1
|
Diaz Kane MM. Evaluation and Management of Blunt Head Trauma in the Pediatric Clinic. Pediatr Ann 2023; 52:e279-e281. [PMID: 37561824 DOI: 10.3928/19382359-20230613-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Head injuries, and specifically blunt head trauma, are common among pediatric patients of all ages. Patients may present to their primary care provider, to urgent care, or to the emergency department after head trauma. Such injuries may occur as a result of a variety of mechanisms, including falls, motor vehicle collisions, or sports injuries. Clinical decision rules exist to help guide the clinician in the initial evaluation of head injury and in determining when head imaging may be indicated. One such guideline that is widely used in the United States is known as the PECARN (Pediatric Emergency Care Applied Research Network) criteria. Pediatricians should also evaluate for the presence of symptoms consistent with concussion that may occur as a result of blunt head trauma and be familiar with the management and sequelae of concussion and head injuries. [Pediatr Ann. 2023;52(8):e279-e281.].
Collapse
|
2
|
Russo RM, Davidson AJ, Alam HB, DuBose JJ, Galante JM, Fabian TC, Savage S, Holcomb JB, Scalea TM, Rasmussen TE. Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry. J Trauma Acute Care Surg 2021; 90:987-995. [PMID: 34016922 DOI: 10.1097/ta.0000000000003127] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. LEVEL OF EVIDENCE Epidemiological III; Therapeutic IV.
Collapse
Affiliation(s)
- Rachel M Russo
- From the University of California Davis Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care (R.R., J.G.), Sacramento; David Grant Medical Center, Department of Surgery (R.R.), Travis AFB, Fairfield, California; University of Michigan, Department of Surgery, Division of Vascular Surgery (A.D.), Ann Arbor, Michigan; Northwestern University, Feinberg School of Medicine, Department of Surgery (H.A.), Chicago, Illinois; University of Maryland R Adams Cowley Shock Trauma Center (J.D., T.S.), Baltimore, Maryland; University of Tennessee Health Sciences Center, Department of Surgery (T.F.), Memphis, Tennessee; University of Wisconsin Madison Medical Center, Department of Surgery (S.S.), Madison, Wisconsin; Uniformed Services University of the Health Sciences, Department of Surgery, Division of Trauma and Acute Care Surgery (J.H., R.R.), Bethesda, Maryland; and Uniformed Services University of the Health Sciences, Department of Surgery, Division of Vascular Surgery (T.R.), Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Schumacher DJ, Holmboe E, Carraccio C, Martini A, van der Vleuten C, Busari J, Sobolewski B, Byczkowski TL. Resident-Sensitive Quality Measures in the Pediatric Emergency Department: Exploring Relationships With Supervisor Entrustment and Patient Acuity and Complexity. Acad Med 2020; 95:1256-1264. [PMID: 32101934 DOI: 10.1097/acm.0000000000003242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE This study explores the associations between resident-sensitive quality measures (RSQMs) and supervisor entrustment as well as between RSQMs and patient acuity and complexity for encounters in the pediatric emergency department (PED) in which residents are caring for patients. METHOD Pediatric residents rotating through Cincinnati Children's Hospital Medical Center PED as well as supervising pediatric emergency medicine faculty and fellows were recruited during the 2017-2018 academic year for the purpose of collecting the following data from the residents' patient encounters for 3 illnesses (acute asthma exacerbation, bronchiolitis, and closed head injury [CHI]): supervisor entrustment decision rating, RSQMs relevant to the care provided, and supervisor patient acuity and complexity ratings. To measure the association of RSQM composite scores with the other variables of interest, mixed models were used. RESULTS A total of 83 residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with CHI. Entrustment decision ratings were positively associated with asthma RSQM composite scores (beta coefficient = 0.03; P < .001). There was no significant association between RSQM composite scores and entrustment decision ratings for bronchiolitis or CHI. RSQM composite scores were significantly higher when acuity was also higher and significantly lower when acuity was also lower for both asthma (P < .001) and bronchiolitis (P = .01). However, RSQM composite scores were almost identical between levels of acuity for CHI (P = .94). There were no significant differences in RSQM composite scores when complexity varied. CONCLUSION This study found limited associations between RSQM composite scores and entrustment decision ratings but offers insight into how RSQMs could be used for the purposes of resident assessment and feedback.
Collapse
Affiliation(s)
- Daniel J Schumacher
- D.J. Schumacher is associate professor of pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric Holmboe
- E. Holmboe is senior vice president for milestones development and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Carol Carraccio
- C. Carraccio is vice president of competency-based assessment, American Board of Pediatrics, Chapel Hill, North Carolina
| | - Abigail Martini
- A. Martini is a clinical research coordinator, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cees van der Vleuten
- C. van der Vleuten is professor of education, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, and scientific director, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - Jamiu Busari
- J. Busari is associate professor of medical education, Maastricht University, Maastricht, The Netherlands
| | - Brad Sobolewski
- B. Sobolewski is associate professor of pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Terri L Byczkowski
- T.L. Byczkowski is associate professor of pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
4
|
Schumacher DJ, Martini A, Holmboe E, Carraccio C, van der Vleuten C, Sobolewski B, Busari J, Byczkowski TL. Initial Implementation of Resident-Sensitive Quality Measures in the Pediatric Emergency Department: A Wide Range of Performance. Acad Med 2020; 95:1248-1255. [PMID: 31913878 DOI: 10.1097/acm.0000000000003147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE A lack of quality measures aligned with residents' work led to the development of resident-sensitive quality measures (RSQMs). This study sought to describe how often residents complete RSQMs, both individually and collectively, when they are implemented in the clinical environment. METHOD During academic year 2017-2018, categorical pediatric residents in the Cincinnati Children's Hospital Medical Center pediatric emergency department were assessed using RSQMs for acute asthma exacerbation (21 RSQMs), bronchiolitis (23 RSQMs), and closed head injury (19 RSQMs). Following eligible patient encounters, all individual RSQMs for the illnesses of interest were extracted from the health record. Frequencies of 3 performance classifications (opportunity and met, opportunity and not met, or no opportunity) were detailed for each RSQM. A composite score for each encounter was calculated by determining the proportion of individual RSQMs performed out of the total possible RSQMs that could have been performed. RESULTS Eighty-three residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with closed head injury during the study period. Residents had the opportunity to meet the RSQMs in most encounters, but exceptions existed. There was a wide range in the frequency of residents meeting RSQMs in encounters in which the opportunity existed. One closed head injury measure was met in all encounters in which the opportunity existed. Across illnesses, some RSQMs were met in almost all encounters, while others were met in far fewer encounters. RSQM composite scores demonstrated significant range and variation as well-asthma: mean = 0.81 (standard deviation [SD] = 0.11) and range = 0.47-1.00, bronchiolitis: mean = 0.62 (SD = 0.12) and range = 0.35-0.91, and closed head injury: mean = 0.63 (SD = 0.10) and range = 0.44-0.89. CONCLUSIONS Individually and collectively, RSQMs can distinguish variations in the tasks residents perform across patient encounters.
Collapse
Affiliation(s)
- Daniel J Schumacher
- D.J. Schumacher is associate professor of pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Abigail Martini
- A. Martini is a clinical research coordinator, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eric Holmboe
- E. Holmboe is chief research, milestone development, and evaluation officer, Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Carol Carraccio
- C. Carraccio is vice president of competency-based assessment, American Board of Pediatrics, Chapel Hill, North Carolina
| | - Cees van der Vleuten
- C. van der Vleuten is professor of education, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, and scientific director, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - Brad Sobolewski
- B. Sobolewski is associate professor of pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jamiu Busari
- J. Busari is consultant pediatrician and associate professor of medical education, Maastricht University, Maastricht, The Netherlands
| | - Terri L Byczkowski
- T.L. Byczkowski is associate professor of pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
5
|
Griffiths BB, Sahbaie P, Rao A, Arvola O, Xu L, Liang D, Ouyang Y, Clark DJ, Giffard RG, Stary CM. Pre-treatment with microRNA-181a Antagomir Prevents Loss of Parvalbumin Expression and Preserves Novel Object Recognition Following Mild Traumatic Brain Injury. Neuromolecular Med 2019; 21:170-181. [PMID: 30900118 PMCID: PMC7213504 DOI: 10.1007/s12017-019-08532-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/12/2019] [Indexed: 01/04/2023]
Abstract
Mild traumatic brain injury (mTBI) can result in permanent impairment in memory and learning and may be a precursor to other neurological sequelae. Clinical treatments to ameliorate the effects of mTBI are lacking. Inhibition of microRNA-181a (miR-181a) is protective in several models of cerebral injury, but its role in mTBI has not been investigated. In the present study, miR-181a-5p antagomir was injected intracerebroventricularly 24 h prior to closed-skull cortical impact in young adult male mice. Paw withdrawal, open field, zero maze, Y maze, object location and novel object recognition tests were performed to assess neurocognitive dysfunction. Brains were assessed immunohistologically for the neuronal marker NeuN, the perineuronal net marker wisteria floribunda lectin (WFA), cFos, and the interneuron marker parvalbumin. Protein quantification was performed with immunoblots for synaptophysin and postsynaptic density 95 (PSD95). Fluorescent in situ hybridization was utilized to localize hippocampal miR-181a expression. MiR-181a antagomir treatment reduced neuronal miR-181a expression after mTBI, restored deficits in novel object recognition and increased hippocampal parvalbumin expression in the dentate gyrus. These changes were associated with decreased dentate gyrus hyperactivity indicated by a relative reduction in PSD95 and cFos expression. These results suggest that miR-181a inhibition may be a therapeutic approach to reduce hippocampal excitotoxicity and prevent cognitive dysfunction following mTBI.
