1
|
Chevignard M, Câmara-Costa H, Dellatolas G. Predicting and improving outcome in severe pediatric traumatic brain injury. Expert Rev Neurother 2024:1-21. [PMID: 39140714 DOI: 10.1080/14737175.2024.2389921] [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: 04/04/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION Severe pediatric traumatic brain injury (spTBI), including abusive head trauma (AHT) in young children, is a major public health problem. Long-term consequences of spTBI include a large variety of physical, neurological, biological, cognitive, behavioral and social deficits and impairments. AREAS COVERED The present narrative review summarizes studies and reviews published from January 2019 to February 2024 on spTBI. Significant papers published before 2019 were also included. The article gives coverage to the causes of spTBI, its epidemiology and fatality rates; disparities, inequalities, and socioeconomic factors; critical care; outcomes; and interventions. EXPERT OPINION There are disparities between countries and according to socio-economic factors regarding causes, treatments and outcomes of spTBI. AHT has an overall poor outcome. Adherence to critical care guidelines is imperfect and the evidence-base of guidelines needs further investigations. Neuroimaging and biomarker predictors of outcomes is a rapidly evolving domain. Long-term cognitive, behavioral and psychosocial difficulties are the most prevalent and disabling. Their investigation should make a clear distinction between objective (clinical examination, cognitive tests, facts) and subjective measures (estimations using patient- and proxy-reported questionnaires), considering possible common source bias in reported difficulties. Family/caregiver-focused interventions, ecological approaches, and use of technology in delivery of interventions are recommended to improve long-term difficulties after spTBI.
Collapse
Affiliation(s)
- Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Paris, France
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
| | - Hugo Câmara-Costa
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Paris, France
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
| | - Georges Dellatolas
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
| |
Collapse
|
2
|
Deng H, Puccio DJ, Anand SK, Yue JK, Hudson JS, Legarreta AD, Wei Z, Okonkwo DO, Puccio AM, Nwachuku EL. Power Drill Craniostomy for Bedside Intracranial Access in Traumatic Brain Injury Patients. Diagnostics (Basel) 2023; 13:2434. [PMID: 37510178 PMCID: PMC10378508 DOI: 10.3390/diagnostics13142434] [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: 06/04/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Invasive neuromonitoring is a bedrock procedure in neurosurgery and neurocritical care. Intracranial hypertension is a recognized emergency that can potentially lead to herniation, ischemia, and neurological decline. Over 50,000 external ventricular drains (EVDs) are performed in the United States annually for traumatic brain injuries (TBI), tumors, cerebrovascular hemorrhaging, and other causes. The technical challenge of a bedside ventriculostomy and/or parenchymal monitor placement may be increased by complex craniofacial trauma or brain swelling, which will decrease the tolerance of brain parenchyma to applied procedural force during a craniostomy. Herein, we report on the implementation and safety of a disposable power drill for bedside neurosurgical practices compared with the manual twist drill that is the current gold standard. Mechanical testing of the drill's stop extension (n = 8) was conducted through a calibrated tensile tester, simulating an axial plunging of 22.68 kilogram (kg) or 50 pounds of force (lbf) and measuring the strength-responsive displacement. The mean displacement following compression was 0.18 ± 0.11 mm (range of 0.03 mm to 0.34 mm). An overall cost analysis was calculated based on the annual institutional pricing, with an estimated $64.90 per unit increase in the cost of the disposable electric drill. Power drill craniostomies were utilized in a total of 34 adult patients, with a median Glasgow Coma Scale (GCS) score of six. Twenty-seven patients were male, with a mean age of 50.7 years old. The two most common injury mechanisms were falls and motor vehicle/motorcycle accidents. EVDs were placed in all subjects, and additional quad-lumen neuromonitoring was applied to 23 patients, with no incidents of plunging events or malfunctions. One patient developed an intracranial infection and another had intraparenchymal tract hemorrhaging. Two illustrative TBI cases with concomitant craniofacial trauma were provided. The disposable power drill was successfully implemented as an option for bedside ventriculostomies and had an acceptable safety profile.
