Guidelines for prehospital management of traumatic brain injury

Guidelines for Prehospital Management of Traumatic Brain Injury 3rd Edition: Executive Summary

Prehospital care markedly influences outcome from traumatic brain injury, yet it remains highly variable. The Brain Trauma Foundation's guidelines informing prehospital care, first published in 2002, have sought to identify and disseminate best practices. Many of its recommendations relate to the management of airway, breathing and circulation, and infrastructure for this care. Compliance with the second edition of these guidelines has been associated with significantly improved survival. A working group developed evidence-based recommendations informing assessment, treatment, and transport decision-making relevant to the prehospital care of brain injured patients. A literature search spanning May 2005 to January 2022 supplemented data contained in the 2nd edition. Identified studies were assessed for quality and used to inform evidence-based recommendations. A total of 122 published articles formed the evidentiary base for this guideline update including 5 providing Class I evidence, 35 providing Class II evidence, and 98 providing Class III evidence for the various topics. Forty evidence-based recommendations were generated, 30 of which were strong and 10 of which were weak. In many cases, new evidence allowed guidelines from the 2nd edition to be strengthened. Development of guidelines on some new topics was possible including the prehospital administration of tranexamic acid. A management algorithm is also presented. These guidelines help to identify best practices for prehospital traumatic brain injury care, and they also identify gaps in knowledge which we hope will be addressed before the next edition.

Alcohol intake before injury and functional and survival outcomes after traumatic brain injury: Pan-Asian trauma outcomes study (PATOS)

There are controversies about the effects of alcohol intake shortly before injury on prognosis of traumatic brain injury (TBI) patients. We investigated the association between alcohol intake and functional/survival outcomes in TBI patients, and whether this effect varied according to age and sex. This was a prospective international multicenter cohort study using the Pan-Asian trauma outcomes study registry in Asian-Pacific countries, conducted on adult patients with TBI who visited participating hospitals. The main exposure variable was alcohol intake before injury, and the main outcomes were poor functional recovery (modified Rankin Scale score, 4-6) and in-hospital mortality. Multivariable logistic regression analyses were conducted to estimate the effects of alcohol intake on study outcomes. Interaction analysis between alcohol intake and age/sex were also performed. Among the study population of 12,451, 3263 (26.2%) patients consumed alcohol before injury. In multivariable logistic regression analysis, alcohol intake was associated with lower odds for poor functional recovery [4.4% vs 6.6%, a odds ratio (95% confidence interval): 0.68 (0.56-0.83)] and in-hospital mortality (1.9% vs 3.1%, 0.64 [0.48-0.86]). The alcohol intake had interaction effects with sex for poor functional recovery: 0.59 (0.45-0.75) for male and 0.94 (0.60-1.49) for female (P for-interaction < .01), whereas there were no interaction between alcohol intake and age. In TBI patients, alcohol intake before injury was associated with lower odds of poor functional recovery and in-hospital mortality, and these effects were maintained in the male group in the interaction analyses.

The reverse shock index multiplied by Glasgow coma scale (rSIG) is predictive of mortality in trauma patients according to age

OBJECTIVE

The role of reverse shock index multiplied Glasgow coma scale (rSIG) in patients post-trauma with traumatic brain injury (TBI) has not yet been defined well. Our study aimed to investigate the predictive performance of rSIG according to age group.

METHOD

This is a prospective multi-national and multi-center cohort study using Pan-Asian Trauma Outcome Study registry in Asian-Pacific, conducted on patients post-trauma who visited participating hospitals. The main exposure was low rSIG measured at emergency department. The main outcome was in-hospital mortality. We performed multilevel logistic regression analysis to estimate the association low rSIG and study outcomes. Interaction analysis between rSIG and age group were also conducted.

RESULTS

Low rSIG was significantly associated with an increase in in-hospital mortality in patients post-trauma with and without TBI (aOR (95% CI): 1.49 (1.04-2.13) and 1.71 (1.16-2.53), respectively). The ORs for in-hospital mortality differed according to the age group in patients post-trauma with TBI (1.72 (1.44-1.94) for the young group and 1.13 (1.07-1.52) for the old group; p < 0.05).

CONCLUSION

Low rSIG is associated with an increase in in-hospital mortality in adult patients post-trauma. However, in patients with TBI, the prediction of mortality is significantly better in younger patient group.

Effect of Fever on the Clinical Outcomes of Traumatic Brain Injury by Age

Background and objective: Fever is a common symptom in patients with traumatic brain injury (TBI). However, the effect of fever on the clinical outcomes of patients with TBI is not well characterized. Our study aims to determine the impact of fever on the clinical outcomes of patients with TBI and test the interaction effect of fever on study outcomes according to age group. Materials and methods: Our retrospective study included adult patients with TBI who were transported to a level 1 trauma center by the emergency medical services (EMS) team. The main exposure is fever, defined as a body temperature of 38 °C or above, in the emergency department (ED). The primary outcome was mortality at hospital discharge. We conducted a multivariable logistic regression analysis to estimate the effect sizes of fever on study outcomes. We also conducted an interaction analysis between fever and age group on study outcomes. Results: In multivariable logistic regression analysis, patients with TBI who had fever showed no significant difference in mortality at hospital discharge (aOR, 95% CIs: 1.24 (0.57−3.02)). Fever significantly increased the mortality of elderly patients (>65 years) with TBI (1.39 (1.13−1.50)), whereas there was no significant effect on mortality in younger patients (18−64 years) (0.85 (0.51−1.54)). Conclusions: Fever was associated with mortality only in elderly patients with TBI.

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

BACKGROUND

Patients with moderate and severe traumatic brain injury (TBI) are admitted to general hospitals (GHs) without neurosurgical services, but few studies have addressed the management of these patients. This study aimed to describe these patients, the rate of and reasons for managing patients entirely at the GH, and differences between patients managed entirely at the GH (GH group) and patients transferred to the regional trauma centre (RTC group). We specifically examined the characteristics of elderly patients.

METHODS

Patients with moderate (Glasgow Coma Scale score 9-13) and severe (score ≤ 8) TBIs who were admitted to one of the seven GHs without neurosurgical services in central Norway between 01.10.2004 and 01.10.2014 were retrospectively identified. Demographic, injury-related and outcome data were collected from medical records. Head CT scans were reviewed.

RESULTS

Among 274 patients admitted to GHs, 137 (50%) were in the GH group. The transferral rate was 58% for severe TBI and 40% for moderate TBI. Compared to the RTC group, patients in the GH group were older (median age: 78 years vs. 54 years, p < 0.001), more often had a preinjury disability (50% vs. 39%, p = 0.037), and more often had moderate TBI (52% vs. 35%, p = 0.005). The six-month case fatality rate was low (8%) in the GH group when transferral was considered unnecessary due to a low risk of further deterioration and high (90%, median age: 87 years) when neurosurgical intervention was considered nonbeneficial. Only 16% of patients ≥ 80 years old were transferred to the RTC. For this age group, the in-hospital case fatality rate was 67% in the GH group and 36% in the RTC group and 84% and 73%, respectively, at 6 months.

