Head-injured patients who "talk and die": The San Diego perspective

Background: Head-injured patients who "talk and die" are potentially salvageable, making their early identification important. This study uses a large, comprehensive database to explore risk factors for head-injured patients who deteriorate after their initial presentation. Methods: Patients with a head Abbreviated Injury Score (AIS) score of 3+ and a preadmission verbal Glasgow Coma Scale (GCS) score of 3+ were identified from our county trauma registry during a 16-year period. Survivors and nonsurvivors were compared with regard to demographics, initial clinical presentation, and various risk factors. Logistic regression was used to explore the impact of multiple factors on outcome, including the significance of a change in GCS score from field to arrival. In addition, patients were stratified by injury severity and hospital day of death to further define the relationship between outcome and multiple clinical variables. Results: A total of 7,443 patients were identified with head AIS 3+ and verbal GCS score 3+. Overall mortality was 6.1%. About one-third of deaths occurred on the first hospital day, with more than one-third occurring after hospital day 5. Logistic regression revealed an association between mortality and older age, more violent mechanisms of injury (fall, gunshot wound, pedestrian versus automobile), greater injury severity (higher head AIS and Injury Severity Score), lower GCS score, and hypotension. In addition, mortality was associated with a decrease in GCS score from field to arrival, the use of anticoagulants, and a diagnosis of pulmonary embolus. Two important groups of "talk-and-die" patients were identified. Early deaths occurred in younger patients with more critical extracranial injuries. Anticoagulant use was also an independent risk factor in these early deaths. Later deaths occurred in older patients with less significant extracranial injuries. Pulmonary embolus also appeared to be an important contributor to late mortality. Conclusions: More severe injuries and use of anticoagulants are independent risk factors for early death in potentially salvageable traumatic brain injury patients, whereas older age and pulmonary embolus are associated with later deaths.