Noninvasive assessment of the intracranial pressure in non-traumatic intracranial hemorrhage.

PubMed

Vaiman, Michael; Sigal, Tal; Kimiagar, Itzhak; Bekerman, Inessa

2016-12-01

The article describes the modified technique of measuring the diameters of the optic nerve sheath (ONSD) for assessment of the intracranial pressure (ICP) in patients with intracerebral or subarachnoid hemorrhage (SAH). The CT scans of 443 patients were analyzed retrospectively. The ONSDs were measured at 3mm behind the globe and at the point where the ophthalmic artery crosses the optic nerve. The ONSD/eyeball transverse diameter (ETD) ratio was calculated. The correlation analysis was performed with the Glasgow Coma Scale score, Hemispheric Stroke Scale score, Glasgow Outcome Score, and invasive ICP readings. ONSD was enlarged in 95% of patients with intracerebral hemorrhage or SAH. Pathological ONSDs were 6.6±0.8mm (cut-off value >5.5mm; p<0.05). ONSD/ETD ratio was 0.29±0.05 against normative 0.19±0.02 (p<0.01) with no correlation with initial Glasgow Coma Scale score or Hemispheric Stroke Scale score. There was an inverse correlation between ONSD/ETD ratio and Glasgow Outcome Score (r=-0.7) and direct correlation with invasive ICP readings. This study provides further evidence that in patients with intracranial hemorrhage and SAH, the presence of ONSD greater than a threshold of 5.5mm is significantly predictive of invasively measured elevated ICP. The prediction of raised ICP can be further refined by measuring ONSD at the point where the optic nerve and the ophthalmic artery cross, and by determining the ratio between the ONSD and ETD. Copyright © 2016 Elsevier Ltd. All rights reserved.

Neurotrauma pediatric scales

PubMed Central

Alexandru, Vlad Ciurea; Aurelia, Mihaela Sandu; Mihai, Popescu; Stefan, Mircea Iencean; Bogdan, Davidescu

2008-01-01

Cranial traumas have different particularities in infants, toddlers, preschool child, school child and teenagers. The assessment of these cases must be individualized according to age. It is completely different in children that in adults. Trauma scales, very useful in grading the severity and predicting outcome in traumatic brain injury, used in adults must be adapted in children. Children have age-related specificity and anatomic particularities, for each of this period of development. Neurotrauma scales, specific for infants and children, such as Pediatric Coma Scale, Children’s Coma Score, Trauma Infant Neurological Score, Glasgow Coma Scale, Liege Scale are reviewed, as well as neurotrauma outcome scales, like Glasgow Outcome Scale, modified Rankin score, KOSCHI score and Barthel Index. The authors present these scales in an exhaustive manner for thoroughgoing pediatric neurotrauma standards. PMID:20108520

First CT findings and improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury.

PubMed

Corral, Luisa; Herrero, José Ignacio; Monfort, José Luis; Ventura, José Luis; Javierre, Casimiro F; Juncadella, Montserrat; García-Huete, Lucía; Bartolomé, Carlos; Gabarrós, Andreu

2009-05-01

To analyse the association between individual initial computerized tomography (CT) scan characteristics and Glasgow Outcome Scale (GOS) and Extended Glasgow Outcome Scale (GOSE) improvement between 6 months and 1 year. Two hundred and twenty-four adult patients with severe traumatic brain injury and Glasgow Coma Scale (GCS) score of 8 or less who were admitted to an intensive care unit were studied. GOS and GOSE scores were obtained 6 and 12 months after injury in 203 subjects. Patients were predominantly male (84%) and median age was 35 years. Traumatic Coma Data Bank (TCDB) CT classification was associated with GOS/GOSE improvement between 6 months and 1 year, with diffuse injury type I, type II and evacuated mass improving more than diffuse injury type III, type IV and non-evacuated mass; for GOS 43/155 (28%) vs 3/48 (6%) (chi(2) = 9.66, p < 0.01) and for GOSE 71/155 (46%) vs 7/48 (15%) (chi(2) = 15.1, p < 0.01). CT individual abnormalities were not associated with GOS/GOSE improvement, with the exception of subarachnoid haemorrhage, which showed a negative association with GOSE improvement (chi(2) = 4.08, p < 0.05). TCDB CT scan classification and subarachnoid haemorrhage were associated with GOS/GOSE improvement from 6-12 months, but individual CT abnormalities were not associated.

Rapid reduction of acute subdural hematoma and redistribution of hematoma: case report.

PubMed

Watanabe, Arata; Omata, Tomohiro; Kinouchi, Hiroyuki

2010-01-01

An 88-year-old woman presented with acute subdural hematoma (ASDH) which showed rapid resolution on computed tomography (CT) and magnetic resonance (MR) imaging. She was transferred to our hospital after falling out of bed. On admission, she was comatose with Japan Coma Scale score of 200 and Glasgow Coma Scale score of E1V1M2. Brain CT showed a thick left frontotemporal ASDH. Conservative treatment consisted of 200 ml of glycerol administered intravenously twice a day, and maintenance in the approximately 20 degree head-up position to reduce intracranial pressure. Three days later, her consciousness recovered to Japan Coma Scale score of 30 and Glasgow Coma Scale score of E2V4M5. CT showed obvious reduction of the hematoma without brain or scalp swelling. Spinal MR imaging detected no redistribution of hematoma to the spine. The present case illustrates that rapid spontaneous reduction of ASDH may occur by redistribution of hematoma, mainly to the supratentorial subdural space because of brain atrophy.

Pressure ulcer development in trauma patients with suspected spinal injury; the influence of risk factors present in the Emergency Department.

PubMed

Ham, H W Wietske; Schoonhoven, L Lisette; Schuurmans, M Marieke J; Leenen, L Luke P H

2017-01-01

To explore the influence of risk factors present at Emergency Department admission on pressure ulcer development in trauma patients with suspected spinal injury, admitted to the hospital for evaluation and treatment of acute traumatic injuries. Prospective cohort study setting level one trauma center in the Netherlands participants adult trauma patients transported to the Emergency Department on a backboard, with extrication collar and headblocks and admitted to the hospital for treatment or evaluation of their injuries. Between January and December 2013, 254 trauma patients were included. The following dependent variables were collected: Age, Skin color and Body Mass Index, and Time in Emergency Department, Injury Severity Score, Mean Arterial Pressure, hemoglobin level, Glasgow Coma Score, and admission ward after Emergency Department. Pressure ulcer development during admission was associated with a higher age (p 0.00, OR 1.05) and a lower Glasgow Coma Scale score (p 0.00, OR 1.21) and higher Injury Severity Scores (p 0.03, OR 1.05). Extra nutrition decreases the probability of PU development during admission (p 0.04, OR 0.20). Pressure ulcer development within the first 48h of admission was positively associated with a higher age (p 0.01, OR 1.03) and a lower Glasgow Coma Scale score (p 0.01, OR 1.16). The proportion of patients admitted to the Intensive Care Unit and Medium Care Unit was higher in patients with pressure ulcers. The pressure ulcer risk during admission is high in patients with an increased age, lower Glasgow Coma Scale and higher Injury Severity Score in the Emergency Department. Pressure ulcer risk should be assessed in the Emergency Department to apply preventive interventions in time. Copyright © 2016 Elsevier Ltd. All rights reserved.

Medical problems related to recreational drug use at nocturnal dance parties.

PubMed

Van Sassenbroeck, Diederik K; Calle, Paul A; Rousseau, Filip M; Verstraete, Alain G; Belpaire, Frans M; Monsieurs, Koenraad G; Haentjens, Raoul; Allonsius, Jacques; Van Brantegem, Jean; Haenen, Wim; Buylaert, Walter A

2003-12-01

During 'I love techno' (edition 2001), an indoor rave party attended by 37 000 people, data about medical problems (especially drug-related problems) were collected. To place these data in a wider perspective, a similar registration was done during 'De Nacht', a traditional New Year's Eve dance party held at the same location and attended by 12 000 people. Furthermore, a prospective study on the time course of the level of consciousness (Glasgow Coma Score) and blood concentrations of illicit drugs, especially gamma-hydroxybutyrate was set up. The results revealed that during 'I love techno' the incidence of medical problems was high (66.5/10 000 attendees), but not higher than during 'De Nacht' (70.0/10 000 attendees). At 'I love techno', however, mainly illicit drugs were used, more frequently leading to severe drug-related medical problems. The observations in patients with a drug-related medical problem who had taken gamma-hydroxybutyrate showed that for a given level of consciousness the gamma-hydroxybutyrate concentrations may show important differences, that the transition from coma (Glasgow Coma Score < or =7) to full recovery (Glasgow Coma Score 15) takes only 30-60 min (and only a small decrease in gamma-hydroxybutyrate concentrations), and that the time it takes before a comatose patient reaches the above-mentioned 'transition area' may be a few hours.

