Management of the mild traumatic brain injured patient using a multidisciplinary observation unit protocol.

OBJECTIVES: We developed an ED based multidisciplinary observation unit (OU) protocol for patients with mild traumatic brain injury (mTBI). We describe the cohort of patients who were placed in the ED OU and we evaluated if changes to our inclusion and exclusion criteria should be made. METHODS: We conducted a retrospective cohort study to evaluate subjects who were admitted to the mTBI observation protocol. We included adults within 24 h of sustaining an mTBI with a Glasgow Coma Scale (GCS) of 14 or 15 who had pre-specified head CT findings, and did not meet exclusion criteria. Predictors of need for hospital admission after completing the OU protocol were determined using multivariable logistic regression analysis. RESULTS: The mean age was 49 (SD 23), 58 (33%) were female, and 136 (78%) were Caucasian. No subjects discharged home required a surgical intervention or ICU admission, and there were no deaths in discharged or admitted subjects. 28 subjects (16%) were admitted to the hospital following their OU stay. Subjects admitted were older (mean age: 56 vs. 48, p = 0.1) and had a higher proportion of traumatic bleeds on head CT (85% vs. 76%, p = 0.3). In multivariable logistic regression, GCS of 15 (aOR 4.24), African-American race (aOR 5.84), and no comorbid cardiac disease predicted discharge home after the observation protocol (aOR 0.28). CONCLUSIONS: A period of observation for a pre-defined cohort of patients with mTBI provided a triage plan that could allow appropriate patient management without requiring admission in the majority of subjects.

Implementation of a Neurotrauma Hotline for post-hospital continuity of care.

BACKGROUND: There are 4.8 million emergency department (ED) visits for traumatic brain injury (TBI) annually in the United States. Many of these patients do not receive educational information or follow-up care. AIMS OF THE STUDY: Our institution implemented a Neurotrauma Hotline for TBI patients. This study describes our implementation and utilization of a Neurotrauma Hotline at a Level I trauma center. METHODS: Callers and outcomes of calls to the hotline over a 12-month period were analyzed. Correlation analysis was done to assess relationship between hotline calls and TBI clinic volumes. RESULTS: There were 1205 calls to the hotline. Calls were most commonly from internal providers or patients, with 338 repeat callers. The call reason was frequently an appointment (36.8%) or advice (32.1%). There were 334 TBI clinic visits, and however, there was no statistically significant correlation between number of hotline calls and number of clinic visits (r = .417; P = .177). CONCLUSIONS: There was widespread utilization of our hotline. Other institutions wishing to adopt similar practices can expect that the majority of calls will be for appointment scheduling or clinical advice. Further work is needed to determine whether implementation of a Neurotrauma Hotline improves resource utilization and patient outcomes.

Pioglitazone improves working memory performance when administered in chronic TBI.

Traumatic brain injury (TBI) is a leading cause of long-term disability in the United States. Even in comparatively mild injuries, cognitive and behavioral symptoms can persist for years, and there are currently no established strategies for mitigating symptoms in chronic injury. A key feature of TBI-induced damage in acute and chronic injury is disruption of metabolic pathways. As neurotransmission, and therefore cognition, are highly dependent on the supply of energy, we hypothesized that modulating metabolic activity could help restore behavioral performance even when treatment was initiated weeks after TBI. We treated rats with pioglitazone, a FDA-approved drug for diabetes, beginning 46 days after lateral fluid percussion injury and tested working memory performance in the radial arm maze (RAM) after 14 days of treatment. Pioglitazone treated TBI rats performed significantly better in the RAM test than untreated TBI rats, and similarly to control animals. While hexokinase activity in hippocampus was increased by pioglitazone treatment, there was no upregulation of either the neuronal glucose transporter or hexokinase enzyme expression. Expression of glial markers GFAP and Iba-1 were also not influenced by pioglitazone treatment. These studies suggest that targeting brain metabolism, in particular hippocampal metabolism, may be effective in alleviating cognitive symptoms in chronic TBI.