Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel corona-virus that causes coronavirus disease 2019 (COVID-19). The first case of COVID-19 was reported in Wuhan, Hubei province, China on December 2019 [9,10,14], following which the infection spread across China to other countries within few weeks. Finally, on January 30, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak as a public health emergency of international concern. On February 11, 2020, the WHO named the infection COVID-19.

To restrict the spread of SARS-CoV-2, voluntary nationwide lockdowns were proposed and implemented worldwide, including restrictions on the movement of people and transportation, and prohibiting economic, educational, sporting, cultural, and religious activities [1,2,4,6]. This lockdown was intended to delay the spread of the disease.

The COVID-19 pandemic is influencing almost every area of life [8]. The COVID-19 pandemic and subsequent social distancing and lockdowns have had an impact on trauma patterns in patients. The spectrum of traumatic injuries has to shift from high-energy trauma such as road traffic accidents to low-energy trauma such as house-hold injuries in the elderly and pediatric populations, which may be partially attributed to the social distancing measures and lockdown [5]. Similarly, the COVID-19 pandemic is changing the characteristics of patients with head injuries [3].

This study aimed to evaluate the effect of the COVID-19 pandemic on patients with head injuries and their management. We compared patients with head injuries between the pre-COVID-19 era and the COVID-19 eras. We also compared the treatment planning decisions for patients.

Of the 350 patients, 249 patients (71.1%) were male. The mean patient age was 53.4 years. There were 107 unmarried and 243 married patients. There were 179 employed patients and 171 unemployed patients. Religions of the 138 patients (39.4%) whose data was available were Catholicism (n=12), Protestantism (n=26), Buddhism (n=97), and others (n=3). The head injury types were as follows : concussion (n=21, 6.00%), skull fracture (n=40, 11.4%), epidural hematoma (n=48, 13.7%), subdural hematoma (n=101, 28.9%), subarachnoid hemorrhage (n=111, 31.7%), intracerebral hematoma (n=28, 8.00%), and intraventricular hemorrhage (n=1, 0.28%). MVCs and non-MVCs were observed in 96 (27.4%) and 254 (72.6%) patients, respectively. The mean hospital days were 16.0±17.6 days (mean days±standard deviation). The overall GCS score was 13.0±3.28, and the overall GOS score was 4.21±1.42. Among the 360 patients with head injuries, 74 patients (20.6%) required surgery. Among these 74 patients, 41 patients (55.4%) underwent surgery and 33 patients (44.6%) refused surgery. The mortality rate was 13.7% (n=48); 43 patients (89.6%) died with DNR, and organ donation was performed in five patients (10.4%).

A comparison of patients with head injuries between the pre-COVID-19 and COVID-19 eras is detailed in Table 1. Head injuries were more frequent in pediatric patients (<3 years) in the COVID-19 era than in the pre-COVID-19 era (16 of 181 [8.8%] vs. 6 of 169 [3.6%], p=0.048). The reasons for 22 pediatric head injuries (<3 year) were as follows : MVC (n=1), dropped by parents (n=16), and slip and fall (n=5). Drop injuries (<3 years) occurred more frequently in the COVID-19 era than in the pre-COVID-19 era (14 of 16 [87.5%] vs. 3 of 6 [50.0%], p=0.100). MVC injuries occurred in 44 patients (26.0%) in the pre-COVID-19 era, and 52 patients (38.7%) in the COVID-19 era; there was no statistically significant difference between the two injury types (p=0.632).

Table 2 shows a comparison of patients who underwent surgery with those who refused surgery among patients with severe head injuries requiring surgery. Patients who refused surgery were significantly older than those who underwent surgery (67.7±14.5 vs. 52.4±19.1, p<0.001). Married patients refused surgery more frequently than unmarried patients (28 of 33 [84.8%] vs. 25 of 41 [61.0%], p=0.037). Unemployed patients refused surgery more frequently than employed patients (17 of 33 [57.6%] vs. 13 of 41 [31.7%], p=0.034). In the pre-COVID-19 era, 25 patients (69.4%) underwent surgery, and 11 patients (30.6%) refused surgery. In the COVID-19 era, 16 patients (42.1%) underwent surgery, and 22 patients (57.9%) re-fused surgery. There was a statistically significant difference between the two periods (p=0.021). Patients who refused surgery had significantly lower GCS scores than those who underwent surgery (6.12±3.08 vs. 10.6±3.80, p<0.001).

The multivariable logistic regression analysis for factors affecting refusal of surgery among patients with severe head injuries requiring surgery, including old age, marital status, employment status, and COVID-19 era, showed that old age (adjusted odds ratio [OR], 1.076; 95% confidence interval [CI], 1.033–1.120; p=0.002), COVID-19 era (adjusted OR, 6.869; 95% CI, 1.624–29.054; p=0.009), and lower GCS scores (adjusted OR, 0.694; 95% CI, 0.568–0.848; p<0.001) were independently associated with refusal of surgery in patients with severe head injuries requiring surgery (Table 3).