Central diabetes insipidus in pediatric severe traumatic brain injury.

PubMed

Alharfi, Ibrahim M; Stewart, Tanya Charyk; Foster, Jennifer; Morrison, Gavin C; Fraser, Douglas D

2013-02-01

To determine the occurrence rate of central diabetes insipidus in pediatric patients with severe traumatic brain injury and to describe the clinical, injury, biochemical, imaging, and intervention variables associated with mortality. Retrospective chart and imaging review. Children's Hospital, level 1 trauma center. Severely injured (Injury Severity Score ≥ 12) pediatric trauma patients (>1 month and <18 yr) with severe traumatic brain injury (presedation Glasgow Coma Scale ≤ 8 and head Maximum Abbreviated Injury Scale ≥ 4) that developed acute central diabetes insipidus between January 2000 and December 2011. Of 818 severely injured trauma patients, 180 had severe traumatic brain injury with an overall mortality rate of 27.2%. Thirty-two of the severe traumatic brain injury patients developed acute central diabetes insipidus that responded to desamino-8-D-arginine vasopressin and/or vasopressin infusion, providing an occurrence rate of 18%. At the time of central diabetes insipidus diagnosis, median urine output and serum sodium were 6.8 ml/kg/hr (interquartile range = 5-11) and 154 mmol/L (interquartile range = 149-159), respectively. The mortality rate of central diabetes insipidus patients was 87.5%, with 71.4% declared brain dead after central diabetes insipidus diagnosis. Early central diabetes insipidus onset, within the first 2 days of severe traumatic brain injury, was strongly associated with mortality (p < 0.001), as were a lower presedation Glasgow Coma Scale (p = 0.03), a lower motor Glasgow Coma Scale (p = 0.01), an occurrence of fixed pupils (p = 0.04), and a prolonged partial thromboplastin time (p = 0.04). Cerebral edema on the initial computed tomography, obtained in the first 24 hrs after injury, was the only imaging finding associated with death (p = 0.002). Survivors of central diabetes insipidus were more likely to have intracranial pressure monitoring (p = 0.03), have thiopental administered to induce coma (p = 0.04) and have received a decompressive craniectomy for elevated intracranial pressure (p = 0.04). The incidence of central diabetes insipidus in pediatric patients with severe traumatic brain injury is 18%. Mortality was associated with early central diabetes insipidus onset and cerebral edema on head computed tomography. Central diabetes insipidus nonsurvivors were less likely to have received intracranial pressure monitoring, thiopental coma and decompressive craniectomy.

Reflex cough PEF as a predictor of successful extubation in neurological patients*

PubMed Central

Kutchak, Fernanda Machado; Debesaitys, Andressa Maciel; Rieder, Marcelo de Mello; Meneguzzi, Carla; Skueresky, Amanda Soares; Alberto, Luiz; Bianchin, Marino Muxfeldt

2015-01-01

Abstract Objective: To evaluate the use of reflex cough PEF as a predictor of successful extubation in neurological patients who were candidates for weaning from mechanical ventilation. Methods: This was a cross-sectional study of 135 patients receiving mechanical ventilation for more than 24 h in the ICU of Cristo Redentor Hospital, in the city of Porto Alegre, Brazil. Reflex cough PEF, the rapid shallow breathing index, MIP, and MEP were measured, as were ventilatory, hemodynamic, and clinical parameters. Results: The mean age of the patients was 47.8 ± 17 years. The extubation failure rate was 33.3%. A reflex cough PEF of < 80 L/min showed a relative risk of 3.6 (95% CI: 2.0-6.7), and the final Glasgow Coma Scale score showed a relative risk of 0.64 (95% CI: 0.51-0.83). For every 1-point increase in a Glasgow Coma Scale score of 8, there was a 36% reduction in the risk of extubation failure. Conclusions: Reflex cough PEF and the Glasgow Coma Scale score are independent predictors of extubation failure in neurological patients admitted to the ICU. PMID:26398756

The relationship between pneumonia and Glasgow coma scale assessment on acute stroke patients

NASA Astrophysics Data System (ADS)

Ritarwan, K.; Batubara, C. A.; Dhanu, R.

2018-03-01

Pneumonia is one of the most frequent medical complications of a stroke. Despite the well-documented association of a stroke associated infections with increased mortality and worse long-term outcome, on the other hand, the limited data available on independent predictors of pneumonia in acute stroke patients in an emergency unit. To determine the independentrelationship between pneumonia and Glasgow Coma Scale assessment on acute stroke patients. The cohort retrospective study observed 55 acute stroke patients who stayed in intensive care unit Adam Malik General Hospital from January until August 2017. Pneumonia was more frequent in patients with Ischemic stroke (OR 5.40; 95% CI: 1.28 – 6.40, p=0.003), higher National Institute of Health Stroke Scale (NIHSS) (p=0.014) and lower Glasgow Coma Scale (p=0.0001). Analysis multivariate logistic regression identified NIHSS as an independent of predictors of pneumonia (95% CI : 1.047 – 1.326, p=0.001). Pneumonia was associated with severity and type of stroke and length of hospital stay. The severity of the deficits evaluated by the NIHSS was shown to be the only independent risk factor for pneumonia in acute stroke patients.

Predictors of Outcome of Convulsive Status Epilepticus Among an Egyptian Pediatric Tertiary Hospital.

PubMed

Halawa, Eman F; Draz, Iman; Ahmed, Dalia; Shaheen, Hala A

2015-11-01

Convulsive status epilepticus is a common neurologic emergency in pediatrics. We aimed to study the etiology, clinical features, and prognostic factors among pediatric patients with convulsive status epilepticus. Seventy patients were included in this cohort study from pediatric emergency department of the specialized Children Hospital of Cairo University. The outcome was evaluated using the Glasgow Outcome Score. Acute symptomatic etiology was the most common cause of convulsive status epilepticus. Refractory convulsive status epilepticus was observed more significantly in cases caused by acute symptomatic etiologies. The outcome was mortality in 26 (37.1%) patients, severe disability in 15 (21.4%), moderate disability in 17 (24.3%), and good recovery in 12 (17.1%) patients. The significant predictor of mortality was lower modified Glasgow Coma Scale score on admission, whereas lower modified Glasgow Coma Scale score on admission and refractory convulsive status epilepticus were the significant predictors for disability and mortality. © The Author(s) 2015.

Acute subdural hematoma because of boxing.

PubMed

Kushi, Hidehiko; Saito, Takeshi; Sakagami, Yuichiro; Ohtsuki, Jyoji; Tanjoh, Katsuhisa

2009-02-01

To identify factors determining the clinical characteristics and prognosis of acute subdural hematoma (ASDH) arising from boxing injuries by comparing with ASDH due to any nonboxing cause. Two groups were selected for this study: 10 patients with ASDH because of boxing injuries and 26 patients with nonboxer ASDH. All of the patients underwent neurologic examination by neurosurgeons. Primary resuscitation and stabilization as well as operative therapy were performed to all patients according to the European Brain Injury Consortium Guidelines. Two groups were compared in terms of age, the Glasgow Coma Scale at admission, neurologic findings, craniogram and brain computed tomography scan findings, operative findings, and prognosis. As potential prognostic indicators for boxers, the time interval until surgery, the Glasgow Outcome Scale, hematoma thickness, midline shift, and the site of bleeding were analyzed. The characteristics of patients because of boxing injuries are that patients were younger, had lucid interval, and had no cerebral contusion or contralateral brain injury. There was no significant difference in initial Glasgow Coma Scale, hematoma thickness, midline shift, and their prognosis. The most peculiar clinical presentation of boxers' ASDH was that all bleedings were limited from "bridging veins" or "cortical veins." The prognosis of boxers was most closely correlated with the site of bleeding (r2 = 0.81; p = 0.0001) and the midline shift (r2 = 0.67; p = 0.007). Our study shows that ASDH because of boxing is characterized by bleeding from bridging or cortical veins, and that the site of bleeding is a significant determinant of their prognosis.

Repetitive transcranial magnetic stimulation improves consciousness disturbance in stroke patients: A quantitative electroencephalography spectral power analysis.

PubMed

Xie, Ying; Zhang, Tong

2012-11-05

Repetitive transcranial magnetic stimulation is a noninvasive treatment technique that can directly alter cortical excitability and improve cerebral functional activity in unconscious patients. To investigate the effects and the electrophysiological changes of repetitive transcranial magnetic stimulation cortical treatment, 10 stroke patients with non-severe brainstem lesions and with disturbance of consciousness were treated with repetitive transcranial magnetic stimulation. A quantitative electroencephalography spectral power analysis was also performed. The absolute power in the alpha band was increased immediately after the first repetitive transcranial magnetic stimulation treatment, and the energy was reduced in the delta band. The alpha band relative power values slightly decreased at 1 day post-treatment, then increased and reached a stable level at 2 weeks post-treatment. Glasgow Coma Score and JFK Coma Recovery Scale-Revised score were improved. Relative power value in the alpha band was positively related to Glasgow Coma Score and JFK Coma Recovery Scale-Revised score. These data suggest that repetitive transcranial magnetic stimulation is a noninvasive, safe, and effective treatment technology for improving brain functional activity and promoting awakening in unconscious stroke patients.

