Intensive management of severe head injury

Clinical efficacy of scalp electroacupuncture combined with rehabilitation training for aphasia after head injury and its effect on patients' language function and quality of life: An observational study

To explore the clinical efficacy of scalp electroacupuncture combined with rehabilitation training for aphasia after head injury, and analyze its effect on patients' language function and quality of life. Our hospital randomly enrolled 100 aphasia patients caused by head injury treated from March 2020 to March 2022 as the experimental object and divided them into the control group and experimental group, with 50 cases in each group. The general rehabilitation training was performed to the control group and the scalp electroacupuncture combined with rehabilitation training was performed to the experimental group to compare their mini-mental state examination scores, communicative activities in daily living scores, aphasia battery of Chinese scores, quality of life scores, mental status scale in nonpsychiatric settings scores, National Institutes of Health Stroke Scale scores, effective rates, satisfaction of patients, and adverse reaction rates. In the between-group comparison, the patients in the experimental group had significantly higher mini-mental state examination scores, communicative activities in daily living scores, aphasia battery of Chinese scores, quality of life scores, effective rates, and satisfaction, and significantly lower mental status scale in nonpsychiatric settings scores, National Institutes of Health Stroke Scale scores and adverse reaction rates, which was statistically significant (P < .05 in all cases). The combination treatment of scalp electroacupuncture and rehabilitation training can effectively improve the language function and quality of life of patients with aphasia after head injury and remarkably enhance the treatment effect.

Management of Elevated Intracranial Pressure

Elevated intracranial pressure (ICP) is a primary cause of morbidity and mortality for many neurologic disorders. The relationship between ICP and brain volume is influenced by autoregulatory processes that can become dysfunctional. As a result, neurologic damage can occur by systemic and intracranial insults such as ischemia and excitatory amino acids. Therefore, survival is dependent on optimizing ICP and cerebral perfusion pressure. Treatment of intracranial hypertension requires intensive monitoring and aggressive therapy. Intracranial pressure monitoring techniques such as intraventricular catheters are useful for determining ICP elevations before changes in vital signs and neurologic status. Therapeutic modalities, generally aimed at reducing cerebral blood volume, brain tissue, and cerebrospinal fluid (CSF) volume, include nonpharmacologic (CSF removal, controlled hyperventilation, and elevating the patient’s head) and pharmacologic management. Mannitol and sedation are first-line agents used to lower ICP. Barbiturate coma may be beneficial in patients with elevated ICP refractory to conventional treatment. The use of prophylactic antiseizure therapy and optimal nutrition prevents significant complication. Currently, investigations are directed at discovering useful neuroprotective agents that prevent secondary neurologic injury.

Effect of prehospital advanced life support on outcomes of major trauma patients

OBJECTIVE

Determine whether prehospital advanced life support (ALS) improves the survival of major trauma patients and whether it is associated with longer on-scene times.

METHODS

A 36-month retrospective study of all major trauma patients who received either prehospital bag-valve-mask (BVM) or endotracheal intubation (ETI) and were transported by paramedics to our Level I trauma center. Logistic regression analysis determined the association of prehospital ALS with patient survival.

RESULTS

Of 9,451 major trauma patients, 496 (5.3%) had either BVM or ETI. Eighty-one percent received BVM, with a mean Injury Severity Score of 29 and a mortality rate of 67%; 93 patients (19%) underwent successful ETI, with a mean Injury Severity Score of 35 and a mortality rate of 93%. Adjusted survival for patients who had BVM was 5.3 times more likely than for patients who had ETI (95% confidence interval, 2.3-14.2, p = 0.00). Survival among patients who received intravenous fluids was 3.9 times more likely than those who did not (p = not significant). Average on-scene times for patients who had ETI or intravenous fluids were not significantly longer than those who had BVM or no intravenous fluids.

CONCLUSION

ALS procedures can be performed by paramedics on major trauma patients without prolonging on-scene time, but they do not seem to improve survival.

[Analysis of indications fo interhospital transfer]

In France there are no clear guidelines for the transfer of severely head-injured patients, due to the difficulties of combining the requirements of a safe transfer with the necessity of a rapid, adapted and specialized management. These various aspects are discussed in order to facilitate the definition of local strategies for the initial orientation of severely head-injured patients to a centre adapted for severe head trauma management.

