czaszkowo- mózgowych porównanie badań sprzed 16 laty do wyników obecnych.

1 Wpływ czasu przyjęcia do szpitala na śmiertelność u pacjentów po ciężkich urazach czaszkowo- mózgowych porównanie badań sprzed 16 laty do wyników obecnych. Stanisław Hendryk, Piotr Bażowski, 1 Dariusz Łątka, 2 Nikodem Przybyłko Klinika Neurochirurgii Śląskiego Uniwersytetu Medycznego w Katowicach, Polska 1 Oddział Neurochirurgii Szpitala Wojewódzkiego w Opolu, Polska 2 Centralny Szpital Kliniczny Śląskiego Uniwersytetu Medycznego w Katowicach, Polska The influence of the time admission to the hospital on mortality in patients after severe head injury - comparison between studies from before 16 th years and recent time. Wpływ czasu interwencji na śmiertelność pacjentów po ciężkich urazach mózgu. Address for correspondence: Hendryk Stanisław MD, PhD; Dept. of Neurosurgery, Medical University of Silesia, Katowice, Medyków 14 str., 40-752 Katowice, Poland - Phone/fax +48 32 7894524/+48 32 2525812; E-mail: stanhendryk@interia.pl

2 Streszczenie Założenia i cel pracy: Czas upływający pomiędzy powstaniem ciężkiego urazu czaszkowomózgowego a przyjęciem chorego do szpitala i rozpoczęciem intensywnego leczenia odgrywa zasadniczą rolę w zmniejszeniu skutków urazu wtórnego i może istotnie wpływać na śmiertelność pacjentów. Celem pracy jest porównanie roli czasu przyjęcia pacjenta do szpitala w badaniach przeprowadzonych przed 16 laty ze stanem obecnym. Materiał i metody: Badania obejmują retrospektywną analizę obejmującą grupę 194 pacjentów leczonych operacyjnie z powodu ciężkich urazów czaszkowo-mózgowych w okresie 1 roku przed 16 laty w Klinice Neurochirurgii w Bytomiu* i podobną grupę 64 chorych leczonych w Klinice Neurochirurgii w Katowicach w 2010 roku. Praca analizuje czynniki mające wpływ na śmiertelność chorych z ciężkimi urazami czaszkowo-mózgowymi: rodzaj urazu czaszkowo-mózgowego, stopień uszkodzenia OUN oceniany w skali motorycznej Glasgow (GCS-M), oraz czas przyjęcia pacjenta do szpitala. Wyniki: Czynnikiem mającym istotny wpływ na śmiertelność pacjentów jest czas jaki upływa od urazu do chwili podjęcia trafnej diagnozy i właściwego leczenia. Procent zgonów pacjentów w grupie przyjętych do szpitala pomiędzy 4-6 godziną i powyżej 6 godzin jest znamienie wyższy niż w grupie chorych leczonych w okresie do 1 godziny od urazu (59,1% do 14,3% w 1994 i 56% do 0% w 2010). Również rodzaj urazu ma istotny wpływ na śmiertelność chorych, która jest najwyższa w grupie pacjentów z ostrym krwiakiem podtwardówkowym (71% i 60% odpowiednio w 1994 i 2010). Porównanie tych czynników w badaniach sprzed 16 laty i obecnych nie wykazało w tym zakresie istotnych różnic, gdzie czas przyjęcia chorych do szpitala jest podobny (5,8% i 5% do 1 godz. i 55,5% i 61% po 6 godz. odpowiednio w 1994 i 2010). Wnioski: Czas przyjęcia pacjentów po ciężkich urazach czaszkowo-mózgowych do szpitala i zakres postępowania leczniczego podejmowanego od pierwszych chwil po urazie może obniżyć śmiertelność tych chorych. Wśród innych czynników obniżających śmiertelność

3 pacjentów są rodzaje i zakresy terapeutycznych procedur włączanych od pierwszych momentów po urazie. Analiza porównująca sytuację w tym zakresie sprzed 16 laty do obecnej nie wykazała istotnej poprawy. Słowa kluczowe: ciężki uraz czaszkowo-mózgowy-wpływ czasu interwencji na śmiertelność pacjentów-porównanie wyników sprzed 16 laty z sytuacją obecną *Część pracy została przedstawiona na I Krajowym Zjeździe Unii Polskich Towarzystw Chirurgicznych, Wrocław, Polska, 10-12 listopada 1994.

