It is difficult to predict outcomes in patients with a TBI, however awareness of clinical and radiological predictors of poor outcomes is useful when discussing ongoing patient needs with family members.
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- Age (>40 years, worse with increasing age)
- Initial GCS post-resuscitation
- Hypotension
- Hypoxia
- Pupil size and reaction to light
- ICP
- Nature & extent of the intracranial injuries (subdural > extradural > SAH)
- Co-morbidities
- Low-to-middle income countries [/accordion] [/az_accordion_section]
There are a number of tools that are predominantly used in the research environment such as the CRASH Head Injury Prognosis calculator and the IMPACT Head Injury Prognosis calculator.
These won’t be discussed further but can be found at the following links:
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Systemic hypotension and hypoxemia, occurring at any time from injury through to the ICU, are the 2 most powerful independent predictors of poor outcome from severe TBI.
The overall mortality of severely head injured patients with documented hypoxia is almost twice that of patients without documented hypoxia. A single episode of hypotension has been associated with a doubling of mortality and an increased morbidity when compared to a matched group of patients without hypotension.
Patients who suffer multiple injuries because of trauma present a unique challenge in managing conflicting interests of different organ systems, particularly those with significant chest injuries. Priority should be given to restoration of the circulation and oxygen delivery. [/accordion] [/az_accordion_section]
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CT Brain
- Absence or compression of the basal cisterns
- Midline shift
- Petechial haemorrhages
- Subarachnoid haemorrhage
- Unevacuated haematoma
- Brainstem injury
MRI
- At 6-8 weeks: injuries to corpus callosum, corona radiata and dorsolateral brainstem predict persistent vegetative state (PVS) [/accordion] [/az_accordion_section]
The Extended Glasgow Outcome Scale (GOS-E) is a scale predominantly used in the research setting that classifies TBI outcomes based on the patient’s functional state.
You will be pleased to know that despite a long ICU stay (in which he received a tracheostomy), Jake was discharged to a neuro-rehabilitation unit 3 months after his presentation. After a further 5 months of inpatient rehab, he was discharged home and intends on returning to work despite mild cognitive impairment (memory impaired).