Collapse
Affiliation(s)
- Brian B Griffiths
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA.
| | - Peyman Sahbaie
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
- Department of Anesthesiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Anand Rao
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
| | - Oiva Arvola
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
| | - Lijun Xu
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
| | - Deyong Liang
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
- Department of Anesthesiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Yibing Ouyang
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
| | - David J Clark
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
- Department of Anesthesiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Rona G Giffard
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA
| | - Creed M Stary
- Dept of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5117, USA.
| |
Collapse
|
6
|
Kühlewindt T, Thienemann F. [Diseases as a 'Stumbling Block' - a Case of Multimorbidity in Clinical Practice]. Praxis (Bern 1994) 2018; 107:677-681. [PMID: 29921186 DOI: 10.1024/1661-8157/a003006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Diseases as a `Stumbling Block` - a Case of Multimorbidity in Clinical Practice Abstract. Here we report on a 83 year-old patient with cardiac syncope and consecutive traumatic brain injury with intracranial haemorrhage receiving anticoagulation for recurrent pulmonary embolism: a 'medical dilemma' due to the syncope with consecutive traumatic event and the underlying condition. A pre-existing underlying cardiac disease was identified as the cause of the syncope and the intracranial haemorrhage was most likely due to oral anticoagulation for recurrent pulmonary embolisms. The intracranial bleeding inhibited an optimal management of the underlying cardiac condition and the patient deceased shortly thereafter.
Collapse
Affiliation(s)
- Tobias Kühlewindt
- 1 Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich, Schweiz
| | | |
Collapse
|
7
|
Boccard SGJ, Rebelo P, Cheeran B, Green A, FitzGerald JJ, Aziz TZ. Post-Traumatic Tremor and Thalamic Deep Brain Stimulation: Evidence for Use of Diffusion Tensor Imaging. World Neurosurg 2016; 96:607.e7-607.e11. [PMID: 27693821 DOI: 10.1016/j.wneu.2016.09.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/16/2016] [Accepted: 09/20/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) is a well-established treatment to reduce tremor, notably in Parkinson disease. DBS may also be effective in post-traumatic tremor, one of the most common movement disorders caused by head injury. However, the cohorts of patients often have multiple lesions that may impact the outcome depending on which fiber tracts are affected. CASE DESCRIPTION A 20-year-old man presented after road traffic accident with severe closed head injury and polytrauma. Computed tomography scan showed left frontal and basal ganglia hemorrhagic contusions and intraventricular hemorrhage. A disabling tremor evolved in step with motor recovery. Despite high-intensity signals in the intended thalamic target, a visual analysis of the preoperative diffusion tensor imaging revealed preservation of connectivity of the intended target, ventralis oralis posterior thalamic nucleus (VOP). This was confirmed by the postoperative tractography study presented here. DBS of the VOP/zona incerta was performed. Six months postimplant, marked improvement of action (postural, kinetic, and intention) tremor was achieved. CONCLUSIONS We demonstrated a strong connectivity between the VOP and the superior frontal gyrus containing the premotor cortex and other central brain areas responsible for movement control. In spite of an existing lesion in the target, the preservation of these tracts may be relevant to the improvement of the patient's symptoms by DBS.
Collapse
Affiliation(s)
- Sandra G J Boccard
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, Oxford, United Kingdom.
| | - Pedro Rebelo
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, Oxford, United Kingdom
| | - Binith Cheeran
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, Oxford, United Kingdom
| | - Alexander Green
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, Oxford, United Kingdom
| | - James J FitzGerald
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, Oxford, United Kingdom
| | - Tipu Z Aziz
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
8
|
Hu Y, Sun H, Yuan Y, Li Q, Huang S, Jiang S, Liu K, Yang C. Acute bilateral mass-occupying lesions in non-penetrating traumatic brain injury: a retrospective study. BMC Surg 2015; 15:6. [PMID: 25618576 PMCID: PMC4324851 DOI: 10.1186/1471-2482-15-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 01/15/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Traumatic acute bilateral mass-occupying lesions (TABML) is a common entity in head injury, with high morbidity and mortality. Our aim in this study was to evaluate the benefits of different treatment options and the outcome predictors in patients with TABML. METHODS From October 2010 to November 2012, a consecutive cohort of patients aged 16-70 years with TABML were retrospectively analyzed based on the clinical and radiological characteristics. Patients with TABML were included if admitted within 24 h after injury and were excluded if they presented with infratentorial lesions, unilateral lesions within the first 24 h after injury, or penetrating head injury. According to their treatment option, patients were divided into three groups: a conservative treatment group, a unilateral surgery group, and a bilateral surgery group. Outcomes were assessed using the Glasgow Outcome Scale (GOS). Binary logistic regression analysis was applied to determine the outcome predictors. RESULTS Forty-seven patients (58.8%) had severe injuries (Glasgow Coma Scale score (GCS), 3-8) upon admission, and the overall mortality was 31.3% at 6 months post-injury. The mortality was 55.6% in patients who underwent conservative treatment (N = 18), 17.9% in unilateral surgery patients (N = 39), and 34.8% in the bilateral surgery group (N = 23). In the surgical group, the mortality was 53.3% (8 of 15) in those with a GCS of 3-5, which decreased steeply to 14.9% (7 of 47) of those with GCS ≥ 6. On logistic regression analysis, the absence of pupillary reactivity, disappearances of basal cisterns and conservative treatment were related to higher mortality. A lower initial GCS score was associated with an unfavorable outcome. Midline shift tended to be associated with mortality and an unfavorable outcome, although statistical analysis did not show a significant difference. CONCLUSIONS TABML is suggestive of severe brain injury. As conservative treatment is always associated with a poorer outcome, surgery is advocated, especially in patients with a GCS score of ≥ 6. Whereas the prognostic value of midline shift might be limited because of the counter-mass effect in TABML, the GCS score, the pupillary reactivity, and particularly, the compression of basal cisterns should be emphasized.
Collapse
Affiliation(s)
- Yu Hu
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Hong Sun
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Yanqing Yuan
- />Department of Orthopedics, Hospital of Chengdu Office People’s Government of Tibetan Autonomous Region, Chengdu, Sichuan Province China
| | - Qiang Li
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Siqing Huang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Shu Jiang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Kaili Liu
- />Department of Neurosurgery, Xindu District People’s Hospital of Chengdu, Chengdu, Sichuan Province China
| | - Chaohua Yang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| |
Collapse
|
9
|
|
10
|
Offerman SR, Nishijima DK, Ballard DW, Chetipally UK, Vinson DR, Holmes JF. The use of delayed telephone informed consent for observational emergency medicine research is ethical and effective. Acad Emerg Med 2013; 20:403-7. [PMID: 23701349 PMCID: PMC4034372 DOI: 10.1111/acem.12117] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 12/09/2012] [Accepted: 12/11/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to describe the rate of successful consent using an altered (deferred telephone) consent process in emergency department (ED) patients. METHODS This study evaluated the consent process employed during a prospective, multicenter, observational study of outcomes in anticoagulated patients with blunt head trauma. The study was approved by the institutional review boards (IRBs) at all participating centers. Patients were not informed of the study during their enrollment at their index ED visit. Patient names, clinical findings, and contact information were collected at the time of initial ED visits. The patients or their legally designated surrogates were contacted by telephone at least 14 days after ED discharge, given all the elements of informed consent, and then consented for study participation. Study results are presented with simple descriptive statistics. RESULTS A total of 506 patients with a mean (±SD) age of 75.8 (±12.2) years including 274 female subjects (54.2%; 95% confidence interval [CI] = 49.7% to 58.6%) were enrolled into the study. Patients or their surrogates were successfully contacted by telephone in 501 of 506 cases (99.0%; 95% CI = 97.7% to 99.7%). Consent was obtained in 500 of 501 cases at time of telephone follow-up (99.8%; 95% CI = 98.9% to 100.0%). Surrogates provided consent in 199 cases (39.7%; 95% CI = 35.4% to 44.2%). Median time from ED visit to phone contact was 21 days (interquartile range [IQR] = 17 to 27 days). The median number of phone attempts for successful contact was 1 (IQR = 1 to 2 attempts). CONCLUSIONS The authors achieved a very high rate of successful telephone follow-up in this predominantly older ED population. Obtaining consent to participate in a research study using a deferred telephone contact process was effective and well received by both subjects and surrogates. IRBs should consider deferred telephone consent for minimal-risk studies requiring telephone follow-up, as opposed to a consent process requiring written documentation at the time of initial ED visit.
