1
|
Haberl H, Unterberg M, Adamzik M, Hagedorn A, Wolf A. [Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 1 - Primary Treatment Strategies, Haemodynamic Management and Multimodal Monitoring]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:450-465. [PMID: 39074790 DOI: 10.1055/a-2075-9351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.
Collapse
|
2
|
Beucler N. Safety of emergency extra-cranial surgery for life-threatening trauma lesions in patients suffering from traumatic brain injury. Neurochirurgie 2024; 70:101579. [PMID: 38924845 DOI: 10.1016/j.neuchi.2024.101579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/03/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, 83800 Toulon Cedex 9, France.
| |
Collapse
|
3
|
Hörauf JA, Woschek M, Schindler CR, Verboket RD, Lustenberger T, Marzi I, Störmann P. Settlement Is at the End-Common Trauma Scores Require a Critical Reassessment Due to the Possible Dynamics of Traumatic Brain Injuries in Patients' Clinical Course. J Clin Med 2024; 13:3333. [PMID: 38893044 PMCID: PMC11173217 DOI: 10.3390/jcm13113333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Scientific studies on severely injured patients commonly utilize the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) for injury assessment and to characterize trauma cohorts. However, due to potential deterioration (e.g., in the case of an increasing hemorrhage) during the clinical course, the assessment of injury severity in traumatic brain injury (TBI) can be challenging. Therefore, the aim of this study was to investigate whether and to what extent the worsening of TBI affects the AIS and ISS. Methods: We retrospectively evaluated 80 polytrauma patients admitted to the trauma room of our level I trauma center with computed-tomography-confirmed TBI. The initial AIS, ISS, and Trauma and Injury Severity Score (TRISS) values were reevaluated after follow-up imaging. Results: A total of 37.5% of the patients showed a significant increase in AIShead (3.7 vs. 4.1; p = 0.002) and the ISS (22.9 vs. 26.7, p = 0.0497). These changes resulted in an eight percent reduction in their TRISS-predicted survival probability (74.82% vs. 66.25%, p = 0.1835). Conclusions: The dynamic nature of intracranial hemorrhage complicates accurate injury severity assessment using the AIS and ISS, necessitating consideration in clinical studies and registries to prevent systematic bias in patient selection and subsequent data analysis.
Collapse
Affiliation(s)
- Jason-Alexander Hörauf
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Mathias Woschek
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Cora Rebecca Schindler
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Rene Danilo Verboket
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas Lustenberger
- Department of Orthopedic Surgery and Traumatology, Inselspital, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Ingo Marzi
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Philipp Störmann
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| |
Collapse
|
4
|
Cáceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñan Garcés AE, González A, Alvarado Arias A, Bhatia K, Samadani U, Reyes LF. PaCO 2 Association with Outcomes of Patients with Traumatic Brain Injury at High Altitude: A Prospective Single-Center Cohort Study. Neurocrit Care 2024:10.1007/s12028-024-01982-8. [PMID: 38740704 DOI: 10.1007/s12028-024-01982-8] [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: 01/18/2024] [Accepted: 03/12/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. METHODS This is a prospective single-center cohort of consecutive patients with TBI admitted to a trauma center located at 2600 m above sea level. An unfavorable outcome was defined as a Glasgow Outcome Scale-Extended (GOSE) score < 4 at the 6-month follow-up. RESULTS We had a total of 81 patients with complete data, 80% (65/81) were men, and the median (interquartile range) age was 36 (25-50) years. Median Glasgow Coma Scale (GCS) score on admission was 9 (6-14); 49% (40/81) of patients had severe TBI (GCS 3-8), 32% (26/81) had moderate TBI (GCS 12-9), and 18% (15/81) had mild TBI (GCS 13-15). The median (interquartile range) Abbreviated Injury Score of the head (AISh) was 3 (2-4). The frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), the median GOSE was 4 (2-5), and the median 6-month mortality rate was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, (median age 49 [30-72] vs. 29 [22-41] years, P < 0.01), had lower admission GCS scores (6 [4-8] vs. 13 [8-15], P < 0.01), had higher AISh scores (4 [4-4] vs. 3 [2-4], P < 0.01), had higher Acute Physiology and Chronic Health disease Classification System II scores (17 [15-23] vs. 10 [6-14], P < 0.01), had higher Charlson scores (0 [0-2] vs. 0 [0-0], P < 0.01), and had higher PaCO2 levels (mean 35 ± 8 vs. 32 ± 6 mm Hg, P < 0.01). In a multivariate analysis, age (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.1-1.30, P < 0.01), AISh (OR 4.7, 95% CI 1.55-21.0, P < 0.05), and PaCO2 levels (OR 1.23, 95% CI 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4, 95% CI 1.61-28.5, P = 0.017) and PaCO2 levels (OR 1.36, 95% CI 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. CONCLUSIONS Higher PaCO2 levels are associated with an unfavorable outcome in ventilated patients with TBI. These results underscore the importance of PaCO2 levels in patients with TBI and whether it should be adjusted for populations living at higher altitudes.
Collapse
Affiliation(s)
- Eder Cáceres
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia.
- Department of Bioscience, School of Engineering, Universidad de La Sabana, Chía, Colombia.
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia.
| | - Afshin A Divani
- Department of Neurology, The University of New Mexico, Albuquerque, NM, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Juan Olivella-Gómez
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Angélica González
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Uzma Samadani
- Department of Neurosurgery, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Luis F Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Coppalini G, Salvagno M, Peluso L, Bogossian EG, Quispe Cornejo A, Labbé V, Annoni F, Taccone FS. Cardiac Injury After Traumatic Brain Injury: Clinical Consequences and Management. Neurocrit Care 2024; 40:477-485. [PMID: 37378852 DOI: 10.1007/s12028-023-01777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
Traumatic brain injury (TBI) is a significant public health issue because of its increasing incidence and the substantial short-term and long-term burden it imposes. This burden includes high mortality rates, morbidity, and a significant impact on productivity and quality of life for survivors. During the management of TBI, extracranial complications commonly arise during the patient's stay in the intensive care unit. These complications can have an impact on both mortality and the neurological outcome of patients with TBI. Among these extracranial complications, cardiac injury is a relatively frequent occurrence, affecting approximately 25-35% of patients with TBI. The pathophysiology underlying cardiac injury in TBI involves the intricate interplay between the brain and the heart. Acute brain injury triggers a systemic inflammatory response and a surge of catecholamines, leading to the release of neurotransmitters and cytokines. These substances have detrimental effects on the brain and peripheral organs, creating a vicious cycle that exacerbates brain damage and cellular dysfunction. The most common manifestation of cardiac injury in TBI is corrected QT (QTc) prolongation and supraventricular arrhythmias, with a prevalence up to 5 to 10 times higher than in the general adult population. Other forms of cardiac injury, such as regional wall motion alteration, troponin elevation, myocardial stunning, or Takotsubo cardiomyopathy, have also been described. In this context, the use of β-blockers has shown potential benefits by intervening in this maladaptive process. β-blockers can limit the pathological effects on cardiac rhythm, blood circulation, and cerebral metabolism. They may also mitigate metabolic acidosis and potentially contribute to improved cerebral perfusion. However, further clinical studies are needed to elucidate the role of new therapeutic strategies in limiting cardiac dysfunction in patients with severe TBI.
Collapse
Affiliation(s)
- Giacomo Coppalini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
- Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Milan, Italy.
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089, Milan, Italy.
| | - Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
- Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care, Humanitas Gavazzeni, Via M. Gavazzeni, 21, 24125, Bergamo, Italy
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Armin Quispe Cornejo
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Vincent Labbé
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| |
Collapse
|
6
|
Al Yacoub ON, Zhang Y, Patankar PS, Standifer KM. Traumatic Brain Injury Induces Nociceptin/Orphanin FQ and Nociceptin Opioid Peptide Receptor Expression within 24 Hours. Int J Mol Sci 2024; 25:1658. [PMID: 38338936 PMCID: PMC10855772 DOI: 10.3390/ijms25031658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Traumatic brain injury (TBI) is a major cause of mortality and disability around the world, for which no treatment has been found. Nociceptin/Orphanin FQ (N/OFQ) and the nociceptin opioid peptide (NOP) receptor are rapidly increased in response to fluid percussion, stab injury, and controlled cortical impact (CCI) TBI. TBI-induced upregulation of N/OFQ contributes to cerebrovascular impairment, increased excitotoxicity, and neurobehavioral deficits. Our objective was to identify changes in N/OFQ and NOP receptor peptide, protein, and mRNA relative to the expression of injury markers and extracellular regulated kinase (ERK) 24 h following mild (mTBI) and moderate TBI (ModTBI) in wildtype (WT) and NOP receptor-knockout (KO) rats. N/OFQ was quantified by radioimmunoassay, mRNA expression was assessed using real-time PCR and protein levels were determined by immunoblot analysis. This study revealed increased N/OFQ mRNA and peptide levels in the CSF and ipsilateral tissue of WT, but not KO, rats 24 h post-TBI; NOP receptor mRNA increased after ModTBI. Cofilin-1 activation increased in the brain tissue of WT but not KO rats, ERK activation increased in all rats following ModTBI; no changes in injury marker levels were noted in brain tissue at this time. In conclusion, this study elucidates transcriptional and translational changes in the N/OFQ-NOP receptor system relative to TBI-induced neurological deficits and initiation of signaling cascades that support the investigation of the NOP receptor as a therapeutic target for TBI.
