Traumatic Injury to the Developing Brain: Emerging Relationship to Early Life Stress

Chronic Refractory Insomnia in a Patient With Undiagnosed Bipolar Disorder and Long-Standing Traumatic Brain Injury

Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object or when an object pierces the skull and enters brain tissue. TBI can be classified into primary and secondary brain injury. Primary injury refers to the structural damage caused upon impact. Secondary injury refers to the damage from subsequent cellular processes following a prior injury, such as excitotoxicity, free radical generation, calcium-mediated damage, hypoxia, and increased intracranial pressure. Unsurprisingly, these mechanisms can produce structural, biochemical, and genetic changes implicated in sleep disturbance. A coup-contrecoup injury typically occurs at the base of the skull in areas of bony prominences, hence, the anterior temporal and inferior frontal regions, including the basal forebrain, are frequently injured. Because the basal forebrain contributes to sleep initiation, injury to this region can lead to insomnia symptoms. In this report, we present a case study of a 41-year-old Caucasian male who experienced a TBI at the age of seven due to a motor vehicle accident. The left frontotemporal lobe was affected as a result of the incident. He was admitted to the emergency room in March 2023 for safety concerns in the context of extreme anger and irritability, which could endanger others and himself. Additionally, he struggled with chronic insomnia. The chart review showed that the patient's chronic insomnia was poorly controlled and probably contributed to the current presentation. The patient was observed in the days following admission while various medication changes were attempted to treat his chronic insomnia. Unique limitations were encountered in managing this patient's insomnia, as he has multiple drug allergies, including some of the commonly used medications to treat insomnia. A particularly unique observation was that the medications that finally worked for this patient had anticholinergic side effects. They are usually contraindicated in post-TBI patients. However, it was beneficial to use them in this case, which can be explored further.

Epidemiology and pattern of injury of pediatric trauma patients in level l trauma centre of Northern India

Introduction

Uttar Pradesh ranks first in India as far as trauma deaths are concerned with 40% of victims under 18 years of age. In spite of such high mortality and morbidity no national portal for trauma registry data exists. This study was conducted to evaluate the profile of injured pediatric patients, to provide baseline knowledge for further research, management and development of pediatric injury prevention programmes.

Methods

A retrospective observational study was conducted in the only Level 1Trauma Centre of the most populous state of India. Children aged less than 18 years of age admitted to the trauma centre were analysed for mechanism, type and severity of injury, the mode of management and outcome.

Result

In a 2 year period 916 children were admitted and their data analysed. Most were boys (73%) and the most common age group was 12–18 years. Half of injuries were caused by road traffic accidents, and blunt injuries were commonest. Blunt abdominal trauma then head injury were the commonest areas injured; 20% of children had life-threatening injuries. Nearly half (47%) had moderate to severe trauma according to the Pediatric Trauma Score. 507 patients (55.4%) were managed conservatively and 409 children (44.6%) required surgery; 657 (71%) were successfully discharged and 39 children (4.25%) unfortunately died.

Conclusion

This study identifies the need for dedicated trauma registries, training of trauma team according to standard operating procedures, the development of paramedical teams for in-the-field management of patients and development of injury prevention programmes according to both age and gender.