ICP measurement control: laboratory test of 7 types of intracranial pressure transducers

Intracranial pressure (ICP) monitoring has become an important parameter in the assessment of comatose patients, with raised intracranial pressure. The transducers in use have to fulfill the criteria of measurement accuracy, practicability and cost-effectiveness. However, these requirements are not always met in clinical practice. The need for ongoing quality control through independent laboratories remains. We have developed a laboratory set-up for the evaluation of intracranial pressure probes. Seven different types of currently used transducers have been tested for measurement accuracy. Under in vitro conditions 3 parameters were assessed: measurement accuracy, a 24 h drift and 10 day drifts. Tests for measurement accuracy were performed at increasing pressure levels of up to 80 mmHg. They were repeated 10 times per probe. This test allowed the simultaneous assessment of 5 different ICP probes. Drift was evaluated for 24 h and 10 days, at 6 pressure levels between 0 and 50 mmHg. Seven different types of ICP probes were tested (HanniSet, Camino, Codman, Spiegelberg, Medex, Epidyn and Gaeltec). Measurement accuracy was best with HanniSet probes. The maximum errors with this transducer were 3 mmHg. Camino and Codman showed similar results. Spiegelberg had slightly larger deviations. With Epidyn and Gaeltec the highest error were noted, up to 10 mmHg in the high pressure range. The 24 h drift was lowest with HanniSet (0.2 mmHg) and Camino (0.8 mmHg). The largest drifts were seen with Medex, Spiegelberg and Gaeltec (1.8 mmHg). Ten day drift was lowest with HanniSet (0.1 mmHg/day) and Codman (0.2 mmHg/day). The highest long-term drifts were found with Epidyn and Gaeltec (1.5 mmHg/day). Drift did not exhibit a linear pattern. After an initial rise in drift during the first 24-72 h, it decreased slowly during the next 7 days. Most ICP probes revealed measurement inaccuracy and drift. These results emphasize the necessity for ongoing evaluations of ICP probes. Therefore, tests for quality assurance are essential to establish a consistent standard of proficiency of ICP transducers.

Aggressive out-of-hospital treatment regimen for severe closed head injury in patients undergoing air medical transport

The impact of aggressive out-of-hospital management on disposition for 1286 patients with closed head injuries in ground advanced life support (ALS) and helicopter services was evaluated over 60 months in San Diego County. The case group included 196 air medical patients with a scene Glascow coma scale (GCS) < 9 who were treated according to a standard head injury protocol. The frequency matched control group included 1090 ground ALS patients receiving airway management with hyperventilation but neither induction agents nor mannitol. The trauma registry provided admission and discharge dates, neurosurgical interventions, and disposition. Patient age, scene GCS, head and neck abbreviated injury scale (HNAIS), and injury severity score (ISS) served to stratify study groups. Case-control distribution of mortality was compared with the two-tailed Mantel-Haenszel weighted odds ratio (OR) and chisquared test; significance at P < or = 0.05. The case group displayed an 11% decreased mortality (P < 0.01), remaining significant after adjusting for age (P = 0.05) and scene GCS (P = 0.06). The case group displayed 10% (P < 0.01) greater survivor discharges to rehabilitation and 6% (P < 0.05) fewer discharges to extended care facilities. This study's data indicate a strong possibility for improved patient morbidity and mortality in severe closed head injuries treated with an aggressive treatment protocol and rapid air medical transport.

Physiologic principles for volume regulation of a tissue enclosed in a rigid shell with application to the injured brain

BACKGROUND

Preservation of a high cerebral perfusion (mean arterial) pressure to prevent ischemia has become the primary focus during treatment of severe head trauma because ischemia is favored as a triggering mechanism behind intracellular brain edema development and poor outcome. A high cerebral perfusion pressure, however, simultaneously may increase the hydrostatic vasogenic edema. The present paper evaluates the mechanisms behind the vasogenic edema by analyzing the physiologic hemodynamic mechanisms controlling the volume of a tissue that is enclosed in a rigid shell, possesses capillaries permeable for solutes, and has depressed autoregulation.

RESULTS AND CONCLUSIONS

We contend that in the long run, the interstitial volume in such a tissue can be reduced only through reduction in arterial inflow pressure providing an otherwise optimal therapy to improve microcirculation. Therefore we argue, in contrast to the conventional view, that antihypertensive and antistress therapy may be of value by reducing the interstitial tissue volume during treatment of brain edema, and that the problem with ischemia during such therapy can be handled when considering an otherwise optimal intensive care. These physiologic principles of interstitial tissue volume regulation form the basic concept for the "Lund therapy" of severe head injuries, which is a new and controversial therapy of posttraumatic brain edema.

Cerebral haemodynamic effects of dihydroergotamine in patients with severe traumatic brain lesions

Dihydroergotamine (DHE) is used in our recently introduced therapy of post-traumatic brain oedema and is suggested to reduce ICP through reduction in both cerebral blood volume and brain water content. This study aims at increasing our knowledge of the mechanisms behind the ICP reducing effect of DHE by analysing cerebrovascular effects of a bolus dose of DHE in severely head injured patients (GCS < 8). Mean hemispheric cerebral blood flow (CBF) calculated from the clearance of i.v. 133Xenon, ICP, and cerebral arterio-venous difference in oxygen content (AVDO2), were measured before and after hyperventilation and after a bolus dose of DHE (4 micrograms/kg). The patients were divided into two groups, one with preserved and one with impaired cerebrovascular CO2-reactivity to hyperventilation, the latter being predictive of poor outcome. The haemodynamic effects of DHE were compared to those of hyperventilation. Regional CBF and brain volume SPECT measurements were performed in two patients. DHE increased cerebrovascular resistance (CVR) by about 20% and significantly reduced ICP in both groups of patients, resulting in unchanged AVDO2. Hyperventilation with preserved CO2-reactivity caused a similar decrease in ICP as by DHE but with a much larger increase in CVR (by 70%) and a substantial increase in AVDO2. Hyperventilation with impaired CO2-reactivity reduced ICP but otherwise had no significant cerebrovascular effects. The study supports the concept that the ICP reducing effect of DHE results more from constriction of the large veins than from arterial vasoconstriction, also implying a relatively smaller risk of ischaemia with DHE than with hyperventilation.

