Long-term temperature-related morbidity after brain damage: survivor-reported experiences

Environmental Hyperthermia in Prehospital Patients with Major Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) results in an estimated 1.7 million emergency department visits each year in the United States. These injuries frequently occur outside, leaving injured individuals exposed to environmental temperature extremes before they are transported to a hospital.

OBJECTIVE

Evaluate the existing literature for evidence that exposure to high temperatures immediately after TBI could result in elevated body temperatures (EBTs), and whether or not EBTs affect patient outcomes.

DISCUSSION

It has been clear since the early 1980s that after brain injury, exposure to environmental temperatures can cause hypothermia, and that this represents a significant contributor to increased morbidity and mortality. Less is known about elevated body temperature. Early evidence from the Iraq and Afghanistan wars indicated that exposure to elevated environmental temperatures in the prehospital setting may result in significant EBTs, however, it is unclear what impact these EBTs might have on outcomes in TBI patients. In the hospital, EBT, or neurogenic fever, is thought to be due to the acute-phase reaction that follows critical injury, and these high body temperatures are associated with poor outcomes after TBI.

CONCLUSION

Hospital data suggest that EBTs are associated with poor outcomes, and some preliminary reports suggest that early EBTs are common after TBI in the prehospital setting. However, it remains unclear whether patients with TBI have an increased risk of EBTs after exposure to high environmental temperatures, or if this very early "hyperthermia" might cause secondary injury after TBI.

Brain-systemic temperature gradient is temperature-dependent in children with severe traumatic brain injury

OBJECTIVES

To understand the gradient between rectal and brain temperature in children after severe traumatic brain injury. We hypothesized that the rectal temperature and brain temperature gradient will be influenced by the child's body surface area and that this relationship will persist over physiologic temperature ranges.

DESIGN

Retrospective review of a prospectively collected pediatric neurotrauma registry.

SETTING

Academic, university-based pediatric neurotrauma program.

PATIENTS

Consecutive children (n = 40) with severe traumatic brain injury (Glasgow coma scale of <8) who underwent brain temperature monitoring (July 2003 to December 2008) were studied after informed consent was obtained. A subset of children (n = 24) were concurrently enrolled in a randomized, controlled clinical trial of early-moderate hypothermia for neuroprotection.

INTERVENTIONS

Data extraction of multiple clinical variables, including demographic data, body surface area, and rectal and brain temperature at recorded at hourly intervals.

MEASUREMENTS AND MAIN RESULTS

Paired brain and rectal temperature measurements (in degrees Celsius, n = 4369) were collected hourly and compared by using Pearson correlations. Patients were stratified according to body surface area (<1.0 m, 1.0-1.99 m, 2.0-2.99 m, and >3.0 m) and based on brain temperature (≤34.0, 34.1-36.0; 36.1-38, ≥38.1). Body surface area and brain temperature were compared between groups by using Pearson correlations with correction for repeated measures. Mean brain temperature-rectal temperature difference was calculated for stratified brain temperature ranges. Overall, brain and rectal temperatures were highly correlated (r = .86, p < .001). During brain hyperthermia, brain temperature-rectal temperature was similar to that reported in previous studies with brain temperature higher than rectal temperature (1.75 ± 0.4; r = .54). Surprisingly, this relationship was reversed during brain hypothermia (brain temperature-rectal temperature = -1.87 ± 0.8; r = .37), indicating a reversal of the brain-systemic temperature gradient. When stratified for body surface area, the correlation between rectal temperature and brain temperature remained strong (r = .78, 0.91, 0.79 and 0.95, respectively, p < .001). However, the correlation between brain temperature and rectal temperature was substantially decreased when stratified for brain temperature (r = .37, 0.58, 0.48, 0.54, p < .001). In particular, during moderate brain hypothermia (brain temperature ≤34), the correlation between brain temperature and rectal temperature was weakest, indicating the greatest variability during this condition which is often targeted for therapeutic trials.

CONCLUSIONS

Brain temperature and rectal temperature are generally well-correlated in children with traumatic brain injury. This relationship is different at the extremes of the physiologic temperature range, with the temperature gradient reversed during brain hypothermia and hyperthermia. Given that studies showing neuroprotection from hypothermia in animal models of brain injury generally target brain temperature, our data suggest the possibility that, if brain temperature were the therapeutic target in clinical trials, this would result in somewhat higher systemic temperature and potentially fewer side effects. This relationship may be exploited in future clinical trials to maintain brain hypothermia (for neurologic protection) at slightly higher systemic temperatures (and potentially fewer systemic side effects).