CONCLUSIONS

Half of the patients were managed entirely at a GH, and these were mainly patients considered to have a low risk of further deterioration, patients with moderate TBI, and elderly patients. Less than two of ten patients ≥ 80 years old were transferred, and survival was poor regardless of the transferral status.

Emergent craniotomy in rural and regional settings: recommendations from a tertiary neurosurgery unit: diagnosis and surgical decision-making

Largely attributed to the tyranny of distance, timely transfer of patients with major traumatic brain injuries (TBI) from rural or regional hospitals to metropolitan trauma centres is not always feasible. This has warranted emergent craniotomies to be undertaken by non-neurosurgeons at their local hospitals with previous acceptable results reported in regional Australia. Our institution endorses this ongoing potentially life-saving practice when necessary and emphasize the need for neurosurgical units to provide ongoing TBI education to peripheral hospitals. In this first of a two-part narrative review, the authors describe the recommended diagnostic pathway for patients with a suspected TBI presenting to rural or regional hospitals and discuss local surgical management options in the presence or absence of a CT scanner.

Evolution and Impact of the Brain Trauma Foundation Guidelines

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Head Injury were the first clinical practice guidelines published by any surgical specialty. These guidelines have earned a reputation for rigor and have been widely adopted around the world. Implementation of these guidelines has been associated with a 50% reduction in mortality and reduced costs of patient care. Over their 25-yr history the traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards. Here, we discuss the history and accomplishments of BTF guidelines for TBI as well as their limitations. We also discuss planned changes to future TBI guidelines intended to increase their utility and positive impact in an evolving medical landscape. Perhaps the greatest limitation of TBI guidelines now is the lack of high-quality clinical research as well as novel diagnostics and treatments with which to generate substantially new recommendations.

Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study

Background

Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients.

Methods

Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively.

Results

A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90).

Conclusions

Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00930-1.

Intake of NOAC is associated with hematoma expansion of intracerebral hematomas after traumatic brain injury

PURPOSE

Novel oral anticoagulants are increasingly replacing vitamin K antagonists in the prophylaxis of thromboembolism as they are associated with lower incidence of spontaneous intracerebral hematomas and they do not require drug level monitoring. However, management dilemmas are apparent in patients on novel oral anticoagulants who have developed intracerebral hematomas after traumatic brain injury, since clinical experience with their reversal strategies is limited.

METHODS

We retrospectively studied 90 patients with traumatic intracerebral hematomas undergoing treatment at the surgical intensive care unit of the BG University Clinic Bergmannsheil in Bochum between 2015 and 2018. We analyzed potential prognostic factors for their radiological (expansion of intracerebral hematoma) and clinical (patients' outcome) course, in particular the role of novel oral anticoagulants.

RESULTS

71.1% of patients were male; mean age was 67.3 years. Hematoma's expansion occurred in 35.9% of our patients, whereas 62.2% of our cohort showed a favorable outcome, defined as Glasgow Outcome Scale 4 and 5. Intake of novel oral anticoagulants was associated with a higher rate of hematoma's expansion compared to patients on vitamin K antagonists (p = 0.05) or to patients with normal coagulation status (p = 0.002). A younger age (p < 0.001) was identified as the sole independent prognostic factor for a more favorable outcome, after excluding our cases, who underwent a cardiopulmonary resuscitation.

CONCLUSIONS

Our data showed a higher rate of hematoma's expansion in patients with traumatic intracerebral hematomas on novel oral anticoagulants vs. vitamin K antagonists and recommend the consideration of prophylactic reversal of the novel oral anticoagulants at admission. Larger prospective trials are warranted to conclude whether the current specific reversal protocols are safe and effective.

[Quality standards in treatment and rehabilitation of traumatic brain injuries]

The quality standards of the "Deutsche gesetzliche Unfallversicherung" (DGUV) on the treatment of traumatic brain injuries were first published in 2015. They describe the optimal conditions and requirements of acute treatment and in all phases of rehabilitation and aftercare, according to the current state of knowledge. The aim is to enable a life worth living in family, school, occupation and society for as many injuries as possible. The quality standards, as systematic orientation and decision-making aids, should promote the future development of the treatment and rehabilitation of traumatic brain injuries of all grades of severity and guarantee a uniformly high quality of treatment. A special and comprehensive rehabilitative alignment as well as a close networking of medical and occupation-promoting services will be of particular importance for the institutions participating in the rehabilitation of patients with traumatic brain injuries.

Practitioners' opinions on traumatic brain injury care pathways in Finland and France: different organizations, common issues

OBJECTIVE

In traumatic brain injury (TBI), differences in health-care contexts have profound effects on care pathways. Objectives were to compare TBI pathways of care and practitioners' views on quality of care issues in two large European areas: Varsinais-Suomi, Finland and Ile-de-France, France.

METHODS

Thematic analysis of semi-structured interviews was conducted with TBI practitioners (n = 10) from all stages of TBI care. Interviews addressed organization and financing of care, decision-making on care transitions, and perceived issues. The structure-process-outcome model of Donabedian was used to classify findings related to quality of care issues.

RESULTS

Main differences in organization of care pathways for people with TBI were related to financing modalities, number of pathway alternatives, inpatient versus outpatient rehabilitation, and indirect versus direct referrals to rehabilitation. Similar categories of issues were raised in the two settings. Issues in structures involved availability of services, financial access, and heterogeneity of expertise. Issues in processes involved diagnosis and follow-up, training regarding cognitive impairments, decision-making for referrals, transition delays, and care pathways of very severely affected patients.

CONCLUSIONS

These findings provide clues to address care pathways in further comparative studies. Determinants of care pathway quality could be classified as direct or indirect, binding or adaptive organizational factors.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.

Prehospital and Intrahospital Temporal Intervals in Patients Requiring Emergent Trauma Craniotomy. A 6-Year Observational Study in a Level 1 Trauma Center

OBJECTIVE

According to level 2 evidence, earlier evacuation of acute subdural or epidural hematomas necessitating surgery is associated with better outcome. Hence, guidelines recommend performing these procedures immediately. Literature on the extent and causes of prehospital and intrahospital intervals in patients with trauma requiring emergent craniotomies is almost completely lacking. Studies delineating and refining the interval before thrombolytic agent administration in ischemic stroke have dramatically reduced the door-to-needle time. A similar exercise for trauma-to-decompression time might result in comparable reductions. We aim to map intervals in emergent trauma craniotomies in our level 1 trauma center, screen for associated factors, and propose possible ways to reduce these intervals.