Neuroanatomical Predictors of Awakening in Acutely Comatose Patients

PubMed Central

Kowalski, Robert G.; Buitrago, Manuel M.; Duckworth, Josh; Chonka, Zachary D.; Puttgen, H. Adrian; Stevens, Robert D.; Geocadin, Romergryko G.

2016-01-01

Objective Lateral brain displacement has been associated with loss of consciousness and poor outcome in a range of acute neurologic disorders. We studied the association between lateral brain displacement and awakening from acute coma. Methods This prospective observational study included all new onset coma patients admitted to the Neurosciences Critical Care Unit (NCCU) over 12 consecutive months. Head computed tomography (CT) scans were analyzed independently at coma onset, after awakening, and at follow-up. Primary outcome measure was awakening, defined as the ability to follow commands before hospital discharge. Secondary outcome measures were discharge Glasgow Coma Scale (GCS), modified Rankin Scale, Glasgow Outcome Scale, and hospital and NCCU lengths of stay. Results Of the 85 patients studied, the mean age was 58 ± 16 years, 51% were female, and 78% had cerebrovascular etiology of coma. Fifty-one percent of patients had midline shift on head CT at coma onset and 43 (51%) patients awakened. In a multivariate analysis, independent predictors of awakening were younger age (odds ratio [OR] = 1.039, 95% confidence interval [CI] = 1.002–1.079, p = 0.040), higher GCS score at coma onset (OR = 1.455, 95% CI = 1.157–1.831, p = 0.001), nontraumatic coma etiology (OR = 4.464, 95% CI = 1.011–19.608, p = 0.048), lesser pineal shift on follow-up CT (OR = 1.316, 95% CI = 1.073–1.615, p = 0.009), and reduction or no increase in pineal shift on follow-up CT (OR = 11.628, 95% CI = 2.207–62.500, p = 0.004). Interpretation Reversal and/or limitation of lateral brain displacement are associated with acute awakening in comatose patients. These findings suggest objective parameters to guide prognosis and treatment in patients with acute onset of coma. PMID:25628166

Right median nerve electrical stimulation for acute traumatic coma (the Asia Coma Electrical Stimulation trial): study protocol for a randomised controlled trial.

PubMed

Wu, Xiang; Zhang, Chao; Feng, Junfeng; Mao, Qing; Gao, Guoyi; Jiang, Jiyao

2017-07-10

Traumatic brain injury (TBI) has become the most common cause of death and disability in persons between 15 and 30 years of age, and about 10-15% of patients affected by TBI will end up in a coma. Coma caused by TBI presents a significant challenge to neuroscientists. Right median nerve electrical stimulation has been reported as a simple, inexpensive, non-invasive technique to speed recovery and improve outcomes for traumatic comatose patients. This multicentre, prospective, randomised (1:1) controlled trial aims to demonstrate the efficacy and safety of electrical right median nerve stimulation (RMNS) in both accelerating emergence from coma and promoting long-term outcomes. This trial aims to enrol 380 TBI comatose patients to partake in either an electrical stimulation group or a non-stimulation group. Patients assigned to the stimulation group will receive RMNS in addition to standard treatment at an amplitude of 15-20 mA with a pulse width of 300 μs at 40 Hz ON for 20 s and OFF for 40 s. The electrical treatment will last for 8 h per day for 2 weeks. The primary endpoint will be the percentage of patients regaining consciousness 6 months after injury. The secondary endpoints will be Extended Glasgow Outcome Scale, Coma Recovery Scale-Revised and Disability Rating Scale scores at 28 days, 3 months and 6 months after injury; Glasgow Coma Scale, Glasgow Coma Scale Motor Part and Full Outline of Unresponsiveness scale scores on day 1 and day 7 after enrolment and 28 days, 3 months and 6 months after injury; duration of unconsciousness and mechanical ventilation; length of intensive care unit and hospital stays; and incidence of adverse events. Right median nerve electrical stimulation has been used as a safe, inexpensive, non-invasive therapy for neuroresuscitation of coma patients for more than two decades, yet no trial has robustly proven the efficacy and safety of this treatment. The Asia Coma Electrical Stimulation (ACES) trial has the following novel features compared with other major RMNS trials: (1) the ACES trial is an Asian multicentre randomised controlled trial; (2) RMNS therapy starts at an early stage 7-14 days after the injury; and (3) various assessment scales are used to evaluate the condition of patients. We hope the ACES trial will lead to optimal use of right median nerve electrical treatment. ClinicalTrials.gov, NCT02645578 . Registered on 23 December 2015.

Development of an objective tool for the diagnosis of myxedema coma.

PubMed

Chiong, Yien V; Bammerlin, Elaine; Mariash, Cary N

2015-09-01

Myxedema coma, a rare entity, with a reported 25%-65% mortality had no objective criteria for making the diagnosis when we began our study. We developed an objective screening tool for myxedema coma to more easily identify patients and examine the best treatment method in future prospective studies to reduce the mortality of this entity. We conducted a retrospective chart review to find all patients aged ≥18 years admitted with myxedema coma from January 1, 2005 through June 13, 2010 at Indiana University Health Methodist Hospital. On the basis of both our retrospective chart review and on literature accounts, we identified 6 criteria to diagnose myxedema coma. We identified 10 patients initially diagnosed with myxedema coma and established a control group consisting of 13 patients identified with altered mental status and increased thyroid-stimulating hormone (TSH) levels. The 6 variables we created for the screening tool were heart rate, temperature, Glasgow coma scale, TSH, free thyroxine, and precipitating factors. The screening tool has a sensitivity and specificity of about 80%. We ran a logistic regression model using the 10 study patients and 13 controls with the 6 variables. No variables alone significantly contributed to the model. However, the overall model was highly significant (P = 0.012), providing strong support for a scoring system that uses these variables simultaneously. This screening tool enables physicians to rapidly diagnose myxedema coma to expedite treatment. A more refined diagnostic tool may be used in future clinical studies designed to determine the optimal treatment. Copyright © 2015 Elsevier Inc. All rights reserved.

Recovery of Patients with Pure Diffuse Axonal Injury Who Remained in a Coma for 6 Hours or More.

PubMed

Almeida Vieira, Rita de Cássia; Paiva, Wellingson Silva; de Oliveira, Daniel Vieira; de Paula Guirado, Vinícius Monteiro; Caetano Lança, Ellen de Fátima; de Sousa, Regina Márcia Cardoso

2018-01-01

Diffuse axonal injury (DAI) is a traumatic brain injury and one of the most common causes of unfavorable outcome and death. The aim of this study was to investigate the recovery of patients with pure DAI who remained in a coma for 6 hours or longer after brain injury. This was a follow-up study of 75 patients diagnosed with pure DAI, aged 18-60 years, with a Glasgow Coma Scale score ≤8 at hospital admission. Patient data were collected at hospital admission, hospital discharge, and 3 and 6 months after DAI. Recovery was assessed by score changes in the Katz Index of Independence in Activities of Daily Living and Extended Glasgow Outcome Scale. The percentage of patients in a coma for 6-24 hours, >24 hours without brainstem signs, and >24 hours with brainstem signs was 42.7%, 20%, and 37.3%, respectively. The 6-month mortality rate was 32.0%, and the mean Extended Glasgow Outcome Scale score among survivors decreased from 3.8 at discharge (SD = 1.2) to 2.1 at 3 months (SD = 1.6) and 1.2 at 6 months (SD = 1.6). The mean Katz Index of Independence in Activities of Daily Living scores were 8.5 (SD = 5.5), 3.5 (SD = 5.8), and 1.8 (SD = 4.5) at discharge and 3 and 6 months after trauma, respectively. Statistically significant differences were observed among the 3 evaluation periods. Mortality was high among patients with DAI, but almost all survivors had favorable outcomes at 6 months. Functional improvement was more pronounced in the first 3 months. Copyright © 2017. Published by Elsevier Inc.

Dysphagia Management and Research in an Acute-Care Military Treatment Facility: The Role of Applied Informatics.