Collapse
Affiliation(s)
| | | | | | - Kelly M. Standifer
- Department of Pharmaceutical Sciences, University of Oklahoma College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, USA; (O.N.A.Y.); (Y.Z.); (P.S.P.)
| |
Collapse
|
7
|
Iaccarino C, Chibbaro S, Sauvigny T, Timofeev I, Zaed I, Franchetti S, Mee H, Belli A, Buki A, De Bonis P, Demetriades AK, Depreitere B, Fountas K, Ganau M, Germanò A, Hutchinson P, Kolias A, Lindner D, Lippa L, Marklund N, McMahon C, Mielke D, Nasi D, Peul W, Poca MA, Pompucci A, Posti JP, Serban NL, Splavski B, Florian IS, Tasiou A, Zona G, Servadei F. Consensus-based recommendations for diagnosis and surgical management of cranioplasty and post-traumatic hydrocephalus from a European panel. BRAIN & SPINE 2024; 4:102761. [PMID: 38510640 PMCID: PMC10951750 DOI: 10.1016/j.bas.2024.102761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction Planning cranioplasty (CPL) in patients with suspected or proven post-traumatic hydrocephalus (PTH) poses a significant management challenge due to a lack of clear guidance. Research question This project aims to create a European document to improve adherence and adapt to local protocols based on available resources and national health systems. Methods After a thorough non-systematic review, a steering committee (SC) formed a European expert panel (EP) for a two-round questionnaire using the Delphi method. The questionnaire employed a 9-point Likert scale to assess the appropriateness of statements inherent to two sections: "Diagnostic criteria for PTH" and "Surgical strategies for PTH and cranial reconstruction." Results The panel reached a consensus on 29 statements. In the "Diagnostic criteria for PTH" section, five statements were deemed "appropriate" (consensus 74.2-90.3 %), two were labeled "inappropriate," and seven were marked as "uncertain."In the "Surgical strategies for PTH and cranial reconstruction" section, four statements were considered "appropriate" (consensus 74.2-90.4 %), six were "inappropriate," and five were "uncertain." Discussion and conclusion Planning a cranioplasty alongside hydrocephalus remains a significant challenge in neurosurgery. Our consensus conference suggests that, in patients with cranial decompression and suspected hydrocephalus, the most suitable diagnostic approach involves a combination of evolving clinical conditions and neuroradiological imaging. The recommended management sequence prioritizes cranial reconstruction, with the option of a ventriculoperitoneal shunt when needed, preferably with a programmable valve. We strongly recommend to adopt local protocols based on expert consensus, such as this, to guide patient care.
Collapse
Affiliation(s)
- Corrado Iaccarino
- School of Neurosurgery, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Neurosurgery Unit, University Hospital of Modena, Modena, Italy
- Neurosurgery Unit, AUSL RE IRCCS, Reggio Emilia, Italy
| | - Salvatore Chibbaro
- Neurosurgery Department, University of Siena, AOUS Le Scotte, Siena, Italy
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ivan Timofeev
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | | | - Harry Mee
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Rehabilitation Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Box 167, Level 4, A block Addenbrookes Hospital, Cambridge, UK
- NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, UK
| | - Antonio Belli
- The Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andras Buki
- Department of Neurosurgery, School of Medical Sciences, University of Orebro, Orebro, Sweden
| | - Pasquale De Bonis
- Department of Neurosurgery, University of Ferrara and Sant'Anna University Hospital, Ferrara, Italy
| | - Andreas K. Demetriades
- Department of Neurosurgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
- Edinburgh Spinal Surgery Outcome Studies Group, Edinburgh, UK
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital Leuven, Leuven, Belgium
| | - Kostantinos Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Dirk Lindner
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Laura Lippa
- Department of Neurosurgery, ASST Grande Ospedale Metrnoplitano Niguarda, Milano, Italy
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Catherine McMahon
- Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Davide Nasi
- Neurosurgery Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Wilco Peul
- University Neurosurgical Centre Holland, Leiden University Medical Centre,l, Leiden-The Hague, the Netherlands
| | - Maria Antonia Poca
- Centre de Recerca Matemàtica (CRM), Bellaterra, Spain
- Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain
- Department of Surgery, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Angelo Pompucci
- Neurosurgery Unit, Santa Maria Goretti Hospital, Latina, Italy
| | - Jussi P. Posti
- Department of Neurosurgery and Turku Brain Injury Centre, University of Turku, Turku, Finland
| | | | - Bruno Splavski
- Department of Anatomy, University of Applied Health Sciences, Zagreb, Croatia
- Department of Surgery, Service of Neurosurgery, Dubrovnik General Hospital, Dubrovnik, Croatia
| | | | - Anastasia Tasiou
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gianluigi Zona
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Franco Servadei
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| |
Collapse
|
8
|
Caceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñán-Garcés AE, González A, Alvarado-Arias A, Bathia K, Samadani U, Reyes LF. PaCO2 Association with Traumatic Brain Injury Patients Outcomes at High Altitude: A Prospective Single-Center Cohort Study. RESEARCH SQUARE 2024:rs.3.rs-3876988. [PMID: 38343855 PMCID: PMC10854293 DOI: 10.21203/rs.3.rs-3876988/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. Methods This is a prospective single-center cohort of consecutive TBI patients admitted to a trauma center located at 2600 meter above sea level. An unfavorable outcome was defined as the Glasgow Outcome Scale-Extended (GOSE) < 4 at 6-month follow-up. Results 81 patients with complete data, 80% (65/81) were men, and median (IQR) age was 36 (25-50) years). Median Glasgow Coma Scale (GCS) on admission was 9 (6-14), 49% (40/81) were severe (GCS: 3-8), 32% (26/81) moderate (GCS 12 - 9), and 18% (15/81) mild (GCS 13-15) TBI. The median (IQR) Abbreviated Injury Score of the Head (AISh) was 3 (2-4). Frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), median GOSE was 4 (2-5), and 6-month mortality was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, median [49 (30-72) vs. 29 (22-41), P < 0.01], had lower admission GCS [6 (4-8) vs. 13 (8-15), P < 0.01], higher AIS head [4 (4-4) vs. 3(2-4), p < 0.01], higher APACHE II score [17(15-23) vs 10 (6-14), < 0.01), higher Charlson score [0(0-2) vs. 0 (0-0), P < 0.01] and higher PaCO2 (mmHg), mean ± SD, 39 ± 9 vs. 32 ± 6, P < 0.01. In a multivariate analysis, age (OR 1.14 95% CI 1.1-1.30, P < 0.01), AISh (OR 4.7 95% CI 1.55-21.0, P < 0.05), and PaCO2 (OR 1.23 95% CI: 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4 95% CI: 1.61-28.5, P = 0.017) and PaCO2 (OR 1.36 95% CI: 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. Conclusion Higher PaCO2 levels are associated with an unfavorable outcome in ventilated TBI patients. These results underscore the importance of PaCO2 level in TBI patients and whether it should be adjusted for populations living at higher altitudes.
Collapse
Affiliation(s)
| | - Afshin A Divani
- University of New Mexico - Albuquerque: The University of New Mexico
| | - Clio A Rubinos
- University of North Carolina at Chapel Hill Health Sciences Library: The University of North Carolina at Chapel Hill
| | | | | | | | - Alexis Alvarado-Arias
- University of Mississippi University Hospital: The University of Mississippi Medical Center
| | - Kunal Bathia
- University of Mississippi University Hospital: The University of Mississippi Medical Center
| | | | | |
Collapse
|
9
|
Picetti E, Demetriades AK, Catena F, Aarabi B, Abu-Zidan FM, Alves OL, Ansaloni L, Armonda RA, Badenes R, Bala M, Balogh ZJ, Barbanera A, Bertuccio A, Biffl WL, Bouzat P, Buki A, Castano-Leon AM, Cerasti D, Citerio G, Coccolini F, Coimbra R, Coniglio C, Costa F, De Iure F, Depreitere B, Fainardi E, Fehlings MJ, Gabrovsky N, Godoy DA, Gruen P, Gupta D, Hawryluk GWJ, Helbok R, Hossain I, Hutchinson PJ, Iaccarino C, Inaba K, Ivanov M, Kaprovoy S, Kirkpatrick AW, Klein S, Kolias A, Konovalov NA, Lagares A, Lippa L, Loza-Gomez A, Luoto TM, Maas AIR, Maciejczak A, Maier RV, Marklund N, Martin MJ, Melloni I, Mendoza-Lattes S, Meyfroidt G, Munari M, Napolitano LM, Okonkwo DO, Otomo Y, Papadopoulos MC, Petr O, Peul WC, Pudkrong AK, Qasim Z, Rasulo F, Reizinho C, Ringel F, Rizoli S, Rostami E, Rubiano AM, Russo E, Sarwal A, Schwab JM, Servadei F, Sharma D, Sharif S, Shiban E, Shutter L, Stahel PF, Taccone FS, Terpolilli NA, Thomé C, Toth P, Tsitsopoulos PP, Udy A, Vaccaro AR, Varon AJ, Vavilala MS, Younsi A, Zackova M, Zoerle T, Robba C. Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS). World J Emerg Surg 2024; 19:4. [PMID: 38238783 PMCID: PMC10795357 DOI: 10.1186/s13017-023-00525-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/25/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.
