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Paul MM, Mieden HJ, Lefering R, Kupczyk EK, Jordan MC, Gilbert F, Meffert RH, Sirén AL, Hoelscher-Doht S. Impact of a Femoral Fracture on Outcome after Traumatic Brain Injury-A Matched-Pair Analysis of the TraumaRegister DGU ®. J Clin Med 2023; 12:jcm12113802. [PMID: 37297997 DOI: 10.3390/jcm12113802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in polytrauma and is often accompanied by concomitant injuries. We conducted a retrospective matched-pair analysis of data from a 10-year period from the multicenter database TraumaRegister DGU® to analyze the impact of a concomitant femoral fracture on the outcome of TBI patients. A total of 4508 patients with moderate to critical TBI were included and matched by severity of TBI, American Society of Anesthesiologists (ASA) risk classification, initial Glasgow Coma Scale (GCS), age, and sex. Patients who suffered combined TBI and femoral fracture showed increased mortality and worse outcome at the time of discharge, a higher chance of multi-organ failure, and a rate of neurosurgical intervention. Especially those with moderate TBI showed enhanced in-hospital mortality when presenting with a concomitant femoral fracture (p = 0.037). The choice of fracture treatment (damage control orthopedics vs. early total care) did not impact mortality. In summary, patients with combined TBI and femoral fracture have higher mortality, more in-hospital complications, an increased need for neurosurgical intervention, and inferior outcome compared to patients with TBI solely. More investigations are needed to decipher the pathophysiological consequences of a long-bone fracture on the outcome after TBI.
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Affiliation(s)
- Mila M Paul
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Würzburg, 97080 Würzburg, Germany
- Department of Neurophysiology, Institute for Physiology, Julius-Maximilians-University Würzburg, 97070 Würzburg, Germany
- Department of Neurosurgery, University Hospital of Würzburg, 97080 Würzburg, Germany
| | - Hannah J Mieden
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Würzburg, 97080 Würzburg, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, 51109 Cologne, Germany
| | - Eva K Kupczyk
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Würzburg, 97080 Würzburg, Germany
| | - Martin C Jordan
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Würzburg, 97080 Würzburg, Germany
| | - Fabian Gilbert
- LMU Klinikum Campus Innenstadt, University of München, 80336 Munich, Germany
| | - Rainer H Meffert
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Würzburg, 97080 Würzburg, Germany
| | - Anna-Leena Sirén
- Department of Neurophysiology, Institute for Physiology, Julius-Maximilians-University Würzburg, 97070 Würzburg, Germany
- Department of Neurosurgery, University Hospital of Würzburg, 97080 Würzburg, Germany
| | - Stefanie Hoelscher-Doht
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Würzburg, 97080 Würzburg, Germany
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Mrlian A, Smrcka M, Juran V, Navratil O, Neuman E, Duris K. Immune system disorders in the early post-injury period in patients after severe brain injury from the perspective of the severity of the injury. Neurol Sci 2023; 44:1031-1038. [PMID: 36355330 DOI: 10.1007/s10072-022-06482-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/27/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Brain injuries are the most common cause of death in productive age. Besides the extent of the injury, other systemic factors can also affect the outcome. Patients suffering from severe brain injury often experience extracranial inflammatory complications during the early period of treatment. Here, we investigate the changes in immunity in patients with brain injury. METHODS 121 patients and 92 healthy controls were included in the research. Blood samples were collected on admission and analyzed by flow cytometry and biochemical methods. Multiple clusters of differentiation (CD) and antibody levels were investigated. The results were compared between patients and controls. In addition, results of two classes of severity (Glasgow Coma Scale, GCS, of 3-5 vs. 6-8) were also compared. RESULTS Parameters of humoral immunity in patients immediately after admission were significantly lower than those from healthy donors, with the exception of IgE elevated as much as to resemble allergic reaction (p < 0.01). Of cellular parameters, only natural killer (NK) cluster CD56 + was elevated (p < 0.01). Extracranial infectious complications were more common in patients with GCS 3-5. CONCLUSIONS Strong immune system disorders were observed in patients after severe brain injury, which may contribute to the worse outcome in such patients.
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Affiliation(s)
- Andrej Mrlian
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and University Hospital, Brno, Czech Republic.
| | - Martin Smrcka
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and University Hospital, Brno, Czech Republic
| | - Vilem Juran
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and University Hospital, Brno, Czech Republic
| | - Ondrej Navratil
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and University Hospital, Brno, Czech Republic
| | - Eduard Neuman
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and University Hospital, Brno, Czech Republic
| | - Kamil Duris
- Department of Pathophysiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Beucler N, Sellier A, Joubert C, Lesquen HD, Schlienger G, Caubere A, Holay Q, Desse N, Esnault P, Dagain A. Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept. J Neurosci Rural Pract 2022; 13:585-607. [PMID: 36743747 PMCID: PMC9893946 DOI: 10.25259/jnrp-2022-1-38-r1-(2348)] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods A scoping review was conducted on Medline database from inception to September 2021. Results The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.
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Affiliation(s)
- Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | - Aurore Sellier
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Christophe Joubert
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Henri De Lesquen
- Department of Thoracic and Vascular Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Ghislain Schlienger
- Department of Visceral Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Alexandre Caubere
- Department of Orthopaedic Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Quentin Holay
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
- Department of Diagnostic and Interventional Radiology, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Nicolas Desse
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Pierre Esnault
- Department of Intensive care unit, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Department of Val-de-Grâce Military Academy, Paris, France
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Beucler N, Sellier A, Joubert C, Bernard C, Desse N, Esnault P, Dagain A. Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study. Mil Med 2022; 187:1127-1135. [PMID: 35038725 DOI: 10.1093/milmed/usab555] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/06/2021] [Accepted: 12/23/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. MATERIALS AND METHODS We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. RESULTS The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). CONCLUSION Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, Ile-de-France 75230, France
| | - Aurore Sellier
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Christophe Joubert
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Cédric Bernard
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Nicolas Desse
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Pierre Esnault
- Intensive Care Unit, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Val-de-Grâce Military Academy, Paris, Ile-de-France 75230, France
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Palekar SG, Jaiswal M, Patil M, Malpathak V. Outcome Prediction in Patients of Traumatic Brain Injury Based on Midline Shift on CT Scan of Brain. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0040-1716990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Background Clinicians treating patients with head injury often take decisions based on their assessment of prognosis. Assessment of prognosis could help communication with a patient and the family. One of the most widely used clinical tools for such prediction is the Glasgow coma scale (GCS); however, the tool has a limitation with regard to its use in patients who are under sedation, are intubated, or under the influence of alcohol or psychoactive drugs. CT scan findings such as status of basal cistern, midline shift, associated traumatic subarachnoid hemorrhage (SAH), and intraventricular hemorrhage are useful indicators in predicting outcome and also considered as valid options for prognostication of the patients with traumatic brain injury (TBI), especially in emergency setting.
Materials and Methods 108 patients of head injury were assessed at admission with clinical examination, history, and CT scan of brain. CT findings were classified according to type of lesion and midline shift correlated to GCS score at admission. All the subjects in this study were managed with an identical treatment protocol. Outcome of these patients were assessed on GCS score at discharge.
Results Among patients with severe GCS, 51% had midline shift. The degree of midline shift in CT head was a statistically significant determinant of outcome (p = 0.023). Seventeen out of 48 patients (35.4%) with midline shift had poor outcome as compared with 8 out of 60 patients (13.3%) with no midline shift.
Conclusion In patients with TBI, the degree of midline shift on CT scan was significantly related to the severity of head injury and resulted in poor clinical outcome.
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Affiliation(s)
- Shrikant Govindrao Palekar
- Department of General Surgery, Dr. Vasantrao Pawar Medical College, Hospital & research center, Adgaon, Nasik, India
| | - Manish Jaiswal
- Department of Neurosurgery, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Mandar Patil
- Department of Neurosurgery, Tirunelveli Government Medical College, Tamil Nadu, India
| | - Vijay Malpathak
- Department of General Surgery, Dr. Vasantrao Pawar Medical College, Hospital & research center, Adgaon, Nasik, India
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Bharti R, Sindhu S, Sundaram PK, Chauhan G. Prospective Observational Study of Early Tracheostomy Role in Operated Severe Head Injury Patients at A Level 1 Trauma Center. Bull Emerg Trauma 2021; 9:188-194. [PMID: 34692870 PMCID: PMC8525695 DOI: 10.30476/beat.2021.86725.1198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 06/15/2021] [Accepted: 06/29/2021] [Indexed: 11/19/2022] Open
Abstract
Objective: To evaluate the impact of the early tracheostomy on operated patients with severe head injury. Methods: This prospective observational study was conducted at a level 1 trauma center and medical college over one-year period. The study included all surgically managed severe head injury patients without any other life-threatening major injuries. Patients who underwent tracheostomy within 7 days were classified as early tracheostomy. Results: The patient’s mean age of this cohort study was 43.4±14.5 years. Motor-vehicle accidents were being the most common cause of severe head injury. Operated patients were undergoing early tracheostomy on an average of 2.9 days. We were observed that the patients spent on a mechanical ventilation on an average 3.67±2.26 days. This was significantly lower than previous four published studies (p<0.05) which had a range of mean 9.8-15.7 days. Conclusion: We have shown that it is possible to decrease mechanical ventilation (MV) time, intensive care unit (ICU) stay and total hospital stay by doing early tracheostomy in operated severe head injury patients.