PubMed

Solomon, Nancy Pearl; Dietsch, Angela M; Dietrich-Burns, Katie E; Styrmisdottir, Edda L; Armao, Christopher S

2016-05-01

This report describes the development and preliminary analysis of a database for traumatically injured military service members with dysphagia. A multidimensional database was developed to capture clinical variables related to swallowing. Data were derived from clinical records and instrumental swallow studies, and ranged from demographics, injury characteristics, swallowing biomechanics, medications, and standardized tools (e.g., Glasgow Coma Scale, Penetration-Aspiration Scale). Bayesian Belief Network modeling was used to analyze the data at intermediate points, guide data collection, and predict outcomes. Predictive models were validated with independent data via receiver operating characteristic curves. The first iteration of the model (n = 48) revealed variables that could be collapsed for the second model (n = 96). The ability to predict recovery from dysphagia improved from the second to third models (area under the curve = 0.68 to 0.86). The third model, based on 161 cases, revealed "initial diet restrictions" as first-degree, and "Glasgow Coma Scale, intubation history, and diet change" as second-degree associates for diet restrictions at discharge. This project demonstrates the potential for bioinformatics to advance understanding of dysphagia. This database in concert with Bayesian Belief Network modeling makes it possible to explore predictive relationships between injuries and swallowing function, individual variability in recovery, and appropriate treatment options. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

Coma Associated with Microscopy-Diagnosed Plasmodium vivax: A Prospective Study in Papua, Indonesia

PubMed Central

Hardianto, Setiawan O.; Tjitra, Emiliana; Kenangalem, Enny; Sugiarto, Paulus; Price, Ric N.; Anstey, Nicholas M.

2011-01-01

Background Coma complicates Plasmodium falciparum infection but is uncommonly associated with P. vivax. Most series of vivax coma have been retrospective and have not utilized molecular methods to exclude mixed infections with P. falciparum. Methods We prospectively enrolled patients hospitalized in Timika, Indonesia, with a Glasgow Coma Score (GCS) ≤10 and P. vivax monoinfection on initial microscopy over a four year period. Hematological, biochemical, serological, radiological and cerebrospinal fluid (CSF) examinations were performed to identify other causes of coma. Repeat microscopy, antigen detection and polymerase chain reaction (PCR) were performed to exclude infections with other Plasmodium species. Results Of 24 patients fulfilling enrolment criteria, 5 had clear evidence for other non-malarial etiologies. PCR demonstrated 10 mixed infections and 3 P. falciparum monoinfections. 6 (25%) patients had vivax monoinfection and no apparent alternative cause, with a median GCS of 9 (range 8–10) and a median coma duration of 42 (range 36–48) hours. CSF leukocyte counts were <10/ul (n = 3); 2 of the 3 patients without CSF examination recovered with antimalarial therapy alone. One patient had a tremor on discharge consistent with a post-malarial neurological syndrome. No patient had other organ dysfunction. The only death was associated with pure P. falciparum infection by PCR. Vivax monoinfection-associated risk of coma was estimated at 1 in 29,486 clinical vivax infections with no deaths. In comparison, the risk of falciparum-associated coma was estimated at 1 in 1,276 clinical infections with an 18.5% mortality rate. Conclusions P. vivax-associated coma is rare, occurring 23 times less frequently than that seen with falciparum malaria, and is associated with a high proportion of non-malarial causes and mixed infections using PCR. The pathogenesis of coma associated with vivax malaria, particularly the role of comorbidities, is uncertain and requires further investigation. PMID:21666785

Effect of private versus emergency medical systems transportation in motor vehicle accident victims: Trauma Center Experience in Saudi Arabia.

PubMed

Alshahrani, Mohammed S

2017-01-01

To assess the effect of the mode of transportation of trauma patients (emergency medical service [EMS] vs. non-EMS) on their final clinical outcome in terms of mortality and length of hospital stay. A retrospective study included all patients who were involved in motor vehicle crashes, and who were transferred immediately to an emergency department of a trauma care center from December 2008 to December 2012. Patients were classified into two groups: those brought through EMS and those brought by non-EMS (private transport). Information on demographic characteristics including age and gender was recorded and medical data such as blood pressure, pulse, oxygen saturation, temperature, initial Glasgow Coma Score (GCS), saturation, temperature, initial Glasgow Coma Score (GCS), injury severity score (ISS), and final outcome (discharged or expired) were obtained. Descriptive statistics, mean and standard deviation (SD) were computed for continuous variables and statistical significance was tested by t -test or Mann-Whitney U-test. Categorical variables were described by frequency distribution and percentages; Chi-square or Fisher's exact test as appropriate were employed to test for statistical significance. Logistics regression was performed with mortality as dependent variable and mode of transport and all demographic and prehospital variables as independent variables. A general linear model analysis was performed to test whether the mode of transport was significant to length of hospital stay in EMS and non-EMS clients. Out of 308 patients identified during the study period, 232 were transported through EMS and 76 through non-EMS. The two groups were similar with regard to mortality and length of stay. The crude mortality rate was 30.6% (95% confidence interval [CI]: 24.64-36.53) in the EMS group and 28.9% (95% CI: 18.44-38.76) in the non-EMS group ( p = 0.785). The average length of hospital stay was 9 days (interquartile range [IQR] = 8, 95% CI: 7.3-10.1) for the EMS group and 8 days (IQR = 9.5, 95% CI: 6.7-10.9) for the non-EMS group ( p = 0.803). Multivariate analysis showed that of the study variables, only the injury severity score (ISS) and Glasgow coma score (GCS) were significant to mortality ( p < 0.01), and GCS was more significant to the length of hospital stay ( p < 0.01). There was no significant difference between the EMS and non-EMS groups as they relate to mortality and length of stay in hospital. However, the mortality and length of hospital stay was statistically significant to ISS and GCS.

Gastrointestinal bleeding after intracerebral hemorrhage: a retrospective review of 808 cases.

PubMed

Yang, Tie-Cheng; Li, Jian-Guo; Shi, Hong-Mei; Yu, Dong-Ming; Shan, Kai; Li, Li-Xia; Dong, Xiao-Yan; Ren, Tian-Hua

2013-10-01

This study examined the incidence and risk factors for gastrointestinal (GI) bleeding after spontaneous intracerebral hemorrhage (ICH). The available medical records of patients with ICH admitted from June 2008 to December 2009 for any episode of GI bleeding, possible precipitating factors and administration of ulcer prophylaxis were reviewed. The prevalence of GI bleeding was 26.7%, including 3 cases of severe GI bleeding (0.35%). Patients with GI bleeding had significantly longer hospital stay and higher in-hospital mortality compared with patients without GI bleeding. Multivariate logistic regression analyses showed that age, Glasgow Coma Scale scores, sepsis and ICH volume were independent predictors of GI bleeding. About 63.4% of patients with ICH received stress ulcer prophylaxis. GI bleeding occurred frequently after ICH, but severe events were rare. Age, Glasgow Coma Scale score, sepsis and ICH volume were independent predictors of GI bleeding occurring after ICH.

Inclusion of Highest Glasgow Coma Scale Motor Component Score in Mortality Risk Adjustment for Benchmarking of Trauma Center Performance.

PubMed

Gomez, David; Byrne, James P; Alali, Aziz S; Xiong, Wei; Hoeft, Chris; Neal, Melanie; Subacius, Harris; Nathens, Avery B

2017-12-01

The Glasgow Coma Scale (GCS) is the most widely used measure of traumatic brain injury (TBI) severity. Currently, the arrival GCS motor component (mGCS) score is used in risk-adjustment models for external benchmarking of mortality. However, there is evidence that the highest mGCS score in the first 24 hours after injury might be a better predictor of death. Our objective was to evaluate the impact of including the highest mGCS score on the performance of risk-adjustment models and subsequent external benchmarking results. Data were derived from the Trauma Quality Improvement Program analytic dataset (January 2014 through March 2015) and were limited to the severe TBI cohort (16 years or older, isolated head injury, GCS ≤8). Risk-adjustment models were created that varied in the mGCS covariates only (initial score, highest score, or both initial and highest mGCS scores). Model performance and fit, as well as external benchmarking results, were compared. There were 6,553 patients with severe TBI across 231 trauma centers included. Initial and highest mGCS scores were different in 47% of patients (n = 3,097). Model performance and fit improved when both initial and highest mGCS scores were included, as evidenced by improved C-statistic, Akaike Information Criterion, and adjusted R-squared values. Three-quarters of centers changed their adjusted odds ratio decile, 2.6% of centers changed outlier status, and 45% of centers exhibited a ≥0.5-SD change in the odds ratio of death after including highest mGCS score in the model. This study supports the concept that additional clinical information has the potential to not only improve the performance of current risk-adjustment models, but can also have a meaningful impact on external benchmarking strategies. Highest mGCS score is a good potential candidate for inclusion in additional models. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Mannitol dosing error during interfacility transfer for intracranial emergencies.

