TBI risk stratification at presentation: a prospective study of the incidence and timing of radiographic worsening in the Parkland Protocol.

Department of Surgery, University of Texas-Southwestern Medical Center, Parkland Memorial Hospital, Dallas, Texas 75390-9158, USA.
The journal of trauma and acute care surgery 08/2012; 73(2 Suppl 1):S122-7. DOI: 10.1097/TA.0b013e3182606327
Source: PubMed

ABSTRACT We have created a theoretical algorithm for venous thromboembolism prophylaxis after traumatic brain injury (TBI) known as the Parkland Protocol, which stratifies patients into low-, medium-, and high-risk categories for spontaneous progression of hemorrhage. This prospective study characterizes the incidence and timing of radiographic progression of the TBI patterns in these categories.
Inclusion criterion was presentation with intracranial blood between February 2010 and March 2011; exclusion was receipt of only one computed tomographic scan of the head during the inpatient stay or preinjury warfarin. At admission, all patients were preliminarily categorized per the Parkland Protocol as follows: low risk (LR), patients meeting the modified Berne-Norwood criteria; moderate risk (MR), injuries larger than the modified Berne-Norwood criteria without requiring a neurosurgical procedure; high risk (HR), any patient with a craniotomy/monitor.
A total of 245 patients with intracranial hemorrhage were enrolled during the 13-month study period. Of patients preliminarily classified as LR at admission (n = 136), progression was seen in 25.0%. Spontaneous worsening was seen in 7.4% of LR patients at 24 hours after injury, and no LR patients progressed at 72 hours after injury. In patients initially classified as MR at admission (n = 42), progression was seen in 42.9%, with 91.5% of patients demonstrating stable computed tomographic head scans at 72 hours after injury. In patients initially classified as HR (n = 67), 64.2% demonstrated spontaneous progression of their TBI patterns, with 10.5% continuing to progress at 72 hours after injury. Most repeat scans were performed as routinely scheduled studies (81-91%).
Increases in the incidence of spontaneous worsening were seen as severities of injury progressed from the Parkland Protocol's LR to MR to HR arms. The time frames for these spontaneous worsenings seem to be such that the protocol's theoretical recommendations for venous thromboembolism prophylaxis are worth pursuing as future points of investigation.

1 Bookmark
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose of review A major challenge in the treatment of brain-injured patients is the decision on indication and timing of prophylactic anticoagulation. In addition, an increasing number of patients suffering from traumatic brain injury (TBI) are on preinjury anticoagulation therapy. Despite clear evidence for an increased risk of venous thromboembolic events and pulmonary embolism in traumatized patients without prophylactic anticoagulation, there is a lack of distinct recommendations and standardized clinical practice guidelines. This review summarizes current research evidence regarding post-traumatic prophylactic anticoagulation and management of patients with prehospital use of anticoagulants. Recent findings In addition to nonpharmacological techniques like compression stockings, use of low-dose unfractionated heparin or low-molecular-weight heparin is effective in different studies in terms of thromboprophylaxis. If follow-up computed tomography scans and clinical neurological examinations do not show progression within 24 h after initial evaluation, prophylactic anticoagulation does not increase risk for hemorrhage progression and therefore seems to be safe after TBI. Summary Stratification scores for identification of TBI patients with low, moderate, or high risk for spontaneous cerebral bleeding may help to allow early thromboprophylaxis while maintaining a good risk–benefit ratio. So far, these scores require validation by prospective trials. Therefore, current evidence requires control computed tomography scans prior to early pharmacological thromboprophylaxis.
    Current Opinion in Anaesthesiology 01/2013; 26(5):529-534. · 2.53 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: As a basis for venous thromboembolism (VTE) prophylaxis after traumatic brain injury (TBI), we have previously published an algorithm known as the Parkland Protocol. Patients are classified by risk for spontaneous progression of hemorrhage with chemoprophylaxis regimens tailored to each tier. We sought to validate this schema. In our algorithm, patients with any of the following are classified "Low-risk" for spontaneous progression: subdural hemorrhage <8 mm thick; epidural hemorrhage <8 mm thick; contusions <20 mm in diameter; a single contusion per lobe; any amount of subarachnoid hemorrhage; or any amount of intraventricular hemorrhage. Patients with any injury exceeding these are "Moderate-risk" for progression, and any patient receiving a monitor or craniotomy is "High-risk." From 2/2010 to 11/2012, TBI patients were entered into a dedicated database tracking injury types and sizes, risk category at presentation, and progression on subsequent CTs. The cohort (n=414) was classified as Low-risk (n=200), Moderate-risk (n=75), or High-risk (n=139) after first CT. After repeat CT scan, radiographic progression was noted in 27% of Low-risk subjects, 53% of Moderate-risk, and 58% of High-risk. Omnibus ANOVA test for differences in progression rates was highly significant (p<0.0001). Tukey's post-hoc test showed the Low-risk progression rate to be significantly different than both the Moderate and the High-risk arms; no difference was seen between the Moderate and High-risk arms themselves. These criteria are a valid tool for classifying TBI patients into two categories of risk for spontaneous progression. This supports tailored chemoprophylaxis regimens for each arm. Key words: TBI, progression, validation, venous thromboembolism.
    Journal of Neurotrauma 06/2014; · 3.97 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Evidence is emerging that isolated traumatic subarachnoid hemorrhage (ITSAH) may be a milder form of traumatic brain injury (TBI). If true, ITSAH may not benefit from intensive care unit (ICU) admission which would in turn decrease resource utilization. We conducted a retrospective review of all TBI admissions to our institution between 2/2010 and 11/2012 to compare the presentation and clinical course of subjects with ITSAH to all other TBI. We then performed descriptive statistics on the subset of ITSAH subjects presenting with a Glasgow Coma Score (GCS) of 13 to 15. Of 698 subjects, 102 had ITSAH and 596 had any other intracranial hemorrhage pattern. Compared to all other TBI, ITSAH had significantly lower injury severity scores (p<0.0001), lower head abbreviated injury scores (p<0.0001), higher emergency department GCS (p<0.0001), shorter ICU stays (p=0.007), higher discharge GCS (p=0.005), lower mortality (p=0.003), and significantly fewer head CT scans (p<0.0001). Of those ITSAH subjects presenting with a GCS of 13 to 15 (n=77), none underwent placement of an intracranial monitor nor craniotomy. One subject (1.3%) demonstrated a change in exam (worsened headache and dizziness) concomitant with a progression of his intracranial injury. His symptoms resolved with readmission to the ICU and continued observation. Our results suggest that ITSAH are less severe brain injuries than other TBI. ITSAH patients with GCS scores of 13 to 15 demonstrate low rates of clinical progression, and when progression occurs it resolves without further intervention. This subset of TBI patients does not appear to benefit from ICU admission. Key words: isolated; traumatic; subarachnoid; progression; sequelae.
    Journal of Neurotrauma 06/2014; · 3.97 Impact Factor


Available from
May 20, 2014