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Mirkin S, Wu M, Colon J, Burgos JJ, Perez F. Severe Pediatric Open Skull Fracture With Exposed Brain Matter: A Case Report. Cureus 2023; 15:e46521. [PMID: 37927750 PMCID: PMC10625338 DOI: 10.7759/cureus.46521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Head trauma in the pediatric population carries a high rate of morbidity and mortality. The major causes of head trauma are related to falls, recreational activities, motor vehicle accidents, and gunshot wounds. Traumatic brain injury (TBI) can occur after severe head trauma and is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force. Intracranial edema and herniation are common consequences of a TBI in pediatric patients and are commonly relieved via decompressive craniectomy. This case study describes a 13-year-old male presenting to the trauma center after an unhelmeted all-terrain vehicle (ATV) accident with a positive head strike and loss of consciousness. The evaluation revealed extensive skull fractures extending from the frontal to the occipital lobe with brain exposure. Computed tomography (CT) scan of the head demonstrated extensive, open skull fractures with significant displacement of the exposed brain, extensive bilateral parietal and frontal bone fractures, and bilateral temporal bone displaced fractures more extensive on the left. A bilateral hemicraniectomy was performed due to diffuse cerebral edema and a left frontal ventriculostomy was placed to monitor and manage intracranial pressure (ICP). It is believed that the unique presentation of an open skull fracture with an exposed brain acted as a decompressive method allowing for extreme lifesaving measures to be performed to save the patient. Further exploration is needed to truly understand the effects of the unique injury presentation and the role of an open fracture in the delay of increased ICP.
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Affiliation(s)
- Sophia Mirkin
- Osteopathic Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Michael Wu
- Osteopathic Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Jessica Colon
- Osteopathic Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Jose J Burgos
- General Surgery, HCA Florida Kendall Hospital, Miami, USA
| | - Fernando Perez
- Pediatric Critical Care, HCA Florida Kendall Hospital, Miami, USA
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Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance. Pediatr Crit Care Med 2019; 20:847-887. [PMID: 31483379 DOI: 10.1097/pcc.0000000000001963] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.
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Wang H, Zhu X, Xiang H, Liao Z, Gao M, Luo Y, Wu P, Zhang Y, Ren M, Zhao H, Xu M. Effects of altitude changes on mild-to-moderate closed-head injury in rats following acute high-altitude exposure. Exp Ther Med 2019; 17:847-856. [PMID: 30651871 DOI: 10.3892/etm.2018.7020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/12/2018] [Indexed: 11/05/2022] Open
Abstract
Mild-to-moderate closed-head injury (mmCHI) is an acute disease induced by high-altitudes. It is general practice to transfer patients to lower altitudes for treatment, but the pathophysiological changes at different altitudes following mmCHI remain unknown. The present study simulated acute high-altitude exposure (6,000 m above sea level) in rats to establish a model of mmCHI and recorded their vital signs. The rats were then randomly assigned into different altitude exposure groups (6,000, 4,500 and 3,000 m) and neurological severity score (NSS), body weight (BW), brain magnetic resonance imaging (MRI), brain water content (BWC) and the ratio of BW/BWC at 6, 12 and 24 h following mmCHI, and the glial fibrillary acidic protein levels were analysed in all groups. The results revealed that within the first 24 h following acute high-altitude exposure, mmCHI induced dehydration, brain oedema and neuronal damage. Brain injury in rats was significantly reversed following descent to 4,500 m compared with the results from 6,000 or 3,000 m. The results indicated that subjects should be transported as early as possible. Furthermore, avoiding large-span descent altitude was beneficial to reduce neurological impairment. The examination of brain-specific biomarkers and MRI may further be useful in determining the prognosis of high-altitude mmCHI. These results may provide guidance for rescuing high altitude injuries.