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Affiliation(s)
- Rohit Bharti
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
| | | | | | - Ganesh Chauhan
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
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Xu LB, Yue JK, Korley F, Puccio AM, Yuh EL, Sun X, Rabinowitz M, Vassar MJ, Taylor SR, Winkler EA, Puffer RC, Deng H, McCrea M, Stein MB, Robertson CS, Levin HS, Dikmen S, Temkin NR, Giacino JT, Mukherjee P, Wang KK, Okonkwo DO, Markowitz AJ, Jain S, Manley GT, Diaz-Arrastia R. High-Sensitivity C-Reactive Protein is a Prognostic Biomarker of Six-Month Disability after Traumatic Brain Injury: Results from the TRACK-TBI Study. J Neurotrauma 2021; 38:918-927. [PMID: 33161875 PMCID: PMC7987360 DOI: 10.1089/neu.2020.7177] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Systemic inflammation impacts outcome after traumatic brain injury (TBI), but most TBI biomarker studies have focused on brain-specific proteins. C-reactive protein (CRP) is a widely used biomarker of inflammation with potential as a prognostic biomarker after TBI. The Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study prospectively enrolled TBI patients within 24 h of injury, as well as orthopedic injury and uninjured controls; biospecimens were collected at enrollment. A subset of hospitalized participants had blood collected on day 3, day 5, and 2 weeks. High-sensitivity CRP (hsCRP) and glial fibrillary acidic protein (GFAP) were measured. Receiver operating characteristic analysis was used to evaluate the prognostic ability of hsCRP for 6-month outcome, using the Glasgow Outcome Scale-Extended (GOSE). We included 1206 TBI subjects, 122 orthopedic trauma controls (OTCs), and 209 healthy controls (HCs). Longitudinal biomarker sampling was performed in 254 hospitalized TBI subjects and 19 OTCs. hsCRP rose between days 1 and 5 for TBI and OTC subjects, and fell by 2 weeks, but remained elevated compared with HCs (p < 0.001). Longitudinally, hsCRP was significantly higher in the first 2 weeks for subjects with death/severe disability (GOSE <5) compared with those with moderate disability/good recovery (GOSE ≥5); AUC was highest at 2 weeks (AUC = 0.892). Combining hsCRP and GFAP at 2 weeks produced AUC = 0.939 for prediction of disability. Serum hsCRP measured within 2 weeks of TBI is a prognostic biomarker for disability 6 months later. hsCRP may have utility as a biomarker of target engagement for anti-inflammatory therapies.
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Affiliation(s)
- Linda B. Xu
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John K. Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Frederick Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ava M. Puccio
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Esther L. Yuh
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Miri Rabinowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mary J. Vassar
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sabrina R. Taylor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ethan A. Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ross C. Puffer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Murray B. Stein
- Department of Psychiatry and Family Medicine, University of California San Diego, San Diego, California, USA
| | - Claudia S. Robertson
- Department of Neurosurgery and Critical Care, Baylor College of Medicine, Houston, Texas, USA
| | - Harvey S. Levin
- Department of Neurosurgery and Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Nancy R. Temkin
- Department of Neurosurgery and Biostatistics, University of Washington, Seattle, Washington, USA
| | - Joseph T. Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pratik Mukherjee
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Kevin K.W. Wang
- Department of Psychiatry and Neurosciences, McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Geoffrey T. Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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Firsching R, Voellger B, Woischneck D, Rashidi AM, König R, Luchtmann M. Collision of Priorities in Posttraumatic Coma and Suspected Multiple Injuries: A Prospective Multicenter Trial. J Neurol Surg A Cent Eur Neurosurg 2020; 81:430-441. [PMID: 32438418 DOI: 10.1055/s-0040-1701620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The presence of multiple injuries in addition to a traumatic brain injury (TBI) is initially uncertain in most patients with posttraumatic coma. The interdisciplinary team of physicians in charge of initial treatment after hospital admission may face a collision of vital priorities. The purpose of this study was to analyze which diagnostic and surgical measures were given priority over others in comatose patients after injury and to draw conclusions from these data. METHODS In this prospective multicenter cohort study, the outcomes of 1,003 comatose patients with suspected multiple injuries were studied. The analysis was divided into an early and a late stage. Diagnostic and surgical measures were analyzed for a 6-month period. The prognostic value of the Glasgow Coma Scale (GCS) and the World Federation of Neurosurgical Societies grading scale were investigated. RESULTS Removal of intracranial hematomas and decompressive craniotomies were the most frequent procedures within the first 48 hours after admission to the hospital. Prognosis depends on the location and the combination of injuries. Outcome is significantly correlated to initial signs of brainstem dysfunction. The GCS did not adequately predict clinical outcome. CONCLUSION Comatose patients with suspected multiple injuries should only be admitted to hospitals with a continuous neurosurgical service because intracranial operations are more frequent in the first 48 hours than extracranial operations. Depending on the neurologic status of the patient, an urgent surgical decompression may be essential for a good outcome. The GCS alone is not a sufficient tool for the neurologic assessment and the prognosis of patients with multiple injuries. The onset of clinical signs of brainstem dysfunction indicates a critical deterioration of the functioning of the central nervous system. The priority of surgical measures should be tailored accordingly.
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Affiliation(s)
- Raimund Firsching
- Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Klinik für Neurochirurgie, Magdeburg, Germany
| | - Benjamin Voellger
- Otto-von-Guericke-Universitaet, Klinik für Neurochirurgie, Magdeburg, Germany
| | | | - Ali Mohammed Rashidi
- Klinik für Neurochirurgie Magdeburg, Universitätsklinikum Magdeburg, Sachsen-Anhalt, Germany
| | - Rebecca König
- Klinik für Neurochirurgie Magdeburg, Universitätsklinikum Magdeburg, Sachsen-Anhalt, Germany
| | - Michael Luchtmann
- Klinik für Neurochirurgie Magdeburg, Universitätsklinikum Magdeburg, Sachsen-Anhalt, Germany
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Lindblad C, Nelson DW, Zeiler FA, Ercole A, Ghatan PH, von Horn H, Risling M, Svensson M, Agoston DV, Bellander BM, Thelin EP. Influence of Blood-Brain Barrier Integrity on Brain Protein Biomarker Clearance in Severe Traumatic Brain Injury: A Longitudinal Prospective Study. J Neurotrauma 2020; 37:1381-1391. [PMID: 32013731 PMCID: PMC7249468 DOI: 10.1089/neu.2019.6741] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Brain protein biomarker clearance to blood in traumatic brain injury (TBI) is not fully understood. The aim of this study was to analyze the effect that a disrupted blood–brain barrier (BBB) had on biomarker clearance. Seventeen severe TBI patients admitted to Karolinska University Hospital were prospectively included. Cerebrospinal fluid (CSF) and blood concentrations of S100 calcium binding protein B (S100B) and neuron-specific enolase (NSE) were analyzed every 6–12 h for ∼1 week. Blood and CSF albumin were analyzed every 12–24 h, and BBB integrity was assessed using the CSF:blood albumin quotient (QA). We found that time-dependent changes in the CSF and blood levels of the two biomarkers were similar, but that the correlation between the biomarkers and QA was lower for NSE (ρ = 0.444) than for S100B (ρ = 0.668). Because data were longitudinal, we also conducted cross correlation analyses, which indicated a directional flow and lag-time of biomarkers from CSF to blood. For S100B, this lag-time could be ascribed to BBB integrity, whereas for NSE it could not. Upon inferential modelling, using generalized least square estimation (S100B) or linear mixed models (NSE), QA (p = 0.045), time from trauma (p < 0.001), time from trauma2 (p = 0.023), and CSF biomarker levels (p = 0.008) were independent predictors of S100B in blood. In contrast, for NSE, only time from trauma was significant (p < 0.001). These findings are novel and important, but must be carefully interpreted because of different characteristics between the two proteins. Nonetheless, we present the first data that indicate that S100B and NSE are cleared differently from the central nervous system, and that both the disrupted BBB and additional alternative pathways, such as the recently described glymphatic system, may play a role. This is of importance both for clinicians aiming to utilize these biomarkers and for the pathophysiological understanding of brain protein clearance, but warrants further examination.
