Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings

Intratympanic hemorrhage and concussion in a football offensive lineman

BACKGROUND

A 26-year-old arena football lineman participating in a "bull in the ring" blocking and tackling drill was blindsided by an opposing teammate. He sustained a direct helmet-to-helmet blow to the right temporal area.

OBJECTIVES

This case describes a unique mechanism of ear barotrauma (intratympanic hemorrhage) and concussion caused by helmet-to-helmet contact in American football.

CASE REPORT

Initial sideline evaluation revealed mild headache, confusion, dizziness, photophobia, and tinnitus, all consistent with a concussion diagnosis. Physical examination revealed a large postauricular contusion over the right mastoid process and diffuse right intratympanic hemorrhage on examination. No hemotympanum or effusion of the middle ear was noted. Abnormalities were seen on vestibular testing and visual accommodation and convergence testing. Computed tomography and magnetic resonance imaging were performed with attention to the temporal bones and were normal. Neuropsychological testing was abnormal compared to baseline. Audiology testing was within normal limits. Diagnosis was intratympanic hemorrhage secondary to barotrauma caused by helmet-to-helmet contact, with mastoid contusion and season-ending concussion.

CONCLUSIONS

The tympanic membrane (TM) is a highly vascular membrane that is very sensitive to variations of atmospheric pressure. Overpressure can enter the external auditory canal, stretching and displacing the TM medially and causing injury to the tympanic membrane secondary to barotrauma. This concussed football player was never able to return to play due to his postconcussive symptoms. He had no residual hearing or ear problems.

Mechanisms of hearing loss after blast injury to the ear

Given the frequent use of improvised explosive devices (IEDs) around the world, the study of traumatic blast injuries is of increasing interest. The ear is the most common organ affected by blast injury because it is the body's most sensitive pressure transducer. We fabricated a blast chamber to re-create blast profiles similar to that of IEDs and used it to develop a reproducible mouse model to study blast-induced hearing loss. The tympanic membrane was perforated in all mice after blast exposure and found to heal spontaneously. Micro-computed tomography demonstrated no evidence for middle ear or otic capsule injuries; however, the healed tympanic membrane was thickened. Auditory brainstem response and distortion product otoacoustic emission threshold shifts were found to be correlated with blast intensity. As well, these threshold shifts were larger than those found in control mice that underwent surgical perforation of their tympanic membranes, indicating cochlear trauma. Histological studies one week and three months after the blast demonstrated no disruption or damage to the intra-cochlear membranes. However, there was loss of outer hair cells (OHCs) within the basal turn of the cochlea and decreased spiral ganglion neurons (SGNs) and afferent nerve synapses. Using our mouse model that recapitulates human IED exposure, our results identify that the mechanisms underlying blast-induced hearing loss does not include gross membranous rupture as is commonly believed. Instead, there is both OHC and SGN loss that produce auditory dysfunction.

Duration and predictors of emergency surgical operations--basis for medical management of mass casualty incidents

BACKGROUND

Hospitals have a critically important role in the management of mass causality incidents (MCI), yet there is little information to assist emergency planners. A significantly limiting factor of a hospital's capability to treat those affected is its surgical capacity. We therefore intended to provide data about the duration and predictors of life saving operations.

METHODS

The data of 20,815 predominantly blunt trauma patients recorded in the Trauma Registry of the German-Trauma-Society was retrospectively analyzed to calculate the duration of life-saving operations as well as their predictors. Inclusion criteria were an ISS≥16 and the performance of relevant ICPM-coded procedures within 6h of admission.

RESULTS

From 1,228 patients fulfilling the inclusion criteria 1,793 operations could be identified as life-saving operations. Acute injuries to the abdomen accounted for 54.1% followed by head injuries (26.3%), pelvic injuries (11.5%), thoracic injuries (5.0%) and major amputations (3.1%). The mean cut to suture time was 130min (IQR 65-165min). Logistic regression revealed 8 variables associated with an emergency operation: AIS of abdomen ≥3 (OR 4,00), ISS ≥35 (OR 2,94), hemoglobin level ≤8 mg/dL (OR 1,40), pulse rate on hospital admission <40 or >120/min (OR 1,39), blood pressure on hospital admission <90 mmHg (OR 1,35), prehospital infusion volume ≥2000 ml (OR 1,34), GCS ≤8 (OR 1,32) and anisocoria (OR 1,28) on-scene.

CONCLUSIONS

The mean operation time of 130min calculated for emergency life-saving surgical operations provides a realistic guideline for the prospective treatment capacity which can be estimated and projected into an actual incident admission capacity. Knowledge of predictive factors for life-saving emergency operations helps to identify those patients that need most urgent operative treatment in case of blunt MCI.

Burn Disasters—An Audit of the Literature

All events that result in disasters are unique, and it is impossible to become fully prepared. However, through thorough planning and preparedness, it is possible to gain a better understanding of the typical injury patterns and problems that arise from a variety of hazards. Such events have the potential to claim many lives and overwhelm local medical resources. Burn disasters vary in scope of injury and procedures required, and are much more labor and resource intensive than non-burn disasters.

This review of the literature should help determine whether, despite each event having its own unique features, there still are common problems disaster responders face in the prehospital and hospital phases, what recommendations were made from these disasters, and whether these recommendations have been implemented into practice and the current disaster planning processes.

The objective of this review was to assess: (1) prehospital and hospital responses used during past burn disasters; (2) problems faced during those disaster responses; (3) recommendations made following those disasters; (4) whether these recommendations were integrated into practice; and (5) the key characteristics of burn disasters and how they differ from other disasters. This review is important to determine why, despite having disaster plans, things still go wrong.

