Outcome of traumatic brain injury patients with concomitant chest injuries: A retrospective single–center based study

Karthikeyan¹, Santhosham. C. M²

Department of Neuro-Surgery, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Background

Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Extracranial injuries, especially chest injuries, increase the mortality in TBI. It has been estimated that up to 30% of TBI patients have concomitant chest injuries. TBI alone has mortality of 30%. TBI with chest injuries can cause mortality up to 80% with average of 43%. Chest trauma alone has a mortality rate of 22-26% globally.

Aim

To study the impact of thoracic trauma on the in- hospital course and outcome of patients with TBI.

Study Design

Study Type: A retrospective single-center database collected from MRD, Kauvery hospitals, cantonment, Trichy.
Place of Audit: Neuro ICU, Kauvery Specialty Hospital, Cantonment, Trichy
Duration of Audit: May 2024-May 2025
Clinical Audit done by: Neuro Critical Care Team.

Inclusion Criteria

All polytrauma patients involving head and chest, admitted in neuro critical care.
All age group
All gender

Exclusion criteria

Old polytrauma

Study Population

Total number of patients: 468

TBI without chest injury: 376

TBI with Chest injury:72

Total number of AMA discharge: 13

Mode of Head and chest injury

Mode	Number	Percentage
Road Traffic Accident	57	96.61%
Gun Shot	0	0%
Assault	0	0%
Iatrogenic	0	0%
Falls	2	3.39%
Total	59	100%

Mode	Number	Percentage
Road Traffic Accident	57	96.61%
Gun Shot	0	0%
Assault	0	0%
Iatrogenic	0	0%
Falls	2	3.39%
Total	59	100%

Types of associated chest wall injuries in the 59 patients

Injuries - Chest Wall	Number	Percentages	Spine involved
Laceration	1	1.69%	0
Penetrating	0	0%	0
Rib fractures	45	76.27%	7
Flail chest	2	3.38%	1
Thoracic spine	15	25.42%	0

Patient specific type injuries identified

Head injury with rib fracture alone – excluded

Head injury type	Intrathoracic chest injuries
	Lung contusion	Haemo-thorax	Pneumo-thorax	Haemo/pneumo-thorax	Total	P-value
Extradural hematoma	2	1	1	2	6	Χ2 = 0.005 sig
Subdural Hematoma	0	1	1	3	5
Intracerebral hematoma	0	0	0	0	0
DAI – Contusion	6	19	2	14	41
Total	8	21	4	19	52
Mortality	1	1	0	1	3

Mortality related to management
Treatment modality - Chest injury with Head Injury	Number	Survived	Survival %	Died	Mortality %	P-Value
Rib fixation	3	3	5%	0	0%	X2=0.002 sig
Thoracostomy drainage	22	20	34%	2	3%
Conservative	34	33	56%	1	2%
Total	59	56	95%	3	5%

Statistical analysis

Statistical analysis was performed using SPSS, (Version 26.0). Chi- square test and fisher’s exact test will be used to find out association between the categorical variables.

P < 0.05 will be considered as statistically significant.

Outcome at discharge (GOS) in relation to time to arrival to hospital

Time to arrival	Total	GOS and ICD
		Good Outcome	Moderate Disability	Severe Disability	Persistent Vegetative	Death
< 48 Hours	54	28 (6)	7 (3)	13 (7)	3 (2)	3 (2)
2–7 Days	2	2 (1)	1	1	0	0
8–14 Days	0	0	0	0	0	0
> 14 Days	3	1 (1)	0	0	0	0
Total	59	27	8	14	3	3

AIS	Head injury	Chest injury
Minor	12	10
Moderate	12	13
Serious	12	13
Severe	8	4
Critical	12	16
Fatal	3	3
Score >3	35	36

Ventilated	38
Tracheostomy	17
Not intubated	21

Outcome at discharge (GOS) in relation to GCS on arrival to hospital

Outcome	GCS on admission			Total
	mild 13-15	moderate 9-12	severe 3-8
Good	24	4	5	33	55%
Moderate disability	1	2	4	7	11%
Severe disability	1	4	8	13	22%
Persistent vegetative	0	1	2	3	5.6%
Death	0	2	1	3	5.6%
Total	26	13	20	59

Outcome at discharge (GOS) in relation to GCS on arrival to hospital

Challenges

TBI is a common cause of mortality and severe morbidity. Although there have been significant advances in management, associated chest injuries remain a major challenge.
Avoiding hypoxemia, hypercarbia and hypotension are essential to maintain cerebral perfusion and prevention of secondary insults to brain.
Impaired alveolar gas occurs frequently resulting in hypoxemia and worsening brain injury and increasing mortality.
Complications of chest injuries include Ventilator associated Pneumonia, ARDS, Sepsis, Shock and MODS.

Limitations

It’s a retrospective study only.
Trauma severity scores and Comorbidities of the patients were not included.
Follow up of the patients were not done.

Conclusion

Our In-hospital mortality – 3 of 59 (5% only).
Non survivors – cause of death not related to chest injury directly.
Early Rapid management adhering to ATLS protocols reduce the mortality in these patients.

References

Risk factors associated with mortality in Severe Chest Trauma Patients admitted to the ICU. – Jesus Abelardo Barea- Mendoza et al,
Impact of blunt chest trauma on outcome after traumatic brain injury- a matched – pair analysis of the trauma register DGU – Mark Schieren et al,
Scand J Trauma Resuscitation Emerg. Med Chest injuries associated with head injury – Nigerian Journal of Surgery.

Acknowledgement

Neurosurgical and Critical care team
Emergency Department
Anesthesia team
Orthopaedics team
Surgical Gastro enterology Team

Kauverian Bookshelf

Applied Medical Statistics

Outcome of traumatic brain injury patients with concomitant chest injuries: A retrospective single–center based study