Collapse
Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
| | - Andreas K Demetriades
- Department of Neurosurgery, Royal Infirmary Edinburgh, Edinburgh, UK
- Leiden University Neurosurgical Centre Holland, HMC-HAGA The Hague & LUMC Leiden, Leiden, The Netherlands
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Oscar L Alves
- Hospital Lusíadas Porto, Centro Hospitalar de Gaia/Espinho, Porto, Portugal
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, Pavia, Italy
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Andrea Barbanera
- Department of Neurosurgery, SS Antonio e Biagio e Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Alessandro Bertuccio
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Pierre Bouzat
- Universite Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Andras Buki
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Davide Cerasti
- Neuroradiology Unit, Parma University Hospital, Parma, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Neuroscience, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Division of Trauma and Acute Care Surgery, Riverside University Health System Medical Center, Riverside, CA, USA
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Francesco Costa
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | - Federico De Iure
- Department of Spine Surgery, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Louvain, Belgium
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Michael J Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, ON, Canada
| | - Nikolay Gabrovsky
- Clinic of Neurosurgery, University Hospital Pirogov, Sofia, Bulgaria
| | | | - Peter Gruen
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Gregory W J Hawryluk
- Neurological Institute, Cleveland Clinic, Akron General Hospital, Fairlawn, OH, USA
| | - Raimund Helbok
- Department of Neurology, Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Marcel Ivanov
- Neurosurgery Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Stanislav Kaprovoy
- Department of Spinal and Peripheral Nerve Surgery Burdenko Neurosurgical Center, Moscow, Russia
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Sam Klein
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- ANAPLASI Rehabilitation Centre, Athens, Greece
- 1St Neurosurgery Department, Henry Dunant Hospital Center, Athens, Greece
| | - Nikolay A Konovalov
- Department of Spinal and Peripheral Nerve Surgery Burdenko Neurosurgical Center, Moscow, Russia
| | - Alfonso Lagares
- Neurosurgery Department, University Hospital "12 de Octubre", Madrid, Spain
| | - Laura Lippa
- Department of Neurosurgery, Ospedale Niguarda, Milan, Italy
| | - Angelica Loza-Gomez
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Andrzej Maciejczak
- Department of Neurosurgery, St Luke Hospital, University of Rzeszow, Tarnow, Poland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | | | - Ilaria Melloni
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Louvain, Belgium
| | - Marina Munari
- Neuro-Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Lena M Napolitano
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Wilco C Peul
- Leiden University Neurosurgical Centre Holland, HMC-HAGA The Hague & LUMC Leiden, Leiden, The Netherlands
| | - Aichholz K Pudkrong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Zaffer Qasim
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Rasulo
- Department of Neuroanesthesia and Neurocritical Care, Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy
| | - Carla Reizinho
- Departamento de Neurocirurgia, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Sandro Rizoli
- Trauma Surgery Department, Hamad General Hospital, HMC, Doha, Qatar
| | - Elham Rostami
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Emanuele Russo
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Aarti Sarwal
- Department of Neurology, Atrium Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jan M Schwab
- Belford Center for Spinal Cord Injury and Departments of Neurology and Neuroscience, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Franco Servadei
- Humanitas Research Hospital-IRCCS & Humanitas University, Rozzano, Milan, Italy
| | - Deepak Sharma
- Neuroanesthesia & Perioperative Neuroscience, University of Washington, Seattle, WA, USA
| | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Fabio S Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicole A Terpolilli
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Toth
- Department of Neurosurgery, Medical School, University of Pecs, Pecs, Hungary
| | - Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloníki, Greece
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, 3004, Australia
| | - Alexander R Vaccaro
- Department of Orthopedic Surgery, Delaware Valley Spinal Cord Injury Center, Rothman Orthopedics, Sidney Kimmel Medical Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Albert J Varon
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine/Ryder Trauma Center, Miami, FL, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Monika Zackova
- Division of Intensive Care and Neurology Unit, Montecatone Rehabilitation Institute, Imola, Italy
| | - Tommaso Zoerle
- Department of Pathophysiology and Transplantation, University of Milan, Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Robba
- IRCCS Policlinico San Martino, Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, Università di Genova, Genoa, Italy
| |
Collapse
|
10
|
Hossain I, Rostami E, Marklund N. The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 2023; 29:650-658. [PMID: 37851061 PMCID: PMC10624411 DOI: 10.1097/mcc.0000000000001094] [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] [Indexed: 10/19/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. RECENT FINDINGS Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. SUMMARY Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
Collapse
Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala
- Department of Neuroscience, Karolinska institute, Stockholm
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
11
|
Badarni K, Harush N, Andrawus E, Bahouth H, Bar-Lavie Y, Raz A, Roimi M, Epstein D. Association Between Admission Ionized Calcium Level and Neurological Outcome of Patients with Isolated Severe Traumatic Brain Injury: A Retrospective Cohort Study. Neurocrit Care 2023; 39:386-398. [PMID: 36854866 DOI: 10.1007/s12028-023-01687-4] [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: 09/30/2022] [Accepted: 01/30/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Pathophysiological processes following initial insult are complex and not fully understood. Ionized calcium (Ca++) is an essential cofactor in the coagulation cascade and platelet aggregation, and hypocalcemia may contribute to the progression of intracranial bleeding. On the other hand, Ca++ is an important mediator of cell damage after TBI and cellular hypocalcemia may have a neuroprotective effect after brain injury. We hypothesized that early hypocalcemia might have an adverse effect on the neurological outcome of patients suffering from isolated severe TBI. In this study, we aimed to evaluate the relationship between admission Ca++ level and the neurological outcome of these patients. METHODS This was a retrospective, single-center, cohort study of all patients admitted between January 2014 and December 2020 due to isolated severe TBI, which was defined as head abbreviated injury score ≥ 4 and an absence of severe (abbreviated injury score > 2) extracranial injuries. The primary outcome was a favorable neurological status at discharge, defined by a modified Rankin Scale of 0-2. Multivariable logistic regression was performed to determine whether admission hypocalcemia (Ca++ < 1.16 mmol L-1) is an independent predictor of neurological status at discharge. RESULTS The final analysis included 201 patients. Hypocalcemia was common among patients with isolated severe TBI (73.1%). Most of the patients had mild hypocalcemia (1 < Ca++ < 1.16 mmol L-1), and only 13 (6.5%) patients had Ca++ ≤ 1.00 mmol L-1. In the entire cohort, hypocalcemia was independently associated with higher rates of good neurological status at discharge (adjusted odds ratio of 3.03, 95% confidence interval 1.11-8.33, p = 0.03). In the subgroup of 81 patients with an admission Glasgow Coma Scale > 8, 52 (64.2%) had hypocalcemia. Good neurological status at discharge was recorded in 28 (53.8%) of hypocalcemic patients compared with 14 (17.2%) of those with normal Ca++ (p = 0.002). In multivariate analyses, hypocalcemia was independently associated with good neurological status at discharge (adjusted odds ratio of 6.67, 95% confidence interval 1.39-33.33, p = 0.02). CONCLUSIONS Our study demonstrates that among patients with isolated severe TBI, mild admission hypocalcemia is associated with better neurological status at hospital discharge. The prognostic value of Ca++ may be greater among patients with admission Glasgow Coma Scale > 8. Trials are needed to investigate the role of hypocalcemia in brain injury.
Collapse
Affiliation(s)
- Karawan Badarni
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel.
| | - Noi Harush
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Elias Andrawus
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Hany Bahouth
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Trauma and Emergency Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Yaron Bar-Lavie
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Michael Roimi
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| |
Collapse
|
12
|
Callum J, Evans CCD, Barkun A, Karkouti K. Prise en charge non chirurgicale de l’hémorragie majeure. CMAJ 2023; 195:E1126-E1135. [PMID: 37640404 PMCID: PMC10462413 DOI: 10.1503/cmaj.221731-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Jeannie Callum
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont.
| | - Christopher C D Evans
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont
| | - Alan Barkun
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont
| | - Keyvan Karkouti
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont
| |
Collapse
|
13
|
Karagianni MD, Tasiou A, Brotis AG, Tzerefos C, Lambrianou X, Alkiviadis T, Kalogeras A, Spiliotopoulos T, Arvaniti C, Papageorgakopoulou M, Gatos C, Fountas KN. Critical Assessment of the Guidelines-Based Management of Severe Traumatic Brain Injury with the Appraisal of Guidelines for Research and Evaluation II. World Neurosurg 2023; 176:179-188. [PMID: 36682533 DOI: 10.1016/j.wneu.2023.01.054] [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: 12/14/2022] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Severe traumatic brain injury constitutes a clinical entity with complex underlying pathophysiology. Management of patients with severe traumatic brain injury is guided by Clinical Practice Guidelines and Consensus Statements (CPG and CS). The published CPG and CS vary in quality, comprehensiveness, and clinical applicability. The value of critically assessing CPG and CS cannot be overemphasized. The aim of our study was to assess the quality of the published CPG and CS, based on the Appraisal of Guidelines for Research and Evaluation II instrument. METHODS A systematic search was performed in PubMed, Scopus, Embase, and Web of Science focusing on guidelines and consensi about severe traumatic brain injury . The search terms used were "traumatic brain injury," "TBI," "brain injury," "cerebral trauma," "head trauma," "closed head injury," "head injury," "guidelines," "recommendations," "consensus" in any possible combination. The search period extended from 1964 to 2021 and was limited to literature published in English. The eligible studies were scored by 4 raters, using the Appraisal of Guidelines for Research and Evaluation II instrument. The inter-rater agreement was assessed using the Cronbach's alpha. RESULTS Twelve CPG and CS were assessed. Overall, the study by Carney et al. was the most Appraisal of Guidelines for Research and Evaluation II compliant study. In general, the domains of clarity of presentation, and scope and purpose, achieved the highest scores. The lowest inter-rater agreement in our analysis was "fair." CONCLUSIONS The purpose of our study for assessing the quality of CPG and CS was served. We present the strong and weak points of CPG and CS. Our findings support the idea of periodically updating guidelines and improving their rigor of development.
