Fluid resuscitation of patients with multiple injuries and severe closed head injury: experience with an aggressive fluid resuscitation strategy

BACKGROUND

Despite increasing experimental and clinical evidence to the contrary, a dichotomy of management strategies of the patient with multiple injuries still exists, based on the presence or absence of traumatic brain injury. Many still advocate fluid restriction or small volume resuscitation if traumatic brain injury is present.

PURPOSE

To demonstrate results of aggressive fluid resuscitation in a prospective case series of patients with multiple injuries and with severe head injury.

METHODS

Thirty-four patients with Glasgow Coma Scale score < or = 8 and Injury Severity Score > or = 16 were enrolled into the study over a period of 18 months. Fluid resuscitation was guided in part by cerebral perfusion pressures (mean cerebral perfusion pressures > 80) as well as by hemodynamic monitoring and evidence of end organ perfusion. Overall fluid intake, intensive care unit fluid balance, presence or absence of hypoxia, hypotension, or both, were analyzed. Ninety- and 180-day Glasgow Outcome Scale and Disability Rating Scale scores were also obtained.

RESULTS

By using an aggressive fluid resuscitation strategy, secondary insults were avoided in 74% of the patients. A good functional outcome was achieved in 74% and mortality was impressively low at 6%.

CONCLUSION

Fluid restriction is not necessary to achieve good results in the severely injured patient who also has a severe head injury.

Changes in the management of severe traumatic brain injury: 1991-1997

OBJECTIVE

To survey the management of head-injured patients in 1997 and to identify differences compared with a survey conducted in 1991.

DESIGN

A two-page questionnaire was mailed to all neurosurgeons in North America certified by the American Board of Neurologic Surgeons, asking their views regarding the most appropriate acute care of patients with severe traumatic brain injury (TBI).

SETTING

North American neurosurgical practices.

PATIENTS

Not applicable.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Compared with a 1991 survey, there was a significant increase in the proportion of neurosurgeons who felt these patients should have intracranial pressure monitoring (28% vs. 83%) and a decrease in the proportion who used prophylactic hyperventilation therapy (83% vs. 36%) and steroids (64% vs. 19%). Ninety-seven percent of respondents felt that the cerebral perfusion pressure should be maintained at >70 mm Hg, and 44% indicated that patients with severe TBI should be treated at Level I trauma centers.

CONCLUSIONS

There have been significant changes in the acute management of patients with severe TBI since 1991. Current practices more closely reflect the recommendations of evidence-based guidelines.

The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome

The authors retrospectively analysed two groups of consecutive patients who were similarly matched for brain injury severity. From a total of 39 severe head injury patients, 23 were treated according to the Guidelines for the Management of Severe Head Injury with intracranial pressure (ICP) monitoring ("Guidelines group"). Such an approach allowed the maintenance of ICP within normal values, especially in patients with intraventricular ICP monitoring allowing the release of cerebrospinal fluid (CSF) from the ventricular system. In the Guidelines group only two patients were administered barbiturates, after all other means of ICP lowering had been exhausted. The second group consisted of 16 patients who were not monitored for ICP ("non-Guidelines group"). In this group, management consisted of the prophylactic administration of barbiturates, high dose osmotic diuretics and hyperventilation usually at levels below 25 mm Hg. In the Guidelines group the mortality rate was 30% compared to 44% in the non-Guidelines group. Almost twice as many patients achieved a "favourable" (good recovery and moderate disability) outcome (49%) compared to the non-Guidelines treated patients (25%). Furthermore, there was a 32% decrease in severe neurological disabilities in those patients in the Guidelines group. It seems that the implementation of "Guidelines" in the treatment of severe head injury, based on the result of our clinical study, reduces death and disability rates in patients with severe head injury. The administration of therapy based on the "Guidelines principles" and monitoring of ICP, can minimise the application of those therapeutic modalities (barbiturate coma and prolonged hyperventilation) which, in addition to favourable effects, may also have harmful effects on patients with severe head injury.

Survey of the management of patients with minor head injuries in hospitals in Sweden

OBJECTIVES

Development of guidelines for quality assurance in head injury care has to be based on knowledge about how today's management is organized. To address the need for guidelines in minor head injury (MHI), the authors studied management practice in Sweden.

METHODS

We performed a cross-sectional mail survey including all 76 hospitals treating head-injured patients. The questionnaire outlined present management practice in MHI; including routines for clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up.

RESULTS

The initial evaluation is frequently performed by inexperienced physicians. The level of consciousness is assessed according to the Swedish Reaction Level Scale or the Glasgow Coma Scale in 96% of the hospitals. Routine computerized tomography is used in 4%. Skull radiography is not routinely performed. Eighty percent of the hospitals discharge selected patients without in-hospital observation and most (93%) offer no routine follow-up.

CONCLUSIONS

This survey shows a variation in the management of MHI in hospitals in Sweden. Routines for assessment of consciousness level are satisfactory, but CT scan for detection of skull fracture and early diagnoses of intracranial complications is usually not performed. Guidelines should be based on present routines including decision rules for CT scan.