4 The influence of the time admission to the hospital on mortality in patients after severe head injury - comparison between studies from before 16 th years and recent time. Stanisław Hendryk, Piotr Bażowski, 1 Dariusz Łątka, 2 Nikodem Przybyłko Department of Neurosurgery, Medical University of Silesia in Katowice, Poland 1 Division of Neurosurgery, Main Regional Hospital in Opole, Poland 2 Central Clinical Hospital, Medical University of Silesia in Katowice, Poland Abstract Purpose: The time elapses between origin severe head injury and admission patients to the hospital and initiate of the adequate and emergency treatment act crucial role in diminish consequences of the second injury and improve survivals patients. The aim of this investigation is comparison significance of the time admission patients to the hospital on mortality in studies from before 16 th years and recent time. Material and Methods: The retrospective investigate was carried out on group 194 patients surgical treatment in period one year 16 th years ago in Dept. of Neurosurgery in Bytom* and similar group 64 patients treatment in Dept. of Neurosurgery in Katowice in 2010. The study analyse factors influencing on the mortality in patients with severe head injury: type of intracranial injury, grade of brain damage estimate in Glasgow motor scale (GCS-M) and the time admission patients to the hospital. Results: The time passing from injury to establishment of an accurate diagnosis and initiating the emergency treatment is found to be the factor with most impact on effective treatment. The percentage of mortality in group patients admission to the hospital between 4-6 and above 6 hours after injury is significant higher nor in group admitted and treatment to 1 hour after severe head injury (59.1% to 14.3% in 1994, and 56% to 0% in 2010). Also type of intracranial injury has significant influence on the patients mortality, and is highest in patients with acute subdural haematoma (71% and 60% respectively in 1994 and 2010).

5 Comparison these factors in studies from before 16 th years and recent time didn t show a significant difference, and the time admission patients to the hospital is similar (5.8% and 5% to 1 hour and 55.5% and 61% above 6 hour respectively in 1994 and 2010). Conclusion: The time admission patients following severe head injury to the hospital and begin emergency and surgical treatment is most important factor in improve results and diminish of patients mortality. Another factor that may reduce the mortality rate is the type and range of therapeutic procedures carried out from the first moments after trauma. The comparison analyse in this range in study from before 16 th years and recent time didn t show a significant improve. Key words: severe head injury-time admission to the hospital-patients mortality-comparison between studies from before 16 th years and recent time * Part of this research was presented at the I st National Congress Union of the Polish Surgery Society, Wrocław, Poland, 10-12 November 1994.

6 Introduction The problems of improvement in trauma patient s treatment, generally considered both difficult and vitally important, are reported in medical literature worldwide [1,2,3,4,5,6,7]. In Poland, in recent years, the problems have become particularly acute due to a growing number of accidents that are characterized by a large number of severe injuries and, consequently, high mortality [8]. The reasons for such a situation are twofold. On one hand, there is significant traffic congestion present in Poland, not infrequently the vehicles are in bad technical condition, and both drivers and pedestrians exhibit irresponsible behaviour. On the other hand, treatment effectiveness depends on the organization and preparation of health service. The progress being made in this field is evident in hospital treatment, as nowadays there is easier access to modern diagnostic methods, more effective operative procedures, intensive care, and rehabilitation. The pre hospital treatment, however, is still worse developed as far as its range, organization, and methods are concerned. Treatment efficacy is dependent on many factors of which the most crucial ones seem to be the time - passing from injury to bringing the patient to an adequately equipped hospital (with computed tomography and multi specialist surgical treatment) - and the range and type of treatment initiated at that stage. The effectiveness of aid given in the first hour after trauma is critical for preventing the development of the so called secondary traumas; in the literature the first hour following the injury is given the name of the golden hour [1,2, 9-11]. Martin NA. et al. (1997) [10] identified three posttraumatic hemodynamic phases following severe head trauma: Phase I, hypo perfusion during the first 24 hours (post injury Day 0): Phase II, hyperaemia on post injury Days 1 to 3: and Phase III, vasospasm during Days 4 to 14. They suggest that the cause of the cerebral hypo perfusion during the first 24 hours post injury may be multi factorial and might be caused by trauma-induced release of vasoactive substances such as calcium, catecholamine s, prostaglandins, or neuropeptides (endothelin, neuropeptides Y) and

7 haemoglobin. These factors and also intravascular thrombosis may play a role in microcirculatory obstruction and might be the cause narrowing of the microcirculation. It is strongly suggest that the posttraumatic hypoxia contribute to the vascular pathogenesis of brain injury and exacerbates the permeability of the BBB with maximum at 6 hours after injury [12]. In Poland, pre hospital treatment has not been modernized for many years, and it also shows huge differences in its level and capabilities between major cities and rural communities, which may be another reason for a high posttraumatic mortality rate. This condition appeared our studies which carry out 16 th years ago [13]. How it was changed in recent years shows this current date.

8 Material and Methods The study retrospectively analyses cases of severe head injuries treated in the Dept. of Neurosurgery in Bytom, Poland, during one year 16 th years ago and similar group patients treated in Dept. of Neurosurgery Silesian Medical University in Katowice in 2010. The following factors were assessed with reference to mortality: 2). cerebral trauma severity on admission (on the basis of the so called Glasgow motor scale - GSC-M) [2]; 3). type and severity of the central nervous system (CNS) injury as assessed by computed tomography (CT); 3). time passing from injury to bringing the patient to the hospital and the methods and range of treatment instituted. The results were calculated as a group mean ± SEM.