Collapse
|
11
|
Roberts J, Weigelt JA. A case study of a multiply injured patient. Surg Clin North Am 2012; 92:1649-60. [PMID: 23153888 DOI: 10.1016/j.suc.2012.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Initial evaluation of severely injured patients requires an organized, rapid, and thorough evaluation of the patient where life-threatening injuries are identified and treated simultaneously. A case study provides the basis for discussion of the management of the multiply injured trauma patient. The ultimate goal in rehabilitation of a multiply injured patient is to return each patient to as much independent function and ability to contribute to society as possible.
Collapse
Affiliation(s)
- Jennifer Roberts
- Department of Surgery, Division of Trauma and Surgical Critical Care, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | |
Collapse
|
12
|
Stippler M, Smith C, McLean AR, Carlson A, Morley S, Murray-Krezan C, Kraynik J, Kennedy G. Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature. Emerg Med J 2012; 29:528-32. [PMID: 22307924 DOI: 10.1136/emermed-2011-200162] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the efficacy of routine follow-up CT scans of the head after complicated mild traumatic brain injury (TBI). METHODS 74 English language studies published from 1999 to February 2011 were reviewed. The papers were found by searching the PubMed database using a combination of keywords according to Cochrane guidelines. Excluding studies with missing or inappropriate data, 1630 patients in 19 studies met the inclusion criteria: complicated mild TBI, defined as a GCS score 13-15 with abnormal initial CT findings and the presence of follow-up CT scans. For these studies, the progression and type of intracranial haemorrhage, time from trauma to first scan, time between first and second scans, whether second scans were obtained routinely or for neurological decline and the number of patients who had a neurosurgical intervention were recorded. RESULTS Routine follow-up CT scans showed hemorrhagic progression in 324 patients (19.9%). Routine follow-up head CT scans did not predict the need for neurosurgical intervention (p=0.10) but a CT scan of the head performed for decline in status did (p=0.00046). For the 56 patients (3.4%) who declined neurologically, findings on the second CT scan were worse in 38 subjects (67%) and unchanged in the rest. Overall, 39 patients (2.4%) underwent neurosurgical intervention. CONCLUSION Routine follow-up CT scans rarely alter treatment for patients with complicated mild TBI. Follow-up CT scans based on neurological decline alter treatment five times more often than routine follow-up CT scans.
Collapse
Affiliation(s)
- Martina Stippler
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA.
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Parnikoza TP. [Medical care to patients with remote consequences of traumatic craniocerebral injury using methods of reflexology]. Lik Sprava 2012:117-121. [PMID: 23350129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Head injury--is an important medical and social problem. In recent years Ukraine prevalence rate of patients with TBI is growing and now is 4-4,2 cases per 100 thousand population. In 50-80% or 2 of the 3 victims formed long-term consequences of closed head injuries that occur with frequent decompensation states with a temporary disability, often (11-12% of patients) have a strong disability. Use in osnovnovnomu acupuncture points of general application, segmental acupuncture points in the head, neck and scalp area. Treatment ought to be lengthy, with mnohorazovym conducting repeated courses. Most often, the following AND: VB(XI)20, VB(XI)21, T(XII)14, T(XII)20, GI(II)11, GI(II)15, GI(II)10, IG(VI)3, IG(VI)15, IG(VI)16, TR(X)5, TR(X)9, C(V)5, MC(IX)5, MC(IX)6, V(VII)40, V(VII)62, VB(XI)34, VB(XI)30, E(III)36, RP(IV)6. Take Effect braking method.
Collapse
|
14
|
Masaoka H. Cerebral blood flow and metabolism during mild hypothermia in patients with severe traumatic brain injury. J Med Dent Sci 2010; 57:133-138. [PMID: 21073131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Cerebral blood flow (CBF) measurements during mild hypothermia therapy were made in 30 adult patients with severe head injuries (Glasgow Coma Scale score < or =18), by xenon enhanced computed tomography (Xe-CT). All patients but one underwent removal of hematomas and decompressive craniectomy. Immediately after surgery, hypothermia was induced by surface cooling, and a brain temperature of 32-35 degrees C was maintained for 3 days. During hypothermia therapy, CBF measurements by Xe-CT were made for all patients on post-injury days 1 to 4. From the arteriovenous-oxygen content difference and CBF values, the cerebral metabolic rate of oxygen (CMRO2) values were obtained. Outcome was assessed at discharge according to the patients' Glasgow Outcome Scale (GOS) scores. Patients were divided into two groups based on their outcomes. Nineteen patients (63%) showed good outcomes (GOS score of 4 or 5) and 11 (37%) showed poor outcomes (GOS score of 1, 2, or 3). Statistically significant differences were obtained for the mean global CBF and CMRO2 values between the good and poor outcome groups. In this study, we demonstrated that CBF measurement may be useful to predict neurological outcomes following severe traumatic brain injury in patients undergoing hypothermia as well as to identify those who might not likely benefit from hypothermia therapy.
Collapse
Affiliation(s)
- Hiroyuki Masaoka
- Department of Neurosurgery, School of Medicine, Tokyo Medical and Dental University.
| |
Collapse
|
15
|
Pachalska M, Grochmal-Bach B, MacQueen BD, Wilk M, Lipowska M, Herman-Sucharska I. Neuropsychological diagnosis and treatment after closed-head injury in a patient with a psychiatric history of schizophrenia. Med Sci Monit 2008; 14:CS76-CS85. [PMID: 18668003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Despite recent interest in the brain/mind problem and possible organic correlates of mental disease, relatively few case studies have examined the problem concretely. The present paper describes a 66-year-old male patient with a long history of schizophrenia, whose psychotic symptoms displayed qualitative and quantitative changes after a closed-head injury. CASE REPORT After a very disturbed childhood and youth, including several jail terms, the patient was diagnosed with schizophrenia in the early 1960s and frequently thereafter hospitalized. Visual hallucinations were the dominant symptom, and art therapy provided some relief, which led to a successful artistic career. In 1989, while actively hallucinating, he suffered a mild TBI in a pedestrian accident. Despite findings of organic dysfunction, he did not receive full neuropsychological diagnosis and treatment until four years later, when he presented with symptoms of perseveration, hemispatial neglect, and disturbances of working memory. The patient then received an individual program of neuropsychological rehabilitation, while his treating psychiatrist gradually withdrew psychotropic medication. After a year of therapy there was marked improvement of both neuropsychological and psychiatric symptoms. At the same time, he began to paint in a completely different style. CONCLUSIONS The case described here shows that the pathomechanisms of schizophrenia and neurobehavioral disturbances resulting from organic brain damage are not after all unrelated. Microgenetic theory can provide a basis for explaining the course of symptoms in this and similar cases, as we re-think the brain-mind relationship.
Collapse
|
16
|
Rotarescu V, Ciurea AV. Quality of life in children after mild head injury. J Med Life 2008; 1:307-22. [PMID: 20108508 PMCID: PMC5654308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
INTRODUCTION The study was conducted to evaluate the effects of Mild Head Injury (MHI) in children not only in terms of impairment, but also in terms of disability, handicap and quality of life (QOL). CONTEXT Emergency Clinical Hospital "Bagdasar-Arseni", Bucharest, Romania, between 2000 and 2004 METHODS We take into account the patients with mild head injury MHI (CCS of 14 and 15 and amnesia). From a cohort of 1,319 children, consecutive patients with MHI, presented at the emergency room in a period of four years (2000-2003), 528 children (40.0%) were selected for admission, based on the presence of the risk factors. All admitted patients were investigated based on a protocol of neurosurgical evaluation and were followed for a period of 12 months. RESULTS The Falls were the most common cause of MHI (30.6% - 162 cases). The proportion of children with detectable CT scan abnormalities was smaller (19.8% - 105 cases) and surgery was necessary in only 5.5% (29 cases). Special attention was paid to child-abuse and traffic accident cases. Post-concussion syndrome (PCS) was observed in 26.9% cases. Neuropsychological tests were performed in 96 children (21.2%), to evaluate neuropsychological, emotional, psychosocial and behavioral impairments. The study has shown that cognitive dysfunctions mainly were observed after MHI (especially deficits in information processing speed, memory and attention). CONCLUSIONS The neurosurgeon should perform a complete evaluation of the children-patient with MHI, including a current physical examination, a neuro-radiological evaluation and a formal neuropsychological assessment, in order to detect the abnormalities and to treat them. Psychotherapy can be of benefit in cases with MHI. Any common case of MHI may hide a possible lesion with delayed consequences.