The management of minor closed head injury in children. Committee on Quality Improvement, American Academy of Pediatrics. Commission on Clinical Policies and Research, American Academy of Family Physicians

The American Academy of Pediatrics (AAP) and its Committee on Quality Improvement in collaboration with the American Academy of Family Physicians (AAFP) and its Commission on Clinical Policies and Research, and in conjunction with experts in neurology, emergency medicine and critical care, research methodologists, and practicing physicians have developed this practice parameter. This parameter provides recommendations for the management of a previously neurologically healthy child with a minor closed head injury who, at the time of injury, may have experienced temporary loss of consciousness, experienced an impact seizure, vomited, or experienced other signs and symptoms. These recommendations derive from a thorough review of the literature and expert consensus. The methods and results of the literature review and data analyses including evidence tables can be found in the technical report. This practice parameter is not intended as a sole source of guidance for the management of children with minor closed head injuries. Rather, it is designed to assist physicians by providing an analytic framework for the evaluation and management of this condition. It is not intended to replace clinical judgment or establish a protocol for all patients with a minor head injury, and rarely will provide the only appropriate approach to the problem.

Ingested endotracheal tube in an adult following intubation attempt for head injury

General surgeons are often consulted for assistance in the management of ingested foreign bodies. Deglutition of an endotracheal tube is an unusual complication of airway management. In these cases, the artificial airway is "lost" when it becomes lodged deep into the esophagus. Endoscopic extraction has been described as therapeutic. We report a case in which prehospital endotracheal intubation attempt for the management of closed head injury resulted in a swallowed endotracheal tube. The tube remained undetected until radiographs were performed for a second unrelated traumatic event 2 years later. Endoscopic extraction was unsuccessful, due to rigidity of the tube. Surgical extraction via gastrotomy was uneventful. Surgeons involved in trauma and other emergency settings should be aware of this complication and options in management.

Albumin or hetastarch improves neurological outcome and decreases volume of brain tissue necrosis but not brain edema following closed-head trauma in rats

The present study examined whether hemodilution with 20% human serum albumin (HSA) or 10% hydroxyethyl starch (HES) improved the outcome from closed-head trauma (CHT) in rats. Rats anesthetized with halothane were given one of three hemodilution solutions (i.e., 20% HSA, 10% HES, or control [0.9% saline]) after CHT or sham surgery. CHT was delivered using a weight drop impact of 0.5 J onto the closed cranium. The hemodilution solution (volume = 1% of body weight) was given just after determining the neurological severity score (NSS) at 1 hour following CHT. The NSS was determined again at 24, 48, and 72 hours following CHT. At 72 hours, brains were removed, and brain edema and brain tissue necrosis volume were determined. Solutions of 20% HSA and 10% HES significantly improved brain tissue necrosis volume (143 +/- 72 mm3 and 104 +/- 53 mm3 as compared to 271 +/- 65 mm3 in controls, mean +/- SD) and NSS (12 +/- 2 and 9 +/- 2 as compared to 15 +/- 2 in controls at 72 hours, median +/- range) but not brain edema. The hematocrit decreased similarly in all groups during hemodilution. Hemodilution with 20% HSA and 10% HES following CHT in rats did not decrease brain edema but did decrease brain tissue necrosis volume and NSS (improved neurological function), suggesting that the beneficial effect of hemodilution resulted not from decreased edema formation but rather from effects not measured in this study such as improved perfusion of the salvageable brain tissue surrounding the core injury.

Sports-specific concerns in the young athlete: football

There are over 1.5 million males playing American football at all levels in the United States. American football is the most common participant sport among high-school-aged males. Owing to its high rate of injury per exposure hour, American football injuries are commonly treated in the emergency department during the autumn sports season. This article will review the history, epidemiology, and specific injury patterns seen in American football, with a focus on head and shoulder injuries.

Severe head injury patients in a multidisciplinary ICU: are they a burden?

OBJECTIVE

Patients with severe head injury (HI) are often considered to be a burden in a multidisciplinary intensive care unit (ICU). This study was undertaken to compare the severe closed HI patients with all other patients in the ICU in terms of age group involved, stay in the unit, complications and outcome.

DESIGN

Retrospective analysis.

SETTING

Multidisciplinary ICU of a tertiary care hospital in Northern India.

PATIENTS AND PARTICIPANTS

All the patients admitted to the ICU between January 1995 and December 1997. The patients were classified into two groups: group A comprising patients with severe closed HI and group B consisting of all other patients.

RESULTS

The mean age of the patients was around 30 years in both the groups. The average stay of the patients in the unit was 12.71 +/- 11.9 days in group A, compared to 9.9 +/- 14.4 days for group B (p < 0.05). The duration on the ventilator or on an endotracheal airway was not different between the groups (p > 0.05). The mortality in group A was 46.8 % and that in group B was 38.5 % (p > 0.05). The mortality was directly proportional to the age in group A. Hypotension, renal failure and septicaemia were the commonest complications in both the groups but the difference was not statistically significant.

