Diagnosis and management of pediatric closed head injury

Closed head injury in the pediatric population accounts for almost half of all new cases of traumatic brain injury. The incidence of severe brain injury appears to be less in children as compared to the adult population. Over the past several years, advances in recognition and treatment of traumatic brain injury have led to improved outcomes in both children and adults. It is imperative, therefore, for the pediatric surgeon dealing with head trauma to have an understanding of the common brain injuries in the pediatric population, their early recognition and initial management. In this article, early diagnosis and initial management of the most common forms of pediatric closed head injury are reviewed.

Cerebral perfusion pressure management of severe diffuse head injury: effect on brain compliance and intracranial pressure

BACKGROUND

Cerebral perfusion pressure management (CPPM) is an accepted modality of treatment of severe diffuse head injury (SDHI). However, CPPM has the potential to cause transcapillary exudation in the presence of a disrupted blood brain barrier and can lead to further increase of intracranial pressure (ICP) and worsening of compliance.

AIMS

This study attempts to evaluate the effect of both transient and prolonged changes in cerebral perfusion pressure (CPP) on ICP and cerebral compliance as measured by the Pressure Volume Index (PVI), and to correlate changes in PVI with outcome at 12 months using the Glasgow Outcome Score.

SETTINGS AND DESIGN

Prospective study in a neurosurgical ICU.

MATERIAL AND METHODS

Twenty-seven SDHI patients managed using standard protocol to maintain CPP above 70 mmHg. Mean arterial pressure (MAP), ICP and CPP were monitored every half-hour. Daily monitoring of the PVI and ICP was done before, and after the induced elevation of MAP using IV Dopamine infusion. The relationship between CPP, MAP, ICP, PVI and outcome was evaluated.

STATISTICAL ANALYSIS USED

The paired and independent samples T-test, and the Pearson correlation coefficient.

RESULTS

CPPM rarely leads to progressive rise in ICP. Maintaining CPP above 70mmHg does not influence ICP or PVI. Transient elevations in CPP above 70mmHg may produce a small rise in ICP. Trend of change in PVI influenced outcome despite similar ICP and CPP.

CONCLUSION

Elevating the CPP above 70mmHg does not either reduce the ICP or worsen the compliance. Monitoring changes in compliance should form an integral part of CPPM.

Management of Brain-Injured Patients by an Evidence-Based Medicine Protocol Improves Outcomes and Decreases Hospital Charges

OBJECTIVE

Traumatic brain injury (TBI) is the leading cause of death from blunt trauma, with an estimated cost to society of over dollar 40 billion annually. Evidence-based guidelines for TBI care have been widely discussed, but in-hospital treatment of these patients has been highly variable. The purpose of this study was to determine whether management of TBI patients according to a protocol based on the Brain Trauma Foundation (BTF) guidelines would reduce mortality, length of stay, charges, and disability.

METHODS

In 1995, a protocol following the BTF guidelines was developed by members of the Level I trauma center's interdisciplinary neurotrauma task force. Inclusion criteria for the protocol were blunt head injury, age > 14 years, and Glasgow Coma Scale score < or = 8. An extensive educational process was conducted to develop compliance among all disciplines for this new management strategy. A historical control group of patients eligible for the protocol was identified by retrospective analysis of trauma registry data for 1991 to 1994. Mortality, intensive care unit days, total hospital days, total charges, Rancho Los Amigos Scores, and Glasgow Outcome Scale scores were compared.

RESULTS

Between 1991 and 2000, over 7,000 blunt TBI patients were managed by the Trauma Service. Of these, 830 met the inclusion criteria for the TBI protocol and lived > 48 hours. After implementation, initial analysis of the 1995-96 cohort indicated only 50% compliance with the protocol. By 1997, compliance had risen to 88%. Patients were therefore compared as three groups: before the protocol (1991-94, n = 219), during low compliance (1995-96, n = 188), and during high compliance (1997-2000, n = 423). Groups did not differ significantly on Injury Severity Score, head Abbreviated Injury Scale score, or age (p > 0.05). Admission Glasgow Coma Scale score was slightly higher in the 1991-94 cohort (4.0 vs. 3.5, p = 0.001). From 1991-94 to 1997-2000, intensive care unit stay was reduced by 1.8 days (p = 0.021) and total hospital stay was reduced by 5.4 days (p < 0.001). The charge reduction (calculated in 1997 dollars) per patient for the length of stay decrease was dollar 6,577 in 1995-96 and dollar 8,266 in 1997-2000 (p = 0.002). This represents a total reduction over 6 years of dollar 4.7 million in charges. In addition, the overall mortality rate showed a reduction of 4.0% from 1991-94 to 1997-2000 (17.8% vs. 13.8%), although this was not statistically significant. On the basis of the Glasgow Outcome Scale score, in 1997-2000, 61.5% of the patients had either a "good recovery" or only "moderate disability," compared with 503% in 1995-96 and 43.3% in 1991-94 (p < 0.001). The Rancho Los Amigos Scores showed a similar trend, with 56.6% of the 1997-2000 patients having appropriate responses at 10 to 14 days, compared with only 44.0% of the 1995-96 patients and 43.9% of the 1991-94 patients (p = 0.004).

CONCLUSION

Adherence to a protocol based on the BTF guidelines can result in a significant decrease in hospital days and charges for TBI patients who live > 48 hours. In addition, mortality and outcome may be significantly affected. This analysis suggests that increased efforts to improve adherence to national guidelines may have a significant impact on head injury care outcomes and could dramatically reduce the substantial financial resources that are currently consumed in the acute care phases for this injury.

Routinely Repeated Computed Tomography after Blunt Head Trauma: Does it Benefit Patients?