Collapse
Affiliation(s)
- Virginia Rotarescu
- Neurosurgical Department, Clinical Hospital "Bagdasar - Arseni", "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | | |
Collapse
|
17
|
Albayrak BS, Gorgulu A. Persistent bilateral amaurosis in a child caused by damage to the calcarine cortex and the claustrum in contralateral hemispheres after a closed head injury. J Trauma 2008; 64:E81-E82. [PMID: 18556806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Baki S Albayrak
- Department of Neurosurgery, Suleyman Demirel University, Medical Faculty Hospital, Isparta, Turkey.
| | | |
Collapse
|
18
|
Yoshida T, Jinnouchi J, Toyoda K, Hasegawa E, Fujimoto S, Okada Y. [Cerebellar infarction in a young adult due to traumatic vertebral artery dissection after lateral mass fracture at the sixth cervical vertebrae]. Brain Nerve 2008; 60:567-570. [PMID: 18516980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A 23-years-old man fell off stairs and got a blow on the left head and right shoulder. He felt dysesthesia at the right thumb on the following day, and received chiropractic therapy from the forth day after injury. On the sixth day after injury, he developed dizziness and nausea, and was urgently hospitalized in our cerebrovascular center. On admission, he had horizontal nystagmus and truncal ataxia. Diffusion-weighted magnetic resonance imaging showed high intensity lesions in right cerebellum hemisphere of posterior inferior cerebellar artery territory, indicating fresh infarcts. On angiogram, right vertebral artery showed tapering occlusion at C6 level, indicating dissection. Computed tomogram showed fracture of the right lateral mass at C6 which extended into the transverse foramen. Under diagnosis of the traumatic vertebral artery dissection due to cervical fracture, we started anticoagulation therapy, which was followed by oral antiplatelet therapy in the chronic stage. Extracranial vertebral artery dissection due to cervical fracture is an important cause of brain infarction in a young adult. Radiological examinations are necessary to rule out traumatic vertebral artery dissection for patients with prolonged dizziness after head injury.
Collapse
Affiliation(s)
- Takefumi Yoshida
- Department of Cerebrovascular Disease and Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
OBJECTIVE To determine: 1. the degrees of consensus and disagreement among Canadian critical care clinicians regarding the appropriateness (benefit exceeding risk) of common therapeutic manoeuvres in patients with severe closed head injury (CHI), and 2. the frequency with which clinicians employed these manoeuvres. METHODS The study design was a systematic scenario-based survey of all neurosurgeons and critical care physicians treating patients with severe CHI in Canada. RESULTS In the scenario of acute epidural hematoma with mass effect, respondents agreed very strongly that surgery was appropriate. Clinicians reported mannitol and hypertonic saline as appropriate. Beyond these two interventions, agreement was less strong, and the use of the extraventricular drain (EVD), phenytoin, cooling, hyperventilation, nimodipine, and jugular venous oximetry (JVO) were of uncertain appropriateness. Steroids were considered inappropriate. In a scenario of diffuse axonal injury (DAI), clinicians agreed strongly that fever reduction, early enteral feeding, intensive glucose control, and cerebral perfusion pressure (CPP)-directed management were appropriate. The use of mannitol, hypertonic saline, EVD, JVO, narcotics and propofol were also appropriate. Neuromuscular blockade, surgery, and hyperventilation were of uncertain appropriateness. The appropriateness ratings of the interventions considered in the scenario of an intracranial contusion mirrored the DAI scenario. In general, correlations between the reported appropriateness and frequency of use of each intervention were very high. An exception noted was the use of the JVO. The correlation between CPP-guided therapy and the use of the EVD was weak. CONCLUSIONS This survey has described current practice with regard to treatment of patients with severe CHI. Areas of variation in perceived appropriateness were identified that may benefit from further evaluation. Suggested priorities for evaluation include the use of osmotic diuretics, anticonvulsants, and intracranial manometry.
Collapse
MESH Headings
- Adult
- Anticonvulsants/therapeutic use
- Brain Injuries/epidemiology
- Brain Injuries/physiopathology
- Brain Injuries/therapy
- Canada/epidemiology
- Critical Care/methods
- Critical Care/standards
- Diffuse Axonal Injury/drug therapy
- Diffuse Axonal Injury/physiopathology
- Diuretics, Osmotic/therapeutic use
- Female
- Head Injuries, Closed/epidemiology
- Head Injuries, Closed/physiopathology
- Head Injuries, Closed/therapy
- Health Care Surveys
- Hematoma, Epidural, Cranial/drug therapy
- Hematoma, Epidural, Cranial/physiopathology
- Hematoma, Epidural, Cranial/surgery
- Humans
- Hypothermia, Induced/statistics & numerical data
- Intensive Care Units
- Intracranial Hypertension/diagnosis
- Intracranial Hypertension/prevention & control
- Intracranial Hypertension/therapy
- Male
- Malnutrition/prevention & control
- Malnutrition/therapy
- Middle Aged
- Neurology/methods
- Neurology/standards
- Neurosurgery/methods
- Neurosurgery/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Risk Assessment
Collapse
Affiliation(s)
- Michael J Jacka
- Department of Anesthesiology, Division of Critical Care (MJJ), University of Alberta, Edmonton, Canada
| | | |
Collapse
|
20
|
Abstract
Boxing may well be the oldest sport known to mankind and probably the most controversial. Injuries are common in boxing, occurring most often to the head, neck, face, and hands. Brain injury, both acute and chronic, is the major risk for potential catastrophe. Medical care for the boxer extends beyond the competition in the boxing ring; the ringside physician is responsible for protecting both boxers and must make quick decisions about their continued participation based upon a limited examination. A thorough knowledge of the rules and regulations of boxing is necessary for the ringside physician to effectively care for the athlete. In spite of the perceived brutality associated with the sport, most injuries are minor, although serious injuries and deaths do occur, most commonly due to brain injury. Given the potential for catastrophic injury, the ringside physician must be prepared and equipped to care for the boxer.
Collapse
Affiliation(s)
- Robert C Gambrell
- Sports Medicine Associates of Augusta, 3624 J. Dewey Gray Circle, Suite 308, Augusta, GA 30909, USA.
| |
Collapse
|
21
|
Oron A, Oron U, Streeter J, de Taboada L, Alexandrovich A, Trembovler V, Shohami E. low-level laser therapy applied transcranially to mice following traumatic brain injury significantly reduces long-term neurological deficits. J Neurotrauma 2007; 24:651-6. [PMID: 17439348 DOI: 10.1089/neu.2006.0198] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Low-level laser therapy (LLLT) has been evaluated in this study as a potential therapy for traumatic brain injury (TBI). LLLT has been found to modulate various biological processes. Following TBI in mice, we assessed the hypothesis that LLLT might have a beneficial effect on their neurobehavioral and histological outcome. TBI was induced by a weight-drop device, and motor function was assessed 1 h post-trauma using a neurological severity score (NSS). Mice were then divided into three groups of eight mice each: one control group that received a sham LLLT procedure and was not irradiated; and two groups that received LLLT at two different doses (10 and 20 mW/cm(2) ) transcranially. An 808-nm Ga-As diode laser was employed transcranially 4 h post-trauma to illuminate the entire cortex of the brain. Motor function was assessed up to 4 weeks, and lesion volume was measured. There were no significant changes in NSS at 24 and 48 h between the laser-treated and non-treated mice. Yet, from 5 days and up to 28 days, the NSS of the laser-treated mice were significantly lower (p < 0.05) than the traumatized control mice that were not treated with the laser. The lesion volume of the laser treated mice was significantly lower (1.4%) than the non-treated group (12.1%). Our data suggest that a non-invasive transcranial application of LLLT given 4 h following TBI provides a significant long-term functional neurological benefit. Further confirmatory trials are warranted.
Collapse
Affiliation(s)
- Amir Oron
- Department of Orthopedics, Assaf Harofeh Medical Center, Zerifin, Israel.
| | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
PURPOSE OF REVIEW We present data from recently conducted research regarding controversial aspects of the evaluation and management of children with minor blunt head trauma. RECENT FINDINGS Clinicians frequently but at times indiscriminately perform computed tomography scans for children with minor blunt head trauma resulting in potentially harmful radiation exposure. Recent guidelines recognize the limited but increasing data available to make strong recommendations regarding appropriate neuroimaging decisions. Investigators have derived and validated clinical prediction models to accurately identify patients with substantial traumatic brain injury, though no clear definitive rule exists. Children younger than 2 years appear to have a higher risk of intracranial injury following minor head trauma. These patients can be difficult to assess, with the evidence suggesting the need for a more conservative approach to diagnostic imaging. We present current and accepted definitions of concussion along with risk factors and treatment for postconcussion syndrome. Current return-to-play guidelines suggest that athletes who have sustained concussion should not resume play until symptoms have resolved because of the possibility, though rare, of second impact syndrome. SUMMARY Research in the management of children with minor head trauma is actively evolving. We present a review of recent developments that can influence current clinical practice.
Collapse
Affiliation(s)
- David Schnadower
- Division of Pediatric Emergency Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University College of Physicians & Surgeons, 622 West 168th Street, New York, NY 10032, USA.
| | | | | | | | | |
Collapse
|
23
|
Akopian G, Gaspard DJ, Alexander M. Outcomes of blunt head trauma without intracranial pressure monitoring. Am Surg 2007; 73:447-50. [PMID: 17520996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Although guidelines exist for intracranial pressure (ICP)-guided treatment after head trauma, no conclusive data exist that support routine ICP monitoring. A retrospective case series was reviewed of all patients admitted to the intensive care unit with a diagnosis of blunt head trauma between January 1, 1999 and December 31, 2004. None of the patients in the final analysis had ICP monitoring. Data collected included age, sex, mechanism of injury, Glasgow Coma Score (GCS) at admission, injury severity score, disposition, and length of stay. One hundred thirty-one patients with a median age of 41 years were included. There were 104 men (79%). The median GCS at admission was 12. There were 22 deaths (17% mortality). Stepwise logistic regression analysis identified older age, higher injury severity score, and lower GCS to be predictors of death. The mortality rate was higher in patients with GCS < or =8 compared with GCS >8 (33% vs 8%, respectively; P < 0.001). Ten of 23 patients with a GCS of 3 died (43% mortality). The median time to death for patients with a GCS of 3 was 2 days. Although the Brain Trauma Foundation has published guidelines advocating routine ICP monitoring, no large randomized prospective studies are available to determine its effect on outcome. None of the patients in this study had ICP monitoring. Our overall survival rate of 83 per cent is relatively high. Patients with a low GCS and, specifically, those with a GCS of 3 may not benefit from ICP monitoring because of early and irreversible trauma. Variability in the use of ICP monitoring will remain until ICP monitoring can be conclusively proven to improve outcome.