CONCLUSIONS

This study demonstrates that patients with severe HI do not pose an extra burden in a multidisciplinary ICU.

Primary brainstem injury: benign course and improved survival

Primary brainstem injury following head injury is a rare event. The victims often have features of supratentorial injury, and a primary isolated injury to the brainstem occurring due to shearing stresses or to injury from the tentorial edge is extremely rare. In the presence of supratentorial injury, these patients may have altered sensorium. Isolated brainstem injury may manifest itself as internuclear ophthalmoplegia, anisocoria, rigidity and cerebellar tremor. Such injuries are now being diagnosed more often due to improved imaging techniques. We treated nine such cases who had sustained primary brainstem injury in road traffic accidents, all but one of whom were subsequently independent. Primary brainstem injuries need not be associated with poor prognosis and mortality and may run a benign course with good quality of survival.

Determining cerebral perfusion pressure thresholds in severe head trauma

Laboratory studies suggest the pulsatile component of the transcranial doppler (TCD) waveform may be useful in determining lower autoregulatory threshold. This study aimed to assess the effect of increasing CPP on jugular bulb oximetry (SjO2) and middle cerebral artery (MCA) TCD flow velocities in the early management of severe head injury. 16 severely head injured patients (GCS < or = 8), had intracranial pressure (ICP), mean arterial pressure, SjO2 and MCA Doppler velocity monitored continuously. CPP was increased by intravenous fluids (right atrial pressure approximately equal to 10) and supplemented with adrenaline infusion until TCD pulsatility (Gosling pulsatility index [PI] reached a plateau. The mean CPP at which SjO2 surpassed 55% was 62 +/- 6.2 mm Hg. TCD PI did not plateau until a significantly higher mean CPP of 74 +/- 5.1 mm Hg was achieved (p < 0.01). In 8 cases, increased CPP was associated with a fall in ICP, ranging from 1 to 8 mm Hg. We conclude that a critically low level of SjO2 is a late indicator of failed autoregulation. CPP values associated with intact autoregulation identified by TCD assessment of MCA flow are significantly higher than those indicated by SjO2 monitoring. MCA Doppler flow assessment may be useful in determining the level of CPP at which therapy should be aimed in the early resuscitation of head trauma.

External lumbar drainage in uncontrollable intracranial pressure in adults with severe head injury: a report of 7 cases

The retrospective results of external lumbar drainage in 7 adult patients with severe closed head injury and intracranial pressure (ICP) refractory to aggressive management strategies are presented. All patients had Glasgow Coma Scale (GCS) scores of 8 or less within 24 hours after admission and were treated by a staircase protocol including sedation, ventricular drainage, hyperventilation and mannitol. In three cases barbiturate drugs and an artificially induced hypothermia were used. Four patients required surgical evacuation of mass lesions. Three patients made a good functional recovery, 2 were severely disabled and 2 patients died. In none of the patients clinical signs of cerebral herniation occurred. We recommend additional external lumbar drainage in adults with severe head injury unresponsive to aggressive ICP control with open basilar cisterns and absent focal mass lesions on computerized-tomography scan before drainage.

Traumatic intraventricular hemorrhage treated with intraventricular recombinant-tissue plasminogen activator: technical case report

OBJECTIVE AND IMPORTANCE

Traumatic intraventricular hemorrhage (IVH) can result in association with acute obstructive hydrocephalus, repetitive malfunction of external ventricular drains (EVDs), and uncontrollable increased intracranial pressure. We report a case showing the safe and effective use of intraventricular recombinant-tissue plasminogen activator in a child with severe brain injury and acute hydrocephalus from IVH.

CLINICAL PRESENTATION

A 15-year-old male patient presented to us after a motor vehicle accident with bilateral extensor posturing, intracerebral and IVH, and acute obstructive hydrocephalus.

INTERVENTION

A right EVD was placed and functioned only transiently. A left EVD was placed and functioned only transiently. Because of the inability to maintain ventricular drainage, rising intracranial pressure, and worsening clinical status, 5 mg of recombinant-tissue plasminogen activator was injected through each EVD. Excellent EVD function was obtained quickly, with control of intracranial pressure and improvement in clinical status and without hemorrhagic complication.

CONCLUSION

With obstructive hydrocephalus secondary to acute traumatic IVH that cannot be controlled with EVD because of recurrent obstruction from intraventricular blood, intraventricular recombinant-tissue plasminogen activator can be effective and safe, despite preexisting multiple hemorrhagic intracranial injuries.