Collapse
Affiliation(s)
- Maria D Karagianni
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece.
| | - Anastasia Tasiou
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | - Alexandros G Brotis
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | - Xanthoula Lambrianou
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | - Tzannis Alkiviadis
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | - Adamantios Kalogeras
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | | | - Christina Arvaniti
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | | | - Charalambos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, Greece
| | - Konstantinos N Fountas
- Department of Neurosurgery, General University Hospital of Larissa, Biopolis, Larissa, Greece; Faculty of Medicine, University of Thessaly, Biopolis, Larissa, Greece
| |
Collapse
|
14
|
Beucler N. Hybrid emergency operating room for life-saving combined cranial surgery and extra-cranial surgery or procedure in severe trauma patients: A promising technical alternative. Injury 2023; 54:110895. [PMID: 37349168 DOI: 10.1016/j.injury.2023.110895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 06/04/2023] [Accepted: 06/12/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Nathan Beucler
- Neurosurgery department, Sainte-Anne Military Teachign Hospital, 2 boulevard Sainte-Anne, 83800 Toulon Cedex 9, France; Ecole du Val-de-Grâce, French Military Health Service Academy, 1 place Alphonse Laveran, 75230 Paris Cedex 5, France.
| |
Collapse
|
15
|
Shim Y, Kim J, Kim HS, Oh J, Lee S, Ha EJ. Intracranial Pressure Monitoring for Acute Brain Injured Patients: When, How, What Should We Monitor. Korean J Neurotrauma 2023; 19:149-161. [PMID: 37431379 PMCID: PMC10329885 DOI: 10.13004/kjnt.2023.19.e32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/12/2023] Open
Abstract
While there is no level I recommendation for intracranial pressure (ICP) monitoring, it is typically indicated for patients with severe traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) score of 3-8 (class II). Even for moderate TBI patients with GCS 9-12, ICP monitoring should be considered for risk of increased ICP. The impact of ICP monitoring on patient outcomes is still not well-established, but recent studies reported a reduction of early mortality (class III) in TBI patients. There is no standard protocol for the application of ICP monitoring. In cases where cerebrospinal fluid drainage is required, an external ventricular drain is commonly used. In other cases, parenchymal ICP monitoring devices are generally employed. Subdural or non-invasive forms are not suitable for ICP monitoring. The mean value of ICP is the parameter recommended for observation in many guidelines. In TBI, values above 22 mmHg are associated with increased mortality. However, recent studies proposed various parameters including cumulative time with ICP above 20 mmHg (pressure-time dose), pressure reactivity index, ICP waveform characteristics (pulse amplitude of ICP, mean ICP wave amplitude), and the compensatory reserve of the brain (reserve-amplitude-pressure), which are useful in predicting patient outcomes and guiding treatment. Further research is required for validation of these parameters compared to simple ICP monitoring.
Collapse
Affiliation(s)
- Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Jungook Kim
- Gachon University Gil Hospital Regional Trauma Center, Gachon, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University, Incheon, Korea
| | - Jiwoong Oh
- Departments of Neurological Surgery and Critical Care Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Departments of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
16
|
Latif RK, Clifford SP, Baker JA, Lenhardt R, Haq MZ, Huang J, Farah I, Businger JR. Traumatic hemorrhage and chain of survival. Scand J Trauma Resusc Emerg Med 2023; 31:25. [PMID: 37226264 DOI: 10.1186/s13049-023-01088-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.
Collapse
Affiliation(s)
- Rana K Latif
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA.
- Paris Simulation Center, Office of Medical Education, University of Louisville School of Medicine, Louisville, KY, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sean P Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jeffery A Baker
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rainer Lenhardt
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Mohammad Z Haq
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
- Department of Cardiovascular & Thoracic Surgery, Cardiovascular Innovation Institute, University of Louisville, Louisville, KY, USA
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA
- Division of Infectious Diseases, Department of Medicine, Center of Excellence for Research in Infectious Diseases (CERID), University of Louisville, Louisville, KY, USA
| | - Ian Farah
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jerrad R Businger
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| |
Collapse
|
17
|
Alao DO, Cevik AA, Abu-Zidan FM. Trauma deaths of hospitalized patients in Abu Dhabi Emirate: a retrospective descriptive study. World J Emerg Surg 2023; 18:31. [PMID: 37118764 PMCID: PMC10148441 DOI: 10.1186/s13017-023-00501-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023] Open
Abstract
AIM To study the epidemiology and pattern of trauma-related deaths of hospitalized patients in Abu Dhabi Emirate, United Arab Emirates, in order to improve trauma management and injury prevention. METHODS The Abu Dhabi Trauma Registry prospectively collects data of all hospitalized trauma patients from seven major trauma centres in Abu Dhabi Emirate. We studied all patients who died on arrival or after admission to these hospitals from January 2014 to December 2019. RESULTS There were 453 deaths constituting 13.5% of all trauma deaths in the Abu Dhabi Emirate. The median (IQR) age of the patients was 33 (25-45) years, and 82% were males. 85% of the deaths occurred in the emergency department (ED) and the intensive care unit (ICU). Motor vehicle collision (63.8%) was the leading cause of death. 45.5% of the patients had head injury. Two of the seven hospitals admitted around 50% of all patients but accounted for only 25.8% of the total deaths (p < 0.001). Those who died in the ward (7%) were significantly older, median (IQR) age: of 65.5 (31.75-82.25) years, (p < 0.001), 34.4% of them were females (p = 0.09). The median (IQR) GCS of those who died in the ward was 15 (5.75-15) compared with 3 (3-3) for those who died in ED and ICU (P < 0.001). CONCLUSIONS Death from trauma predominantly affects young males with motor traffic collision as the leading cause. Over 85% of in-hospital deaths occur in the ICU and ED, mainly from head injuries. Injury prevention of traffic collisions through enforcement of law and improved hospital care in the ED and ICU will reduce trauma death.
Collapse
Affiliation(s)
- David O Alao
- Department of Internal Medicine, Section of Emergency Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
- The Department of Emergency Medicine, Tawam Hospital, Al-Ain, United Arab Emirates.
| | - Arif Alper Cevik
- Department of Internal Medicine, Section of Emergency Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
- The Department of Emergency Medicine, Tawam Hospital, Al-Ain, United Arab Emirates
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| |
Collapse
|
18
|
Zamora R, Forsberg JA, Shah AM, Unselt D, Grey S, Lisboa FA, Billiar TR, Schobel SA, Potter BK, Elster EA, Vodovotz Y. Central role for neurally dysregulated IL-17A in dynamic networks of systemic and local inflammation in combat casualties. Sci Rep 2023; 13:6618. [PMID: 37095162 PMCID: PMC10126120 DOI: 10.1038/s41598-023-33623-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/15/2023] [Indexed: 04/26/2023] Open
Abstract
Dynamic Network Analysis (DyNA) and Dynamic Hypergraphs (DyHyp) were used to define protein-level inflammatory networks at the local (wound effluent) and systemic circulation (serum) levels from 140 active-duty, injured service members (59 with TBI and 81 non-TBI). Interleukin (IL)-17A was the only biomarker elevated significantly in both serum and effluent in TBI vs. non-TBI casualties, and the mediator with the most DyNA connections in TBI wounds. DyNA combining serum and effluent data to define cross-compartment correlations suggested that IL-17A bridges local and systemic circulation at late time points. DyHyp suggested that systemic IL-17A upregulation in TBI patients was associated with tumor necrosis factor-α, while IL-17A downregulation in non-TBI patients was associated with interferon-γ. Correlation analysis suggested differential upregulation of pathogenic Th17 cells, non-pathogenic Th17 cells, and memory/effector T cells. This was associated with reduced procalcitonin in both effluent and serum of TBI patients, in support of an antibacterial effect of Th17 cells in TBI patients. Dysregulation of Th17 responses following TBI may drive cross-compartment inflammation following combat injury, counteracting wound infection at the cost of elevated systemic inflammation.
Collapse
Affiliation(s)
- Ruben Zamora
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jonathan A Forsberg
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Ashti M Shah
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Desiree Unselt
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Scott Grey
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Felipe A Lisboa
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Benjamin K Potter
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA.
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA.
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
| |
Collapse
|
19
|
Servadei F, Cannizzaro D, Zaed I, Iaccarino C, Cardia A. Neurotrauma Care: A Worldwide Perspective. J Neurotrauma 2023; 40:597-601. [PMID: 36893218 DOI: 10.1089/neu.2023.29137.fs] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Affiliation(s)
- Franco Servadei
- Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | - Delia Cannizzaro
- Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of South Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Neurocenter of South Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| |
Collapse
|
20
|
Butterfield M, Bodnar D, Williamson F, Parker L, Ryan G. Prevalence of secondary insults and outcomes of patients with traumatic brain injury intubated in the prehospital setting: a retrospective cohort study. Emerg Med J 2023; 40:167-174. [PMID: 36604161 PMCID: PMC9985756 DOI: 10.1136/emermed-2022-212513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 12/21/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Prehospital neuroprotective strategies aim to prevent secondary insults (SIs) in traumatic brain injury (TBI). This includes haemodynamic optimisation in addition to oxygenation and ventilation targets achieved through rapid sequence intubation (RSI).The primary aim was to report the incidence and prevalence of SIs (prolonged hypotension, prolonged hypoxia and hyperventilation) and outcomes of patients with TBI who were intubated in the prehospital setting. METHODS A retrospective cohort study of adult patients with TBI who underwent RSI by a metropolitan road-based service in South-East Queensland, Australia between 1 January 2017 and 31 December 2020. Patients were divided into two cohorts based on the presence or absence of any SI sustained. Prolonged SIs were defined as occurring for ≥5 min. The association between SIs and mortality was examined in multivariable logistic regression and reported with adjusted ORs (aORs) and 95% CIs. RESULTS 277 patients were included for analysis. Median 'Head' Abbreviated Injury Scale and Injury Severity Score were 4 (IQR: 3-5) and 26 (IQR: 17-34), respectively. Most episodes of prolonged hypotension and prolonged hypoxia were detected with the first patient contact on scene. Overall, 28-day mortality was 26%. Patients who sustained any SI had a higher mortality than those sustaining no SI (34.9% vs 14.7%, p<0.001). Prolonged hypoxia was an independent predictor of mortality (aOR 4.86 (95% CI 1.65 to 15.61)) but not prolonged hypotension (aOR 1.45 (95% CI 0.5 to 4.25)) or an end-tidal carbon dioxide <30 mm Hg on hospital arrival (aOR 1.28 (95% CI 0.5 to 3.21)). CONCLUSION SIs were common in the early phase of prehospital care. The association of prolonged hypoxia and mortality in TBI is potentially more significant than previously recognised, and if corrected early, may improve outcomes. There may be a greater role for bystander intervention in prevention of early hypoxic insult in TBI.
