hospital transport. In
univariate analysis both hypotension and hypoxia were
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
significantly associated with direct admission. However, in
multivariate analysis hypotension but not hypoxia was
showed significant association with direct admission. To
further investigate this we looked at the number of
hypotensive and hypoxic patients accompanied by a
pre-hospital physician, as the presence of a physician
was the strongest independent predictor of direct admission in the logistic regression analysis. However, we found
no significant difference in hypotensive respectively hypoxic
patients accompanied by a physician (76%, 70%).
Securing the airway and adequate oxygenation and
ventilation is of vital role in the pre-hospital management
of patients with TBI [3]. A significant higher proportion of
patients in the direct admission group were intubated on
the field compared to patients in the delayed admission
group. Of all patients intubated in the field 82% were
accompanied by a physician (3 out of 7 in the delayed
admission group and 133 out of 158 in the direct admission
group). However, a considerable proportion of patients in
the delayed admission group were intubated at the local
hospital before transfer to the TC. Notable is that there
were no significant difference in time to TC admission
between patients intubated and not intubated at the local
hospital before transfer to the TC.
We found that severe alcohol intoxication was associated
with delayed admission. Alcohol intoxication in TBI
patients is an internationally acknowledged problem
[1]. Studies have shown that roughly half of TBI patients
are alcohol-intoxicated at the time of injury and that
alcohol intoxication increases the risk of TBI, especially as a result of binge drinking [31-34]. Alcohol
has also been shown to impede with the clinical TBI
diagnosis by having a level of consciousness lowering
effect [25]. This makes it challenging for the EMS to judge
whether a trauma patient’s altered level of consciousness
(i.e. GCS) is caused by alcohol intoxication, intracranial
lesion or other injuries. Ground level falls is the major
cause of injury among alcohol intoxicated patients and the
elderly [35]. Our results show that low energy traumas,
such as GLF, significantly increase the risk of delayed
admission. Thus, GLF might be an underestimated cause
of injury in TBI patients. Though, it has been shown that
there is no difference in TBI severity caused by GLFs
compared to other causes of injury, such as RTA [36].
Hence, the elderly and alcohol-intoxicated patients
may be at the core of this problem; pre-hospital mistriage
leading to delayed life-saving treatment.
Altogether, there are many contributing factors
contributing to difficult triage decisions with the risk
of both under or over triage of these patients. Over
triaging is not a viable option as this would lead to an
excess trauma center burdening and under triage with the
risks of having devastating effects on patient prognosis. It
is in such cases that the importance of pre-hospital
Page 7 of 9
physician consultation is highlighted. We acknowledge the
fact that not all regions have pre-hospital physicians
available 24/7, however in areas of high trauma burdening
this could be an opportunity worth exploring.
In conclusion our study shows that some patients with
TBI are often misdiagnosed in the field due to a number
of reasons and that there is a major need for further
studies exploring diagnostic and educational means to
improve rapid identification of those requiring neurosurgical treatment in patients whose initial clinical presentation is confounded by factors such as low level of initial
symptoms and alcohol intoxication.
Study limitations
Our study has several limitations. Most important, due
to the retrospective nature of this study we were unable
to collect the number of patients with a TBI requiring
intensive care initially transported to another hospital
were the patient died before reaching the trauma center’s
emergency department. Likewise we are unaware of the
number patients dying at the scene of injury before
reaching the TC, or at the local hospital prior to trauma
center transfer. However, in a large prospective study by
Myburgh et al. they found that only 3% of patients with
TBI die during the pre-intensive period [7]. We believe
that these numbers are representative for our study as it is
very rare that trauma patients requiring neurosurgical expertise are not referred to the designated TC (directly
or indirectly) since the other hospitals do not offer
any neurosurgical services. Second, BAL is not routinely tested for in the pre-hospital setting without indications, giving us a substantial amount of patients
untested for BAL. It is clear that BAL testing is not
indicated nor is it possible for everyone and this is
probably the current situation in most countries where
BAL is mainly tested when it might impact treatment decisions. Furthermore, measuring BAL in the pre-hospital setting using an alcohol breath-test is challenging in TBI
patients considering the nature of the disease (potential lack of co-operation and unconscious patients). However, following TC admission a total of 48% of patients
were tested for blood alcohol levels using standard laboratory blood samples. This was shown to correlate extremely
well with the BAL measured in the pre-hospital setting.
Third, in the present retrospective study we could not
note any statistical significant association between initial
transport location and long-term mortality, which is
probably a consequence of lack of power.
Conclusion
Delayed trauma center admission following TBI is
common. Factors increasing likelihood of this were:
male gender, incident at public place compared to home,
low energy trauma, absence of pre-hospital physician
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
involvement, stable blood pressure, no major extra cranial
injuries, normal pupillary light reflex and severe alcohol
intoxication. These data suggest that educational efforts for
the EMS about the common clinical reasons impeding
with early TBI diagnosis may help expedite access to
appropriate level of care for such patients are warranted.
These data also highlight the need for improved diagnostic
tools for identifying cases that require immediate neurosurgical intervention in patients whose clinical picture is
confounded by minimal initial symptoms and especially
alcohol intoxication.