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Affiliation(s)
- Hao Wang
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Xiyan Zhu
- Chongqing Key Laboratory of Vehicle Crash/Bio-impact and Traffic Safety, Institute for Traffic Medicine, Third Military Medical University, Chongqing 400042, P.R. China
| | - Hongyi Xiang
- Chongqing Key Laboratory of Vehicle Crash/Bio-impact and Traffic Safety, Institute for Traffic Medicine, Third Military Medical University, Chongqing 400042, P.R. China
| | - Zhikang Liao
- Chongqing Key Laboratory of Vehicle Crash/Bio-impact and Traffic Safety, Institute for Traffic Medicine, Third Military Medical University, Chongqing 400042, P.R. China
| | - Mou Gao
- Affiliated Bayi Brain Hospital P.L.A Army General Hospital, Beijing 100038, P.R. China
| | - Yetao Luo
- School of Public Health and Management, Chongqing Medical University, Chongqing 400016, P.R. China
| | - Pengfei Wu
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Yihua Zhang
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Mingliang Ren
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Hui Zhao
- Chongqing Key Laboratory of Vehicle Crash/Bio-impact and Traffic Safety, Institute for Traffic Medicine, Third Military Medical University, Chongqing 400042, P.R. China
| | - Minhui Xu
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
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Abstract
OBJECTIVES Pre-trauma center care is a critical component in severe pediatric traumatic brain injury (TBI). For geographically large trauma catchment areas, optimizing increased intracranial pressure (ICP) management may potentially improve outcomes. This retrospective study examined ICP management in nontrauma centers and during interfacility transport to the trauma center. METHODS Charts from a pediatric level I trauma center were reviewed for admissions between 2008 and 2013. Patients with a Glasgow Coma Scale score of 8 or less, head Abbreviated Injury Scale score of 3 or higher, and requiring intubation at a nontrauma center were included. Exclusion criteria included head injury secondary to drowning, stroke, obstetrical complications, asphyxia, and afflicted head trauma (younger than 5 years). Trauma center charts contained coalesced data from first responders, nontrauma centers, and transport. RESULTS Twenty-five patients (74%) had increased ICP upon admission at trauma center, 48% experienced ICPs greater than 20 cm H2O within 12 hours of admission, 12% required an urgent craniotomy, and 16% had herniation syndromes on neuroimaging. Pre-trauma center ICP management included osmotherapy and head-of-bed elevation. Sixty-four percent of patients with increased ICP at trauma center admission received pre-trauma center ICP management. CONCLUSIONS Early increased ICP is a common presentation of severe pediatric TBI during pre-trauma center management. However, what constitutes optimal care remains unknown. Given the difficulties of diagnosing early increased ICP in this setting, prophylactic raising ICP-lowering strategies may be considered.
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Pikstra ARA, Metting Z, Fock JM, van der Naalt J. The juvenile head trauma syndrome - Deterioration after mild TBI: Diagnosis and clinical presentation at the Emergency Department. Eur J Paediatr Neurol 2017; 21:344-349. [PMID: 27707655 DOI: 10.1016/j.ejpn.2016.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 08/26/2016] [Accepted: 09/11/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Annually 14.000 children with traumatic brain injury (TBI) are admitted to the Emergency Department (ED) in the Netherlands. Presentation varies and a specific entity comprises the juvenile head trauma syndrome (JHTS) with secondary deterioration after a mild trauma. As outcome of JHTS can be fatal, early recognition is essential. AIM To outline the epidemiology and clinical features of JHTS, in comparison to paediatric mild TBI patients without JHTS. METHODS Retrospective study of 570 patients with mild TBI admitted to the ED of a level-one trauma centre from 2008 to 2014. Diagnosis of JHTS by experienced neurologists was compared with diagnosis by physicians at the ED. RESULTS Physicians at the ED diagnosed JHTS more frequently (14%) compared to experienced neurologists (8%). JHTS occurred after a lucid interval varying from 5 to 225 min (mean 44 (SD 64)) with changes in consciousness. JHTS patients were younger compared to mild TBI patients (4.1 (SD 2.4) vs. 7.3 (SD 5.7), p < 0.01), (range: 1-10 years). Falls occurred more often in JHTS (84% vs. 69%, p = 0.03) and at presentation, vomiting (42% vs. 22%, p < 0.01) and changed behaviour (29% vs. 1%, p = 0.03) were more present compared to the mild TBI group. CONCLUSION AND DISCUSSION JHTS occurs more often in children up to 10 years with falls as major cause of injury. Clues for recognition of this syndrome comprise changes in consciousness and vomiting or changed behaviour on presentation at the ED. For clinical practice, these factors should guide the decision for hospital admission or discharge.