PubMed

Elliott, Cameron A; MacKenzie, Mark; O'Kelly, Cian J

2015-11-01

Mannitol is commonly used to treat elevated intracranial pressure (ICP). The authors analyzed mannitol dosing errors at peripheral hospitals prior to or during transport to tertiary care facilities for intracranial emergencies. They also investigated the appropriateness of mannitol use based on the 2007 Brain Trauma Foundation guidelines for severe traumatic brain injury. The authors conducted a retrospective review of the Shock Trauma Air Rescue Society (STARS) electronic patient database of helicopter medical evacuations in Alberta, Canada, between 2004 and 2012, limited to patients receiving mannitol before transfer. They extracted data on mannitol administration and patient characteristics, including diagnosis, mechanism, Glasgow Coma Scale score, weight, age, and pupil status. A total of 120 patients with an intracranial emergency received a mannitol infusion initiated at a peripheral hospital (median Glasgow Coma Scale score 6; range 3-13). Overall, there was a 22% dosing error rate, which comprised an underdosing rate (<0.25 g/kg) of 8.3% (10 of 120 patients), an overdosing rate (>1.5 g/kg) of 7.5% (9 of 120), and a nonbolus administration rate (>1 hour) of 6.7% (8 of 120). Overall, 72% of patients had a clear indication to receive mannitol as defined by meeting at least one of the following criteria based on Brain Trauma Foundation guidelines: neurological deterioration (11%), severe traumatic brain injury (69%), or pupillary abnormality (25%). Mannitol administration at peripheral hospitals is prone to dosing error. Strategies such as a pretransport checklist may mitigate this risk.

The relation between persistent coma and brain ischemia after severe brain injury.

PubMed

Cheng, Quan; Jiang, Bing; Xi, Jian; Li, Zhen Yan; Liu, Jin Fang; Wang, Jun Yu

2013-12-01

To investigate the relation between brain ischemia and persistent vegetative state after severe traumatic brain injury. The 66 patients with severe brain injury were divided into two groups: The persistent coma group (coma duration ≥10 d) included 51 patients who had an admission Glasgow Coma Scale (GCS) of 5-8 and were unconscious for more than 10 d. There were 15 patients in the control group, their admission GCS was 5-8, and were unconscious for less than 10 d. The brain areas, including frontal, parietal, temporal, occipital lobes and thalamus, were measured by Single Photon Emission Computed Tomography (SPECT). In the first SPECT scan, multiple areas of cerebral ischemia were documented in all patients in both groups, whereas bilateral thalamic ischemia were presented in all patients in the persistent coma group and were absented in the control group. In the second SPECT scan taken during the period of analepsia, with an indication that unilateral thalamic ischemia were persisted in 28 of 41 patients in persistent coma group(28/41,68.29%). Persistent coma after severe brain injury is associated with bilateral thalamic ischemia.

Predictive Value of Glasgow Coma Score and Full Outline of Unresponsiveness Score on the Outcome of Multiple Trauma Patients.

PubMed

Baratloo, Alireza; Shokravi, Masumeh; Safari, Saeed; Aziz, Awat Kamal

2016-03-01

The Full Outline of Unresponsiveness (FOUR) score was developed to compensate for the limitations of Glasgow coma score (GCS) in recent years. This study aimed to assess the predictive value of GCS and FOUR score on the outcome of multiple trauma patients admitted to the emergency department. The present prospective cross-sectional study was conducted on multiple trauma patients admitted to the emergency department. GCS and FOUR scores were evaluated at the time of admission and at the sixth and twelfth hours after admission. Then the receiver operating characteristic (ROC) curve, sensitivity, specificity, as well as positive and negative predictive value of GCS and FOUR score were evaluated to predict patients' outcome. Patients' outcome was divided into discharge with and without a medical injury (motor deficit, coma or death). Finally, 89 patients were studied. Sensitivity and specificity of GCS in predicting adverse outcome (motor deficit, coma or death) were 84.2% and 88.6% at the time of admission, 89.5% and 95.4% at the sixth hour and 89.5% and 91.5% at the twelfth hour, respectively. These values for the FOUR score were 86.9% and 88.4% at the time of admission, 89.5% and 100% at the sixth hour and 89.5% and 94.4% at the twelfth hour, respectively. Findings of this study indicate that the predictive value of FOUR score and GCS on the outcome of multiple trauma patients admitted to the emergency department is similar.

Poor outcome prediction by burst suppression ratio in adults with post-anoxic coma without hypothermia.

PubMed

Yang, Qinglin; Su, Yingying; Hussain, Mohammed; Chen, Weibi; Ye, Hong; Gao, Daiquan; Tian, Fei

2014-05-01

Burst suppression ratio (BSR) is a quantitative electroencephalography (qEEG) parameter. The purpose of our study was to compare the accuracy of BSR when compared to other EEG parameters in predicting poor outcomes in adults who sustained post-anoxic coma while not being subjected to therapeutic hypothermia. EEG was registered and recorded at least once within 7 days of post-anoxic coma onset. Electrodes were placed according to the international 10-20 system, using a 16-channel layout. Each EEG expert scored raw EEG using a grading scale adapted from Young and scored amplitude-integrated electroencephalography tracings, in addition to obtaining qEEG parameters defined as BSR with a defined threshold. Glasgow outcome scales of 1 and 2 at 3 months, determined by two blinded neurologists, were defined as poor outcome. Sixty patients with Glasgow coma scale score of 8 or less after anoxic accident were included. The sensitivity (97.1%), specificity (73.3%), positive predictive value (82.5%), and negative prediction value (95.0%) of BSR in predicting poor outcome were higher than other EEG variables. BSR1 and BSR2 were reliable in predicting death (area under the curve > 0.8, P < 0.05), with the respective cutoff points being 39.8% and 61.6%. BSR1 was reliable in predicting poor outcome (area under the curve  =  0.820, P < 0.05) with a cutoff point of 23.9%. BSR1 was also an independent predictor of increased risk of death (odds ratio  =  1.042, 95% confidence intervals: 1.012-1.073, P  =  0.006). BSR may be a better predictor in prognosticating poor outcomes in patients with post-anoxic coma who do not undergo therapeutic hypothermia when compared to other qEEG parameters.

Pediatric Major Head Injury: Not a Minor Problem.

PubMed

Leetch, Aaron N; Wilson, Bryan

2018-05-01

Traumatic brain injury is a highly prevalent and devastating cause of morbidity and mortality in children. A rapid, stepwise approach to the traumatized child should proceed, addressing life-threatening problems first. Management focuses on preventing secondary injury from physiologic extremes such as hypoxemia, hypotension, prolonged hyperventilation, temperature extremes, and rapid changes in cerebral blood flow. Initial Glasgow Coma Score, hyperglycemia, and imaging are often prognostic of outcome. Surgically amenable lesions should be evacuated promptly. Reduction of intracranial pressure through hyperosmolar therapy, decompressive craniotomy, and seizure prophylaxis may be considered after stabilization. Nonaccidental trauma should be considered when evaluating pediatric trauma patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical "seatbelt sign".

PubMed

Desai, N K; Kang, J; Chokshi, F H

2014-09-01

There are no standard screening guidelines to evaluate blunt cerebrovascular injury in children. The purpose of this retrospective study was to understand the clinical and radiologic risk factors associated with pediatric blunt cerebrovascular injury on CTA of the neck with primary attention to the cervical "seatbelt sign." Radiology reports from 2002 to 2012 were queried for the examination "CTA neck." The electronic medical record was reviewed for mechanism of injury, Glasgow Coma Scale score, and physical examination findings. Radiology reports from adjunct radiographic studies were reviewed. CTA neck examinations with reported blunt cerebrovascular injury were reviewed to confirm imaging findings. Patients with penetrating injury or those without a history of trauma were excluded. Four hundred sixty-three patients underwent CTA of the neck; 137 had blunt trauma. Forty-two of 85 patients involved in a motor vehicle collision had a cervical seatbelt sign; none had blunt cerebrovascular injury. Nine vessels (4 vertebral arteries, 4 ICAs, 1 common carotid artery) in 8 patients ultimately were diagnosed with various grades (I-IV) of blunt cerebrovascular injury, representing 5.8% (8/137) of the population screened for blunt neck trauma. The mean Glasgow Coma Scale score was significantly lower (P=.02) in the blunt cerebrovascular injury group versus the non-blunt cerebrovascular injury group. Although not statistically significant, patients with blunt cerebrovascular injury had a higher tendency to have additional traumatic injuries, primarily basilar skull fractures (P=.05) and intracranial hemorrhage (P=.13). A common indication for neck CTA, the cervical seatbelt sign, was not associated with blunt cerebrovascular injury. With the exception of Glasgow Coma Scale score, no single risk factor was statistically significant in predicting vascular injury in this series. © 2014 by American Journal of Neuroradiology.