BACKGROUND

Computed tomography of the head (HCT) is an integral part of the diagnosis and management of the patient with head injury, but the utility of repeated HCT performed solely for routine follow-up in the patient with blunt head trauma has not been defined. In the absence of clinical indications, routinely repeated HCT, even in patients with significant brain injury, does not contribute to patient care.

METHODS

Trauma registry records at a Level I trauma center from July 1, 1997, to June 30, 2002, were reviewed. Patients with severe blunt head injury (Abbreviated Injury Scale score > or = 3) admitted to the intensive care unit and who had a repeat HCT scan obtained for scheduled follow-up were included. Those patients with initial craniotomy, repeat HCT more than 72 hours after the initial HCT, or repeat HCT ordered for clinical indications were excluded. Data included were age, mechanism of injury, time to initial (HCT1) and repeat HCT (HCT2), indications for HCT2, and HCT findings. Additional data included Glasgow Coma Scale (GCS) score (admission and at HCT2); Injury Severity Score; occurrence of hypotension, coagulopathy, or elevated intracranial pressure (ICP); interventions made; and patient outcome.

RESULTS

Entry criteria were met in 462 patients. Most were injured in motor vehicle crashes; the average age was 36 years and the mean initial GCS score was 9. The mean time to HCT1 was 1.3 hours and the mean time to HCT2 was 22.6 hours. HCT2 showed worsening in 85 patients (18.4%), and 16 patients had interventions in response to HCT2 (repeat HCT in 8, ICP monitoring or drainage in 6, and craniotomy in 2). No patient undergoing routine repeat HCT without other clinical findings required intervention. All patients with worsening HCT findings requiring intervention had coagulopathy, hypotension, ICP elevation, or marked decrease in GCS score.

CONCLUSION

In the absence of clinical indicators or risk factors, repeat HCT after blunt head injury does not alter patient management and is unnecessary.

Regional CBF in chronic stable TBI treated with hyperbaric oxygen

To investigate whether Hyperbaric Oxygen Therapy (HBO2) could improve neurologic deficits and regional cerebral blood flow (rCBF) in chronic traumatic brain injuries (TBI), the authors employed a nonrandomized control pilot trial. Five subjects, at least three years post head injury, received HBO2. Five head injured controls (HIC) were matched for age, sex, and type of injury. Five healthy subjects served as normal controls. Sixty-eight normal volunteers comprised a reference data bank against which to compare SPECT brain scans. HBO2 subjects received 120 HBO2 in blocks of 80 and 40 treatments with an interval five-month break. Normal controls underwent a single SPECT brain scan, HBO2, and repeat SPECT battery. TBI subjects were evaluated by neurologic, neuropsychometric, exercise testing, and pre and post study MRIs, or CT scans if MRI was contraindicated. Statistical Parametric Mapping was applied to SPECT scans for rCBF analysis. There were no significant objective changes in neurologic, neuropsychometric, exercise testing, MRIs, or rCBF. In this small pilot study, HBO2 did not effect clinical or regional cerebral blood flow improvement in TBI subjects.

Objective indications for early tracheostomy after blunt head trauma

BACKGROUND

Early tracheostomy has been shown to be beneficial after trauma; however, there are few objective data to identify early in the recovery period which patients will ultimately require tracheostomy after blunt head trauma.

METHODS

The charts of all patients admitted to the surgical intensive care unit intubated at a level 1 urban trauma center, over a 5-year period with a primary admission diagnosis of blunt head trauma were retrospectively reviewed.

RESULTS

Sixty-four patients met inclusion and exclusion criteria and were divided into two groups: those extubated and those that required tracheostomy. By day 3 the Glasgow Coma Scores for the two groups were significantly different and on day 4 the Simplified Acute Physiology (SAPS) Scores were significantly different.

CONCLUSIONS

Calculating objective scores such as GCS and SAPS can aid in identifying those patients who will ultimately require a tracheostomy for prolonged airway protection after blunt head trauma with high positive predictive value.

Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation

STUDY OBJECTIVE

We determine the incidence of desaturation and pulse rate reactivity during paramedic rapid sequence intubation of patients with severe head injuries (Glasgow Coma Scale score <or=8).

METHODS

Adult patients with severe head injuries had recording oximeter-capnometers applied before rapid sequence intubation. Desaturation was defined as a reduction in oxygen saturation (Spo(2)) to less than 90% from an initial Spo(2) of greater than or equal to 90% or a decrease from a baseline of less than 90%. Event records were analyzed with emergency medical services (EMS) run sheets and debriefing reports.

RESULTS

Thirty-one (57%) of 54 patients demonstrated desaturation during rapid sequence intubation. Twenty-six (84%) of these 31 events occurred in patients whose initial Spo(2) value with basic airway skills was greater than or equal to 90%. The median duration of desaturation was 160 seconds (interquartile range 48 to 272 seconds), and the median decrease in Spo(2) was 22%. Six (19%) patients experienced marked bradycardia (pulse rate <50 beats/min) during desaturation events. Paramedics described rapid sequence intubation as "easy" in 26 (84%) of 31 patients with desaturation.

CONCLUSION

Out-of-hospital rapid sequence intubation by paramedics was complicated by a concerning incidence of desaturation and bradycardia. Paramedic reports did not reflect the presence of these concerning derangements. Most patients had acceptable Spo(2) values before rapid sequence intubation. An effective strategy for preoxygenation is needed before it can be concluded that rapid sequence intubation is of value in the out-of-hospital care of patients with serious closed head injury.

Level of prehospital care and risk of mortality in patients with and without severe blunt head injury

OBJECTIVES

To determine the association between mortality and the level of prehospital care in severely injured blunt trauma patients with or without severe head injury.

