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Hörauf JA, Woschek M, Schindler CR, Verboket RD, Lustenberger T, Marzi I, Störmann P. Settlement Is at the End-Common Trauma Scores Require a Critical Reassessment Due to the Possible Dynamics of Traumatic Brain Injuries in Patients' Clinical Course. J Clin Med 2024; 13:3333. [PMID: 38893044 PMCID: PMC11173217 DOI: 10.3390/jcm13113333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Scientific studies on severely injured patients commonly utilize the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) for injury assessment and to characterize trauma cohorts. However, due to potential deterioration (e.g., in the case of an increasing hemorrhage) during the clinical course, the assessment of injury severity in traumatic brain injury (TBI) can be challenging. Therefore, the aim of this study was to investigate whether and to what extent the worsening of TBI affects the AIS and ISS. Methods: We retrospectively evaluated 80 polytrauma patients admitted to the trauma room of our level I trauma center with computed-tomography-confirmed TBI. The initial AIS, ISS, and Trauma and Injury Severity Score (TRISS) values were reevaluated after follow-up imaging. Results: A total of 37.5% of the patients showed a significant increase in AIShead (3.7 vs. 4.1; p = 0.002) and the ISS (22.9 vs. 26.7, p = 0.0497). These changes resulted in an eight percent reduction in their TRISS-predicted survival probability (74.82% vs. 66.25%, p = 0.1835). Conclusions: The dynamic nature of intracranial hemorrhage complicates accurate injury severity assessment using the AIS and ISS, necessitating consideration in clinical studies and registries to prevent systematic bias in patient selection and subsequent data analysis.
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Affiliation(s)
- Jason-Alexander Hörauf
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Mathias Woschek
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Cora Rebecca Schindler
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Rene Danilo Verboket
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas Lustenberger
- Department of Orthopedic Surgery and Traumatology, Inselspital, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Ingo Marzi
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Philipp Störmann
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Foster N, Martin L, Raby E, Wood FM, Fear M, Pavlos N, Edgar DW. Trauma patient heterotopic ossification diagnosis is associated with increased hospital length of stay. Injury 2024; 55:111328. [PMID: 38428100 DOI: 10.1016/j.injury.2024.111328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 12/21/2023] [Accepted: 01/14/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Traumatic heterotopic ossification (tHO) refers to the development of extra-skeletal bone in muscle and soft tissues following tissue insult secondary to surgery or trauma. This presents a persistent clinical concern associated with significant patient morbidity and expense to diagnose and treat. Traumatic HO is a substantial barrier to rehabilitation for trauma-injured patients. As such, the development of tHO after burn and other trauma is hypothesised to prolong inpatient length of stay (LOS) and thus increase health care costs. OBJECTIVE To investigate the association between an inpatient tHO diagnosis and hospital LOS in trauma patients. METHODS A retrospective audit of trauma patients over a 14-year period was completed using data from four WA hospitals. Burn and neurological trauma patients diagnosed with tHO as an inpatient (tHO+) and control subjects (tHO-), matched (1:3) by age, gender, and injury severity factors, were identified using medical diagnostic codes. Data relating to patient and injury-related determinants of LOS from tHO+ and tHO- subjects were analysed to model the association of tHO on total hospital length of stay. RESULTS 188 identified patients were hospitalised due to traumatic injury; 47 patients with tHO following burn injury (n = 17), spinal cord injury (n = 13) and traumatic brain injury (n = 17), and 141 control patients. Those who developed tHO during hospitalisation had a significantly higher median LOS than matched trauma patients who did not develop tHO (142 days vs. 61 days). Multivariate regression analyses identified the following independent predictive factors of a prolonged hospital LOS: tHO diagnosis, mechanical ventilation hours, injury to the hip region and thigh area, other ossification disorder, pressure injury, admission to intensive care unit and deep vein thrombosis. Trauma patients diagnosed with tHO during their hospital admission stayed 1.6 times longer than trauma patients matched for injury severity without a tHO diagnosis (IRR 1.56, 95% CI 1.35-1.79, p<0.001). CONCLUSION Traumatic heterotopic ossification is an independent explanatory factor for increased hospital LOS in patients following burns, spinal cord, and traumatic brain injury. Early diagnosis may assist in reducing the impact of tHO on acute hospital stay after trauma.
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Affiliation(s)
- Nichola Foster
- Burn Injury Research Node, Institute for Health Research, School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia 6160, Australia; Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia; Physiotherapy Department, Sir Charles Gairdner Osborne Park Health Care Group, North Metropolitan Health Service, Nedlands, Western Australia 6009, Australia.
| | - Lisa Martin
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Edward Raby
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Mark Fear
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Nathan Pavlos
- School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia 6009, Australia
| | - Dale W Edgar
- Burn Injury Research Node, Institute for Health Research, School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia 6160, Australia; Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia; Safety and Quality Unit, Armadale Kalamunda Group Health Service, East Metropolitan Health Service, Mt Nasura, Western Australia 6112, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
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3
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Anand KV, Shahid PT, Shameel KK. Assessment of GCS and FOUR Score as Prognostic Indicators for Hospital Stay and Morbidity in Traumatic Brain Injury Patients: An Observational Study. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2024; 16:S601-S604. [PMID: 38595590 PMCID: PMC11000942 DOI: 10.4103/jpbs.jpbs_885_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 09/18/2023] [Accepted: 09/23/2023] [Indexed: 04/11/2024] Open
Abstract
Aim The objective of the present research was to evaluate variations in hospital stay as well as morbidity based on the Glasgow Coma Scale (GCS) and Full Outline of Un-Responsive (FOUR) scores for patients who had traumatic brain injury (TBI). Materials and Methods A total of 107 patients with TBI patients who attended the emergency department of MES Medical College, Perinthalmanna, were enrolled into the study. FOUR and GCS scoring systems were used to assess the patients within 24 hours of the presentation to the emergency department. Both FOUR and GCS scoring systems were assessed at the same time. The outcome was measured in terms of length of hospital stay and morbidity, which was assessed using modified Rankin score. Chi-square test was used to calculate sensitivity, specificity, positive predictive value, and negative predictive value. The area under the curve (AUC) was calculated using receiver operating characteristic curve analysis. A P value <0.05 was considered significant. Results We found a strong positive correlation between GCS and FOUR score with a Spearman coefficient of 0.9. Comparison of AUC between GCS score and FOUR score showed a statistically significant difference (P = 0.0044), predicting that FOUR score was a better predictor of hospital stay (>15 days) than GCS score. Comparison of AUC between GCS score and FOUR score showed a significant statistical difference (P = 0.0002), showing that FOUR score was a better predictor of morbidity than GCS. Conclusion FOUR score was a better predictor of hospital stay and morbidity as compared to GCS score.
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Affiliation(s)
- K. V. Anand
- Department of Emergency Medicine, MES Medical College and Hospital, Malappuram, Kerala, India
| | - P. T. Shahid
- Department of Emergency Medicine, MES Medical College and Hospital, Malappuram, Kerala, India
| | - K. K. Shameel
- Department of Emergency Medicine, MES Medical College and Hospital, Malappuram, Kerala, India
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4
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Essl D, Schöchl H, Oberladstätter D, Lockie C, Islam M, Slezak C, Voelckel WG. Admission S100B fails as neuro-marker but is a good predictor for intrahospital mortality in major trauma patients. Injury 2024; 55:111187. [PMID: 37980176 DOI: 10.1016/j.injury.2023.111187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 10/08/2023] [Accepted: 11/04/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND S100 B is an extensively studied neuro-trauma marker, but its specificity and subsequently interpretation in major trauma patients might be limited, since extracerebral injuries are known to increase serum levels. Thus, we evaluated the potential role of S100B in the assessment of severe traumatic brain injury (TBI) in multiple injured patients upon emergency room (ER) admission and the first days of intensive care unit (ICU) stay. METHODS Retrospective study employing trauma registry data derived from a level 1 trauma center. Four cohorts of patients were grouped: isolated TBI (iTBI), polytrauma patients with TBI (PT + TBI), polytrauma patients without TBI (PT-TBI) and patients without polytrauma or TBI (control). S100B-serum levels were assessed immediately after admission in the emergency room and during the subsequent ICU stay. Values were correlated with injury severity score (ISS), Glasgow Coma Score (GCS) and in-hospital mortality. RESULTS 780 predominantly male patients (76 %) with a median age of 48 (30-63) and a median ISS of 24 (17-30) were enrolled in the study. Admission S100B correlated with ISS and TBI severity defined by the GCS (both p < 0.0001) but not with head abbreviated injury score (AIS) (p = 0.38). Compared with survivors, non-survivors had significantly higher median S100B levels in the ER (6.14 μg/L vs. 2.06 μg/L; p < 0.0001) and at ICU-day 1 (0.69 μg/L vs. 0.17 μg/L; p < 0.0001). S100B in the ER predicted mortality with an area under curve (AUC) of 0.77 (95 % CI 0,70-0,83, p < 0.0001), vs. 0.86 at ICU-day 1 (95 % CI 0,80-0,91, p < 0.0001). CONCLUSION In conclusion, S100B is a valid biomarker for prediction of mortality in major trauma patients with a higher accuracy when assessed at the first day of ICU stay vs. immediately after ER admission. Since S100B did not correlate with pathologic TBI findings in multiple injured patients, it failed as predictive neuro-marker because extracerebral injuries demonstrated a higher influence on admission levels than neurotrauma. Although S100B levels are indicative for injury severity they should be interpreted with caution in polytrauma patients.
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Affiliation(s)
- Daniel Essl
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria; Department of Anesthesiology and Critical Care Medicine, Medical University, Innsbruck, Austria
| | - Herbert Schöchl
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Daniel Oberladstätter
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Chris Lockie
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Mohamed Islam
- Department of Mathematics, Utah Valley University, Orem, USA
| | - Cyrill Slezak
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria; Department of Mathematics, Utah Valley University, Orem, USA
| | - Wolfgang G Voelckel
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria; University of Stavanger, Network for Medical Science, Stavanger, Norway.
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5
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Soltani A, Chugaeva UY, Ramadan MF, Saleh EAM, Al-Hasnawi SS, Romero-Parra RM, Alsaalamy A, Mustafa YF, Zamanian MY, Golmohammadi M. A narrative review of the effects of dexamethasone on traumatic brain injury in clinical and animal studies: focusing on inflammation. Inflammopharmacology 2023; 31:2955-2971. [PMID: 37843641 DOI: 10.1007/s10787-023-01361-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023]
Abstract
Traumatic brain injury (TBI) is a type of brain injury resulting from a sudden physical force to the head. TBI can range from mild, such as a concussion, to severe, which might result in long-term complications or even death. The initial impact or primary injury to the brain is followed by neuroinflammation, excitotoxicity, and oxidative stress, which are the hallmarks of the secondary injury phase, that can further damage the brain tissue. Dexamethasone (DXM) has neuroprotective effects. It reduces neuroinflammation, a critical factor in secondary injury-associated neuronal damage. DXM can also suppress the microglia activation and infiltrated macrophages, which are responsible for producing pro-inflammatory cytokines that contribute to neuroinflammation. Considering the outcomes of this research, some of the effects of DXM on TBI include: (1) DXM-loaded hydrogels reduce apoptosis, neuroinflammation, and lesion volume and improves neuronal cell survival and motor performance, (2) DXM treatment elevates the levels of Ndufs2, Gria3, MAOB, and Ndufv2 in the hippocampus following TBI, (3) DXM decreases the quantity of circulating endothelial progenitor cells, (4) DXM reduces the expression of IL1, (5) DXM suppresses the infiltration of RhoA + cells into primary lesions of TBI and (6) DXM treatment led to an increase in fractional anisotropy values and a decrease in apparent diffusion coefficient values, indicating improved white matter integrity. According to the study, the findings show that DXM treatment has neuroprotective effects in TBI. This indicates that DXM is a promising therapeutic approach to treating TBI.
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Affiliation(s)
- Afsaneh Soltani
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- USERN Office, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Uliana Y Chugaeva
- Department of Pediatric, Preventive Dentistry and Orthodontics, Institute of Dentistry, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | - Ebraheem Abdu Musad Saleh
- Department of Chemistry, Prince Sattam Bin Abdulaziz University, College of Arts and Science, 11991, Wadi Al-Dawasir, Saudi Arabia
| | | | | | - Ali Alsaalamy
- College of Technical Engineering, Imam Ja'afar Al-Sadiq University, Al-Muthanna, 66002, Iraq
| | - Yasser Fakri Mustafa
- Department of Pharmaceutical Chemistry, College of Pharmacy, University of Mosul, Mosul, 41001, Iraq
| | - Mohammad Yasin Zamanian
- Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, 6718773654, Iran.
- Department of Pharmacology and Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, 6718773654, Iran.
- Department of Physiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, 6718773654, Iran.
| | - Maryam Golmohammadi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Bashir MT, Bhatt P, Thiruvothiyur M, Khan I, Cooper JG, Poobalan AS. The impact of minimum unit pricing on traumatic brain injury in Scotland: a retrospective cohort study of routine national data. Br J Neurosurg 2023; 37:1628-1634. [PMID: 36916311 DOI: 10.1080/02688697.2023.2181312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 02/12/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a common cause of disability and mortality and is associated with alcohol consumption. On 1st May 2018, the Scottish Government introduced Minimum Unit Pricing (MUP) legislation which set the floor price at which alcohol can be sold to 50 pence per unit. While MUP has led to a 7.6% decrease in off trade alcohol purchases, there are limited studies investigating the clinical impact of this legislation. This study aims to explore the impact of MUP on traumatic brain injury in Scotland. METHODS Retrospective cohort study using routinely collected national data collated by the Scottish Trauma Audit Group. Data were requested for all TBI incidents from 1st May to 31st December for both 2017 and 2018. Primary outcome was alcohol-related TBI. Secondary outcomes were injury mechanism, injury severity, clinical course, and short-term mortality. Analysis was conducted using multiple regression models adjusted for age, sex, season, and deprivation. RESULTS A total of 1166 patients (66% male, and 46% in the 60-79-year bracket) were identified. Alcohol-related TBI was evident in 184 of 509 (36%) patients before MUP and in 239 of 657 (36%) patients injured after its implementation (p = 0.638). Further, there was no change in injury mechanism, injury severity, hospital course and short-term mortality of TBI after MUP. CONCLUSIONS MUP has not resulted in a change in alcohol-related TBI nor in the mechanism and severity of TBI. Limitations in two-point analysis mean that findings should be interpreted with caution and further studies investigating the clinical outcomes of MUP must be conducted.
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Affiliation(s)
- Mohammed Talha Bashir
- The School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Pragnesh Bhatt
- Department of Neurosurgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Ibraaheem Khan
- The School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Jamie G Cooper
- Department of Emergency Medicine, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Amudha S Poobalan
- The School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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7
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Bulis S, Talmy T, Radomislensky I, Gelman D, Bushinsky S, Nachum D, Tomer G, Tsur AM, Paulman O, Gendler S, Almog O, Benov A. The Association Between Glasgow Coma Scale Scores and PTSD in Military Trauma Casualties: Does Mental Status Following Injury Play a Role in PTSD Development? Mil Med 2023; 188:428-435. [PMID: 37948204 DOI: 10.1093/milmed/usad180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/23/2023] [Accepted: 08/07/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is prevalent among military personnel and may arise following a wide range of traumatic exposures. Consciousness level following traumatic injury may play a role in the development of PTSD, but its effects have been primarily investigated in the context of traumatic brain injury. METHODS Registry-based study surveying three databases documenting care from point of injury to long-term rehabilitation of traumatic injuries among military personnel. The study population was divided according to Glasgow Coma Scale (GCS) scores upon emergency department admission (GCS scores 15, 13 and 14, 9-12, and 3-8), with PTSD diagnoses being determined according to disability claim records. Multivariable logistic regression was utilized to determine the association between GCS score at admission and PTSD. RESULTS Overall, 3,376 military personnel hospitalized following traumatic injuries between 1997 and 2020 were included. The majority were male (92.3%), with a median age of 20 (interquartile range 19-22) at the injury time. Of these, 569 (16.9%) were diagnosed with PTSD according to disability claims, with a median follow-up time of 10.9 years. PTSD diagnosis was most prevalent (30.3% of patients), with a GCS score of 13 and 14. In the adjusted multivariable model, a GCS score of 13 and 14 was associated with significantly higher odds of PTSD diagnosis when compared to a GCS score of 15 (odds ratio 2.19, 95% CI, 1.21-3.88). The associations of other GCS groupings with PTSD diagnosis were nonsignificant. CONCLUSIONS Minimally impaired consciousness following traumatic injuries is associated with increased odds of PTSD. The role of patient awareness, analgesia, and sedation following an injury in developing PTSD warrants further investigation and could guide early diagnosis and preventive interventions.
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Affiliation(s)
- Shir Bulis
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9574869, Israel
| | - Irina Radomislensky
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer 5262000, Israel
| | - Daniel Gelman
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9574869, Israel
| | - Shir Bushinsky
- Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Jerusalem 91905, Israel
| | - Dikla Nachum
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Gaia Tomer
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Avishai M Tsur
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Omer Paulman
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9574869, Israel
| | - Avi Benov
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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8
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John Baptist S, Joel K, Kaddumukasa M, Michael D, Kasereka Kamabu L, Galukande M, Kaddumukasa M, Sajatovic M, Timothy Kabanda M. Fibrinogen; a predictor of injury severity and mortality among patients with traumatic brain injury in Sub-Saharan Africa: A cross-sectional observational study. Medicine (Baltimore) 2023; 102:e35685. [PMID: 37861493 PMCID: PMC10589598 DOI: 10.1097/md.0000000000035685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023] Open
Abstract
Studies show that fibrinogen concentrations <2 g/L in patients with traumatic brain injury (TBI) is associated with increased mortality. However, little is known regarding fibrinogen levels and TBI severity as well as mortality in sub-Saharan Africa despite shouldering a high burden of TBI. We therefore set out to determine whether fibrinogen levels are associated with TBI severity and outcome. To determine the sensitivity and specificity of fibrinogen levels and the association with severity and mortality among TBI patients at Mulago Hospital. We prospectively enrolled 213 patients with TBI aged between 13 and 60 years of age and presenting within 24 hours of injury. Patients with preexisting coagulopathy, concurrent use of anticoagulant or antiplatelet agents, preexisting hepatic insufficiency, diabetes mellitus and who were pregnant were excluded. Fibrinogen levels were determined using the Clauss fibrinogen assay. Logistic regression analyses were conducted to identify the association between fibrinogen level and 7-day outcomes. Majority of the patients were male (88.7%) and nearly half were aged 30 or less (48.8%). Fibrinogen levels <2 g/L were observed in 35.1% of the study participants. The average time spent in the study was 3.7 ± 2.4 days. The sensitivity and specificity using fibrinogen <2 g/L was 56.5% and 72.9% respectively. Fibrinogen levels predict TBI severity with an AUC = 0.656 (95% CI 0.58-0.73: P = .000) Fibrinogen levels <2 g/L (hypofibrinogenemia) were independently associated with severe TBI. (Adjusted odds ratio 2.87 CI, 1.34-6.14: P = .007). Levels above 4.5 g/L were also independently associated with injury severity (adjusted odds ratio 2.89, CI 1.12-7.48: P < .05) Fibrinogen levels more than 4.5 g/L were independently associated with mortality (OR 4.5, CI; 1.47-13.61, P < .05). The fibrinogen level is a useful tool in predicting severity including mortality of TBI. Fibrinogen levels may be used as an additional tool to screen TBI patients for injury severity especially among patients with Glasgow coma scale scores of <14.
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Affiliation(s)
| | - Kiryabwire Joel
- Neurosurgery Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Martin Kaddumukasa
- Department of Medicine, College of Health Sciences Makerere University, Kampala, Uganda
| | - Devereaux Michael
- Neurological and Behavioral Outcome Center, University Hospitals, Case Medical Center, Cleveland, OH, USA
| | | | - Moses Galukande
- Department of Surgery, College of Health Sciences Makerere University, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, College of Health Sciences Makerere University, Kampala, Uganda
| | - Martha Sajatovic
- Neurological and Behavioral Outcome Center, University Hospitals, Case Medical Center, Cleveland, OH, USA
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9
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Marhold F, Prihoda R, Pruckner P, Eder V, Glechner A, Klerings I, Gombos J, Popadic B, Antoni A, Sherif C, Scheichel F. The importance of additional intracranial injuries in epidural hematomas: detailed clinical analysis, long-term outcome, and literature review in surgically managed epidural hematomas. Front Surg 2023; 10:1188861. [PMID: 37592941 PMCID: PMC10427765 DOI: 10.3389/fsurg.2023.1188861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/03/2023] [Indexed: 08/19/2023] Open
Abstract
Objective Epidural hematomas (EDH) occur in up to 8.2% of all traumatic brain injury patients, with more than half needing surgical treatment. In most patients suffering from this perilous disease, good recovery with an excellent clinical course is possible. However, the clinical course is mainly dependent on the presence of additional intracerebral injuries. Few studies comparing isolated and combined EDH in detail exist. Methods We performed a retrospective single-center study from April 2002 to December 2014. The mean follow-up time was more than 6 years. In addition to analyzing diverse clinicoradiological data, we performed a systematic literature review dealing with a detailed comparison of patients with (combined) and without (isolated) additional intracerebral injuries. Results We included 72 patients in the study. With increasing age, combined EDH had a higher incidence than isolated EDH. The mortality rate of the patients in the cohort was 10%, of which 0% had isolated EDH and 10% had combined EDH. Good recovery was achieved in 69% of patients, of which 91% had isolated EDH and 50% had combined EDH. A subgroup analysis of the different additional intracerebral injuries in combined EDH demonstrated no significant difference in outcome. A systematic literature review only identified six studies. Patients with isolated EDH had a statistically significantly lower mortality risk [relative risk (RR): 0.22; 95% CI: 0.12-0.39] and a statistically significantly lower risk of unfavorable Glasgow outcome scale score (RR: 0.21; 95% CI: 0.14-0.31) than patients with combined EDH. Conclusions An excellent outcome in patients with surgically treated isolated EDH is possible. Furthermore, patients with combined EDH or isolated EDH with a low Glasgow coma scale (GCS) score may have favorable outcomes in 50% of the cases. Therefore, every possible effort for treatment should be made for this potentially lethal injury.
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Affiliation(s)
- Franz Marhold
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Romana Prihoda
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Philip Pruckner
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Vanessa Eder
- Division of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Anna Glechner
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems, Austria
| | - Irma Klerings
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems, Austria
| | - Jozsef Gombos
- Department of Urology, General Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Branko Popadic
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Anna Antoni
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Camillo Sherif
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Florian Scheichel
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
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10
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Marino MA, Siddiqi I, Maniakhina L, Burton PM, Reier L, Duong J, Miulli DE. Neurosurgical Outcomes in Severe Traumatic Brain Injuries Between Service Lines: Review of a Single Institution Database. Cureus 2023; 15:e37445. [PMID: 37182018 PMCID: PMC10174636 DOI: 10.7759/cureus.37445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
Severe traumatic injury (sTBI) continues to be a common source of morbidity and mortality. While there have been several advances in understanding the pathophysiology of this injury, the clinical outcome has remained grim. These trauma patients often require multidisciplinary care and are admitted to a surgical service line, depending on hospital policy. A retrospective chart review spanning 2019-2022 was completed using the electronic health record of the neurosurgery service. We identified 140 patients with a Glasgow Coma Scale (GCS) of eight or less, ages 18-99, who were admitted to a level-one trauma center in Southern California. Seventy patients were admitted under the neurosurgery service, while the other half were admitted to the surgical intensive care unit (SICU) service after initial assessment in the emergency department by both services to evaluate for multisystem injury. Between both groups, the injury severity scores that evaluated patients' overall injuries were not significantly different. The results demonstrate a significant difference in GCS change, modified Rankin Scale (mRS) change, and Glasgow Outcome Scale (GOS) change between the two groups. Furthermore, the mortality rate differed between neurosurgical care and other service care by 27% and 51%, respectively, despite similar Injury Severity Scores (ISS) (p=0.0026). Therefore, this data demonstrates that a well-trained neurosurgeon with critical care experience can safely manage a severe traumatic brain injury patient with an isolated head injury as a primary service while in the intensive care unit. Since injury severity scores did not differ between these two service lines, we further theorize that this is likely due to a deep understanding of the nuances of neurosurgical pathophysiology and Brain Trauma Foundation (BTF) guidelines.
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Affiliation(s)
- Maxwell A Marino
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Imran Siddiqi
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Lana Maniakhina
- Medical School, Edward Via College of Osteopathic Medicine, Spartanburg, USA
- Medical School, Cleveland Clinic Indian River Medical Center, Vero Beach, USA
| | - Patrick M Burton
- Medical School, Edward Via College of Osteopathic Medicine, Spartanburg, USA
| | - Louis Reier
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Jason Duong
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
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11
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Kiwanuka O, Lassarén P, Thelin EP, Hånell A, Sandblom G, Fagerdahl A, Boström L. Long-term health-related quality of life after trauma with and without traumatic brain injury: a prospective cohort study. Sci Rep 2023; 13:2986. [PMID: 36805021 PMCID: PMC9941121 DOI: 10.1038/s41598-023-30082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
To purpose was to assess and compare the health-related quality of life (HRQoL) and risk of depression two years after trauma, between patients with and without traumatic brain injury (TBI) in a mixed Swedish trauma cohort. In this prospective cohort study, TBI and non-TBI trauma patients included in the Swedish Trauma registry 2019 at a level II trauma center in Stockholm, Sweden, were contacted two years after admission. HRQoL was assessed with RAND-36 and EQ-5D-3L, and depression with Montgomery Åsberg depression Rating Scale self-report (MADRS-S). Abbreviated Injury Score (AIS) head was used to grade TBI severity, and American Society of Anesthesiologists (ASA) score was used to assess comorbidities. Data were compared using Chi-squared test, Mann Whitney U test and ordered logistic regression, and Bonferroni correction was applied. A total of 170 of 737 eligible patients were included. TBI was associated with higher scores in 5/8 domains of RAND-36 and 3/5 domains of EQ-5D (p < 0.05). No significant difference in MADRS-S. An AIS (head) of three or higher was associated with lower scores in five domains of RAND-36 and two domains of EQ-5D but not for MADRS-S. An ASA-score of three was associated with lower scores in all domains of both RAND-36 (p < 0.05, except mental health) and EQ-5D (p < 0.001, except anxiety/depression), but not for MADRS-S. In conclusion, patients without TBI reported a lower HRQoL than TBI patients two years after trauma. TBI severity assessed according to AIS (head) was associated with HRQoL, and ASA-score was found to be a predictor of HRQoL, emphasizing the importance of considering pre-injury health status when assessing outcomes in TBI patients.
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Affiliation(s)
- Olivia Kiwanuka
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden. .,Department of Surgery, Södersjukhuset, Stockholm, Sweden.
| | - Philipp Lassarén
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Eric P. Thelin
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Hånell
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Gabriel Sandblom
- grid.4714.60000 0004 1937 0626Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Ami Fagerdahl
- grid.4714.60000 0004 1937 0626Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Lennart Boström
- grid.416648.90000 0000 8986 2221Department of Surgery, Södersjukhuset, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
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12
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Modifications of Glasgow Coma Scale—a Systematic Review. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03678-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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13
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Selvakumar S, Chan K, Ngatuvai M, Newsome K, Ang D, Bilski T, Elkbuli A. Timing of tracheostomy in patients with severe traumatic brain injuries: The need for tailored practice management guidelines. Injury 2022; 53:2717-2724. [PMID: 35768327 DOI: 10.1016/j.injury.2022.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/01/2022] [Accepted: 06/20/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is one of the leading causes of fatal trauma, and patients often require prolonged ventilation and tracheostomy. There are currently no standardized guidelines regarding the optimal timing of tracheostomy placement for mechanically ventilated patients with severe TBI. This review aims to investigate the impact of tracheostomy timing on the clinical outcomes in patients with severe TBI. METHODS A literature search was conducted according to PRISMA 2020 guidelines. PubMed, Google Scholar, EMBASE, MedLine, Web of Science, Cochrane, and CINAHL were searched for studies evaluating the impact of early versus late tracheostomy on TBI patient outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Newcastle-Ottawa Scale (NOS) were used for quality of evidence and risk of bias assessment, respectively. RESULTS A total of nine studies met eligibility criteria. All nine studies investigated tracheostomy timing in severe TBI patients and demonstrated that early tracheostomy is associated with decreased ICU length-of-stay (LOS) and increased ventilator free-days compared to late tracheostomy. CONCLUSION Current evidence suggests that patients with severe TBI following traumatic injury may benefit from an early tracheostomy due to improved clinical outcomes, including decreased MV duration and ICU-LOS, compared to late tracheostomy. Further multi-institutional studies are needed to develop evidence-based guidelines.
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Affiliation(s)
| | - Kelvin Chan
- NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Micah Ngatuvai
- NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Kevin Newsome
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, Ocala, FL, USA
| | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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14
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Satyadev N, Warman PI, Seas A, Kolls BJ, Haglund MM, Fuller AT, Dunn TW. Machine Learning for Predicting Discharge Disposition After Traumatic Brain Injury. Neurosurgery 2022; 90:768-774. [PMID: 35319523 DOI: 10.1227/neu.0000000000001911] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/16/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Current traumatic brain injury (TBI) prognostic calculators are commonly used to predict the mortality and Glasgow Outcome Scale, but these outcomes are most relevant for severe TBI. Because mild and moderate TBI rarely reaches severe outcomes, there is a need for novel prognostic endpoints. OBJECTIVE To generate machine learning (ML) models with a strong predictive capacity for trichotomized discharge disposition, an outcome not previously used in TBI prognostic models. The outcome can serve as a proxy for patients' functional status, even in mild and moderate patients with TBI. METHODS Using a large data set (n = 5292) of patients with TBI from a quaternary care center and 84 predictors, including vitals, demographics, mechanism of injury, initial Glasgow Coma Scale, and comorbidities, we trained 6 different ML algorithms using a nested-stratified-cross-validation protocol. After optimizing hyperparameters and performing model selection, isotonic regression was applied to calibrate models. RESULTS When maximizing the microaveraged area under the receiver operating characteristic curve during hyperparameter optimization, a random forest model exhibited top performance. A random forest model was also selected when maximizing the microaveraged area under the precision-recall curve. For both models, the weighted average area under the receiver operating characteristic curves was 0.84 (95% CI 0.81-0.87) and the weighted average area under the precision-recall curves was 0.85 (95% CI 0.82-0.88). CONCLUSION Our group presents high-performing ML models to predict trichotomized discharge disposition. These models can assist in optimization of patient triage and treatment, especially in cases of mild and moderate TBI.
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Affiliation(s)
- Nihal Satyadev
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Pranav I Warman
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Andreas Seas
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Brad J Kolls
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, North Carolina, USA
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael M Haglund
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, North Carolina, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Anthony T Fuller
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, North Carolina, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Timothy W Dunn
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, North Carolina, USA
- Department of Biomedical Engineering, Duke Pratt School of Engineering, Durham, North Carolina, USA
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15
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A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients. Sci Rep 2022; 12:3336. [PMID: 35228569 PMCID: PMC8885918 DOI: 10.1038/s41598-022-06787-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 02/04/2022] [Indexed: 11/08/2022] Open
Abstract
In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50-64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69-0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.
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16
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Choi Y, Park JH, Hong KJ, Ro YS, Song KJ, Shin SD. Development and validation of a prehospital-stage prediction tool for traumatic brain injury: a multicentre retrospective cohort study in Korea. BMJ Open 2022; 12:e055918. [PMID: 35022177 PMCID: PMC8756263 DOI: 10.1136/bmjopen-2021-055918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Predicting diagnosis and prognosis of traumatic brain injury (TBI) at the prehospital stage is challenging; however, using comprehensive prehospital information and machine learning may improve the performance of the predictive model. We developed and tested predictive models for TBI that use machine learning algorithms using information that can be obtained in the prehospital stage. DESIGN This was a multicentre retrospective study. SETTING AND PARTICIPANTS This study was conducted at three tertiary academic emergency departments (EDs) located in an urban area of South Korea. The data from adult patients with severe trauma who were assessed by emergency medical service providers and transported to three participating hospitals between 2014 to 2018 were analysed. RESULTS We developed and tested five machine learning algorithms-logistic regression analyses, extreme gradient boosting, support vector machine, random forest and elastic net (EN)-to predict TBI, TBI with intracranial haemorrhage or injury (TBI-I), TBI with ED or admission result of admission or transferred (TBI with non-discharge (TBI-ND)) and TBI with ED or admission result of death (TBI-D). A total of 1169 patients were included in the final analysis, and the proportions of TBI, TBI-I, TBI-ND and TBI-D were 24.0%, 21.5%, 21.3% and 3.7%, respectively. The EN model yielded an area under receiver-operator curve of 0.799 for TBI, 0.844 for TBI-I, 0.811 for TBI-ND and 0.871 for TBI-D. The EN model also yielded the highest specificity and significant reclassification improvement. Variables related to loss of consciousness, Glasgow Coma Scale and light reflex were the three most important variables to predict all outcomes. CONCLUSION Our results inform the diagnosis and prognosis of TBI. Machine learning models resulted in significant performance improvement over that with logistic regression analyses, and the best performing model was EN.
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Affiliation(s)
- Yeongho Choi
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jeong Ho Park
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ki Jeong Hong
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Sang Do Shin
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
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17
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Epstein D, Rakedzon S, Kaplan B, Ben Lulu H, Chen J, Samuel N, Lipsky AM, Miller A, Bahouth H, Raz A. Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness. Am J Emerg Med 2021; 52:159-165. [PMID: 34922237 DOI: 10.1016/j.ajem.2021.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/10/2021] [Accepted: 12/08/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. METHODS Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. RESULTS In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively. CONCLUSION Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.
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Affiliation(s)
- Danny Epstein
- Critical Care Division, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel.
| | - Stav Rakedzon
- Department of Internal Medicine B, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Ben Kaplan
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel
| | - Hen Ben Lulu
- Trauma and Emergency Surgery, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Jacob Chen
- Hospital Management, Meir Medical Center, Tchernichovsky St 59, Kefar Saba 4428164, Israel; Sackler Faculty of Medicine, Tel Aviv University, Klachkin St 35, Tel Aviv 6997801, Israel
| | - Nir Samuel
- Pediatric Emergency Department, Schneider Children's Medical Center, Kaplan St 14, Petah Tikva 4920235, Israel
| | - Ari M Lipsky
- Emergency Department, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula 1834111, Israel
| | - Asaf Miller
- Medical Intensive Care Unit, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Hany Bahouth
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel; Trauma and Emergency Surgery, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel; Department of Anesthesiology, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
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Schmid W, Fan Y, Chi T, Golanov E, Regnier-Golanov AS, Austerman RJ, Podell K, Cherukuri P, Bentley T, Steele CT, Schodrof S, Aazhang B, Britz GW. Review of wearable technologies and machine learning methodologies for systematic detection of mild traumatic brain injuries. J Neural Eng 2021; 18. [PMID: 34330120 DOI: 10.1088/1741-2552/ac1982] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/30/2021] [Indexed: 12/16/2022]
Abstract
Mild traumatic brain injuries (mTBIs) are the most common type of brain injury. Timely diagnosis of mTBI is crucial in making 'go/no-go' decision in order to prevent repeated injury, avoid strenuous activities which may prolong recovery, and assure capabilities of high-level performance of the subject. If undiagnosed, mTBI may lead to various short- and long-term abnormalities, which include, but are not limited to impaired cognitive function, fatigue, depression, irritability, and headaches. Existing screening and diagnostic tools to detect acute andearly-stagemTBIs have insufficient sensitivity and specificity. This results in uncertainty in clinical decision-making regarding diagnosis and returning to activity or requiring further medical treatment. Therefore, it is important to identify relevant physiological biomarkers that can be integrated into a mutually complementary set and provide a combination of data modalities for improved on-site diagnostic sensitivity of mTBI. In recent years, the processing power, signal fidelity, and the number of recording channels and modalities of wearable healthcare devices have improved tremendously and generated an enormous amount of data. During the same period, there have been incredible advances in machine learning tools and data processing methodologies. These achievements are enabling clinicians and engineers to develop and implement multiparametric high-precision diagnostic tools for mTBI. In this review, we first assess clinical challenges in the diagnosis of acute mTBI, and then consider recording modalities and hardware implementation of various sensing technologies used to assess physiological biomarkers that may be related to mTBI. Finally, we discuss the state of the art in machine learning-based detection of mTBI and consider how a more diverse list of quantitative physiological biomarker features may improve current data-driven approaches in providing mTBI patients timely diagnosis and treatment.
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Affiliation(s)
- William Schmid
- Department of Electrical and Computer Engineering and Neuroengineering Initiative (NEI), Rice University, Houston, TX 77005, United States of America
| | - Yingying Fan
- Department of Electrical and Computer Engineering and Neuroengineering Initiative (NEI), Rice University, Houston, TX 77005, United States of America
| | - Taiyun Chi
- Department of Electrical and Computer Engineering and Neuroengineering Initiative (NEI), Rice University, Houston, TX 77005, United States of America
| | - Eugene Golanov
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX 77030, United States of America
| | | | - Ryan J Austerman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX 77030, United States of America
| | - Kenneth Podell
- Department of Neurology, Houston Methodist Hospital, Houston, TX 77030, United States of America
| | - Paul Cherukuri
- Institute of Biosciences and Bioengineering (IBB), Rice University, Houston, TX 77005, United States of America
| | - Timothy Bentley
- Office of Naval Research, Arlington, VA 22203, United States of America
| | - Christopher T Steele
- Military Operational Medicine Research Program, US Army Medical Research and Development Command, Fort Detrick, MD 21702, United States of America
| | - Sarah Schodrof
- Department of Athletics-Sports Medicine, Rice University, Houston, TX 77005, United States of America
| | - Behnaam Aazhang
- Department of Electrical and Computer Engineering and Neuroengineering Initiative (NEI), Rice University, Houston, TX 77005, United States of America
| | - Gavin W Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX 77030, United States of America
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Wendling-Keim DS, Hefele A, Muensterer O, Lehner M. Trauma Scores and Their Prognostic Value for the Outcome Following Pediatric Polytrauma. Front Pediatr 2021; 9:721585. [PMID: 34540770 PMCID: PMC8446435 DOI: 10.3389/fped.2021.721585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/04/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose: The management and prognostic assessment of pediatric polytrauma patients can pose substantial challenges. Trauma scores developed for adults are not universally applicable in children. An accurate prediction of the severity of trauma and correct assessment of the necessity of surgical procedures are important for optimal treatment. Several trauma scores are currently available, but the advantages and drawbacks for use in pediatric patients are unclear. This study examines the value of the trauma scores Injury Severity Score (ISS), Pediatric Trauma Score (PTS), National Advisory Committee for Aeronautics (NACA), and Glasgow Coma Score (GCS) for the assessment of the polytraumatized child. Methods: In a retrospective study, 97 patients aged 0-17 years who presented with polytrauma and an ISS ≥16 in the trauma bay were included in the study. Patient records including radiological studies were analyzed. Pathological imaging findings and emergency surgery were assessed as outcome variables and the predictive value of the trauma scores were analyzed using receiver operator characteristic (ROC) curves. Statistical significance was set at an alpha level of P ≤ 0.05. Results: In this study, 35 of the 97 studied children had pathological cranial computed findings. These either underwent craniectomy or trepanation or a parenchymal catheter was placed for intracranial pressure monitoring. Abdominal trauma was present in 45 patients, 16 of which were treated surgically. Forty-three patients arrived with thoracic injuries, 10 of which received a thoracic drainage. One child underwent an emergency thoracotomy. Predictive accuracy for emergency surgery calculated using receiver-operator characteristic (ROC) curves was highest for ISS and NACA scores (0,732 and 0.683, respectively), and lower for GCS (0.246) and PTS (0.261). Conclusion: In our study cohort, initial ISS and NACA scores better predicted operative interventions and outcome than PTS or GCS for polytraumatized pediatric patients.
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Affiliation(s)
- Danielle S Wendling-Keim
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Anja Hefele
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Oliver Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Markus Lehner
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany.,Department of Pediatric Surgery, Children's Hospital, Luzerner Kantonsspital, Lucerne, Switzerland
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Park J, Park T, Ko JI, Yeo W. Alcohol Intoxication and Glasgow Coma Scale Scores in Patients with Head Trauma. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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STING-Mediated Autophagy Is Protective against H 2O 2-Induced Cell Death. Int J Mol Sci 2020; 21:ijms21197059. [PMID: 32992769 PMCID: PMC7582849 DOI: 10.3390/ijms21197059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022] Open
Abstract
Stimulator of interferon genes (STING)-mediated type-I interferon signaling is a well characterized instigator of the innate immune response following bacterial or viral infections in the periphery. Emerging evidence has recently linked STING to various neuropathological conditions, however, both protective and deleterious effects of the pathway have been reported. Elevated oxidative stress, such as neuroinflammation, is a feature of a number of neuropathologies, therefore, this study investigated the role of the STING pathway in cell death induced by elevated oxidative stress. Here, we report that the H2O2-induced activation of the STING pathway is protective against cell death in wildtype (WT) MEFSV40 cells as compared to STING−/− MEF SV40 cells. This protective effect of STING can be attributed, in part, to an increase in autophagy flux with an increased LC3II/I ratio identified in H2O2-treated WT cells as compared to STING−/− cells. STING−/− cells also exhibited impaired autophagic flux as indicated by p62, LC3-II and LAMP2 accumulation following H2O2 treatment, suggestive of an impairment at the autophagosome-lysosomal fusion step. This indicates a previously unrecognized role for STING in maintaining efficient autophagy flux and protecting against H2O2-induced cell death. This finding supports a multifaceted role for the STING pathway in the underlying cellular mechanisms contributing to the pathogenesis of neurological disorders.
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Keenan HT, Clark AE, Holubkov R, Cox CS, Patel RP, Moore KR, Ewing-Cobbs L. Latent Class Analysis to Classify Injury Severity in Pediatric Traumatic Brain Injury. J Neurotrauma 2020; 37:1512-1520. [PMID: 32103698 PMCID: PMC8024352 DOI: 10.1089/neu.2019.6874] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Heterogeneity of injury severity among children with traumatic brain injury (TBI) classified by the Glasgow Coma Scale (GCS) makes comparisons across research cohorts, enrollment in clinical trials, and clinical predictions of outcomes difficult. The present study uses latent class analysis (LCA) to distinguish severity subgroups from a prospective cohort of 433 children 2.5-15 years of age with TBI who were recruited from two level 1 pediatric trauma centers. Indicator variables available within 48 h post-injury including emergency department (ED) GCS, hospital motor GCS, Abbreviated Injury Score (AIS), Rotterdam Score, hypotension in the ED, and pre-hospital loss of consciousness, intubation, seizures, and sedation were evaluated to define subgroups. To understand whether latent class subgroups were predictive of clinically meaningful outcomes, the Pediatric Injury Functional Outcome Scale (PIFOS) at 6 and 12 months, and the Behavior Rating Inventory of Executive Function at 12 months, were compared across subgroups. Then, outcomes were examined by GCS (primary) and AIS (secondary) classification alone to assess whether LCA provided improved outcome prediction. LCA identified four distinct increasing severity subgroups (1-4). Unlike GCS classification, mean outcome differences on PIFOS at 6 months showed decreasing function across classes. PIFOS differences relative to the lowest latent class (LC1) were: LC2 2.27 (0.83, 3.72), LC3 3.99 (1.88, 6.10), and LC4 11.2 (7.04, 15.4). Differences in 12 month outcomes were seen between the most and least severely injured groups. Differences in outcomes in relation to AIS were restricted to the most and less severely injured at both time points. This study distinguished four latent classes that are clinically meaningful, distinguished a more homogenous severe injury group, and separated children by 6-month functional outcomes better than GCS alone. Systematic reporting of these variables would allow comparisons across research cohorts, potentially improve clinical predictions, and increase sensitivity to treatment effects in clinical trials.
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Affiliation(s)
- Heather T. Keenan
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Amy E. Clark
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Charles S. Cox
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Rajan P. Patel
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Kevin R. Moore
- Department of Medical Imaging, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Linda Ewing-Cobbs
- Department of Pediatrics and Children's Learning Institute, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Firsching R, Voellger B, Woischneck D, Rashidi AM, König R, Luchtmann M. Collision of Priorities in Posttraumatic Coma and Suspected Multiple Injuries: A Prospective Multicenter Trial. J Neurol Surg A Cent Eur Neurosurg 2020; 81:430-441. [PMID: 32438418 DOI: 10.1055/s-0040-1701620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The presence of multiple injuries in addition to a traumatic brain injury (TBI) is initially uncertain in most patients with posttraumatic coma. The interdisciplinary team of physicians in charge of initial treatment after hospital admission may face a collision of vital priorities. The purpose of this study was to analyze which diagnostic and surgical measures were given priority over others in comatose patients after injury and to draw conclusions from these data. METHODS In this prospective multicenter cohort study, the outcomes of 1,003 comatose patients with suspected multiple injuries were studied. The analysis was divided into an early and a late stage. Diagnostic and surgical measures were analyzed for a 6-month period. The prognostic value of the Glasgow Coma Scale (GCS) and the World Federation of Neurosurgical Societies grading scale were investigated. RESULTS Removal of intracranial hematomas and decompressive craniotomies were the most frequent procedures within the first 48 hours after admission to the hospital. Prognosis depends on the location and the combination of injuries. Outcome is significantly correlated to initial signs of brainstem dysfunction. The GCS did not adequately predict clinical outcome. CONCLUSION Comatose patients with suspected multiple injuries should only be admitted to hospitals with a continuous neurosurgical service because intracranial operations are more frequent in the first 48 hours than extracranial operations. Depending on the neurologic status of the patient, an urgent surgical decompression may be essential for a good outcome. The GCS alone is not a sufficient tool for the neurologic assessment and the prognosis of patients with multiple injuries. The onset of clinical signs of brainstem dysfunction indicates a critical deterioration of the functioning of the central nervous system. The priority of surgical measures should be tailored accordingly.
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Affiliation(s)
- Raimund Firsching
- Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Klinik für Neurochirurgie, Magdeburg, Germany
| | - Benjamin Voellger
- Otto-von-Guericke-Universitaet, Klinik für Neurochirurgie, Magdeburg, Germany
| | | | - Ali Mohammed Rashidi
- Klinik für Neurochirurgie Magdeburg, Universitätsklinikum Magdeburg, Sachsen-Anhalt, Germany
| | - Rebecca König
- Klinik für Neurochirurgie Magdeburg, Universitätsklinikum Magdeburg, Sachsen-Anhalt, Germany
| | - Michael Luchtmann
- Klinik für Neurochirurgie Magdeburg, Universitätsklinikum Magdeburg, Sachsen-Anhalt, Germany
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Gaertner LHC, Tsur N, Haller CS. Patients’ recovery after severe TBI is associated with their close relatives’ interpersonal functioning: a 12-months prospective cohort study. Brain Inj 2020; 34:764-772. [DOI: 10.1080/02699052.2020.1753241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Lynn H. C. Gaertner
- Department of Psychology, Harvard University, Cambridge, Massachusetts, USA
- Department of Psychology, University of Luebeck, Luebeck, Germany
| | - Noga Tsur
- School of Social Work, Tel Aviv University, Tel Aviv, Israel
| | - Chiara S. Haller
- Department of Psychology, Harvard University, Cambridge, Massachusetts, USA
- Division of Public Psychiatry, Massachusetts Mental Health Center, Harvard Medical School, Boston, Massachusetts, USA
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Hamböck M, Hosmann A, Seemann R, Wolf H, Schachinger F, Hajdu S, Widhalm H. The impact of implant material and patient age on the long-term outcome of secondary cranioplasty following decompressive craniectomy for severe traumatic brain injury. Acta Neurochir (Wien) 2020; 162:745-753. [PMID: 32025876 PMCID: PMC7066309 DOI: 10.1007/s00701-020-04243-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/23/2020] [Indexed: 12/17/2022]
Abstract
Background Secondary cranioplasty (CP) is considered to support the neurological recovery of patients after decompressive craniectomy (DC), but the treatment success might be limited by complications associated to confounders, which are not yet fully characterized. The aim of this study was to identify the most relevant factors based on the necessity to perform revision surgeries. Methods Data from 156 patients who received secondary CP following DC for severe traumatic brain injury (TBI) between 1984 and 2015 have been retrospectively analyzed and arranged into cohorts according to the occurrence of complications requiring surgical intervention. Results Cox regression analysis revealed a lower revision rate in patients with polymethylmethacrylate (PMMA) implants than in patients with autologous calvarial bone (ACB) implants (HR 0.2, 95% CI 0.1 to 1.0, p = 0.04). A similar effect could be observed in the population of patients aged between 18 and 65 years, who had a lower risk to suffer complications requiring surgical treatment than individuals aged under 18 or over 65 years (HR 0.4, 95% CI 0.2 to 0.9, p = 0.02). Revision rates were not influenced by the gender (p = 0.88), timing of the CP (p = 0.53), the severity of the TBI (p = 0.86), or the size of the cranial defect (p = 0.16). Conclusions In this study, the implant material and patient age were identified as the most relevant parameters independently predicting the long-term outcome of secondary CP. The use of PMMA was associated with lower revision rates than ACB and might provide a therapeutic benefit for selected patients with traumatic cranial defects. Electronic supplementary material The online version of this article (10.1007/s00701-020-04243-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martina Hamböck
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Rudolf Seemann
- Department of Cranio-Maxillofacial and Oral Surgery, Medical University of Vienna, Vienna, Austria
| | - Harald Wolf
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Florian Schachinger
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Widhalm
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Early enteral nutrition in patients with severe traumatic brain injury: a propensity score-matched analysis using a nationwide inpatient database in Japan. Am J Clin Nutr 2020; 111:378-384. [PMID: 31751450 DOI: 10.1093/ajcn/nqz290] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/30/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Whether enteral nutrition (EN) should be administered early in severe traumatic brain injury (TBI) patients has not been fully addressed. OBJECTIVE The present study aimed to evaluate whether early EN can reduce mortality or nosocomial pneumonia among severe TBI patients. METHODS Using the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2017 linked with the Survey for Medical Institutions, we identified patients admitted for intracranial injury with Japan Coma Scale scores ≥30 (corresponding to Glasgow Coma Scale scores ≤8) at admission. We designated patients who started EN within 2 d of admission as the early EN group, and those who started EN at 3-5 d after admission as the delayed EN group. The primary outcome was in-hospital mortality. The secondary outcome was nosocomial pneumonia. Propensity score-matched analyses were performed to compare the outcomes between the 2 groups. RESULTS We identified 3080 eligible patients during the 36-mo study period, comprising 1100 (36%) in the early EN group and 1980 (64%) in the delayed EN group. After propensity score matching, there was no significant difference in in-hospital mortality (difference: -0.3%; 95% CI: -3.7%, 3.1%) between the 2 groups. The proportion of nosocomial pneumonia was significantly lower in the early EN group than in the delayed EN group (difference: -3.2%; 95% CI: -5.9%, -0.4%). CONCLUSIONS Early EN may not reduce mortality, but may reduce nosocomial pneumonia in patients with severe TBI.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Physician Prehospital Care in Mexico City: Retrospective Analysis of Endotracheal Intubation in Patients with Severe Head Trauma. Prehosp Disaster Med 2020; 35:128-132. [PMID: 31973785 DOI: 10.1017/s1049023x20000035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION In Mexico, physicians have become part of public service prehospital care. Head injured patients are a sensitive group that can benefit from early advanced measures to protect the airway, with the objective to reduce hypoxia and maintain normocapnia. PROBLEM The occurrence of endotracheal intubation to patients with severe head injuries by prehospital physicians working at Mexico City's Service of Emergency Medical Care (SAMU) is unknown. METHODS A retrospective analysis of five-year data (2012-2016) from Mexico City's Medical Emergencies Regulation Center was performed. Only SAMU ambulance services were analyzed. Adult patients with a prehospital diagnosis of head injury based on mechanism of injury and physical examination with a Glasgow Coma Scale (GCS) <nine were included. RESULTS A total of 293 cases met the inclusion criteria; the mean GCS was five points. Of those, 150 (51.1%) patients were intubated. There was no difference in the occurrence of intubation among the different GCS scales, or if the patient was considered to have isolated head trauma versus polytrauma. Fifteen patients were intubated using sedation and neuromuscular blockage. Four patients were intubated with sedation alone and six patients with neuromuscular blockage alone. One patient was intubated using opioid analgesia, sedation, and neuromuscular blockage. CONCLUSIONS Patients with severe head injuries cared by prehospital physicians in Mexico City were intubated 51.1% of the time and were more likely to be intubated without the assistance of anesthetics.
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Auricular Electroacupuncture for Late Posttraumatic Epilepsy after Severe Brain Injury: A Retrospective Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:5798912. [PMID: 31737082 PMCID: PMC6815526 DOI: 10.1155/2019/5798912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/10/2019] [Accepted: 08/30/2019] [Indexed: 01/20/2023]
Abstract
Background Posttraumatic epilepsy (PTE) is a common complication of traumatic brain injury (TBI), which seriously affects patients' survival and recovery. Vagus nerve stimulation (VNS) is a nonpharmacological therapy for epilepsy. The auricular branch of the vagus nerve (ABVN) is the only peripheral branch and has antiepileptic effects, but the efficacy of ABVN stimulation as treatment of late PTE is uncertain. We retrospectively analyzed the clinical efficacy of ABVN stimulation by auricular electroacupuncture for the treatment of late PTE, and investigated the influence of sodium valproate and edaravone on the anti-PTE effects of auricular electroacupuncture. Method Univariate and multivariate logistic regression analyses were used to investigate the relationship of age, cause of PTE, use of auricular electroacupuncture, sodium valproate, and edaravone with the incidence of late PTE. To compare the curative effects of auricular electroacupuncture, 89 cases of late PTE were divided into an auricular electroacupuncture and a control group according to whether they were treated with auricular electroacupuncture. We further analyzed the influence of sodium valproate and edaravone on the effects of the treatment of PTE with auricular electroacupuncture. Results Among age, cause, use of auricular electroacupuncture, sodium valproate, and edaravone, the use of auricular electroacupuncture was associated with significantly reduced incidence of late PTE (P < 0.05). Compared with the control group, there were more seizure-free cases in the auricular electroacupuncture group (P < 0.01). The total effective rate of the auricular electroacupuncture group was 90%. The seizure-free rate among patients treated with auricular electroacupuncture was significantly reduced, regardless of the use of sodium valproate or edaravone (P < 0.05). Conclusion Auricular electroacupuncture can reduce the incidence of late PTE and is a safe and economical therapy for late PTE.
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Li Y, Chen L, Fang W, Chen H. Application value of procalcitonin, C-reactive protein and interleukin-6 in the evaluation of traumatic shock. Exp Ther Med 2019; 17:4586-4592. [PMID: 31086589 PMCID: PMC6488981 DOI: 10.3892/etm.2019.7492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/02/2019] [Indexed: 12/13/2022] Open
Abstract
Procalcitonin (PCT), C-reactive protein (CRP) and interleukin-6 (IL-6) were detected to explore the value of these inflammatory markers in the assessment of traumatic shock patients. The clinical data of 80 patients with traumatic shock and infections in Zhangzhou Municipal Hospital of Fujian Province from January 2014 to December 2017 were collected as the experimental group. During the same period, 80 acute trauma patients who did not suffer from traumatic shock were regarded as the control group. According to the prognosis outcomes, the experimental group was divided into 56 patients with good prognosis and 24 patients with poor prognosis. Also the PCT, CRP and IL-6 levels in serum of patients at admission (T1), 12 h after admission (T2), three days after admission (T3) and on day 7 (T4) were detected. The differences between the three inflammatory indicators, the pre-admission injury severity score (ISS score), the acute physiology and chronic psychological score (APACHE II score) were compared between the good prognosis and the poor prognosis group. The serum CRP at the T4 time period was significantly lower than both the T1 and T2 time periods (P<0.05). There were differences in serum PCT, CRP and IL-6 between the good prognosis and the poor prognosis group at the time of T1-T4 (P<0.05). The expression levels of PCT, CRP and IL-6 in the serum of patients with poor prognosis were higher than those with good prognosis (P<0.05). Pre-admission ISS scores and APACHE II scores in patients with good prognosis were lower than those with poor prognosis (P<0.05). Detection of PCT, CRP and IL-6 expression levels in serum of the patients has an important reference value for assessing the condition of patients with traumatic shock.
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Affiliation(s)
- Yang Li
- Department of Emergency, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Ling Chen
- Department of Emergency, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, Fujian 363000, P.R. China
| | - Wenge Fang
- Department of Emergency, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, Fujian 363000, P.R. China
| | - Huihong Chen
- Department of Emergency, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, Fujian 363000, P.R. China
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Prediction of Minimally Conscious State With Brain Stem Reflexes in Unconscious Patients After Traumatic Brain Injury. J Craniofac Surg 2019; 30:1942-1945. [PMID: 30908437 DOI: 10.1097/scs.0000000000005404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the predictive power of the brain stem reflexes (BSRs) for minimally conscious state in unconscious patients after traumatic brain injury. MATERIALS AND METHODS A total of 120 patients with duration of unconsciousness were enrolled in this study. BSRs were recorded 14 days after Traumatic brain injury, and classified into 3 grades. Predictors including BSRs, age, sex, Glasgow Coma Scale (GCS), and cause of injury were also analyzed, respectively. The outcome was divided into 2 groups including unconscious group and minimally conscious state (MCS) group. RESULTS Seventy-two of 120 were minimally conscious and 48 of 120 were unconscious at 6 months from the onset of injury. The BSRs outmatched the predictive accuracy of the GCS for outcome (AUROC, 0.853; 95% confidence interval, 0.753-0.953; and AUROC, 0.655; 95% confidence interval, 0.512-0.799, respectively). BSRs grade (P < 0.001) and GCS (P < 0.05) were significantly associated with the outcome. The accuracy of the whole regression model for predicting unconscious and MCS was 91.7% and 79.2%, respectively. CONCLUSION The BSRs grade shows a significantly higher accuracy for prediction of MCS compared with the GCS. BSRs grade is a simple, yet reliable and stratification tool for early decision making.
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Fitschen-Oestern S, Lippross S, Lefering R, Besch L, Klüter T, Schenzer-Hoffmann E, Seekamp A, TraumaRegister Dgu. Missed foot fractures in multiple trauma patients. BMC Musculoskelet Disord 2019; 20:121. [PMID: 30909889 PMCID: PMC6434880 DOI: 10.1186/s12891-019-2501-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/13/2019] [Indexed: 11/22/2022] Open
Abstract
Background Missed or underestimated injuries are one of the central problems in trauma care. Foot injuries can easily be missed because they lay beyond the regularly screened field of a trauma computer tomography scan (CT scan). During primary and secondary survey a careful examination of the extremities often becomes of secondary interest in the severely injured patient. Methods Thirty-four thousand ninety-one multiple trauma patients of the TraumaRegister DGU® were evaluated from 2002 to 2014. We differentiated between patients with foot injuries, patients with missed foot injuries and patients without foot injuries. Included were ankle fractures, calcaneus fractures, talus fractures, metatarsal fractures, toe fractures, amputation, soft tissue injuries and/or ligamentous injuries. Results Summarized evaluation of 34,091 trauma patients showed a share of 2532 patients with foot injuries. Time of diagnosis was documented in 2199 cases. 2055 patients had early diagnosed foot injuries and 144 patients had initially missed foot injuries. Missed foot injuries were especially found in patients with car accidents or fall from ≥3 m. Patients with higher Abbreviated Injury Scale (AIS) or lower Glasgow Coma Scale (GCS) were not significantly more affected by missed foot injuries. Missing foot injuries was also not caused by injury severity or higher age. Conclusions Our data highlights the need of careful evaluation of the feet during primary and secondary survey particularly when a tibia or femur fracture is diagnosed. Special attention should be turned to patients after car accidents or fall from great height. Suicide victims also need major attention. Patients with early operations also need careful examination and tertiary survey is highly recommended.
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Affiliation(s)
- Stefanie Fitschen-Oestern
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Arnold-Heller Straße 7, 24105, Kiel, Germany.
| | - Sebastian Lippross
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Arnold-Heller Straße 7, 24105, Kiel, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Lutz Besch
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Arnold-Heller Straße 7, 24105, Kiel, Germany
| | - Tim Klüter
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Arnold-Heller Straße 7, 24105, Kiel, Germany
| | - Elke Schenzer-Hoffmann
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Arnold-Heller Straße 7, 24105, Kiel, Germany
| | - Andreas Seekamp
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Arnold-Heller Straße 7, 24105, Kiel, Germany
| | - TraumaRegister Dgu
- Committee on Emergency Medicine, Intensive Care and Trauma Management, (Sektion NIS) of the German Trauma Society (DGU), Cologne, Germany
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Comparison of two simple models for prediction of short term mortality in patients after severe traumatic brain injury. Injury 2019; 50:65-72. [PMID: 30213562 DOI: 10.1016/j.injury.2018.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/06/2018] [Accepted: 08/23/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The subscale motor score of Glasgow Coma Scale (msGCS) and the Abbreviated Injury Score of head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim was to compare the prognostic performance of a HAIS-based prediction model including HAIS, pupil reactivity and age, and the reference prediction model including msGCS in emergency department (ED), pupil reactivity and age. METHODS Secondary analysis of a prospective epidemiological study including patients after severe TBI (HAIS > 3) with follow-up from the time of accident until 14 days or earlier death was performed in Switzerland. Performance of prediction, based on accuracy of discrimination [area under the receiver-operating curve (AUROC)], calibration (Hosmer-Lemeshow test) and validity (bootstrapping with 2000 repetitions to correct) for optimism of the two prediction models were investigated. A non-inferiority approach was performed and an a priori threshold for important differences was established. RESULTS The cohort included 808 patients [median age 56 {inter-quartile range (IQR) 33-71}, median motor part of GCS in ED 1 (1-6), abnormal pupil reactivity 29.0%] with a death rate of 29.7% at 14 days. The accuracy of discrimination was similar (AUROC HAIS-based prediction model: 0.839; AUROC msGCS-based prediction model: 0.826, difference of the 2 AUROC 0.013 (-0.007 to 0.037). A similar calibration was observed (Hosmer-Lemeshow X2 11.64, p = 0.168 vs. Hosmer-Lemeshow X2 8.66, p = 0.372). Internal validity of HAIS-based prediction model was high (optimism corrected AUROC: 0.837). CONCLUSIONS Performance of prediction for short-term mortality after severe TBI with HAIS-based prediction model was non-inferior to reference prediction model using msGCS as predictor.
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Pannatier M, Delhumeau C, Walder B. Comparison of two prehospital predictive models for mortality and impaired consciousness after severe traumatic brain injury. Acta Anaesthesiol Scand 2019; 63:74-85. [PMID: 30117150 DOI: 10.1111/aas.13229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 06/15/2018] [Accepted: 07/05/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The primary aim was to investigate the performance of a National Advisory Committee for Aeronautics based predictive model (NACA-BM) for mortality at 14 days and a reference model using motor GCS (GCS-RM). The secondary aim was to compare the models for impaired consciousness of survivors at 14 days (IC-14; GCS ≤ 13). METHODS Patients ≥16 years having sustained TBI with an abbreviated injury scale score of head region (HAIS) of >3 were included. Multivariate logistic regression models were used to test models for death and IC-14. The discrimination was assessed using area under the receiver-operating curves (AUROCs); noninferiority margin was -5% between the AUROCs. Calibration was assessed using the Hosmer Lemeshow goodness-of-fit test. RESULTS Six hundred and seventy seven patients were included. The median age was 54 (IQR 32-71). The mortality rate was 31.6%; 99 of 438 surviving patients (22.6%) had an IC-14. Discrimination of mortality was 0.835 (95%CI 0.803-0.867) for the NACA-BM and 0.839 (0.807-0.872) for the GCS-RM; the difference of the discriminative ability was -0.4% (-2.3% to +1.7%). Calibration was appropriate for the NACA-BM (χ2 8.42; P = 0. 393) and for the GCS-RM (χ2 3.90; P = 0. 866). Discrimination of IC-14 was 0.757 (0.706-0.808) for the NACA-BM and 0.784 (0.734-0.835) for the GCS-RM; the difference of the discriminative ability was -2.5% (-7.8% to +2.6%). Calibration was appropriate for the NACA-BM (χ2 10.61; P = 0.225) and for the GCS-RM (χ2 6.26; P = 0.618). CONCLUSIONS Prehospital prediction of mortality after TBI was good with both models, and the NACA-BM was not inferior to the GCS-RM. Prediction of IC-14 was moderate in both models.
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Affiliation(s)
- Michel Pannatier
- Division of Anaesthesiology; University Hospitals of Geneva; Geneva Switzerland
| | - Cécile Delhumeau
- Division of Anaesthesiology; University Hospitals of Geneva; Geneva Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology; University Hospitals of Geneva; Geneva Switzerland
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The Residential Status of Working Age Adults Following Severe Traumatic Brain Injury. BRAIN IMPAIR 2018. [DOI: 10.1017/brimp.2018.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objective: To describe place of residence and examine factors associated with place of residence following severe traumatic brain injury (TBI) in working age adults.Setting, participants, design: Retrospective cohort study (1 January 2007 to 31 December 2013) of adults (16–64 years) with severe TBI who survived to hospital discharge in Victoria, Australia.Main measures: Place of residence (dichotomised as ‘private residence’ and ‘other destination’) at 6, 12 and 24 months post injury. A modified Poisson model was fitted with a random effect for the participant.Results: There were 684 cases that were followed-up at one or more time points. At 24 months post injury, 87% (n = 537) adults with TBI were living at a private residence, of whom 66% did not require additional support. Cases were more likely to be living at a private residence at 24 months post injury compared to 6 months (adjusted relative risk = 1.08, 95% Confidence Interval, 1.04–1.11, p < .001). At 24 months post injury, 5% (n = 29) remained in rehabilitation and 4% (n = 23) lived in a nursing home.Conclusion: While the majority of cases were living at a private residence at 2 years post injury, 13% were residing in rehabilitation, a nursing home or other supported living. Longer follow-up is needed to understand if a transition to a private residence is possible for these groups.
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Venkata C, Kasal J. Cardiac Dysfunction in Adult Patients with Traumatic Brain Injury: A Prospective Cohort Study. Clin Med Res 2018; 16:57-65. [PMID: 30587559 PMCID: PMC6306140 DOI: 10.3121/cmr.2018.1437] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 10/09/2018] [Accepted: 10/31/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are limited data regarding the development of myocardial dysfunction after a traumatic brain injury (TBI). We investigated incidence, risk factors, and prognostic importance of cardiac dysfunction in adult patients admitted to the intensive care unit (ICU) after a moderate to severe TBI. METHODS Prospective observational study of consecutive patients admitted to neuro-trauma ICU with moderate to severe TBI from August 2014 to June 2015. RESULTS A total of 46 patients were included. Patients' mean (±SD) age was 44.7 (±20.7) years and mean Glasgow Coma Scale value was 5.6 (±3). Motor vehicle accident was the most common mechanism of TBI, with subdural and subarachnoid hemorrhages as the most common pathologies. Cardiac dysfunction developed in 6 of 46 (13%) patients. Patients with cardiac dysfunction had higher prevalence of diabetes mellitus (50% vs. 10%, P = 0.03) and higher proportion of electrocardiogram abnormalities (83% vs. 27%, P = 0.02) compared to the patients without cardiac dysfunction. Mean Glasgow Coma Scale scores were not significantly different between patients who developed cardiac dysfunction from those who did not (5.5 vs. 5.6, P = 0.95). Requirement for vasopressor support (33.3% vs. 40%, P = 1.0) and median ventilator days (5.2 vs. 4.7, P = 0.9) were similar between patients with and without cardiac dysfunction. There were no significant differences in hospital lengths of stay (12.3 vs. 13.8 days, P = 0.34) and hospital mortality (33% vs. 17.5%, P = 0.58) between the two groups. CONCLUSIONS Cardiac dysfunction occurs in patients after moderate to severe TBI, with mild to moderate reduction in left ventricular ejection fraction. Patients who developed cardiac dysfunction after TBI had a higher prevalence of diabetes mellitus and higher proportion of abnormalities in electrocardiograms. Development of cardiac dysfunction was not associated with adverse clinical outcomes.
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Affiliation(s)
- Chakradhar Venkata
- Corresponding Author: Chakradhar Venkata, MD, 62S S New Ballas Rd, Suite 7020, St. Louis, MO 63141 USA, Tel: (314) 251-6486, Fax: (314) 251-4155,
| | - Jan Kasal
- Department of Anesthesia and Critical Care Medicine, Washington University, St. Louis, Missouri USA
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Gross T, Braken P, Amsler F. Trauma center need: the American College of Surgeons' definition in contrast to Swiss highly specialized medicine regulations-a Swiss trauma center perspective. Eur J Trauma Emerg Surg 2018; 46:397-406. [PMID: 30317378 DOI: 10.1007/s00068-018-1027-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/06/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE According to the American College of Surgeons (ACS) recommendations, the benchmark for trauma center need (TCN) is an Injury Severity Score (ISS) > 15. In contrast, Swiss highly specialized medicine (HSM) regulations set out TCN for all patients with an ISS > 19 or an Abbreviated Injury Severity (AIS) of the head ≥ 3. This investigation assessed to what extent the modification might be justified. METHODS Consecutive analysis of all significantly injured (new ISS, NISS ≥ 8) adults treated in a trauma center from 2010 to 2016 based on their ISS and AIS head and in respect to utilized resources and outcome. RESULTS Of 2171 patients (mean age 57.2 ± 21.6; ISS 15.0 ± 8.5) 40.1% fulfilled the ACS and 52.7% the HSM-definition of TCN. Comparative analysis of specified subgroups representing combinations of the ISS and the AIS head revealed that patients within the HSM but not within the ACS-definition of TCN achieved worse outcomes in mortality or on the Glasgow Outcome Score and had a higher inpatient rehabilitation rate than patients with an ISS < 15 and an AIS head < 3 compared to patients with an ISS > 15. Mortality for patients with an ISS 16-19 and AIS head < 3 (qualifying for the ACS but not the HSM-definition of TCN) was found to be twice as high for patients who were not in the ACS or the HSM group (ISS < 16 & AIS head < 3). CONCLUSIONS If confirmed by others, both the ACS and the Swiss-recommendations for TCN should be adapted accordingly, provided that the resultant increased workload is feasible for the trauma centers concerned.
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Affiliation(s)
- Thomas Gross
- Department of Traumatology, Cantonal Hospital Aarau, Tellstr.1, 5001, Aarau, Switzerland.
| | - Philipp Braken
- Department of Traumatology, Cantonal Hospital Aarau, Tellstr.1, 5001, Aarau, Switzerland
| | - Felix Amsler
- Amsler Consulting, Gundeldingerrain 111, 4059, Basel, Switzerland
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Presenting Characteristics Associated With Outcome in Children With Severe Traumatic Brain Injury: A Secondary Analysis From a Randomized, Controlled Trial of Therapeutic Hypothermia. Pediatr Crit Care Med 2018; 19:957-964. [PMID: 30067578 PMCID: PMC6170689 DOI: 10.1097/pcc.0000000000001676] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To identify injury patterns and characteristics associated with severe traumatic brain injury course and outcome, within a well-characterized cohort, which may help guide new research and treatment initiatives. DESIGN A secondary analysis of a phase 3, randomized, controlled trial that compared therapeutic hypothermia versus normothermia following severe traumatic brain injury in children. SETTING Fifteen sites in the United States, Australia, and New Zealand. PATIENTS Children (< 18 yr old) with severe traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Baseline, clinical, and CT characteristics of patients (n = 77) were examined for association with mortality and outcome, as measured by the Glasgow Outcome Scale-Extended Pediatric Revision 3 months after traumatic brain injury. Data are presented as odds ratios with 95% CIs. No demographic, clinical, or CT characteristic was associated with mortality in bivariate analysis. Characteristics associated with worse Glasgow Outcome Scale-Extended Pediatric Revision in bivariate analysis were two fixed pupils (14.17 [3.38-59.37]), abdominal Abbreviated Injury Severity score (2.03 [1.19-3.49]), and subarachnoid hemorrhage (3.36 [1.30-8.70]). Forward stepwise regression demonstrated that Abbreviated Injury Severity spine (3.48 [1.14-10.58]) and midline shift on CT (8.35 [1.05-66.59]) were significantly associated with mortality. Number of fixed pupils (one fixed pupil 3.47 [0.79-15.30]; two fixed pupils 13.61 [2.89-64.07]), hypoxia (5.22 [1.02-26.67]), and subarachnoid hemorrhage (3.01 [1.01-9.01]) were independently associated with worse Glasgow Outcome Scale-Extended Pediatric Revision following forward stepwise regression. CONCLUSIONS Severe traumatic brain injury is a clinically heterogeneous disease that can be accompanied by a range of neurologic impairment and a variety of injury patterns at presentation. This secondary analysis of prospectively collected data identifies several characteristics associated with outcome among children with severe traumatic brain injury. Future, larger trials are needed to better characterize phenotypes within this population.
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Association of Posttraumatic Stress Symptom Severity With Health-Related Quality of Life and Self-Reported Functioning Across 12 Months After Severe Traumatic Brain Injury. Arch Phys Med Rehabil 2018; 99:1576-1583. [DOI: 10.1016/j.apmr.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/05/2018] [Accepted: 02/10/2018] [Indexed: 11/15/2022]
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Becker A, Peleg K, Olsha O, Givon A, Kessel B. Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less. Chin J Traumatol 2018; 21:152-155. [PMID: 29776836 PMCID: PMC6034161 DOI: 10.1016/j.cjtee.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/20/2018] [Accepted: 02/18/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients. METHODS A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant. RESULTS There were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3-12 that including 6351 (72%) patients with GCS of 3-8 and 2380 (28%) patient with GCS of 9-12. In these 8731 patients with GCS of 3-12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12, 1256 (89%) patients with GCS 3-8, 148 (11%) patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI. CONCLUSION The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.
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Affiliation(s)
- Alexander Becker
- Department of Surgery A, Emek Medical Center, Afula, Israel,Rappoport Medical School, Technion, Haifa, Israel,Corresponding author. Department of Surgery A, Emek Medical Center, Afula, Israel.
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel,Disaster Medicine Department, School of Public Health, Faculty of Medicine, TelAviv University, Israel
| | - Oded Olsha
- Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel,Rappoport Medical School, Technion, Haifa, Israel
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Dorer CL, Manktelow AE, Allanson J, Sahakian BJ, Pickard JD, Bateman A, Menon DK, Stamatakis EA. Methylphenidate-mediated motor control network enhancement in patients with traumatic brain injury. Brain Inj 2018; 32:1040-1049. [PMID: 29738277 DOI: 10.1080/02699052.2018.1469166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PRIMARY OBJECTIVE To investigate functional improvement late (>6 months) after traumatic brain injury (TBI). To this end, we conducted a double-blind, placebo-controlled experimental medicine study to test the hypothesis that a widely used cognitive enhancer would benefit patients with TBI. RESEARCH DESIGN We focused on motor control function using a sequential finger opposition fMRI paradigm in both patients and age-matched controls. METHODS AND PROCEDURES Patients' fMRI and DTI scans were obtained after randomised administration of methylphenidate or placebo. Controls were scanned without intervention. To assess differences in motor speed, we compared reaction times from the baseline condition of a sustained attention task. MAIN OUTCOMES AND RESULTS Patients' reaction times correlated with wide-spread motor-related white matter abnormalities. Administration of methylphenidate resulted in faster reaction times in patients, which were not significantly different from those achieved by controls. This was also reflected in the fMRI findings in that patients on methylphenidate activated the left inferior frontal gyrus significantly more than when on placebo. Furthermore, stronger functional connections between pre-/post-central cortices and cerebellum were noted for patients on methylphenidate. CONCLUSIONS Our findings suggest that residual functionality in patients with TBI may be enhanced by a single dose of methylphenidate.
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Affiliation(s)
- Charlie L Dorer
- a School of Clinical Medicine, Addenbrooke's Hospital, Division of Anaesthesia , University of Cambridge , Cambridge , UK
| | - Anne E Manktelow
- a School of Clinical Medicine, Addenbrooke's Hospital, Division of Anaesthesia , University of Cambridge , Cambridge , UK
| | - Judith Allanson
- b Department of Neurosciences , Cambridge University Hospitals NHS Foundation , Cambridge , UK
| | | | - John D Pickard
- d Academic Neurosurgery Unit , University of Cambridge , Cambridge , UK
| | | | - David K Menon
- a School of Clinical Medicine, Addenbrooke's Hospital, Division of Anaesthesia , University of Cambridge , Cambridge , UK
| | - Emmanuel A Stamatakis
- a School of Clinical Medicine, Addenbrooke's Hospital, Division of Anaesthesia , University of Cambridge , Cambridge , UK
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Kesmarky K, Delhumeau C, Zenobi M, Walder B. Comparison of Two Predictive Models for Short-Term Mortality in Patients after Severe Traumatic Brain Injury. J Neurotrauma 2017; 34:2235-2242. [PMID: 28323524 DOI: 10.1089/neu.2016.4606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The Glasgow Coma Scale (GCS) and the Abbreviated Injury Score of the head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim of this study was to compare the prognostic performance of an alternative predictive model including motor GCS, pupillary reactivity, age, HAIS, and presence of multi-trauma for short-term mortality with a reference predictive model including motor GCS, pupil reaction, and age (IMPACT core model). A secondary analysis of a prospective epidemiological cohort study in Switzerland including patients after severe TBI (HAIS >3) with the outcome death at 14 days was performed. Performance of prediction, accuracy of discrimination (area under the receiver operating characteristic curve [AUROC]), calibration, and validity of the two predictive models were investigated. The cohort included 808 patients (median age, 56; interquartile range, 33-71), median GCS at hospital admission 3 (3-14), abnormal pupil reaction 29%, with a death rate of 29.7% at 14 days. The alternative predictive model had a higher accuracy of discrimination to predict death at 14 days than the reference predictive model (AUROC 0.852, 95% confidence interval [CI] 0.824-0.880 vs. AUROC 0.826, 95% CI 0.795-0.857; p < 0.0001). The alternative predictive model had an equivalent calibration, compared with the reference predictive model Hosmer-Lemeshow p values (Chi2 8.52, Hosmer-Lemeshow p = 0.345 vs. Chi2 8.66, Hosmer-Lemeshow p = 0.372). The optimism-corrected value of AUROC for the alternative predictive model was 0.845. After severe TBI, a higher performance of prediction for short-term mortality was observed with the alternative predictive model, compared with the reference predictive model.
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Affiliation(s)
- Klara Kesmarky
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Cecile Delhumeau
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Marie Zenobi
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Bernhard Walder
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
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Galeiras Vázquez R, Ferreiro Velasco ME, Mourelo Fariña M, Montoto Marqués A, Salvador de la Barrera S. Update on traumatic acute spinal cord injury. Part 1. Med Intensiva 2017; 41:237-247. [PMID: 28161028 DOI: 10.1016/j.medin.2016.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/30/2016] [Accepted: 11/02/2016] [Indexed: 12/11/2022]
Abstract
Traumatic spinal cord injury requires a multidisciplinary approach both for specialized treatment of the acute phase and for dealing with the secondary complications. A suspicion or diagnosis of spinal cord injury is the first step for a correct management. A review is made of the prehospital management and characteristics of the acute phase of spinal cord injury. Respiratory monitoring for early selective intubation, proper identification and treatment of neurogenic shock are essential for the prevention of secondary spinal cord injury. The use of corticosteroids is currently not a standard practice in neuroprotective treatment, and hemodynamic monitoring and early surgical decompression constitute the cornerstones of adequate management. Traumatic spinal cord injury usually occurs as part of multiple trauma, and this can make diagnosis difficult. Neurological examination and correct selection of radiological exams prevent delayed diagnosis of spinal cord injuries, and help to establish the prognosis.
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Affiliation(s)
- R Galeiras Vázquez
- Unidad de Cuidados Intensivos, Complexo Hospitalario Universitario de A Coruña, A Coruña, España.
| | - M E Ferreiro Velasco
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
| | - M Mourelo Fariña
- Unidad de Cuidados Intensivos, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
| | - A Montoto Marqués
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España; Departamento de Medicina, Universidad de A Coruña, A Coruña, España
| | - S Salvador de la Barrera
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
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Fröhlich M, Driessen A, Böhmer A, Nienaber U, Igressa A, Probst C, Bouillon B, Maegele M, Mutschler M. Is the shock index based classification of hypovolemic shock applicable in multiple injured patients with severe traumatic brain injury?-an analysis of the TraumaRegister DGU ®. Scand J Trauma Resusc Emerg Med 2016; 24:148. [PMID: 27955692 PMCID: PMC5153863 DOI: 10.1186/s13049-016-0340-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/30/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND A new classification of hypovolemic shock based on the shock index (SI) was proposed in 2013. This classification contains four classes of shock and shows good correlation with acidosis, blood product need and mortality. Since their applicability was questioned, the aim of this study was to verify the validity of the new classification in multiple injured patients with traumatic brain injury. METHODS Between 2002 and 2013, data from 40 888 patients from the TraumaRegister DGU® were analysed. Patients were classified according to their initial SI at hospital admission (Class I: SI < 0.6, class II: SI ≥0.6 to <1.0, class III SI ≥1.0 to <1.4, class IV: SI ≥1.4). Patients with an additional severe TBI (AIS ≥ 3) were compared to patients without severe TBI. RESULTS 16,760 multiple injured patients with TBI (AIShead ≥3) were compared to 24,128 patients without severe TBI. With worsening of SI class, mortality rate increased from 20 to 53% in TBI patients. Worsening SI classes were associated with decreased haemoglobin, platelet counts and Quick's values. The number of blood units transfused correlated with worsening of SI. Massive transfusion rates increased from 3% in class I to 46% in class IV. The accuracy for predicting transfusion requirements did not differ between TBI and Non TBI patients. DISCUSSION The use of the SI based classification enables a quick assessment of patients in hypovolemic shock based on universally available parameters. Although the pathophysiology in TBI and Non TBI patients and early treatment methods such as the use of vasopressors differ, both groups showed an identical probability of recieving blood products within the respective SI class. CONCLUSION Regardless of the presence of TBI, the classification of hypovolemic shock based on the SI enables a fast and reliable assessment of hypovolemic shock in the emergency department. Therefore, the presented study supports the SI as a feasible tool to assess patients at risk for blood product transfusions, even in the presence of severe TBI.
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Affiliation(s)
- Matthias Fröhlich
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany. .,Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne Merheim Medical Center (CMMC), Ostmerheimerstr.200, D-51109, Cologne, Germany. .,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany.
| | - Arne Driessen
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Ulrike Nienaber
- AUC-Academy for Trauma Surgery, Straße des 17. Juni 106-108, D-10623, Berlin, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Alhadi Igressa
- Department of Neurosurgery, Cologne-Merheim Medical Centre, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Christian Probst
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Bertil Bouillon
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Marc Maegele
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Manuel Mutschler
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
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Savitsky B, Givon A, Rozenfeld M, Radomislensky I, Peleg K. Traumatic brain injury: It is all about definition. Brain Inj 2016; 30:1194-200. [PMID: 27466967 DOI: 10.1080/02699052.2016.1187290] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND TBI may be defined by different methods. Some may be most useful for immediate clinical purposes, however less optimal for epidemiologic research. Other methods, such as the Abbreviated Injury Score (AIS), may prove more beneficial for this task, if the cut-off-points for their categories are defined correctly. OBJECTIVE To reveal the optimal cut-off-points for AIS in definition of severity of TBI in order to ensure uniformity between future studies of TBI. RESULTS Mortality of patients with TBI AIS 3, 4 was 1.9% and 2.9% respectively, comparing with 31.1% among TBI AIS 5+. Predictive discrimination ability of the model with cut-off-points of 5+ for TBI AIS (in comparison with other cut-off-points) was better. Patients with missing Glasgow Coma Scale (GCS) in the ED had an in-hospital mortality rate of 11.5%. In this group, 25% had critical TBI according to AIS. Normal GCS didn't indicate an absence of head injury, as, among patients with GCS 15 in the ED, 26% had serious/critical TBI injury. Moreover, 7% of patients with multiple injury and GCS 3-8 had another reason than head injury for unconsciousness. CONCLUSIONS This study recommends the adoption of an AIS cut-off ≥ 5 as a valid definition of severe TBI in epidemiological studies, while AIS 3-4 may be defined as 'moderate' TBI and AIS 1-2 as 'mild'.
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Affiliation(s)
- B Savitsky
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel
| | - A Givon
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel
| | - M Rozenfeld
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel.,b Faculty of Medicine , Tel-Aviv University, School of Public Health , Tel-Aviv , Israel
| | - I Radomislensky
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel
| | - K Peleg
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel.,b Faculty of Medicine , Tel-Aviv University, School of Public Health , Tel-Aviv , Israel
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46
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Emami P, Czorlich P, Fritzsche FS, Westphal M, Rueger JM, Lefering R, Hoffmann M. Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study. J Neurosurg 2016; 126:760-767. [PMID: 27035177 DOI: 10.3171/2016.1.jns152385] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIShead) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIShead score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.
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Affiliation(s)
| | | | | | | | - Johannes M Rueger
- Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg; and
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Michael Hoffmann
- Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg; and
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47
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Rønning P, Gunstad PO, Skaga NO, Langmoen IA, Stavem K, Helseth E. The impact of blood ethanol concentration on the classification of head injury severity in traumatic brain injury. Brain Inj 2015; 29:1648-53. [PMID: 26480239 DOI: 10.3109/02699052.2015.1075154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is classified into mild, moderate and severe, based on the Glasgow Coma Score (GCS). However, TBI patients are often influenced by ethanol, which in itself can attenuate the level of consciousness. This study investigated the effect of ethanol on the GCS group classification in TBI patients. METHODS The Oslo University Hospital trauma database was searched for all patients admitted with a head injury where the blood ethanol concentration (BEC) had been measured (n = 1004). The effect of BEC on GCS groups was analysed using multivariate ordinal logistic regression. RESULTS This study identified 546, 142 and 316 patients in the mild, moderate and severe groups, respectively. Increasing BEC by 1 g kg(-1) and pre-hospital intubation had OR = 1.34 and 16.34 for being in a more severe GCS group, respectively. Increasing head abbreviated injury scale (head-AIS) was significantly associated with being in a more severe GCS group. The modelled probability of detecting a head-AIS of 4 or 5 in a patient with BEC of 2.0 g kg(-1) was 20%, 38% and 65% in the mild, moderate and severe groups, respectively. CONCLUSIONS Increasing BEC was associated with increasing odds of being in a more severe GCS group. However, because the modelled probability of significant brain injury was high in patients with high levels of BEC, a reduced level of consciousness in intoxicated patients mandates further radiological investigations.
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Affiliation(s)
- Pål Rønning
- a Department of Neurosurgery , Oslo University Hospital , Norway
| | | | | | - Iver Arne Langmoen
- a Department of Neurosurgery , Oslo University Hospital , Norway .,b The Faculty of Medicine, University of Oslo , Norway
| | - Knut Stavem
- b The Faculty of Medicine, University of Oslo , Norway .,d Department of Pulmonary Medicine , Akershus University Hospital , Norway , and.,e HØKH, Research Centre, Akershus University Hospital , Norway
| | - Eirik Helseth
- a Department of Neurosurgery , Oslo University Hospital , Norway .,b The Faculty of Medicine, University of Oslo , Norway
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48
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Andre JB. Arterial Spin Labeling Magnetic Resonance Perfusion for Traumatic Brain Injury: Technical Challenges and Potentials. Top Magn Reson Imaging 2015; 24:275-287. [PMID: 26502309 DOI: 10.1097/rmr.0000000000000065] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Traumatic brain injury (TBI), including concussion, is a public health concern, as it affects over 1.7 million persons in the United States per year. Yet, the diagnosis of TBI, particularly mild TBI (mTBI), can be controversial, as neuroimaging findings can be sparse on conventional magnetic resonance and computed tomography examinations, and when present, often poorly correlate with clinical signs and symptoms. Furthermore, the discussion of TBI, concussion, and head impact exposure is immediately complicated by the many differing opinions of what constitutes each, their respective severities, and how the underlying biomechanics of the inciting head impact might alter the distribution, severity, and prognosis of the underlying brain injury. Advanced imaging methodologies hold promise in improving the sensitivity and detectability of associated imaging biomarkers that might better correlate with patient outcome and prognostication, allowing for improved triage and therapeutic guidance in the setting of TBI, particularly in mTBI. This work will examine the defining symptom complex associated with mTBI and explore changes in cerebral blood flow measured by arterial spin labeling, as a potential imaging biomarker for TBI, and briefly correlate these observations with findings identified by single photon emission computed tomography and positron emission tomography imaging.
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Affiliation(s)
- Jalal B Andre
- Harborview Medical Center, University of Washington, Seattle, WA
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49
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Bahadur S, McGilloway E, Etherington J. Injury severity at presentation is not associated with long-term vocational outcome in British Military brain injury. J ROY ARMY MED CORPS 2015; 162:120-4. [DOI: 10.1136/jramc-2014-000393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 08/20/2015] [Indexed: 11/03/2022]
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50
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[Mild head injury in children and adults: Diagnostic challenges in the emergency department]. Med Klin Intensivmed Notfmed 2015; 110:379-94; quiz 395-6. [PMID: 26063147 DOI: 10.1007/s00063-015-0047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.
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