Principles of Emergency Department facility design for optimal management of mass-casualty incidents

INTRODUCTION

The Emergency Department (ED) is the triage, stabilization and disposition unit of the hospital during a mass-casualty incident (MCI). With most EDs already functioning at or over capacity, efficient management of an MCI requires optimization of all ED components. While the operational aspects of MCI management have been well described, the architectural/structural principles have not. Further, there are limited reports of the testing of ED design components in actual MCI events. The objective of this study is to outline the important infrastructural design components for optimization of ED response to an MCI, as developed, implemented, and repeatedly tested in one urban medical center.

REPORT

In the authors' experience, the most important aspects of ED design for MCI have included external infrastructure and promoting rapid lockdown of the facility for security purposes; an ambulance bay permitting efficient vehicle flow and casualty discharge; strategic placement of the triage location; patient tracking techniques; planning adequate surge capacity for both patients and staff; sufficient command, control, communications, computers, and information; well-positioned and functional decontamination facilities; adequate, well-located and easily distributed medical supplies; and appropriately built and functioning essential services.

DISCUSSION

Designing the ED to cope well with a large casualty surge during a disaster is not easy, and it may not be feasible for all EDs to implement all the necessary components. However, many of the components of an appropriate infrastructural design add minimal cost to the normal expenditures of building an ED.

CONCLUSION

This study highlights the role of design and infrastructure in MCI preparedness in order to assist planners in improving their ED capabilities. Structural optimization calls for a paradigm shift in the concept of structural and operational ED design, but may be necessary in order to maximize surge capacity, department resilience, and patient and staff safety.

Primary blast survival and injury risk assessment for repeated blast exposures

BACKGROUND

The widespread use of explosives by modern insurgents and terrorists has increased the potential frequency of blast exposure in soldiers and civilians. This growing threat highlights the importance of understanding and evaluating blast injury risk and the increase of injury risk from exposure to repeated blast effects.

METHODS

Data from more than 3,250 large animal experiments were collected from studies focusing on the effects of blast exposure. The current study uses 2,349 experiments from the data collection for analysis of the primary blast injury and survival risk for both long- and short-duration blasts, including the effects from repeated exposures. A piecewise linear logistic regression was performed on the data to develop survival and injury risk assessment curves.

RESULTS

New injury risk assessment curves uniting long- and short-duration blasts were developed for incident and reflected pressure measures and were used to evaluate the risk of injury based on blast over pressure, positive-phase duration, and the number of repeated exposures. The risk assessments were derived for three levels of injury severity: nonauditory, pulmonary, and fatality. The analysis showed a marked initial decrease in injury tolerance with each subsequent blast exposure. This effect decreases with increasing number of blast exposures.

CONCLUSIONS

The new injury risk functions showed good agreement with the existing experimental data and provided a simplified model for primary blast injury risk. This model can be used to predict blast injury or fatality risk for single exposure and repeated exposure cases and has application in modern combat scenarios or in setting occupational health limits.

64-MDCT in mass casualty incidents: volume image reading boosts radiological workflow

OBJECTIVE

The purpose of this study was to evaluate the impact of the use of 64-MDCT and volume image reading on the radiologic workflow during a mass casualty incident simulation.

MATERIALS AND METHODS

For this simulation, casualties were taken to our level I trauma center, and triage was done with whole-body 64-MDCT. The complete raw dataset of thin-section images was sent to a dedicated 3D workstation for further interpretation and simultaneous reformations. This new reading method is called volume image reading. Several time frames were documented to evaluate the workflow: examination time, time needed for image processing, and mean image transfer rates. The results were compared with those of a previous study using a 4-MDCT with axial images only and transfer of data to a PACS.

RESULTS

The time for complete image processing (acquisition, reconstruction, and transfer) for 64-MDCT was 4.1 minutes (range, 3.9-4.3 minutes) compared with 9.0 minutes (range, 6.4-10.2 minutes) for 4-MDCT (p ≤ 0.001). The image processing capacity was 14.8 examinations/h for 64-MDCT compared with 6.7 examinations/h for 4-MDCT. The mean number of images was 953 for 64-MDCT compared with 202 for 4-MDCT (p ≤ 0.001). There were no significant differences between 64- and 4-MDCT for the time needed to prepare patients.

CONCLUSION

The use of 64-MDCT with volume image reading led to evident advantages in the radiologic trauma workflow compared with 4-MDCT. Reading of the full image set including reformations can be initiated earlier with volume image reading.

The role of the radiology department during the London bombings, 7 July 2005: Lessons learnt and strategy in 2011

In the modern age, any major hospital needs to be prepared for a major incident and the radiology department plays a vital role in managing severely injured patients in an efficient manner in this setting. With this in mind, this article describes the impact of the London bombings of 7 July 2005 on the radiology department of the Royal London Hospital in East London. We will describe some of the underlying principles and concepts in major incident management, how the major incident was managed, the lessons learnt from our performance and changes to policies and protocols that have been initiated in response to these lessons.

Critical care management of major disasters: a practical guide to disaster preparation in the intensive care unit

Recent events and regulatory mandates have underlined the importance of medical planning and preparedness for catastrophic events. The purpose of this review is to provide a brief summary of current commonly identified threats, an overview of mass critical care management, and a discussion of resource allocation to provide the intensive care unit (ICU) director with a practical guide to help prepare and coordinate the activities of the multidisciplinary critical care team in the event of a disaster.

Prehospital care algorithm for blast injuries due to bombing incidents

Terrorist bombings continue to remain a risk for local jurisdictions, and retrospective data from the United States show that bombings occur in residential and business areas due to interpersonal violence without political motives. In the event of a mass-casualty bombing incident, prehospital care providers will have the responsibility for identifying and managing blast injuries unique to bombing victims. In a large-scale event, emergency medical services personnel should be required to provide prolonged medical care in the prehospital setting, and they will be able to deliver improved care with a better understanding of blast injuries and a concise algorithm for managing them. Blast injuries are categorized as primary, secondary, tertiary, and quaternary, and these injuries are related to the mechanism of injury from the blast event. After an initial evaluation, the emergency healthcare provider should consider following a universal algorithm to identify and treat blast injuries within these categories to prevent further morbidity or mortality in the prehospital setting.