Acute diabetes insipidus in severe head injury: a prospective study.

PubMed

Hadjizacharia, Pantelis; Beale, Elizabeth O; Inaba, Kenji; Chan, Linda S; Demetriades, Demetrios

2008-10-01

The incidence and risk factors for acute diabetes insipidus after severe head injury and the effect of this complication on outcomes have not been evaluated in any large prospective studies. We conducted a prospective study of all patients admitted to the surgical ICU of a Level I trauma center with severe head injury (head Abbreviated Injury Score [AIS] >or= 3). The following potential risk factors with p < 0.2 on bivariate analysis were included in a stepwise logistic regression to identify independent risk factors for diabetes insipidus and its association with mortality: age, mechanism of injury (blunt or penetrating), blood pressure, Glasgow Coma Scale, Injury Severity Score, head and other body area AIS, skull fracture, cerebral edema and shift, intracranial hemorrhage, and pneumocephaly. There were 436 patients (blunt injuries, 392; penetrating injuries, 44); 387 patients had isolated head injury. Diabetes insipidus occurred in 15.4% of all patients (blunt, 12.5%; penetrating, 40.9%; p < 0.0001) and in 14.7% of patients with isolated head injury (blunt, 11.8%; penetrating, 39.5%; p < 0.0001). The presence of major extracranial injuries did not influence the incidence of diabetes insipidus. Independent risk factors for diabetes insipidus in isolated head injury were Glasgow Coma Scale3. Diabetes insipidus was an independent risk factor for death (adjusted odds ratio, 3.96; 95% CI [1.65, 9.72]; adjusted p value = 0.002). The incidence of acute diabetes insipidus in severe head injury is high, especially in penetrating injuries. Independent risk factors for diabetes insipidus include a Glasgow Coma Scale3. Acute diabetes insipidus was associated with significantly increased mortality.

Mortality risk after head injury increases at 30 years.

PubMed

Harris, Colin; DiRusso, Stephen; Sullivan, Tom; Benzil, Deborah L

2003-11-01

Age has long been recognized as a critical factor in predicting outcomes after head injury, with individuals older than 60 years predicted to have a worse outcome than those younger than 60. The object of this study was to determine the effect of age by decade of life beginning at birth in patients with head injuries of all levels of severity. The New York State Trauma Registry was searched for head injuries from January 1, 1994 to December 31, 1995; the 13,908 cases found were placed into age groups by decade. Data were sought for each patient on demographics, Glasgow Coma Score, ICD-9 injury code, New Injury Severity Score (NISS), and mechanism of injury. These data were analyzed with chi-square and one-way ANOVA tests, with significance set at p < 0.05. The risk of dying was significantly increased in patients beginning at 30 years of age compared with those in the younger age groups, with the greatest increases occurring after age 60 (p < 0.001). For the population with available Glasgow Coma Score data (n = 12,844), the mortality rate for patients ages 0 to 30 was 10.9%, and for patients ages 31 to 50 was 12.4%. The mean Glasgow Coma Score for nonsurvivors ages 0 to 20 (3.9) and for nonsurvivors ages 31 to 50 (5.1) were significantly different, with a risk ratio of 1.3 (p < 0.001). The risk of dying for patients suffering head injuries increases as early as 30 years of age, making it necessary for health-care providers to consider increased monitoring and treatment for patients in this younger age group.

Glasgow Coma Scale and Its Components on Admission: Are They Valuable Prognostic Tools in Acute Mixed Drug Poisoning?

PubMed Central

Eizadi Mood, N.; Sabzghabaee, A. M.; Yadegarfar, Gh.; Yaraghi, A.; Ramazani Chaleshtori, M.

2011-01-01

Introduction. The verbal, eye, and motor components of Glasgow coma scale (GCS) may be influenced by poisoned patients' behavior in an attempted suicide. So, the values of admission GCS and its components for outcomes prediction in mixed drugs poisoning were investigated. Materials and Methods. A followup study data was performed on patients with mixed drugs poisoning. Outcomes were recorded as without complications and with complications. Discrimination was evaluated by calculating the area under the receiver operating characteristic curves (AUC). Results. There was a significant difference between the mean value of each component of GCS as well as the total GCS between patients with and without complication. Discrimination was best for GCS (AUC: 0.933 ± 0.020) and verbal (0.932 ± 0.021), followed by motor (0.911 ± 0.025), then eye (0.89 ± 0.028). Conclusions. Admission GCS and its components seem to be valuable in outcome prediction of patients with mixed drug poisoning. PMID:21559299

Postoperative Conversion Disorder in Elderly Oral Cancer Patient.

PubMed

Yakushiji, Takashi; Hayashi, Kamichika; Morikawa, Takamichi; Migita, Masashi; Ogane, Satoru; Muramatsu, Kyotaro; Kamio, Takashi; Shibahara, Takahiko; Takano, Nobuo

2016-01-01

Conversion disorder is a condition in which psychological stress in response to difficult situations manifests as physical symptoms. Here, we report a case of postoperative coma due to conversion disorder in an elderly oral cancer patient. An 82-year-old woman was referred to Tokyo Dental College Chiba Hospital with a mass lesion on the tongue. A biopsy revealed a well-differentiated squamous cell carcinoma. Surgical treatment was performed for the tongue carcinoma and tracheotomy for management of the airway. On postoperative day 5, the patient exhibited loss of consciousness (Glasgow Coma Scale: E1, VT, M1; Japan Coma Scale: III-300). The patient's vital signs were all normal, as were the results of a full blood count, brain-CT, MRI, and MRA. Only the arm dropping test was positive. Therefore, the cause of the coma was diagnosed as conversion disorder. Seven hours later, the patient showed a complete recovery.

Branched chain amino acids supplemented with L-acetylcarnitine versus BCAA treatment in hepatic coma: a randomized and controlled double blind study.

PubMed

Malaguarnera, Mariano; Risino, Corrado; Cammalleri, Lisa; Malaguarnera, Lucia; Astuto, Marinella; Vecchio, Ignazio; Rampello, Liborio

2009-07-01

Our earlier study has demonstrated that the administration of L-acetylcarnitine (LAC) improves neurological symptoms and serum parameters in hepatic coma. The aim of this work has been to evaluate the efficacy of the LAC and branched chain amino acids (BCAA) versus BCAA, administered in intravenous infusion, in patients with cirrhotic hepatic coma. Forty-eight highly selected patients were enrolled in the study and, after randomization, received blindly LAC+BCAA (n=24) versus BCAA (n=24). The two groups were similar in age, sex, pathogenesis of cirrhosis, and severity of liver disease. The comparison between values before and after LAC planned treatment showed statistical significant differences in neurological findings, evaluated by the Glasgow Scale, ammonia serum levels, blood urea nitrogen, and EEG. After 60 min of the study period, the LAC+BCAA treated patients compared with BCCA treated showed a significant decrease of ammonia serum levels: 41.20 versus 10.40 mumol P<0.05. After 1 day of the study period, the LAC+BCAA treated patients compared with BCCA treated patients showed a significant increase of Glasgow's score: 3.60 versus 1.50 score P<0.05; a significant decrease of ammonia serum levels: 63.30 versus 27.00 mumol P<0.01; a significant improvement of EEG cps/s: 2.70 versus 0.6 P<0.001. No side-effects were observed in our study series. Our study demonstrated that the administration of BCAA supplemented with LAC might improve neurological symptoms and serum ammonium levels in selected cirrhotic patients with hepatic coma.

Comparison of the performances of copeptin and multiple biomarkers in long-term prognosis of severe traumatic brain injury.

PubMed

Zhang, Zu-Yong; Zhang, Li-Xin; Dong, Xiao-Qiao; Yu, Wen-Hua; Du, Quan; Yang, Ding-Bo; Shen, Yong-Feng; Wang, Hao; Zhu, Qiang; Che, Zhi-Hao; Liu, Qun-Jie; Jiang, Li; Du, Yuan-Feng

2014-10-01

Enhanced blood levels of copeptin correlate with poor clinical outcomes after acute critical illness. This study aimed to compare the prognostic performances of plasma concentrations of copeptin and other biomarkers like myelin basic protein, glial fibrillary astrocyte protein, S100B, neuron-specific enolase, phosphorylated axonal neurofilament subunit H, Tau and ubiquitin carboxyl-terminal hydrolase L1 in severe traumatic brain injury. We recruited 102 healthy controls and 102 acute patients with severe traumatic brain injury. Plasma concentrations of these biomarkers were determined using enzyme-linked immunosorbent assay. Their prognostic predictive performances of 6-month mortality and unfavorable outcome (Glasgow Outcome Scale score of 1-3) were compared. Plasma concentrations of these biomarkers were statistically significantly higher in all patients than in healthy controls, in non-survivors than in survivors and in patients with unfavorable outcome than with favorable outcome. Areas under receiver operating characteristic curves of plasma concentrations of these biomarkers were similar to those of Glasgow Coma Scale score for prognostic prediction. Except plasma copeptin concentration, other biomarkers concentrations in plasma did not statistically significantly improve prognostic predictive value of Glasgow Coma Scale score. Copeptin levels may be a useful tool to predict long-term clinical outcomes after severe traumatic brain injury and have a potential to assist clinicians. Copyright © 2014 Elsevier Inc. All rights reserved.