METHOD

Retrospective review of 2010 severe blunt trauma patients (injury severity score (ISS) >15) with or without severe head injury in a tiered trauma system involving ambulance officers (basic life support (BLS) and advanced life support (ALS)) and physicians, and a Level 1 trauma centre.

RESULTS

After adjusting for age, type of head injury, glasgow coma scale score (GCS), systolic blood pressure, ISS and prehospital time, intensive care unit (ICU) admission modified the association between level of prehospital care and mortality. In those patients without ICU admission, patients in the paramedic and physician-staffed emergency services group were more likely to die than patients in the BLS ambulance group (odds ratio (OR) 2.18, 95% confidence intervals (CI): 1.05-4.55; 4.27, 95% CI: 1.46-12.45, respectively). Among patients who survived to ICU treatment, however, there was no association between level of prehospital care and risk of mortality. Presence or absence of a head injury did not modify the risk of mortality.

CONCLUSIONS

The level of prehospital care was associated with the risk of mortality. This was modified by whether the patient survived long enough to be admitted to the ICU.

An initial Glasgow score of 4 and Apgar scores of 9 and 9: A case report of a pregnant comatose woman

A 28-year-old woman admitted to the emergency department with a Glascow Coma Scale score of 4 after a closed head injury resulting from a motor vehicle crash was found to have a positive serum beta-human chorionic gonadotropin level of 27 mIU/mL. After stabilization and treatment for her closed head injury, she remained in a comatose state for more than 240 days. At 36 to 37 weeks' gestation, she had contractions and elevations in her blood pressure. A healthy female infant was born by an operative vaginal delivery with Apgar scores of 9 and 9.

Acute and long-term management of sports-related closed head injuries

Aggressive participation in athletics is rewarded in many ways in our society. As long as there is such strong impetus for participation in athletics, the risks of head injuries for participants will remain. Important strides made in understanding of the pathophysiology of head injuries may lead to improved treatment strategies in the future. In light of the current lack of effective therapies, however, the best options remain injury prevention, early and appropriate recognition, and limitation of subsequent, further injury. Frequently the medical staff is encouraged to allow the athlete to return to play based on the desires of the coach, team, fans, parents, and even the athlete himself. A thorough understanding of the potentially serious risks of repetitive injury, however, mandates that only a proper conservative period of observation and evaluation will best serve the competitor.

On-the-field evaluation of an athlete with a head or neck injury

Head and cervical spine sports-related injuries are intimately associated. The on-field evaluation and management of the athlete with these injuries is of paramount importance to stabilize the athlete and prevent further injury. Clinicians need to be aware of the differential diagnoses and consider each possibility based on the mechanism of injury. Although recognition of head and cervical spine injuries has resulted in significant reductions of catastrophic neurological injuries, especially in the cervical spine, further advances to decrease the incidence and long-term sequelae of head and neck injuries are needed. The first step is education of the athlete and the individuals involved in the care of that athlete.

Necessity of hospital admission for pediatric minor head injury

The objective of this study was to evaluate the need for mandatory hospital admission of all pediatric patients with minor head injury (MHI) and negative computed tomographic (CT) scans for head injury. The study was a retrospective chart review of all patients admitted to a pediatric trauma service over a period of 4 years. MHI was defined as blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and a nonfocal neurological examination. Only patients < or = 13 years of age and with a negative head CT scan were included, and during hospitalization all patients were observed for delayed complications. A total of 197 patients met the inclusion criteria. The patients' mean age was 7.1 years, with a range of 2 months to 13 years. The most common mechanisms of injury were being struck by a motor vehicle while walking (82 patients), and falling (75 patients). No complications were observed, and although persistent symptoms occurred in 5 patients, they did not delay discharge. We conclude that pediatric patients with MHI and negative CT scans of the head do not require routine admission for observation for delayed complications.

Experimental models of head trauma

Traumatic brain injury is one of the most common causes for chronic disability in young people. Despite this there are currently no widely available modes of therapy that would limit the extent of brain damage secondary to trauma. Therefore, new insights into the pathological mechanisms involved in head trauma possibly leading to the identification of new therapeutic targets are urgently needed. In order to attain these goals adequate animal models for traumatic brain injury are needed. In the following paper the authors will review the various animal models for head trauma and emphasize their potential strengths and weaknesses.

[Treatment of traumatic pseudoaneurysm through completely embolizing siphon section of internal carotid artery]

OBJECTIVE

Pseudoaneurysm in siphon section of internal carotid artery (ICA) caused by craniocerebral trauma was diagnosed and totally embolized by applying digital subtraction angiography (DSA) technique, with satisfactory results. The clinical application of this technique was discussed.

METHODS

The patients suffered from craniocerebral trauma with serious epistaxis were managed in our hospital by DSA. The patients with pseudoaneurysm in ICA were chosen from them. The circular function of Willis circulus in these patients were checked. If it was good, the ICA was totally embolised.

RESULTS

Among 32 patients suffered from craniocerebral trauma with serious epistaxis, 6 patients were definitely diagnosed by DSA to have pseudoaneurysm. The embolism was performed in 5 of them. Among these 5 patients, 4 cured, and 1 died. The patient who could not be embolized also died.

CONCLUSION

The pseudoaneurysm definitely diagnosed by DSA can be treated by embolizing siphon section of internal carotid artery completely, after checking the compensatory function of side branches in Willis circulus.

Visual prognosis after indirect traumatic optic neuropathy

OBJECTIVE

To investigate a possible correlation between final visual acuity and the presence at baseline of various systemic and local (orbital/ocular) signs in patients affected by indirect traumatic optic neuropathy.