Analysis of responses of radiology personnel to a simulated mass casualty incident after the implementation of an automated alarm system in hospital emergency planning

The purpose of this study was to evaluate the response to an automated alarm system of a radiology department during a mass casualty incident simulation. An automated alarm system provided by an external telecommunications provider handling up to 480 ISDN lines was used at a level I trauma center. During the exercise, accessibility, availability, and estimated time of arrival (ETA) of the called in staff were recorded. Descriptive methods were used for the statistical analysis. Of the 49 employees, 29 (59%) were accessible, of which 23 (79%) persons declared to be available to come to the department. The ETA was at an average 29 min (SD ±23). Radiologists and residents reported an ETA to their workplace almost two times shorter compared with technicians (19 ± 16 and 22 ± 16 vs. 40 ± 27 min, p > 0.05). Additional staff reserve is crucial for handling mass casualty incidents. An automated alarm procedure might be helpful. However, the real availability of the employees could not be exactly determined because of unpredictable parameters. But our results allow estimation of the manpower reserve and calculation of maximum radiology service capacities.

[Blast lung injuries]

In armed conflicts and during terrorist attacks, explosive devices are a major cause of mortality. The lung is one of the organs most sensitive to blasts. Thus, today it is important that every GP at least knows the basics and practices regarding treatment of blast victims. We suggest, following a review of the explosions and an assessment of the current threats, detailing the lung injuries brought about by the explosions and the main treatments currently recommended.

Facilitating hospital emergency preparedness: introduction of a model memorandum of understanding

Effective emergency response among hospitals and other health care providers stems from multiple factors depending on the nature of the emergency. While local emergencies can test hospital acute care facilities, prolonged national emergencies, such as the 2009 H1N1 outbreak, raise significant challenges. These events involve sustained surges of patients over longer periods and spanning entire regions. They require significant and sustained coordination of personnel, services, and supplies among hospitals and other providers to ensure adequate patient care across regions. Some hospitals, however, may lack structural principles to help coordinate care and guide critical allocation decisions. This article discusses a model Memorandum of Understanding (MOU) that sets forth essential principles on how to allocate scarce resources among providers across regions. The model seeks to align regional hospitals through advance agreements on procedures of mutual aid that reflect modern principles of emergency preparedness and changing legal norms in declared emergencies.

Preparing your intensive care unit for the second wave of H1N1 and future surges

Faced with increased demands for critical care services as a result of the novel H1N1 pandemic, hospitals must prepare a surge response in an attempt to manage these needs. In preparing for a surge response, factors to consider are staff, stuff (supplies and equipment), space, and systems necessary to respond to the event. This article uses this general framework to discuss surge issues in the context of H1N1 challenges that we are facing currently and to provide specific advice for hospitals. Particular attention is given to how hospitals can estimate the potential impact of H1N1 and pharmaceutical stockpiling.

Giving context to post-deployment post-concussive-like symptoms: blast-related potential mild traumatic brain injury and comorbidities

In the military and Veterans Administration systems, individuals with potential MTBI are presenting with symptoms in excess of what would be expected based on initial injury characteristics and/or at unexpected time periods based on current research findings. This article investigates factors that might account for the discrepancy between current research expectations and some occurrences in clinical practice. The physics of blast waves, as well as animal and human research, relevant to explosions are reviewed. Additional factors that occur within the military blast exposure milieu are also explored because the context in which an injury occurs can potentially impact symptom severity and course of recovery. Differential diagnoses, iatrogenic illness, diagnosis threat, and symptom embellishment are also considered.

[Primary care hospital for a mass disaster MANV IV. Experience from a mock disaster exercise]

BACKGROUND

In Hannover and in nationwide contingency plans there are clear instructions for the medical care of mass casualties which are designed to cope with 50 to a maximum of 200 patients. Disaster simulations and practical exercises in Hannover regarding EXPO 2000 and the FIFA World Cup 2006 showed a very good and effective prehospital treatment and management up to a number of about 200 patients. Due to infrastructural settings a scenario with up to 1,000 (MANV IV) patients in the region of Hannover was beyond the capacity of existing concepts for the management of mass casualties, which comprised initial medical care at the on-site treatment area and subsequent transport to local or regional hospitals for definitive management. A new practicable and well trained model was necessary to improve the hospital admission and primary treatment capacity (Erstversorgungsklinik--EVK). In the case of MANV IV it was proposed that the tasks of on-site treatment area should be concentrated on triage and the stabilization of severely injured victims with immediate transport to special primary care hospitals. The main task of these hospitals was further stabilization of patients for inhospital care or further transport to other special facilities.

METHODS

The main aim of the study was, after the initial trauma scenario, to provide the logistical and personal background for the fastest possible advanced life support and the further treatment of more than 60 severely injured patients at a city hospital with trauma centre level I experience. The timescale from the first alarm until the hospital was ready for action was approximately 60 min. To gain knowledge about the regional implementation of the whole logistic scenario in the case of MANV IV and to practice detailed questioning, a major casualty training was needed. This resulted in a large targeted disaster medical training with a realistic situation simulation on the 25.03.2006 including the Diakoniekrankenhaus Friederikenstift under the aspect of a special primary care hospital (EVK) working at full capacity.