9 Results Following one year (1994) 194 patients 83.6% men and 16.4% women, aged 46.8 on average - with severe head injury were treated in Dept. of Neurosurgery in Bytom (Table 1). The mortality rate in the whole group was high - 36.1% - and was caused mainly by severe injuries the patients sustained as shown by low - 3.7- mean GCS-M score on admission. Comparison the demographic and epidemiologic characterization patients group in study with 2010 shows very similarly results (Table 2), although mean mortality in whole group is even higher. The high mortality rate observed resulted also from the fact that the cases analyzed included patients in critically severe conditions who died within 24 hours of injury. The relationship between patients GCS-M score evaluated in time admission and % mortality shown high correlation - in more low GCS-M score all the more high % of mortality and these results were strongly similar in our studies with 1994 and 2010 year (Fig 1. and Fig 2.). In the study from before 16 th years only 5.8% of patients were hospitalized within 1 hour; altogether, the patients admitted within 3 hours constituted only 21.5% of the cases studied (Fig 3.). The results in current studies aren t difference and the same in practice (Fig 4.). The highest mortality rate - nearly 60% - was observed in patients admitted to hospital within more than 6 hours of injury (Fig 5. and Fig 6.). While all the cases analyzed were of a similar trauma severity, the rate was significantly decreased in the patients admitted within 2-3 hours, and in those who arrived to the clinic within 1 hour of injury, the mortality rate was only 14,3% in study with 1994 (Fig 5.) and 0.0% in study with 2010 year (Fig 6.). These facts are confirmed by the results of the studies from before 16 th and present study, in which the mortality rate was lower - 25.0% and 30% - in patients with acute epidural haematomas than in patients with other injuries (Fig 7. and Fig 8.). This is also illustrated by the results of the analysis, which show that the mortality rate in the group of patients with acute subdural hematomas was 71% and 60%, where the coincidence of the extensive brain damage is almost considered a norm (Fig 7. and Fig 8.).

10 Discussion It is now recognized that traumatic injury to the brain causes neurologic deficits through both direct (immediate mechanical disruption of neural pathways) and indirect (secondary or delayed) mechanisms [11]. As far the trauma mechanism and resulting brain and other organ injuries are concerned, doctors are not in a position to change anything in this respect. They can, however, by adequate and competent action in early hours following trauma, reduce secondary effects, which result from the changes developing rapidly in the damaged brain [7,9,12,14-16]. In the case of CNS, the damage secondary to trauma is due to growing posttraumatic intracranial hematomas, and to the development of brain oedema and ischemia that produce irreversible cerebral changes, and may become a death cause. The first hour following injury gives the best possibilities of preventing the unfavourable processes, and that is why the first 60 minutes after injury are called the golden hour [11,14,17-20). The significance of the first hours following head injury is confirmed by the data from the present study. 55.5% and 60% (in studies from 1994 and 2010) of patients were brought to the clinic within more than 6 hours, and in some cases even within a few days, of injury. The high mortality rate revealed must be of deep concern, even if the facts mentioned above are taken into consideration; the situation, therefore, should be improved by finding methods of enhancing the treatment effectiveness. The data presented strongly confirm the significance of fast transport of patients with severe head injuries to hospitals where a complete and competent treatment can be instituted. The prognosis in these cases would have been much better if they had been refereed to the Division of Neurosurgery earlier, or if, after careful diagnosis based on CT, they had undergone an extensive surgery aimed at removing intracranial hematomas and brain decompression in hospitals where they were first admitted. The cardinal importance of sufficient aid given during quick transport of patients to hospital is revealed in the analysis of patients with the lowest mortality rate (14,3% and 0.0%

11 respectively in 1994 and 2010), who were admitted to the hospital within 1 hour of injury. All of them had accidents at work and both at the scene of disaster and during the transport by resuscitation ambulance, were given adequate aid. Prevention of secondary brain injury development is one of the fundamental objectives in treating patients with severe head injuries. When the secondary brain injury is related to growing intracranial hematomas, the treatment aiming at fast and radical hematomas evacuation is the most favourable for the patient [1,2,4,7-9, 13]. The fact is confirmed by the results of the present study, in which the mortality rate was lower 25.0% and 30% - in patients with acute epidural hematomas than in patients with other injuries. The problem becomes more complex and difficult when the trauma causes brain injury, and triggers a dynamic development of processes leading to brain ischemia and oedema [16,18-22]. To improve the treatment efficacy in the last group discussed, it is necessary to initiate during transportation an intensive treatment (intubation and aided respiration, antioxidant and free radical scavengers, steroid and lipid per oxidation inhibitors, calcium channel antagonists), who preventing the development of secondary brain injuries, and, subsequently, to promptly perform a complete surgical brain decompression [1-3, 8,9, 11,13, 23,24]. Time is found to be a crucial factor influencing the improvement of treatment of severe head injuries. The management should take full advantage of chances offered by the first hour after injury, when it can be most effective as shown present study.

12 Conclusion: The time admission patients following severe head injury to the hospital and begin emergency and surgical treatment is most important factor in improve results and diminish of patients mortality. Another factor that may reduce the mortality rate is the type and range of therapeutic procedures carried out from the first moments after trauma. The comparison analyse in this range in study from before 16 th years and recent time didn t show a significant improve. Acknowledgements The authors have no conflicts of interest with respect to this work.

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