Collapse
Affiliation(s)
- Gabriel Akopian
- Huntington Memorial Hospital, Pasadena, California 91105, USA
| | | | | |
Collapse
|
24
|
Abstract
INTRODUCTION Management of intracranial hypertension is pivotal in the care of brain-injured patients. SUMMARY OF CASE We report the case of a patient with both a closed head injury and anoxic encephalopathy, who subsequently experienced episodes of refractory intracranial hypertension. The patient's care was complicated by the development of a pneumonia, which required frequent turning of the patient and chest physiotherapy. Conventional wisdom suggests that these interventions may stimulate the patient and worsen intracranial pressure, and therefore should be avoided. RESULTS Our observations on this patient, however, contradict this belief. This single-subject study presents data to support the use of chest physiotherapy in patients at risk for intracranial hypertension. CONCLUSIONS Further, the evidence is compelling that a randomized-controlled trial is indicated to test the hypothesis that chest physiotherapy may actually result in short-term resolution of high intracranial pressure, and thus provide one more clinical tool in the management of elevated intracranial pressure.
Collapse
Affiliation(s)
- DaiWai M Olson
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | | | | | | |
Collapse
|
25
|
Ciurea AV, Kapsalaki EZ, Coman TC, Roberts JL, Robinson JS, Tascu A, Brehar F, Fountas KN. Supratentorial epidural hematoma of traumatic etiology in infants. Childs Nerv Syst 2007; 23:335-41. [PMID: 17061134 DOI: 10.1007/s00381-006-0230-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Revised: 06/06/2006] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND BACKGROUND Traumatic epidural hematoma (EDH) represents a rare head injury complication in infants. Its diagnosis can be quite challenging because its clinical presentation is usually subtle and nonspecific. In our current communication, we present our data regarding the presentation of infants with EDH, their management, and their long-term outcome. MATERIALS AND METHODS In a retrospective study, the hospital and outpatient clinic charts and imaging studies (head CT and skull X-rays) of 31 infants with pure, supratentorial EDH of traumatic origin were meticulously reviewed. Children Coma Scale score and Trauma Infant Neurologic Score (TINS) were also reviewed. The most common presenting symptom was irritability, which occurred in 18/31 (58.1%) of our patients. Pallor (in 30/31 patients) and cephalhematoma (in 21/31 patients) were the most commonly occurring clinical signs upon admission; both signs represent signs of significant clinical importance. Surgical evacuation via a craniotomy was required in 24/31 of our patients, while 7/31 patients were managed conservatively. The mortality rate in our series was 6.5% (2/31 patients), and our long-term morbidity rate was 3.2% (1/31 patients). CONCLUSIONS EDH in infants represents a life-threatening complication of head injury, which requires early identification and prompt surgical or conservative management depending on the patient's clinical condition, size of EDH, and presence of midline structure shift on head CT scan. Mortality and long-term morbidity are low with early diagnosis and prompt treatment.
Collapse
MESH Headings
- Accidental Falls
- Cerebellum/blood supply
- Decompression, Surgical/methods
- Dura Mater/blood supply
- Female
- Follow-Up Studies
- Head Injuries, Closed/complications
- Head Injuries, Closed/diagnostic imaging
- Head Injuries, Closed/therapy
- Hematoma, Epidural, Cranial/diagnostic imaging
- Hematoma, Epidural, Cranial/etiology
- Hematoma, Epidural, Cranial/therapy
- Humans
- Infant
- Infant, Newborn
- Male
- Radiography
- Retrospective Studies
- Skull Fractures/complications
- Skull Fractures/diagnostic imaging
- Trauma Severity Indices
Collapse
Affiliation(s)
- A V Ciurea
- Department of Neurosurgery, Clinics and Hospital Bagdasar-Arseni, Bucharest, Romania
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Gautschi OP, Frey SP, Zellweger R. [Diagnosis and management of patients with mild traumatic brain injury--an update with recommendations and future perspectives]. Praxis (Bern 1994) 2007; 96:53-8; discussion 59-60. [PMID: 17294579 DOI: 10.1024/1661-8157.96.3.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Mild traumatic brain injury (TBI) is a reversible brain damage, without structural changes, which is caused by an external force. By definition, patients with mild TBI have a GCS of 13-15. It is an established risk factor for both morbidity and mortality. Prognosis is dependent on the primary damage incurred as well as secondary damage, for example, posttraumatic bleeding and oedema. Initial management should focus on the identification of patients at risk for serious intracranial pathologies. Investigations should be directed towards the severity of the injuries. Notably, the conventional X-ray is inadequate for the assessment of TBI. The following article discusses practical algorithms for the management of mild TBI and the indications for early use of CT.
Collapse
Affiliation(s)
- O P Gautschi
- Department of Orthopaedic Surgery, Royal Perth Hospital, University of Western Australia, Perth.
| | | | | |
Collapse
|
27
|
McIntyre LA, Fergusson DA, Hutchison JS, Pagliarello G, Marshall JC, Yetisir E, Hare GMT, Hébert PC. Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care 2006; 5:4-9. [PMID: 16960287 DOI: 10.1385/ncc:5:1:4] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare a restrictive versus a liberal transfusion strategy in patients with moderate to severe closed head injury following multiple trauma in 13 Canadian intensive care units (ICUs). METHODS This is a subgroup analysis of a multicenter randomized controlled clinical trial involving sixty-seven critically ill patients from the Transfusion Requirements in the Critical Care trial who sustained a closed head injury. Patients had a hemoglobin concentration less than 9.0 g/dL within 72 hours of admission to the ICU. Patients were randomized to a restrictive allogeneic red blood cell transfusion strategy (hemoglobin 7.0 g/dL and maintained between 7.0 and 9.0 g/dL) or a liberal strategy (hemoglobin 10.0 g/dL and maintained between 10.0 and 12.0 g/dL). RESULTS Baseline characteristics in the restrictive ( n = 29) and the liberal ( n = 38) transfusion groups were comparable. Average hemoglobin concentrations and red blood cell units transfused per patient were significantly lower in the restrictive compared to the liberal group. The 30-day all-cause mortality rates in the restrictive group were 17% as compared to 13% in the liberal group (risk difference 4.1 with 95% confidence interval [CI], 13.4 to 21.5, p = 0.64). Presence of multiple organ dysfunction (12.1 +/- 6.4 versus 10.6 +/- 6.3, p = 0.35) and changes in multiple organ dysfunction from baseline scores adjusted for death (4.5 +/- 6.2 versus 3.4 +/- 6.2, p = 0.49) were similar between the restrictive and liberal transfusion groups, respectively. Median length of stay in ICU (10 days, interquartile range 5 to 21 days versus 8 days, interquartile range 5 to 11 days, p = 0.26) and hospital (27 days, interquartile range 14 to 39 days versus 30.5 days, interquartile range 17 to 47 days, p = 0.72) were similar between the restrictive and liberal transfusion groups. CONCLUSIONS We were unable to detect significant improvements in mortality with a liberal as compared to restrictive transfusion strategy in critically ill trauma victims with moderate to severe head injury.
Collapse
Affiliation(s)
- Lauralyn A McIntyre
- Centre for Transfusion and Critical Care Research, Clinical Epidemiology Unit, Critical Care Program, University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario.
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Etemadrezaie H, Baharvahdat H, Shariati Z, Lari SM, Shakeri MT, Ganjeifar B. The effect of fresh frozen plasma in severe closed head injury. Clin Neurol Neurosurg 2006; 109:166-71. [PMID: 17029771 DOI: 10.1016/j.clineuro.2006.09.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Revised: 08/27/2006] [Accepted: 09/02/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is one of the most common causes of morbidity and mortality. Coagulopathy, commonly occurring after severe TBI, is associated with poor outcome and secondary complications, especially delayed traumatic intracerebral hematoma (DTICH). In this study we evaluated the effect of fresh frozen plasma (FFP) on the reduction in the incidence of DTICH in severe closed head injury victims. METHODS This study was carried out as a double-blind randomized clinical trial. Ninety patients were entered in two parallel groups taking either FFP or normal saline (N/S). Patients' selection criteria for both groups were: severe closed head injury (Glasgow coma scale < or =8), no mass lesion required evacuation and no history of coagulopathy. The clinical findings, laboratory data, computed tomography (CT) scans and Glasgow outcome scale after 1 month were assessed and compared in two groups. RESULTS Out of 90 patients, 44 received FFP and 46 received N/S. The development of new intracerebral hematoma in follow-up CT scans were more common in the FFP group than the N/S group (p=0.012). Both groups showed similar frequency of poor outcome (p=0.343). The mortality was significantly more common in the FFP group than in the N/S group (63% versus 35%, p=0.006). CONCLUSION The result of this study revealed that early empirical infusion of FFP in patients with severe head injury may lead to adverse effects, such as an increase in the frequency of DTICH and an increase in the mortality.