RESULTS

The AWD arena in Hannover was the site of a simulated major casualty event resulting in 620 patients with various penetrating or blunt trauma injuries. Within 60 min of the first alarm call the admission and casualty treatment capacity at the Diakoniekrankenhaus Friederikenstift was increased up to approximately 60 patients including 30 ventilated patients. After initial inspection of 78 patients according to the ATLS criteria advanced life support was performed (airway management, volume resuscitation, basic diagnostic and surgical techniques) by flexible treatment teams (including physicians of all other faculties) in 3 treatment corridors within 135 min. Of the patients 69 were admitted to the wards and intensive care units, 5 were discharged after ambulant treatment and 3 patients were transferred to an eye and ENT hospital. Of the patients 10 had already been intubated on arrival, another 6 patients were intubated in the treatment corridors. Simulations of 4 urgent laparatomies, 2 trepanations, 1 artery seam, osteosynthesis of 3 perforating fractures was performed in the operating theatre. A total of 6 extremity fractures were immobilized by a fixateur externe, 7 chest tubes were placed and 43 surgical wound dressings were performed in the treatment corridors. There was no significant shortage of logistical or personal resources.

CONCLUSION

In a major disaster with more than 200 seriously injured patients the EVK model is a practicable and regional well tried solution that could increase the capacity of hospital admissions and advanced trauma life support, regardless of the type of casualty, season or weather conditions. It is possible to reduce the interval to advanced trauma life support, temporary fracture stabilization (damage control) and definitive surgical care by means of rapid and targeted utilization of resources and manpower. Physicians involved in the initial treatment play a key role and have to be highly trained (ATLS). The EVK model is variable and can easily be established and adapted to regional conditions at basic regional hospitals as well as at level I trauma centers.

[Validation of the prehospital mSTaRT triage algorithm. A pilot study for the development of a multicenter evaluation]

INTRODUCTION

Successful management of a mass casualty incident requires integrated operating procedures. A common division of victims into descriptive needs-based groups and the corresponding decision processes is the key to ensuring a successful operational response. The mSTaRT ("modified simple triage and rapid treatment") algorithm should enable emergency medical technicians to conduct triage, perform appropriate medical interventions, and coordinate transportation to adequate care facilities. The aim of this study was to design a concept to validate the mSTaRT algorithm.

METHODS

Standardized evaluation sheets were distributed to emergency medical services (EMS) staff to prospectively classify trauma patients according to the mSTaRT algorithm: red (immediate: critically injured patients who can be helped by immediate transport), yellow (urgent: severely injured patients whose transport can be delayed), or green (delayed: patients with minor injuries who need help less urgently). The patients were then reevaluated in the emergency department, and the results were compared. The main points of the comparison were consistency of triage category and rates of overtriage and undertriage.

RESULTS

The study included 151 trauma patients. Of these, 62.3% were triaged correctly, 10.6% were overtriaged (2.6% critical overtriage), and 27.1% were undertriaged (4.0% critical undertriage). In the critically injured (immediate) category, the positive likelihood ratio (LR+) was 17.3 (95% CI 3.8-795), and the negative likelihood ratio (LR-) was 0.51 (95% CI 0.22-0.83). The probability of identifying a critically injured (immediate) patient was 17.3 times higher than the probability of identifying a severely (urgent) or minor (delayed) injured patient as immediate. Therefore, the rate of overtriage was very low. But every second patient who should have been classified as immediate was undertriaged by the EMS personnel. This undertriage was due to patients' suffering from head trauma, a well-known problem in the clinical context but a new problem in the triage context.

CONCLUSION

The results of our pilot study show that by using mSTaRT, patients designated as yellow (urgent) and green (delayed) will be accurately distinguished from red (immediate) patients; therefore, only a small number of patients will be overtriaged as red. However, some patients with severe head injury may not be initially assigned to the red category as required, resulting in undertriage. Consequently, modification of the mSTaRT procedures should be considered. A further identifier in the algorithm or checkpoint in the process should act as a safety net for catching severe head injury. A larger data set is required to further validate the mSTaRT algorithm. This will be acquired by means of a multicenter study.

Hemorrhagic shock after experimental traumatic brain injury in mice: effect on neuronal death

Traumatic brain injury (TBI) from blast injury is often complicated by hemorrhagic shock (HS) in victims of terrorist attacks. Most studies of HS after experimental TBI have focused on intracranial pressure; few have explored the effect of HS on neuronal death after TBI, and none have been done in mice. We hypothesized that neuronal death in CA1 hippocampus would be exacerbated by HS after experimental TBI. C57BL6J male mice were anesthetized with isoflurane, mean arterial blood pressure (MAP) was monitored, and controlled cortical impact (CCI) delivered to the left parietal cortex followed by continued anesthesia (CCI-only), or either 60 or 90 min of volume-controlled HS. Parallel 60- or 90-min HS-only groups were also studied. After HS (+/-CCI), 6% hetastarch was used targeting MAP of > or =50 mm Hg during a 30-min Pre-Hospital resuscitation phase. Then, shed blood was re-infused, and hetastarch was given targeting MAP of > or =60 mm Hg during a 30-min Definitive Care phase. Neurological injury was evaluated at 24 h (fluorojade C) or 7 days (CA1 and CA3 hippocampal neuron counts). HS reduced MAP to 30-40 mm Hg in all groups, p < 0.05 versus CCI-only. Ipsilateral CA1 neuron counts in the 90-min CCI+HS group were reduced at 16.5 +/- 14.1 versus 30.8 +/- 6.8, 32.3 +/- 7.6, 30.6 +/- 2.2, 28.1 +/- 2.2 neurons/100 mum in CCI-only, 60-min HS-only, 90-min HS-only, and 60-min CCI+HS, respectively, all p < 0.05. CA3 neuron counts did not differ between groups. Fluorojade C staining confirmed neurodegeneration in CA1 in the 90-min CCI+HS group. Our data suggest a critical time window for exacerbation of neuronal death by HS after CCI and may have implications for blast injury victims in austere environments where definitive management is delayed.

Blast injuries

Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air-tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications-especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.

