title: TBI risk stratification at presentation: a prospective study of the incidence and timing of radiographic worsening in the Parkland Protocol.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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%).
  
  
  CONCLUSIONS
  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.
authors: Department of Surgery, University of Texas-Southwestern Medical Center, Parkland Memorial Hospital, Dallas, Texas 75390-9158, USA. herb.phelan@utsouthwestern.edu
authors: Herb A
authors: HA
authors: Phelan
authors: Alexander L
authors: AL
authors: Eastman
authors: Christopher J
authors: CJ
authors: Madden
authors: Kim
authors: K
authors: Aldy
authors: John D
authors: JD
authors: Berne
authors: Scott H
authors: SH
authors: Norwood
authors: William W
authors: WW
authors: Scott
authors: Ira H
authors: IH
authors: Bernstein
authors: Jeffrey
authors: J
authors: Pruitt
authors: Gordon
authors: G
authors: Butler
authors: Lowery
authors: L
authors: Rogers
authors: Joseph P
authors: JP
authors: Minei
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000145:classification* / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D015994:Incidence; D020198:Intracranial Hemorrhage, Traumatic / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D054556:Venous Thromboembolism / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control