Pre-hospital and initial management of head injury patients: An update

Factors affecting functional outcomes of traumatic brain injury rehabilitation at a rehabilitation facility in Saudi Arabia

Objectives:

To identify the factors that affect disability after inpatient rehabilitation (IPR) in persons with traumatic brain injury (TBI).

Methods:

This retrospective study identified 140 patients aged ≥16 years who were admitted to the TBI rehabilitation unit at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia between 2015 and 2017. The collected data included demographic variables, TBI cause, coma duration, time from injury to IPR, LOS, and Functional Independence Measure (FIM) scores at IPR admission and discharge.

Results:

Majority of the patients were young males. The TBI was caused by motor vehicle accidents (MVA) in 95% of patients. The mean coma duration, time from injury to IPR admission, and LOS were 47±38, 264±357, and 75±52 days, respectively. The factors that were found to have an association with FIM change were time from injury to IPR admission (p=0.003, r=-0.250), admission FIM score (p=0.003, r=-0.253), and discharge FIM score (p<0.001, r=0.390). Employed patients had high FIM scores at admission (p=0.029, r=0.184) and discharge (p=0.003, r=0.252).

Conclusion:

Reduction in disability at discharge was positively associated with the severity of disability at admission and negatively with the time duration from injury to IPR admission, indicating a need to reduce time before admittance to an IPR setup. The high incidence of MVA causing TBI in a young male population strongly points to a need for appropriate measures of prevention.

The Initial Prehospital Management of Traumatic Brain Injuries in Kigali, Rwanda

INTRODUCTION

Traumatic brain injuries (TBIs) are an important cause of mortality and disability around the world. Early intervention and stabilization are necessary to obtain optimal outcomes, yet little is written on the topic in low- and middle-income countries (LMICs). The aim is to provide a descriptive analysis of patients with TBI treated by Service d'Aide Medicale Urgente (SAMU), the prehospital ambulance service in Kigali, Rwanda.

HYPOTHESIS/PROBLEM

What is the incidence and nature of TBI seen on the ambulance in Kigali, Rwanda?

METHODS

A retrospective descriptive analysis was performed using SAMU records captured on an electronic database from December 2012 through May 2016. Variables included demographic information, injury characteristics, and interventional data.

RESULTS

Patients with TBIs accounted for 18.0% (n = 2,012) of all SAMU cases. The incidence of TBIs in Kigali was 234 crashes per 100,000 people. The mean age was 30.5 (SD = 11.5) years and 81.5% (n = 1,615) were men. The most common mechanisms were road traffic incidents (RTIs; 78.5%, n = 1,535), assault (10.7%, n=216), and falls (7.8%, n=156). Most patients experienced mild TBI (Glasgow Coma Score [GCS] ≥ 13; 83.5%, n = 1,625). The most common interventions were provision of pain medications (71.0%, n = 1,429), placement of a cervical collar (53.6%, n = 1,079), and administration of intravenous fluids (48.7%, n = 979). In total, TBIs were involved in 67.0% of all mortalities seen by SAMU.

CONCLUSION

Currently, TBIs represent a large burden of disease managed in the prehospital setting of Kigali, Rwanda. These injuries are most often caused by RTIs and were observed in 67% of mortalities seen by SAMU. Rwanda has implemented several initiatives to reduce the incidence of TBIs with a specific emphasis on road safety. Further efforts are needed to better prevent these injuries. Countries seeking to develop prehospital care capacity should train providers to manage patients with TBIs.

Dodecafluoropentane Emulsion (DDFPE) as a Resuscitation Fluid for Treatment of Hemorrhagic Shock and Traumatic Brain Injury: A Review

Dodecafluoropentane emulsion (DDFPe) is a novel nanotechnology for oxygen delivery with therapeutic potential for hemorrhagic shock and/or traumatic brain injury (TBI). DDFPe demonstrates efficacy at smaller doses than previously tested perfluorocarbon oxygen therapeutics. This smaller dose potentially eliminates toxicities exhibited by previous oxygen therapeutics, whereas anti-inflammatory properties of DDFPe may alleviate damage from ischemia reperfusion injury. This minireview summarizes our progress in developing a battlefield-ready product to prevent combat death due to hemorrhagic shock and/or TBI. Preclinical studies, for both indications, show promising effects of DDFPe as a resuscitation fluid. DDFPe may become a part of the toolkit for tactical healthcare professionals in battlefield and domestic emergency medicine.

Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum

INTRODUCTION

Traumatic brain injury (TBI) represents a significant burden of a global disease, especially in low- and middle-income countries (LMICs) such as India. Efforts to curb the impact of TBI require an appreciation of local factors related to this disease and its treatment.

METHODS

Semi-structured qualitative interviews were administered to paramedics, anesthesiologists, general surgeons, and neurosurgeons in locations throughout Mumbai from April to May 2018. A thematic analysis with an iterative coding was used to analyze the data. The primary objective was to identify provider-perceived themes related to TBI care in Mumbai.

RESULTS

A total of 50 participants were interviewed, including 17 paramedics, 15 anesthesiologists, 9 general surgeons, and 9 neurosurgeons who were involved in caring for TBI patients. The majority of physicians interviewed discussed their experiences in public sector hospitals (82%), while 12% discussed private sector hospitals and 6% discussed both. Four major themes emerged: Workforce, equipment, financing care, and the family and public role. These themes were often discussed in the context of their effects on increasing or decreasing complications and delays. Participants developed adaptations when managing shortcomings in these thematic areas. These adaptations included teamwork during workforce shortages and resource allocation when equipment was limited among others.

CONCLUSIONS

Workforce, equipment, financing care, and the family and public role were identified as major themes in the care for TBI in Mumbai. These thematic elements provide a framework to evaluate and improve care along the care spectrum for TBI. Similar frameworks should be adapted to local contexts in urbanizing cities in LMICs.

The Evolving Concept of Damage Control in Neurotrauma: Application of Military Protocols in Civilian Settings with Limited Resources

OBJECTIVE

The aim of the present review was to describe the evolution of the damage control concept in neurotrauma, including the surgical technique and medical postoperative care, from the lessons learned from civilian and military neurosurgeons who have applied the concept regularly in practice at military hospitals and civilian institutions in areas with limited resources.

METHODS

The present narrative review was based on the experience of a group of neurosurgeons who participated in the development of the concept from their practice working in military theaters and low-resources settings with an important burden of blunt and penetrating cranial neurotrauma.

RESULTS

Damage control surgery in neurotrauma has been described as a sequential therapeutic strategy that supports physiological restoration before anatomical repair in patients with critical injuries. The application of the concept has evolved since the early definitions in 1998. Current strategies have been supported by military neurosurgery experience, and the concept has been applied in civilian settings with limited resources.

CONCLUSION

Damage control in neurotrauma is a therapeutic option for severe traumatic brain injury management in austere environments. To apply the concept while using an appropriate approach, lessons must be learned from experienced neurosurgeons who use this technique regularly.

Pediatric emergency department visits for pedestrian and bicyclist injuries in the US

Background

Despite reductions in youth pedestrian and bicyclist deaths over the past two decades, these injuries remain a substantial cause of morbidity and mortality for children and adolescents. There is a need for additional information on non-fatal pediatric pedestrian injuries and the role of traumatic brain injury (TBI), a leading cause of acquired disability.

Methods

Using a multi-year national sample of emergency department (ED) records, we estimated annual motorized-vehicle related pediatric pedestrian and bicyclist (i.e. pedalcyclist) injury rates by age and region. We modeled in-hospital fatality risk controlling for age, gender, injury severity, TBI, and trauma center status.

Results

ED visits for pediatric pedestrian injuries declined 19.3% (95% CI 16.8, 21.8) from 2006 to 2012, with the largest decreases in 5-to-9 year olds and 10-to-14 year olds. Case fatality rates also declined 14.0%. There was no significant change in bicyclist injury rates.

TBI was implicated in 6.7% (95% CI 6.3, 7.1) of all pedestrian and bicyclist injuries and 55.5% (95% CI 27.9, 83.1) of fatalities. Pedestrian ED visits were more likely to be fatal than bicyclist injuries (aOR = 2.4, 95% CI 2.3, 2.6), with significant additive interaction between pedestrian status and TBI.

Conclusions

TBI in young pedestrian ED patients was associated with a higher risk of mortality compared to cyclists. There is a role for concurrent clinical focus on TBI recovery alongside ongoing efforts to mitigate and prevent motor vehicle crashes with pedestrians and bicyclists. Differences between youth pedestrian and cycling injury trends merit further exploration and localized analyses, with respect to behavior patterns and interventions. ED data captures a substantially larger number of pediatric pedestrian injuries compared to crash reports and can play a role in those analyses.

Electronic supplementary material

The online version of this article (10.1186/s40621-017-0128-5) contains supplementary material, which is available to authorized users.