Collapse
Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David J Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Sharath K Anand
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Enyinna L Nwachuku
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| |
Collapse
|
3
|
Waltzman D, Sarmiento K, Daugherty J, Lumba-Brown A, Klevens J, Miller GF. Firearm-Related Traumatic Brain Injury Homicides in the United States, 2000-2019. Neurosurgery 2023; 93:43-49. [PMID: 36727717 PMCID: PMC10391713 DOI: 10.1227/neu.0000000000002367] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/15/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of homicide-related death in the United States. Penetrating TBI associated with firearms is a unique injury with an exceptionally high mortality rate that requires specialized neurocritical trauma care. OBJECTIVE To report incidence patterns of firearm-related and nonfirearm-related TBI homicides in the United States between 2000 and 2019 by demographic characteristics to provide foundational data for prevention and treatment strategies. METHODS Data were obtained from multiple cause of death records from the National Vital Statistics System using Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for the years 2000 to 2019. Number, age-adjusted rates, and percent of firearm and nonfirearm-related TBI homicides by demographic characteristics were calculated. Temporal trends were also evaluated. RESULTS During the study period, there were 77 602 firearm-related TBI homicides. Firearms were involved in the majority (68%) of all TBI homicides. Overall, men, people living in metro areas, and non-Hispanic Black persons had higher rates of firearm-related TBI homicides. The rate of nonfirearm-related TBI homicides declined by 40%, whereas the rate of firearm-related TBI homicides only declined by 3% during the study period. There was a notable increase in the rate of firearm-related TBI homicides from 2012/2013 through 2019 for women (20%) and nonmetro residents (39%). CONCLUSION Firearm-related violence is an important public health problem and is associated with the majority of TBI homicide deaths in the United States. The findings from this study may be used to inform prevention and guide further research to improve treatment strategies directed at reducing TBI homicides involving firearms.
Collapse
Affiliation(s)
- Dana Waltzman
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Division of Injury Prevention, Atlanta, Georgia, USA
| | - Kelly Sarmiento
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Division of Injury Prevention, Atlanta, Georgia, USA
| | - Jill Daugherty
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Division of Injury Prevention, Atlanta, Georgia, USA
| | | | - Joanne Klevens
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Division of Injury Prevention, Atlanta, Georgia, USA
| | - Gabrielle F. Miller
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Division of Injury Prevention, Atlanta, Georgia, USA
| |
Collapse
|
4
|
Schoen N, Matichak D, Armstrong V, Sedighim S, Lew E, Jagid J, Bullock MR, Richardson A. The Cost of Gunshot Wounds to the Head: An Unevenly Distributed Burden. World Neurosurg 2023; 172:e201-e211. [PMID: 36610644 DOI: 10.1016/j.wneu.2022.12.130] [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: 09/28/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Despite the significant clinical consequences and socioeconomic costs of gunshot wounds to the head (GSWH), studies examining prehospital risk factors, geospatial patterns, and economic cost are lacking. METHODS A retrospective analysis was performed for patients with GSWH (single or multiple injuries) presenting to the level one Ryder Trauma Center (hospital patients) as well as the Miami-Dade County Medical Examiner (ME) Department, from October 2013 to October 2015. In addition, ME data were queried from the previous decade (2008-2017) to analyze longitudinal trends. RESULTS A total of 402 consecutive patients met the inclusion criteria: 297 (74%) presented to the ME and 105 (26%) presented to the hospital. GSWH in our cohort had a case fatality rate of 89%, predominantly affecting males, whites, and individuals who committed suicide, with a mean age of 41.9 ± 20.6 years. Hospital patients were more likely to be black males from low socioeconomic status (SES) regions involved in assault. Older white males were overrepresented in patients attempting and completing suicide and thus comprised a higher percentage of ME cases. Geospatial analysis of hospital patient injury zip codes shows that GSWH are significantly clustered in low-income urban centers with greater poverty rates. In Miami-Dade County, the economic burden of GSWH, as measured by total health care costs and lifetime productivity losses, was estimated to be $11,867,415 and $246,179,498, respectively. CONCLUSIONS In the first analysis of GSWH with the inclusion of both hospital and ME data in a representative urban setting, our findings show prehospital risk factors and the unequal distribution of the significant economic costs of GSWH.