An evaluation of the effects of semirigid cervical collars in patients with severe closed head injury

The use of a semirigid cervical collar has been recommended to prevent further cervical spine injury in the management of trauma patients. These cervical collars are kept on obtunded patients for prolonged periods. We assessed the incidence of cervical collar related decubiti in patients with severe closed head injury (SCHI). We also assessed the utility of fluoroscopy in clearing the cervical spine of patients with SCHI. A retrospective chart review was performed on 52 consecutive patients with SCHI at a community hospital-based Level II trauma center over an 8-month period. Thirteen of 34 patients (38%) who survived >24 hours after admission developed decubiti related to the cervical collar. The patients who developed decubiti had a significantly greater duration of cervical collar placement (21.15 +/- 0.99 days) as compared with patients who did not develop decubiti (4.42 +/- 0.79 days; P = 0.001). Eight patients had their cervical spine assessed for ligamentous injury by bedside fluoroscopy. All eight patients had early collar removal; none of these patients developed decubiti. Patients with SCHI with semirigid cervical collars kept in place for prolonged periods of time are at risk for developing decubiti. Fluoroscopy in addition to standard radiographs may "clear" the cervical spine and allow early removal of these collars.

[Treatment of increased intracranial pressure in craniocerebral trauma]

The management of trauma patients with increased intracranial pressure is based on maintaining a normal "milieu interne", i.e. avoiding posttraumatic hypoxia and hypotension and applying specific treatment modalities, if indicated. If there are clinical signs of increased intracranial pressure or signs of cerebral edema in the CT scan, monitoring of intracranial pressure is indicated. ICP above 20 mmHg should be treated and the cerebral perfusion pressure should be maintained between 60 and 70 mmHg. Accepted treatment modalities of increased ICP are: 1) analgosedation, 2) head elevation, 3) hyperventilation, 4) osmotherapy, 5) barbiturate therapy, and 6) THAM (tris puffer).

Head and spinal cord injury

Traumatic brain and spinal cord injuries remain the leading cause of death and disability for individuals under 50 years of age. This article describes common causes of primary and secondary central nervous system injuries. Particular emphasis is placed on the initial evaluation of trauma patients, detection of head and spinal cord injuries, and critical care of these patients. Definitive management of central nervous system injuries and prognosis and long-term management issues are also discussed.

Assessment of ventilation during the performance of a percutaneous dilatational tracheostomy: hypoventilation is not a common complication

Percutaneous dilatational tracheostomy (PDT) is becoming an accepted cost-effective alternative to surgical tracheostomy. PDT is performed by progressive dilatation of a tracheal opening placed under bronchoscopic guidance. Case reports of hypoventilation with associated hypercarbia during the performance of PDT have raised concerns about the utility of this procedure in patients in whom hypercarbia is problematic (e.g., patients with closed head injury). In a prospective cohort analysis of 11 critically ill patients, we evaluated the effect of PDT on ventilation during and after the procedure using end tidal capnography. We found that hypercarbia does not occur during or after the performance of PDT as compared to baseline levels.

[Must the accident victim be protected from the emergency physician?]

Quality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. Considering these standards, we retrospectively analyzed the preclinical treatment of all multiple trauma patients admitted to our department between 1985 and 1996. The major issues of this analysis were the diagnoses, the indications for invasive measures and the performance. Regarding the triage, for example, it was noted that 28% of patients who should have been admitted to a level I trauma center considering the severity of their injury were first admitted to a level III hospital and needed to be transferred later. In 7% of patients two additional mistakes and in 4% of patients more than two mistakes in the triage were noted. On the other hand, there are records of patients who were considered to be only slightly injured but received invasive treatment. Preclinical intubation and mechanical ventilation was not performed in 16.5% although the severity of injury clearly demanded it. A thoracic drain tube was not positioned in 38% of patients suffering from severe thoracic trauma (AISThorax > or = 4). Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17% of all documented patients. According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.

Anaphylactoid reaction to pentastarch

PURPOSE

To report a probable anaphylactoid reaction to pentastarch, a low molecular weight hydroxyethyl starch (HES) colloid solution.

CLINICAL FEATURES

Following a closed head injury, an 18-yr-old male was admitted to the Intensive Care Unit. Therapy was directed towards control of intracranial pressure (ICP) and maintenance of cerebral perfusion pressure (CPP). In the first 12 hr after admission, he had received 2500 ml polygeline (Haemaccel, Hoechst Marion Roussel Ltd.) and a dopamine infusion (up to 10 micrograms.kg-1.min-1) titrated to achieve a mean arterial pressure (MAP) of > or = 80 mmHg. Subsequent failure to achieve the target MAP resulted in commencement of a noradrenaline infusion (2.67 micrograms.min-1), and rapid administration of 500 ml pentastarch (Pentaspan, DuPont Pharmaceuticals). During the HES infusion, marked hypotension (MAP < 60 mmHg) developed associated with marked truncal urticaria. The hypotension was resistant to escalation of noradrenaline to 36 micrograms.min-1. Haemodynamic stability was rapidly restored and maintained with adrenaline boluses (total 450 micrograms) and infusion (1.67 micrograms.min-1). The remainder of the patient's ICU and hospital stay was unremarkable. A serum tryptase drawn in the first 40 min of the reaction was not elevated. Other biochemical markers were not assayed. Skin testing has not been carried out.

CONCLUSION

The temporal relationship and clinical manifestations observed in this case, together with the resistance to inotropes/vasopressors other than adrenaline is highly suggestive of an anaphylactoid reaction to pentastarch. The diagnostic value of serum tryptase may be compromised when blood samples are drawn too early.