Effects of hypotensive treatment with alpha 2-agonist and beta 1-antagonist on cerebral haemodynamics in severely head injured patients

Therapy of post-traumatic brain oedema often includes preservation of high arterial blood pressure to avoid secondary ischaemic injuries to the brain. This practice can be questioned since high arterial blood pressure may aggravate brain oedema through raised hydrostatic capillary pressure, causing fluid filtration across the damaged blood-brain barrier. This latter view is in agreement with our clinical experience and therefore hypotensive therapy with an alpha 2-adrenergic agonist (clonidine) and a beta 1-adrenergic antagonist (metoprolol) has become part of our treatment protocol for severely head injured patients to decrease the post-traumatic brain oedema. The present study is an attempt to analyse whether there are any direct local cerebrovascular effects of the hypotensive agents used, which also might influence intracranial pressure. Severely head injured patients were investigated. Heart rate, mean arterial blood pressure, intracranial pressure, cerebral blood flow and arteriovenous difference in oxygen content were measured before and after a bolus dose of clonidine (six patients) and metoprolol (nine patients). Clonidine decreased mean arterial blood pressure and cerebrovascular resistance without affecting other parameters measured. Metoprolol decreased heart rate and mean arterial pressure, but had no effect on the cerebrovascular parameters. The results show that clonidine and metoprolol have no, or only minor, direct influence on local cerebral haemodynamics in severely brain injured patients. This implies that if there is an intracranial pressure reducing effect of these drugs, as suggested, this must be due to other mechanisms, namely a reduction in capillary hydrostatic pressure secondary to decreased arterial blood pressure and heart rate.

A new therapy of post-trauma brain oedema based on haemodynamic principles for brain volume regulation

OBJECTIVE

To evaluate a new therapy of posttraumatic brain oedema, with the main concept that opening of the blood-brain barrier upsets the normal brain volume regulation, inducing oedema formation. This means that transcapillary fluid fluxes will be controlled by hydrostatic capillary and colloid osmotic pressures, rather than by crystalloid osmotic pressure. If so, brain oedema therapy should include reduction of hydrostatic capillary pressure and preservation of normal colloid osmotic pressure.

PATIENTS

11 severely head injured comatose patients with brain swelling, raised intracranial pressure (ICP), and impaired cerebrovascular response to hyperventilation.

INTERVENTIONS

To reduce capillary hydrostatic pressure the patients were given hypotensive therapy (beta 1-antagonist, metoprolol and alpha 2-agonist, clonidine) and a potential precapillary vasoconstrictor (dihydroergotamine). The latter may also decrease cerebral blood volume through venous capacitance constriction. Colloid osmotic pressure was maintained by albumin infusions. The concept implies the need of a negative fluid balance with preserved normovolaemia.

RESULTS

ICP decreased significantly within a few hours of treatment with unaltered perfusion pressure in spite of lowered blood pressure. Of 11 patients 9 survived with good recovery/moderate disability, 2 died. This was compared to outcome in a historical control group with identical entry criteria, given conventional brain oedema therapy, where mortality/vegetativity/severe disability was 100%.

CONCLUSION

The results indicate that the therapy should focus on extracellular rather than intracellular oedema and that ischemia is not the main triggering mechanism behind oedema formation. We suggest that our therapy is superior to conventional therapy by preventing herniation during the healing period of the blood-brain barrier.

Medical complications of head injury

There are many common and significant medical complications of head injury. These include (1) cardiovascular problems such as hyperdynamic state, myocardial injury, and dysrhythmias; (2) respiratory changes such as neurogenic pulmonary edema, hypoxia, abnormal ventilatory patterns, pulmonary infections, and pulmonary emboli secondary to deep vein thrombosis; (3) consumption coagulopathy; (4) water and electrolyte derangements--hypo- and hypernatremia; (5) hypothalamic/pituitary dysfunction--syndrome of inappropriate secretion of antidiuretic hormone and diabetes insipidus; (6) increased general metabolism with loss of immunocompetence, respiratory compromise, and complications of decreased activity; (7) gastrointestinal difficulties, particularly stress gastritis; and (8) infectious problems including those related to contamination from open wounds and foreign bodies such as monitors.