METHODS

35 cases of traumatic optic neuropathy were examined retrospectively and 13 variables were tested. Univariate analysis with "no recovery of visual acuity" as the primary outcome was performed. Relative risk (RR) and 95% confidence intervals (CI) were calculated. Fisher's exact test was used for two variables to test differences between proportions.

RESULTS

Four variables showed a significantly increased risk for no recovery of visual acuity: presence of blood within the posterior ethmoidal cells (RR = 2.25, 95% CI 1.25 to 4.04); age over 40 years (RR = 1.79, 1.07 to 2.99); loss of consciousness associated with traumatic optic neuropathy (RR = 2.21, 1.17 to 4.16); and absence of recovery after 48 hours of steroid treatment (p < 0.01, Fisher's exact test). Recovery documented at the first follow up visit after treatment was significantly associated with recovery at the last follow up visit (p < 0.01, Fisher's exact test).

CONCLUSIONS

These four negative prognostic signs in patients affected by traumatic optic neuropathy may be useful in predicting the visual outcome in patients developing visual loss after head trauma and in deciding on the need for surgical treatment.

Apolipoprotein E polymorphism and outcome after closed traumatic brain injury: influence of ethnic and regional differences

OBJECT

The presence of the apolipoprotein E-epsilon4 (APOE-epsilon4) allele is reported to be associated with poor outcome after traumatic brain injury (TBI). This study was performed to determine if the presence of the APOE-epsilon4 allele influenced outcome in a cohort of black patients with TBI who had homogeneous neuropathological findings.

METHODS

Venous blood was collected at the time of admission to determine the APOE genotype in black Zulu-speaking patients who presented with traumatic cerebral contusions. The frequency of the APOE-epsilon4 allele's appearance was correlated with outcome at a minimum of 6 months of follow up. Univariate and multivariate analyses were performed to determine independent risk factors and to control for confounding factors. In 110 black Zulu-speaking patients with traumatic cerebral contusions, genotypes for APOE were analyzed. Eleven of 45 (24.4%) with the APOE-epsilon4 allele experienced a poor outcome, compared with 10 (15.4%) of 65 without this allele (p = 0.34). Both patients with homozygous APOE-epsilon4 alleles experienced a good outcome (Glasgow Outcome Score 5). Univariate and multivariate analysis revealed no significant relationship in patients with the APOE-epsilon4 allele with regard to age, admission Glasgow Comas Scale score, contusion volume, type of neurosurgical management, and outcome. The risk of a poor outcome was, however, greater in patients with the APOE-epsilon4 allele (relative risk 1.59; 95% confidence interval 0.74-3.42).

CONCLUSIONS

The authors recorded no relationship between APOE-epsilon4 allele status and outcome after TBI in black patients. Given the high regional susceptibility to the APOE gene, further studies, possibly even community-based investigations and studies conducted in other geographic areas, are probably warranted.

Electrical treatment of coma via the median nerve

The median nerve is a portal to interact with the injured comatose brain. Peripheral nerve electrical stimulation has a central nervous system effect. Two to three weeks of right median nerve stimulation (RMNS) can hasten awakening from deep coma by increasing the dopamine levels. Three cases of electrically treated GCS-4 teenagers with acute diffuse brain injuries from motor vehicle crashes are presented by video. Pilot studies of RMNS for acute post-traumatic coma states have been done over the last ten years at East Carolina University and the University of Virginia. The neurophysiological effects of RMNS have been well documented at several neurosurgical centers in Japan using neuroimaging and spinal fluid assays. RMNS is a safe, inexpensive, non-invasive therapy for neuro-resuscitation of coma patients. When employed early in the coma, the time in the ICU may be shortened and the quality of the final outcome may be enhanced.

[Minor craniocerebral trauma]

Mild craniocerebral injury or mild traumatic brain injury (MTBI) predominates, occurring with an 80% frequency. A 1997 publication by the American Academy of Neurology clearly defines MTBI as a transient alteration of mental status, without any neurological deficit, that may or may not involve loss of consciousness or amnesia. On the Glasgow Coma Scale (GCS), mild craniocerebral injury corresponds to a score of 14 and 15. The GCS must be taken immediately. Advanced trauma life support follows primary survey methodology and ABCDE protocol. The prognosis in MTBI is significantly worse when the patient suffers from intercurrent hypotension and hypoxia. In smaller hospitals, 24-hour monitoring is imperative. Wherever computerized tomography (CT) is available, a CT examination is broadly indicated. There is no knowledge of any adverse effects on patients whose GCS worsened when the CT revealed normal findings.

Preliminary report on the safety of heparin for deep venous thrombosis prophylaxis after severe head injury

BACKGROUND

Prophylaxis for venous thromboembolism (VTE) in head injured patients has avoided heparin products because of concern for exacerbating intracranial bleeding. The purpose of this study was to evaluate the safety of unfractionated heparin (UFH) for VTE prophylaxis after traumatic brain injury.

METHODS

We retrospectively evaluated the early use of UFH in patients sustaining a severe closed head injury (Abbreviated Injury Scale score > 3) from January 1, 2000, through December 31, 2000. Two groups were formed on the basis of the timing of UFH administration: within 72 hours of admission (Early group), or after the third day of hospitalization (Late group), if at all. Intracranial bleeding related to UFH administration was assessed by computed tomographic scan of the head and/or clinical examination.

RESULTS

Sixty-four of 76 patients with intracranial blood on admission head computed tomographic scan fulfilled study criteria. Seventy-three percent (n = 47) were in the Early group and 27% (n = 17) were in the Late group. None of the Early group had an increase in intracranial bleeding or deterioration on neurologic examination as a result of UFH administration. However, there was no statistical difference in VTE events between the two groups.

CONCLUSION

Early use of UFH in the severe head injured patient does not increase bleeding complications.