The intensive care of severe head injury: a survey of non-neurosurgical centres in the United Kingdom

Few data exist regarding the management of severe head injury in non-neurosurgical centres within the UK. We aimed to discover the number of intensive care units admitting head injury patients, the number of patients admitted annually, and the monitoring and treatment methods followed. Questionnaires were sent to the senior nurse and consultant in 263 intensive care units within non-neurosurgical hospitals. The response rate was 78.8%, with at least one response received from 93.2% of hospitals. The severely head injured were routinely admitted in 56.7% of units. Approximately 2100 patients are admitted annually, a mean of 15 per unit. Intracranial pressure monitoring is routine in only 9% of units and 7% are without 24-h facilities for CT, a cause for concern. More encouragingly, 63% of hospitals have access to rehabilitation facilities. Distribution of guidelines to all intensive care units participating in the care of head injury may improve management and outcome.

Metabolic responses and nutritional therapy in patients with severe head injuries

The severe hypermetabolism and hypercatabolism seen in patients with severe head injuries results in malnutrition that occurs very rapidly and can cause impaired healing and an increased tendency to infection and multiple organ failure. Thus, early adequate nutritional support plays a role in functional outcome. Total enteral nutrition (TEN) is preferred over total parenteral nutrition (TPN), but TPN should be supplied promptly while increasing TEN to a goal of at least 25 to 35 nonprotein kcal/kg/d and 2.0 to 2.5 g protein/kg/d. Nutritional formulas high in branched chain amino acids, glutamine, arginine, vitamins E and C, and zinc may also have some advantages. Growth hormone may improve anabolism. Hyperglycemia, especially glucose levels exceeding 200 mg/dL, must be prevented and/or treated promptly with insulin or decreased glucose intake. Careful monitoring with indirect calorimetry and nitrogen balance studies should help prevent inadequate protein or excessive carbohydrate intake.

An audit on guidelines used for the initial management of patients with minor head injuries in Denmark

The purpose of this quality assurance study was to compare the practice used in the management of patients with minor head injuries (MHI) in Denmark with guidelines recommended by Danish neurosurgeons and analyse differences between hospitals in the treatment of patients with MHI. All 68 accident and emergency departments in Denmark covering a population of 5,146,000 inhabitants and 895,000 attenders received a questionnaire containing questions about epidemiological data, the clinical practice and the use of skull x-ray. Ninety-four per cent of the hospitals responded. The number of patients admitted per 100,000 inhabitants per year was the same (mean 235) in large and small hospitals, but in the small hospitals significantly more patients per 100,000 attenders per year were admitted (p < 0.05). More than 80% of the hospitals recommended admission if the patient reported unconsciousness, significant headache, dizziness or nausea and vomiting. Symptoms found at the examination in the A & E department had high priority in the decision to admit patients in more than 90% of the hospitals. Skull x-ray was always used in only 2/64 hospitals. The compliance with guidelines give by Danish neurosurgeons was unsatisfactory as far as the symptoms in the history were concerned.

Neurologic outcome with hemorrhagic hypotension after closed head trauma in rats: effect of early versus delayed conservative fluid therapy

OBJECTIVE

This study examined (1) whether two previously reported, well-established models in rats, one a model of hemorrhagic hypotension and the other a model of closed head trauma, could be combined to evaluate neurologic outcome when hemorrhage occurs subsequent to head injury, and (2) the ability of the traditional, conservative approach to fluid therapy (3 mL of intravenous fluid for 1 mL of blood loss) to reverse the detrimental effects of hemorrhagic hypotension after closed head trauma. In addition, two strategies of fluid therapy (early and delayed) were examined.

METHODS

Fifty-six Sprague-Dawley male rats were divided into five groups with head injury at time 0 in groups 3 to 5, hemorrhage at 1 hour in groups 1, 2, 4, and 5, and intravenous fluid at 15 minutes (groups 2 and 5) or 60 minutes (groups 1 and 4) after hemorrhage. Head injury was delivered using a weight-drop impact of 0.5 J onto the closed cranium. Neurologic Severity Score (NSS) was determined at 1 hour (just before hemorrhage) and at 4 hours.

RESULTS

NSS at 1 hour did not differ between groups 3 to 5 (15.5 (9-24) to 16 (2-21), median (range)). The amount of bleeding did not differ between groups during the first 15 minutes of hemorrhage (2.8 +/- 0.8 to 3.7 +/- 2.0 mL, mean +/- SD). After 60 minutes, cumulative blood loss in the delayed fluid therapy groups was less (3.1 +/- 1.13 mL in group 1 and 4.25 +/- 2.39 mL in group 4) than in the early fluid therapy groups (7.73 +/- 4.41 mL in group 2 and 6.85 +/- 2.36 mL in group 5) (analysis of variance, p < 0.01). The NSS of group 3 (head injury only) improved at 4 hours after injury (12 (5-20)), whereas the NSS of groups 4 and 5 (head injury followed by hemorrhage) deteriorated (24 (17-25) and 19.5 (9-25), respectively) (Kruskal-Wallis test,p < 0.05). In all the hemorrhage groups, fluid therapy failed to restore blood pressure to prehemorrhage levels.