METHODS

We analyzed patients who were primarily referred (1R; n = 45) and secondarily referred (after computed tomography imaging in a community hospital [2R; n = 22]) to our emergency department (ED) and underwent emergent trauma craniotomies between 2010 and 2016.

RESULTS

Median prehospital interval (between emergency call and arrival at the ED) was 42 minutes for 1R patients. Median intrahospital interval (between initial ED arrival and skin incision [SI]) was 140 minutes and 268 minutes for 1R and 2R patients, respectively. In 1R patients, ED-SI interval was positively correlated with Glasgow Coma Scale score (ρ=.49; P < 0.001), but not with age, time of ED arrival, or extended Glasgow Outcome Scale score at 6 months. Based on outlier analysis, we propose prehospital and intrahospital measures to improve performance.

CONCLUSIONS

This is the first report on emergency call-SI interval in emergent trauma craniotomy, with a median of 174 minutes and >297 minutes for 1R and 2R patients, respectively, in our center.

[Prehospital assessment of injury type and severity in severely injured patients by emergency physicians : An analysis of the TraumaRegister DGU®]

BACKGROUND

Prehospital assessment of injury type and severity by emergency medical services physicians impacts treatment including appropriate destination hospital selection, especially in (potentially) life-threatening cases. Injuries which are underestimated or overlooked by the emergency physician can delay adequate therapy and thus significantly influence the overall outcome. The current study used data from the TraumaRegister DGU® to evaluate the reliability of prehospital injury assessments made by emergency physicians.

MATERIAL AND METHODS

Data of 30,777 patients from the TraumaRegister DGU® between 1993 and 2009 were retrospectively evaluated. Using the abbreviated injury scale (AIS), subjective prehospital assessments of injury severity by emergency physicians were correlated with objectively identified injuries diagnosed after admission to hospital. For this evaluation, prehospital injury assessments rated moderate or severe by the emergency physician as well as injuries diagnosed in hospital with an AIS score ≥3 points were deemed relevant.

RESULTS

The 30,777 patients with an injury severity score (ISS) ≥ 9 suffered a total of 202,496 injuries and of these 26 % (51,839 out of 202,496) were considered relevant with an AIS ≥3 points. The most frequent relevant injuries were to the head (47 %) and chest (46 %). Of the 51,839 relevant injuries, the prehospital assessment by the emergency physician was accurate for 71 % and in 29 % of the cases relevant injuries were underestimated. Relevant injuries were unrecognized or underestimated in prehospital assessments for almost 1 out of every 7 cases of head trauma, almost 1 out of every 3 thoracic trauma and almost 1 out of every 2 abdominal and pelvic trauma.

CONCLUSION

The assessment of injury severity by emergency medical services physicians based on physical examination at the scene of the trauma is not very reliable. Thus, mechanisms of injury and overall presentation as well as identifiable injuries and vital parameters should be recognized by the emergency physician when considering treatment strategies and choice of appropriate destination hospital. The patient should be re-evaluated in a priority-oriented manner at the latest on arrival in the trauma room to avoid the consequences of unrecognized or underestimated injuries.

Limit Crystalloid Resuscitation after Traumatic Brain Injury

Patients with traumatic brain injury (TBI) are often resuscitated with crystalloids in the emergency department (ED) to maintain cerebral perfusion. The purpose of this study was to evaluate whether crystalloid resuscitation volume impacts mortality in TBI patients. This was a retrospective study of trauma patients with head abbreviated injury scale score ≥2, who received crystalloids during ED resuscitation between 2004 and 2013. Clinical characteristics and volume of crystalloids received in the ED were collected. Patients who received <2 L of crystalloids were categorized as low volume (LOW), whereas those who received ≥2 L were considered high volume (HIGH). Mortality and outcomes were compared. Multivariable regression analysis was used to determine the odds of mortality while controlling for confounders. Over 10 years, 875 patients met inclusion criteria. Overall mortality was 12.5 per cent. Seven hundred and forty-two (85%) were in the LOW cohort and 133 (15%) in the HIGH cohort. Gender and age were similar between the groups. The HIGH cohort had lower admission systolic blood pressure (128 vs 138 mm Hg, P = 0.001), lower Glasgow coma scale score (10 vs 12, P < 0.001), higher head abbreviated injury scale (3.8 vs 3.3, P < 0.001), and higher injury severity score (25 vs 18, P < 0.001). The LOW group had a lower unadjusted mortality (10 vs 26%, P < 0.001). Multivariable analysis adjusting for confounders demonstrated that those resuscitated with ≥2 L of crystalloids had increased odds of mortality (adjusted odds ratio 2.25, P = 0.005). Higher volume crystalloid resuscitation after TBI is associated with increased mortality, thus limited resuscitation for TBI patients may be indicated.

Considerations in Fluids and Electrolytes After Traumatic Brain Injury

Appropriate fluid management of patients with traumatic brain injury (TBI) presents a challenge for many clinicians. Many of these patients may receive osmotic diuretics for the treatment of increased intracranial pressure or develop sodium disturbances, which act to alter fluid balance. However, establishment of fluid balance is extremely important for improving patient outcomes after neurologic injury. The use of hyperosmolar fluids, such as hypertonic saline, has gained significant interest because they are devoid of dehydrating properties and may have other beneficial properties for patients with TBI. Electrolyte derangements are also common after neurologic injury, with many having neurologic manifestations. In addition, the role of electrolyte abnormalities in the secondary neurologic injury cascade is being delineated and may offer a potential future therapeutic intervention.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.

Emergency induction of anaesthesia in the prehospital setting: a review of the anaesthetic induction agents

The standard of prehospital care is improving in many trauma systems around the world. For patients surviving the primary injury, the optimal prehospital interven tions remain debatable. Current evidence suggests that patients with severe head injury may benefit from advanced airway management, most commonly per formed by rapid sequence induction of anaesthesia and orotracheal intubation. The ‘best choice’ induction agent remains unclear, and choice seems to depend on local preferences and the skill mix of the prehospital care team. In this review we look at the recent evidence for selected hypnotic agents.

Past, Present, and Future of Traumatic Brain Injury Research

Traumatic brain injury (TBI) is the greatest cause of death and severe disability in young adults; its incidence is increasing in the elderly and in the developing world. Outcome from severe TBI has improved dramatically as a result of advancements in trauma systems and supportive critical care, however we remain without a therapeutic which acts directly to attenuate brain injury. Recognition of secondary injury and its molecular mediators has raised hopes for such targeted treatments. Unfortunately, over 30 late-phase clinical trials investigating promising agents have failed to translate a therapeutic for clinical use. Numerous explanations for this failure have been postulated and are reviewed here. With this historical context we review ongoing research and anticipated future trends which are armed with lessons from past trials, new scientific advances, as well as improved research infrastructure and funding. There is great hope that these new efforts will finally lead to an effective therapeutic for TBI as well as better clinical management strategies.