Severe traumatic brain injury in children--are the results improving?

QUESTIONS UNDER STUDY

Traumatic brain injury (TBI) remains an important cause of mortality and morbidity in children. Medical management is constantly being refined, and thus results should improve. The aim of the present study was to analyse our data of recent years and to compare them with previous series (1978-83 and 1988-92).

PATIENTS AND METHODS

The data of 51 children (1 month to 16 years old) with severe blunt TBI treated in our unit from 1994 to 1998 were analyzed retrospectively. Severe TBI was defined by immediate loss of consciousness and an admission Glasgow coma scale (GCS) <8. Outcome was classified by using the Glasgow outcome scale (GOS) 6 to 12 months after injury.

RESULTS

35 patients (69%) showed a good outcome (GOS 4 and 5), 14 died (GOS 1), one survived in a permanent vegetative state (GOS 2), and another was severely disabled (GOS 3) (GOS 1-3 = bad outcome, 31%). Bad outcome was associated with low GCS (i.e. 3 and 4), fixed and dilated pupils at admission, invisible basal cisterns on first computerized tomography, and presence of coagulopathy. Moderate to severe intracranial hypertension was also significantly related to bad outcome in the 26 patients with intracranial pressure monitoring. Compared to our first series severity of TBI was unchanged, and the incidence of multiple injury and consumption coagulopathy was less frequent. Intubation rate prior to admission to the centre increased from 35% to 94%. Intensive care measures (duration of mechanical ventilation, use of hypothermia, mannitol, thiopentone etc.) were less aggressive. The rate of good outcome remained unchanged (69% vs. 60%).

CONCLUSIONS

Despite changing management policies, results were comparable with those of our former series. This fact underlines the importance of primary injury and the secondary role of intensive care management on final outcome.

Cerebral salt wasting syndrome following brain injury in three pediatric patients: suggestions for rapid diagnosis and therapy

The association between hyponatremia and intracranial pathology has been well described. When accompanied by natriuresis, hyponatremia has most commonly been attributed to inappropriate secretion of antidiuretic hormone. However, there is growing evidence to suggest that many of these patients may actually have cerebral mediated salt losses, a disorder referred to as the cerebral salt wasting syndrome (CSWS). While this syndrome has been reasonably well described in adults, data regarding CSWS in pediatric-aged patients remains sparse. Since fluid management of these disorders is different, it is important that the clinician be able to rapidly differentiate between them. We report three cases of CSWS in acutely brain-injured children and comment on the role that early quantitation of urine volume and urine sodium concentration had in rapidly establishing the correct diagnosis.

The neurobehavioural rating scale-revised: sensitivity and validity in closed head injury assessment

OBJECTIVES

To investigate the factor structure and psychometric properties of the neurobehavioural rating scale-revised (NRS-R) and to determine its usefulness in clinical trials.

METHODS

A consecutive series of patients sustaining severe closed head injury were evacuated to one of 11 large regional North American trauma centres and entered into a randomised, phase III, multicentre clinical trial investigating the therapeutic use of moderate hypothermia. Acute care personnel were blinded to outcome and outcome personnel were blinded to treatment condition. The Glasgow outcome scale (GOS) was the primary outcome measure. Secondary outcome measures included the disability rating scale (DRS) and the NRS-R.

RESULTS

Exploratory factor analysis of NRS-R data collected at 6 months after injury (n=210) resulted in a five factor model including: (1) executive/cognition, (2) positive symptoms, (3) negative symptoms, (4) mood/affect, and (5) oral/motor. These factors showed acceptable internal consistency (0.62 to 0.88), low to moderate interfactor correlations (0.19 to 0.61), and discriminated well between GOS defined groups. Factor validity was demonstrated by significant correlations with specific neuropsychological domains. Significant change was measured from 3 to 6 months after injury for the total score (sum of all 29 item ratings) and all factor scores except mood/affect and positive symptoms. The total score and all factor scores correlated significantly with concurrent GOS and DRS scores.

CONCLUSIONS

The NRS-R is well suited as a secondary outcome measure for clinical trials as its completion rate exceeds that of neuropsychological assessment and it provides important neurobehavioural information complementary to that provided by global outcome and neuropsychological measures.

Should transient loss of consciousness in blunt head trauma be a pre-hospital trauma triage criterion?

The objective of this study was to evaluate pre-hospital triage of patients with an isolated brief loss of consciousness (LOC) to a regional trauma center (RTC). Data from a 6-month period were retrospectively reviewed from an existing pre-hospital data collection set. Patients were included if either they or a witness claimed a LOC, but they had regained consciousness to at least a Glasgow Coma Score (GCS) > 13 by the time the paramedics arrived. Endpoints for need for trauma center services included positive head computed tomography (CT) scan, the occurrence of emergency non-orthopedic surgery in < 6 h, admission to a surgical intensive care unit (ICU), or a length of stay (LOS) greater than 3 days for surgical evaluation. There were 655 complete records available for 275 cases of vehicular trauma and 380 cases of non-vehicular trauma. There were 170 (62%) patients in the vehicular group, and 287 (76%) in the non-vehicular group evaluated in the emergency department and discharged. In the vehicular group, only one (0.4%) patient required operative intervention in less than 6 h, three (1.1%) had a positive head CT scan, 10 (3.6%) were admitted to a surgical ICU, and four (1.5%) had a LOS > 3 days. In the non-vehicular trauma group, only one (0.3%) had surgery in < 6 h, eight (2.1%) had a positive CT scan, six (1.6%) were admitted to a surgical ICU or had a LOS > 3 days. Overall, 19 (2.9%, CI 0.018-0.045) patients met any one of the end-point criteria for trauma center utilization; however, only one patient (0.2% CI < 0.0001-0.008) required immediate neurosurgical intervention. Transient LOC, in the absence of any other American College of Surgeons (ACS) trauma triage criteria, triaged 97% of patients to a trauma center, who did not require trauma center services based on our criteria.