Blast Lung Injury

Current trends in global terrorism mandate that emergency medical services, emergency medicine and other acute care clinicians have a basic understanding of the physics of explosions, the types of injuries that can result from an explosion, and current management for patients injured by explosions. High-order explosive detonations result in near instantaneous transformation of the explosive material into a highly pressurized gas, releasing energy at supersonic speeds. This results in the formation of a blast wave that travels out from the epicenter of the blast. Primary blast injuries are characterized by anatomical and physiological changes from the force generated by the blast wave impacting the body's surface, and affect primarily gas-containing structures (lungs, gastrointestinal tract, ears). "Blast lung" is a clinical diagnosis and is characterized as respiratory difficulty and hypoxia without obvious external injury to the chest. It may be complicated by pneumothoraces and air emboli and may be associated with multiple other injuries. Patients may present with a variety of symptoms, including dyspnea, chest pain, cough, and hemoptysis. Physical examination may reveal tachypnea, hypoxia, cyanosis, and decreased breath sounds. Chest radiography, computerized tomography, and arterial blood gases may assist with diagnosis and management; however, they should not delay diagnosis and emergency interventions in the patient exposed to a blast. High flow oxygen, airway management, tube thoracostomy in the setting of pneumothoraces, mechanical ventilation (when required) with permissive hypercapnia, and judicious fluid administration are essential components in the management of blast lung injury.

Injuries from explosions: physics, biophysics, pathology, and required research focus

BACKGROUND

Explosions cause more complex and multiple forms of damage than any other wounding agent, are the leading cause of death on the battlefield, and are often used by terrorists. Because explosion-related injuries are infrequently seen in civilian practice, a broader base of knowledge is needed in the medical community to address acute needs of patients with explosion-related injuries and to broaden mitigation-focused research efforts. The objective of this review is to provide insight into the complexities of explosion-related injury to help more precisely target research efforts to the most pressing areas of need in primary prevention, mitigation, and consequence management.

METHODS

An understanding of the physics and biological consequences of explosions together with data on the nature or severity of contemporary combat injuries provide an empiric basis for a comprehensive and balanced portfolio of explosion-related research. Cited works were identified using MeSH terms as directed by subtopic. Uncited information was drawn from the authors' surgical experience in Iraq, analysis of current combat trauma databases, and explosion-related research.

RESULTS

Data from Iraq and Afghanistan confirm that survivable injuries from explosions are dominated by penetrating fragment wounds, substantiating longstanding and well-known blast physics mechanisms. Keeping this factual basis in mind will allow for appropriate vectoring of funds to increase understanding of this military and public health problem; address specific research and training needs; and improve mitigation strategies, tactics, and techniques for vehicles and personal protective equipment.

CONCLUSIONS

A comprehensive approach to injury from explosions should include not only primary prevention, but also injury mitigation and consequence management. Recalibration of medical research focus will improve management of injuries from explosions, with profound implications in both civilian and military healthcare systems.

[Diagnostic imaging departments' responses to terrorist attempts with multiple victims.]

OBJECTIVES

To analyze whether the radiological management of seriously injured victims from the March 11 terrorist attempt was affected by the large number of victims treated at two hospitals in Madrid. To evaluate the organization for providing imaging services, detect failings, and propose a protocol for diagnostic imaging departments.

MATERIAL AND METHODS

Two hundred and fifty one patients arrived at hospital A and 36 at hospital B. Both centers have emergency imaging areas and protocols for the treatment of patients with multiple trauma. We compared organizational aspects (classification, identification), material resources, human resources, healthcare resources (number and type of examinations), as well as the initial radiological management with the usual protocol and with the recommendations for incidents with multiple victims.

RESULTS

In hospital A, patients' injuries were classified as severe (175) or minor (76); in hospital B, injuries were classified as extremely severe (13), severe (4), or minor (19). Additional staff were assigned to the emergency imaging areas in both hospitals. In hospital A, 62 portable plain-film radiographs, 39 ultrasonographic examinations, 25 cranial CT examinations, 6 cervical CT examinations, 2 chest CT examinations, and 2 abdominopelvic CT examinations were performed. In hospital B, 19 portable plain-film radiographs (74 in total), 9 ultrasonographic examinations, 17 cranial-chest-abdominopelvic CT examinations, 2 cervical CT examinations, 2 orbital CT examinations, and 2 CT examinations of the sinuses were performed.

CONCLUSION

In both hospitals, each victim was managed as if he or she were the only patient. The discrepancies between the two hospitals were due to differences in the usual protocol for multiple trauma patients. In light of the organizational errors discovered, we propose a plan of action based on the identification and progressive activation of material and human resources until sufficient levels are achieved.

Hospital response to a major freeway bridge collapse

BACKGROUND

We describe the hospital system response to the Interstate 35W bridge collapse in Minneapolis into the Mississippi River on August 1, 2007, which resulted in 13 deaths and 127 injuries. Comparative analysis of response activities at the 3 hospitals that received critical or serious casualties is provided.

METHODS

First-hand experiences of hospital physicians, issues identified in after-action reports, injury severity scores, and other relevant patient data were collected from the 3 hospitals that received seriously injured patients, including the closest hospitals to the collapse on each side of the river.

RESULTS/DISCUSSION

Injuries were consistent with major acceleration/deceleration force injuries. The most critical patients arrived first at each hospital, suggesting appropriate prehospital triage. Capacity of the health care system was not overwhelmed and the involved hospitals generally reported an overresponse by staff. Communication and patient tracking problems occurred at all of the hospitals. Situational awareness was limited due to the scope of structural collapse and incomplete information from the scene.

CONCLUSIONS

Hospitals were generally satisfied with their surge capacity and incident management plan activation. Issues such as communications, patient tracking, and staff overreporting that have been identified in past incidents also were problematic in this event. Hospitals will need to address deficiencies and build on successful actions to cope with future, potentially larger incidents.