CONCLUSION

It is concluded that the two individual models of hemorrhagic hypotension and closed head trauma in rats can be combined to evaluate outcome when hemorrhage occurs subsequent to head injury. Furthermore, traditional, conservative fluid therapy, whether early or delayed, failed to restore blood pressure or to improve NSS when hemorrhage occurred after head injury. Blood loss was greater with early fluid therapy whether or not head injury was present.

[Monitoring head trauma]

Cerebral monitoring after head trauma aims at reducing secondary lesions resulting mainly from additional cerebral ischemia-hypoxia. Such monitoring must include repetitive (preferably continuous) estimation of cerebral blood flow, cerebral oxygenation and their variations. Based on this information the evaluation and modulation of the main determinants of cerebral blood flow (cerebral metabolism, cerebral perfusion pressure, arterial oxygen content and PaCO2 variations) often allows optimization of cerebral blood flow and metabolism balance. This therapeutic strategy may lead to improvement of severe head trauma outcome through reduction of additional cerebral ischemia-hypoxia.

Inter-hemispheric scissure, a rare location for a traumatic subdural hematoma, case report and review of the literature

Subdural interhemispheric hematomas (ISH), though not really rare, are quite an uncommon complication of head traumas. This condition is more frequent in childhood, where it is generally considered as a part of a more complex syndrome, called 'Shaken Children Syndrome', usually pointing out child abuse. Although a head injury is very often considered the cause (in about 80-90% of the cases), possible predisposing factors such as coagulopathies, alcohol abuse or anticoagulant therapy can also be considered. Furthermore, as the rupture of an intracranial aneurysm has also occasionally pinpointed as a possible cause, this event should be kept in mind in order to be able to address exactly both the diagnostic and therapeutical procedures. A new conservatively managed case is thereby described. A review of the literature with particular attention drawn to the diagnosis and the different therapeutical possibilities is also elaborated.

[Treatment of drug-induced agranulocytosis with granulocyte colony stimulating factor (G-CSF) in a surgical intensive care unit]

Following repeated metamizole applications a 41-year old intensive-care patient suffering from severe craniocerebral trauma and sepsis developed a drug-induced agranulocytosis. Early G-CSF treatment reduced the neutropenic period to 4 days.

Guidelines for minor head injured patients' management in adult age. The Study Group on Head Injury of the Italian Society for Neurosurgery

The study group on Head Injury of the Italian Society for Neurosurgery suggests the following guidelines for minor head injured patients management. Patients either oriented to time, space and person (GCS 15) or confused (GCS 14) are included among the group of minor head injury. Criteria of exclusion are the presence of focal neurological deficits, open injury and a GCS < or = 13. Six categories of risk factors (coagulopathies, alcoholism, drug abuse, epilepsy, previous neurosurgical treatments and disabled elderly patients) relevant to the clinical course are identified. Three group of patients are distinguished. Patients in the Group 0 (GCS 15, without loss of consciousness, amnesia, diffuse headache, vomiting) could be sent home from Emergency Department after at least 6 hours period of observation with an information sheet. Patients in the Group 1 (GCS 15, with loss of consciousness and/or amnesia and/or diffuse headache and/or vomiting) require clinical observation (> or = 6 hours) and neuroradiological assessment. According to hospital availability, either skull-X rays or CT scan is obtained. In the presence of a skull fracture a CT scan is mandatory. In the presence of intracranial lesions, neurosurgical consultation is requested. In the absence of skull fractures or intracranial lesions the patient is admitted for observation (> or = 24 hours). Patients in the Group 0 and in the Group 1 with a risk factor (R) are admitted to the hospital (> or = 24 hours) and submitted to a CT scan. In patients with coagulopathies or in treatment with anticoagulants a CT scan should be repeated before discharge even in the absence of intracranial lesion on the first CT. In patients in the Group 2 (GCS 14) a CT scan is obtained in all cases independent of the presence of a risk factor.

Traumatic aneurysm of the basilar artery

We report a case in which a "false" aneurysm of the basilar artery developed after an assault on a patient resulting in head injuries. Diagnostic imaging and endovascular treatment are described. Formation mechanisms of traumatic intracranial aneurysms are discussed and the literature is reviewed.

Fluid resuscitation of the trauma patient: how much is enough?