Collapse
Affiliation(s)
- Nathan Schoen
- Department of General Surgery, University of Miami Hospitals and Clinics, Miami, Florida, USA; Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - David Matichak
- Miller School of Medicine, University of Miami, Miami, Florida, USA.
| | | | - Shaina Sedighim
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Emma Lew
- Miami-Dade County Medical Examiner Department, Miami, Florida, USA
| | - Jonathan Jagid
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - M Ross Bullock
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Angela Richardson
- Department of Neurosurgery, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| |
Collapse
|
5
|
Hoefer L, Camarena A, Twohig K, Polcari A, Keskey R, LaVigne D, Slidell MB, Wilson K, Hampton D. Rising Mortality in Pediatric Self-Inflicted Firearm Trauma Associated With Distinct Anatomic Injury. J Surg Res 2023; 283:259-265. [PMID: 36423474 DOI: 10.1016/j.jss.2022.10.047] [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: 03/03/2022] [Revised: 08/25/2022] [Accepted: 10/15/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Self-inflicted injuries are the second leading cause of pediatric (10-18 y old) mortality. Self-inflicted firearm trauma (SIFT) was responsible for up to half of these deaths in certain age groups. We hypothesized that SIFT prevalence has increased and is associated with specific demographics, injury patterns, and outcomes. MATERIALS AND METHODS Data were abstracted from the 2007-2018 American College of Surgeons (ACS) Trauma Quality Programs Participant Use Files (TQP-PUF). Pediatric (1-17 yold) victims of firearm violence were eligible. Age, race, gender, anatomic region, and intent were abstracted. Variables were analyzed using chi-squared tests, t-tests, and single-variate linear regression models. Temporal trends were analyzed using ANCOVA tests. Multivariate logistic regressions were conducted to identify factors influencing mortality. Significance was P < 0.05. RESULTS There were 41,239 pediatric firearm trauma patients (SIFT: 5.5% [n = 2272]). SIFT incidence increased over the 12-y period (2007 (n = 67) versus 2018 (n = 232), P < 0.05). SIFT was significantly associated with Caucasian race, 67% (n = 1537), teenagers, 90% (n = 2056), male gender, 87% (n = 1978), and a higher median injury severity score (ISS) than other intents of injury (SIFT: 20.0 (IQR: 9.0, 25.0) versus other: 9.0 (IQR: 1.0-13.0), P < 0.001). The SIFT mortality rate was 44% (n = 1005). On multivariate regression head gunshot wounds (OR: 21.1, 95% C.I.: 9.9-45.2, P = 0.001), and ISS (OR:1.1, 95% C.I.: 1.1-1.1, P = 0.001) were significantly associated with mortality. Compared to other intents, SIFT mortality rates increased at a higher annual rate (P < 0.001). CONCLUSIONS Comprehensive local and federal policy changes to reduce firearms access and increase pediatric mental health support may mitigate these injuries.
Collapse
Affiliation(s)
- Lea Hoefer
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Adrian Camarena
- Duke University, Department of Surgery, Durham, North Carolina
| | - Kelly Twohig
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Ann Polcari
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Robert Keskey
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Danielle LaVigne
- Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
| | - Mark B Slidell
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Kenneth Wilson
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - David Hampton
- University of Chicago, Department of Surgery, Chicago, Illinois.
| |
Collapse
|
6
|
Zakrison TL, Essig R, Polcari A, McKinley W, Arnold D, Beyene R, Wilson K, Rogers S, Matthews JB, Millis JM, Angelos P, O’Connor M, Mansour A, Goldenberg F, Spiegel T, Horowitz P, Das P, Slidell M, Chokshi N, Okeke I, Barth R, Wilkins HE, Kass-Hout T, Lazaridis C. Review Paper on Penetrating Brain Injury: Ethical Quandaries in the Trauma Bay and Beyond. Ann Surg 2023; 277:66-72. [PMID: 35997268 PMCID: PMC9762724 DOI: 10.1097/sla.0000000000005608] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.