Injury patterns from major urban terrorist bombings in trains: the Madrid experience

BACKGROUND

Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI.

METHODS

We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS.

RESULTS

The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h.

CONCLUSIONS

Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.

A thoracic mechanism of mild traumatic brain injury due to blast pressure waves

The mechanisms by which blast pressure waves cause mild-to-moderate traumatic brain injury (mTBI) are an open question. Possibilities include acceleration of the head, direct passage of the blast wave via the cranium, and propagation of the blast wave to the brain via a thoracic mechanism. The hypothesis that the blast pressure wave reaches the brain via a thoracic mechanism is considered in light of ballistic and blast pressure wave research. Ballistic pressure waves, caused by penetrating ballistic projectiles or ballistic impacts to body armor, can only reach the brain via an internal mechanism and have been shown to cause cerebral effects. Similar effects have been documented when a blast pressure wave has been applied to the whole body or focused on the thorax in animal models. While vagotomy reduces apnea and bradycardia due to ballistic or blast pressure waves, it does not eliminate neural damage in the brain, suggesting that the pressure wave directly affects the brain cells via a thoracic mechanism. An experiment is proposed which isolates the thoracic mechanism from cranial mechanisms of mTBI due to blast wave exposure. Results have implications for evaluating risk of mTBI due to blast exposure and for developing effective protection.

Overall Asessment of the Response to Terrorist Bombings in Trains, Madrid, 11 March 2004

OBJECTIVES

To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times.

MATERIALS AND METHODS

Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15.

RESULTS

Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic.

CONCLUSION

There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.

Advanced trauma life support, 8th edition, the evidence for change

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Clinical review: the role of the intensive care physician in mass casualty incidents: planning, organisation, and leadership

There is a long-standing, broad assumption that hospitals will ably receive and efficiently provide comprehensive care to victims following a mass casualty event. Unfortunately, the majority of medical major incident plans are insufficiently focused on strategies and procedures that extend beyond the pre-hospital and early-hospital phases of care. Recent events underscore two important lessons: (a) the role of intensive care specialists extends well beyond the intensive care unit during such events, and (b) non-intensive care hospital personnel must have the ability to provide basic critical care. The bombing of the London transport network, while highlighting some good practices in our major incident planning, also exposed weaknesses already described by others. Whilst this paper uses the events of the 7 July 2005 as its point of reference, the lessons learned and the changes incorporated in our planning have generic applications to mass casualty events. In the UK, the Department of Health convened an expert symposium in June 2007 to identify lessons learned from 7 July 2005 and disseminate them for the benefit of the wider medical community. The experiences of clinicians from critical care units in London made a large contribution to this process and are discussed in this paper.

Blast Injury in a Civilian Trauma Setting is Associated with a Delay in Diagnosis of Traumatic Brain Injury

High-pressure waves (blast) account for the majority of combat injuries and are becoming increasingly common in terrorist attacks. To our knowledge, there are no data evaluating the epidemiology of blast injury in a domestic nonterrorist setting. Data were analyzed retrospectively on patients admitted with any type of blast injury over a 10-year period at a busy urban trauma center. Injuries were classified by etiology of explosion and anatomical location. Eighty-nine cases of blast injury were identified in 57,392 patients (0.2%) treated over the study period. The majority of patients were male (78%) with a mean age of 40 ± 17 years. The mean Injury Severity Score was 13 ± 11 with an admission Trauma and Injury Severity Score of 0.9 ± 0.2 and Revised Trauma Score of 7.5 ± 0.8. The mean intensive care unit and hospital length of stay was 2 ± 7 days and 4.6 ± 10 days, respectively, with an overall mortality rate of 4.5 per cent. Private dwelling explosion [n = 31 (35%)] was the most common etiology followed by industrial pressure blast [n = 20 (22%)], industrial gas explosion [n = 16 (18%)], military training-related explosion [n = 15 (17%)], home explosive device [n = 8 (9%)], and fireworks explosion [n = 1 (1%)]. Maxillofacial injuries were the most common injury (n = 78) followed by upper extremity orthopedic (n = 29), head injury (n = 32), abdominal (n = 30), lower extremity orthopedic (n = 29), and thoracic (n = 19). The majority of patients with head injury [28 of 32 (88%)] presented with a Glasgow Coma Scale score of 15. CT scans on admission were initially positive for brain injury in 14 of 28 patients (50%). Seven patients (25%) who did not have a CT scan on admission had a CT performed later in their hospital course as a result of mental status change and were positive for traumatic brain injury (TBI). Three patients (11%) had a negative admission CT with a subsequently positive CT for TBI over the next 48 hours. The remaining four patients (14%) were diagnosed with skull fractures. All patients (n = 4) with an admission Glasgow Coma Scale score of less than 8 died from diffuse axonal injury. Blast injury is a complicated disease process, which may evolve over time, particularly with TBI. The missed injury rate for TBI in patients with a Glasgow Coma Scale score of 15 was 36 per cent. More studies are needed in the area of blast injury to better understand this disease process.

Clinical review: mass casualty triage--pandemic influenza and critical care

Worst case scenarios for pandemic influenza planning in the US involve over 700,000 patients requiring mechanical ventilation. UK planning predicts a 231% occupancy of current level 3 (intensive care unit) bed capacity. Critical care planners need to recognise that mortality is likely to be high and the risk to healthcare workers significant. Contingency planning should, therefore, be multi-faceted, involving a robust health command structure, the facility to expand critical care provision in terms of space, equipment and staff and cohorting of affected patients in the early stages. It should also be recognised that despite this expansion of critical care, demand will exceed supply and a process for triage needs to be developed that is valid, reproducible, transparent and consistent with distributive justice. We advocate the development and validation of physiological scores for use as a triage tool, coupled with candid public discussion of the process.