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Affiliation(s)
- Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Address correspondence to: Caroline Lindblad, MD, Karolinska Universitetssjukhuset Solna J5:20, Tema Neuro, forskargrupp Svensson, SE-17176 Stockholm, Sweden
| | - David W. Nelson
- Department of Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, and University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, and Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, and Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Per Hamid Ghatan
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Henrik von Horn
- Department of Division of Clinical Chemistry, and Karolinska Institutet, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Risling
- Department of Neuroscience, and Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | - Denes V. Agoston
- Department of Neuroscience, and Karolinska Institutet, Stockholm, Sweden
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Department of Theme Neuro, Karolinska Institutet, Stockholm, Sweden
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11
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Khandelwal A, Bithal PK, Rath GP. Anesthetic considerations for extracranial injuries in patients with associated brain trauma. J Anaesthesiol Clin Pharmacol 2019; 35:302-311. [PMID: 31543576 PMCID: PMC6748016 DOI: 10.4103/joacp.joacp_278_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.
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Affiliation(s)
- Ankur Khandelwal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Parmod Kumar Bithal
- Department of Anesthesia and OR Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Carabias CS, Castaño-León AM, Blanca Navarro B, Panero I, Eiriz C, Gómez PA, Egea J, Lagares A. Serum Amyloid A1 as a Potential Intracranial and Extracranial Clinical Severity Biomarker in Traumatic Brain Injury. J Intensive Care Med 2019; 35:1180-1195. [PMID: 30961443 DOI: 10.1177/0885066619837913] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extracranial injury is frequently present in patients with traumatic brain injury (TBI). However, no reliable biomarker exists nowadays to evaluate the magnitude and extension of extracranial injury as well as the identification of patients who are at risk of developing secondary injuries. The purpose of this study was to identify new possible peptide biomarkers by mass spectrometry analysis in patients with TBI and ascertain whether the novel biomarker discovered by peptide mass fingerprinting, serum amyloid A1 (SAA1), is capable of reflecting the condition of the patient and both intracranial and extracranial injury extension. Demographic characteristics, clinical data, and serum samples were prospectively collected from 120 patients with TBI (Glasgow Coma Scale [GCS] score 3-15) on admission. Biomarkers were quantified by enzyme-linked immunosorbent assay. Intracranial lesion volume was measured from the semiautomatic segmentation of hematoma on computed tomography (CT) using Analyze software. Functional outcome was evaluated using the Glasgow Outcome Scale (GOS) at hospital discharge and GOS extended scores at 6 months. The SAA1 levels were significantly associated with intracranial (GCS score at admission, lesion load measured with cranial CT, and pupil responsiveness) and extracranial clinical severity (all Abbreviated Injury Scale regions, Injury Severity Score, major extracranial injury, polytrauma, and orthopedic fractures presence), along with systemic secondary insults and functional outcome. SAA1 was is associated with the volume of traumatic intracranial lesions. The SAA1 levels were correlated with astroglial S100β and glial fibrillary acidic protein (GFAP), neuronal neuron-specific enolase (NSE), and axonal total tau (T-tau) and phosphorylated neurofilament heavy chain (pNF-H) injury markers. SAA1 predicts unfavorable outcome and mortality at hospital discharge (area under the curve [AUC] = 0.90, 0.82) and 6 months (AUC = 0.89). SAA1 can be established as a marker for the overall patient condition due to its involvement in the neuroendocrine axis of the systemic response to craniocerebral trauma.
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Affiliation(s)
- Cristina Sánchez Carabias
- Department of Neurosurgery, Neurotraumatology and Subarachnoid Hemorrhage Research Unit, Instituto de Investigación 16473Hospital 12 de Octubre (i+12), Madrid, Spain
| | | | - B Blanca Navarro
- Department of Neurosurgery, 16473Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Irene Panero
- Department of Neurosurgery, 16473Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carla Eiriz
- Department of Neurosurgery, 16473Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pedro A Gómez
- Department of Neurosurgery, 16473Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Javier Egea
- Molecular Neuroinflammation and Neuronal Plasticity Research Unit, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Hospital Universitario La Princesa, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Neurotraumatology and Subarachnoid Hemorrhage Research Unit, Instituto de Investigación 16473Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Neurosurgery, 16473Hospital Universitario 12 de Octubre, Madrid, Spain
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Baucher G, Troude L, Pauly V, Bernard F, Zieleskiewicz L, Roche PH. Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series. World Neurosurg 2019; 126:e944-e952. [PMID: 30876998 DOI: 10.1016/j.wneu.2019.02.194] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on. METHODS This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed. RESULTS At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5. CONCLUSIONS The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.
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Affiliation(s)
- Guillaume Baucher
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France.
| | - Lucas Troude
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France
| | - Vanessa Pauly
- CEReSS, Health Service Research and Quality of life Center, La Timone Medical Campus, Aix Marseille University, Marseille, France; Department of Public Health, La Conception Hospital, APHM, Aix Marseille University, Marseille, France
| | - Florian Bernard
- Department of Neurosurgery, CHU Angers, University of Angers, Angers, France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Critical Care, North University Hospital, APHM, Aix Marseille University, Marseille, France
| | - Pierre-Hugues Roche
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France
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14
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Watanabe T, Kawai Y, Iwamura A, Maegawa N, Fukushima H, Okuchi K. Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries. Neurol Med Chir (Tokyo) 2018; 58:393-399. [PMID: 30101808 PMCID: PMC6156128 DOI: 10.2176/nmc.oa.2018-0116] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≧ 3. SEI was defined as AIS ≧ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≦ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.
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Affiliation(s)
- Tomoo Watanabe
- Department of Emergency and Critical Care, Nara Medical University
| | - Yasuyuki Kawai
- Department of Emergency and Critical Care, Nara Medical University
| | - Asami Iwamura
- Department of Emergency and Critical Care, Nara Medical University
| | - Naoki Maegawa
- Department of Emergency and Critical Care, Nara Medical University
| | | | - Kazuo Okuchi
- Department of Emergency and Critical Care, Nara Medical University
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15
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Doerfler S, Faerber J, McKhann GM, Elliott JP, Winn HR, Kumar M, Levine J, Le Roux PD. The Incidence and Impact of Secondary Cerebral Insults on Outcome After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 114:e483-e494. [DOI: 10.1016/j.wneu.2018.02.195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/25/2018] [Accepted: 02/28/2018] [Indexed: 02/04/2023]
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16
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Lee HR, You NK, Seo SJ, Choi MS. Concurrent Surgery of Craniectomy and Splenectomy as Initial Treatment in Severe Traumatic Head Injury: A Case Report. Korean J Neurotrauma 2017; 13:141-143. [PMID: 29201849 PMCID: PMC5702750 DOI: 10.13004/kjnt.2017.13.2.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 12/05/2022] Open
Abstract
It is not a common case for neurosurgery department and the other departments to perform joint operation at the same time. Patients with severe head injury are a condition in which vital signs are unstable due to severe brain swelling and increased intracranial pressure, and emergency surgery is required. A 44-year-old man visited the trauma center with a motorcycle accident. The Glasgow Coma Scale score at the time of emergency department was 3 points, and the pupil was fixed at 6 mm on both sides. His medical history was unknown. His vital signs including blood pressure (BP), heart rate, respiratory rate and oxygen saturation were stable. Associated injuries included multiple fractures of whole body. Brain computed tomography revealed subarachnoid hemorrhage, intraventricular hemorrhage and severe cerebral edema. During the preparation of the craniectomy, abdominal ultrasonography performed because of decreased BP resulted in a large amount of hemoperitoneum. The bi-coronal craniectomy and splenectomy were performed simultaneously for about 4 hours. After fifty days of treatment, he was discharged with Glasgow Outcome Scale-extended 4 points and is undergoing rehabilitation. In severe polytrauma patients, active concurrent surgery is a good method to save their lives.
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Affiliation(s)
- Hyeong Rae Lee
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Nam Kyu You
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Sook Jin Seo
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Mi Sun Choi
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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Irvine KA, Clark JD. Chronic Pain After Traumatic Brain Injury: Pathophysiology and Pain Mechanisms. PAIN MEDICINE 2017; 19:1315-1333. [DOI: 10.1093/pm/pnx153] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Karen-Amanda Irvine
- Veterans Affairs Palo Alto Health Care System, Anesthesiology Service, Palo Alto, California
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - J David Clark
- Veterans Affairs Palo Alto Health Care System, Anesthesiology Service, Palo Alto, California
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
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19
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[Outcome in traumatic brain injury : Considered from a neurological viewpoint]. Unfallchirurg 2016; 119:554-9. [PMID: 27271326 DOI: 10.1007/s00113-016-0190-4] [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: 10/21/2022]
Abstract
BACKGROUND There are many studies on the prognosis and mortality for the acute care of traumatic brain injury (TBI) during the first year. Prediction of the long-term outcome after TBI is more difficult, and can be ascribed to indistinct methods and the necessity of taking into account multiple influencing factors. OBJECTIVE The main factors that determine the long-term outcome of TBI are described. MATERIALS AND METHODES A summary of the relevant literature and experience of the reintegration of TBI patients are presented. RESULTS The major factors predicting the long-term outcome of TBI are well-known. They can be measured by International Classification of Functioning, Disability and Health (ICF) of the World Health Organization and self-reported quality of life, which are important for the prognosis. Returning to work has a particularly positive effect on the quality of life. CONCLUSIONS Environmental factors are most predictive of long-term TBI outcome. The awareness of the interaction of all these factors requires a individualized long-term rehabilitation.
