Abstract
Objective The presence of multiple injuries in addition to a traumatic brain injury (TBI) is
initially uncertain in most patients with posttraumatic coma. The interdisciplinary
team of physicians in charge of initial treatment after hospital admission may face
a collision of vital priorities. The purpose of this study was to analyze which diagnostic
and surgical measures were given priority over others in comatose patients after injury
and to draw conclusions from these data.
Methods In this prospective multicenter cohort study, the outcomes of 1,003 comatose patients
with suspected multiple injuries were studied. The analysis was divided into an early
and a late stage. Diagnostic and surgical measures were analyzed for a 6-month period.
The prognostic value of the Glasgow Coma Scale (GCS) and the World Federation of Neurosurgical
Societies grading scale were investigated.
Results Removal of intracranial hematomas and decompressive craniotomies were the most frequent
procedures within the first 48 hours after admission to the hospital. Prognosis depends
on the location and the combination of injuries. Outcome is significantly correlated
to initial signs of brainstem dysfunction. The GCS did not adequately predict clinical
outcome.
Conclusion Comatose patients with suspected multiple injuries should only be admitted to hospitals
with a continuous neurosurgical service because intracranial operations are more frequent
in the first 48 hours than extracranial operations. Depending on the neurologic status
of the patient, an urgent surgical decompression may be essential for a good outcome.
The GCS alone is not a sufficient tool for the neurologic assessment and the prognosis
of patients with multiple injuries. The onset of clinical signs of brainstem dysfunction
indicates a critical deterioration of the functioning of the central nervous system.
The priority of surgical measures should be tailored accordingly.
Keywords
multiple injuries - brain injury - coma - collision of priorities