Autonomic Impairment in Severe Traumatic Brain Injury: A Multimodal Neuromonitoring Study.

PubMed

Sykora, Marek; Czosnyka, Marek; Liu, Xiuyun; Donnelly, Joseph; Nasr, Nathalie; Diedler, Jennifer; Okoroafor, Francois; Hutchinson, Peter; Menon, David; Smielewski, Peter

2016-06-01

Autonomic impairment after acute traumatic brain injury has been associated independently with both increased morbidity and mortality. Links between autonomic impairment and increased intracranial pressure or impaired cerebral autoregulation have been described as well. However, relationships between autonomic impairment, intracranial pressure, impaired cerebral autoregulation, and outcome remain poorly explored. Using continuous measurements of heart rate variability and baroreflex sensitivity we aimed to test whether autonomic markers are associated with functional outcome and mortality independently of intracranial variables. Further, we aimed to evaluate the relationships between autonomic functions, intracranial pressure, and cerebral autoregulation. Retrospective analysis of a prospective database. Neurocritical care unit in a university hospital. Sedated patients with severe traumatic brain injury. Waveforms of intracranial pressure and arterial blood pressure, baseline Glasgow Coma Scale and 6 months Glasgow Outcome Scale were recorded. Baroreflex sensitivity was assessed every 10 seconds using a modified cross-correlational method. Frequency domain analyses of heart rate variability were performed automatically every 10 seconds from a moving 300 seconds of the monitoring time window. Mean values of baroreflex sensitivity, heart rate variability, intracranial pressure, arterial blood pressure, cerebral perfusion pressure, and impaired cerebral autoregulation over the entire monitoring period were calculated for each patient. Two hundred and sixty-two patients with a median age of 36 years entered the analysis. The median admission Glasgow Coma Scale was 6, the median Glasgow Outcome Scale was 3, and the mortality at 6 months was 23%. Baroreflex sensitivity (adjusted odds ratio, 0.9; p = 0.02) and relative power of a high frequency band of heart rate variability (adjusted odds ratio, 1.05; p < 0.001) were individually associated with mortality, independently of age, admission Glasgow Coma Scale, intracranial pressure, pressure reactivity index, or cerebral perfusion pressure. Baroreflex sensitivity showed no correlation with intracranial pressure or cerebral perfusion pressure; the correlation with pressure reactivity index was strong in older patients (age, > 60 yr). The relative power of high frequency correlated significantly with intracranial pressure and cerebral perfusion pressure, but not with pressure reactivity index. The relative power of low frequency correlated significantly with pressure reactivity index. Autonomic impairment, as measured by heart rate variability and baroreflex sensitivity, is significantly associated with increased mortality after traumatic brain injury. These effects, though partially interlinked, seem to be independent of age, trauma severity, intracranial pressure, or autoregulatory status, and thus represent a discrete phenomenon in the pathophysiology of traumatic brain injury. Continuous measurements of heart rate variability and baroreflex sensitivity in the neuromonitoring setting of severe traumatic brain injury may carry novel pathophysiological and predictive information.

Successful management of drug-induced hypercapnic acidosis with naloxone and noninvasive positive pressure ventilation.

PubMed

Agrafiotis, Michalis; Tryfon, Stavros; Siopi, Demetra; Chassapidou, Georgia; Galanou, Artemis; Tsara, Venetia

2015-02-01

A 74-year-old man was referred to our hospital due to deteriorating level of consciousness and desaturation. His Glasgow Coma Scale was 6, and his pupils were constricted but responded to light. Chest radiograph was negative for significant findings. Arterial blood gas evaluation on supplemental oxygen revealed severe acute on chronic respiratory acidosis: pH 7.15; PCO2, 133 mm Hg; PO2,64 mm Hg; and HCO3, 31 mmol/L. He regained full consciousness (Glasgow Coma Scale, 15) after receiving a 0.4 mg dose of naloxone, but because of persistent severe respiratory acidosis (pH 7.21; PCO2, 105 mm Hg), he was immediately commenced on noninvasive positive pressure ventilation (NIV) displaying a remarkable improvement in arterial blood gas values within the next few hours. However, in the days that followed, he remained dependent on NIV, and he was finally discharged on a home mechanical ventilation prescription. In cases of drug-induced respiratory depression, NIV should be regarded as an acceptable treatment, as it can provide ventilatory support without the increased risks associated with invasive mechanical ventilation.

Effect of the Modified Glasgow Coma Scale Score Criteria for Mild Traumatic Brain Injury on Mortality Prediction: Comparing Classic and Modified Glasgow Coma Scale Score Model Scores of 13

PubMed Central

Mena, Jorge Humberto; Sanchez, Alvaro Ignacio; Rubiano, Andres M.; Peitzman, Andrew B.; Sperry, Jason L.; Gutierrez, Maria Isabel; Puyana, Juan Carlos

2011-01-01

Objective The Glasgow Coma Scale (GCS) classifies Traumatic Brain Injuries (TBI) as Mild (14–15); Moderate (9–13) or Severe (3–8). The ATLS modified this classification so that a GCS score of 13 is categorized as mild TBI. We investigated the effect of this modification on mortality prediction, comparing patients with a GCS of 13 classified as moderate TBI (Classic Model) to patients with GCS of 13 classified as mild TBI (Modified Model). Methods We selected adult TBI patients from the Pennsylvania Outcome Study database (PTOS). Logistic regressions adjusting for age, sex, cause, severity, trauma center level, comorbidities, and isolated TBI were performed. A second evaluation included the time trend of mortality. A third evaluation also included hypothermia, hypotension, mechanical ventilation, screening for drugs, and severity of TBI. Discrimination of the models was evaluated using the area under receiver operating characteristic curve (AUC). Calibration was evaluated using the Hoslmer-Lemershow goodness of fit (GOF) test. Results In the first evaluation, the AUCs were 0.922 (95 %CI, 0.917–0.926) and 0.908 (95 %CI, 0.903–0.912) for classic and modified models, respectively. Both models showed poor calibration (p<0.001). In the third evaluation, the AUCs were 0.946 (95 %CI, 0.943 – 0.949) and 0.938 (95 %CI, 0.934 –0.940) for the classic and modified models, respectively, with improvements in calibration (p=0.30 and p=0.02 for the classic and modified models, respectively). Conclusion The lack of overlap between ROC curves of both models reveals a statistically significant difference in their ability to predict mortality. The classic model demonstrated better GOF than the modified model. A GCS of 13 classified as moderate TBI in a multivariate logistic regression model performed better than a GCS of 13 classified as mild. PMID:22071923

Effects and Clinical Characteristics of Intracranial Pressure Monitoring-Targeted Management for Subsets of Traumatic Brain Injury: An Observational Multicenter Study.

PubMed

Yuan, Qiang; Wu, Xing; Yu, Jian; Sun, Yirui; Li, Zhiqi; Du, Zhuoying; Mao, Ying; Zhou, Liangfu; Hu, Jin

