A total of 14,175 patients who suffered trauma were admitted to Dankook University Hospital Regional Trauma Center, a regional trauma center, between January 2015 and December 2019. We focused on the cases of 25 consecutive patients with severe TBI who underwent operations for brain injury and torso hemorrhage, including chest or abdomen injury. We excluded patients who underwent surgery for organ donation or simple procedures such as tracheostomy or wound management. We defined TBI as severe when a patient’s initial Glasgow Coma Scale (GCS) score was 3–8, when the head Abbreviated Injury Scale (AIS) score was 4–5 (including subdural score of 4–5, epidural score of 5, or intracerebral hematoma score of 4–5), or when decompressive craniectomy was necessary. Clinical information was obtained through a retrospective review of each patient’s medical records. We also documented each patient’s demographic data, AIS score, Injury Severity Score (ISS), initial GCS score, initial vital sign measurements (blood pressure, heart rate, and respiration rate), and Revised Trauma Score (RTS), and we investigated various data for treatment results, including mortality rate, preventable trauma death rate (PTDR), and Glasgow Outcome Scale (GOS) score 3 months after injury.

In accordance with the Advanced Trauma Life Support (ATLS) guidelines of the American College of Surgeons, we conducted the primary and secondary surveys after initial resuscitation of patients at Dankook University Hospital Regional Trauma Center and then planned appropriate treatment. In cases of severe TBI and abdominal injuries that necessitated emergency surgery, various factors such as blood pressure, neurological signs, and radiologic findings were used to prioritize injuries, and in cases of severe TBI and thoracic injuries, vital signs such as blood pressure, heart rate, and respiration rate were also considered. Simultaneous brain and abdominal or thoracic surgery was performed only in patients with poor vital signs in whom brain surgery was inevitable because of worsening neurological symptoms.

To analyze the correlation of each factor with the occurrence of complications, we performed univariable regression analysis, using the chi-squared test or Fisher’s exact test, along with SPSS Statistics 20.0 (IBM Corporation, Armonk, NY, USA). p-values of <0.05 were considered statistically significant.

The demographic characteristics of the 25 patients (17 men and eight women) are summarized in Table 1. All patients underwent brain surgery and thoracic or abdominal surgery; their average age was 55.4 years. The mean ISS was 34.7 (range 9–59), the mean initial GCS score was 9 (range 3–15), and the mean initial systolic blood pressure (SBP) was 125 mmHg (range 0–227 mmHg). The causes of injury included 14 traffic accidents, 10 falls, and one crushing by heavy machinery. Fourteen patients underwent surgery on the same day as the injury, of whom five patients underwent simultaneous surgery for TBI and ECI, four patients underwent brain surgery first, one patient underwent chest surgery first, and four patients underwent abdominal surgery first. Ten patients (40%) died during treatment: 5 from severe brain injury, four from hemorrhagic shock, and 1 from multiorgan failure. Of the 15 survivors, seven patients had a good prognosis according to their GOS scores (≥4). Among the patients who underwent multiple surgeries, significant factors associated with mortality were lower SBP, higher initial heart rate, lower GCS score, and higher ISS. In addition, the higher the head AIS score, the more likely a patient was to die. However, age, initial RTS, and initial hemoglobin level were not associated with mortality.

We evaluated the 14 patients with TBI and torso hemorrhage who underwent resuscitative operations (Table 2). Operations for TBI included decompressive craniectomy and hematoma evacuation in 10 patients and external ventricular drainage in four patients. Some patients with higher ISS and GCS score underwent surgery for ECI before surgery for TBI because their vital signs were unstable; in this group, the mortality rate was significantly lower (25%) than in other groups, and none of the deaths were preventable. Conversely, in patients who had low GCS scores (because of low blood pressure) who underwent surgery for ECI before surgery for TBI because of unstable vital signs, the injuries were no more severe than those of other groups, but the mortality rate was very high (60%). In addition, among the patients who underwent TBI and ECI surgeries simultaneously, the overall injuries were extremely severe (mean ISS 42), the vital signs were unstable, and the level of consciousness was poor (mean initial GCS score 5.6), and so the prognosis was very poor; the mortality rate was 100%.

Patients with TBI and ECI were classified as those with thoracic injury (the TT group) and those with abdominal injury (the TA group). Surgical results for these groups are summarized in Table 3. In comparison with the TA group, the TT group had a significantly lower mean ISS (p=0.004) and a significantly higher mean initial GCS score (p<0.001). The patient’s treatment outcomes did not differ statistically, but 50% of the TT group and only 21% of the TA group had GOS scores of ≥4, and the PTDR was a patient in the TA group.

The treatment strategy for isolated TBI is completely different from that for TBI with multiple injuries. In patients with multiple injuries, the selection of which injury to treat first influences the outcome. If the vital signs of the patient are stable, surgical treatment can focus on the TBI; if not, the priority of surgical treatment is always to stabilize blood pressure and tissue oxygen saturation. This is because no matter how severe a TBI is, aggressive surgical treatment cannot be performed if the vital signs are unstable. Furthermore, persistent hypotension caused by ongoing hemorrhage worsens neurologic outcomes.

Several authors have discussed the strategy of simultaneous surgery when priorities cannot be determined. Lee et al. [21] proposed collaboration between neurosurgeons and surgeons from other departments for multiple life-threatening traumatic injuries. They stated that when serious damage to other organs is accompanied by severe TBI, active concurrent surgery can save a patient’s life. To prevent secondary brain injury caused by hypotension, hypoxia, and hypercapnia, surgeons must determine why vital signs are unstable and then correct the problem rapidly because the prognosis of patients with poor head AIS scores and low GCS scores depends on how early optimal function is restored [22].

Our findings are preliminary because information about surgical outcomes in patients who had severe TBI with severe ECI is sparse. Survival rates were higher among patients who underwent chest and brain surgeries than among those who underwent abdominal and brain surgeries. We presume that thoracic injury is less dangerous than abdominal injury and also more responsive to early resuscitative therapy, including fluid therapy, transfusion, and vasopressor or inotropic medication. Also, patients with severe thoracic injury are often excluded from studies because by the time they arrive at the hospital, resuscitation is often unsuccessful.

For patients with severe TBI who require definitive surgical intervention for massive bleeding in the chest or abdominal organs, hypotension and hypoxia must be addressed first; the next most important concern is the severity of neurological defects. In patients in very critical condition with severe hypotension, hypoxia, and neurological deficits, the treatment results are often poor when different types of surgery are performed simultaneously. In such cases, we recommend performing sequential surgery, with a short interval between procedures, starting with correction of hypotension and hypoxia (Fig. 1), because, as stated previously, if brain surgery is performed in the setting of hypotension and hypoxia, secondary brain injury will occur. General surgeons and neurosurgeons must collaborate during this process to optimize the outcome [23].

This study had several limitations. First, it was a retrospective single center study with a small number of cases. Second, surgical treatment was limited to stopping bleeding and lowering intracranial pressure; subordinate procedures such as angiographic embolization, resuscitative endovascular balloon occlusion of the aorta, tracheostomy, and wound debridement surgery were excluded. Third, our evaluation of PTDR was limited to a single center. Further studies are needed to assess the long-term outcomes in a larger population of patients with both TBI and torso hemorrhage.