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McDonald SJ, Sun M, Agoston DV, Shultz SR. The effect of concomitant peripheral injury on traumatic brain injury pathobiology and outcome. J Neuroinflammation 2016; 13:90. [PMID: 27117191 PMCID: PMC4847339 DOI: 10.1186/s12974-016-0555-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/18/2016] [Indexed: 01/08/2023] Open
Abstract
Background Traumatic injuries are physical insults to the body that are prevalent worldwide. Many individuals involved in accidents suffer injuries affecting a number of extremities and organs, otherwise known as multitrauma or polytrauma. Traumatic brain injury is one of the most serious forms of the trauma-induced injuries and is a leading cause of death and long-term disability. Despite over dozens of phase III clinical trials, there are currently no specific treatments known to improve traumatic brain injury outcomes. These failures are in part due to our still poor understanding of the heterogeneous and evolving pathophysiology of traumatic brain injury and how factors such as concomitant extracranial injuries can impact these processes. Main body Here, we review the available clinical and pre-clinical studies that have investigated the possible impact of concomitant injuries on traumatic brain injury pathobiology and outcomes. We then list the pathophysiological processes that may interact and affect outcomes and discuss promising areas for future research. Taken together, many of the clinical multitrauma/polytrauma studies discussed in this review suggest that concomitant peripheral injuries may increase the risk of mortality and functional deficits following traumatic brain injury, particularly when severe extracranial injuries are combined with mild to moderate brain injury. In addition, recent animal studies have provided strong evidence that concomitant injuries may increase both peripheral and central inflammatory responses and that structural and functional deficits associated with traumatic brain injury may be exacerbated in multiply injured animals. Conclusions The findings of this review suggest that concomitant extracranial injuries are capable of modifying the outcomes and pathobiology of traumatic brain injury, in particular neuroinflammation. Though additional studies are needed to further identify the factors and mechanisms involved in central and peripheral injury interactions following multitrauma and polytrauma, concomitant injuries should be recognized and accounted for in future pre-clinical and clinical traumatic brain injury studies.
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Affiliation(s)
- Stuart J McDonald
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Melbourne, VIC, Australia.
| | - Mujun Sun
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Denes V Agoston
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sandy R Shultz
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.
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A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients. BIOMED RESEARCH INTERNATIONAL 2015; 2015:529580. [PMID: 26413530 PMCID: PMC4564619 DOI: 10.1155/2015/529580] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to compare the effect of PbtO2-guided therapy with traditional intracranial pressure- (ICP-) guided treatment on the management of cerebral variables, therapeutic interventions, survival rates, and neurological outcomes of moderate and severe traumatic brain injury (TBI) patients. From 2009 to 2010, TBI patients with a Glasgow coma scale <12 were recruited from 6 collaborative hospitals in northern Taiwan, excluding patients with severe systemic injuries, fixed and dilated pupils, and other major diseases. In total, 23 patients were treated with PbtO2-guided management (PbtO2 > 20 mmHg), and 27 patients were treated with ICP-guided therapy (ICP < 20 mmHg and CPP > 60 mmHg) in the neurosurgical intensive care unit (NICU); demographic characteristics were similar across groups. The survival rate in the PbtO2-guided group was also significantly increased at 3 and 6 months after injury. Moreover, there was a significant correlation between the PbtO2 signal and Glasgow outcome scale-extended in patients from 1 to 6 months after injury. This finding demonstrates that therapy directed by PbtO2 monitoring is valuable for the treatment of patients with moderate and severe TBI and that increasing PaO2 to 150 mmHg may be efficacious for preventing cerebral hypoxic events after brain trauma.
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Scholten AC, Haagsma JA, Andriessen TMJC, Vos PE, Steyerberg EW, van Beeck EF, Polinder S. Health-related quality of life after mild, moderate and severe traumatic brain injury: patterns and predictors of suboptimal functioning during the first year after injury. Injury 2015; 46:616-24. [PMID: 25476014 DOI: 10.1016/j.injury.2014.10.064] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 10/15/2014] [Accepted: 10/26/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Glasgow Outcome Scale Extended (GOSE) is the established functional outcome scale to assess disability following traumatic brain injury (TBI), however does not capture the patient's subjective perspective. Health-related quality of life (HRQL) does capture the individual's perception of disability after TBI, and has therefore been recognized as an important outcome in TBI. In contrast to GOSE, HRQL enables comparison of health outcome across various disease states and with healthy individuals. We aimed to assess functional outcome, HRQL, recovery, and predictors of 6 and 12-month outcome in a comprehensive sample of patients with mild, moderate or severe TBI, and to examine the relationship between functional impairment (GOSE) and HRQL. METHODS A prospective cohort study was conducted among a sample of 2066 adult TBI patients who attended the emergency department (ED). GOSE was determined through questionnaires or structured interviews. Questionnaires 6 and 12 months after ED treatment included socio-demographic information and HRQL measured with Short-Form Health Survey (SF-36; reflecting physical, mental and social functioning) and Perceived Quality of Life Scale (PQoL; measuring degree of satisfaction with functioning). RESULTS 996 TBI survivors with mild, moderate or severe TBI completed the 6-month questionnaire. Functional outcome and HRQL after moderate or severe TBI was significantly lower than after mild TBI. Patients with moderate TBI showed greatest improvement. After one year, the mild TBI group reached outcomes comparable to population norms. TBI of all severities highly affected SF-36 domains physical and social functioning, and physical and emotional role functioning. GOSE scores were highly related to all SF-36 domains and PQoL scores. Female gender, older age, co-morbidity and high ISS were strongest independent predictors of decreased HRQL at 6 and 12 months after TBI. CONCLUSIONS HRQL and recovery patterns differ for mild, moderate and severe TBI. This study indicates that GOSE, although clinically relevant, fails to capture the subjective perspective of TBI patients, which endorses the use of HRQL as valuable addition to established instruments in assessing disability following TBI. Influence of TBI severity on recovery, together with female gender, older age, co-morbidity and high ISS should be considered in long-term follow-up and intervention programs.
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Affiliation(s)
- A C Scholten
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - J A Haagsma
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - T M J C Andriessen
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - P E Vos
- Department of Neurology, Slingeland Hospital, PO Box 169, 7000 AD Doetinchem, The Netherlands
| | - E W Steyerberg
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - E F van Beeck
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - S Polinder
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Maas AI, Lingsma HF, Roozenbeek B. Predicting outcome after traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 128:455-74. [DOI: 10.1016/b978-0-444-63521-1.00029-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Tang A, Pandit V, Fennell V, Jones T, Joseph B, O'Keeffe T, Friese RS, Rhee P. Intracranial pressure monitor in patients with traumatic brain injury. J Surg Res 2014; 194:565-570. [PMID: 25553841 DOI: 10.1016/j.jss.2014.11.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 10/22/2014] [Accepted: 11/12/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring for traumatic brain injury (TBI) patients with a Glasgow Coma Scale score of 8 or less with an abnormal head computed tomography, or a normal head computed tomography scan with systolic blood pressure ≤90 mm Hg, posturing, or in patients of age ≥40. The benefits of these guidelines on outcome remain unproven. We hypothesized that adherence to BTF guidelines for ICP monitoring does not improve outcomes in patients with TBI. METHODS All TBI patients with an admission Glasgow Coma Scale ≤8 admitted to our level I trauma center over a 3-y period were identified. Adherence to the individual components of our institutional TBI Bundle (ICP monitoring, SpO2 ≥95%, PaCO2 30-39 mm Hg, systolic blood pressure ≥90 mm Hg, cerebral perfusion pressure ≥60 mm Hg, ICP ≤25 mm Hg, and temperature 36°C-37°C) was assessed. Patients were stratified into two groups as follows: patients with ICP monitoring (ICP) and patients without ICP monitoring (no-ICP). Outcome measures were survival and discharge disposition. Multivariate regression analysis was performed. RESULTS We identified 2618 TBI patients, 261 of whom met the BTF criteria for ICP monitoring. After excluding those with nonsurvivable injuries (n = 67), 194 patients were available for analysis. The two groups were similar in demographics and severity of head injury. Survival rate was higher in the no-ICP group compared with that in the ICP group (98% versus 76%, P < 0.004). Non-monitored patients were discharged with higher levels of function per discharge location (28% home versus 4% home; P < 0.001). Patients without ICP monitoring were 1.21 times more likely to survive compared with that of patients with ICP monitoring (odds ratio: 1.21, 95% confidence interval [1.1-1.9], P = 0.01). In the ICP group, the overall compliance rate to the ICP and cerebral perfusion pressure goals as required by the BTF guidelines was poor. CONCLUSIONS Our data suggest that there is a subset of patients meeting BTF criteria for ICP monitoring that do well without ICP monitoring. This finding should provoke reevaluation of the indication and utility of ICP monitoring in TBI patients.