Factors that may improve outcomes of early traumatic brain injury care: prospective multicenter study in Austria

Background

Existing evidence concerning the management of traumatic brain injury (TBI) patients underlines the importance of appropriate treatment strategies in both prehospital and early in-hospital care. The objectives of this study were to analyze the current state of early TBI care in Austria with its physician-based emergency medical service. Subsequently, identified areas for improvement were transformed into treatment recommendations. The proposed changes were implemented in participating emergency medical services and hospitals and evaluated for their effect.

Methods

14 Austrian centers treating TBI patients participated in the study. Between 2009 and 2012 all patients with Glasgow Coma Scale score < 13 and/or AIS head > 2 within 48 h after the accident, were enrolled. Data were collected in 2 phases: in the first phase data of 408 patients were analyzed. Based on this, a set of recommendations expected to improve outcomes was developed by the study group and implemented in participating centers. Recommendations included time factors (transport to appropriate trauma center, avoiding secondary transfer), adequate treatment strategies (prehospital fluid and airway management, anesthesia, ventilation), monitoring (pulse oximetry and blood pressure monitoring in all patients, capnography in ventilated patients) for prehospital treatment. In the emergency department focus was on first CT scan as soon as possible, short interval between CT scan and surgery and early use of thrombelastometry to optimize coagulation. Following implementation of these recommendations, data on 325 patients were collected and analyzed in phase 2. Final analysis investigated the impact of the recommendations on patient outcomes.

Results

Patients in both data collection phases showed comparable demographic and injury severity characteristics. Treatment changes, especially in terms of fluid management, monitoring and normoventilation as well as thrombelastometry measurements were implemented successfully in phase 2, and led to significant improvement of patient outcomes. Hospital mortality was reduced from 31 % to 23 %. We found a lower rate of unfavorable outcomes, a significant increase in unexpected survivors and more patients with unexpected favorable outcomes as well.

Conclusions

The results of this study clearly demonstrate that the outcomes of TBI patients can be improved with appropriate early care.

Airway management of patients with traumatic brain injury/C-spine injury

Traumatic brain injury (TBI) is usually combined with cervical spine (C-spine) injury. The possibility of C-spine injury is always considered when performing endotracheal intubation in these patients. Rapid sequence intubation is recommended with adequate sedative or analgesics and a muscle relaxant to prevent an increase in intracranial pressure during intubation in TBI patients. Normocapnia and mild hyperoxemia should be maintained to prevent secondary brain injury. The manual-in-line-stabilization (MILS) technique effectively lessens C-spine movement during intubation. However, the MILS technique can reduce mouth opening and lead to a poor laryngoscopic view. The newly introduced video laryngoscope can manage these problems. The AirWay Scope® (AWS) and AirTraq laryngoscope decreased the extension movement of C-spines at the occiput-C1 and C2-C4 levels, improving intubation conditions and shortening the time to complete tracheal intubation compared with a direct laryngoscope. The Glidescope® also decreased cervical movement in the C2-C5 levels during intubation and improved vocal cord visualization, but a longer duration was required to complete intubation compared with other devices. A lightwand also reduced cervical motion across all segments. A fiberoptic bronchoscope-guided nasal intubation is the best method to reduce cervical movement, but a skilled operator is required. In conclusion, a video laryngoscope assists airway management in TBI patients with C-spine injury.

Predicting patients that require care at a trauma center: analysis of injuries and other factors

INTRODUCTION

The detection of occult or unpredictable injuries in motor vehicle crashes (MVCs) is crucial in correctly triaging patients and thus reducing fatalities. The purpose of the study was to develop a metric that indicates the likelihood that an injury sustained in a MVC would require management at a Level I/II trauma centre (TC) versus a non-trauma centre (non-TC).

METHODS

Transfer Scores (TSs) were computed for 240 injuries that comprise the top 95% most frequently occurring injuries in the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) with an Abbreviated Injury Scale (AIS) severity of 2 or greater. A TS for each injury was computed using the proportions of patients involved in a MVC from the National Inpatient Sample (NIS) that were transferred to a TC or managed at a non-TC. Similarly, a TSMAIS that excludes patients with higher severity co-injuries was calculated using the proportion of patients with a maximum AIS (MAIS) equal to the AIS severity of a given injury.

RESULTS

The results indicated for injuries of a given AIS severity, body region, and injury type, there were large variations in the TSMAIS. Overall results demonstrated higher TSMAIS values when injuries were internal, haemorrhagic, intracranial or of moderate severity (AIS 3-5). Specifically, injuries to the head possessed a TSMAIS that ranged from 0.000 to 0.889, with head injuries of AIS 3-5 severities being the most likely to be transferred.

DISCUSSION AND CONCLUSIONS

The analysis indicated that the TSMAIS is not solely correlated with AIS severity and therefore it captures other important aspects of injury such as predictability and trauma system capabilities. The TS and TSMAIS can be useful in advanced automatic crash notification (AACN) research for the detection of highly unpredictable injuries in MVCs that require direct transport to a TC.

The prehospital management of traumatic brain injury

Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.

Transcranial Doppler after traumatic brain injury: is there a role?

PURPOSE OF REVIEW

To present the practical aspects of transcranial Doppler (TCD) and provide evidence supporting its use for the management of traumatic brain injury (TBI) patients.

RECENT FINDINGS

TCD measures systolic, mean, and diastolic cerebral blood flow (CBF) velocities and calculates the pulsatility index from basal intracranial arteries. These variables reflect the brain circulation, provided there is control of potential confounding factors. TCD can be useful in patients with severe TBI to detect low CBF, for example, during intracranial hypertension, and to assess cerebral autoregulation. In the emergency room, TCD might complement brain computed tomography (CT) scan and clinical examination to screen patients at risk for further neurological deterioration after mild-to-moderate TBI.

SUMMARY

The diagnostic value of TCD should be incorporated into other findings from multimodal brain monitoring and CT scan to optimize the bedside management of patients with TBI and help guide the choice of appropriate therapies.

Limited volume resuscitation in hypotensive elderly multiple trauma is safe and prevents early clinical dilutive coagulopathy -- a matched-pair analysis from TraumaRegister DGU(®)

BACKGROUND

The use of permissive hypotension includes a restrained volume preclinical therapy. However, in the elderly patients, this approach has raised concerns because of the increased cardiovascular risk profile and a higher incidence of hypertension under normal conditions. The aim of the study was to examine whether preclinical administration of restrictive volume therapy in the elderly patient can be safe.