Patient management in the prehospital resuscitative phase after trauma is vitally important to the outcome. Early definitive care remains the essential element in improving morbidity and mortality. In Canada, where a large proportion of trauma occurs at sites distant from a trauma centre, the prehospital resuscitative phase is long and has even greater potential to affect outcome. Conventional teaching about the end points of resuscitation has promoted the concept of normalization of hemodynamic parameters with maintenance of end-organ perfusion, as measured by the hourly urine output. Recent work in patients with a closed head injury and in patients with penetrating torso trauma challenge the notion that trauma patients are homogeneous with respect to these end points. In the Canadian setting of blunt injury, where a closed head injury is usually suspected and often present, the evidence from clinical studies suggests that an aggressive approach to maintaining blood pressure is warranted. In penetrating torso injury in an urban setting, there is evidence to suggest that delaying resuscitation until hemorrhage is controlled is beneficial. More Canadian clinical trials are required in this area. In the meantime, the priorities of resuscitation must be carefully assessed for each patient and pattern of injury.

Transpyloric passage of feeding tubes in patients with head injuries does not decrease complications

Early enteral nutrition is reported to improve outcome of patients with severe closed head injuries (CHI). The efficacy and safety of nasoenteric tube (NET) feeds, however, has been questioned; the risk of aspiration is the major concern. Our purpose was to determine the rate of transpyloric migration, the efficacy of adjunctive measures to promote passage, and the effect on pulmonary complications. Seventy-four consecutive patients with moderate to severe CHI received enteral nutrition. Glasgow Coma Scale (GSC) score was 5.2 on admission and 6.9 at 48 hours. NETs were placed an average of 5.6 days after admission; an average of three abdominal films per patient were used to assess tube position. No patients had endoscopic NET placement during this period. Ten patients required fluoroscopic placement after failure to pass spontaneously by 5 days. Overall, transpyloric passage was achieved in 32 patients (43%), whereas 42 (57%) remained intragastric. There were no differences between the postpyloric and intragastric groups in days to full feeding (5 vs. 7 days), ventilator days (11.9 vs. 12.5), intensive care unit length of stay (15.5 vs. 15.1), or incidence of pneumonia (81 vs. 69%) or aspiration (6 vs 7%). Sixty-two patients (83%) were transferred to extended care facilities and 50 (68%) were still receiving NET feedings. Spontaneous transpyloric passage of NET occurred in less than one-half of patients with severe CHI. The routine use of adjunctive measures to promote transpyloric passage was not particularly successful, had no obvious benefit, and therefore may not be necessary.

Airway management and mechanical ventilation

The care of the acutely head-injured patient involves rapid evaluation and correction of hypoxia with appropriate airway management and treatment of associated problems. The primary focus is correction of underlying pathophysiology and prevention of secondary brain injury. Anesthetics and muscle relaxants are used to control intracranial dynamics and maintain systemic and cerebral perfusion. Airway management requires prompt intervention and definitive control, while protecting the cervical spine. Preparation for the possibility of failed intubation is important.

ECT as a therapeutic option in severe brain injury

Electroconvulsive therapy (ECT) is a safe, highly effective, and rapidly acting treatment for certain major psychiatric illnesses, most notably severe mood disorders. Disturbances in mood and behavior as symptoms of delirium may complicate recovery from traumatic brain injury, but virtually no data exist on the role of ECT as a treatment modality in such clinical situations. We describe a patient with severe, unremitting, agitated behavior following a severe closed head injury from a motor vehicle accident. The initial Glasgow Coma Scale score was 3, with computed tomographic evidence of bilateral frontal and left thalamic contusions. After awakening from a 21-day coma, the patient failed to improve beyond a Ranchos Los Amigos level 4 recovery stage. He exhibited persistent severe agitation with vocal outbursts and failed to assist in performing activities of daily living. His difficulties proved unresponsive to combined behavioral therapy and multiple trials of various psychopharmacologic agents. As an intervention of "last resort," he then received six brief-pulse, bilateral ECT treatments that resulted in marked lessening of his agitation and improvement in his ability to express his needs and participate in his self-care. Also, following the ECT, he showed a markedly enhanced response to psychopharmacologic agents. These findings may have important clinical implications for treatment of prolonged delirium after traumatic brain injury.

Posttraumatic primary brainstem haematoma

Nine cases of posttraumatic primary brain stem haematoma are described. All cases presented ocular and vegetative symptoms. Hyperextension was regarded as the most likely mechanism of injury. All patients were treated conservatively; half of them with a good outcome.

The effect of growth hormone on nutritional markers in enterally fed immobilized trauma patients

BACKGROUND

Earlier clinical studies have demonstrated improved nitrogen balance in nonstressed patients receiving hypocaloric feedings and growth hormone (GH). This study investigates the effect of GH on nitrogen balance, on serum protein concentrations, and on other indices of nutrition when combined with enteral feeding in immobilized patients after closed-head injury or spinal cord injury.

METHODS

Sixteen patients who tolerated enteral feedings and remained nonseptic were randomized to receive either placebo or 0.2 mg/kg recombinant human GH for 7 to 13 days. Nitrogen balances were collected daily, and serum proteins were measured at study entrance and exit.

RESULTS

GH treatment resulted in higher GH and insulin-like growth factor-1 concentrations but did not improve nitrogen balance. GH treatment also resulted in increased transferrin and serum albumin levels and total lymphocyte count during the study period.