Collapse
Affiliation(s)
- Hamid Etemadrezaie
- Neurosurgical Department, Shahid Kamyab (Emdadi) Hospital, Mashhad University of Medical Sciences (MUMS), Mashhad, Iran.
| | | | | | | | | | | |
Collapse
|
29
|
Mowafi HO, Hickey KS. Occipital condyle fracture in a victim of a motor vehicle collision. J Emerg Med 2006; 31:259-62. [PMID: 16982357 DOI: 10.1016/j.jemermed.2005.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Revised: 07/14/2005] [Accepted: 12/02/2005] [Indexed: 11/19/2022]
Abstract
Occipital condyle fractures are rarely reported in the Emergency Medicine literature. It is unclear whether these fractures are rare or under-diagnosed. Occipital condyle fractures are associated with high-energy blunt trauma with significant cranial-cervical torque or axial loading. We report a case of a female patient with an occipital condyle fracture. The patient only complained of shoulder pain, but was found to have high cervical spine tenderness, after a moderate-speed front-end motor vehicle collision. Initial cervical spine radiographs were non-diagnostic. Computed tomography of the cervical spine demonstrated a non-displaced occipital condyle fracture. Conservative management with a semi-rigid cervical collar was successful in treating this patient's fracture. A review of the literature covers the diagnosis, radiographic findings, and management of this fracture.
Collapse
Affiliation(s)
- Hani O Mowafi
- Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | | |
Collapse
|
30
|
Stiefel MF, Udoetuk JD, Spiotta AM, Gracias VH, Goldberg A, Maloney-Wilensky E, Bloom S, Le Roux PD. Conventional neurocritical care and cerebral oxygenation after traumatic brain injury. J Neurosurg 2006; 105:568-75. [PMID: 17044560 DOI: 10.3171/jns.2006.105.4.568] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Object
Control of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is the foundation of traumatic brain injury (TBI) management. In this study, the authors examined whether conventional ICP- and CPP-guided neurocritical care ensures adequate brain tissue O2 in the first 6 hours after resuscitation.
Methods
Resuscitated patients with severe TBI (Glasgow Coma Scale score ≤ 8 and Injury Severity Scale score ≥ 16) who were admitted to a Level I trauma center and who underwent brain tissue O2 monitoring within 6 hours of injury were evaluated as part of a prospective observational database. Therapy was directed to maintain an ICP of 25 mm Hg or less and a CPP of 60 mm Hg or higher.
Data from a group of 25 patients that included 19 men and six women (mean age 39 ± 20 years) were examined. After resuscitation, ICP was 25 mm Hg or less in 84% and CPP was 60 mm Hg or greater in 88% of the patients. Brain O2 probes were allowed to stabilize; the initial brain tissue O2 level was 25 mm Hg or less in 68% of the patients, 20 mm Hg or less in 56%, and 10 mm Hg or less in 36%. Nearly one third (29%) of patients with ICP readings of 25 mm Hg or less and 27% with CPP levels of 60 mm Hg or greater had severe cerebral hypoxia (brain tissue O2 ≤10 mm Hg). Nineteen patients had both optimal ICP (≤25 mm Hg) and CPP (> 60 mm Hg); brain tissue O2 was 20 mm Hg or less in 47% and 10 mm Hg or less in 21% of these patients. The mortality rate was higher in patients with reduced brain tissue O2.
Conclusions
Brain resuscitation based on current neurocritical care standards (that is, control of ICP and CPP) does not prevent cerebral hypoxia in some patients. This finding may help explain why secondary neuronal injury occurs in some patients with adequate CPP and suggests that the definition of adequate brain resuscitation after TBI may need to be reconsidered.
Collapse
Affiliation(s)
- Michael F Stiefel
- Department of Neurosurgery and Division of Trauma Surgery and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19107, USA
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Trenchs V, Curcoy AI, Pou J. Head trauma and hospital admission. Pediatr Emerg Care 2006; 22:392; author reply 393. [PMID: 16714975 DOI: 10.1097/01.pec.0000216799.50889.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Seguin P, Tanguy M, Laviolle B, Tirel O, Mallédant Y. Effect of oropharyngeal decontamination by povidone-iodine on ventilator-associated pneumonia in patients with head trauma*. Crit Care Med 2006; 34:1514-9. [PMID: 16540962 DOI: 10.1097/01.ccm.0000214516.73076.82] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effect of a regular oropharyngeal application of povidone-iodine on the prevalence of ventilator-associated pneumonia in patients with severe head trauma. DESIGN Prospective randomized study. SETTING A surgical intensive care unit of a university hospital. INTERVENTIONS Patients with severe head trauma (Glasgow Coma Score of < or =8) expected to need ventilation for > or =2 days were prospectively randomized into three groups: those receiving nasopharynx and oropharynx rinsing with 20 mL of a 10% povidone-iodine aqueous solution, reconstituted in a 60-mL solution with sterile water (povidone-iodine group); those receiving nasopharynx and oropharynx rinsing with 60 mL of saline solution (saline group); or those undergoing a standard regimen without any instillation but with aspiration of oropharyngeal secretions (control group). MEASUREMENTS AND MAIN RESULTS The prevalence of ventilator-associated pneumonia was compared among the three groups. A total of 98 patients were analyzed (povidone-iodine group, n = 36; saline group, n = 31; and control group, n = 31). A total of 28 cases of ventilator-associated pneumonia were diagnosed. There was a significant decrease in the rate of ventilator-associated pneumonia in the povidone-iodine group when compared with the saline and control groups (3 of 36 patients [8%] vs. 12 of 31 patients [39%] and 13 of 31 patients [42%], respectively; p = .003 and .001, respectively). The length of stay and mortality in the surgical intensive care unit were not statistically different between the three groups. CONCLUSIONS The regular administration of povidone-iodine may be an effective strategy for decreasing the prevalence of ventilator-associated pneumonia in patients with severe head trauma.
Collapse
Affiliation(s)
- Philippe Seguin
- Surgical Intensive Care Unit, INSERM U620, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes cedex, France
| | | | | | | | | |
Collapse
|
33
|
|
34
|
Tien HC, Cunha JRF, Wu SN, Chughtai T, Tremblay LN, Brenneman FD, Rizoli SB. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? ACTA ACUST UNITED AC 2006; 60:274-8. [PMID: 16508482 DOI: 10.1097/01.ta.0000197177.13379.f4] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low Glasgow Coma Scale score (GCS) and pupillary status predict poor outcomes in head injury (HI) patients. We compared the mortality of GCS 3 patients having bilateral fixed and dilated pupils (BFDP) with GCS 3 patients having reactive pupils (RP). We then determined if trauma system or patient factors were responsible for the difference in mortality. METHODS We reviewed all adult, blunt HI patients with GCS=3, admitted to our institution from January 1, 2001 to December 31, 2003. Demographics, injury data, prehospital times, procedures, and outcomes were recorded. RESULTS During this period, 245 patients were admitted with GCS of 3, and met inclusion criteria. In all, 173 patients were analyzed, after excluding 23 patients who were dead-on-arrival, and 45 others, who were intoxicated with alcohol, or received paralytic agents in the trauma room. All BFDP patients died, whereas 42.0% of reactive pupil (RP) patients died (p < 0.0001). With regards to patient factors, BFDP patients were more likely to be unstable, have extra-axial bleeding, and evidence of midline shift and/or herniation. Trauma system factors, however, may also have had an impact on outcome. Despite having more extra-axial bleeding, BFDP patients were less likely to have a neurosurgical operation than RP patients. CONCLUSION Patients with GCS of 3 and BFDP have a dismal prognosis. These patients have suffered devastating brain injuries and tend to be hemodynamically unstable. Clinicians, however, are less likely to aggressively treat BFDP patients than RP patients. Further prospective studies are required to determine which patients with GCS of 3 and BFDP are likely to benefit from aggressive treatment.
Collapse
Affiliation(s)
- Homer C Tien
- Trauma Program and the Department of Surgery, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
35
|
Velmahos GC, Gervasini A, Petrovick L, Dorer DJ, Doran ME, Spaniolas K, Alam HB, De Moya M, Borges LF, Conn AK. Routine repeat head CT for minimal head injury is unnecessary. ACTA ACUST UNITED AC 2006; 60:494-9; discussion 499-501. [PMID: 16531845 DOI: 10.1097/01.ta.0000203546.14824.0d] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with MHI and a positive head computed tomography (CT) scan frequently have a routine repeat head CT (RRHCT) to identify possible evolution of the head injury requiring intervention. RRHCT is ordered based on the premise that significant injury progression may take place in the absence of clinical deterioration. METHODS In a Level I urban trauma center with a policy of RRHCT, we reviewed the records of 692 consecutive trauma patients with Glasgow Coma Scale scores of 13-15 and a head CT (October 2004 through October 2005). The need for medical or surgical neurologic intervention after RRHCT was recorded. Patients with a worse and unchanged RRHCT were compared, and independent predictors of a worse RRHCT were identified by stepwise logistic regression. RESULTS There were 179 patients with MHI and RRHCT ordered. Of them, 37 (21%) showed signs of injury evolution on RRHCT and 7 (4%) required intervention. All 7 had clinical deterioration preceding RRHCT. In no patient without clinical deterioration did RRHCT prompt a change in management. A Glasgow Coma Scale score less than 15 (13 or 14), age higher than 65 years, multiple traumatic lesions found on first head CT, and interval shorter than 90 minutes from arrival to first head CT predicted independently a worse RRHCT. CONCLUSIONS RRHCT is unnecessary in patients with MHI. Clinical examination identifies accurately the few who will show significant evolution and require intervention.