9.
10.
11.
12.
Competing interests
The authors declare that they have no competing interests.
13.
Authors’ contribution
RR, JS and MS designed the study. RR drafted the manuscript assisted by MS,
JS and JL, RR, TB and RK performed the data collection. RR is responsible for
integrity of the collected data. The statistical analysis of the data was
performed and interpreted by RR, JS and MS. RK viewed and interpreted CT
scans of the included patients. MS, JL contributed to the interpretation of
the data and writing of the manuscript. All authors revised the manuscript
and approved it in the final form.
14.
15.
16.
Author details
1
Department of Neurosurgery, Helsinki University Central Hospital, Helsinki,
Finland. 2Department of Anesthesiology, Intensive Care, Emergency Care and
Pain management, Helsinki University Central Hospital, Helsinki, Finland.
3
Department of Orthopedics and Traumatology, Helsinki University Central
Hospital, Helsinki, Finland.
17.
18.
Received: 10 May 2013 Accepted: 8 September 2013
Published: 10 September 2013
References
1. Jennett B: Epidemiology of head injury. J Neurol Neurosurg Psychiatr 1996,
60:362–369.
2. Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, Wald MM,
Jurkovich GJ, Newgard CD, Lerner EB, Centers for Disease Control and
Prevention (CDC): Guidelines for field triage of injured patients:
recommendations of the national expert panel on field triage.
MMWR Recomm Rep 2011, 2012:1–20.
3. Badjatia N, Carney N, Crocco TJ, Fallat ME, Hennes HMA, Jagoda AS,
Jernigan S, Letarte PB, Lerner EB, Moriarty TM, Pons PT, Sasser S, Scalea T,
Schleien CL, Wright DW, Brain Trauma Foundation, BTF Center for
Guidelines Management: Guidelines for prehospital management of
traumatic brain injury 2nd edition. Prehosp Emerg Care 2008,
12(Suppl 1):S1–S52.
4. Fakhry SM, Trask AL, Waller MA, Watts DD, IRTC Neurotrauma Task Force:
Management of brain-injured patients by an evidence-based medicine
protocol improves outcomes and decreases hospital charges. J Trauma
2004, 56:492–499. discussion 499–500.
5. Hartl R, Gerber LM, Iacono L, Ni Q, Lyons K, Ghajar J: Direct transport
within an organized state trauma system reduces mortality in patients
with severe traumatic brain injury. J Trauma 2006, 60:1250–1256.
discussion 1256.
6. Stiver SI, Manley GT: Prehospital management of traumatic brain injury.
Neurosurg Focus 2008, 25:E5.
7. Myburgh JA, Cooper DJ, Finfer SR, Venkatesh B, Jones D, Higgins A, Bishop
N, Higlett T, Australasian Traumatic Brain Injury Study (ATBIS) Investigators
for the Australian, New Zealand Intensive Care Society Clinical Trials Group:
Epidemiology and 12-month outcomes from traumatic brain injury in
australia and new zealand. J Trauma 2008, 64:854–862.
8. Berry C, Ley EJ, Margulies DR, Mirocha J, Bukur M, Malinoski D, Salim A:
Correlating the blood alcohol concentration with outcome after
traumatic brain injury: too much is not a bad thing. Am Surg 2011,
77:1416–1419.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Page 8 of 9
Lindberg L, Brauer S, Wollmer P, Goldberg L, Jones AW, Olsson SG: Breath
alcohol concentration determined with a new analyzer using free
exhalation predicts almost precisely the arterial blood alcohol
concentration. Forensic Sci Int 2007, 168:200–207.
Maas AIR, Marmarou A, Murray GD, Teasdale SGM, Steyerberg EW:
Prognosis and clinical trial design in traumatic brain injury: the IMPACT
study. J Neurotrauma 2007, 24:232–238.
MRC CRASH Trial Collaborators, Perel P, Arango M, Clayton T, Edwards P,
Komolafe E, Poccock S, Roberts I, Shakur H, Steyerberg E, Yutthakasemsunt S:
Predicting outcome after traumatic brain injury: practical prognostic models
based on large cohort of international patients. BMJ 2008, 336:425–429.
Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW: Prediction of
outcome in traumatic brain injury with computed tomographic
characteristics: a comparison between the computed tomographic
classification and combinations of computed tomographic predictors.
Neurosurgery 2005, 57:1173–1182. discussion 1173–82.
Baker SP, O’Neill B, Haddon W, Long WB: The injury severity score: a
method for describing patients with multiple injuries and evaluating
emergency care. J Trauma 1974, 14:187–196.
Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, Murray
GD, Marmarou A, Roberts I, Habbema JDF, Maas AIR: Predicting outcome
after traumatic brain injury: development and international validation of
prognostic scores based on admission characteristics. PLoS Med 2008,
5:e165. Discussion e165.
MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL,
Salkever DS, Scharfstein DO: A national evaluation of the effect of
trauma-center care on mortality. N Engl J Med 2006, 354:366–378.