CONCLUSIONS

Adjuvant recombinant human GH has no effect on nitrogen balance in highly stressed, totally immobilized patients after head or spinal cord injury, but it significantly enhances constitutive serum protein concentrations and other indices of nutritional repletion.

Traumatic arteriovenous fistula treated by superselective embolisation with microcoils: case report

A 27-year-old man with a traumatic direct dural arteriovenous fistula (DAVF) was treated using embolisation microcoils. He had suffered blunt trauma to the head while drunk and was aware of no neurological deficit. A few days after the accident, however, he noticed a bruit in the right temple. Angiography demonstrated a direct DAVF fed by the right middle meningeal artery and draining into a right temporal dural vein and the ipsilateral cavernous sinus. A Tracker-18 catheter was passed without difficulty through the fistula and the draining vein was then embolised from distal to proximal with microcoils, and finally the fistula was occluded with microcoils, resulting in total obliteration of the fistula. Immediately after the embolisation, the patient could no longer hear the bruit. Thus, when a microcatheter can be introduced into the draining vein, microcoils can be used as emboli in the treatment of direct DAVF.

Direct thrombosis of a pseudoaneurysm after obliteration of a carotid-cavernous fistula with cellulose acetate polymer: technical case report

A 55-year-old man who suffered a head injury resulting in a left traumatic carotid-cavernous fistula was successfully treated with an intravascular detachable balloon. A pseudoaneurysm formed adjacent to the balloon. Seven months after the initial procedure, treatment with cellulose acetate polymer, a new liquid thrombotic material, occluded the pseudoaneurysm and preserved the internal carotid artery.

Hyperbaric oxygen for treatment of closed head injury

Traumatic and vascular brain injuries consist of acute episodes followed by development of chronic components of varying magnitude and duration whose potentials for recovery differ. We discuss a case of closed head injury in which interventional hyperbaric oxygen (HBO) with single photon emission computed tomography were used as aids in determining the presence of recoverable neurons, to follow therapeutic progress, and to determine the end point of therapy. This case also shows the successful use of intensive HBO as a therapeutic modality.

Enteral versus parenteral nutrition after severe closed head injury

We measured energy expenditure (MREE) and nitrogen excretion (UUN) in patients with severe head injury randomized to early parenteral (TPN, n = 21) or jejunal (ENT, n = 27) feeding with identical formulations. The MREE rose to 2400 +/- 531 kcal/day in both groups and remained at 135% +/- 26% to 146% +/- 42% of predicted energy expenditure over 4 weeks. Nitrogen excretion peaked the second week at 33.4 +/- 10 (TPN) and 31.2 +/- 7.5 (ENT) g N/day. Both routes were equally effective at meeting nutritional goals (1.2 x MREE, 2.5 g protein/kg/day intake, stabilized albumin and transferrin levels). Infections were equally frequent: 1.86 episodes/TPN patient versus 1.89 episodes/ENT patient. While patient charges were much greater for TPN, the hospital costs were similar for TPN and ENT support regimens. These findings show that patients with head injuries are hypermetabolic for weeks, that only 27% are capable of spontaneously eating nutritional requirements by discharge, and that either TPN or ENT support is equally effective when prescribed according to individual measurements of MREE and nitrogen excretion.

Closed head injury and the treatment of sequelae after a motor vehicle accident

Approximately 2 million closed head injuries (CHIs) occur yearly in the United States. Twenty-five percent of these injuries require hospitalization, and 70,000 to 90,000 of those hospitalized suffer long-term disability. This case conference details one such case of CHI in which the patient ultimately died. Close attention is given to the pathophysiology and treatment of this process. Commonly accepted, as well as investigational, modalities of therapy are discussed.

Somatosensory evoked potentials and intracranial pressure in severe head injury

The purpose of this study was to explore the relationship between neurologic function, using a quantitative measurement of continuous somatosensory evoked potentials (SSEPs), and intracranial pressure (ICP) following traumatic brain injury. During a 6 year period, severely head-injured patients with a Glascow Coma Scale < or = 8 who were not moribund were monitored with SSEPs and ICP measurements. SSEPs from each hemisphere and ICP were recorded hourly for each patient. Neurologic outcomes were scored using the Glasgow Outcome Scale at three months post injury. Although initial SSEP amplitude did not correlate well with outcome, final SSEP summed peak to peak amplitude from both hemispheres (p = .0001), the best hemisphere (p = .0004), and the worst hemisphere (p = .0001) correlated well with the Glasgow Outcome Scale groups. Of a total of 72 patients, 40 had deteriorating SSEPs and 32 had stable or improving SSEPs. Peak ICP values were not statistically different in these groups (p = .6). Among patients with deteriorating SSEPs, 52.5% lost the greatest proportion of hemispheric electrical activity prior to ICP elevation. In the remaining patients, the percent reduction of SSEP activity after peak ICP levels was not statistically different from the percent reduction in SSEP activity prior to the peak ICP levels (p = .9). This data suggests that in a select group of patients with severe head injury, ICP does not cause SSEP deterioration, but rather is the consequence of deterioration of brain function.