Traumatic Brain Injuries after Mass-Casualty Incidents: Lessons from the 11 September 2001 World Trade Center Attacks

Preclinical characterization of macrophage-adhering gadolinium micropatches for MRI contrast after traumatic brain injury in pigs

The choroid plexus (ChP) of the brain plays a central role in orchestrating the recruitment of peripheral leukocytes into the central nervous system (CNS) through the blood-cerebrospinal fluid (BCSF) barrier in pathological conditions, thus offering a unique niche to diagnose CNS disorders. We explored whether magnetic resonance imaging of the ChP could be optimized for mild traumatic brain injury (mTBI). mTBI induces subtle, yet influential, changes in the brain and is currently severely underdiagnosed. We hypothesized that mTBI induces sufficient alterations in the ChP to cause infiltration of circulating leukocytes through the BCSF barrier and developed macrophage-adhering gadolinium [Gd(III)]-loaded anisotropic micropatches (GLAMs), specifically designed to image infiltrating immune cells. GLAMs are hydrogel-based discoidal microparticles that adhere to macrophages without phagocytosis. We present a fabrication process to prepare GLAMs at scale and demonstrate their loading with Gd(III) at high relaxivities, a key indicator of their effectiveness in enhancing image contrast and clarity in medical imaging. In vitro experiments with primary murine and porcine macrophages demonstrated that GLAMs adhere to macrophages also under shear stress and did not affect macrophage viability or functions. Studies in a porcine mTBI model confirmed that intravenously administered macrophage-adhering GLAMs provide a differential signal in the ChP and lateral ventricles at Gd(III) doses 500- to 1000-fold lower than those used in the current clinical standard Gadavist. Under the same mTBI conditions, Gadavist did not offer a differential signal at clinically used doses. Our results suggest that macrophage-adhering GLAMs could facilitate mTBI diagnosis.

Epidemiologic Investigation of Injuries Associated With the 2013 Fertilizer Plant Explosion in West, Texas

OBJECTIVE

On April 17, 2013, a fire and subsequent explosion occurred at the West Fertilizer Company plant in West, Texas, and caused extensive damage to the adjacent neighborhood. This investigation described the fatal and nonfatal injuries caused by the explosion.

METHODS

Persons injured by the fertilizer plant explosion were identified through death certificates, medical examination reports, medical records, and survivor interviews. Data on patient characteristics, type of injury, and location of injury were collected.

RESULTS

Medical record review indicated that 252 individuals sought medical care for nonfatal injuries directly related to the explosion immediately after the explosion. Fifteen patients died of injuries sustained by the blast. Almost one-quarter of patients were admitted for treatment of injuries. Injuries sustained in the explosion included abrasions/contusions, lacerations/penetrating trauma, traumatic brain injuries/concussions, tinnitus/hearing problems, eye injuries, and inhalational injuries. Patients located closer to the explosion were more likely to be admitted to the hospital for treatment of injuries than were those who were located further away.

CONCLUSION

Explosions of this magnitude are rare, but can inflict severe damage to a community and its residents. This investigation could be a useful planning resource for other communities, public health agencies, first responders, and medical facilities. (Disaster Med Public Health Preparedness. 2016;10:583-590).

Pathophysiology of battlefield associated traumatic brain injury

As more data is accumulated from Operation Iraqi Freedom and Operation Enduring Freedom (OEF in Afghanistan), it is becoming increasing evident that traumatic brain injury (TBI) is a serious and highly prevalent battle related injury. Although traditional TBIs such as closed head and penetrating occur in the modern battle space, the most common cause of modern battle related TBI is exposure to explosive blast. Many believe that explosive blast TBI is unique from the other forms of TBI. This is because the physical forces responsible for explosive blast TBI are different than those for closed head TBI and penetrating TBI. The unique force associated with explosive blast is the blast shock pressure wave. This shock wave occurs over a very short period, milliseconds, and has a specific profile known as the Freidlander curve. This pressure-time curve is characterized by an initial very rapid up-rise followed by a longer decay that reaches a negative inflection point before returning to baseline. This is important as the effect of this shock pressure on brain parenchyma is distinct. The diffuse interaction of the pressure wave with the brain leads to a complex cascade of events that affects neurons, axons, glia cells, and vasculature. It is only by properly studying this disease will meaningful therapies be realized.

Managing traumatic brain injury secondary to explosions

Explosions and bombings are the most common deliberate cause of disasters with large numbers of casualties. Despite this fact, disaster medical response training has traditionally focused on the management of injuries following natural disasters and terrorist attacks with biological, chemical, and nuclear agents. The following article is a clinical primer for physicians regarding traumatic brain injury (TBI) caused by explosions and bombings. The history, physics, and treatment of TBI are outlined.

