Carol Hawley1, Magdy Sakr2, Sarah Scapinello, Jesse Salvo, Paul Wren, Helga Magnusson, Harald Bjorndalen 1 Warwick Medical School 2 University Hospitals Coventry and Warwickshire NHS Trust

Major Head Trauma in Older Patients: One year of data from one UK Trauma Centre

Objectives and Background•Traumatic Brain Injury (TBI) is an important cause of hospital admission for older adults. Previous research has shown that mortality from TBI increases with age, rising from 71% in 65 - 70-year-old patients to 87% for patients >80 years1.

•There are currently 3 million people aged 65 and over in the UK representing 17% of the population2, and by 2041 this is estimated to rise to 25%2.

•The number of older adults presenting with TBI is likely to increase. •The National Institute for Clinical Excellence (NICE) provides clear guidance pertaining to the treatment of head injuries within Emergency Departments3.•This study examines incidence and outcomes for a year of admissions due TBI to one Major Trauma Centre.

MethodsData were collected from the Trauma and Audit Research Network (TARN) documentation over a twelve month period from April 1st 2012 to March 31st 2013 at University Hospital Coventry Warwickshire. TARN aims to provide doctors, nurses and managers with information to benefit their service4. TARN inclusion criteria include:

• Trauma admissions whose length of stay is 72 or more hours

• Patients admitted to a High Dependency Area regardless of the length of stay

• Patients transferred to other hospital for specialist care

• Any occurrences of death in the ED4.

• Patients included in TARN must also meet injury criteria, including:

• Those with displaced, open, compound, or comminuted facial fractures

• Skin injuries involving >20% blood loss

• Damage to an underlying vessel, bone, or organ4.

Patients aged ≥65 admitted with TBI were included. Data were collected on age, injury cause, clinical presentation, Injury Severity Score (ISS),Glasgow Coma Score (GCS), neuro-imaging, neurosurgical involvement and other injuries. Glasgow Outcome Scale (GOS) scores were also assessed at time of discharge. Descriptive statistics and epidemiological data were then extracted from the data set to examine trends and themes.

Results•110 patients during the 12 months period presented with head injuries. •Men represented 47% of patients used in the study population, with women representing the remaining 53%.•96(87%) patients survived their head injury. •The ages of patients ranged from 65 to 99 years, with a mean presenting age of 79.5 years (SD 28.91). The length of hospital stay for patients varied from 1 to 151 days, with a mean length of 26.34 days (SD 28.13) (Table 1)•For the majority of patients a low level fall (less than 2 metres height) was responsible for their injury (Table 2)•The time between patient presentation and a CT scan ranged from 0.1 hrs to 158 hrs, with a mean wait time for 10.61 hrs (SD. 27.04) (Table 2)•Although a wide variety of brain injuries were noted in the study population, the most frequently cited injuries were; cerebral haematoma, subdural; subarachnoid haemorrhage and scalp contusion (Figure 1).•One third of patients presenting with major head injury were documented to have been seen by the trauma team at the hospital.•Patients demonstrated a range of brain injury severities, with most patients (83) having a GCS of 13-15, putting them in the category of mild brain injury. Seven patients had a GCS between 3-8 indicating severe brain injury. The severity of GCS was associated with lower GOS at discharge and therefore higher rates of death and disability

Table 1: Descriptive Statistics for the Study population

Table 2: Causes of Head Injury and Frequency of head injuries in each causal category.

References1) Patel HC, Bouamra O, Woodford M, Yates DW, Lecky FE. Mortality associated with severe head injury in the elderly. Acta Neurochirurgica, 2010;152,8:1353-7. 2) Office for National Statistics. Population and Household estimates for England and Wales. 2012.http://www.ons.gov.uk/ons/publications/re-reference-tables.html. accessed February 2013.

3) NICE Guidance [online] CG56, Head Injury: Full Guideline (2010) viewed at: http://www.nice.org.uk/nicemedia/live/11836/36259/36259.pdf

4) The Trauma Audit & Research Network [online] Procedures manual viewed at: https://www.tarn.ac.uk/content/downloads/53/Procedures%20manual.pdf

Figure 1: Varieties and Frequencies of Head Trauma presentations

Figure 2: Glasgow Outcome Scale scores of patients at discharge

N Range Minimum Maximum Mean Std. Deviation

Age in years 110 33 66 99 79.48 8.910

Length of Stay (Days)

110 150 1 151 26.34 28.134

Time to First CT Scan (Hours)

104 158.3 1 158.4 10.60 27.0431

Injury Severity Score (ISS)

110 45 5 50 19.21 8.285

Valid N 104

Glasgow Coma Scale Score (GCS)

Frequency Percent

Severe

Moderate

Mild

3 3 2.7

4 1 0.9

7 2 1.8

8 1 0.9

9 2 1.8

11 2 1.8

12 3 2.7

13 7 6.4

14 22 20.0

15 54 49.1

Total 97 88.2

Missing System 13 11.8

Total 110 100.0

Figure 3: Glasgow Coma Scale Scores and frequency of scores in the study population. Severe brain injury = GCS score of 3-8, Moderate brain injury = GCS score of 9-12, and Mild brain injury = a GCS score of 13-15. The majority of patients presented with mild head injuries.

AcknowledgementsWith special thanks to all the staff at the Accident and Emergency Department At University Hospitals Coventry and Warwickshire

Thanks to URSS for providing funding and support for this project.

Discussion and Interpretation•Fall less than 2 meters caused most of head injuries in the elderly (69%). Prevention of falls would be a most effective way of reducing morbidity and mortality in such age group.•Intracerebral,subdural haematomas are common and in many cases occur without skull fracture.•The length of stay in hospital for this group of patients is high(26 days). A rehabilitation or social care facility may aid early discharge.