Long-term disabilities after traumatic head injury (THI): a retrospective analysis from a large level-I trauma center in Saudi Arabia

BACKGROUND

Traumatic head injuries (THI) are a critical public health problem worldwide, with more than 10 million individuals affected every year. In Saudi Arabia (SA), the burden of THI is unknown even though injury is the leading cause of death and a major cause of disability. Therefore, we aim to estimate the prevalence of long-term of disabilities among survivors of THI treated at a large level-I trauma center in Riyadh.

METHODS

The study included 258 patients, who were hospitalized due to a non-fatal THI between years 2005-2014. Patients (age = 16-60 years) were contacted via the phone and information about their Activity of Daily Living (ADL) and Instrumental Activity of Daily Living (IADL) was ascertained. Univariate analyses were performed to examine patients' characteristics and to estimate the prevalence of any disability. Logistic regression was used to evaluate independent predictors of long-term disability.

RESULTS

Respondents were relatively young (mean age = 24.8; SD = 9.8), predominantly males (92.7%) and the majority sustained THI following traffic crashes (91.4%). The average time since the injury was 6.8 years (range = 3-12, SD = 2.6). Close to third of the sample (32.5%) reported at least some limitations in ADL or IADL. Regression analysis suggests that a one-unit increase in Revised Trauma Scale (RTS) was associated with 31% lower odds of disability adjusting for other covariates. While responders with a below high school education were 4.7 times more likely to report a disability than those with at least a college degree (P < 0.05).

CONCLUSIONS

THI was associated with significant limitations in various aspects of everyday life. The magnitude and impact of THI in Saudi Arabia requires public health measures to prevent these injuries and to improve their health outcomes. Advocates may use these findings to educate the public about secondary and tertiary prevention and elicit support from policymakers to facilitate interventions toward reducing THI's associated disabilities.

Epidemiology, clinical characteristics and outcomes of head injured patients in an Ethiopian emergency centre

INTRODUCTION

Head injury is a leading cause of mortality in Africa. We characterise the epidemiology and outcomes of head injury at an Ethiopian emergency centre.

METHODS

We conducted a prospective cohort study of all head injured patients presenting to the Emergency Centre of Tikur Anbessa Specialised Hospital, Addis Ababa. Data was collected via a standardised form from the patient's chart, radiology reports and operative reports. Patients were followed until discharge, facility transfer, death, or 7 days in hospital. Consent was obtained from the patient or substitute decision maker.

RESULTS

Among 204 head injured patients enrolled, the majority were <30 years old (51.0%) and male (86.8%). Forty-one percent of injuries occurred from road traffic accidents (RTAs). A significant number of patients had at least one indicator of severe injury on presentation: 51 (25.0%) had a GCS < 9, 53 (26.0%) had multi-system trauma, 95 (46.6%) had ≥1 abnormal vital sign and of the 133 patients with data available, 37 (27.8%) had a Revised Trauma Score (RTS) < 6. Patients injured by RTA were more likely to have indicators of severe injury than other mechanisms, including multi-system trauma (OR 3.2, 95% CI 1.7-6.2, p = 0.00), GCS < 9 (OR 3.7, 95% CI 1.8-7.4, p = 0.00), ≥1 abnormal vital sign (OR 2.5, 95% CI 1.4-4.6, p = 0.00) or an RTS score < 6 (OR 3.6, 95% CI 1.6-8.1, p = 0.00). Overall, 149 (73.0%) patients were discharged from hospital, 34 (16.7%) were transferred to another hospital, and 21 patients died (10.3%). In multivariable analysis, death was significantly associated with age over 60 years (aOR 68.8, 95% CI 2.0-2329.0, p = 0.02), GCS < 9 (aOR 14.8, 95% CI 2.2-99.5, p = 0.01), fixed bilateral pupils (aOR 39.1, 95% CI 4.2-362.8, p < 0.01) and hypoxia (oxygen saturation <90%; aOR 14.2%, 95% CI 2.6-123.9, p = 0.01).

CONCLUSION

Head injury represents a significant risk for morbidity and mortality in Ethiopia, of which RTA's increase injury severity. Targeted approaches to improving care of the injured may improve outcomes.

Measurement of intracranial pressure and short-term outcomes of patients with traumatic brain injury: a propensity-matched analysis

Objective

To assess the impact of intracranial pressure monitoring on the short-term outcomes of traumatic brain injury patients.