Collapse
Affiliation(s)
- George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Neurosurgery, and Biostatistics Center (DJD), Massachusetts General Hospital, Harvard School of Medicine, Boston, MA 02114, USA. gvelmahos@partners
| | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Newgard CD, Hedges JR, Stone JV, Lenfesty B, Diggs B, Arthur M, Mullins RJ. Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury. Emerg Med J 2006; 22:855-60. [PMID: 16299192 PMCID: PMC1726623 DOI: 10.1136/emj.2004.020206] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. METHODS We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS > or =3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule. RESULTS 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation. CONCLUSIONS This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.
Collapse
Affiliation(s)
- C D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA.
| | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
Many studies have found conflicting evidence over the use of clinical indicators to predict intracranial injury in pediatric mild head injury. Although altered mental status, loss of consciousness, and abnormal neurologic examination have all been found to be more prevalent among head-injured children, studies have observed inconsistent results over their specificity and predictive value. Children older than 2 years have been evaluated, managed, and studied differently than those less than 2 years old. Evidence strongly supports a lower threshold to perform a CT scan in younger children because they have a higher risk of significant brain injury after blunt head trauma.
Collapse
Affiliation(s)
- Mary L Thiessen
- Department of Emergency Medicine, University of Arizona, 1515 North Campbell Avenue, Tucson, AZ 85724, USA
| | | |
Collapse
|
38
|
Abstract
BACKGROUND Growing evidence supports the premise that adult trauma centers lower the risk of death for severely injured patients. The same principles have been applied to the pediatric population and mounting research suggests that, as in the adult population, gravely injured children have better outcomes at pediatric trauma centers where personnel trained and experienced in the specific needs and unique physiology of injured children provide care. As in the United States, acute traumatic injury represents an important public healthcare concern to the Tuscan regional government whose goal is to maximize clinical outcomes within available resources. In order to address this problem, the Tuscan regional government has created a new and innovative collaboration between the Meyer Pediatric Hospital/University of Florence School of Medicine and the Children's Hospital Boston/Harvard Medical School to build a pediatric trauma center and regional pediatric trauma referral system. GOALS AND OBJECTIVES This long-term international initiative will seek to develop a demonstration model for pediatric trauma care that may later be replicated elsewhere. The initial goals of the project will focus on expanding the role of the pediatricians working in the emergency department to include the acute care of medical, surgical, orthopedic and multiple trauma patients. This new configuration will closely resemble the single provider model of emergency medical care commonly utilized in the United States. During this transition period to a more broadly trained emergency physician, a multi-disciplinary trauma team will be created and pediatric trauma clinical practice guidelines will be introduced into the emergency department and inpatient care units. Systems measurements will be achieved through a comprehensive quality improvement and risk management program. Ultimately, all Tuscan regional pediatric major trauma will be consolidated at the Meyer Pediatric Hospital in Florence.
Collapse
Affiliation(s)
- Kevin M Ban
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, West CC2, 2nd Floor, Boston, MA 02215, USA.
| | | | | | | | | | | | | | | |
Collapse
|
39
|
|
40
|
Shah Q, Friedman J, Mamourian A. Spontaneous resolution of traumatic pseudoaneurysm of the middle meningeal artery. AJNR Am J Neuroradiol 2005; 26:2530-2. [PMID: 16286396 PMCID: PMC7976179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
We describe a case of traumatic pseudoaneurysm of the middle meningeal artery in a patient after a head trauma. The aneurysm was found incidentally and resolved spontaneously without any intervention; this outcome suggests that middle meningeal artery aneurysm may not require treatment in all cases and can be followed conservatively with follow-up conventional angiography.
Collapse
MESH Headings
- Adult
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/pathology
- Aneurysm, False/therapy
- Cerebral Angiography
- Embolization, Therapeutic
- Head Injuries, Closed/diagnostic imaging
- Head Injuries, Closed/pathology
- Head Injuries, Closed/therapy
- Hematoma, Epidural, Cranial/diagnostic imaging
- Hematoma, Epidural, Cranial/pathology
- Hematoma, Epidural, Cranial/therapy
- Humans
- Male
- Maxillary Artery/diagnostic imaging
- Maxillary Artery/injuries
- Maxillary Artery/surgery
- Meningeal Arteries/diagnostic imaging
- Meningeal Arteries/injuries
- Meningeal Arteries/surgery
- Remission, Spontaneous
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/pathology
- Subarachnoid Hemorrhage/therapy
- Tomography, X-Ray Computed
Collapse
Affiliation(s)
- Qaisar Shah
- Department of Neurology, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA
| | | | | |
Collapse
|
41
|
Abstract
BACKGROUND Closed head injury (CHI) is common in childhood and frequently results in hospital admission for observation and treatment. Observation units (OUs) have shown significant benefits for patients and physicians. At our institution, a level 1 pediatric trauma center, patients with CHI are often admitted to an OU for up to 24 hours of observation and treatment. STUDY OBJECTIVES To describe characteristics of patients with a CHI admitted to a pediatric OU and to identify demographic, historical, clinical, and radiographic factors associated with the need for unplanned inpatient admission (UIA) after OU management. METHODS Retrospective cohort review of all OU admissions for CHI at Primary Children's Medical Center (PCMC) from August 1999 through July 2001. Data collected included age, gender, mechanism of injury, presenting symptoms, physical examination findings, head computed tomography (CT) results, diagnosis, length of stay, outcome of the injury, and need for UIA. RESULTS During the study period, 827 patients were seen in the ED for CHI. Two hundred eighty-five patients (34%) were admitted to the OU, 273 (33%) were admitted to an inpatient service, and 269 (33%) were discharged home. OU patients had a median age of 5.2 years, ranging from 2 weeks to 17 years. Sixty-one percent were male. The median admission length of stay was 13 hours. Common mechanisms of injury included: falls (60%), motor vehicle accidents (12%), bicycle accidents (10%), impacts from objects (9%), auto-pedestrian accidents (4.6%), and snow-related accidents (4.6%). Presenting symptoms in the ED included vomiting (39%), loss of consciousness (26%), amnesia to event (19%), persistent amnesia (5%), and seizures (4%). Physical examination findings noted in the ED included altered mental status (45%), facial abnormalities (43%), scalp abnormalities (38%), and neurologic deficits (9%). Two hundred eighty patients (98%) admitted to the OU had a head CT performed. Skull fractures were present in 109 patients (39%) and intracranial pathology (ie, epidural hematoma, subdural hematoma, or intraparenchymal contusion) was present in 38 patients (13%). Only 13 patients (5%) required admission to an inpatient service from the OU for the following reasons: continued need for intravenous (IV) fluids (n = 5), venous thrombosis (n = 2), persistent CSF leakage (n = 3), decreased level of consciousness (n = 1), pain management (n = 1), and clearing of the patient's cervical spine (n = 1). No patient deteriorated or required neurosurgery. Patients with basilar skull fractures, a head laceration (scalp or facial), and patients that needed IV fluids in the ED were more likely to need inpatient admission after a 24-hour observation stay. Logistic regression analysis identified basilar skull fractures (OR 11.61), face/scalp lacerations (OR 7.52), and the need for ED IV fluid administration (OR 4.26) to be associated with UIA. Most children with these findings were successfully discharged within 24 hours, however. Age, sex, loss of consciousness, seizure, vomiting, amnesia, altered mental status, neurologic deficits, intracranial pathology, and skull fractures (aside from basilar skull fractures) were not related to UIA. CONCLUSION The vast majority (96%) of pediatric OU patients with CHI such as small intracranial hematomas, skull fractures, and concussions were discharged safely within 24 hours without serious complications. The presence of a basilar skull fracture, head laceration, and the need for ED IV fluids were associated with increased risk of UIA. OU admission is an efficient and effective management setting for children with stable intracranial pathology, skull fractures, and concussions.
Collapse
Affiliation(s)
- Maija Holsti
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Primary Children's Medical Center, University of Utah, Salt Lake City, USA.
| | | | | | | | | |
Collapse
|
42
|
Abstract
This report describes a pediatric case of delayed glossopharyngeal nerve, vagus nerve, and facial nerve palsies after a head injury. Computed tomography scan of the skull base revealed the fracture of the petrous part of the temporal bone, and the fracture involved the tip of petrous pyramid, in front of the jugular foramen. The anatomical features, mechanisms, diagnosis, and treatment are discussed.
