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Abstract
BackgroundHead injury is an extremely common clinical presentation to hospital emergency departments (EDs). Ninety-five percent of patients present with an initial Glasgow Coma Scale (GCS) score of 13–15, indicating a normal or near-normal conscious level. In this group, around 7% of patients have brain injuries identified by CT imaging but only 1% of patients have life-threatening brain injuries. It is unclear which brain injuries are clinically significant, so all patients with brain injuries identified by CT imaging are admitted for monitoring. If risk could be accurately determined in this group, admissions for low-risk patients could be avoided and resources could be focused on those with greater need.This study aims to (a) estimate the proportion of GCS13–15 patients with traumatic brain injury identified by CT imaging admitted to hospital who clinically deteriorate and (b) develop a prognostic model highly sensitive to clinical deterioration which could help inform discharge decision making in the ED.MethodsA retrospective case note review of 2000 patients with an initial GCS13–15 and traumatic brain injury identified by CT imaging (2007–2017) will be completed in two English major trauma centres. The prevalence of clinically significant deterioration including death, neurosurgery, intubation, seizures or drop in GCS by more than 1 point will be estimated. Candidate prognostic factors have been identified in a previous systematic review. Multivariable logistic regression will be used to derive a prognostic model, and its sensitivity and specificity to the outcome of deterioration will be explored.DiscussionThis study will potentially derive a statistical model that predicts clinically relevant deterioration and could be used to develop a clinical risk tool guiding the need for hospital admission in this group.
Highlights
Head injury is an extremely common clinical presentation to hospital emergency departments (EDs)
The management of GCS13–15 patients with CTidentified traumatic brain injury (TBI) is controversial with some advocating admission to higher levels of care and mandatory repeat Computed tomography (CT) imaging due to the risk of deterioration [7]
Research is required to estimate the risks of adverse outcomes in GCS13–15 patients with injuries identified by CT imaging in the UK
Summary
Study design This is a retrospective and consecutive cohort observational study. The proportion of the cohort that clinically deteriorates will be estimated, and a multivariable prognostic model that predicts deterioration will be developed. Data collection Screening A database of all emergency department CT brain requests and reports for patients aged 16 and over between 2007 and 2017 will be generated at the two sites from the electronic requesting and reporting system This will be screened to identify potentially eligible patients with CT requests related to head injury and CT scans with reported abnormalities related to TBI or intra-cranial haematomas (Fig. 2). We have based our sample size on a 10% estimated prevalence of clinical deterioration in our systematic review and our desired precision of the sensitivity of the derived model for this outcome [9]. The sample size of 2000, with an anticipated prevalence of clinical deterioration of around 10%, will allow the model to include 20 variables, based on the rule of at least 10 outcome events per parameter estimated. If the effect estimates are similar to those estimated in the data collected in England, we will combine the individual patient data of the two data sets to improve the precision of the model estimates
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