Moderate hypothermia therapy for patients with severe head injury

OBJECTIVE

To evaluate the effect and safety of early moderate hypothermia therapy (MHT) on patients with head injury by using parallel-control test.

METHODS

Thirty patients with severe head injury within 6 hours after accidents were treated by MHT generally for 4-10 days. The other 30 patients with similar head injury treated routinely were enrolled for a parallel-control test. The mortality, morbidity and changes of some neuro-functional indexes as Glasgow Coma Scores, and Glasgow Outcome Scale, levels of endothelin and some other factors of neurobiochemistry in blood plasma were observed. Meanwhile, the dynamic monitoring by transcranial Doppler ultrasonography was conducted in these patients.

RESULTS

The mortality in MHT group was significantly lower than that in control group. MHT not only reduced endothelin but also increased the brain biochemical factors, which were helpful to the protection of neurons in the early brain ischemia after head injury.

CONCLUSIONS

Early MHT can help reduce mortality and morbidity in patients with acute head injury.

Relationship between hyperventilation and intracranial pressure in patients with severe head injury

With high fatality rate and disability rate, the pathophysiologic changes of severe head injury are complicated. But the method of lowering intracranial pressure (ICP) through artificial hyperventilation is called in question recently. To understand the related changes of the partial pressure of carbon dioxide in artery (PaCO(2)) and the ICP at the acute period of severe head injury, a total of 64 patients with severe head injury were monitored and analyzed on the 3rd day after injury.

Posttraumatic headache

Chronic posttraumatic headache is a common condition, often part of the postconcussion/posttraumatic syndrome. The pathophysiology is not well understood but includes biological, psychological, and social factors. Tension-type headache is the most common manifestation, but exacerbations of migraine-like headaches often occur. After a structural lesion has been ruled out, the treatment of posttraumatic headache is similar to that of the primary headaches.

Shaken baby syndrome: rotational cranial injuries-technical report

Shaken baby syndrome is a serious and clearly definable form of child abuse. It results from extreme rotational cranial acceleration induced by violent shaking or shaking/impact, which would be easily recognizable by others as dangerous. More resources should be devoted to prevention of this and other forms of child abuse.

Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting

OBJECTIVE

To determine whether prehospital critical care teams (CCT) would result in improved functional outcomes for road trauma related severe head injury in the Australian setting, when compared with standard advanced life support measures provided by paramedics.

METHODS

Retrospective review of 250 patients treated by paramedics and 46 patients treated by CCT transported directly from the accident scene, with a prehospital Glasgow coma scale (GCS)< or =8.

RESULTS

CCT-treated patients had longer median prehospital times (113 versus 45 min, P<0.001), and a higher prehospital intubation rate (100% versus 36%, P<0.001) than paramedic-treated patients. On multivariate analysis, revised trauma score > or =4.45 (odds ratio [OR] 2.31, 95% CI: 1.15-4.65), lower injury severity score (OR 1.04, 95% CI: 1.02-1.06), age< or =25 years (OR 1.76, 95% CI: 1.13-2.75), absence of an acute subdural haematoma (OR 3.36, 95% CI: 1.89-5.95) and prehospital treatment by a CCT (OR 2.70, 95% CI: 1.48-4.95) independently predicted better outcome.

CONCLUSION

The range of advanced interventions provided by the CCT were associated with improved functional outcome. Further studies are required to determine the individual factors responsible.

Secondary insults in severe head injury--do multiply injured patients do worse?

OBJECTIVES

To study the occurrence of secondary insults and the influence of extracranial injuries on cerebral oxygenation and outcome in patients with closed severe head injury (Glasgow Coma Scale score < or =8).

DESIGN

Two-year prospective, clinical study.

SETTING

Two intensive care units in a level III trauma center.

PATIENTS

We studied 119 patients. Eighty patients had severe head injury and were divided into two categories: "isolated" severe head injury patients (n = 36, Injury Severity Score <30), and severe head injury patients with associated extracranial injuries (n = 44, Injury Severity Score >29). Thirty-nine patients with extracranial injuries and no head injury served as the control group.

INTERVENTIONS

After patients were admitted to the intensive care unit, we began continuous multimodal cerebral monitoring of intracranial pressure, mean arterial blood pressure, cerebral perfusion pressure, end-tidal Co2, brain tissue Po2 (Licox), jugular bulb oxyhemoglobin saturation in severe head injury patients, and mean arterial blood pressure in the control group. Targets of management included intracranial pressure <20 mm Hg, cerebral perfusion pressure >60 mm Hg, Paco2 > 30 mm Hg, control of cerebral oxygenation, and delayed surgery for non-life-threatening extracranial lesions.

MEASUREMENTS AND MAIN RESULTS

Data were analyzed for critical thresholds. The occurrence of secondary insults (intracranial pressure >20 mm Hg, mean arterial blood pressure <70 mm Hg, cerebral perfusion pressure <60 mm Hg, end-tidal Co2 <30 torr, brain tissue Po2 <10 torr, jugular bulb oxyhemoglobin saturation <50%) was comparable in patients with isolated severe head injury and those with severe head injury with associated extracranial lesions (Abbreviated Injury Scale score < or =5). The duration of intracranial hypertension and arterial hypotension significantly correlated with an unfavorable outcome, independent of the Injury Severity Score. In patients with severe head injury, 1-yr outcome was 29% dead or vegetative, 17% severely disabled, and 54% moderate or good outcome. This was similar to patients with severe head injury and extracranial injuries (31% dead or vegetative, 14% severely disabled, and 56% moderate or good outcome) and was independent of the Injury Severity Score. Patients with no head injury had less secondary insults (mean arterial blood pressure <70 mm Hg, p <.01) and a better outcome compared with both severe head injury groups (p <.044).