Patel HC, Bouamra O, Woodford M, King AT, Yates DW, Lecky FE, Trauma
Audit and Research Network: Trends in head injury outcome from 1989 to
2003 and the effect of neurosurgical care: an observational study.
Lancet 2005, 366:1538–1544.
Moen KG, Klepstad P, Skandsen T, Fredriksli OA, Vik A: Direct transport
versus interhospital transfer of patients with severe head injury in
Norway. Eur J Emerg Med 2008, 15:249–255.
Sampalis JS, Denis R, Fréchette P, Brown R, Fleiszer D, Mulder D: Direct
transport to tertiary trauma centers versus transfer from lower level
facilities: impact on mortality and morbidity among patients with major
trauma. J Trauma 1997, 43:288–295. discussion 295–6.
Hannan EL, Farrell LS, Cooper A, Henry M, Simon B, Simon R: Physiologic
trauma triage criteria in adult trauma patients: are they effective in
saving lives by transporting patients to trauma centers? J Am Coll Surg
2005, 200:584–592.
Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Choi SC: Traumatic
acute subdural hematoma: major mortality reduction in comatose
patients treated within four hours. N Engl J Med 1981, 304:1511–1518.
Haselsberger K, Pucher R, Auer LM: Prognosis after acute subdural or
epidural haemorrhage. Acta Neurochir (Wien) 1988, 90:111–116.
Wright KD, Knowles CH, Coats TJ, Sutcliffe JC: “Efficient” timely evacuation
of intracranial haematoma–the effect of transport direct to a specialist
centre. Injury 1996, 27:719–721.
Stone JL, Lowe RJ, Jonasson O, Baker RJ, Barrett J, Oldershaw JB, Crowell
RM, Stein RJ: Acute subdural hematoma: direct admission to a trauma
center yields improved results. J Trauma 1986, 26:445–450.
Brain Trauma Foundation, American Association of Neurological Surgeons,
Congress of Neurological Surgeons: Guidelines for the management of
severe traumatic brain injury. J Neurotrauma 2007, 24(Suppl 1):S1–S106.
Shahin H, Gopinath SP, Robertson CS: Influence of alcohol on early
glasgow coma scale in head-injured patients. J Trauma 2010,
69:1176–1181. discussion 1181.
Smits M, Dippel DWJ, Steyerberg EW, de Haan GG, Dekker HM, Vos PE, Kool
DR, Nederkoorn PJ, Hofman PAM, Twijnstra A, Tanghe HLJ, Hunink MGM:
Predicting intracranial traumatic findings on computed tomography in
patients with minor head injury: the CHIP prediction rule. Ann Intern Med
2007, 146:397–405.
Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A,
McKnight RD, Verbeek R, Brison R, Cass D, Eisenhauer ME, Greenberg G,
Worthington J: The Canadian CT head rule for patients with minor head
injury. Lancet 2001, 357:1391–1396.
Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM:
Indications for computed tomography in patients with minor head
injury. N Engl J Med 2000, 343:100–105.
Raj et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:67
http://www.sjtrem.com/content/21/1/67
Page 9 of 9
29. Goldschlager T, Rosenfeld JV, Winter CD: “Talk and die” patients
presenting to a major trauma centre over a 10 year period: a critical
review. J Clin Neurosci 2007, 14:618–623. discussion 624.
30. Marshall LF, Toole BM, Bowers SA: The national traumatic coma data bank:
part 2: patients who talk and deteriorate: implications for treatment.
J Neurosurg 1983, 59:285–288.
31. Tagliaferri F, Compagnone C, Korsic M, Servadei F, Kraus J: A systematic
review of brain injury epidemiology in Europe. Acta Neurochir (Wien)
2006, 148:255–268. discussion 268.
32. Savola O, Niemelä O, Hillbom M: Alcohol intake and the pattern of trauma
in young adults and working aged people admitted after trauma.
Alcohol Alcohol 2005, 40:269–273.
33. Chen CM, Yi H-Y, Yoon Y-H, Dong C: Alcohol use at time of injury and
survival following traumatic brain injury: results from the National
Trauma Data Bank. J Stud Alcohol Drugs 2012, 73:531–541.
34. Andelic N, Jerstad T, Sigurdardottir S, Schanke A-K, Sandvik L, Roe C: Effects
of acute substance use and pre-injury substance abuse on traumatic
brain injury severity in adults admitted to a trauma centre. J Trauma
Manag Outcomes 2010, 4:6.
35. Kool B, Ameratunga S, Jackson R: The role of alcohol in unintentional falls
among young and middle-aged adults: a systematic review of
epidemiological studies. Inj Prev 2009, 15:341–347.
36. Pöyry T, Luoto TM, Kataja A, Brander A, Tenovuo O, Iverson GL, Ohman J:
Acute assessment of brain injuries in ground-level falls. J Head Trauma
Rehabil 2013, 28(2):89–97.
doi:10.1186/1757-7241-21-67
Cite this article as: Raj et al.: Factors correlating with delayed trauma
center admission following traumatic brain injury. Scandinavian Journal
of Trauma, Resuscitation and Emergency Medicine 2013 21:67.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit