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Al-Fadhl MD, Karam MN, Chen J, Zackariya SK, Lain MC, Bales JR, Higgins AB, Laing JT, Wang HS, Andrews MG, Thomas AV, Smith L, Fox MD, Zackariya SK, Thomas SJ, Tincher AM, Al-Fadhl HD, Weston M, Marsh PL, Khan HA, Thomas EJ, Miller JB, Bailey JA, Koenig JJ, Waxman DA, Srikureja D, Fulkerson DH, Fox S, Bingaman G, Zimmer DF, Thompson MA, Bunch CM, Walsh MM. Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock. J Clin Med 2024; 13:3915. [PMID: 38999481 PMCID: PMC11242176 DOI: 10.3390/jcm13133915] [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: 04/01/2024] [Revised: 06/08/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.
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Affiliation(s)
- Mahmoud D Al-Fadhl
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Marie Nour Karam
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Jenny Chen
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Sufyan K Zackariya
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Morgan C Lain
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - John R Bales
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Alexis B Higgins
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Jordan T Laing
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Hannah S Wang
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Madeline G Andrews
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Anthony V Thomas
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Leah Smith
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Mark D Fox
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Saniya K Zackariya
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Samuel J Thomas
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Anna M Tincher
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Hamid D Al-Fadhl
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - May Weston
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Phillip L Marsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Hassaan A Khan
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Emmanuel J Thomas
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Jason A Bailey
- Department of Emergency Medicine, Elkhart General Hospital, Elkhart, IN 46515, USA
| | - Justin J Koenig
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Dan A Waxman
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46601, USA
- Versiti Blood Center of Indiana, Indianapolis, IN 46208, USA
| | - Daniel Srikureja
- Department of Surgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Daniel H Fulkerson
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Sarah Fox
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Greg Bingaman
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Donald F Zimmer
- Department of Emergency Medicine, Memorial Hospital, South Bend, IN 46601, USA
| | - Mark A Thompson
- Department of Surgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Mark M Walsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
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Park JH, Jung IH, Yun JH. The Efficacy of Traumatic Brain Injury Treatment by Neurotrauma Specialists. Korean J Neurotrauma 2024; 20:8-16. [PMID: 38576504 PMCID: PMC10990690 DOI: 10.13004/kjnt.2024.20.e12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
Objective Since the establishment of Regional Trauma Centers (RTCs) in Korea, significant efforts have been made to improve the quality of care for patients with trauma. Simultaneously, the Department of Neurosurgery assigned neurotrauma specialists to RTCs to provide specialized care to patients with traumatic brain injury (TBI). In this study, we sought to determine whether neurotrauma specialists, compared to general neurosurgeons, could make a significant difference in treatment outcomes of patients with TBI. Methods In total, 156 patients with acute TBI who required decompression were included. We reviewed their records and compared the characteristics, outcomes, and prognosis of those who received surgical treatment from either neurotrauma specialists or general neurosurgeons at our institution. Results A significant difference was observed between treatment by trauma neurosurgery specialists and general neurosurgeons in time to surgery, with trauma specialists experiencing shorter surgical delays. However, no significant differences existed in mortality rates or Extended Glasgow Outcome Scale scores. Univariate and multivariable regression analyses revealed that lower Glasgow Coma Scale scores, an abnormal pupil reflex, larger transfusion volume, and prolonged time from emergency room admission to surgery were associated with high mortality rates. Conclusion Neurotrauma specialists can provide prompt surgical treatment to patients with TBI compared to general neurosurgeons. Our study did not reveal a significant difference in outcomes between the two groups. However, it is clear that rapid decompression is effective in patients with impending brain herniation. Therefore, the effectiveness of neurotrauma specialists needs to be confirmed through further systematic studies.
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Affiliation(s)
- Jung Hwan Park
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - In-Ho Jung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
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Guillotte AR, Fry L, Gattozzi D, Shah K. Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury. Korean J Neurotrauma 2023; 19:454-465. [PMID: 38222836 PMCID: PMC10782100 DOI: 10.13004/kjnt.2023.19.e53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Many patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy. Methods The neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups. Results All patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101. Conclusion GCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.
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Affiliation(s)
- Andrew R. Guillotte
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lane Fry
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, KS, USA
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Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. PREHOSP EMERG CARE 2023:1-32. [PMID: 37079803 DOI: 10.1080/10903127.2023.2187905] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Affiliation(s)
- Al Lulla
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Patrick J Maher
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neeraj Badjatia
- Department of Neurocritical Care, Neurology, Anesthesiology, Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randy Bell
- Uniformed Services University, Bethesda, Maryland
| | | | - Mary E Fallat
- Hiram C. Polk Jr Department of Pediatric Surgery, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic and Akron General Hospital, Fairlawn, Ohio
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Halim M A Hennes
- Department of Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas Children's Medical Center, Dallas, Texas
| | - Steven P Ignell
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel Nishijima
- Department of Emergency Medicine, UC Davis, Sacramento, California
| | - Charles Schleien
- Pediatric Critical Care, Cohen Children's Medical Center, Hofstra Northwell School of Medicine, Uniondale, New York
| | - Stacy Shackelford
- Trauma and Critical Care, USAF Center for Sustainment of Trauma Readiness Skills, Seattle, Washington
| | - Erik Swartz
- Department of Physical Therapy and Kinesiology, University of Massachusetts, Lowell, Massachusetts
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Rachel Zhang
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Andy Jagoda
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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Sharma R, Tsikvadze M, Peel J, Howard L, Kapoor N, Freeman WD. Multimodal monitoring: practical recommendations (dos and don'ts) in challenging situations and uncertainty. Front Neurol 2023; 14:1135406. [PMID: 37206910 PMCID: PMC10188941 DOI: 10.3389/fneur.2023.1135406] [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: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
With the advancements in modern medicine, new methods are being developed to monitor patients in the intensive care unit. Different modalities evaluate different aspects of the patient's physiology and clinical status. The complexity of these modalities often restricts their use to the realm of clinical research, thereby limiting their use in the real world. Understanding their salient features and their limitations can aid physicians in interpreting the concomitant information provided by multiple modalities to make informed decisions that may affect clinical care and outcomes. Here, we present a review of the commonly used methods in the neurological intensive care unit with practical recommendations for their use.
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Affiliation(s)
- Rohan Sharma
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Rohan Sharma
| | - Mariam Tsikvadze
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Jeffrey Peel
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Levi Howard
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Nidhi Kapoor
- Department of Neurology, Baptist Medical Center, Jacksonville, FL, United States
| | - William D. Freeman
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
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Chang HYM, Flahive J, Bose A, Goostrey K, Osgood M, Carandang R, Hall W, Muehlschlegel S. Predicting mortality in moderate-severe TBI patients without early withdrawal of life-sustaining treatments including ICU complications: The MYSTIC-score. J Crit Care 2022; 72:154147. [PMID: 36166912 DOI: 10.1016/j.jcrc.2022.154147] [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: 01/16/2022] [Revised: 08/12/2022] [Accepted: 08/28/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments. METHODS We analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009-5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration. RESULTS The MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161). CONCLUSIONS Certain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.
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Affiliation(s)
- Han Yan Michelle Chang
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Julie Flahive
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Abigail Bose
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Kelsey Goostrey
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Marcey Osgood
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Raphael Carandang
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Anesthesia/Critical Care, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Wiley Hall
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Anesthesia/Critical Care, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
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Laaksonen M, Björkman J, Iirola T, Raatiniemi L, Nurmi J. The effect of time of measurement on the discriminant ability for mortality in trauma of a pre-hospital shock index multiplied by age and divided by the Glasgow Coma Score: a registry study. BMC Emerg Med 2022; 22:189. [PMID: 36447156 PMCID: PMC9710012 DOI: 10.1186/s12873-022-00749-8] [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: 01/24/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The shock index (SI) and its derivatives have been shown to predict mortality in severely injured patients, both in pre-hospital and in-hospital settings. However, the impact of the time of measurement on the discriminative ability of the pre-hospital SI is unknown. The aim of this study was to evaluate whether the time of measurement influences the discriminative ability of the SI multiplied by age (SIA) and divided by the Glasgow Coma Score (SIA/G). METHODS Registry data were obtained from the national helicopter emergency medical services (HEMS) on trauma patients aged ≥ 18 years. The SI values were calculated based on the first measured vitals of the trauma patients by the HEMS unit. The discriminative ability of the SIA/G, with 30-day mortality as the endpoint, was evaluated according to different delay times (0 - 19, 20 - 39 and ≥ 40 min) from the initial incident. Sub-group analyses were performed for trauma patients without a traumatic brain injury (TBI), patients with an isolated TBI and patients with polytrauma, including a TBI. RESULTS In total, 3,497 patients were included in the study. The SIA/G was higher in non-survivors (median 7.8 [interquartile range 4.7-12.3] vs. 2.4 [1.7-3.6], P < 0.001). The overall area under the receiver operator characteristic curve (AUROC) for the SIA/G was 0.87 (95% CI: 0.85-0.89). The AUROC for the SIA/G was similar in the short (0.88, 95% CI: 0.85-0.91), intermediate (0.86, 95% CI: 0.84-0.89) and long (0.86, 95% CI: 0.82-0.89) measurement delay groups. The findings were similar in the three trauma sub-groups. CONCLUSIONS The discriminative ability of the SIA/G in predicting 30-day mortality was not significantly affected by the measurement time of the index in the pre-hospital setting. The SIA/G is a simple and reliable tool for assessing the risk of mortality among severely injured patients in the pre-hospital setting.
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Affiliation(s)
- Mikael Laaksonen
- grid.410552.70000 0004 0628 215XDepartment of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Timo Iirola
- grid.410552.70000 0004 0628 215XEmergency Medical Services, Turku University Hospital and University of Turku, Turku, Finland
| | - Lasse Raatiniemi
- grid.412326.00000 0004 4685 4917Centre for Emergency Medical Services, Oulu University Hospital, Oulu, Finland
| | - Jouni Nurmi
- FinnHEMS Research and Development Unit, Vantaa, Finland ,grid.15485.3d0000 0000 9950 5666Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Iirola T, Björkman J, Laaksonen M, Nurmi J. Predictive value of shock index variants on 30-day mortality of trauma patients in helicopter emergency medical services: a nationwide observational retrospective multicenter study. Sci Rep 2022; 12:19696. [PMID: 36385325 PMCID: PMC9668921 DOI: 10.1038/s41598-022-24272-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022] Open
Abstract
The original shock index (SI) has been further developed to increase its prognostic value. We aimed to evaluate the predictive value of different SI variants on 30-day mortality among severely injured trauma patients in pre-hospital critical care settings. Adult trauma patients in the national Helicopter Emergency Medical Services (HEMS) registry were evaluated based on the primary outcome of 30-day mortality. SI, SIA (SI multiplied by age), SI/G (SI divided by Glasgow Coma Scale (GCS)), SIA/G (SI multiplied by age and divided by GCS), and SS (SI divided by oxygen saturation) were calculated based on the first vital signs measured at the time of HEMS contact. The area under the receiver operating curve (AUROC) was calculated for each SI variant. In total 4108 patients were included in the study. The overall 30-day mortality was 13.5%. The SIA/G and SI/G had the highest predictive ability (AUROC 0.884 [95% CI 0.869-0.899] and 0.8000 [95% CI 0.7780-0.8239], respectively). The SIA/G yielded good predictive performance between 30-day survivors and non-survivors in the pre-hospital critical care setting.
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Affiliation(s)
- Timo Iirola
- grid.410552.70000 0004 0628 215XEmergency Medical Services, Turku University Hospital and University of Turku, Turku, Finland
| | - Johannes Björkman
- FinnHEMS Research and Development Unit, Vantaa, Finland ,grid.7737.40000 0004 0410 2071Department of Anaesthesiology and Intensive Care Medicine, The University of Helsinki, Helsinki, Finland
| | - Mikael Laaksonen
- grid.410552.70000 0004 0628 215XDepartment of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland
| | - Jouni Nurmi
- grid.15485.3d0000 0000 9950 5666Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
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Zhang J, Zhang H, Yan F, Zhang H, Zhang E, Wang X, Wei M, Pei Y, Yang Z, Li Y, Dong L, Wang X. Investigating the mechanism and prognosis of patients with disorders of consciousness on the basis of brain networks between the thalamus and whole-brain. Front Neurol 2022; 13:990686. [PMID: 36237619 PMCID: PMC9552841 DOI: 10.3389/fneur.2022.990686] [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: 07/10/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeThis study aimed to investigate the changes in the functional connectivity between the bilateral thalamus and the whole-brain in patients with severe traumatic brain injury (sTBI) patients suffering from disorders of consciousness (DOC) and to explore their potential prognostic representation capacity.MethodsThe sTBI patients suffering from DOC and healthy controls underwent functional magnetic resonance imaging. We defined patients with the Extended Glasgow Outcome Score (GOS-E) ≥ 3 as the wake group and GOS-E = 2 as the coma group. The differences in functional connectivity between sTBI and healthy controls and between wake and coma groups were compared. Based on the brain regions with altered functional connectivity between wake and coma groups, they were divided into 26 regions of interest. Based on the Z-values of regions of interest, the receiver operating characteristic analysis was conducted to classify the prognosis of patients.ResultsA total of 28 patients and 15 healthy controls were finally included. Patients who had DOC indicated a significant disruption of functional connectivity between the bilateral thalamus and the whole-brain (FDR corrected, P < 0.0007). The functional connectivity strength (bilateral thalamus to whole-brain) was significantly different between coma patients who went on to wake and those who were eventually non-awake at 6 months after sTBI (Alphasim corrected, P < 0.05). Furthermore, the 26 regions of interest had a similar or even better prognostic distinction ability than the admission Glasgow coma score.ConclusionThe thalamus-based system of consciousness of sTBI patients suffering from DOC is disrupted. There are differences in the thalamus-to-whole-brain network between wake and coma groups and these differences have potential prognostic characterization capability.
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Affiliation(s)
- Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hongying Zhang
- Department of Radiology, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Fuli Yan
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Enpeng Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Xingdong Wang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Min Wei
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yunlong Pei
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Zhijie Yang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuping Li
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Lun Dong
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- Lun Dong
| | - Xiaodong Wang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- *Correspondence: Xiaodong Wang
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Xu J, Xiao Q. Assessment of the effects of dexmedetomidine on outcomes of traumatic brain injury using propensity score analysis. BMC Anesthesiol 2022; 22:280. [PMID: 36056318 PMCID: PMC9438148 DOI: 10.1186/s12871-022-01822-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dexmedetomidine was found to be protective against traumatic brain injury (TBI) in animal studies and safe for use in previous clinical studies, but whether it improves TBI patient survival remains to be determined. We sought to answer this question by analyzing data from the MIMIC clinical database. METHODS Data for TBI patients from the MIMIC III and MIMIC IV databases were extracted and divided into a dexmedetomidine group and a control group. In the former group, dexmedetomidine was used for sedation, while in the latter, it was not used. Parameters including patient age, the Acute Physiology score III, the Glasgow Coma Scale, other sedatives used, and pupillary response within 24 h were employed in propensity score matching to achieve a balance between groups for further analysis. In-hospital survival and 6-month survival were analyzed by Kaplan-Meier survival analysis and compared by log-rank test. Cox regression was used repeatedly for the univariate analysis, the multivariate analysis, the propensity score-matched analysis, and the inverse probability of treatment weighted analysis of survival data. Meanwhile, the influences of hypotension, bradycardia, infection, and seizure on outcome were also analyzed. RESULTS Different types of survival analyses demonstrated the same trend. Dexmedetomidine significantly improved TBI patient survival. It caused no more incidents of hypotension, infection, and seizure. Hypotension was not correlated with in-hospital mortality, but was significantly correlated with 6-month mortality. CONCLUSIONS Dexmedetomidine may improve the survival of TBI patients. It should be used with careful avoidance of hypotension.
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Affiliation(s)
- Jinbu Xu
- Critical Care Medicine Department, Foshan Women and Children Hospital, No. 11, Western Renmin Road, Foshan City, 528000, Guangdong Province, China
| | - Qing Xiao
- Critical Care Medicine Department, Lianyungang Second People's Hospital, No. 161, Xingfu Road, Lianyungang City, 222000, Jiangsu Province, China.
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11
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Wang R, Hua Y, He M, Xu J. Prognostic Value of Serum Procalcitonin Based Model in Moderate to Severe Traumatic Brain Injury Patients. J Inflamm Res 2022; 15:4981-4993. [PMID: 36065318 PMCID: PMC9440674 DOI: 10.2147/jir.s358621] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Procalcitonin (PCT) is an acknowledged marker of systemic inflammatory response. Previous studies have not reached agreement on the association between serum PCT and outcome of traumatic brain injury (TBI) patients. We designed this study to confirm the prognostic value of PCT in isolated TBI and those with extracranial injury, respectively. Methods Patients hospitalized in our hospital for moderate-to-severe TBI between March 2015 and December 2019 were included. Logistic regression analysis was performed to validate the association between PCT and in-hospital mortality in these patients. AUC (area under the receiver operating characteristics curve) of PCT and constructed model were calculated and compared. Results Among the included 211 patients, 81 patients suffered a poor outcome, with a mortality rate of 38.4%. Non-survivors had a higher level of serum PCT (2.73 vs 0.72, p<0.001) and lower GCS (5 vs 7, p<0.001) on admission than survivors. AUC of single PCT for predicting mortality in isolated TBI and those with extracranial injury were 0.767 and 0.553, respectively. Multivariate logistic regression showed that GCS (OR=0.744, p=0.008), glucose (OR=1.236, p<0.001), cholesterol (OR=0.526, p=0.002), and PCT (OR=1.107, p=0.022) were independently associated with mortality of isolated TBI. The AUC of the prognostic model composed of GCS, glucose, cholesterol, and PCT was 0.868 in isolated TBI. Conclusion PCT is an efficient marker of outcome in isolated moderate-to-severe TBI but not those with extracranial injury. A prognostic model incorporating PCT is useful for clinicians to make early risk stratification for isolated TBI.
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Affiliation(s)
- Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yusi Hua
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Min He, Department of Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, People’s Republic of China, Email
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Correspondence: Jianguo Xu, Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, People’s Republic of China, Email
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12
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Initial CT-based radiomics nomogram for predicting in-hospital mortality in patients with traumatic brain injury: a multicenter development and validation study. Neurol Sci 2022; 43:4363-4372. [DOI: 10.1007/s10072-022-05954-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 02/15/2022] [Indexed: 12/09/2022]
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13
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Neurological Pupil Index for the Early Prediction of Outcome in Severe Acute Brain Injury Patients. Brain Sci 2022; 12:brainsci12050609. [PMID: 35624996 PMCID: PMC9139348 DOI: 10.3390/brainsci12050609] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/27/2022] Open
Abstract
In this study, we examined the early value of automated quantitative pupillary examination, using the Neurological Pupil index (NPi), to predict the long-term outcome of acute brain injured (ABI) patients. We performed a single-centre retrospective study (October 2016−March 2019) in ABI patients who underwent NPi measurement during the first 3 days following brain insult. We examined the performance of NPi—alone or in combination with other baseline demographic (age) and radiologic (CT midline shift) predictors—to prognosticate unfavourable 6-month outcome (Glasgow Outcome Scale 1−3). A total of 145 severely brain-injured subjects (65 traumatic brain injury, TBI; 80 non-TBI) were studied. At each time point tested, NPi <3 was highly predictive of unfavourable outcome, with highest specificity (100% (90−100)) at day 3 (sensitivity 24% (15−35), negative predictive value 36% (34−39)). The addition of NPi, from day 1 following ABI to age and cerebral CT scan, provided the best prognostic performance (AUROC curve 0.85 vs. 0.78 without NPi, p = 0.008; DeLong test) for 6-month neurological outcome prediction. NPi, assessed at the early post-injury phase, has a superior ability to predict unfavourable long-term neurological outcomes in severely brain-injured patients. The added prognostic value of NPi was most significant when complemented with baseline demographic and radiologic information.
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14
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How do we identify the crashing traumatic brain injury patient - the neurosurgeon's view. Curr Opin Crit Care 2021; 27:87-94. [PMID: 33395087 DOI: 10.1097/mcc.0000000000000799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view. RECENT FINDINGS In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected. SUMMARY Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another.
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15
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Musick S, Alberico A. Neurologic Assessment of the Neurocritical Care Patient. Front Neurol 2021; 12:588989. [PMID: 33828517 PMCID: PMC8019734 DOI: 10.3389/fneur.2021.588989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.
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Affiliation(s)
- Shane Musick
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
| | - Anthony Alberico
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
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16
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Zhao Z, Liang JJ, Wang Z, Winans NJ, Morris M, Doyle S, Fry A, Fiore SM, Mofakham S, Mikell CB. Cardiac arrest after severe traumatic brain injury can be survivable with good outcomes. Trauma Surg Acute Care Open 2021; 6:e000638. [PMID: 33634211 PMCID: PMC7880094 DOI: 10.1136/tsaco-2020-000638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/12/2020] [Accepted: 01/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background Resuscitation for traumatic cardiac arrest (TCA) in patients with severe traumatic brain injury (sTBI) has historically been considered futile. There is little information on the characteristics and outcomes of these patients to guide intervention and prognosis. The purpose of the current study is to report the clinical characteristics, survival, and long-term neurological outcomes in patients who experienced TCA after sTBI and analyze the factors contributing to survival. Methods A retrospective review identified 42 patients with TCA from a total of 402 patients with sTBI (Glasgow Coma Scale (GCS) score ≤8) who were admitted to Stony Brook University Hospital, a level I trauma center, from January 2011 to December 2018. Patient demographics, clinical characteristics, survival, and neurological functioning during hospitalization and at follow-up visits were collected. Results Of the 42 patients, the average age was 45 years and 21.4% were female. Eight patients survived the injury (19.0%) to discharge and seven survived with good neurological function. Admission GCS score and bilateral pupil reactivity were found to be significant indicators of survival. The mean GCS score was 5.3 in survivors and 3.2 in non-survivors (p=0.020). Age, Injury Severity Score, or cardiac rhythm was not associated with survival. Frequent neuroimaging findings included subarachnoid hemorrhage, subdural hematoma, and diffuse axonal injury. Discussion TCA after sTBI is survivable and seven out of eight patients in our study recovered with good neurological function. GCS score and pupil reactivity are the best indicators of survival. Our results suggest that due to the possibility of recovery, resuscitation and neurosurgical care should not be withheld from this patient population. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
- Zirun Zhao
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Justine J Liang
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Zhe Wang
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Nathan J Winans
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Matthew Morris
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Stephen Doyle
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Adam Fry
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Susan M Fiore
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Sima Mofakham
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Charles B Mikell
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
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17
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Balakrishnan B, VanDongen-Trimmer H, Kim I, Hanson SJ, Zhang L, Simpson PM, Farias-Moeller R. GCS-Pupil Score Has a Stronger Association with Mortality and Poor Functional Outcome than GCS Alone in Pediatric Severe Traumatic Brain Injury. Pediatr Neurosurg 2021; 56:432-439. [PMID: 34284393 DOI: 10.1159/000517330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Glasgow Coma Scale (GCS), used to classify the severity of traumatic brain injury (TBI), is associated with mortality and functional outcomes. However, GCS can be affected by sedation and neuromuscular blockade. GCS-Pupil (GCS-P) score, calculated as GCS minus Pupil Reactivity Score (PRS), was shown to better predict outcomes in a retrospective cohort of adult TBI patients. We evaluated the applicability of GCS-P to a large retrospective pediatric severe TBI (sTBI) cohort. METHODS Admissions to pediatric intensive care units in the Virtual Pediatric Systems (VPS, LLC) database from 2010 to 2015 with sTBI were included. We collected GCS, PRS (number of nonreactive pupils), cardiac arrest, abusive head trauma status, illness severity scores, pediatric cerebral performance category (PCPC) score, and mortality. GCS-P was calculated as GCS minus PRS. χ2 or Fisher's exact test and Mann-Whitney U test compared categorical and continuous variables, respectively. Classification and regression tree analysis identified thresholds of GCS-P and GCS along with other independent factors which were further examined using multivariable regression analysis to identify factors independently associated with mortality and unfavorable PCPC at PICU discharge. RESULTS Among the 2,682 patients included in the study, mortality was 23%, increasing from 4.7% for PRS = 0 to 80% for PRS = 2. GCS-P identified more severely injured patients with GCS-P scores 1 and 2 who had worse outcomes. GCS-P ≤ 2 had higher odds for mortality, OR = 68.4 (95% CI = 50.6-92.4) and unfavorable PCPC, OR = 17.3 (8.1, 37.0) compared to GCS ≤ 5. GCS-P ≤ 2 also had higher specificity and positive predictive value for both mortality and unfavorable PCPC compared to GCS ≤ 5. CONCLUSIONS GCS-P, by incorporating pupil reactivity to GCS scoring, is more strongly associated with mortality and poor functional outcome at PICU discharge in children with sTBI.
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Affiliation(s)
- Binod Balakrishnan
- Section of Critical Care, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pediatrics at Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Heather VanDongen-Trimmer
- Department of Neurology at Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Division of Child Neurology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Irene Kim
- Department of Neurosurgery at Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Division of Pediatric Neurosurgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sheila J Hanson
- Section of Critical Care, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pediatrics at Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liyun Zhang
- Department of Pediatrics at Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Section of Quantitative Health Sciences at Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa M Simpson
- Department of Pediatrics at Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Section of Quantitative Health Sciences at Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Raquel Farias-Moeller
- Section of Critical Care, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pediatrics at Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Neurology at Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Division of Child Neurology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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18
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El Shehaby DM, Farahat AMA, Shahine MS, Mohammed HM. Medico-legal evaluation and trend of the different patterns of maxillofacial fractures concomitant with closed head injury in Upper Egypt: retrospective study. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2020. [DOI: 10.1186/s41935-020-0178-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Maxillofacial fractures are of great medico-legal implications because they are of common occurrence with other injuries, predominantly head injuries that might involve serious esthetic and functional problems, and so clinically described as consequential injuries. The aims were to assess the medico-legal aspects of maxillofacial fractured cases concomitant with closed head injury over a 6-year period (2011–2016) in the Trauma Unit of Assiut University Hospitals, Egypt, and to evaluate the demographic feature and the trend of different patterns of such fractures.
Patient and methods
A descriptive hospital-based study included all cases of maxillofacial fractures combined with closed head injury attending the Trauma Unit of Assiut University Hospitals in the period of January 2011 to December 2016.
Results
The study included 1221 cases, the percent of maxillofacial fractures with a closed head injury was 4%, the age group 18–40 years was having the highest incidence, and mean age was 25.9 ± 15.3 years with male to female ratio of 7:1. Road traffic accidents were the main etiology of injury (69.7%), followed by falls (15.1%) and violent assaults (10.2%) while firearm injuries were the last (5%). Unintentional injuries were the commonest in 83.1% followed by homicidal (16.3%); only 7 cases were due to suicidal attacks. The mandibular fracture was the commonest (49.7%) followed by fracture maxilla (19.2%), fracture zygoma (16.8%), and lastly frontal bone and nasal fracture. The trend of maxillofacial fractures over the 6-year period tended to be increased with the highest number in 2011 (21.5%) and the lowest in 2014 (13.3%).
Conclusion
Maxillofacial fracture with a closed head injury in Upper Egypt is common in the middle age with male predominance. Road traffic accident is the main etiologic factor, and accidental trauma is the commonest manner. Mandibular fractures are the commonest pattern followed by fracture maxilla. Traumatic head injuries in cases of maxillofacial fractures were mild in about half of the cases. The trend of maxillofacial fractures over the 6-year period of the study (2011–2016) tended to be increased with the highest number in 2011 and the lowest in 2014.
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19
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Lan Z, Richard SA, Li Q, Wu C, Zhang Q, Chen R, Yang C. Outcomes of patients undergoing craniotomy and decompressive craniectomy for severe traumatic brain injury with brain herniation: A retrospective study. Medicine (Baltimore) 2020; 99:e22742. [PMID: 33120775 PMCID: PMC7581028 DOI: 10.1097/md.0000000000022742] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The treatment of severe traumatic brain injury (TBI) with brain herniation is challenging because outcomes are often associated with high mortality and morbidity. Our aim was to identity factors contributing to decompressive craniectomy (DC) and evaluate treatment outcomes in patients with severe TBI with brain herniation.In this retrospective study, we analyzed medical records of severe TBI with brain herniation from May 2009 to December 2013. We reviewed their demographic data, mechanism of injury, Glasgow Coma Scale (GCS) score, pupil status, computed tomography findings, surgical treatment methods, time interval between brain herniation and surgery, as well as outcomes. GCS and pupil status are clinical parameters for detecting increase intracranial pressure while brain parenchyma bulged above the inner plate of the skull during operation indicated brain swelling as well as increased intracranial pressure on which basis the decision to perform DC or craniotomy was determined intraoperatively.One hundred ninety-four patients were included in the study. We performed DC in 143 of the patients while 51 of them we performed craniotomy. There were no statistically significant differences in the age, gender, or injury mechanism between the 2 groups. GCS, pupillary dilation, midline shift, hematoma type and timing of surgery were associated with DC. Nevertheless, logistic regression analysis revealed that hematoma type and timing of surgery were significantly associated with favorable DC outcomes (P < .001 and P = .023). Subdural hematoma and timing of surgery >1 hour were both identified as risk factors for DC. Six months after TBI, 34.0% of patients exhibited favorable outcomes. Overall mortality rate was 30.4%. Age, GCS, pupil dilation, hematoma type, and timing of surgery were all associated with patient outcomes. Further logistic regression analysis revealed that, lower GCS, bilateral pupil dilation, timing of surgery >1 hour, and advanced age were independent risk factors for poor outcomes (P = .001, P = .037, P = .028, and P = .001, respectively).Our study revealed that, DC is not mandatory for all TBI patients with brain herniation. Nevertheless, DC decreases mortality rate in severe TBI patients with brain herniation. Subdural hematoma and timing of surgery >1 hour are key indicators for DC. Lower GCS, bilateral pupil dilation, delayed timing of surgery and advance age are indicators of poor outcomes.
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Affiliation(s)
- Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
- Department of Medicine, Princefield University, Ghana West Africa
| | - Qiang Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Cong Wu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Qiao Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Ruiqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Chaohua Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
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20
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Birle C, Slavoaca D, Muresanu I, Chira D, Vacaras V, Stan AD, Dina C, Strilciuc S. The Effect of Cerebrolysin on the Predictive Value of Baseline Prognostic Risk Score in Moderate and Severe Traumatic Brain Injury. J Med Life 2020; 13:283-288. [PMID: 33072197 PMCID: PMC7550150 DOI: 10.25122/jml-2020-0146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Cognitive dysfunction is a significant complaint among patients after moderate to severe traumatic brain injury (TBI), with devastating consequences on functional recovery and quality of life. Prognostic models allow a better assessment and management of neurotrauma patients. The aim of the study was to demonstrate the predictive value of the Baseline Prognostic Risk Score (BPRS) in moderate to severe TBI, in a sample of patients treated with neurotrophic factors. Eighty patients with moderate-severe TBI from the CAPTAIN II study were included in secondary data analysis. Patients received active treatment with Cerebrolysin, 50 mL per day for ten days, followed by two treatment cycles with 10 mL per day for ten days. BPRS was determined on admission; the age was recorded, and patients were evaluated using the following neurocognitive tests: Mini-Mental State Essay (MMSE), Wechsler Adult Intelligence Scale-Third Edition Processing Speed Index (WAIS-III PSI) and Stroop Colour Word Test-Victoria Version at 10, 30 and 90 days. Hierarchical regression analysis was performed to investigate the unique predictive value of BPRS on cognitive evolution, independent of age. BPRS independently predicted scores on the WAIS-III PSI DSCales and the Word subscale of the Stroop Colour Word Test at 90 days. Age was a significant predictor for all the investigated scales at 10, 30, and 90 days. This study demonstrates the predictive value of a validated prognostic model (BPRS) for medium-term neurocognitive outcomes in a sample of moderate-severe traumatic brain injury treated with neurotrophic factors.
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Affiliation(s)
- Codruta Birle
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,"RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Dana Slavoaca
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,"RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Ioana Muresanu
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,"RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Diana Chira
- "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Vitalie Vacaras
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,"RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania.,Neurology Clinic, Cluj Emergency County Hospital, Cluj-Napoca, Romania
| | - Adina Dora Stan
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,"RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania.,Neurology Clinic, Cluj Emergency County Hospital, Cluj-Napoca, Romania
| | - Constantin Dina
- Department of Radiology, "Ovidius" University, Faculty of Medicine, Constanta, Romania
| | - Stefan Strilciuc
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,"RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
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21
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El Ahmadieh TY, Bedros N, Stutzman SE, Nyancho D, Venkatachalam AM, MacAllister M, Ban VS, Dahdaleh NS, Aiyagari V, Figueroa S, White JA, Batjer HH, Bagley CA, Olson DM, Aoun SG. Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury. World Neurosurg 2020; 145:e163-e169. [PMID: 33011358 DOI: 10.1016/j.wneu.2020.09.152] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes. METHODS We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied. RESULTS Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention. CONCLUSIONS AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bedros
- Division of Trauma, Department of Surgery, Baylor University Medical Center, Baylor, Texas, USA
| | - Sonja E Stutzman
- O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Nyancho
- Department of Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Aardhra M Venkatachalam
- O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew MacAllister
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Vin Shen Ban
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nader S Dahdaleh
- Department of Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Venkatesh Aiyagari
- Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neuro-Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephen Figueroa
- Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neuro-Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan A White
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - H Hunt Batjer
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - DaiWai M Olson
- Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neuro-Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Early cognitive impairment is common after intracranial hemorrhage with mild traumatic brain injury. J Trauma Acute Care Surg 2020; 89:215-221. [PMID: 32102043 DOI: 10.1097/ta.0000000000002641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKDROP The incidence of early cognitive impairment (ECI) after traumatic brain injury (TBI) is unknown. We hypothesized ECI is common and can be predicted based on Glasgow Coma Scale (GCS) and Brain Injury Guideline (BIG) category. METHODS A single-center, retrospective review of adult trauma patients (2014-2016) with intracranial hemorrhage (ICH) and mild TBI (GCS score, 13-15) was performed. The primary outcome was ECI, defined as a Rancho Los Amigos score less than 8. Routine cognitive evaluation is performed on all ICH patients at our institution. Comparisons between ECI and no-ECI groups regarding demographic, cognitive, and clinical outcomes were evaluated using bivariate statistics. The odds of ECI were evaluated using a multivariable logistic regression. RESULTS There were 465 patients with mild TBI, 70.3% were male, and the average age was 53 ± 23 years. The most common mechanism of injury was fall (41.1%) followed by motor vehicle collision (15.9%). The incidence of ECI was 51.4% (n = 239). The incidence in patients with a GCS score of 15 was 42.9%, and BIG 1 category was 42.7%. There were no differences in demographics (age, sex, comorbidities), mechanism of injury, or imaging when comparing ECI patients with no-ECI patients. The GCS score was lower in the ECI group (14.4 vs. 14.7, p < 0.001). Patients with ECI were also less likely to be discharged home (58.2% vs. 78.3%, p < 0.001). Lower GCS-verbal, BIG category 3, and presence of pelvic/extremity fractures were strong risk factors for ECI in a logistic regression model adjusted for age, loss of consciousness, anticoagulants, narcotic administration, and Rotterdam score. CONCLUSION Half of all patients with ICH and mild TBI had ECI. Both lower initial GCS score and BIG category 3 were associated with increased likelihood of ECI. Therefore, we recommend all patients with ICH and mild TBI undergo cognitive evaluation. LEVEL OF EVIDENCE Prognostic Study, Level III.
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23
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Interrater reliability in pupillary assessment among intensive care nurses. Intensive Crit Care Nurs 2020; 58:102801. [PMID: 32035804 DOI: 10.1016/j.iccn.2020.102801] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/18/2019] [Accepted: 01/04/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pupillary abnormalities are a common and reliable finding of brain herniation, ischaemia, and acute brain injury in critically ill patients. Reliable pupil assessment is a vital evaluation in diagnostic and therapeutic procedures for neurocritical patients. AIM To evaluate inter-rater reliability of pupillary assessment among intensive care. METHODS In this prospective, blind observational study, intensive care nurses and two researchers evaluated the pupil size, reactivity and symmetry of 200 patients with neurosurgery or neurological diseases. A total of 200 pupillary measurement sets were completed independently and blindly. RESULTS Three observers -two researchers and the nurse- found fair-to-good and excellent agreements in initial pupil size evaluations of right and left pupils, respectively (ICC = 0.70, 95%; ICC = 0.75, 95%). In patients with pupil size ≥4 mm, the observers found fair-to-good agreements in both right and left pupil initial size measurements (ICC = 0.52; ICC = 0.65). Agreement in pupil symmetry was moderated (K = 0.58), and reactivity was near perfect (K = 0.89) between the three observers. CONCLUSION Although the two researchers found near perfect agreement in pupil size, symmetry and reactivity assessment, two researchers and the nurse found moderate agreement in pupil symmetry and fair-to-good agreement in pre- and post-light stimulation pupil size.
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Assessment of intracranial pressure monitoring in patients with moderate traumatic brain injury: A retrospective cohort study. Clin Neurol Neurosurg 2020; 189:105538. [DOI: 10.1016/j.clineuro.2019.105538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 11/17/2022]
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Glasgow Coma Scale Score Fluctuations are Inversely Associated With a NIRS-based Index of Cerebral Autoregulation in Acutely Comatose Patients. J Neurosurg Anesthesiol 2019; 31:306-310. [PMID: 29782388 DOI: 10.1097/ana.0000000000000513] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) is an essential coma scale in critical care for determining the neurological status of patients and for estimating their long-term prognosis. Similarly, cerebral autoregulation (CA) monitoring has shown to be an accurate technique for predicting clinical outcomes. However, little is known about the relationship between CA measurements and GCS scores among neurological critically ill patients. This study aimed to explore the association between noninvasive CA multimodal monitoring measurements and GCS scores. METHODS Acutely comatose patients with a variety of neurological injuries admitted to a neurocritical care unit were monitored using near-infrared spectroscopy-based multimodal monitoring for up to 72 hours. Regional cerebral oxygen saturation (rScO2), cerebral oximetry index (COx), GCS, and GCS motor data were measured hourly. COx was calculated as a Pearson correlation coefficient between low-frequency changes in rScO2 and mean arterial pressure. Mixed random effects models with random intercept was used to determine the relationship between hourly near-infrared spectroscopy-based measurements and GCS or GCS motor scores. RESULTS A total of 871 observations (h) were analyzed from 57 patients with a variety of neurological conditions. Mean age was 58.7±14.2 years and the male to female ratio was 1:1.3. After adjusting for hemoglobin and partial pressure of carbon dioxide in arterial blood, COx was inversely associated with GCS (β=-1.12, 95% confidence interval [CI], -1.94 to -0.31, P=0.007) and GCS motor score (β=-1.06, 95% CI, -2.10 to -0.04, P=0.04). In contrast rScO2 was not associated with GCS (β=-0.002, 95% CI, -0.01 to 0.01, P=0.76) or GCS motor score (β=-0.001, 95% CI, -0.01 to 0.01, P=0.84). CONCLUSIONS This study showed that fluctuations in GCS scores are inversely associated with fluctuations in COx; as COx increases (impaired autoregulation), more severe neurological impairment is observed. However, the difference in COx between high and low GCS is small and warrants further studies investigating this association. CA multimodal monitoring with COx may have the potential to be used as a surrogate of neurological status when the neurological examination is not reliable (ie, sedation and paralytic drug administration).
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Chitinase-3-Like Protein 1, Serum Amyloid A1, C-Reactive Protein, and Procalcitonin Are Promising Biomarkers for Intracranial Severity Assessment of Traumatic Brain Injury: Relationship with Glasgow Coma Scale and Computed Tomography Volumetry. World Neurosurg 2019; 134:e120-e143. [PMID: 31606503 DOI: 10.1016/j.wneu.2019.09.143] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The volume and location of intracranial hematomas are well-known prognostic factors for traumatic brain injury. The aim of this study was to determine the relationship of serum biomarkers S100β, glial fibrillary acidic protein, neuron-specific enolase, total tau, phosphorylated neurofilament heavy chain, serum amyloid A1 (SAA1), C-reactive protein, procalcitonin (PCT), and chitinase-3-like protein 1 (YKL-40) with traumatic brain injury severity and the amount and location of hemorrhagic traumatic lesions. METHODS A prospective observational cohort of 115 patients with a Glasgow Coma Scale (GCS) score of 3-15 were evaluated. Intracranial lesion volume was measured from the semiautomatic segmentation of hematoma on computed tomography using Analyze software. The establishment of possible biomarker cutoff points for intracranial lesion detection was estimated using the Youden Index (J) obtained from the area under the receiver operating characteristic curve. RESULTS SAA1, YKL-40, PCT, and S100β showed the most robust association with level of consciousness, both with total GCS and motor score. Biomarkers significantly correlated with volumetric measurements of subdural hematoma, traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage, intraventricular hemorrhage, and total amount of bleeding. The type of intracranial hemorrhage was associated with various release patterns of neurobiochemical markers. CONCLUSIONS YKL-40, SAA1, C-reactive protein, and PCT combined with S100β were the most promising biomarkers to determine the presence, location, and extent of traumatic intracranial lesions. Combination of biomarkers further increased the discriminatory capacity for the detection of intracranial bleeding.
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Gravesteijn BY, Sewalt CA, Ercole A, Lecky F, Menon D, Steyerberg EW, Maas AIR, Lingsma HF, Klimek M. Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study. Anaesthesia 2019; 75:45-53. [PMID: 31520421 PMCID: PMC7344983 DOI: 10.1111/anae.14838] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 01/03/2023]
Abstract
Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER‐TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed‐effects multinomial regression to quantify the effects on pre‐hospital or in‐hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre‐hospital and 483 (13%) in‐hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre‐hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1–4.3) for pre‐hospital intubation, and 2.7 (95%CI 1.9–3.5) for in‐hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre‐hospital intubation (OR 2.9, 95%CI 1.3–6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3–0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between‐centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.
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Affiliation(s)
- B Y Gravesteijn
- Departments of Anesthesiology and Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C A Sewalt
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A Ercole
- Department of Anaesthesiology, University of Cambridge, UK
| | - F Lecky
- Emergency Medicine Research in Sheffield, School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, UK
| | - D Menon
- Department of Anaesthesia, University of Cambridge, UK
| | - E W Steyerberg
- Department of Biostatistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - A I R Maas
- Department of Neurosurgery, University Hospital Antwerp, Belgium
| | - H F Lingsma
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Majdan M, Brazinova A, Rusnak M, Leitgeb J. Outcome Prediction after Traumatic Brain Injury: Comparison of the Performance of Routinely Used Severity Scores and Multivariable Prognostic Models. J Neurosci Rural Pract 2019; 8:20-29. [PMID: 28149077 PMCID: PMC5225716 DOI: 10.4103/0976-3147.193543] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objectives: Prognosis of outcome after traumatic brain injury (TBI) is important in the assessment of quality of care and can help improve treatment and outcome. The aim of this study was to compare the prognostic value of relatively simple injury severity scores between each other and against a gold standard model – the IMPACT-extended (IMP-E) multivariable prognostic model. Materials and Methods: For this study, 866 patients with moderate/severe TBI from Austria were analyzed. The prognostic performances of the Glasgow coma scale (GCS), GCS motor (GCSM) score, abbreviated injury scale for the head region, Marshall computed tomographic (CT) classification, and Rotterdam CT score were compared side-by-side and against the IMP-E score. The area under the receiver operating characteristics curve (AUC) and Nagelkerke's R2 were used to assess the prognostic performance. Outcomes at the Intensive Care Unit, at hospital discharge, and at 6 months (mortality and unfavorable outcome) were used as end-points. Results: Comparing AUCs and R2s of the same model across four outcomes, only little variation was apparent. A similar pattern is observed when comparing the models between each other: Variation of AUCs <±0.09 and R2s by up to ±0.17 points suggest that all scores perform similarly in predicting outcomes at various points (AUCs: 0.65–0.77; R2s: 0.09–0.27). All scores performed significantly worse than the IMP-E model (with AUC > 0.83 and R2 > 0.42 for all outcomes): AUCs were worse by 0.10–0.22 (P < 0.05) and R2s were worse by 0.22–0.39 points. Conclusions: All tested simple scores can provide reasonably valid prognosis. However, it is confirmed that well-developed multivariable prognostic models outperform these scores significantly and should be used for prognosis in patients after TBI wherever possible.
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Affiliation(s)
- Marek Majdan
- Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; International Neurotrauma Research Organization, Trnava University, 1090 Vienna, Austria
| | - Alexandra Brazinova
- Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; International Neurotrauma Research Organization, Trnava University, 1090 Vienna, Austria
| | - Martin Rusnak
- Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Johannes Leitgeb
- Department of Traumatology, Medical University of Vienna, 1090 Vienna, Austria
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Dardiotis E, Siokas V, Aloizou AM, Karampinis E, Brotis AG, Grigoriadis S, Paterakis K, Dardioti M, Komnos A, Kapsalaki E, Fountas K, Hadjigeorgiou GM. Effect of integrin AV and B8 gene polymorphisms in patients with traumatic brain injury. Brain Inj 2019; 33:836-845. [PMID: 31033358 DOI: 10.1080/02699052.2019.1606444] [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: 10/26/2022]
Abstract
Background: Α few genetic variants are associated with the outcome after traumatic brain injury (TBI). Integrins are glycoprotein receptors that play an important role in the integrity of microvasculature of the brain. Objective: To examine the role of integrin-AV (ITGAV) and integrin-B8 (ITGB8) tag single nucleotide polymorphisms (SNPs) on the outcome of patients with TBI. Methods: 363 participants were included and genotyped for 11 SNPs for ITGAV and 11 for ITGB8 gene. SNPs were tested for associations with the 6-month outcome after TBI, the presence of a hemorrhagic event after TBI, and the initial TBI severity after adjustment for TBI's main predictors. Results: The ITGAV rs3911239 CC and rs7596996 GG genotypes were associated with an unfavorable outcome after TBI, compared to the TT and AA genotypes, respectively. The ITGB8 rs10239099 CC and rs3757727 CC genotypes were associated with increased risk of any cerebral hemorrhagic event after TBI compared to GG and TT respectively. The ITGAV rs7589470 and rs7565633 were associated with the TBI's initial severity. Conclusions: ITGAV gene SNPs may be implicated in the outcome after TBI, as well as in the initial TBI severity, and also of ITGB8 gene SNPs in the risk of hemorrhagic event after a TBI.
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Affiliation(s)
- Efthimios Dardiotis
- a Department of Neurology, Laboratory of Neurogenetics , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Vasileios Siokas
- a Department of Neurology, Laboratory of Neurogenetics , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Athina-Maria Aloizou
- a Department of Neurology, Laboratory of Neurogenetics , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Emmanouil Karampinis
- a Department of Neurology, Laboratory of Neurogenetics , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Alexandros G Brotis
- b Department of Neurosurgery , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Savas Grigoriadis
- c Second Department of Neurosurgery , Hippokration University Hospital, Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Konstantinos Paterakis
- b Department of Neurosurgery , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Maria Dardioti
- a Department of Neurology, Laboratory of Neurogenetics , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Apostolos Komnos
- d Intensive Care Unit , General Hospital of Larissa , Larissa , Greece
| | - Eftychia Kapsalaki
- e Department of Radiology , University of Thessaly, School of Medicine , Larissa , Greece
| | - Kostas Fountas
- b Department of Neurosurgery , University of Thessaly, University Hospital of Larissa , Larissa , Greece
| | - Georgios M Hadjigeorgiou
- a Department of Neurology, Laboratory of Neurogenetics , University of Thessaly, University Hospital of Larissa , Larissa , Greece.,f Department of Neurology , Medical School, University of Cyprus , Nicosia , USA
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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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Gerges PRA, Moore L, Léger C, Lauzier F, Shemilt M, Zarychanski R, Scales DC, Burns KEA, Bernard F, Zygun D, Neveu X, Turgeon AF. Intensity of care and withdrawal of life-sustaining therapies in severe traumatic brain injury patients: a post-hoc analysis of a multicentre retrospective cohort study. Can J Anaesth 2018; 65:996-1003. [PMID: 29949093 DOI: 10.1007/s12630-018-1171-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/20/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The intensity of care provided to critically ill patients has been shown to be associated with mortality. In patients with traumatic brain injury (TBI), specialized neurocritical care is often required, but whether it affects clinically significant outcomes is unknown. We aimed to determine the association of the intensity of care on mortality and the incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI. METHODS We conducted a post hoc analysis of a multicentre retrospective cohort study of critically ill adult patients with severe TBI. We defined the intensity of care as a daily cumulative sum of interventions during the intensive care unit stay. Our outcome measures were all-cause hospital mortality and the incidence of withdrawal of life-sustaining therapies. RESULTS Seven hundred sixteen severe TBI patients were included in our study. Most were male (77%) with a mean (standard deviation) age of 42 (20.5) yr and a median [interquartile range] Glasgow Coma Scale score of 3 [3-6]. Our results showed an association between the intensity of care and mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.63 to 0.74) and the incidence of withdrawal of life-sustaining therapy (HR, 0.73; 95% CI, 0.67 to 0.79). CONCLUSION In general, more intense care was associated with fewer deaths and a lower incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI.
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Affiliation(s)
- Peter R A Gerges
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada.,Department of Social and Preventive Medicine, Université Laval, Québec City, QC, Canada
| | - Caroline Léger
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Department of Medicine, Université Laval, Québec City, QC, Canada
| | - Michèle Shemilt
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and of Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St-Michaels Hospital, Toronto, ON, Canada
| | - Francis Bernard
- Department of Internal Medicine, Université de Montréal, Montréal, QC, Canada
| | - David Zygun
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Xavier Neveu
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada. .,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.
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Posti JP, Takala RSK, Runtti H, Newcombe VF, Outtrim J, Katila AJ, Frantzén J, Ala-Seppälä H, Coles JP, Hossain MI, Kyllönen A, Maanpää HR, Tallus J, Hutchinson PJ, van Gils M, Menon DK, Tenovuo O. The Levels of Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 During the First Week After a Traumatic Brain Injury: Correlations With Clinical and Imaging Findings. Neurosurgery 2017; 79:456-64. [PMID: 26963330 DOI: 10.1227/neu.0000000000001226] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) are promising biomarkers of traumatic brain injury (TBI). OBJECTIVE We investigated the relation of the GFAP and UCH-L1 levels to the severity of TBI during the first week after injury. METHODS Plasma UCH-L1 and GFAP were measured from 324 consecutive patients with acute TBI and 81 control subject enrolled in a 2-center prospective study. The baseline measures included initial Glasgow Coma Scale (GCS), head computed tomographic (CT) scan at admission, and blood samples for protein biomarkers that were collected at admission and on days 1, 2, 3, and 7 after injury. RESULTS Plasma levels of GFAP and UCH-L1 during the first 2 days after the injury strongly correlated with the initial severity of TBI as assessed with GCS. Additionally, levels of UCH-L1 on the seventh day after the injury were significantly related to the admission GCS scores. At admission, both biomarkers were capable of distinguishing mass lesions from diffuse injuries in CT, and the area under the curve of the receiver-operating characteristic curve for prediction of any pathological finding in CT was 0.739 (95% confidence interval, 0.636-0.815) and 0.621 (95% confidence interval, 0.517-0.713) for GFAP and UCH-L1, respectively. CONCLUSION These results support the prior findings of the potential role of GFAP and UCH-L1 in acute-phase diagnostics of TBI. The novel finding is that levels of GFAP and UCH-L1 correlated with the initial severity of TBI during the first 2 days after the injury, thus enabling a window for TBI diagnostics with latency. ABBREVIATIONS AUC, area under the curveCI, confidence intervalED, emergency departmentGCS, Glasgow Coma ScaleGRAP, glial fibrillary acidic proteinIMPACT, International Mission for Prognosis and Clinical TrialROC, receiver-operating characteristicTBI, traumatic brain injuryTRACK-TBI, Transforming Research and Clinical Knowledge in Traumatic Brain InjuryUCH-L1, ubiquitin C-terminal hydrolase-L1.
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Affiliation(s)
- Jussi P Posti
- *Division of Clinical Neurosciences, Department of Neurosurgery and ‡Division of Clinical Neurosciences, Department of Rehabilitation and Brain Trauma, Turku University Hospital, Turku, Finland; §Department of Neurology, University of Turku, Turku, Finland; ¶Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland; ‖Systems Medicine, VTT Technical Research Centre of Finland, Tampere, Finland; #Division of Anaesthesia, Department of Medicine and **Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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Big Data and Clinical Research in Traumatic Brain Injury. World Neurosurg 2017; 109:465-466. [PMID: 28987829 DOI: 10.1016/j.wneu.2017.09.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 09/22/2017] [Indexed: 11/23/2022]
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Najafi Z, Zakeri H, Mirhaghi A. The accuracy of acuity scoring tools to predict 24-h mortality in traumatic brain injury patients: A guide to triage criteria. Int Emerg Nurs 2017; 36:27-33. [PMID: 28965751 DOI: 10.1016/j.ienj.2017.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/11/2017] [Accepted: 08/21/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIM Prompt identification of traumatic brain injury (TBI) is vital for patients in critical condition; however, it is not clear which acuity scoring tools are associated with short-term mortality. The aim of this study was to determine the accuracy of acuity scoring tools and 24-h mortality among TBI patients in both prehospital and hospital settings. METHODS This study was an observational, prospective cohort, in which patients with TBI were followed from the accident scene to the hospital. Vital signs and acuity scoring tools, including the Revised Trauma Score (RTS), Injury Severity Score (ISS), National Early Warning Score (NEWS), Shock Index (SI), Modified Shock Index (MSI) and Trauma and Injury Severity Score (TRISS), were collected both on the scene as well as at the hospital. A logistic regression was performed to ascertain the effects of clinical parameters on the likelihood of survival of patients with TBI regarding 24-h mortality. RESULTS A total of 185 patients were included in this study. The mortality rate was 14% (25/185). The logistic regression model was statistically significant at χ2=60.8, p=0.001. A hierarchical forward stepwise logistic regression analysis showed that age, hospital RTS and prehospital NEWS significantly improved mortality predictions. The model explained the 51.2% variance in survival of patients with TBI. CONCLUSIONS The NEWS and the RTS may be used to triage TBI patients for prehospital and hospital emergency care, respectively. Therefore, because traditional vital signs criteria may be of limited use for the triage of TBI patients, it is recommended that acuity scoring tools be used in such cases.
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Affiliation(s)
- Zohre Najafi
- Department of Medical-Surgical Nursing, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
| | - Hossien Zakeri
- Emergency Medicine, Hasheminejad Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Amir Mirhaghi
- Evidence-Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.
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D'sa SR, Nair S, Joe Philip V, Reji KK, Karuppusamy R, Joseph M. Study of the factors at admission predicting the outcome in patients with attempted suicidal hanging. Trop Doct 2017; 48:3-6. [PMID: 28862515 DOI: 10.1177/0049475517729065] [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: 11/16/2022]
Abstract
Our study sought to identify factors at presentation which can predict the outcome after an attempted hanging. A retrospective analysis of patients over a 12-year period was carried out. A poor outcome was found in 17.8% and this could be predicted by the presence of myoclonus, a Glasgow coma motor score of ≤3 or an abnormal chest radiograph.
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Affiliation(s)
- Shilpa Reynal D'sa
- 1 Assistant Professor, Department of Critical Care, Medicine 30025 Christian Medical College, Vellore , India
| | - Shalini Nair
- 2 Professor, Department of Neurointensive Care, 30025 Christian Medical College, Vellore , India
| | - Vinu Joe Philip
- 3 Junior Registrar, 30025 Christian Medical College, Vellore , India
| | | | - Reka Karuppusamy
- 4 Senior Demonstrator, Department of Biostatistics, 30025 Christian Medical College, Vellore , India
| | - Mathew Joseph
- 5 Professor and Head, Department of Neurointensive Care, 30025 Christian Medical College, Vellore , India
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Otten EJ, Dorlac WC. Managing Traumatic Brain Injury: Translating Military Guidelines to the Wilderness. Wilderness Environ Med 2017; 28:S117-S123. [DOI: 10.1016/j.wem.2017.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/26/2017] [Accepted: 02/28/2017] [Indexed: 11/25/2022]
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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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Junior JR, Welling LC, Schafranski M, Yeng LT, do Prado RR, Koterba E, de Andrade AF, Teixeira MJ, Figueiredo EG. Prognostic model for patients with traumatic brain injuries and abnormal computed tomography scans. J Clin Neurosci 2017; 42:122-128. [PMID: 28347684 DOI: 10.1016/j.jocn.2017.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/10/2017] [Accepted: 03/05/2017] [Indexed: 11/27/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of death and disability worldwide. The prognosis evaluation is a challenge when many variables are involved. The authors aimed to develop prognostic model for assessment of survival chances after TBI based on admission characteristics, including extracranial injuries, which would allow application of the model before in-hospital therapeutic interventions. A cohort study evaluated 1275 patients with TBI and abnormal CT scans upon admission to the emergency unit of Hospital das Clinicas of University of Sao Paulo and analyzed the final outcome on mortality. A logistic regression analysis was undertaken to determine the adjusted weigh of each independent variable in the outcome. Four variables were found to be significant in the model: age (years), Glasgow Coma Scale (3-15), Marshall Scale (MS, stratified into 2,3 or 4,5,6; according to the best group positive predictive value) and anysochoria (yes/no). The following formula is in a logistic model (USP index to head injury) estimates the probability of death of patients according to characteristics that influence on mortality. We consider that our mathematical probability model (USP Index) may be applied to clinical prognosis in patients with abnormal CT scans after severe traumatic brain injury.
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Affiliation(s)
| | - Leonardo C Welling
- Division of Neurological Surgery, State University of Ponta Grossa, Brazil.
| | | | - Lin Tchia Yeng
- Division of Neurological Surgery, University of Sao Paulo, Brazil.
| | | | - Edwin Koterba
- Division of Neurological Surgery, University of Sao Paulo, Brazil.
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Majdan M, Brazinova A, Rusnak M, Leitgeb J. Outcome Prediction after Traumatic Brain Injury: Comparison of the Performance of Routinely Used Severity Scores and Multivariable Prognostic Models. J Neurosci Rural Pract 2017. [PMID: 28149077 DOI: 10.4103/0976--3147.193543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Prognosis of outcome after traumatic brain injury (TBI) is important in the assessment of quality of care and can help improve treatment and outcome. The aim of this study was to compare the prognostic value of relatively simple injury severity scores between each other and against a gold standard model - the IMPACT-extended (IMP-E) multivariable prognostic model. MATERIALS AND METHODS For this study, 866 patients with moderate/severe TBI from Austria were analyzed. The prognostic performances of the Glasgow coma scale (GCS), GCS motor (GCSM) score, abbreviated injury scale for the head region, Marshall computed tomographic (CT) classification, and Rotterdam CT score were compared side-by-side and against the IMP-E score. The area under the receiver operating characteristics curve (AUC) and Nagelkerke's R2 were used to assess the prognostic performance. Outcomes at the Intensive Care Unit, at hospital discharge, and at 6 months (mortality and unfavorable outcome) were used as end-points. RESULTS Comparing AUCs and R2s of the same model across four outcomes, only little variation was apparent. A similar pattern is observed when comparing the models between each other: Variation of AUCs <±0.09 and R2s by up to ±0.17 points suggest that all scores perform similarly in predicting outcomes at various points (AUCs: 0.65-0.77; R2s: 0.09-0.27). All scores performed significantly worse than the IMP-E model (with AUC > 0.83 and R2 > 0.42 for all outcomes): AUCs were worse by 0.10-0.22 (P < 0.05) and R2s were worse by 0.22-0.39 points. CONCLUSIONS All tested simple scores can provide reasonably valid prognosis. However, it is confirmed that well-developed multivariable prognostic models outperform these scores significantly and should be used for prognosis in patients after TBI wherever possible.
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Affiliation(s)
- Marek Majdan
- Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; International Neurotrauma Research Organization, Trnava University, 1090 Vienna, Austria
| | - Alexandra Brazinova
- Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; International Neurotrauma Research Organization, Trnava University, 1090 Vienna, Austria
| | - Martin Rusnak
- Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Johannes Leitgeb
- Department of Traumatology, Medical University of Vienna, 1090 Vienna, Austria
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Yumoto T, Mitsuhashi T, Yamakawa Y, Iida A, Nosaka N, Tsukahara K, Naito H, Nakao A. Impact of Cushing's sign in the prehospital setting on predicting the need for immediate neurosurgical intervention in trauma patients: a nationwide retrospective observational study. Scand J Trauma Resusc Emerg Med 2016; 24:147. [PMID: 27938387 PMCID: PMC5148882 DOI: 10.1186/s13049-016-0341-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 12/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background Cushing’s reflex usually results from intracranial hypertension. Although Cushing’s sign can implicate severe traumatic brain injury (TBI) in injured patients, no major investigations have been made. The purpose of this study was to assess the predictability of life-threatening brain injury requiring immediate neurosurgical intervention (LT-BI) among trauma patients with Cushing’s sign in the prehospital setting. Methods This was a retrospective study using data from the Japan Trauma Data Bank from the period of 2010 to 2014. Patients 16 years old or older with blunt mechanisms of injury who were transported directly from the scene and Glasgow Coma Scale for eye opening of one in the prehospital setting were included. LT-BI was defined as patients requiring burr hole evacuation or craniotomy within 24 h of hospital arrival and patients who were non-survivors due to isolated severe TBI. Prehospital systolic blood pressure (pSBP) and heart rate (pHR) were assessed using area under the receiver operating characteristic curve (AUROC) and multiple logistic regression analysis to predict LT-BI. Results Of 6332 eligible patients, 1859 (29%) exhibited LT-BI. AUROC of LT-BI using pSBP and pHR was 0.666 (95% confidence interval (CI); 0.652–0.681, P < 0.001), and 0.578 (95% CI; 0.563–0.594, P < 0.001), respectively. AUROC of pSBP was the highest among the 60 ≤ pHR ≤ 99 subgroup, of which AUROC was 0.680 (95% CI; 0.662–0.699, P < 0.001). Multiple logistic regression analysis showed that the higher the pSBP and the lower the pHR, the more likely that the patients had LT-BI. In a group with pSBP ≥ 180 mmHg and pHR ≤ 59 beats/min, the odds ratio and 95% CI of LT-BI after adjusting for age, sex, and severity of injuries to other body regions was 4.77 (2.85–7.97), P < 0.001 was compared with the reference group, which was defined as patients with normal vital signs. Discussion Our study has found that the combination of hypertension and bradycardia, which are the components of Cushing's sign without eye opening in the prehospital setting was a weak but a significant predictor of LT-BI, or death due to possible isolated severe TBI. Conclusions Prehospital Cushing’s sign with disturbed level of consciousness in trauma patients was a weak but significant predictor of the need for immediate neurosurgical intervention.
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Affiliation(s)
- Tetsuya Yumoto
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan.
| | - Toshiharu Mitsuhashi
- Center for Innovative Clinical Medicine, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan
| | - Yasuaki Yamakawa
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan
| | - Atsuyoshi Iida
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan
| | - Nobuyuki Nosaka
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan
| | - Kohei Tsukahara
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan
| | - Hiromichi Naito
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan
| | - Atsunori Nakao
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1 Kita-ku, Shikata-cho, Okayama-shi, Okayama, 700-8558, Japan
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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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Aycan A, Yener U, Aycan N, Gönüllü E, Dursun R, Gönüllü H. Neurosurgical Injuries Caused by the 2011 Van Earthquake: The Experience at the Van Regional Training and Research Hospital. J Emerg Med 2015; 49:464-70. [DOI: 10.1016/j.jemermed.2015.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
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Olson DM, Stutzman S, Saju C, Wilson M, Zhao W, Aiyagari V. Interrater Reliability of Pupillary Assessments. Neurocrit Care 2015; 24:251-7. [DOI: 10.1007/s12028-015-0182-1] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Recommendations for the use of multimodal monitoring in the neurointensive care unit. Curr Opin Crit Care 2015; 21:113-9. [DOI: 10.1097/mcc.0000000000000179] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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