Collapse
Affiliation(s)
- Michael Butterfield
- Emergency Department, Logan Hospital, Meadowbrook, Queensland, Australia .,LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia
| | - Daniel Bodnar
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Frances Williamson
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Queensland Ambulance Service, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Lachlan Parker
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Glenn Ryan
- Queensland Ambulance Service, Brisbane, Queensland, Australia.,Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
21
|
Vrettou CS, Giannakoulis VG, Gallos P, Kotanidou A, Siempos II. Effect of Different Early Oxygenation Levels on Clinical Outcomes of Patients Presenting in the Emergency Department With Severe Traumatic Brain Injury. Ann Emerg Med 2023; 81:273-281. [PMID: 36402630 DOI: 10.1016/j.annemergmed.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/06/2022] [Accepted: 09/28/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Despite the almost universal administration of supplemental oxygen in patients presenting in the emergency department (ED) with severe traumatic brain injury, optimal early oxygenation levels are unknown. Therefore, we aimed to examine the effect of different early oxygenation levels on the clinical outcomes of patients presenting in the emergency department with severe traumatic brain injury. METHODS We performed a secondary analysis of the Resuscitation Outcomes Consortium Traumatic Brain Injury Hypertonic Saline randomized controlled trial by including patients with Glasgow Coma Scale ≤8. Early oxygenation levels were assessed by the worst value of arterial partial pressure of oxygen (PaO2) during the first 4 hours of presentation in the emergency department. The primary outcome was 6-month neurologic status, as assessed by the Extended Glasgow Outcome Scale. A binary logistic regression was utilized, and an odds ratio (OR) with 95% (95% confidence intervals) was calculated. RESULTS A total of 910 patients were included. In unadjusted (crude) analysis, a PaO2 of 101 to 250 mmHg (OR, 0.59 [0.38 to 0.91]), or 251 to 400 mmHg (OR, 0.53 [0.34 to 0.83]) or ≥401 mmHg (OR, 0.31 [0.20 to 0.49]) was less likely to be associated with poor neurologic status when compared with a PaO2 of ≤100 mmHg. This was also the case for adjusted analyses (including age, pupillary reactivity, and Revised Trauma Score). CONCLUSION High oxygenation levels as early as the first 4 hours of presentation in the emergency department may not be adversely associated with the long-term neurologic status of patients with severe traumatic brain injury. Therefore, during the early phase of trauma, clinicians may focus on stabilizing patients while giving low priority to the titration of oxygenation levels.
Collapse
Affiliation(s)
- Charikleia S Vrettou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Vassilis G Giannakoulis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Parisis Gallos
- Department of Digital Systems, Computational Biomedicine Laboratory, University of Piraeus, Piraeus, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY.
| |
Collapse
|
22
|
Abergel H, Bidder M, Ashkenazi I, Reytman L, Alfici R, Krausz MM. Fresh Frozen Plasma Increases Hemorrhage in Blunt Traumatic Brain Injury and Uncontrolled Hemorrhagic Shock. Rambam Maimonides Med J 2023; 14:RMMJ.10489. [PMID: 36719667 PMCID: PMC9888485 DOI: 10.5041/rmmj.10489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Blunt traumatic brain injury (bTBI) and uncontrolled hemorrhagic shock (UCHS) are common causes of mortality in polytrauma. We studied the influence of fresh frozen plasma (FFP) resuscitation in a rat model with both bTBI and UCHS before achieving hemorrhage control. METHODS The bTBI was induced by an external weight drop (200 g) onto the bare skull of anesthetized male Lewis (Lew/SdNHsd) rats; UCHS was induced by resection of two-thirds of the rats' tails. Fifteen minutes following trauma, bTBI+UCHS rats underwent resuscitation with FFP or lactated Ringer's solution (LR). Eight groups were evaluated: (1) Sham; (2) bTBI; (3) UCHS; (4) UCHS+FFP; (5) UCHS+LR; (6) bTBI+UCHS; (7) bTBI+UCHS+FFP; and (8) bTBI+UCHS+LR. Bleeding volume, hematocrit, lactate, mean arterial pressure (MAP), heart rate, and mortality were measured. RESULTS The study included 97 rats that survived the immediate trauma. Mean blood loss up to the start of resuscitation was similar among UCHS only and bTBI+UCHS rats (P=0.361). Following resuscitation, bleeding was more extensive in bTBI+UCHS+FFP rats (5.2 mL, 95% confidence interval [CI] 3.7, 6.6) than in bTBI+UCHS+LR rats (2.5 mL, 95% CI 1.2, 3.8) and bTBI+UCHS rats (1.9 mL, 95% CI 0, 3.9) (P=0.005). Overall mortality increased if bleeding was above 4.5 mL (92.3% versus 8%; P<0.001). Mortality was 83.3% (10/12) in bTBI+UCHS+FFP rats, 41.7% (5/12) in bTBI+UCHS+LR rats, and 64.3% (9/14) in bTBI+UCHS rats. CONCLUSION The bTBI did not exacerbate bleeding in rats undergoing UCHS. Compared to LR, FFP resuscitation was associated with a significantly increased blood loss in bTBI+UCHS rats.
Collapse
Affiliation(s)
- Hilla Abergel
- Surgical Research Laboratory, Hillel Yaffe Medical Center, Hadera, Israel
- Technion–Israel Institute of Technology, Haifa, Israel
| | - Miri Bidder
- Surgical Research Laboratory, Hillel Yaffe Medical Center, Hadera, Israel
- Technion–Israel Institute of Technology, Haifa, Israel
| | - Itamar Ashkenazi
- Surgical Research Laboratory, Hillel Yaffe Medical Center, Hadera, Israel
- Technion–Israel Institute of Technology, Haifa, Israel
| | - Leonid Reytman
- Surgical Research Laboratory, Hillel Yaffe Medical Center, Hadera, Israel
- Technion–Israel Institute of Technology, Haifa, Israel
- Department of Anesthesiology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ricardo Alfici
- Surgical Research Laboratory, Hillel Yaffe Medical Center, Hadera, Israel
- Technion–Israel Institute of Technology, Haifa, Israel
- Clinical Professor Emeritus, Department of General Surgery, Hillel Yaffe Medical Center, Hadera, Israel
| | - Michael M. Krausz
- Surgical Research Laboratory, Hillel Yaffe Medical Center, Hadera, Israel
- Technion–Israel Institute of Technology, Haifa, Israel
- Professor Emeritus, Department of General Surgery, Hillel Yaffe Medical Center, Hadera, Israel
- To whom correspondence should be addressed. E-mail:
| |
Collapse
|
23
|
Picetti E, Catena F, Abu-Zidan F, Ansaloni L, Armonda RA, Bala M, Balogh ZJ, Bertuccio A, Biffl WL, Bouzat P, Buki A, Cerasti D, Chesnut RM, Citerio G, Coccolini F, Coimbra R, Coniglio C, Fainardi E, Gupta D, Gurney JM, Hawrylux GWJ, Helbok R, Hutchinson PJA, Iaccarino C, Kolias A, Maier RW, Martin MJ, Meyfroidt G, Okonkwo DO, Rasulo F, Rizoli S, Rubiano A, Sahuquillo J, Sams VG, Servadei F, Sharma D, Shutter L, Stahel PF, Taccone FS, Udy A, Zoerle T, Agnoletti V, Bravi F, De Simone B, Kluger Y, Martino C, Moore EE, Sartelli M, Weber D, Robba C. Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES). World J Emerg Surg 2023; 18:5. [PMID: 36624517 PMCID: PMC9830860 DOI: 10.1186/s13017-022-00468-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/01/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. METHODS A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. RESULTS A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. CONCLUSIONS This consensus provides practical recommendations to support clinician's decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.