Collapse
Affiliation(s)
- Altan Yildirim
- Otolaryngology and Head Neck Surgery Department, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | | | | | | |
Collapse
|
43
|
Affiliation(s)
- Daniel F Saad
- Department of Surgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | | |
Collapse
|
44
|
Health tips. Head trauma: when to get help. Mayo Clin Health Lett 2005; 23:3. [PMID: 16156067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
|
45
|
Abstract
OBJECTIVE To evaluate patients after blunt trauma of the head, neck, and craniocervical junction (without fractures) with vertigo and to report the results of treatment after extensive diagnostics. STUDY DESIGN Prospective study of consecutive new cases with vertigo after trauma at different periods of onset. During 2000-2002, 63 patients were examined and treated. SETTING Regional trauma medical center for the greater Berlin Area, tertiary referral unit. RESULTS The primary disorders included labyrinthine concussion (18), rupture of the round window membrane (6), and cervicogenic vertigo (12). The secondary disorders included otolith disorders (5), delayed endolymphatic hydrops (12), and canalolithiasis (9). The patients were free of vertigo symptoms (except cervicogenic and otolith disorder) after treatment, which consisted of habituation training, medical and surgical therapy options. The follow-up was 1 year. CONCLUSION Posttraumatic vertigo can be treated with a high success rate once the underlying disorder has been identified. The extent of the neurotological test battery determines the precision and quality of diagnostics. Surgical measures should be an integral part of treatment modalities if conservative treatment is not effective. SIGNIFICANCE Minor trauma of the head, neck, and craniocervical junction can have major impact on the vestibular system at different sites. Patients need to be carefully diagnosed, even if the onset of vertigo occurs a few weeks or months after the initial trauma.
Collapse
Affiliation(s)
- Arne Ernst
- Department of Otolaryngology at ukb Medical Center, Berlin, Germany.
| | | | | | | | | | | |
Collapse
|
46
|
Brown CVR, Weng J, Oh D, Salim A, Kasotakis G, Demetriades D, Velmahos GC, Rhee P. Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation. ACTA ACUST UNITED AC 2005; 57:939-43. [PMID: 15580014 DOI: 10.1097/01.ta.0000149492.92558.03] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. METHODS Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. RESULTS Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1). CONCLUSIONS Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.
Collapse
Affiliation(s)
- Carlos V R Brown
- Department of Surgery, Division of Trauma and Critical Care, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA.
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
BACKGROUND The explosion of three bombs on 12 October 2002 in Kuta, Bali resulted in mass casualties akin to those seen in war. The aim of the present report is to describe the sequence of events of Operation Bali Assist including triage, resuscitation and initial wound surgery in Bali at Sanglah Hospital in the aeromedical staging facility (ASF), Denpasar airport and the evacuation to Darwin. METHODS A descriptive report is provided of the event and includes; resuscitation, anaesthesia, initial burns surgery management including escharotomy and fasciotomy, head injury management and importance of supplies and medical records with a description of the evacuation to Darwin. RESULTS Operation Bali Assist involved five C130 Hercules aircraft and aeromedical evacuation medical and nursing teams managing 66 casualties in the Denpasar area and their evacuation to Royal Darwin Hospital with ketamine the most useful anaesthetic agent and cling film the most useful burns dressing. Twelve procedures were performed at the ASF including seven escharotomies, three fasciotomies and two closed reductions. One escharotomy was performed in flight. DISCUSSION The important lessons learnt from the exercise is the inclusion of a surgeon in the aeromedical evacuation team, the importance of debridement and delayed primary closure, the usefulness of cling film as a burns dressing and the importance of continuous assessment. Future disaster planning exercises need to consider a patient age mix that might be expected in a shopping mall, rather than the young adult encountered in Bali, a more familiar age mix for Australian Defence Force medical staff.
Collapse
Affiliation(s)
- David Read
- Department of Surgery, Royal Darwin Hospital, Darwin, NT, Australia.
| | | |
Collapse
|
48
|
Demetriades AK, Cox TCS, Watkins LD. Hyperacute head injuries and the timing of computed tomography. J Trauma 2004; 57:925. [PMID: 15514556 DOI: 10.1097/01.ta.0000082149.79974.e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Andreas K Demetriades
- Department of Neurosurgery , National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
| | | | | |
Collapse
|
49
|
Atzema C, Mower WR, Hoffman JR, Holmes JF, Killian AJ, Oman JA, Shen AH, Greenwood SD. Defining “therapeutically inconsequential” head computed tomographic findings in patients with blunt head trauma. Ann Emerg Med 2004; 44:47-56. [PMID: 15226708 DOI: 10.1016/j.annemergmed.2004.02.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Many injuries detected by computed tomographic (CT) imaging of blunt head trauma patients are considered "therapeutically inconsequential." We estimate the prevalence of these findings and determine how frequently affected patients had "important neurosurgical outcomes," defined as either a directed intervention or a poor Glasgow Outcome Scale score. METHODS We prospectively enrolled all blunt head trauma patients undergoing emergency head CT imaging at 18 centers participating in the National Emergency X-radiography Utilization Study II (NEXUS). From these cases, we identified all patients whose official CT reading met predefined criteria for "therapeutically inconsequential" injuries. We obtained detailed follow-up information on all such patients at 6 sites, including the need for neurosurgical intervention and Glasgow Outcome Scale scores. Among patients having "important neurosurgical outcomes," we assessed the frequency of 2 potential clinical identifiers: altered mental status and coagulopathy. RESULTS "Therapeutically inconsequential" head CT findings were present in 155 of 8,374 subjects (1.85%; 95% confidence interval 1.57% to 2.16%). Sites participating in the follow-up study enrolled 81 of these patients, of whom 10 (12%) had "important neurosurgical outcomes." Follow-up information was available for 9 patients, all of whom had abnormal mental status at CT scanning. Coagulopathy was also present in 5 of 7 patients for whom coagulation status was known. CONCLUSION "Therapeutically inconsequential" findings are identified in less than 2% of blunt head trauma patients who undergo CT scanning. A small proportion of these patients have an "important neurosurgical outcome," but it appears that such patients may be identified clinically by the presence of abnormal mental status or coagulopathy.
Collapse
Affiliation(s)
- Clare Atzema
- Emergency Medicine Center, University of California-Los Angeles School of Medicine, Los Angeles, CA 90024, USA
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Ibañez J, Arikan F, Pedraza S, Sánchez E, Poca MA, Rodriguez D, Rubio E. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg 2004; 100:825-34. [PMID: 15137601 DOI: 10.3171/jns.2004.100.5.0825] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aims of this study were to analyze the relevance of risk factors in mild head injury (MHI) by studying the possibility of establishing prediction models based on these factors and to evaluate the reliability of the clinical guidelines proposed for the management of MHI. METHODS A series of 1101 patients with MHI were prospectively enrolled in this study. In all cases clinical data were collected and a computerized tomography (CT) scan was obtained. The relationship between clinical findings and the presence of intracranial lesions was studied to establish prediction models based on logistic regression and recursive partitioning analysis. Recently proposed guidelines and recommendations for the treatment of MHI were selected, calculating their diagnostic efficiency when applying each of them to our series. The incidence of acute intracranial lesions was 7.5% (83 patients). A Glasgow Coma Scale score of 14, loss of consciousness, vomiting, headache, signs of basilar skull fracture, neurological deficit, coagulopathies, hydrocephalus treated with shunt insertion, associated extracranial lesions, and patient age greater than 65 years were identified as independent risk factors. Prediction models built on clinical variables were able to indicate patients with clinically important lesions, but failed to achieve 100% sensitivity in the detection of all patients with CT scans positive for intracranial lesions within reasonable specificity limits. CONCLUSIONS Clinical variables are insufficient to predict all cases of intracranial lesions following MHI, although they can be used to detect patients with relevant injuries. Avoiding systematic CT scan indication implies a rate of misdiagnosis that should be known and assumed when planning treatment in these patients by using guidelines based on clinical parameters.
Collapse
MESH Headings
- Adolescent
- Adult
- Aged
- Brain Concussion/complications
- Brain Concussion/diagnosis
- Brain Concussion/therapy
- Cerebral Hemorrhage, Traumatic/diagnosis
- Cerebral Hemorrhage, Traumatic/etiology
- Cerebral Hemorrhage, Traumatic/therapy
- Cerebral Ventricles/pathology
- Emergency Service, Hospital
- Female
- Glasgow Coma Scale
- Head Injuries, Closed/complications
- Head Injuries, Closed/diagnosis
- Head Injuries, Closed/therapy
- Hematoma, Epidural, Cranial/diagnosis
- Hematoma, Epidural, Cranial/etiology
- Hematoma, Epidural, Cranial/therapy
- Hematoma, Subdural/diagnosis
- Hematoma, Subdural/etiology
- Hematoma, Subdural/therapy
- Humans
- Logistic Models
- Male
- Middle Aged
- Neurologic Examination
- Pneumocephalus/diagnosis
- Pneumocephalus/etiology
- Pneumocephalus/therapy
- Practice Guidelines as Topic
- Prospective Studies
- Risk Factors
- Spain
- Tomography, X-Ray Computed
Collapse
Affiliation(s)
- Javier Ibañez
- Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain.
| | | | | | | | | | | | | |
Collapse
|