Methods

Retrospective observational study including 299 consecutive patients admitted due to traumatic brain injury from January 2011 through July 2012 at a Level 1 trauma center in São Paulo, Brazil. Patients were categorized in two groups according to the measurement of intracranial pressure (measured intracranial pressure and non-measured intracranial pressure groups). We applied a propensity-matched analysis to adjust for possible confounders (variables contained in the Crash Score prognostic algorithm).

Results

Global mortality at 14 days (16%) was equal to that observed in high-income countries in the CRASH Study and was better than expected based on the CRASH calculator score (20.6%), with a standardized mortality ratio of 0.77. A total of 28 patients received intracranial pressure monitoring (measured intracranial pressure group), of whom 26 were paired in a 1:1 fashion with patients from the non-measured intracranial pressure group. There was no improvement in the measured intracranial pressure group compared to the non-measured intracranial pressure group regarding hospital mortality, 14-day mortality, or combined hospital and chronic care facility mortality. Survival up to 14 days was also similar between groups.

Conclusion

Patients receiving intracranial pressure monitoring tend to have more severe traumatic brain injuries. However, after adjusting for multiple confounders using propensity scoring, no benefits in terms of survival were observed among intracranial pressure-monitored patients and those managed with a systematic clinical protocol.

Sanguinate's effect on pial arterioles in healthy rats and cerebral oxygen tension after controlled cortical impact

Sanguinate, a polyethylene glycol-conjugated carboxyhemoglobin, was investigated for cerebral vasoactivity in healthy male Sprague-Dawley rats (Study 1) and for its ability to increase brain tissue oxygen pressure (PbtO2) after controlled cortical impact (CCI) - traumatic brain injury (TBI) (Study 2). In both studies ketamine-acepromazine anesthetized rats were ventilated with 40% O2. In Study 1, a cranial window was used to measure the diameters of medium - (50-100μm) and small-sized (<50μm) pial arterioles before and after four serial infusions of Sanguinate (8mL/kg/h, cumulative 16mL/kg IV), volume-matched Hextend, or normal saline. In Study 2, PbtO2 was measured using a phosphorescence quenching method before TBI, 15min after TBI (T15) and then every 10min thereafter for 155min. At T15, rats received either 8mL/kg IV Sanguinate (40mL/kg/h) or no treatment (saline, 4mL/kg/h). Results showed: 1) in healthy rats, percentage changes in pial arteriole diameter were the same among the groups, 2) in TBI rats, PbtO2 decreased from 36.5±3.9mmHg to 19.8±3.0mmHg at T15 in both groups after TBI and did not recover in either group for the rest of the study, and 3) MAP increased 16±4mmHg and 36±5mmHg after Sanguinate in healthy and TBI rats, respectively, while MAP was unchanged in control groups. In conclusion, Sanguinate did not cause vasoconstriction in the cerebral pial arterioles of healthy rats but it also did not acutely increase PbtO2 when administered after TBI. Sanguinate was associated with an increase in MAP in both studies.

Perfluorocarbon NVX-108 increased cerebral oxygen tension after traumatic brain injury in rats

BACKGROUND

Hypoxia is a critical secondary injury mechanism in traumatic brain injury (TBI), and early intervention to alleviate post-TBI hypoxia may be beneficial. NVX-108, a dodecafluoropentane perfluorocarbon, was screened for its ability to increase brain tissue oxygen tension (PbtO2) when administered soon after TBI.

METHODS

Ketamine-acepromazine anesthetized rats ventilated with 40% oxygen underwent moderate controlled cortical impact (CCI)-TBI at time 0 (T0). Rats received either no treatment (NON, n=8) or 0.5 ml/kg intravenous (IV) NVX-108 (NVX, n=9) at T15 (15 min after TBI) and T75.

RESULTS

Baseline cortical PbtO2 was 28±3 mm Hg and CCI-TBI resulted in a 46±6% reduction in PbtO2 at T15 (P<0.001). Significant differences in time-group interactions (P=0.013) were found when comparing either absolute or percentage change of PbtO2 to post-injury (mixed-model ANOVA) suggesting that administration of NVX-108 increased PbtO2 above injury levels while it remained depressed in the NON group. Specifically in the NVX group, PbtO2 increased to a peak 143% of T15 (P=0.02) 60 min after completion of NVX-108 injection (T135). Systemic blood pressure was not different between the groups.

CONCLUSION

NVX-108 caused an increase in PbtO2 following CCI-TBI in rats and should be evaluated further as a possible immediate treatment for TBI.