PATIENTS AND METHODS

A retrospective matched-pair analysis with the data set of the TraumaRegister DGU(®) (TR-DGU) was performed based on data of 176 pairs of totally 67,000 patients. To address elderly potentially bleeding patients without major brain injury the following inclusion criteria were chosen: patients ≥ 60 years, ISS ≥ 16, AIS head<4, preclinical blood pressure between 60 and 100 mmHg and recorded preclinical volume administration. Patients that met the inclusion criteria (908) were divided into two groups: pre-clinical volume resuscitation ≤ 1000 ml (=low volume) and >1000 ml (high volume). Patients with high- and low-volume fluid replacement were matched according to the following criteria: age group, gender, date of the accident ± 5 years, ISS, GCS, preclinical intubation, ground-/air-transport, pre-clinical blood pressure.

RESULTS

Preclinical volume resuscitation showed a difference of about 1000 ml between the "low volume" and "high volume" group. The "low volume" group showed a significantly elongated prothrombin time. The amount of blood products given in the emergency department was not significantly different. The ventilation was 2 days shorter in the "low volume", although the number of patients with severe thoracic trauma was greater in this group. The length of stay in the ICU differed by 3 days in favour of the "low volume" group. The overall mortality was almost the same in both groups.

CONCLUSIONS

Based on these data it can be assumed that the lower preclinical volume administration has a positive effect on the initial coagulation status in elderly patients. In spite of some limitations such as low number of matched pairs, we draw the cautious conclusion that a restrictive preclinical volume therapy is safe and also indicated in elderly patients.

Has increased nursing competence in the ambulance services impacted on pre-hospital assessment and interventions in severe traumatic brain-injured patients?

OBJECTIVE

Trauma is one of the most common causes of morbidity and mortality in modern society, and traumatic brain injuries (TBI) are the single leading cause of mortality among young adults. Pre-hospital acute care management has developed during recent years and guidelines have shown positive effects on the pre-hospital treatment and outcome for patients with severe traumatic brain injury. However, reports of impacts on improved nursing competence in the ambulance services are scarce. Therefore, the aim of this study was to investigate if increased nursing competence level has had an impact on pre-hospital assessment and interventions in severe traumatic brain-injured patients in the ambulance services.

METHOD

A retrospective study was conducted. It included all severe TBI patients (>15 years of age) with a Glasgow Coma Score (GCS) of less than eight measured on admission to a level one trauma centre hospital, and requiring intensive care (ICU) during the years 2000-2009.

RESULTS

651 patients were included, and between the years 2000-2005, 395 (60.7%) severe TBI patients were injured, while during 2006-2009, there were 256 (39.3%) patients. The performed assessment and interventions made at the scene of the injury and the mortality in hospital showed no significant difference between the two groups. However, the assessment of saturation was measured more frequently and length of stay in the ICU was significantly less in the group of TBI patients treated between 2006-2009.

CONCLUSION

Greater competence of the ambulance personnel may result in better assessment of patient needs, but showed no impact on performed pre-hospital interventions or hospital mortality.

Alcohol and NMDA receptor: current research and future direction

The brain is one of the major targets of alcohol actions. Most of the excitatory synaptic transmission in the central nervous system is mediated by N-methyl-D-aspartate (NMDA) receptors. However, one of the most devastating effects of alcohol leads to brain shrinkage, loss of nerve cells at specific regions through a mechanism involving excitotoxicity, oxidative stress. Earlier studies have indicated that chronic exposure to ethanol both in vivo and in vitro, increases NR1 and NR2B gene expression and their polypeptide levels. The effect of alcohol and molecular changes on the regulatory process, which modulates NMDAR functions including factors altering transcription, translation, post-translational modifications, and protein expression, as well as those influencing their interactions with different regulatory proteins (downstream effectors) are incessantly increasing at the cellular level. Further, I discuss the various genetically altered mice approaches that have been used to study NMDA receptor subunits and their functional implication. In a recent countable review, epigenetic dimension (i.e., histone modification-induced chromatin remodeling and DNA methylation, in the process of alcohol related neuroadaptation) is one of the key molecular mechanisms in alcohol mediated NMDAR alteration. Here, I provide a recount on what has already been achieved, current trends and how the future research/studies of the NMDA receptor might lead to even greater engagement with many possible new insights into the neurobiology and treatment of alcoholism.

Emergency neurological life support: airway, ventilation, and sedation

Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.

Computational gene mapping to analyze continuous automated physiologic monitoring data in neuro-trauma intensive care

BACKGROUND

We asked whether the advanced machine learning applications used in microarray gene profiling could assess critical thresholds in the massive databases generated by continuous electronic physiologic vital signs (VS) monitoring in the neuro-trauma intensive care unit.

METHODS

We used Class Prediction Analysis to predict binary outcomes (life/death, good/bad Extended Glasgow Outcome Score, etc.) based on data accrued within 12, 24, 48, and 72 hours after admission to the neuro-trauma intensive care unit. Univariate analyses selected "features," discriminator VS segments or "genes," in each individual's data set. Prediction models using these selected features were then constructed using six different statistical modeling techniques to predict outcome for other individuals in the sample cohort based on the selected features of each individual then cross-validated with a leave-one-out method.

RESULTS

We gleaned complete sets of 588 VS monitoring segment features for each of four periods and outcomes from 52 of 60 patients with severe traumatic brain injury who met study inclusion criteria. Overall, intracranial pressures and blood pressures over time (e.g., intracranial pressure >20 mm Hg for 20 minutes) provided the best discrimination for outcomes. Modeling performed best in the first 12 hours of care and for mortality. The mean number of selected features included 76 predicting 14-day hospital stay in that period, 11 predicting mortality, and 4 predicting 3-month Extended Glasgow Outcome Score. Four of the six techniques constructed models that correctly identified mortality by 12 hours 75% of the time or higher.

CONCLUSION

Our results suggest that valid prediction models after severe traumatic brain injury can be constructed using gene mapping techniques to analyze large data sets from conventional electronic monitoring data, but that this methodology needs validation in larger data sets, and that additional unstructured learning techniques may also prove useful.

Does a prehospital Glasgow Coma Scale score predict pediatric outcomes?

BACKGROUND

Although the Glasgow Coma Scale (GCS) score is widely used by medical professionals to evaluate and predict neurological outcomes, studies using the prehospital (P) GCS score to predict neurological outcomes in children are few.

OBJECTIVE

The objective of this study was to determine the agreement between the P GCS score and the emergency department (ED) GCS score, and the association between P GCS score and outcomes at hospital discharge in pediatric patients 5 to 18 years of age.