Collapse
Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
| | - Fausto Catena
- grid.414682.d0000 0004 1758 8744Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Fikri Abu-Zidan
- grid.43519.3a0000 0001 2193 6666The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736Unit of General Surgery, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy
| | - Rocco A. Armonda
- grid.411663.70000 0000 8937 0972Department of Neurosurgery, 71541MedStar Georgetown University Hospital, Washington, DC USA ,grid.415235.40000 0000 8585 5745Department of Neurosurgery, 8405MedStar Washington Hospital Center, Washington, DC USA
| | - Miklosh Bala
- grid.9619.70000 0004 1937 0538Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, Jerusalem, Israel
| | - Zsolt J. Balogh
- grid.413648.cDepartment of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW Australia
| | - Alessandro Bertuccio
- Department of Neurosurgery, SS Antonio E Biagio E Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Walt L. Biffl
- grid.415401.5Scripps Clinic Medical Group, La Jolla, CA USA
| | - Pierre Bouzat
- grid.450308.a0000 0004 0369 268XInserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Andras Buki
- grid.15895.300000 0001 0738 8966Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Davide Cerasti
- grid.411482.aNeuroradiology Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Randall M. Chesnut
- grid.34477.330000000122986657Department of Neurological Surgery, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
| | - Giuseppe Citerio
- grid.7563.70000 0001 2174 1754School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy ,grid.415025.70000 0004 1756 8604Neuroscience Department, NeuroIntensive Care Unit, Hospital San Gerardo, ASST Monza, Monza, Italy
| | - Federico Coccolini
- grid.144189.10000 0004 1756 8209Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- grid.43582.380000 0000 9852 649XRiverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA USA
| | - Carlo Coniglio
- grid.416290.80000 0004 1759 7093Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Enrico Fainardi
- grid.8404.80000 0004 1757 2304Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Deepak Gupta
- grid.413618.90000 0004 1767 6103Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jennifer M. Gurney
- grid.420328.f0000 0001 2110 0308Department of Trauma, San Antonio Military Medical Center and the U.S. Army Institute of Surgical Research, San Antonio, TX 78234 USA ,grid.461685.80000 0004 0467 8038The Department of Defense Center of Excellence for Trauma, Joint Trauma System (JTS), JBSA Fort Sam Houston, San Antonio, TX 78234 USA
| | - Gregory W. J. Hawrylux
- grid.239578.20000 0001 0675 4725Cleveland Clinic, 762 S. Cleveland-Massillon Rd, Akron, OH 44333 USA
| | - Raimund Helbok
- grid.5361.10000 0000 8853 2677Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter J. A. Hutchinson
- grid.5335.00000000121885934Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Corrado Iaccarino
- grid.413363.00000 0004 1769 5275Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Angelos Kolias
- grid.5335.00000000121885934National Institute for Health Research Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital,, University of Cambridge, Cambridge, UK
| | - Ronald W. Maier
- grid.34477.330000000122986657Harborview Medical Center, University of Washington, Seattle, WA USA
| | - Matthew J. Martin
- grid.42505.360000 0001 2156 6853Division of Trauma and Acute Care Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA USA
| | - Geert Meyfroidt
- grid.410569.f0000 0004 0626 3338Department of Intensive Care, University Hospitals Leuven, Louvain, Belgium ,grid.5596.f0000 0001 0668 7884Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Louvain, Belgium
| | - David O. Okonkwo
- grid.412689.00000 0001 0650 7433Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Frank Rasulo
- grid.412725.7Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Sandro Rizoli
- grid.413542.50000 0004 0637 437XSurgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Andres Rubiano
- grid.412195.a0000 0004 1761 4447INUB-MEDITECH Research Group, Institute of Neurosciences, Universidad El Bosque, Bogotá, Colombia
| | - Juan Sahuquillo
- grid.7080.f0000 0001 2296 0625Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Valerie G. Sams
- grid.413561.40000 0000 9881 9161Trauma Critical Care and Acute Care Surgery, Air Force Center for Sustainment of Trauma and Readiness Skills, University of Cincinnati Medical Center, Cincinnati, OH USA
| | - Franco Servadei
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy ,grid.417728.f0000 0004 1756 8807Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Deepak Sharma
- grid.34477.330000000122986657Department of Anesthesiology and Pain Medicine and Neurological Surgery, University of Washington, Seattle, WA USA
| | - Lori Shutter
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, UPMC/University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Philip F. Stahel
- grid.461417.10000 0004 0445 646XCollege of Osteopathic Medicine, Rocky Vista University, Parker, CO USA
| | - Fabio S. Taccone
- grid.410566.00000 0004 0626 3303Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Andrew Udy
- grid.1623.60000 0004 0432 511XDepartment of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC 3004 Australia
| | - Tommaso Zoerle
- grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy ,grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vanni Agnoletti
- grid.414682.d0000 0004 1758 8744Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Francesca Bravi
- grid.415207.50000 0004 1760 3756Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Yoram Kluger
- grid.413731.30000 0000 9950 8111Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl Della Romagna, Lugo, Italy
| | - Ernest E. Moore
- grid.241116.10000000107903411Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO USA
| | | | - Dieter Weber
- grid.1012.20000 0004 1936 7910Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| |
Collapse
|
24
|
Abdulla E, Rahman S, Rahman MM. Letter: Protocol for a Multicenter, Prospective, Observational Pilot Study on the Implementation of Resource-Stratified Algorithms for the Treatment of Severe Traumatic Brain Injury Across Four Treatment Phases: Prehospital, Emergency Department, Neurosurgery, and Intensive Care Unit. Neurosurgery 2022; 91:e174. [PMID: 36218361 DOI: 10.1227/neu.0000000000002174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ebtesam Abdulla
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Sabrina Rahman
- Department of Public Health, Independent University-Bangladesh, Dhaka, Bangladesh
| | - Md Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
| |
Collapse
|
25
|
Beucler N, Sellier A, Fawaz R, Dagain A. Letter to the Editor Regarding Outcomes Following Penetrating Brain Injuries in Military Settings: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 167:241-242. [PMID: 36793168 DOI: 10.1016/j.wneu.2022.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France; Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France.
| | - Aurore Sellier
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Rayan Fawaz
- Neurosurgery Department, Percy Military Teaching Hospital, Clamart, France; Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France; Val-de-Grâce Military Academy, Paris, France
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Gantner D, Cooper DJ, Finfer S, Bragge P. Determinants of Adherence to Best Practice in Severe Traumatic Brain Injury: A Qualitative Study. Neurocrit Care 2022; 37:744-753. [PMID: 35948737 PMCID: PMC9672018 DOI: 10.1007/s12028-022-01551-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 06/04/2022] [Indexed: 11/25/2022]
Abstract
Background Management of patients with severe traumatic brain injury (sTBI) is highly variable and inconsistently aligned with evidence derived from high-quality trials, including those examining intravenous fluid resuscitation and use of decompressive craniectomy surgery. This study explored the barriers and facilitators of general and specific evidence-based practices in sTBI from the perspectives of stakeholder clinicians. Methods This was a qualitative study of semistructured interviews conducted with specialist clinicians responsible for acute care of patients with sTBI. Interview analysis was guided by the Theoretical domains framework (TDF), and key themes were mapped to relevant TDF behavioral domains. Results Ten neurosurgeons, 12 intensive care specialists, and three trauma physicians from six high-income countries participated between May 2020 and May 2021. Key TDF domains were environmental context and resources, social influences, and beliefs about consequences. Evidence-aligned management of patients with sTBI is perceived to be facilitated by admission to academic research-oriented hospitals, development of local practice protocols, and interdisciplinary collaboration. Determinants of specific practices varied and included health policy change for fluid resuscitation and development of patient-centered goals for surgical decision-making. Conclusions In choosing interventions for patients with sTBI, clinicians integrate local environmental, social, professional, and emotional influences with evidence and associated clinical practice guideline recommendations. This study highlights determinants of evidence-based practice that may inform implementation efforts and thereby improve outcomes for patients with sTBI. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01551-x.
Collapse
Affiliation(s)
- Dashiell Gantner
- Australian and New Zealand Intensive Care Research Centre, Monash University, Level 3, 553 St Kilda Road, Melbourne, VIC, 3004, Australia. .,Department of Intensive Care, Alfred Health, Melbourne, Australia.
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Level 3, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King Street, Newtown, Sydney, NSW, 2042, Australia.,School of Public Health, Imperial College London, London, UK
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Melbourne, VIC, 3800, Australia
| |
Collapse
|
28
|
Melatonin and the Brain–Heart Crosstalk in Neurocritically Ill Patients—From Molecular Action to Clinical Practice. Int J Mol Sci 2022; 23:ijms23137094. [PMID: 35806098 PMCID: PMC9267006 DOI: 10.3390/ijms23137094] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 01/27/2023] Open
Abstract
Brain injury, especially traumatic brain injury (TBI), may induce severe dysfunction of extracerebral organs. Cardiac dysfunction associated with TBI is common and well known as the brain–heart crosstalk, which broadly refers to different cardiac disorders such as cardiac arrhythmias, ischemia, hemodynamic insufficiency, and sudden cardiac death, which corresponds to acute disorders of brain function. TBI-related cardiac dysfunction can both worsen the brain damage and increase the risk of death. TBI-related cardiac disorders have been mainly treated symptomatically. However, the analysis of pathomechanisms of TBI-related cardiac dysfunction has highlighted an important role of melatonin in the prevention and treatment of such disorders. Melatonin is a neurohormone released by the pineal gland. It plays a crucial role in the coordination of the circadian rhythm. Additionally, melatonin possesses strong anti-inflammatory, antioxidative, and antiapoptotic properties and can modulate sympathetic and parasympathetic activities. Melatonin has a protective effect not only on the brain, by attenuating its injury, but on extracranial organs, including the heart. The aim of this study was to analyze the molecular activity of melatonin in terms of TBI-related cardiac disorders. Our article describes the benefits resulting from using melatonin as an adjuvant in protection and treatment of brain injury-induced cardiac dysfunction.
Collapse
|
29
|
Gupta A, Jamir L, Aravindakshan R, Debnath DJ, Sathiyanarayanan S, Kakkar R. New normal of academic virtual conference: Imperative during pandemic. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:166. [PMID: 35847144 PMCID: PMC9277758 DOI: 10.4103/jehp.jehp_353_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/19/2021] [Indexed: 06/15/2023]
Abstract
In COVID pandemic, attending the continuing medical education, workshops, and conferences with physical attendance is not possible. We designed, developed, and hosted the first of its kind academic virtual/online conference at par with an in-person academic conference to disseminate the expertise of the renowned subject experts along with researchers to present their research work due to the ongoing pandemic. We, in this article, had summarized the most critical steps in order to make the process easier for first-timers while providing our more comprehensive walkthroughs on each step. We choose a live session of the speakers on the Zoom meeting mode to retain the atmosphere of a live conference. WhatsApp, Google (Google Meet and E-mail), and Kahoot were other platforms to communicate with speakers, researchers, and participants to seamlessly participate. A number of advantages in terms of protection for delegates/speakers and their families came from the Virtual Conference on Nutrition and Health, restricting the spread of COVID-19, low budget for organizers, economically much cheaper alternatives both for speakers and participants, dissemination of knowledge, time productive, and meeting research paper presentation eligibility for a professional course. When one is new to technology, try adding an innovative aspect as a starting point to future virtual and in-person events, and seeing how it works is imperative. Ensuring Internet bandwidth, updated hardware, or webcam and/or microphone functionality at the participant end is critical.