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Affiliation(s)
- Andrew Tang
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Viraj Pandit
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Vernard Fennell
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Trevor Jones
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'Keeffe
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Randall S Friese
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
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Leung LY, Wei G, Shear DA, Tortella FC. The acute effects of hemorrhagic shock on cerebral blood flow, brain tissue oxygen tension, and spreading depolarization following penetrating ballistic-like brain injury. J Neurotrauma 2013; 30:1288-98. [PMID: 23461630 DOI: 10.1089/neu.2012.2715] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Traumatic brain injury (TBI) often occurs in conjunction with additional trauma, resulting in secondary complications, such as hypotension as a result of blood loss. This study investigated the combined effects of penetrating ballistic-like brain injury (PBBI) and hemorrhagic shock (HS) on physiological parameters, including acute changes in regional cerebral blood flow (rCBF), brain tissue oxygen tension (P(bt)O₂), and cortical spreading depolarizations (CSDs). All recordings were initiated before injury (PBBI/HS/both) and maintained for 2.5 h. Results showed that PBBI alone and combined PBBI and HS produced a sustained impairment of ipsilateral rCBF that decreased by 70% from baseline (p<0.05). Significant and sustained reductions in P(bt)O₂ (50% baseline; p<0.05) were also observed in the injured hemisphere of the animals subjected to both PBBI and HS (PBBI+HS). In contrast, PBBI alone produced smaller, more transient reductions in P(bt)O₂ levels. The lower limit of cerebral autoregulation was significantly higher in the PBBI+HS group (p<0.05, compared to HS alone). Critically, combined injury resulted in twice the number of spontaneous CSDs as in PBBI alone (p<0.05). It also lowered the propagation speed of CSD and the threshold of CSD occurrence [induced CSD at higher mean arterial pressure (MAP)]. However, rCBF and P(bt)O₂ were not responsive to the depolarizations. Our data suggest that PBBI together with HS causes persistent impairment of CBF and brain tissue oxygen tension, increasing the probability of CSDs that likely contribute to secondary neuropathology and compromise neurological recovery.
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Affiliation(s)
- Lai Yee Leung
- Brain Trauma Neuroprotection and Neurorestoration Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, 2W12, Silver Spring, MD 20910, USA.
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Majidi S, Siddiq F, Qureshi AI. Prehospital neurologic deterioration is independent predictor of outcome in traumatic brain injury: analysis from National Trauma Data Bank. Am J Emerg Med 2013; 31:1215-9. [PMID: 23809095 DOI: 10.1016/j.ajem.2013.05.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 05/15/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The prevalence and impact of prehospital neurologic deterioration (PhND) in patients with traumatic brain injury (TBI) have not been investigated. We aimed to determine the prevalence of PhND during emergency medical service (EMS) transportation among patients with TBI and its impact on patient's outcome. METHODS We used the National Trauma Data Bank, using data files from 2009 to 2010 to identify patients with TBI through International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The initial Glasgow Coma Scale (GCS) score ascertained at the scene by EMS was compared with the subsequent GCS score evaluation in the emergency department (ED) to identify neurologic deterioration (defined as a decrease in GCS of ≥2 points). Patients' demographics, initial injury severity score (ISS), admission GCS score, and hospital outcome were compared between patients with PhND and patients without neurologic deterioration. RESULTS A total of 257 127 patients with TBI were identified. Among patients with TBI, 22 254 patients had PhND, which comprised 9% of all patients with TBI. The mean of GCS score decrease during EMS transport was 5 points (±3). Patients without PhND tended to have higher GCS recorded by EMS (median, 15 vs 12; P < .0001). Patients with TBI who had PhND had significantly higher hospital length of stay and intensive care unit days after adjusting for baseline characteristics and EMS GCS score, EMS transport time, type of injury, presence of intracranial hemorrhages, and ED ISS (P < .0001). These patients had higher rate of in-hospital mortality after adjusting for the same variables (odds ratio, 2.30; 95% confidence interval, 2.18-2.41). CONCLUSION Prehospital neurologic deterioration occurs in 9% of patients with TBI. It is more prevalent in men and associated with lower EMS GCS level and higher ED ISS. Prehospital neurologic deterioration is an independent predictor of worse hospital outcome and higher resource use in patients with TBI.
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Affiliation(s)
- Shahram Majidi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN 55455, USA.
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Thelin EP, Johannesson L, Nelson D, Bellander BM. S100B is an important outcome predictor in traumatic brain injury. J Neurotrauma 2013; 30:519-28. [PMID: 23297751 DOI: 10.1089/neu.2012.2553] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The objective of the study was to examine how S100B, a biomarker of traumatic brain injury (TBI), contributes to outcome prediction after adjusting for known parameters, including age, Glasgow Coma Scale (GCS), pupil reaction, and computed tomography (CT) variables; to examine which parameters have the best correlation to elevated serum levels of S100B; and to investigate when to sample S100B to achieve the strongest association to outcome. This retrospective study included 265 patients with TBI admitted to the neurointensive care unit, Karolinska University Hospital Solna, Stockholm, Sweden. Univariate and multivariate proportional odds regressions were performed to determine parameters most closely related to outcome, and how S100B adds to prediction accuracy. Age (p<0.0001), pupil reaction (p<0.0001), and levels of S100B (p<0.0001) had the strongest statistical correlation to outcome. The area under curve of S100B, the first 48 h after trauma, yielded an additional explained variance of 6.6% in excess of known outcome parameters, including age, GCS, pupil reaction, and CT variables, themselves exhibiting an explained variance of 29.3%. S100B adds substantial information regarding patient outcome, in excess of that provided by known parameters. Only CT variables were found to be significant predictors of increased levels of S100B in uni- and multivariate analysis. Early samples of S100B, within 12 h after trauma, appear to have little prognostic value, and S100B should likely be sampled 12-36 h following trauma to best enhance TBI outcome prediction.
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Affiliation(s)
- Eric Peter Thelin
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
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Leong BK, Mazlan M, Rahim RBA, Ganesan D. Concomitant injuries and its influence on functional outcome after traumatic brain injury. Disabil Rehabil 2013; 35:1546-51. [DOI: 10.3109/09638288.2012.748832] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Leitgeb J, Mauritz W, Brazinova A, Majdan M, Wilbacher I. Impact of concomitant injuries on outcomes after traumatic brain injury. Arch Orthop Trauma Surg 2013; 133:659-68. [PMID: 23463257 PMCID: PMC3631113 DOI: 10.1007/s00402-013-1710-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with traumatic brain injury (TBI) frequently have concomitant injuries; we aimed to investigate their impact on outcomes. METHODS Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on accident, treatment, and outcomes were collected. Patients who survived until intensive care unit (ICU) admission and had survivable TBI were selected, and were assigned to "isolated TBI" or "TBI + injury" groups. Six-month outcomes were classified as "favorable" if Glasgow Outcome Scale (GOS) scores were five or four, and were classified as "unfavorable" if GOS scores were three or less. Univariate statistics (Fisher's exact test, t test, χ(2)-test) and logistic regression were used to identify factors associated with hospital mortality and unfavorable outcome. RESULTS Of the 767 patients, 403 (52.5 %) had isolated TBI, 364 (47.5 %) had concomitant injuries. Patients with isolated TBI had higher mean age (53 vs. 44 years, P = 0.001); hospital mortality (30.0 vs. 27.2 %, P = 0.42) and rate of unfavorable outcome (50.4 vs. 41.8 %, P = 0.02) were higher, too. There were no significant mortality differences for factors like age groups, trauma mechanisms, neurologic status, CT findings, or treatment factors. Concomitant injuries were associated with higher mortality (33.3 vs. 12.5 %, P = 0.05) in patients with moderate TBI, and were significantly associated with more ventilation, ICU, and hospitals days. Logistic regression revealed that age, Glasgow Coma Scale score, pupillary reactivity, severity of TBI and CT score were the main factors that influenced outcomes. CONCLUSIONS Concomitant injuries have a significant effect upon the mortality of patients with moderate TBI. They do not affect the mortality in patients with severe TBI.