The COVID-19 pandemic and subsequent social distancing and nation-wide lock-downs to cope with the spread of SARS-CoV-2 have impacted almost every area of life [1-6,8]. Recent studies have reported that the number of trauma cases have decreased during the COVID-19 pandemic [3,5,13]. Other studies have reported that the spectrum of trauma has shifted from high-energy trauma such as road traffic accidents to low-energy trauma such as house-hold injuries [2,5]. These results have been reported to be associated with social distancing and nation-wide lockdowns. The purpose of this study was to evaluate the effect of the COVID-19 pandemic on patients with head injuries and their management at a regional emergency medical center in South Korea.

A previous study reported that the prevalence of trauma in children aged <20 years was reduced by nearly two-thirds during the COVID-19 pandemic, with a significant reduction due to decreased sports injuries [1]. In our study, head injuries in patients <20 years were not significantly different in the preCOVID-19 and COVID-19 eras. However, our results indicated that there was an increase in the number of pediatric patients (<3 years) with head injuries in the COVID-19 era (8.8% vs. 3.6%, p=0.048). Although the statistical significance was not significant (p=0.100), pediatric drop injuries (<3 years) occurred more frequently in the COVID-19 era than in the pre-COVID-19 era (87.5% vs. 50.0%). Our findings that pediatric head injuries (<3 years) increased during the COVID-19 pandemic may be partially explained by the increased amount of time spent indoors, resulting in head injuries as the parents held and dropped their children.

Patients with severe head injuries have a high mortality and morbidity [7,11,15]. Previous studies have proven the relationship between high mortality and lower GCS scores, pupil dilatation, and old age [7]. Long-term outcomes of surgeries for patients with severe head injuries have been reported to be associated with unfavorable outcomes and disabilities; therefore, it is difficult to decide whether to perform surgery in patients with poor prognosis. Patients with severe head injuries are unconscious and lack decision-making capacity; therefore, they depend on their family to decide whether to undergo surgery [12,16].

Current trends in decisions making regarding life-sustaining treatments focus on the medical futility and patient’s wishes, especially in those with poor prognosis [16]. Recently, an increasing number of patients and their families want to discontinue life-sustaining treatments when medical futility is expected; however, there are few studies on the topic of discontinuing life-sustaining treatments, such as deciding whether to undergo surgery in patients with severe head injuries.

This study showed that among the 74 patients with severe head injuries requiring surgery, 33 (44.6%) refused surgery, which was a considerable number. In addition, the rate of refusing surgery increased significantly in the COVID-19 era compared to pre-COVID-19 era (57.9% vs. 30.6%, p=0.021). Our study suggests that discontinuation of life-supporting treatment is increasing in patients with severe head injuries and the COVID-19 pandemic is influencing the increase.

In univariate analysis of refusal of surgery, old age and lower GCS scores were associated with refusal of surgery, which are poor prognostic factors of severe head injuries in previous studies. Families of patients with poor prognostic factors, such as old age and lower GCS scores, tended to refuse surgery more often. In our study, married patients refused surgery more frequently than unmarried patients (84.8% vs. 61.0%, p=0.037), which may be partially explained by the rapid decision-making by family. The decision for unmarried patients was generally made by relatives, such as siblings, which delayed the decision on whether to undergo surgery, while the decision for married patients was made faster, because the spouse, son or daughter made the decision. Our results also showed that unemployed patients had a higher rate of refusal of surgery than employed patients (68.3% vs. 42.4%, p=0.034). This may be explained by the severity of the economic burden of surgery on unemployed patients with severe head injuries.

In our study, multivariable logistic regression analysis revealed that the COVID-19 pandemic was significantly influencing the treatment planning decisions in patients with severe head injuries (adjusted OR, 6.869). Our results revealed that refusal of surgery in patients with severe head injuries was associated with old age, unemployment, and lower GCS scores. The COVID-19 pandemic and subsequent social distancing and lock-downs may have added an economic burden to the treatment planning decisions in patients with severe head injuries, persuading them to refuse surgery.

Higher rate of refusing surgery among patients with severe head injuries requiring surgery during the COVID-19 pandemic may have been affected by the shift in hospital policy that restricts the number of families allowed in the hospital, including emergency rooms and intensive care units, to prevent the spread of the virus. When more than one family member is involved in decision-making, families tend to opt for surgery in order to avoid the worst case that may result in other family members blaming each other. On the contrary, when the number of family member is restricted to only one, the decision is made faster, thus making it more likely to refuse surgery. However, it is still possible that other causes, such as recent trends over time or regional characteristics, also might affect patient’s family to decide not to undergo surgery.

Our study has several limitations. First, this study has a retrospective design with an attendant selection bias. However, the selection bias may be low because all patients with head injuries during the study period in our hospital were included. Second, this study was performed in a single center in Korea, and the generalizability of the results may be limited. The types of trauma and the factors that need to be considered during the treatment of head injuries may vary by institution and country. Studies on the recent increase in refusal of surgery in patients with severe head injuries are necessary. This study is meaningful in that it is the first study on this topic. Further studies with larger sample sizes are needed to confirm these preliminary results.

Pediatric head injuries (<3 years) occurred more frequently during the COVID-19 pandemic, possibly due to social distancing and isolation. Patients with severe head injuries are likely to refuse surgery, probably due to the economic burden of the COVID-19 pandemic and subsequent social distancing and lockdowns. Further studies with larger sample sizes are needed to confirm these preliminary results.