CONCLUSIONS

In patients with severe head injury who have targeted management including intracranial pressure- and cerebral perfusion pressure-guided therapy and delayed surgery for extracranial lesions, the occurrence of secondary insults in the intensive care unit and long-term neurological outcome were comparable and independent of the presence of extracranial lesions (Abbreviated Injury Severity level < or =5). A severe head injury is still a major contributor predicting an unfavorable outcome in multiply injured patients.

Early recovery after closed traumatic head injury: Somatosensory evoked potentials and clinical findings

OBJECTIVE

To determine the ability of somatosensory evoked potentials (SEP) compared with clinical findings to monitor and predict recovery in patients suffering from closed head injury with predominantly diffuse axonal injury (DAI).

DESIGN

Prospective cohort study.

SETTING

Neurologic intensive care unit (ICU) of a university hospital.

PATIENTS

Serial SEP recordings were obtained from 31 consecutive patients with closed head injury. The first SEP was recorded within 48 hrs after trauma, followed by recordings after another 2 days, after which the time interval for each consecutive recording was doubled. Clinical examinations were performed every 6 hrs during the ICU stay and daily after transfer to a general neurologic ward.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-three of 31 patients demonstrated pathologic SEP findings at initial examination. Of these patients, 11 recovered clinically, two remained vegetative, and ten died. In all 11 patients with clinical recovery, SEP also recovered. In 8 of 31 patients, initial SEPs were normal and remained normal until discharge, all eight had a good outcome. Initial SEP findings were related with outcome at 6 months (p = .02), and follow-up studies increased the predictive value of SEP studies (p = .009). Other factors related to outcome included age, severity of DAI, and length of ICU/hospital stay. In the 11 patients with SEP and clinical recovery, early (day 2) and late (>or=2 months) recovery was documented. Early and reliable SEP indicators of improvement included N20-P25-Amplitudes (mean recovery, 8.5 days) and central conduction time (9.6 days). Pupillary light reaction (6.4 days), Babinski reflex (12.4 days), and Glasgow Coma Score (9.6 days) were the most valuable clinical findings. Recovery of the Glasgow Coma Score frequently coincided with reduction of sedatives. In most patients, recovery was detected with SEP before clinical recovery (7/11 patients, time difference 1 wk).

CONCLUSIONS

Initial SEP findings correlate with long-term outcome in patients with closed head injury with DAI. Initial bilaterally absent cortical responses in the SEP reliably predicted death, whereas completely normal SEP findings predicted good long-term outcome. Early recovery after DAI can be detected with serial SEP recordings despite sedative medications. Electrophysiologic recovery frequently precedes clinical recovery.

[Management of closed head injury]

OBJECTIVE

To review current concepts regarding the management of severe closed head injury and determine the possible causes of brain damage in these patients.

DEVELOPMENT

Severe closed head injury causes a high rate of mortality and disability in developed countries. The diagnosis and management of these patients has progressed in recent years, from the availability of brain scanning to varied therapeutic methods based on brain metabolism and intracranial dynamics. We have reviewed the different neuropathological processes in relation to closed head injury and emphasized the importance of recognition and control of the secondary lesions, which may have disastrous consequences for the patient. After clinical evaluation and early cardiorespiratory stabilization, the patients are taken to a critical care unit for continuous monitoring of the intracranial pressure, cerebral perfusion pressure and cerebral extraction of oxygen. We have discussed several therapeutic interventions taking into account the values obtained by continuous monitoring of these patients. As well as traditional measures (hyperventilation, manitol and barbiturate coma), there are other possibilities for treatment of these patients such as hypothermia, hypertonic saline solutions and neuroprotector agents.

CONCLUSIONS

All patients with closed head injuries should be evaluated and treated as emergencies, and admitted to a critical care unit to avoid secondary lesions such as hypoxemia, arterial hypotension and cerebral edema. Treatment should be aimed at maintenance of the intracranial pressure and cerebral perfusion within normal limits and also maintenance satisfactory jugular saturation.

An examination of the impact of participation in a conversation group for individuals with a closed head injury

This study describes the impact of participation in a conversational group for individuals with chronic closed head injury in the Department of Communication Pathology at the University of Pretoria over the period 1995-2000. The information was obtained through a combination of clinical observations by the writers; the examination of data from Pragmatic measures; and a Quality of Life Scale that was compiled and administered (to both the subjects and their significant others) examining the perceived effects of group therapy over time. The results showed that despite the plateauing of pragmatic competence over time, the impact of group therapy appeared to reveal itself in perceived improvements in social-communicative competence and quality of life by the subjects. Recommendation and suggestions were made for the refinement of the QOL Scale to more reliably measure the subjective perceptions of group members regarding the perceived value of group therapy. In addition to addressing future implications to move the conversation group forward, the results of the current study lead the authors to advocate the establishment of conversation groups for individuals with CHI who are suitable candidates.

[Minimal craniocerebral trauma]

The patient with mild head injury is the most frequently hospitalised trauma patient. The costs for this treatment are enormous. Guidelines for managing the patients are changing for the last 20 years. Haematoma rates of 10% have been shown with CT scans in prospective studies for patients with GCS 14/15 and normal neurological examination. One out of ten of these patients had to undergo craniotomy. CT scans have shown to reduce costs if done on all patients with mild head injury and discharged with normal findings. Patients with skull fractures and age over 65 years are at higher risk, but not patients with loss of consciousness and post traumatic amnesia. We suggest CT scans on all patients. If a CT scan is not available we recommend to observe the patient for 24 hours in the hospital. If a patient with GCS 15 is to be discharged, an information leaflet with instructions for surveillance at home should be given to the patients and to the care taker.