Collapse
Affiliation(s)
- Arti Gupta
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | - Limalemla Jamir
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Guwahati, Assam, India
| | - Rajeev Aravindakshan
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | - Dhrubajyoti J. Debnath
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | - S. Sathiyanarayanan
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | - Rakesh Kakkar
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bathinda, Punjab, India
| |
Collapse
|
30
|
Picetti E, Iaccarino C, Coimbra R, Abu-Zidan F, Tebala GD, Balogh ZJ, Biffl WL, Coccolini F, Gupta D, Maier RV, Marzi I, Robba C, Sartelli M, Servadei F, Stahel PF, Taccone FS, Unterberg AW, Antonini MV, Galante JM, Ansaloni L, Kirkpatrick AW, Rizoli S, Leppaniemi A, Chiara O, De Simone B, Chirica M, Shelat VG, Fraga GP, Ceresoli M, Cattani L, Minardi F, Tan E, Wani I, Petranca M, Domenichelli F, Cui Y, Malchiodi L, Sani E, Litvin A, Hecker A, Montanaro V, Beka SG, Di Saverio S, Rossi S, Catena F. The acute phase management of spinal cord injury affecting polytrauma patients: the ASAP study. World J Emerg Surg 2022; 17:20. [PMID: 35468806 PMCID: PMC9036814 DOI: 10.1186/s13017-022-00422-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/28/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Few data on the management of acute phase of traumatic spinal cord injury (tSCI) in patients suffering polytrauma are available. As the therapeutic choices in the first hours may have a deep impact on outcome of tSCI patients, we conducted an international survey investigating this topic. METHODS The survey was composed of 29 items. The main endpoints of the survey were to examine: (1) the hemodynamic and respiratory management, (2) the coagulation management, (3) the timing of magnetic resonance imaging (MRI) and spinal surgery, (4) the use of corticosteroid therapy, (5) the role of intraspinal pressure (ISP)/spinal cord perfusion pressure (SCPP) monitoring and (6) the utilization of therapeutic hypothermia. RESULTS There were 171 respondents from 139 centers worldwide. A target mean arterial pressure (MAP) target of 80-90 mmHg was chosen in almost half of the cases [n = 84 (49.1%)]. A temporary reduction in the target MAP, for the time strictly necessary to achieve bleeding control in polytrauma, was accepted by most respondents [n = 100 (58.5%)]. Sixty-one respondents (35.7%) considered acceptable a hemoglobin (Hb) level of 7 g/dl in tSCI polytraumatized patients. An arterial partial pressure of oxygen (PaO2) of 80-100 mmHg [n = 94 (55%)] and an arterial partial pressure of carbon dioxide (PaCO2) of 35-40 mmHg [n = 130 (76%)] were chosen in most cases. A little more than half of respondents considered safe a platelet (PLT) count > 100.000/mm3 [n = 99 (57.9%)] and prothrombin time (PT)/activated partial thromboplastin time (aPTT) < 1.5 times the normal control [n = 85 (49.7%)] in patients needing spinal surgery. MRI [n = 160 (93.6%)] and spinal surgery [n = 158 (92.4%)] should be performed after intracranial, hemodynamic, and respiratory stabilization by most respondents. Corticosteroids [n = 103 (60.2%)], ISP/SCPP monitoring [n = 148 (86.5%)], and therapeutic hypothermia [n = 137 (80%)] were not utilized by most respondents. CONCLUSIONS Our survey has shown a great worldwide variability in clinical practices for acute phase management of tSCI patients with polytrauma. These findings can be helpful to define future research in order to optimize the care of patients suffering tSCI.
Collapse
Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy.
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Reggio Emilia, Italy
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System Medical Center, Moreno Valley, CA, USA
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Giovanni D Tebala
- Department of General Surgery, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, UK
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | | | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University Frankfurt Am Main, Frankfurt am Main, Germany
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento Di Scienze Chirurgiche Diagnostiche Integrate, University of Genova, Genova, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Franco Servadei
- Humanitas University, Pieve Emanuele, Milan, Italy
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
- The Medical Center of Aurora, Aurora, CO, USA
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Marta Velia Antonini
- ECMO Team, Bufalini Hospital, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Reggio Emilia, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Luca Ansaloni
- Department of General Surgery, University Hospital of Pavia, Pavia, Italy
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Mircea Chirica
- Department of Digestive Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Gustavo P Fraga
- Surgery Department, Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Marco Ceresoli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Luca Cattani
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | - Francesco Minardi
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Imtiaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Srinagar, Kashmir, India
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | - Francesco Domenichelli
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Laura Malchiodi
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | - Emanuele Sani
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | | | - Salomone Di Saverio
- Department of General Surgery, Ospedale Civile "Madonna del Soccorso", San Benedetto del Tronto, AP, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy
| | - Fausto Catena
- Department of General and Emergency Surgery, "M. Bufalini" Hospital, Cesena, Italy
| |
Collapse
|
31
|
Ng IC, Barnes C, Biswas S, Wright D, Dagal A. When is it safe to resume anticoagulation in traumatic brain injury? Curr Opin Anaesthesiol 2022; 35:166-171. [PMID: 35131968 DOI: 10.1097/aco.0000000000001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW When to resume or initiate anticoagulation therapy following traumatic brain injury (TBI) is controversial. This summary describes the latest evidence to guide best practice. RECENT FINDINGS Following trauma, prophylactic, and therapeutic anticoagulation (TAC) have been widely encouraged to prevent major comorbidities such as pulmonary embolism and deep venous thrombosis. Increased rebleeding risk and potentially catastrophic outcome from initiation of anticoagulation treatment in TBI are mainly influenced by institutional guidelines or physician preference in the absence of level I or II recommendations. In recent years, there has been an increasing number of TBI in the elderly population on anticoagulation for other medical conditions; this complicates the decision and timing to restart anticoagulation after the injury. SUMMARY Strategies and timing to start prophylactic and TAC differ significantly between institutions and physicians. Each TBI patient should be evaluated on a case-by-case basis on when to start anticoagulation. More investigation is required to guide best practice.
Collapse
Affiliation(s)
- Ireana C Ng
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | | | - Subarna Biswas
- Keck School of Medicine of USC, Health Sciences Campus, Los Angeles, California, USA
| | - David Wright
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | - Arman Dagal
- Harborview Medical Center, UW Medicine, Seattle, Washington
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts. RECENT FINDINGS Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull. SUMMARY ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.
Collapse
|
33
|
Bissoni L, Gamberini E, Viola L, Bergamini C, Russo E, Bolondi G, Agnoletti V. REBOA as a bridge to brain CT in a patient with concomitant brain herniation and haemorrhagic shock - A case report. Trauma Case Rep 2022; 38:100623. [PMID: 35242987 PMCID: PMC8885615 DOI: 10.1016/j.tcr.2022.100623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction The management of complex trauma patient with concomitant brain injury and extra-cranial lesions is challenging since the requirement of a low pressure to limit the bleeding clashes with the need to maintain an adequate cerebral perfusion and to obtain a brain CT-scan. Here we present the use of REBOA as a bridge to CT scan in complex head and torso trauma. Case presentation A 59 years old male patient involved in a road traffic crash was admitted to our hospital after a car accident. He had a GCS of 3 with a left fixed pupil anisocoria. Despite right-sided chest decompression for pneumothorax and massive transfusion protocol for haemoperitoneum, blood pressure remained low; to temporally stabilize the patient and perform a brain CT scan a zone 1 REBOA was inserted and systolic blood pressure rose up from 60 mmHg to 110 mmHg. A brain CT scan highlighted a right subdural hematoma with a 8-mm midline shift. The patient went to the operating room to perform damage control surgery and, subsequently, a decompressive craniotomy. After 96 days of hospital stay, the patient was discharged at home with a complete neurological recovery. Conclusions The achievement of a rapid brain CT scan in traumatic brain injury is often crucial and has a deep impact in changing surgical management; moreover, duration of cerebral herniation is associated with worse outcome and increased mortality. In the light of this, the use of REBOA in selected cases of complex head and torso trauma could allow to gain time to go to the CT room in safe conditions.
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
El-Swaify ST, Refaat MA, Ali SH, Abdelrazek AEM, Beshay PW, Kamel M, Bahaa B, Amir A, Basha AK. Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs. Trauma Surg Acute Care Open 2022; 7:e000859. [PMID: 35071780 PMCID: PMC8734008 DOI: 10.1136/tsaco-2021-000859] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Abstract
Traumatic brain injury (TBI) accounts for around 30% of all trauma-related deaths. Over the past 40 years, TBI has remained a major cause of mortality after trauma. The primary injury caused by the injurious mechanical force leads to irreversible damage to brain tissue. The potentially preventable secondary injury can be accentuated by addressing systemic insults. Early recognition and prompt intervention are integral to achieve better outcomes. Consequently, surgeons still need to be aware of the basic yet integral emergency management strategies for severe TBI (sTBI). In this narrative review, we outlined some of the controversies in the early care of sTBI that have not been settled by the publication of the Brain Trauma Foundation’s 4th edition guidelines in 2017. The topics covered included the following: mode of prehospital transport, maintaining airway patency while securing the cervical spine, achieving adequate ventilation, and optimizing circulatory physiology. We discuss fluid resuscitation and blood product transfusion as components of improving circulatory mechanics and oxygen delivery to injured brain tissue. An outline of evidence-based antiplatelet and anticoagulant reversal strategies is discussed in the review. In addition, the current evidence as well as the evidence gaps for using tranexamic acid in sTBI are briefly reviewed. A brief note on the controversial emergency surgical interventions for sTBI is included. Clinicians should be aware of the latest evidence for sTBI. Periods between different editions of guidelines can have an abundance of new literature that can influence patient care. The recent advances included in this review should be considered both for formulating future guidelines for the management of sTBI and for designing future clinical studies in domains with clinical equipoise.
Collapse
Affiliation(s)
| | - Mazen A Refaat
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Sara H Ali
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | | | | | - Menna Kamel
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Bassem Bahaa
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Abdelrahman Amir
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Kamel Basha
- Department of neurosurgery, Ain Shams University Faculty of Medicine, Cairo, Egypt
| |
Collapse
|
36
|
Picetti E, Rosenstein I, Balogh ZJ, Catena F, Taccone FS, Fornaciari A, Votta D, Badenes R, Bilotta F. Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review. J Clin Med 2021; 11:18. [PMID: 35011760 PMCID: PMC8745292 DOI: 10.3390/jcm11010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 01/28/2023] Open
Abstract
Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.