METHODS

Medical record review of children 5 to 18 years old with traumatic brain injury (TBI) was conducted. Children with documented P and ED GCS scores were eligible for enrollment. The hospital records of each enrolled child were reviewed, and the Glasgow outcome score and the disability rating scale scores were calculated. Agreement between the P and ED GCS scores was calculated using χ (κ statistic).

RESULTS

One hundred eighty-five subjects were included. There was strong agreement between P and ED GCS scores (κ = +0.69; confidence interval, 0.57-0.81). The Glasgow outcome score category improved with improving GCS category. The median disability rating scale score was also similar for P and ED GCS scores and was higher with decreasing GCS.

CONCLUSIONS

Our data showed strong agreement between P and ED GCS scores. Also, there was strong association between P GCS scores and short-term outcomes in children with TBI. The results support the use of GCS in prehospital transport destination guidelines for children with TBI.

Referral to Rehabilitation After Severe Traumatic Brain Injury

Background. After a severe traumatic brain injury (TBI), some patients are discharged home without rehabilitation, although rehabilitation is assumed to improve outcome. Objective. To assess factors that predict referral to rehabilitation following acute care. This study is part of a larger inception cohort study assessing the care network in the Parisian area (France). Methods. Between July 2005 and April 2007, 504 adults with severe TBI (Glasgow Coma Scale score ≤8) were prospectively recruited by mobile emergency services. This study included 254 acute care survivors (80% male, median age 32 years). Data regarding demographics, injury severity, and acute care pathway were collected. The first analysis compared patients referred to a rehabilitation facility with patients discharged to a living place. The second analysis compared patients referred to a specialized neurorehabilitation (NR) facility with patients referred to nonspecialized rehabilitation. Univariate and multivariate statistics were computed. Results. In all, 162 patients (64%) were referred to rehabilitation, 115 (45%) of which were referred to NR and 47 (19%) to nonspecialized rehabilitation. The following factors were significantly predictive of nonreferral to rehabilitation: living alone, a lower income professional category, pretraumatic alcohol abuse, lower TBI severity, and transfer through a nonspecialized medical ward before discharge. Patients referred to specialized NR were significantly younger and from a higher income professional category. Conclusions. These results raise concern regarding care pathways because many patients were discharged to living places, probably without adequate assessment and management of rehabilitation needs. Injury severity and social characteristics influenced discharge destination.

Blindness following severe midfacial trauma--case report and review

PURPOSE

Severe trauma of the viscerocranium or neurocranium may result in impaired visual acuity or even blindness. Case based epidemiology, pathomechanism and actual strategies in midfacial trauma for initial therapy and prevention of posttraumatic blindness are discussed.

CASE AND REVIEW

A 58-year old patient was treated at our Department of Oral and Maxillofacial Plastic Surgery after his central midface had been hit by a swinging steel girder. Initially he was blind on both eyes. Initial treatment started by applying 24 mg of dexamethasone and omeprazole. During the following 2 weeks, amaurosis persisted on the left eye. On the right eye complete visual acuity was regained. On the basis of data from our Department of Oral and Maxillofacial Plastic Surgery an Odds Ratio of 0.12 was calculated for the combination of blindness and midfacial trauma. Today cortisol therapy is still used. However, hypothermia, anti-Trendelenburg position, and application of mannitol seem to be more effective therapeutic strategies. Erythropoetine and progesterone are promising drugs with neuroprotective, anti-inflammatory as well as anti-oedematous effects.

CONCLUSION

The risk of blindness is higher than expected. Latest findings regarding the neuroprotective effects of erythropoetine or/and progesterone seem to promise a more successful treatment.

Transfusions and long-term functional outcomes in traumatic brain injury

OBJECT

In this paper, the authors' goal was to examine the relationship between transfusion and long-term functional outcomes in moderately anemic patients (lowest hematocrit [HCT] level 21-30%) with traumatic brain injury (TBI). While evidence suggests that transfusions are associated with poor hospital outcomes, no study has examined transfusions and long-term functional outcomes in this population. The preferred transfusion threshold remains controversial.

METHODS

The authors performed a retrospective review of patients who were admitted with TBI between September 2005 and November 2007, extracting data such as HCT level, status of red blood cell transfusion, admission Glasgow Coma Scale (GCS) score, serum glucose, and length of hospital stay. Outcome measures assessed at 6 months were Glasgow Outcome Scale-Extended score, Functional Status Examination score, and patient death. A multivariate generalized linear model controlling for confounding variables was used to assess the association between transfusion and outcome.

RESULTS

During the study period, 292 patients were identified, and 139 (47.6%) met the criteria for moderate anemia. Roughly half (54.7%) underwent transfusions. Univariate analyses showed significant correlations between outcome score and patient age, admission GCS score, head Abbreviated Injury Scale score, number of days with an HCT level < 30%, highest glucose level, number of days with a glucose level > 200 mg/dl, length of hospital stay, number of patients receiving a transfusion, and transfusion volume. In multivariate analysis, admission GCS score, receiving a transfusion, and transfusion volume were the only variables associated with outcome (F = 2.458, p = 0.007; F = 11.694, p = 0.001; and F = 1.991, p = 0.020, respectively). There was no association between transfusion and death.

CONCLUSIONS

Transfusions may contribute to poor long-term functional outcomes in anemic patients with TBI. Transfusion strategies should be aimed at patients with symptomatic anemia or physiological compromise, and transfusion volume should be minimized.

Moderate Ringer's lactate solution resuscitation yields best neurological outcome in controlled hemorrhagic shock combined with brain injury in rats

Anesthetized rats were assigned to sham; brain injury (BI); controlled hemorrhagic shock (CHS); BI combined with CHS (combined injury [CI]); and CI groups resuscitated with 2.5 mL/kg Ringer's lactate solution (RL-2.5), 10 mL/kg RL (RL-10), or 40 mL/kg RL (RL-40). Brain injury was induced by applying 400 millibar negative pressure for 10 s through a hollow screw inserted into a 4.5-mm burr hole drilled into the left parietal region of the skull. Five minutes after BI, 30% of circulating blood volume was withdrawn for 10 min to induce CHS. One hour of fluid resuscitation commenced 20 min posthemorrhage. MAP, lactate, and base excess levels were significantly improved in the RL-40 group compared with all other hemorrhaged groups. The hematocrit level 1 h after resuscitation began was significantly lower in the RL-40 group (27.6% +/- 0.57%) than in all other groups. The RL-40 group had the worst neurological severity score 24 h postsurgery. MAP, lactate, and base excess levels were not significantly improved in the RL-2.5 group, however, the number of surviving neuronal cells in the perilesional brain region was significantly higher than in the CI or RL-40 groups. MAP, lactate, and base excess levels were significantly improved in the RL-10 group (P < 0.05). Mobility and the number of surviving neurons in the perilesional region of the brain were significantly better in the RL-10 group than in the CI or RL-40 groups (P < 0.05). Although massive fluid resuscitation yields preferable hemodynamic and metabolic outcomes, neurological outcomes are better after moderate fluid resuscitation for BI combined with controlled hemorrhagic shock.