Occipital condylar fractures: a review

The purpose of this review article is to summarize the epidemiology, pertinent anatomy, mechanisms of injury, and classification systems of occipital condylar fractures (OCFs), as well as their clinical presentation and screening, the importance of computed tomography (CT) for detection, and current treatment options. The authors emphasize the rate of occurrence of OCFs, which may be detected in as many as 16% of patients with craniocervical injury. Clinical presentation is not specific, and OCF is not readily diagnosed at physical examination. Failure to diagnose may result in substantial morbidity, and thus accurate diagnosis is mandatory for both therapeutic and medicolegal implications. The diagnosis is most likely to be made with CT. Thin-section CT technique is the method of choice to evaluate the traumatized craniocervical junction. OCFs should be suspected in all patients sustaining high-energy blunt trauma to the head and/or upper cervical spine, resulting from axial loading, lateral bending and/or rotation, and/or direct blow. Besides a CT study assessing potential intracranial injuries, these patients require CT of the craniocervical junction. Radiologists should be aware of the types of OCFs and associated injuries.

Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury

OBJECTIVE

To determine the negative predictive value of cranial computed tomography (CT) scanning in a prospective series of patients and whether hospital admission for observation is mandatory after a negative diagnostic evaluation after minimal head injury (MHI).

SUMMARY BACKGROUND DATA

Hospital admission for observation is a current standard of practice for patients who have sustained MHI, despite having undergone diagnostic studies that exclude the presence of an intracranial injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that admission will allow prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge.

METHODS

In a prospective, multiinstitutional study during a 22-month period at four level I trauma centers, all patients with MHI were evaluated using the following protocol: a standardized physical and neurologic examination in the emergency department, cranial CT scanning, and then admission for observation. MHI was defined as either a documented loss of consciousness or evidence of posttraumatic amnesia and an emergency department Glasgow Coma Scale score of 14 or 15. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, need for craniotomy, and death.

RESULTS

Two thousand one hundred fifty-two consecutive patients fulfilled the study protocol. The CT was interpreted as negative for intracranial injury in 1,788, positive in 217, and equivocal in 119. Five patients with CT scans initially interpreted as negative required intervention. There was one craniotomy in a patient whose CT scan was initially interpreted as negative. This patient had facial fractures that required surgical intervention and elevation of depressed intracranial fracture fragments. The negative predictive power of a cranial CT scan based on the preliminary reading of the CT scan and defined by the subsequent need for neurosurgical intervention in the population fully satisfying the protocol was 99.70%.

CONCLUSIONS

Patients with a cranial CT scan, obtained on a helical CT scanner, that shows no intracerebral injury and who do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation. Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually.

Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries

BACKGROUND

Although early enteral feeding clearly reduces septic morbidity after blunt and penetrating trauma, data for head-injured patients are conflicting. This study examines the effects of early vs delayed enteral feedings on outcome in patients with severe closed-head injuries with a Glasgow Coma Scale (GCS) score greater than 3 and less than 11.

METHODS

Thirty patients were prospectively randomized to receive an immune-enhancing diet (Impact with fiber) early (initiated < 72 hours after trauma) delivered via an endoscopically placed nasoenteric tube (Stay-Put) or late (administered after gastric ileus resolved). This formula was continued for 14 days or until the patient tolerated oral feeding. Goal rate of nutrition was 21 nonprotein cal/kg/d and 0.3 g N/kg/d.

RESULTS

Two patients in the early group were excluded due to inability to place the tube, and one patient in the late group died before 72 hours. Five of the remaining 27 died, 1 in the early group and 4 in the late group. There were no significant differences between the groups in length of stay, intensive care unit (ICU) days, significant infection, or GCS score. However, major infection correlated inversely with admission GCS score (R = -0.6, p < .003). Time to reach a GCS score of 14 was significantly longer in patients with significant infections compared with those without (p < .02).

CONCLUSIONS

No difference in length of stay or infectious complications is shown in patients with severe closed-head injury when they are given early vs delayed feeding using an immune-enhancing formula. Severity of the head injury is closely associated with significant infection.

Intubation and survival in severe paediatric blunt head injury

The majority of severe childhood injuries are due to head injuries. We studied the impact of emergency intubation in a cohort of children suffering severe blunt head trauma. A 10-year retrospective case note analysis was performed on 176 children (age < 16 years) with severe blunt head trauma (abbreviated injury scale > or =4) in Southern Finland, who required intensive care in a level 1 trauma centre, or who died despite initiation of life supporting measures at the scene. Children in whom emergency intubation was performed either at the scene, or in the emergency room (ER) were analysed. Of the 59 children who fulfilled the study criteria, 20 had an isolated head injury. Most injuries (56/59) were caused by road traffic accidents. Field-intubation was performed in 24 children, and emergency intubation in the ERs of regional hospitals or the level 1 trauma centre, in 13 and 22 children respectively. Mortality was 54.2% (32/59), and was highest in children intubated in regional hospital ERs or in the field. Children intubated at the scene or in the ER of regional hospitals, had significantly worse AIS (head/neck), injury severity score (ISS), and Glasgow coma (GCS) scores than those children intubated in the ER of the level 1 trauma centre. Survival was better in field-intubated children compared with those intubated in regional hospital ERs, despite similar trauma scores (p = 0.05). It is concluded that although children with severe (AIS > or =4) head injury who require emergency intubation have a high overall mortality, field-intubation may improve survival, compared with 'scoop and run' with BLS airway management and deferred emergency intubation.