Collapse
Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Israel Rosenstein
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle 2305, Australia;
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital, 47521 Cesena, Italy;
| | - Fabio S. Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Anna Fornaciari
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Danilo Votta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Rafael Badenes
- Department of Anesthesiology and Intensive Care, Hospital Clìnico Universitario de Valencia, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| |
Collapse
|
37
|
Picetti E, Bouzat P, Cattani L, Taccone FS. Perioperative management of severe brain injured patients. Minerva Anestesiol 2021; 88:380-389. [PMID: 34636222 DOI: 10.23736/s0375-9393.21.15927-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.
Collapse
Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy -
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care Medicine, Grenoble Alps Trauma Centre, Grenoble Alpes University Hospital, Grenoble, France
| | - Luca Cattani
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
38
|
Anania P, Battaglini D, Miller JP, Balestrino A, Prior A, D'Andrea A, Badaloni F, Pelosi P, Robba C, Zona G, Fiaschi P. Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary? Neurosurg Rev 2021; 44:2415-2423. [PMID: 33215367 PMCID: PMC7676754 DOI: 10.1007/s10143-020-01438-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/29/2020] [Accepted: 11/11/2020] [Indexed: 11/24/2022]
Abstract
Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.
Collapse
Affiliation(s)
- Pasquale Anania
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - John P Miller
- Louisiana State University, Health Sciences University, New Orleans, LA, USA
| | - Alberto Balestrino
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro Prior
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro D'Andrea
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Filippo Badaloni
- Division of Neurosurgery, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
| |
Collapse
|
39
|
Ehrhardt JD, Elkbuli A, McKenney M, Renda M. Multidisciplinary management of a traumatic posterior meningeal artery pseudoaneurysm: A case report and review of the literature. Int J Surg Case Rep 2021; 82:105933. [PMID: 33957406 PMCID: PMC8113848 DOI: 10.1016/j.ijscr.2021.105933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/22/2021] [Indexed: 12/01/2022] Open
Abstract
Background Meningeal arterial injuries represent <1% of all blunt traumatic brain injuries (TBIs). Middle meningeal artery (MMA) lesions comprise the majority. However, there is little clinical data on posterior meningeal artery (PMA) injuries. Case report A 69-year-old man was brought to our trauma center after sustaining a fall inside a warehouse. He was GCS (Glasgow Coma Scale) 3 on arrival. Non-contrast CT (computed tomography) brain showed subarachnoid hemorrhage with diffuse cerebral edema and a basilar skull fracture. The patient subsequently underwent emergency ventriculostomy. Immediately after the procedure, further imaging with CTA (computed tomography angiography) head identified a hyperintense posterior cranial fossa lesion, prompting cerebral angiography with identification and embolization of a traumatic PMA pseudoaneurysm. The patient improved and was discharged to a long-term acute care facility. At 3 months post-discharge, the patient was eating, talking with family, and working aggressively with physical therapy. Discussion This case represents a functional neurologic outcome from a rare subset of TBI. Early CTA head imaging is not supported by limited literature, but allowed for expedient identification and definitive management of this PMA pseudoaneurysm. In the critical care setting, hyperosmolar therapy, CSF (cerebrospinal fluid) drainage, prompt enteral nutritional support, and early tracheostomy all represent evolving evidence-based strategies to optimize care for severe TBI. Conclusions The initial evaluation and management of severe TBI can be nuanced. Future research may refine indications for CTA head to the diagnostic evaluation of patients with both severe TBI and skull fractures. Traumatic intracerebral hemorrhage caused by meningeal artery injuries are rare, and usually involve the middle meningeal artery; lesions of the posterior meningeal artery remain even more obscure Severe traumatic brain injury (TBI) associated with basilar skull fractures represents a pattern of injury for which CT angiography of the head can be useful in identifying meningeal vascular injuries Critical care for severe TBI involves preventing secondary insult to cerebral tissue; strategies continue to evolve with hyperosmolar therapy, CSF drainage, prompt enteral nutritional support, and early tracheostomy
Collapse
Affiliation(s)
- John D Ehrhardt
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA
| | - Michael Renda
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA
| |
Collapse
|
40
|
Mader MMD, Rotermund R, Lefering R, Westphal M, Maegele M, Czorlich P. The faster the better? Time to first CT scan after admission in moderate-to-severe traumatic brain injury and its association with mortality. Neurosurg Rev 2020; 44:2697-2706. [PMID: 33340052 PMCID: PMC8490239 DOI: 10.1007/s10143-020-01456-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Fast acquisition of a first computed tomography (CT) scan after traumatic brain injury (TBI) is recommended. This study is aimed at investigating whether the length of the period preceding initial CT scan influences mortality in patients with leading TBI. A retrospective cohort analysis of patients registered in the TraumaRegister DGU® was conducted including adult patients with TBI, defined as Abbreviated Injury ScaleHead ≥ 3 and GCS ≤ 13 who had been treated in level 1 or 2 trauma centers from 2007-2016. Patients were grouped according to time intervals either from trauma or from admission to CT. A total of 6904 patients met the inclusion criteria. Mean time period from trauma to hospital admission was 68.8 min. From admission to first CT, a mean of 19.0 min elapsed. Trauma severity was higher in groups with a longer duration from trauma to CT as represented by a mean (± standard deviation) Injury Severity Score (ISS) of 19.8 ± 9.0, 20.7 ± 9.3, and 21.4 ± 7.5 and similar distribution of mortality of 24.9%, 29.9%, and 36.3% in the ≤ 60-min, 61-120-min, and ≥ 121-min groups, respectively. An adjusted multivariable logistic regression model showed a significant influence of the level of the trauma center (p = 0.037) but not for interval from admission to CT (p = 0.528). TBI patients with a longer time span from trauma to first CT were more severely injured and demonstrated a worse prognosis, but received a CT scan faster when duration from admission is observed. The duration until the CT scan was obtained showed no significant impact on the mortality.
Collapse
Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rolf Lefering
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany.,Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | | |
Collapse
|
41
|
Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: Who and when? – A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 199:106252. [DOI: 10.1016/j.clineuro.2020.106252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
|
42
|
Brown-Taylor L, Jaramillo C, Eapen BC, Kretzmer T, Gavin LP, Cooper T, Pugh MJ. Accumulation of Good Intentions: How Individual Practice Guidelines Lead to Polypharmacy in the Treatment of Patients with Polytrauma. PM R 2020; 13:1169-1175. [PMID: 33247558 DOI: 10.1002/pmrj.12526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 11/12/2022]
Abstract
Polytrauma clinical triad (PCT) is the comorbid occurrence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain after trauma. No clinical practice guidelines for postacute care of patients with PCT currently exist; instead, clinical practice guidelines have been published for the three conditions (TBI, PTSD, and pain) as distinct clinical entities. Using multiple, individual practice guidelines for a patient with PCT may lead to unintended prescription of multiple and potentially adversely interacting medications (ie, polypharmacy). Polypharmacy, especially that which includes central nervous system-acting medications, may lead to overdose, suicidality, and chronic symptomatology. Current individual guidelines for each condition of PCT do not address how to coordinate care for the polytraumatic diagnosis. The purpose of this Practice Management piece is to describe the unintended consequences of polypharmacy in patients with PCT and to discuss mitigation approaches including rational prescribing, nonpharmacologic alternatives, and interdisciplinary coordination.
Collapse
Affiliation(s)
- Lindsey Brown-Taylor
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Salt Lake City, UT
| | - Carlos Jaramillo
- San Antonio Polytrauma Center, South Texas Veterans Health Care System, San Antonio, TX
| | - Blessen C Eapen
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | | | - Tyler Cooper
- School of Medicine, University of Utah, Salt Lake City, UT
| | - Mary J Pugh
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Salt Lake City, UT.,School of Medicine, University of Utah, Salt Lake City, UT
| |
Collapse
|
43
|
Shriki J, Galvagno SM. Sedation for Rapid Sequence Induction and Intubation of Neurologically Injured Patients. Emerg Med Clin North Am 2020; 39:203-216. [PMID: 33218658 DOI: 10.1016/j.emc.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There are subtle physiologic and pharmacologic principles that should be understood for patients with neurologic injuries. These principles are especially true for managing patients with traumatic brain injuries. Prevention of hypotension and hypoxemia are major goals in the management of these patients. This article discusses the physiology, pitfalls, and pharmacology necessary to skillfully care for this subset of patients with trauma. The principles endorsed in this article are applicable both for patients with traumatic brain injury and those with spinal cord injuries.
Collapse
Affiliation(s)
- Jesse Shriki
- Surgical Critical Care, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Samuel M Galvagno
- Multi Trauma Critical Care Unit, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
44
|
Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
Collapse
Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | | |
Collapse
|
45
|
Schepici G, Silvestro S, Bramanti P, Mazzon E. Traumatic Brain Injury and Stem Cells: An Overview of Clinical Trials, the Current Treatments and Future Therapeutic Approaches. ACTA ACUST UNITED AC 2020; 56:medicina56030137. [PMID: 32204311 PMCID: PMC7143935 DOI: 10.3390/medicina56030137] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/04/2020] [Accepted: 03/15/2020] [Indexed: 02/07/2023]
Abstract
Traumatic brain injury represents physical damage to the brain tissue that induces transitory or permanent neurological disabilities. The traumatic injury activates an important inflammatory response, followed by a cascade of events that lead to neuronal loss and further brain damage. Maintaining proper ventilation, a normal level of oxygenation, and adequate blood pressure are the main therapeutic strategies performed after injury. Surgery is often necessary for patients with more serious injuries. However, to date, there are no therapies that completely resolve the brain damage suffered following the trauma. Stem cells, due to their capacity to differentiate into neuronal cells and through releasing neurotrophic factors, seem to be a valid strategy to use in the treatment of traumatic brain injury. The purpose of this review is to provide an overview of clinical trials, aimed to evaluate the use of stem cell-based therapy in traumatic brain injury. These studies aim to assess the safety and efficacy of stem cells in this disease. The results available so far are few; therefore, future studies need in order to evaluate the safety and efficacy of stem cell transplantation in traumatic brain injury.
Collapse
|