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Affiliation(s)
- Angelina R A Pikstra
- Department of Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Zwany Metting
- Department of Paediatric Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Johanna M Fock
- Department of Paediatric Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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McLendon LA, Kralik SF, Grayson PA, Golomb MR. The Controversial Second Impact Syndrome: A Review of the Literature. Pediatr Neurol 2016; 62:9-17. [PMID: 27421756 DOI: 10.1016/j.pediatrneurol.2016.03.009] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 03/11/2016] [Accepted: 03/18/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Second impact syndrome is a devastating injury that primarily affects athletic children and young adults. It occurs when a second concussion occurs before symptoms from the first concussion have resolved. Diffuse and often catastrophic cerebral edema results. Reports of second impact syndrome are few, and some argue that second impact syndrome is simply diffuse cerebral swelling unrelated to the first concussion. METHODS Ovid and PubMed were searched from years 1946 to 2015 using the terms "second impact syndrome," "repeat concussion," and "catastrophic brain injury." In addition, review articles were found using a combination of the terms, "concussion," "second impact syndrome," and "repetitive head trauma." RESULTS Seventeen patients in seven publications met the criteria of having two witnessed hits and persistent symptoms from the first to the second concussion. Ten of the 17 (59%) included individuals were football players. All were male. Ages ranged from 13 to 23 years. All children with poor outcomes (death or permanent disability) were younger than 20 years, while four of the five players with good outcomes were older than 19 years. The lag time from first to second concussion ranged from one hour to four weeks, and in many cases, at least one of the two hits appeared minor. CONCLUSIONS American football, male gender, and young age appear to be associated with second impact syndrome. Controversies surrounding this syndrome are discussed. There is a need for prospective studies to clarify risk factors and outcomes of second impact syndrome to guide return-to-play recommendations for young athletes.
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Affiliation(s)
- Loren A McLendon
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Stephen F Kralik
- Division of Pediatric Neuroradiology, Department of Radiology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Patricia A Grayson
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Meredith R Golomb
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.
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Multimodality monitoring consensus statement: monitoring in emerging economies. Neurocrit Care 2015; 21 Suppl 2:S239-69. [PMID: 25208665 DOI: 10.1007/s12028-014-0019-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The burden of disease and so the need for care is often greater at hospitals in emerging economies. This is compounded by frequent restrictions in the delivery of good quality clinical care due to resource limitations. However, there is substantial heterogeneity in this economically defined group, such that advanced brain monitoring is routinely practiced at certain centers that have an interest in neurocritical care. It also must be recognized that significant heterogeneity in the delivery of neurocritical care exists even within individual high-income countries (HICs), determined by costs and level of interest. Direct comparisons of data between HICs and the group of low- and middle-income countries (LAMICs) are made difficult by differences in patient demographics, selection for ICU admission, therapies administered, and outcome assessment. Evidence suggests that potential benefits of multimodality monitoring depend on an appropriate environment and clinical expertise. There is no evidence to suggest that patients in LAMICs where such resources exist should be treated any differently to patients from HICs. The potential for outcome benefits in LAMICs is arguably greater in absolute terms because of the large burden of disease; however, the relative cost/benefit ratio of such monitoring in this setting must be viewed in context of the overall priorities in delivering health care at individual institutions.
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Treating cerebral edema in diabetic ketoacidosis: caveats in extrapolating from traumatic brain injury*. Pediatr Crit Care Med 2013; 14:723-4. [PMID: 24162960 PMCID: PMC3811019 DOI: 10.1097/pcc.0b013e31829f6c77] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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