Collapse
Affiliation(s)
| | - Rachael Essig
- Department of Surgery, University of Chicago, Chicago, IL
| | - Ann Polcari
- Department of Surgery, University of Chicago, Chicago, IL
| | | | - Damon Arnold
- Medical Director II at Blue Cross and Blue Shield of Illinois, Chicago, Illinois
| | - Robel Beyene
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Kenneth Wilson
- Department of Surgery, University of Chicago, Chicago, IL
| | - Selwyn Rogers
- Department of Surgery, University of Chicago, Chicago, IL
| | | | | | - Peter Angelos
- Department of Surgery, University of Chicago, Chicago, IL
| | - Michael O’Connor
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, IL
| | | | - Thomas Spiegel
- Department of Medicine, University of Chicago, Chicago, IL
| | - Peleg Horowitz
- Department of Neurological Surgery, University of Chicago, Chicago, IL
| | - Paramita Das
- Department of Neurological Surgery, University of Chicago, Chicago, IL
| | - Mark Slidell
- Department of Surgery, University of Chicago, Chicago, IL
| | - Nikunj Chokshi
- Department of Surgery, University of Chicago, Chicago, IL
| | - Iheoma Okeke
- Gift of Hope Organ and Tissue Donor Network, Itasca, IL
| | - Rolf Barth
- Department of Surgery, University of Chicago, Chicago, IL
| | | | | | | |
Collapse
|
7
|
Gadot R, LoPresti MA, Smith DN, Ouellette L, Lam S. Firearm-Related Pediatric Head Trauma: A Scoping Review. Neurosurgery 2022; 91:239-246. [PMID: 35535986 DOI: 10.1227/neu.0000000000002025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/10/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Firearm-related injury is a significant cause of morbidity and mortality in pediatric populations. Despite a disproportionate role in the most morbid outcomes in both traumatic brain injury and firearm-related injury populations, firearm-related traumatic brain injury (frTBI) is an understudied epidemiological entity. There is need to increase understanding and promote interventions that reduce this burden of disease. OBJECTIVE To assess the evidence characterizing pediatric frTBI to highlight trends and gaps regarding burden of disease and interventions to reduce frTBI. METHODS We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review (PRISMA-ScR) guidelines on peer-reviewed studies across 5 databases (Medline OVID, EMBASE, Web of Science Legal Collection, PsychINFO, and Academic Search Complete). English studies examining pediatric frTBI epidemiology, prevention, and/or social or legal policy advocacy were included. Articles were excluded if they more generally discussed pediatric firearm-related injury without specific analysis of frTBI. RESULTS Six studies satisfied inclusion criteria after screening and full-text assessment. Limited studies specifically addressed the burden of disease caused by frTBI. There was an increased risk for both injury and death from frTBI in men, preteenage and teenage youths, minorities, and individuals in firearm-owning households. Further study is required to ascertain if suggested methods of targeted patient screening, firearm-injury prevention counseling, and advocacy of safety-oriented policy tangibly affect rates or outcomes of pediatric frTBI. CONCLUSION By understanding published epidemiological data and areas of intervention shown to reduce frTBIs, neurosurgeons can become further engaged in public health and prevention rather than strictly treatment after injury.
Collapse
Affiliation(s)
- Ron Gadot
- Division of Neurosurgery, Texas Children's Hospital, Houston, Texas, USA.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Melissa A LoPresti
- Division of Neurosurgery, Texas Children's Hospital, Houston, Texas, USA.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - David N Smith
- Division of Neurosurgery, Texas Children's Hospital, Houston, Texas, USA.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Sandi Lam
- Division of Neurosurgery, Lurie Children's Hospital, Chicago, Illinois, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
8
|
Hink AB, Killings X, Bhatt A, Ridings LE, Andrews AL. Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death. CURRENT TRAUMA REPORTS 2022; 8:41-53. [PMID: 35399601 PMCID: PMC8976221 DOI: 10.1007/s40719-022-00223-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 11/21/2022]
Abstract
Purpose of Review This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers. Recent Findings The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide. Summary Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.
Collapse
|
9
|
Campbell J, Piatt J. Tangential cranial gunshot wound in an infant in historical context: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE227. [PMID: 36209403 PMCID: PMC9379624 DOI: 10.3171/case227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/02/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Military neurosurgeons have long known that tangential cranial gunshot wounds can be associated with intracranial complications out of proportion to the external appearance of the injury. This phenomenon seems not to have been described in infancy. OBSERVATIONS An infant suffered a massive, acute subdural hemorrhage from a contralateral tangential gunshot wound that did not facture the skull. LESSONS Similar to adults, infants are subject to catastrophic intracranial injury from gunshots that do not penetrate the skull. The nature of the injury in this case reflected distinctive aspects of the tissue characteristics and proportions of the infant head.