Automated measurement of "pressure times time dose" of intracranial hypertension best predicts outcome after severe traumatic brain injury

BACKGROUND

Earlier, more accurate assessment of secondary brain injury is essential in management of patients with traumatic brain injury (TBI). We assessed the accuracy and utility of high-resolution automated intracranial pressure (ICP) and cerebral perfusion pressure (CPP) recording and their analysis in patients with severe TBI.

METHODS

ICP and CPP data for 30 severe TBI patients were collected automatically at 6-second intervals. The degree and duration of ICP and CPP above and below treatment thresholds were calculated as "pressure times time dose" (PTD; mm Hg . h) using automated recordings (PTDa) or manual recordings (PTDm) for early stage (trauma resuscitation unit [TRU]) and total monitoring time (TRU and intensive care unit).

RESULTS

Bland-Altman plots showed lack of agreement between PTDa and PTDm. For ICP >20 mm Hg and CPP <60 mm Hg, PTDa, but not PTDm, was significantly higher in patients with unfavorable outcome (Extended Glasgow Outcome Scale score <or=4) than in patients with favorable outcome (Extended Glasgow Outcome Scale score >4). Total PTDa for ICP >20 mm Hg and CPP <60 mm Hg had high predictive power for functional outcome (area under the receiver operating characteristics curve: 0.92 +/- 0.05 and 0.82 +/- 0.08, respectively) and inhospital mortality (0.76 +/- 0.15 and 0.79 +/- 0.14, respectively) and were strongly correlated with length of intensive care unit stay (p = 0.009 and 0.007), length of hospital stay (p = 0.009 and 0.005), and discharge Glasgow Coma Scale scores (p = 0.008 and p = 0.038). PTDa of CPP >100 mm Hg during TRU monitoring and during the first 24 hours showed highest predictive power for mortality (area under the receiver operating characteristics curve: 0.72 +/- 0.18 and 0.85 +/- 0.13, respectively). PTDa was better than PTDm and the duration of episodes alone in predicting outcome.

CONCLUSIONS

PTD calculation of high resolution ICP and CPP recording is a reliable and feasible way of monitoring severe TBI patients.

Detrended fluctuation analysis of intracranial pressure predicts outcome following traumatic brain injury

Detrended fluctuation analysis (DFA) is a recently developed technique suitable for describing scaling behavior of variability in physiological signals. The purpose of this study is to explore applicability of DFA methods to intracranial pressure (ICP) signals recorded in patients with traumatic brain injury (TBI). In addition to establishing the degree of fit of the power-law scaling model of detrended fluctuations of ICP in TBI patients, we also examined the relationship of DFA coefficients (scaling exponent and intercept) to: 1) measures of initial neurological functioning; 2) measures of functional outcome at six month follow-up; and 3) measures of outcome, controlling for patient characteristics, and initial neurological status. In a sample of 147 moderate-to-severely injured TBI patients, we found that a higher DFA scaling exponent is significantly associated with poorer initial neurological functioning, and that lower DFA intercept and higher DFA scaling exponent jointly predict poorer functional outcome at six month follow-up, even after statistical control for covariates reflecting initial neurological condition. DFA describes properties of ICP signal in TBI patients that are associated with both initial neurological condition and outcome at six months postinjury.

Early resuscitation of children with moderate-to-severe traumatic brain injury

OBJECTIVES

Traumatic brain injury is a leading cause of death and disability in children. Guidelines have been established to prevent secondary brain injury caused by hypotension or hypoxia. The purpose of this study was to identify the prevalence, monitoring, and treatment of hypotension and hypoxia during "early" (prehospital and emergency department) care and to evaluate their relationship to vital status and neurologic outcomes at hospital discharge.

METHODS

This was a retrospective study of 299 children with moderate-to-severe traumatic brain injury presenting to a level 1 pediatric trauma center. We recorded vital signs and medical provider response to hypotension and/or hypoxia during all portions of early care.

RESULTS

Blood pressure (31%) and oxygenation (34%) were not recorded during some portion of "early care." Documented hypotension occurred in 118 children (39%). An attempt to treat documented hypotension was made in 48% (57 of 118 children). After adjusting for severity of illness, children who did not receive an attempt to treat hypotension had an increased odds of death of 3.4 and were 3.7 times more likely to suffer disability compared with treated hypotensive children. Documented hypoxia occurred in 131 children (44%). An attempt to treat hypoxia was made in 92% (121 of 131 children). Untreated hypoxia was not significantly associated with death or disability, except in the setting of hypotension.

CONCLUSIONS

Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved outcomes.

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.

Direct transport versus interhospital transfer of patients with severe head injury in Norway

OBJECTIVE

This study compares injury severity and outcome of patients with severe head injury admitted directly to a neurosurgical department with those initially transferred to a local hospital.

METHODS

A retrospective analysis of all patients with severe head injury admitted to the Department of Neurosurgery at St Olav University Hospital, Norway, was carried out from 1998 throughout 2002.

RESULTS

The study included 146 patients with a median age of 34 (1-88) years. Patients transported directly (57%) had lower field Glasgow Coma Scale (fGCS) [5.5 (3-15) vs. 7 (3-15), P=0.002], higher Injury Severity Score [31.8 (9-75) vs. 27.0 (9-75), P=0.023], higher mortality rates (31 vs. 15%, P=0.042) and reached the neurosurgical department earlier [1.8 (0.3-15.8) vs. 5.5h (0.8-23.0), P<0.001] than those undergoing transfer to a local hospital. Significantly more patients in the direct admission group with a fGCS <or=8 (83%) were intubated at the scene of accident than in the transfer group (38%) (P<0.001). Multiple regression analysis adjusting for age, GCS and pupillary abnormalities did not predict increased mortality for the transfer group [odds ratio 0.43 (0.16, 1.14), P=0.09].

CONCLUSION

Patients with a severe head injury admitted directly to the neurosurgical department are more severely injured, more frequently get advanced medical treatment in the field, and are undergoing surgery earlier than transferred patients.