Management and analysis of out-of-hospital health-related responses to simultaneous railway explosions in Madrid, Spain

OBJECTIVES

On 11 March 2004, 10 simultaneous explosions at four different locations of the rail network in Madrid caused 198 deaths and 2312 persons were injured. The aim of this manuscript is to describe the prehospital health-related activities from the Emergency Medical Service of Madrid and to analyze the responses, the major conclusions, and the lessons learned.

METHODS

Three meetings were held with professionals from the Emergency Medical Service of Madrid who were involved in the catastrophe. Two experts in quality management chaired the meetings. Detailed data were gathered on what occurred at the sites following the explosions. Additional data were gathered from professionals from the Coordination Service of Urgencies and from those who assisted relatives and friends of victims in the days following the bombings. All of the data were collected and were included in the final report.

RESULTS

We describe the activities carried out by the Coordination Service of Urgencies at each site immediately after the explosions and during the 11 days following the catastrophe. The successful performances and those that need to be improved at the four sites and elsewhere are detailed.

CONCLUSIONS

The main reasons for the 'positive responses' are the number of resources that acted, the professional abilities, and the flexibility of the services. The 'areas to be improved' are communications, the establishment of the top of the command at each site, and the organization of supplies for catastrophic assistance. From the analysis, we describe the main lessons learned and we present proposals for improvement, should a future catastrophe occur.

Ocular injuries in survivors of improvised explosive devices (IED) in commuter trains

BACKGROUND

Ocular injuries are common in survivors of terror incidents that involve the use of explosive materials. These explosives are commonly of a High Explosive type (HE) and may be fashioned into improvised explosive devices (IED) that incorporate additional materials to maximise trauma and injuries. Serial IED explosions have occurred in commuter trains in several cities including London and Madrid but data on ocular injuries is limited. We report the ocular injuries of the survivors of a series of IED explosions in crowded commuter trains.

METHODS

28 patients (56 eyes, 28 male, ages ranging from 22 to 52 years (mean 35.27 years) were screened in the triage area or the Intensive Care Unit (ICU). Testing included bedside visual acuity testing, torchlight examination of the anterior segment and dilated (or if necessary, undilated) fundus examination. Selected patients underwent B-scan examination, magnetic resonance imaging of the brain, orbits and the optic nerves or visual evoked potential assessment. The injuries, investigations and procedures were entered into the patient's case sheet as well as into a standardised format suggested by the Indian eye injury registry (IER).

RESULTS

16 of 28 patients (57.1%) had ocular injuries whereas 12 (42.8%) were found to be normal. Injuries were seen unilaterally in 10 patients and bilaterally in six yielding a total of 22 injured eyes. The common injuries were periorbital haemorrhages (09 eyes, 40%); first or second degree burns to the upper or lower lids (seen in 07 eyes, 31.8 %) and corneal injuries (seen in 08 eyes, 36.3%). Open globe injuries were seen in two eyes of two patients (09%). One patient (4.5%) had a traumatic optic neuropathy.

CONCLUSION

Ophthalmologists and traumatologists should be aware of these patterns of ocular injuries. Protocols need to include the screening of large numbers of patients in a short time, diagnostic tests (B scan, visual evoked potential (VEP) etc) and early surgery preferably at the initial triage itself as most of the serious injuries in our studies had been missed or not treated at an initial assessment.

Civilian hospital response to a mass casualty event: the role of the intensive care unit

BACKGROUND

We studied the response of the Shaare Zedek Medical Center (SZMC) in Jerusalem, Israel, to terrorist multiple- or mass-casualty events (TMCEs) that occurred between 1983 and 2004, to document the role of the intensive care unit (ICU) in this response.

METHODS

The SZMC Disaster Plan was reviewed in detail. Hospital and ICU records were retrospectively reviewed for all patients presenting to SZMC between 1983 and 2004 after a TMCE. Data were coded for age, sex, injuries, length of stay, and mortality.

RESULTS

Eight hundred seventy-five patients presented to SZMC after 31 TMCEs. The number of patients presenting ranged from 1 to 84 with an average of 28 patients per TMCE. Forty-one (4.7%) of the patients were admitted to the ICU. The age of the ICU patients ranged from 4 to 80 with an average of 30.9 years. Twenty-nine (70%) of the patients had blast lung injury, 3 (7%) had intestinal blast injury, and 30 (73%) had ruptured tympanic membranes. Forty-two surgical procedures were performed in 23 patients. Thirty (73%) patients required mechanical ventilation. One patient (2.4%) died of multiple organ failure caused by a delay in diagnosis of intestinal blast injury.

CONCLUSION

Of the patients presenting to SZMC after TMCE, 4.7% required ICU care. Seventy-three percent of the ICU patients required mechanical ventilation. The ICU plays a critical role in the SZMC response to TMCEs.

Mass casualty respiratory failure

PURPOSE OF REVIEW

The severe acute respiratory syndrome epidemic of 2002-2003, recent natural catastrophes, burgeoning concerns regarding intentional catastrophes, and the looming threat of an influenza pandemic have focused attention on large-scale, survivable respiratory failure. In this article, we review appropriate medical equipment, treatment space, and strategies to augment health professional staff in response to a massive increase in need for sustained critical care.

RECENT FINDINGS

There is insufficient modern healthcare experience with mass casualty respiratory failure to develop evidence-based preparedness efforts. For this reason, initial efforts to augment critical care capability in response to disasters have relied on extrapolation from the routine critical care knowledge base, military medicine, critical care transport, and expert opinion. We review recently published documents on augmenting supplies of positive pressure ventilation equipment, ongoing projects for increasing health professional staff, and infection control issues during epidemics.

SUMMARY

Mass casualty respiratory failure remains a largely unstudied field, but we believe informed decisions about equipment stockpiling and use, the development of creative operational concepts to increase staffing, and the careful implementation of rational infection control practices can lay a foundation for an appropriate response until additional data become available.