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Affiliation(s)
- Johannes Leitgeb
- Department of Traumatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Walter Mauritz
- Anesthesiology and Intensive Care Medicine, Trauma Hospital “Lorenz Boehler”, Vienna, Austria ,International Neurotrauma Research Organization (INRO), Vienna, Austria
| | - Alexandra Brazinova
- International Neurotrauma Research Organization (INRO), Vienna, Austria ,Department of Public Health, Faculty of Health and Social Services, Trnava University, Trnava, Slovak Republic
| | - Marek Majdan
- International Neurotrauma Research Organization (INRO), Vienna, Austria ,Department of Public Health, Faculty of Health and Social Services, Trnava University, Trnava, Slovak Republic
| | - Ingrid Wilbacher
- Department of Public Health, Faculty of Health and Social Services, Trnava University, Trnava, Slovak Republic
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Sheridan RL, Schaefer PW, Whalen M, Fagan S, Stoddard FJ, Schneider JC, McConkey B, Cancio LC. Case records of the Massachusetts General Hospital. Case 36-2012. Recovery of a 16-year-old girl from trauma and burns after a car accident. N Engl J Med 2012; 367:2027-37. [PMID: 23171100 DOI: 10.1056/nejmcpc1200088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Katsnelson M, Mackenzie L, Frangos S, Oddo M, Levine JM, Pukenas B, Faerber J, Dong C, Kofke WA, le Roux PD. Are initial radiographic and clinical scales associated with subsequent intracranial pressure and brain oxygen levels after severe traumatic brain injury? Neurosurgery 2012; 70:1095-105; discussion 1105. [PMID: 22076531 DOI: 10.1227/neu.0b013e318240c1ed] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prediction of clinical course and outcome after severe traumatic brain injury (TBI) is important. OBJECTIVE To examine whether clinical scales (Glasgow Coma Scale [GCS], Injury Severity Score [ISS], and Acute Physiology and Chronic Health Evaluation II [APACHE II]) or radiographic scales based on admission computed tomography (Marshall and Rotterdam) were associated with intensive care unit (ICU) physiology (intracranial pressure [ICP], brain tissue oxygen tension [PbtO2]), and clinical outcome after severe TBI. METHODS One hundred one patients (median age, 41.0 years; interquartile range [26-55]) with severe TBI who had ICP and PbtO2 monitoring were identified. The relationship between admission GCS, ISS, APACHE II, Marshall and Rotterdam scores and ICP, PbtO2, and outcome was examined by using mixed-effects models and logistic regression. RESULTS Median (25%-75% interquartile range) admission GCS and APACHE II without GCS scores were 3.0 (3-7) and 11.0 (8-13), respectively. Marshall and Rotterdam scores were 3.0 (3-5) and 4.0 (4-5). Mean ICP and PbtO2 during the patients' ICU course were 15.5 ± 10.7 mm Hg and 29.9 ± 10.8 mm Hg, respectively. Three-month mortality was 37.6%. Admission GCS was not associated with mortality. APACHE II (P = .003), APACHE-non-GCS (P = .004), Marshall (P < .001), and Rotterdam scores (P < .001) were associated with mortality. No relationship between GCS, ISS, Marshall, or Rotterdam scores and subsequent ICP or PbtO2 was observed. The APACHE II score was inversely associated with median PbtO2 (P = .03) and minimum PbtO2 (P = .008) and had a stronger correlation with amount of time of reduced PbtO2. CONCLUSION Following severe TBI, factors associated with outcome may not always predict a patient's ICU course and, in particular, intracranial physiology.
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Affiliation(s)
- Michael Katsnelson
- Department of Neurology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19106, USA
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Mathai K, Yadav R, Muley K, Kulkarni V, Mathai S. Severe traumatic brain injury in a child falling from the fourth floor and a remarkable recovery with exquisite team management. INDIAN JOURNAL OF NEUROTRAUMA 2012. [DOI: 10.1016/j.ijnt.2012.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Keddie S, Rohman L. Reviewing the reliability, effectiveness and applications of Licox in traumatic brain injury. Nurs Crit Care 2012; 17:204-12. [PMID: 22698163 DOI: 10.1111/j.1478-5153.2012.00499.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To review the pathophysiology, accuracy, effectiveness and use of Licox for brain tissue oxygen monitoring in traumatic brain injury (TBI). BACKGROUND The Licox monitoring system allows continuous monitoring of partial pressure of brain tissue oxygen (PbO(2)), brain tissue temperature and intracranial pressure (ICP). The application and effectiveness of the use of Licox in TBI is not clearly explored within the literature. INCLUSION CRITERIA A date limit of 1995-2009, English language, all animal and human studies and the following terms were searched: Licox, brain tissue oxygenation, cerebral oxygenation and TBI. MEDLINE database was the primary data source. EXCLUSION CRITERIA All paediatric papers were excluded from the search. Studies not related to pathophysiology and management of TBI and brain tissue oximetry in adults were excluded. Data relevant to the subject under consideration were extracted by three independent clinicians to form a narrative report. Studies were critically evaluated using the NHS Public Health Resource Unit's checklist for each study analysed. CONCLUSIONS Licox offers new insights into cerebral pathology and physiology. The continuous bedside monitoring provides real-time data that can be used to improve patient management and prognosis in specialist units by trained and experienced staff. More research is required to understand the limitations of this technology and why it is not in widespread use. RELEVENCE TO CLINICAL PRACTICE: A clinical tool that could be utilized more often in the right setting to improve care to patients suffering from TBI by disseminating more information on this unique tool.
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Affiliation(s)
- Stephen Keddie
- Wansbeck General Hospital, Education Centre, Woodhorn Lane, Ashington, Northumberland, UK
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Stübig T, Mommsen P, Krettek C, Probst C, Frink M, Zeckey C, Andruszkow H, Hildebrand F. [Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs]. Unfallchirurg 2011; 113:923-30. [PMID: 20960146 DOI: 10.1007/s00113-010-1887-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).
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Affiliation(s)
- T Stübig
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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Frink M, Mommsen P, Andruszkow H, Zeckey C, Krettek C, Hildebrand F. Challenges of surgical trauma emergency admission. Langenbecks Arch Surg 2011; 396:499-505. [PMID: 21384186 DOI: 10.1007/s00423-011-0771-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 02/24/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Trauma still remains as one of the leading causes for mortality in Western civilization. The early clinical management of severely injured patients leads to structural and organizational challenges involving different specialties. EMERGENCY DEPARTMENT Trauma team leaders have to coordinate diagnostic and therapeutic steps in cooperation with different involved specialties. Furthermore, they have to make decisions based on contrary department-depending assessments. In addition, several special injuries commonly found in multiple traumatized patients require special attention. RECENT DEVELOPMENT Actually, structural changes in generating trauma networks are to be mentioned. Trauma networks suggest to improve patients survival in close cooperation between hospitals with different structural and personal capabilities. Close communication networks are required to guarantee transportation to an adequate trauma center.
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Affiliation(s)
- Michael Frink
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Lack of recovery in monocyte human leukocyte antigen-DR expression is independently associated with the development of sepsis after major trauma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R208. [PMID: 21092108 PMCID: PMC3220028 DOI: 10.1186/cc9331] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 09/27/2010] [Accepted: 11/19/2010] [Indexed: 12/16/2022]
Abstract
Introduction Major trauma is characterized by an overwhelming pro-inflammatory response and an accompanying anti-inflammatory response that lead to a state of immunosuppression, as observed after septic shock. Diminished monocyte Human Leukocyte Antigen DR (mHLA-DR) is a reliable marker of monocyte dysfunction and immunosuppression. The main objective of this study was to determine the relation between mHLA-DR expression in severe trauma patients and the development of sepsis. Methods We conducted a prospective observational study over 23 months in a trauma intensive care unit at a university hospital. Patients with an Injury Severity Score (ISS) over 25 and age over 18 were included. mHLA-DR was assessed by flow cytometry protocol according to standardized protocol. Mann-Whitney U-test for continuous non-parametric variables, independent paired t test for continuous parametric variables and chi-square test for categorical data were used. Results mHLA-DR was measured three times a week during the first 14 days. One hundred five consecutive severely injured patients were monitored (ISS 38 ± 17, SAPS II 37 ± 16). Thirty-seven patients (35%) developed sepsis over the 14 days post-trauma. At days 1-2, mHLA-DR was diminished in the whole patient population, with no difference with the development of sepsis. At days 3-4, a highly significant difference appeared between septic and non-septic patients. Non- septic patients showed an increase in mHLA-DR levels, whereas septic patients did not (13,723 ± 7,766 versus 9,271 ± 6,029 antibodies per cell, p = .004). Most importantly, multivariate logistic regression analysis, after adjustment for usual clinical confounders (adjusted OR 5.41, 95% CI 1.42-20.52), revealed that a slope of mHLA-DR expression between days1-2 and days 3-4 below 1.2 remained associated with the development of sepsis. Conclusions Major trauma induced an immunosuppression, characterized by a decrease in mHLA-DR expression. Importantly, after multivariate regression logistic analysis, persistent decreased expression was assessed to be in relation with the development of sepsis. This is the first study in trauma patients showing a link between the lack of immune recovery and the development of sepsis on the basis of the standardized protocol. Monitoring immune function by mHLA-DR measurement could be useful to identify trauma patients at a high risk of infection.