Surgery of cerebral trauma and associated critical care

The last 30 years have been both exciting and frustrating for those in the field of traumatic brain injury (TBI). Much has been learned, but no new treatment has been shown to improve patient outcomes despite the execution of many clinical trials. The overall incidence of TBI has decreased, probably because of intensive efforts toward prevention and education. Rigorous assessment of available research has produced several evidence-based guidelines for the management of neurotrauma patients. The creation of organized emergency medical services systems in many regions has improved prehospital care. Computed tomographic scans have become the gold standard for obtaining immediate images of patients with TBI, and ongoing advances in visualizing cerebral metabolism continue to be remarkable. The major current question regarding surgical treatment for TBI involves the role of decompressive craniectomy, an operation that first fell out of favor and has since (in the last three decades) enjoyed a resurgence of interest. Growing interest in the intensive care management of TBI patients helped to establish the new field of neurocritical care. Prophylactic hyperventilation is no longer recommended, and earlier recommendations for aggressive elevation of blood pressure have been softened to endorsement of a cerebral perfusion pressure of 60 mmHg. Recombinant factor VIIa is increasingly used for minimizing complications related to coagulopathy. Intracranial pressure monitoring is now recommended for the majority of TBI patients. At present, available technologies allow measurement of other aspects of cerebral metabolism including cerebral blood flow, brain oxygen tension, biochemistry, and electrical activity. Therapeutic interventions that are growing in popularity or are presently under investigation include administration of hypertonic saline, hyperoxygenation, decompressive craniectomy, and hypothermia. Rehabilitation has become accepted as an important part of the TBI recovery process, and additional work is needed to identify optimal interventions in this area. Socioeconomic factors will play a growing role in our treatment of TBI patients. Although much progress has been made in the last 30 years, the challenge now is to find ways to translate that progress into improved care and outcomes for TBI patients.

Normoxic ventilatory resuscitation following controlled cortical impact reduces peroxynitrite-mediated protein nitration in the hippocampus

OBJECTIVES

Ventilatory resuscitation with 100% O2 after severe traumatic brain injury (TBI) raises concerns about the increased production of reactive oxygen species (ROS). The product of peroxynitrite-meditated tyrosine residue nitration, 3-nitrotyrosine (3-NT), is a marker for oxidative damage to proteins. The authors hypothesized that posttraumatic resuscitation with hyperoxia (100% fraction of inspired oxygen [FiO2] concentration) results in increased ROS-induced damage to proteins compared with resuscitation using normoxia (21% FiO2 concentration).

METHODS

Male Sprague-Dawley rats underwent controlled cortical impact (CCI) injury and resuscitation with either normoxic or hyperoxic ventilation for 1 hour (5 rats per group). Twenty-four hours after injury, rat hippocampi were evaluated using 3-NT immunostaining. In a second experiment, animals similarly underwent CCI injury and normoxic or hyperoxic ventilation for 1 hour (4 rats per group). One week after injury, neuronal counts were performed after neuronal nuclei immunostaining.

RESULTS

The 3-NT staining was significantly increased in the hippocampi of the hyperoxic group. The normoxic group showed a 51.0% reduction of staining in the CA1 region compared with the hyperoxic group and a 50.8% reduction in the CA3 region (p < 0.05, both regions). There was no significant difference in staining between the injured normoxic group and sham-operated control groups. In the delayed analysis of neuronal survival (neuronal counts), there was no significant difference between the hyperoxic and normoxic groups.

CONCLUSIONS

In this clinically relevant model of TBI, normoxic resuscitation significantly reduced oxidative damage to proteins compared with hyperoxic resuscitation. Neuronal counts showed no benefit from hyperoxic resuscitation. These findings indicate that hyperoxic ventilation in the early stages after severe TBI may exacerbate oxidative damage to proteins.

Severe traumatic brain injury in Austria III: prehospital status and treatment

OBJECTIVES

The goal of this paper is to describe prehospital status and treatment of patients with severe TBI in Austria.

PATIENTS AND METHODS

Data sets from 396 patients with severe TBI (Glasgow Coma Scale score < 9) included by 5 Austrian hospitals were available. The analysis focused on incidence and/or degree of severity of typical clinical signs, frequency of use of different management options, and association with outcomes for both. ICU mortality, 90-day mortality, final outcome (favorable = good recovery or moderate disability; unfavorable = severe disability, vegetative state, or death) after 6 or 12 months, and ratio of observed (90-day) to predicted mortality (O/E ratio) are reported for the selected parameters. Chi2 -test, t-test, Fisher's exact test, and logistic regression were used to identify significant (p < 0.05) differences for association with survival and favorable outcome (both coded as 1).

RESULTS

The majority of patients were male (72%), mean age was 49 +/- 21 years, mean injury severity score (ISS) was 27 +/- 17, mean first GCS score was 5.6 +/- 2.9, and expected hospital survival was 63 +/- 30%. ICU mortality was 32%, 90-day mortality was 37%, and final outcome was favorable in 35%, unfavorable in 53%, unknown in 12%. We found that age > 60 years, ISS > 50 points, GCS score < 4, bilateral changes in pupil size and reactivity, respiratory rate < 10/min, systolic blood pressure (SBP) < 90 mm Hg, and heart rate < 60/min were associated with significantly higher ICU and 90-day mortality rates, and lower rates of favorable outcome. With regard to prognostic value the GCS motor response score is identical to the full GCS score. Administration of > 1000 ml of fluid and helicopter transport were associated with better outcomes than expected, while endotracheal intubation in the field had neither a positive nor a negative effect on outcomes. Administration of no or < 500 ml of fluids was associated with worse outcomes than expected. Outcomes were better than expected in the few patients (5%) who received hypertonic saline.

CONCLUSIONS

Age, ISS, and initial neuro status are the factors most closely associated with outcome. Hypotension must be avoided. Fluids should be given to restore and/or maintain SBP > 110 mm Hg. Helicopter transport should be arranged for more seriously injured patients.

Head injury mortality in the Nordic countries

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in Western countries. Effective management planning for these patients requires knowledge of TBI epidemiology. The purpose of this study was to describe and analyze the development of TBI mortality in the Nordic countries during the period 1987-2001. Data on TBI deaths were retrieved from the national official statistical agencies according to specified diagnostic codes. We also collected data on the number of operations for acute TBI in the year 2000 from all Nordic hospitals admitting trauma patients. Finland had about twice as high a TBI mortality rate as the other countries. Similarly, the Finnish incidence of acute TBI operations was nearly twice that of the other countries. The median TBI death rate for Finland was 21.2 per 100,000 per year, and for Denmark, Norway, and Sweden 11.5, 10.4, and 9.5, respectively. There were more male than female deaths in all countries. The mortality rate from extracranial injuries was relatively equal between the countries. We observed a sizeable reduction in TBI mortality rates for all countries, except in Finland. Younger age groups had the most pronounced decrease in TBI mortality rates. The oldest age group had the least favorable development of TBI mortality rates, and the mean age of TBI casualties increased substantially during the study period. This study demonstrates considerable differences in and between the Nordic countries regarding TBI mortality. Preventive measures and implementation of regional guidelines are needed to assure a positive development in the future.