Acute blindness in a dog caused by an explosive blast

A 3-year-old, intact male, mixed breed dog was presented with a complaint of acute blindness. Ten days previously, the area where the dog was walking came under a rocket attack, and a rocket landed and exploded 300 meters away from the dog. Physical examination was unremarkable. Ophthalmoscopic examination revealed posterior segment fibrin clots and extensive vitreal hemorrhage in the right eye. A total retinal detachment (360 degrees retinal dialysis) with no evidence of hemorrhage was noted in the left eye. There was no sign of any penetrating ocular trauma, and it was assumed that the posterior segment findings were primary injuries caused by the blast wave itself. Following anti-inflammatory treatment, partial vision was restored in the right eye. Surgical re-attachment of the retina was discussed and declined by the owner. This report describes, for the first time, vitreal hemorrhage and retinal detachment as the sole injuries caused by an explosive blast wave.

[Estimation of surgical treatment capacity for managing mass casualty incidents based on time needed for life-saving emergency operations]

The surgical treatment capacity of a hospital constitutes a significant restriction in the capability to deal with critically injured patients from multiple or mass casualty incidents (MCI). With regard to the time needed for life-saving operative interventions there are no basic reference values available in the literature, which can aid in detailed planning for management of mass casualty incidents. The data of 20,815 trauma patients, recorded in the trauma registry hosted by the German Association for Trauma Surgery DGU, were analyzed to extract the median duration of life-saving surgical interventions carried out in an operating theatre. Inclusion criteria were an ISS > or = 16 and the performance of relevant ICPM coded procedures within 6 h after trauma room admission. Orthopedic procedures as well as the placement of ICP catheters and chest tubes or performance of laparoscopies were not included. Complete data sets with the required variables were available from 9,988 trauma patients with an ISS > or = 16, and included 7,907 interventions that took place within 6 h after hospital admission. From among 1,228 patients 1,793 operations could be identified as relevant life-saving emergency operations. Acute injury to the abdomen was the major cause accounting for 54.1% of all emergency surgical procedures with a median intervention duration of 137 min followed by head injuries accounting for 26.3% with a median duration of 110 min. Interventions in the pelvis amounted to 11.5% taking an average of 136 min, 5.0% were in the thorax requiring 91 min and 3.1% major amputations with 142 min. The average cut to suture time for all emergency surgical interventions was 130 min. A prerequisite for estimating the surgical operation capacity for critically injured patients of an MCI is the number of OR teams available during and outside of the normal working hours of the hospital. The average operation time of 130 min calculated from investigation of 1,793 emergency life-saving surgical procedures provides a realistic guideline. Used in combination with the number of available OR teams the prospective treatment capacity can be estimated and projected into an actual incident admission capacity. The identification and numerical value of such significant variables are the basis for operations research and realistic planning in emergency and disaster medicine.

Cerebrovascular resuscitation after polytrauma and fluid restriction

BACKGROUND

There are few reproducible models of blast injury, so it is difficult to evaluate new or existing therapies. We developed a clinically relevant polytrauma model to test the hypothesis that cerebrovascular resuscitation is optimized when intravenous fluid is restricted.

STUDY DESIGN

Anesthetized swine (42+/-5 kg, n=35) received blasts to the head and bilateral chests with captive bolt guns, followed by hypoventilation (4 breaths/min; FiO(2)=0.21). After 30 minutes, resuscitation was divided into phases to simulate typical prehospital, emergency room, and ICU care. For 30 to 45 minutes, group 1, the control group (n=5), received 1L of normal saline (NS). For 45 to 120 minutes, additional NS was titrated to mean arterial pressure (MAP) > 60 mmHg. After 120 minutes, mannitol (1g/kg) and phenylephrine were administered to manage cerebral perfusion pressure (CPP) > 70 mmHg, plus additional NS was given to maintain central venous pressure (CVP) > 12 mmHg. In group 2 (n=5), MAP and CPP targets were the same, but the CVP target was>8 mmHg. Group 3 (n=5) received 1 L of NS followed only by CPP management. Group 4 (n=5) received Hextend (Abbott Laboratories), instead of NS, to the same MAP and CPP targets as group 2.

RESULTS

Polytrauma caused 13 deaths in the 35 animals. In survivors, at 30 minutes, MAP was 60 to 65 mmHg, heart rate was >100 beats/min, PaO(2) was < 50 mmHg, and lactate was>5 mmol/L. In two experiments, no fluid or pressor was administered; the tachycardia and hypotension persisted. The first liter of intravenous fluid partially corrected these variables, and also partially corrected mixed venous O(2), gastric and portal venous O(2), cardiac output, renal blood flow, and urine output. Additional NS (total of 36+/-1 mL/kg/h and 17+/-6 mL/kg/h, in groups 1 and 2, respectively) correlated with increased intracranial pressure to 38+/-4 mmHg (group 1) and 26+/-4 mmHg (group 2) versus 22+/-4 mmHg in group 3 (who received 5+/-1 mL/kg/h). CPP was maintained only after mannitol and phenylephrine. By 5 hours, brain tissue PO(2) was>20 mmHg in groups 1 and 2, but only 6+/-1 mmHg in group 3. In contrast, minimal Hextend (6+/-3 mL/kg/h) was needed; the corrections in MAP and CPP were immediate and sustained, intracranial pressure was lower (14+/-2 mmHg), and brain tissue PO(2) was> 20 mmHg. Neuropathologic changes were consistent with traumatic brain injury, but there were no statistically significant differences between groups.

CONCLUSIONS

After polytrauma and resuscitation to standard MAP and CPP targets with mannitol and pressor therapy, we concluded that intracranial hypertension was attenuated and brain oxygenation was maintained with intravenous fluid restriction; cerebrovascular resuscitation was optimized with Hextend versus NS; and longer term studies are needed to determine neuropathologic consequences.