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Wagner J, Dusick JR, McArthur DL, Cohan P, Wang C, Swerdloff R, Boscardin WJ, Kelly DF. Acute gonadotroph and somatotroph hormonal suppression after traumatic brain injury. J Neurotrauma 2010; 27:1007-19. [PMID: 20214417 DOI: 10.1089/neu.2009.1092] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hormonal dysfunction is a known consequence of moderate and severe traumatic brain injury (TBI). In this study we determined the incidence, time course, and clinical correlates of acute post-TBI gonadotroph and somatotroph dysfunction. Patients had daily measurement of serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, estradiol, growth hormone, and insulin-like growth factor-1 (IGF-1) for up to 10 days post-injury. Values below the fifth percentile of a healthy cohort were considered abnormal, as were non-measurable growth hormone (GH) values. Outcome measures were frequency and time course of hormonal suppression, injury characteristics, and Glasgow Outcome Scale (GOS) score. The cohort consisted of 101 patients (82% males; mean age 35 years; Glasgow Coma Scale [GCS] score <or=8 in 87%). In men, 100% had at least one low testosterone value, and 93% of all values were low; in premenopausal women, 43% had at least one low estradiol value, and 39% of all values were low. Non-measurable GH levels occurred in 38% of patients, while low IGF-1 levels were observed in 77% of patients, but tended to normalize within 10 days. Multivariate analysis revealed associations of younger age with low FSH and low IGF-1, acute anemia with low IGF-1, and older age and higher body mass index (BMI) with low GH. Hormonal suppression was not predictive of GOS score. These results indicate that within 10 days of complicated mild, moderate, and severe TBI, testosterone suppression occurs in all men and estrogen suppression occurs in over 40% of women. Transient somatotroph suppression occurs in over 75% of patients. Although this acute neuroendocrine dysfunction may not be TBI-specific, low gonadal steroids, IGF-1, and GH may be important given their putative neuroprotective functions.
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Affiliation(s)
- Justin Wagner
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Velly L, Pellegrini L, Bruder N. [Early or delayed peripheral surgery in patients with severe head injury?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2010; 29:e183-e188. [PMID: 20656447 DOI: 10.1016/j.annfar.2010.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Head injuries are present in up to 65 % of multiple trauma patients with a frequent association with orthopaedic injuries. The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1980s. However, optimal timing of long bone fracture fixation in trauma patients with associated severe traumatic brain injury has been a lively topic. The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. In recent years, some studies reported a worse outcome, with secondary brain damage, resulting from hypotension, hypoxia and increased intraoperative fluid administration. This review summarises the current evidence available regarding the management of these patients in particular the recent concept of early temporary surgical stabilization in the era of "damage control orthopaedic surgery".
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Affiliation(s)
- L Velly
- Service d'anesthésie-réanimation, CHU Timone-Adultes, 264 rue Saint-Pierre, Marseille, France.
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Frink M, Zeckey C, Haasper C, Krettek C, Hildebrand F. [Injury severity and pattern at the scene. What is the influence of the mechanism of injury?]. Unfallchirurg 2010; 113:360-5. [PMID: 20376617 DOI: 10.1007/s00113-010-1776-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The mechanism of injury is the major cause for trauma team activation and emergency room resuscitation of trauma victims. To date, it remains unclear to what extent the injury mechanism influences injury pattern and severity. METHODS A comprehensive systematic literature search based on Medline was carried out. RESULTS Only a limited number of studies are available which investigated the influence of injury mechanisms on injury patterns and severity. There are no specific mechanisms for traumatic brain and spine injuries. Injuries to the chest and abdomen most frequently resulted from motor vehicle accidents involving passengers sitting on the side of the impact. Steering wheel deformity correlated with the injury severity. Pelvic fractures occurred most frequently due to motor vehicle accidents. The highest mortality resulted from pedestrians being struck by a vehicle and additional loss of life in the same vehicle compartment. CONCLUSIONS The systematic literature research showed inconsistent results regarding the influence of trauma mechanisms on the resulting injury. Therefore, a treatment algorithm for trauma patients should be independent of the mechanism which is represented in several training programs (e.g. ATLS and PHTLS). However, the mechanism of injury may increase the alertness of the trauma team with respect to injury distribution and severity.
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Affiliation(s)
- M Frink
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover.
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Georgoff P, Meghan S, Mirza K, Stein SC. Geographic Variation in Outcomes from Severe Traumatic Brain Injury. World Neurosurg 2010; 74:331-45. [DOI: 10.1016/j.wneu.2010.03.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 03/13/2010] [Indexed: 01/01/2023]
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Lingsma HF, Roozenbeek B, Steyerberg EW, Murray GD, Maas AIR. Early prognosis in traumatic brain injury: from prophecies to predictions. Lancet Neurol 2010; 9:543-54. [PMID: 20398861 DOI: 10.1016/s1474-4422(10)70065-x] [Citation(s) in RCA: 287] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Traumatic brain injury (TBI) is a heterogeneous condition that encompasses a broad spectrum of disorders. Outcome can be highly variable, particularly in more severely injured patients. Despite the association of many variables with outcome, prognostic predictions are notoriously difficult to make. Multivariable analysis has identified age, clinical severity, CT abnormalities, systemic insults (hypoxia and hypotension), and laboratory variables as relevant factors to include in models to predict outcome in individual patients. Advances in statistical modelling and the availability of large datasets have facilitated the development of prognostic models that have greater performance and generalisability. Two prediction models are currently available, both of which have been developed on large datasets with state-of-the-art methods, and offer new opportunities. We see great potential for their use in clinical practice, research, and policy making, as well as for assessment of the quality of health-care delivery. Continued development, refinement, and validation is advocated, together with assessment of the clinical impact of prediction models, including treatment response.
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Affiliation(s)
- Hester F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Sarrafzadeh AS, Nagel A, Czabanka M, Denecke T, Vajkoczy P, Plotkin M. Imaging of hypoxic-ischemic penumbra with (18)F-fluoromisonidazole PET/CT and measurement of related cerebral metabolism in aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2010; 30:36-45. [PMID: 19773799 PMCID: PMC2949093 DOI: 10.1038/jcbfm.2009.199] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This study aimed to characterize hypoxic, but salvageable, tissue imaged by (18)F-fluoromisonidazole ((18)F-FMISO), combining with perfusion-computed tomography (PCT) for regional cerebral blood flow (rCBF) measurement and metabolism by microdialysis (MD) in aneurysmal subarachnoidal hemorrhage (SAH) patients. (18)F-FMISO positron-emission tomography (PET)/CT was performed within the period of possible vasospasm (day 6.8+/-3 after SAH) in seven SAH patients. In parallel, rCBF was determined within the MD region of interest (MD-ROI) (n=5). The MD catheter was inserted into the brain parenchyma with highest risk for ischemia; extracellular levels of glutamate and energy metabolites were registered at time of PET and hourly for 10 days. Twelve-month outcome was evaluated. In asymptomatic patients (n=3) no hypoxia was detected and glutamate levels were low (<10 mmol/L), whereas symptomatic patients had higher glutamate concentrations (P<0.001). Increased (18)F-FMISO uptake within the MD-ROI (n=3) was related to higher glutamate levels, while rCBF was above the ischemic range. Hypoxia (increased (18)F-FMISO uptake) was present in symptomatic patients and associated with relevant metabolic derangement of extracellular glutamate levels, whereas energy metabolism and rCBF were preserved. This technique has the potential to improve our understanding of the role of cellular hypoxia in aneurysmal SAH.
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Affiliation(s)
- Asita S Sarrafzadeh
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy. J Neurosurg 2009; 111:672-82. [PMID: 19463048 DOI: 10.3171/2009.4.jns081150] [Citation(s) in RCA: 215] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral ischemia is the leading cause of preventable death in cases of major trauma with severe traumatic brain injury (TBI). Intracranial pressure (ICP) control and cerebral perfusion pressure (CPP) manipulation have significantly reduced the mortality but not the morbidity rate in these patients. In this study, the authors describe their 5-year experience with brain tissue oxygen (PbtO(2)) monitoring, and the effect of a brain tissue oxygen-directed critical care guide (PbtO(2)-CCG) on the 6-month clinical outcome (based on the 6-month Glasgow Outcome Scale score) in patients with TBIs. METHODS One hundred thirty-nine patients admitted to Creighton University Medical Center with major traumatic injuries (Injury Severity Scale [ISS] scores >or= 16) and TBI underwent prospective evaluation. All patients were treated with a PbtO(2)-CCG to maintain a brain oxygen level > 20 mm Hg, and control ICP < 20 mm Hg. The role of demographic, clinical, and imaging parameters in the identification of patients at risk for cerebral hypooxygenation and the influence of hypooxygenation on clinical outcome were recorded. Outcomes were compared with those in a historical ICP/CPP patient cohort. Subgroup analysis of severe TBI was performed and compared to data reported in the Traumatic Coma Data Bank. RESULTS The majority of injuries were sustained in motor vehicle crashes (63%), and diffuse brain injury was the most common abnormality (58%). Mechanism of injury, severity of TBI, pathological entity, neuroimaging results, and trauma indices were not predictive of ischemia. Factors affecting death included gunshot injury, poor trauma indices, subarachnoid hemorrhage, and coma. After standard resuscitation, 65% of patients had an initially low PbtO(2). Data are presented as means +/- SDs. Treatment with the PbtO(2)-CCG resulted in a 44% improvement in mean PbtO(2) (16.21 +/- 12.30 vs 23.65 +/- 14.40 mm Hg; p < 0.001), control of ICP (mean 12.76 +/- 6.42 mm Hg), and the maintenance of CPP (mean 76.13 +/- 15.37 mm Hg). Persistently low cerebral oxygenation was seen in 37% of patients at 2 hours, 31% at 24 hours, and 18% at 48 hours of treatment. Thus elevated ICP and a persistent low PbtO(2) after 2 hours represented increasing odds of death (OR 14.3 at 48 hours). Survivors and patients with good outcomes generally had significantly higher mean daily PbtO(2) and CPP values compared to nonsurvivors. Polytrauma, associated with higher ISS scores, presented an increased risk of vegetative outcome (OR 9.0). Compared to the ICP/CPP cohort, the mean Glasgow Outcome Scale score at 6 months in patients treated with PbtO(2)-CCG was higher (3.55 +/- 1.75 vs 2.71 +/- 1.65, p < 0.01; OR for good outcome 2.09, 95% CI 1.031-4.24) as was the reduction in mortality rate (25.9 vs 41.50%; relative risk reduction 37%), despite higher ISS scores in the PbtO(2) group (31.6 +/- 13.4 vs 27.1 +/- 8.9; p < 0.05). Subgroup analysis of severe closed TBI revealed a significant relative risk reduction in mortality rate of 37-51% compared with the Traumatic Coma Data Bank data, and an increased OR for good outcome especially in patients with diffuse brain injury without mass lesions (OR 4.9, 95% CI 2.9-8.4). CONCLUSIONS The prevention and aggressive treatment of cerebral hypooxygenation and control of ICP with a PbtO(2)-directed protocol reduced the mortality rate after TBI in major trauma, but more importantly, resulted in improved 6-month clinical outcomes over the standard ICP/CPP-directed therapy at the authors' institution.