Recurrent medical response problems during five recent disasters in the Netherlands

OBJECTIVES

The aim of this qualitative, retrospective review is to identify and analyze the occurrence of recurrent problems in 20 processes that cover all relevant aspects of disaster health during the response phase. Consequently, an attempt is made to determine if there are generic themes of coherences in these problems.

METHODS

Eight after-action reports of five consecutive disasters in the Netherlands, between 1996 and 2005, were integrally analyzed in a structured manner. The analysis was confined to processes from the start of the event up to and including the initial stages of hospital admission.

RESULTS

Problems during all five disasters arose with eight processes: (1) submission of information to the ambulance dispatch center (ADC); (2) provision of information by the ADC to disaster response personnel; (3) scaling-up of prehospital response; (4) communication; (5) logistics; (6) registration; (7) multidisciplinary cooperation; and (8) preparation. Three generic themes of coherence were identified: (1) processes in which exchange of information among medical personal plays a major role are more likely to be affected by problems than processes in which this is less relevant; (2) processes in which disaster circumstances differ from day-to-day health care, or do not figure in day-to-day health care, are more likely to give rise to problems than processes that remain essentially similar; and (3) the existence of a protocol or disaster plan governing a process does not prevent problems.

CONCLUSIONS

The method used enables a systematic analysis of the problems in health-related processes following five consecutive disasters. The analysis confirms that the majority of problems are repeated. The identified themes of coherences are in agreement with case reports and expert opinions. They are now supported with a higher level of evidence.

Prehospital management of traumatic brain injury

The aim of this study was to review the current protocols of prehospital practice and their impact on outcome in the management of traumatic brain injury. A literature review of the National Library of Medicine encompassing the years 1980 to May 2008 was performed. The primary impact of a head injury sets in motion a cascade of secondary events that can worsen neurological injury and outcome. The goals of care during prehospital triage, stabilization, and transport are to recognize life-threatening raised intracranial pressure and to circumvent cerebral herniation. In that process, prevention of secondary injury and secondary insults is a major determinant of both short- and longterm outcome. Management of brain oxygenation, blood pressure, cerebral perfusion pressure, and raised intracranial pressure in the prehospital setting are discussed. Patient outcomes are dependent upon an organized trauma response system. Dispatch and transport timing, field stabilization, modes of transport, and destination levels of care are addressed. In addition, special considerations for mass casualty and disaster planning are outlined and recommendations are made regarding early response efforts and the ethical impact of aggressive prehospital resuscitation. The most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of prehospital care is a major determinant of long-term outcome for patients with traumatic brain injury.

International emergency medicine: a review of the literature from 2007

The subspecialty of international emergency medicine (IEM) continues to grow within the United States, just as the specialty of emergency medicine (EM) continues to spread to both developed and developing countries around the world. One of the greatest obstacles, however, faced by IEM researchers and practitioners alike, remains the lack of a high-quality, consolidated, and easily accessible evidence-base of literature. In response to this perceived need, members of the Emergency Medicine Resident Association (EMRA) International Emergency Medicine Committee, in conjunction with members of the Society for Academic Emergency Medicine (SAEM) International Health Interest Group, have embarked on the task of creating a recurring review of IEM literature. This publication represents the third annual review, covering the top 30 IEM research articles published in 2007. Articles were selected for the review according to explicit, predetermined criteria that included both methodologic quality and perceived impact of the research. It is hoped that this annual review will act as a forum for disseminating best practices, while also stimulating further research in the field of IEM.

Improving identification of traumatic brain injury after nonmilitary bomb blasts

OBJECTIVE

To improve identification of traumatic brain injury (TBI) in survivors of nonmilitary bomb blasts during the acute care phase.

METHODS

The Centers for Disease Control and Prevention convened a meeting of experts in TBI, emergency medicine, and disaster response to review the recent literature and make recommendations.

RESULTS

Seven key recommendations were proposed: (1) increase TBI awareness among medical professionals; (2) encourage use of standard definitions and consistent terminology; (3) improve screening methods for TBI in the acute care setting; (4) clarify the distinction between TBI and acute stress disorder; (5) encourage routine screening of hospitalized trauma patients for TBI; (6) improve identification of nonhospitalized TBI patients; and (7) integrate the appropriate level of TBI identification into all-hazards mass casualty preparedness.

CONCLUSIONS

By adopting these recommendations, the United States could be better prepared to identify and respond to TBI following future bombing events.