Collapse
Affiliation(s)
- Jeffrey Campbell
- Division of Neurosurgery, Nemours Children’s Hospital Delaware, Wilmington, Delaware; and
- Departments of Neurological Surgery and
- Pediatrics, Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph Piatt
- Division of Neurosurgery, Nemours Children’s Hospital Delaware, Wilmington, Delaware; and
- Departments of Neurological Surgery and
- Pediatrics, Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Yue JK, Chang D, Han KJ, Wang AS, Oh T, Sun PP. Management of migrating intracranial bullet fragments in a 13-year-old female after firearm brain injury: technical and surgical nuances. Brain Inj 2022; 36:432-439. [PMID: 35099341 DOI: 10.1080/02699052.2022.2034185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION We present the challenges and nuances of management in a rare case of multiple migrating intracranial fragments after pediatric gunshot wound to the head (GSWH). CASE PRESENTATION A 13-year-old girl suffered left parietal GSWH, with new neurologic decline 3 days after initial debridement. Serial imaging showed the largest intracranial fragments had migrated into the left trigone, and descended further with head of bed (HOB) elevation. HOB was iteratively decreased, with concurrent intracranial pressure monitoring. After extubation, with an alert and stable neurologic exam, HOB was decreased to -15 degrees, allowing gravity-assisted migration of the fragments to an anatomically favorable position within the left occipital horn. The patient underwent occipital craniotomy for fragment retrieval on hospital day 27. Two large and >20 smaller fragments were retrieved using neuronavigation and intraoperative ultrasound. Forensics showed these to be .45 caliber handgun bullet fragments. The patient recovered well after 2-months of intensive inpatient rehabilitation. DISCUSSION During new neurologic decline after GSWH, bullet migration must be considered and serial cranial imaging is requisite. Surgical retrieval of deep fragments requires judicious planning to minimize further injury. Tightly controlled HOB adjustments with gravity assistance for repositioning of fragments may have utility in optimizing anatomic favorability prior to surgery.
Collapse
Affiliation(s)
- John K Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kasey J Han
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Albert S Wang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Peter P Sun
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
11
|
Nadkarni T, Roy J, Balasubramaniam S, Barve P. Clinical profile, evaluation of imaging guidelines, and management of pediatric traumatic brain injury at a tertiary care center in India: A review of 269 patients. J Pediatr Neurosci 2022. [DOI: 10.4103/jpn.jpn_30_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
12
|
Abstract
OBJECTIVE To evaluate racial disparities among White and Black pediatric firearm injury patients on a national level. BACKGROUND Pediatric firearm-related morbidity and mortality are rising in the United States. There is a paucity of data examining racial disparities in those patients. METHODS The Pediatric Trauma Quality Improvement Program (2017) was queried for pediatric (age ≤17 years) patients admitted with firearm injuries. Patients were stratified by race: White and Black. Injury characteristics were assessed. Outcomes were mortality, hospital length of stay, and discharge disposition. Hierarchical regression models were performed to determine predictors of mortality and longer hospital stays. RESULTS A total of 3717 pediatric firearm injury patients were identified: Blacks (67.0%) and Whites (33.0%). The majority of patients were male (84.2%). The most common injury intent in both groups was assault (77.3% in Blacks vs in 45.4% Whites; P<0.001), followed by unintentional (21.1% vs 35.4%; P<0.001), and suicide (1.0% vs 14.0%; P<0.001). The highest fatality rate was in suicide injuries (62.6%). On univariate analysis, White children had higher mortality (17.5% vs 9.8%; P<0.001), longer hospital stay [3 (1-7) vs 2 (1-5) days; P = 0.021], and more psychiatric hospital admissions (1.3% vs 0.1%; P<0.001). On multivariate analysis, suicide intent was found to be an independent predictor of mortality (aOR 2.67; 95% CI 1.35-5.29) and longer hospital stay (β + 4.13; P<0.001), while White race was not. CONCLUSION Assault is the leading intent of injury in both Black and White children, but White children suffer more from suicide injuries that are associated with worse outcomes. LEVEL OF EVIDENCE Level III Prognostic.
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Firearms are a leading cause of death and injury in children, especially in the United States. Many of these injuries present to emergency departments and pediatric ICUs, prompting a need for updated prevention, interventions, and trauma-informed care. This review explores the evidence for prevention and screening for access to firearms, types of injuries, and considerations for mass casualty events. RECENT FINDINGS Firearm-related injuries lead to over 20 000 emergency department visits annually in children and carry a higher risk of severe injury or death. Screening high-risk patients for access to firearms is suboptimal, despite evidence showing reduction in suicide deaths and increased safe storage. While mass casualty shootings represent a low proportion of all firearm-related morbidity, they have brought heightened attention to focus on quality research. SUMMARY Firearm-related injury is a public health crisis and presents a unique risk to children and adolescents. A firearm in the home, especially one with children, significantly increases the risk of death by homicide or suicide. Research on gun violence is leading to important national conversations on gun control and the role of physicians in the prevention of injury and advocacy for effective interventions and legislation.
Collapse
|