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Head Injury and Outcome—What Influence do Concomitant Injuries Have? ACTA ACUST UNITED AC 2008; 65:1036-43; discussion 1043-4. [PMID: 19001971 DOI: 10.1097/ta.0b013e318184ee48] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Bavisetty S, Bavisetty S, McArthur DL, Dusick JR, Wang C, Cohan P, Boscardin WJ, Swerdloff R, Levin H, Chang DJ, Muizelaar JP, Kelly DF. Chronic hypopituitarism after traumatic brain injury: risk assessment and relationship to outcome. Neurosurgery 2008; 62:1080-93; discussion 1093-4. [PMID: 18580806 DOI: 10.1227/01.neu.0000325870.60129.6a] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Chronic pituitary dysfunction is increasingly recognized as a sequela of traumatic brain injury. We sought to define the incidence, risk factors, and neurobehavioral consequences of chronic hormonal deficiencies after complicated mild, moderate, or severe traumatic brain injury. METHODS Patients aged 14 to 80 years were prospectively enrolled at the time of injury and assessed at 3 and 6 to 9 months after injury for hormonal function and neurobehavioral consequences. Major and minor (subclinical) hormonal deficiencies, including growth hormone deficiency (GHD) and growth hormone insufficiency (GHI), were identified. Acute injury characteristics, neurobehavioral, and quality of life measures were compared in patients with and without major hormonal deficits by the use of multivariate analysis. RESULTS Out of 70 patients (mean age, 32 yr; median Glasgow Coma Scale score, 7; 19% women) tested at 6 to 9 months after injury, 15 (21%) had at least one major hormonal deficiency, 20 (29%) had minor deficiencies, and 30 (43%) had major and/or minor deficiencies. Patients with major deficiencies included 16% with GHD or GHI, 10.5% with hypogonadism, and 1.4% with diabetes insipidus. None of the patients required adrenal or thyroid replacement. At 6 to 9 months after injury, patients with major hormonal deficits had more abnormal acute computed tomographic findings (P = 0.014), greater acute and chronic body mass index (P < 0.01), and a worse Disability Rating Scale score (multivariate P = 0.04). Compared with the 59 growth hormone-sufficient patients, the 11 patients with GHD or GHI had worse Disability Rating Scale scores (multivariate P = 0.04), greater rates of depression, (90 versus 53%; multivariate P = 0.06), and worse quality of life in the Short Form-36 domains of energy and fatigue (multivariate P = 0.03), emotional well-being (multivariate P = 0.02), and general health (multivariate P = 0.07). CONCLUSION Chronic hypopituitarism warranting hormone replacement occurs in approximately 20% of patients after complicated mild, moderate, or severe traumatic brain injury and is associated with more severe brain injuries and increased disability. GHD and GHI are also associated with increased disability, poor quality of life, and a greater likelihood of depression. The clinical significance of minor hormonal deficits, which occur in almost 30% of patients, warrants further study. Given that major deficiencies are readily treatable, routine pituitary hormonal testing within 6 months of injury is indicated for this patient population.
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Affiliation(s)
- Sumati Bavisetty
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California Division of Neurosurgery, UCLA School of Medicine, Los Angeles, California, USA
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Bavisetty S, Bavisetty S, McArthur DL, Dusick JR, Wang C, Cohan P, Boscardin WJ, Swerdloff R, Levin H, Chang DJ, Muizelaar JP, Kelly DF. CHRONIC HYPOPITUITARISM AFTER TRAUMATIC BRAIN INJURY. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000313577.16309.cd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Modification of acute cardiovascular homeostatic responses to hemorrhage following mild to moderate traumatic brain injury. Crit Care Med 2008; 36:216-24. [PMID: 18090349 DOI: 10.1097/01.ccm.0000295425.41831.85] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The cardiovascular homeostatic responses to hemorrhage are coordinated in the central nervous system. Coincidental brain injury, which is present in 64% of trauma patients, could impair these responses. Our objective was to test the hypothesis that mild to moderate traumatic brain injury alters cardiovascular reflex responses to acute hemorrhage. DESIGN Experimental prospective, randomized study in terminally anesthetized rats. SETTING Experimental laboratory of university. SUBJECTS Twenty-four male Wistar rats weighing 240-260 g. INTERVENTIONS Brain injury was induced using the lateral fluid percussion injury model in anesthetized rats. The fluid percussion device delivered an applied cortical pressure of 1.2 atm and 1.8 atm, producing mild and moderate injury, respectively. Control animals underwent identical surgical procedures but with no applied cortical pressure. Hemorrhage was carried out 10 mins after brain injury, at a rate of 2% of blood volume per minute until 40% blood volume was withdrawn. MEASUREMENTS AND MAIN RESULTS The effects of acute traumatic brain injury on the biphasic heart rate and mean arterial blood pressure response to hemorrhage were studied. Traumatic brain injury attenuated the normal bradycardic response and delayed the hypotensive response to hemorrhage. This effect was graded according to the severity of brain injury. In mild injury, the depressor phase was delayed, but the biphasic pattern of heart rate response was maintained. No mortality was observed in this group. Following moderate brain injury, marked attenuation of the biphasic heart rate and mean arterial blood pressure response (p < .001 and p = .0007) was observed. Fifty percent of this group died within 90 mins of hemorrhage completion. Significant differences in the biphasic response were observed between survivors and nonsurvivors (p = .013, p = .001, respectively). In nonsurvivors, the biphasic response was abolished. CONCLUSIONS Acute mild and moderate traumatic brain injury disrupts cardiovascular homeostatic responses to extracranial hemorrhage; this disruption is graded according to the severity of traumatic brain injury. Severe disruption is associated with an increase in early mortality.
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Lippert-Grüner M, Maegele M, Haverkamp H, Klug N, Wedekind C. Health-related quality of life during the first year after severe brain trauma with and without polytrauma. Brain Inj 2008; 21:451-5. [PMID: 17522984 DOI: 10.1080/02699050701343961] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The increasing number of patients surviving severe traumatic brain injury (sTBI) but with significant sensorimotor and neuropsychological deficits is a challenge to rehabilitation medicine. So far, most research initiatives have focused on mortality rates, physiological or economic parameters to estimate therapeutic effects of rehabilitation strategies. Investigations on health-related quality of life (HRQoL) after TBI with and without concomitant polytrauma are rare compared to other disorders. DESIGN/PATIENTS A prospective study was conducted to investigate HRQoL using the SF-36 questionnaire in 49 patients with sTBI (Glasgow Coma Scale < 9 for more than 24 hours) with and without concomitant polytrauma 6 and 12 months after injury. RESULTS The SF-36 score profiles 6 and 12 months after trauma were similar. Scores 12 months after trauma, however, were higher in 7/8 dimensions indicating an improvement over time. Similar observations were made for physical and mental sum scores. There was no difference in the SF-36 scoring pattern between the patients with isolated TBI and the patients with concomitant polytrauma, except for physical functioning after 12 months. CONCLUSION While there is significant overall improvement of HRQoL over time, sTBI appears to bear major influence on post-traumatic HRQoL and outcome.
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Lorich DG, Gardner MJ, Helfet DL. Trauma to the Pelvis and Extremities. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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