2015-07-01

To evaluate the efficacy of traumatic brain injury management guided by intracranial pressure monitoring and to explore the specific subgroups for which intracranial pressure monitoring might be significantly associated with improved outcomes based on a classification of the various traumatic brain injury pathophysiologies using the clinical features and CT scans. Retrospective observational multicenter study. Twenty-two hospitals (16 level I trauma centers and six level II trauma centers) in nine provinces in China. Moderate or severe traumatic brain injury patients who were more than 14 years old. Intracranial pressure monitoring. All data were collected by physicians from medical records. The 6-month mortality and favorable outcome were assessed with the Glasgow Outcome Scale Extended score. An intracranial pressure monitor was inserted into 838 patients (58.1%). The mean duration of intracranial pressure monitoring was 4.44 ± 3.65 days. The significant predictors of intracranial pressure monitoring included the mechanism of injury, a Glasgow Coma Scale score of 9-12 at admission that dropped to a score of 3-8 within 24 hours after injury, a Marshall CT classification of III-IV, the presence of a major extracranial injury, subdural hematoma, intraparenchymal lesions, trauma center level, and intracranial pressure monitoring utilization of hospital. The intracranial pressure monitoring and no intracranial pressure monitoring groups did not significantly differ in terms of complications. For the total sample, the placement of intracranial pressure monitoring was not associated with either 6-month mortality (16.9% vs 20.5%; p = 0.086) or 6-month unfavorable outcome (49.4% vs 45.8%; p = 0.175). For patients with a Glasgow Coma Scale score of 3-8 at admission, intracranial pressure monitoring was also not significantly associated with 6-month mortality (20.9% vs 26.0%; p = 0.053) or an unfavorable outcome (56.9% vs 55.5%; p = 0.646). Multivariate logistic regression analyses showed that intracranial pressure monitoring resulted in a significantly lower 6-month mortality for patients who had a Glasgow Coma Scale score of 3-5 at admission (adjusted odds ratio, 0.57; 95% CI, 0.36-0.90; adjusted p = 0.016), those who had a Glasgow Coma Scale score of 9-12 at admission that dropped to 3-8 within 24 hours after injury (adjusted odds ratio, 0.28; 95% CI, 0.08-0.96; adjusted p = 0.043), and those who had a probability of death at 6 months greater than 0.6 (adjusted odds ratio, 0.55; 95% CI, 0.32-0.94; adjusted p = 0.029). There were multiple differences between the intracranial pressure monitoring and no intracranial pressure monitoring groups regarding patient characteristics, injury severity, characteristics of CT scan, and hospital type. Intracranial pressure monitoring in conjunction with intracranial pressure-targeted therapies is significantly associated with lower mortality in some special traumatic brain injury subgroups. The prospective randomized controlled trials specifically investigating these subgroups will be required to further characterize the effects of intracranial pressure monitoring on behavioral outcomes in patients with traumatic brain injury.

Clinical Value of Dorsal Medulla Oblongata Involvement Detected with Conventional MRI for Prediction of Outcome in Children with Enterovirus 71-related Brainstem Encephalitis.

PubMed

Liu, Kun; Zhou, Yongjin; Cui, Shihan; Song, Jiawen; Ye, Peipei; Xiang, Wei; Huang, Xiaoyan; Chen, Yiping; Yan, Zhihan; Ye, Xinjian

2018-04-05

Brainstem encephalitis is the most common neurologic complication after enterovirus 71 infection. The involvement of brainstem, especially the dorsal medulla oblongata, can cause severe sequelae or death in children with enterovirus 71 infection. We aimed to determine the prevalence of dorsal medulla oblongata involvement in children with enterovirus 71-related brainstem encephalitis (EBE) by using conventional MRI and to evaluate the value of dorsal medulla oblongata involvement in outcome prediction. 46 children with EBE were enrolled in the study. All subjects underwent a 1.5 Tesla MR examination of the brain. The disease distribution and clinical data were collected. Dichotomized outcomes (good versus poor) at longer than 6 months were available for 28 patients. Logistic regression was used to determine whether the MRI-confirmed dorsal medulla oblongata involvement resulted in improved clinical outcome prediction when compared with other location involvement. Of the 46 patients, 35 had MRI evidence of dorsal medulla oblongata involvement, 32 had pons involvement, 10 had midbrain involvement, and 7 had dentate nuclei involvement. Patients with dorsal medulla oblongata involvement or multiple area involvement were significantly more often in the poor outcome group than in the good outcome group. Logistic regression analysis showed that dorsal medulla oblongata involvement was the most significant single variable in outcome prediction (predictive accuracy, 90.5%), followed by multiple area involvement, age, and initial glasgow coma scale score. Dorsal medulla oblongata involvement on conventional MRI correlated significantly with poor outcomes in EBE children, improved outcome prediction when compared with other clinical and disease location variables, and was most predictive when combined with multiple area involvement, glasgow coma scale score and age.

The inter-rater reliability and prognostic value of coma scales in Nepali children with acute encephalitis syndrome.

PubMed

Ray, Stephen; Rayamajhi, Ajit; Bonnett, Laura J; Solomon, Tom; Kneen, Rachel; Griffiths, Michael J

2018-02-01

Background Acute encephalitis syndrome (AES) is a common cause of coma in Nepali children. The Glasgow coma scale (GCS) is used to assess the level of coma in these patients and predict outcome. Alternative coma scales may have better inter-rater reliability and prognostic value in encephalitis in Nepali children, but this has not been studied. The Adelaide coma scale (ACS), Blantyre coma scale (BCS) and the Alert, Verbal, Pain, Unresponsive scale (AVPU) are alternatives to the GCS which can be used. Methods Children aged 1-14 years who presented to Kanti Children's Hospital, Kathmandu with AES between September 2010 and November 2011 were recruited. All four coma scales (GCS, ACS, BCS and AVPU) were applied on admission, 48 h later and on discharge. Inter-rater reliability (unweighted kappa) was measured for each. Correlation and agreement between total coma score and outcome (Liverpool outcome score) was measured by Spearman's rank and Bland-Altman plot. The prognostic value of coma scales alone and in combination with physiological variables was investigated in a subgroup (n = 22). A multivariable logistic regression model was fitted by backward stepwise. Results Fifty children were recruited. Inter-rater reliability using the variables scales was fair to moderate. However, the scales poorly predicted clinical outcome. Combining the scales with physiological parameters such as systolic blood pressure improved outcome prediction. Conclusion This is the first study to compare four coma scales in Nepali children with AES. The scales exhibited fair to moderate inter-rater reliability. However, the study is inadequately powered to answer the question on the relationship between coma scales and outcome. Further larger studies are required.

Severe cyanide poisoning from an alternative medicine treatment with amygdalin and apricot kernels in a 4-year-old child.

PubMed

Sauer, Harald; Wollny, Caroline; Oster, Isabel; Tutdibi, Erol; Gortner, Ludwig; Gottschling, Sven; Meyer, Sascha

2015-05-01

The use of complementary and alternative medicine (CAM) is widespread in children with cancer and is poorly regulated. Case report. We describe a case of severe cyanide poisoning arising from CAM use. A severely agitated, encephalopathic, unresponsive 4-year-old boy (initial Glasgow Coma Scale of 3) with a history of metastatic ependymoma was brought to our emergency department by ambulance services. Initial blood gas analysis demonstrated severe metabolic/lactic acidosis. On detailed questioning of the parents, the use of CAM including intravenous and oral "vitamin B 17" (amygdalin) and oral apricot kernel was reported. After administering sodium thiosulfate, rapid improvement in his medical condition with complete recovery without need for further intensive care treatment was seen. Serum cyanide level was markedly elevated. Cyanide poisoning can be the cause of severe encephalopathy in children receiving CAM treatment with substances containing cyanogenic glycosides.

Clearing the Cervical Spine in a War Zone: What Other Injuries Matter?

DTIC Science & Technology

2015-07-01

Defense Trauma Registry January 2008 to August 2013, identifying blunt trauma patients with cervical spine injury and Glasgow Coma Score > 14...negative clinical examination of the cervical spine . Coexisting injuries identified in patients with negative physical examination included...distracting injuries were present, the physical examination was accurate in all patients. 15. SUBJECT TERMS Cervical spine clearance; cervical spine

Head Injuries in School-Age Children Who Play Golf

ERIC Educational Resources Information Center

Reuter-Rice, Karin; Krebs, Madelyn; Eads, Julia K.

2016-01-01

Traumatic brain injury (TBI) is the leading cause of death and disability in children. We conducted a prospective study, which examined injury characteristics and outcomes of school-age children of 5.0-15.0 years (N = 10) who were admitted to hospital for a TBI. This study evaluated the role of age, gender, the Glasgow Coma Scale, mechanisms and…

38 CFR 3.310 - Disabilities that are proximately due to, or aggravated by, service-connected disease or injury.

Code of Federal Regulations, 2014 CFR

2014-07-01

...) Traumatic brain injury. (1) In a veteran who has a service-connected traumatic brain injury, the following shall be held to be the proximate result of the service-connected traumatic brain injury (TBI), in the.../mental state. PTA—Post-traumatic amnesia. GCS—Glasgow Coma Scale. (For purposes of injury stratification...

The prognostic reliability of intracranial pressure monitoring and MRI data in severe traumatic brain injury.

PubMed

Woischneck, Dieter; Kapapa, Thomas

2017-02-01

The predictive quality of intracranial pressure (ICP) monitoring has for many years been a matter of debate. We correlate ICP data comparing MRI data with the outcome after severe traumatic brain injury to evaluate their prognostic potency. This study compares the results of ICP monitoring, MRI, coma duration and outcome according to Glasgow Outcome Scale obtained in 32 patients having suffered severe TBI. Level of significance was set to p≤0.05 in statistical tests. The MRI results were closely correlated with coma duration and Glasgow Outcome Scale, but the ICP measurements were not. With the exception of severe, bipontine lesions, there is no other region of the brain in which increased evidence of traumatogenic lesions emerges as the intracranial pressure rises. Just bipontine lesions that proof to be infaust correlate with elevated ICP values. ICP monitoring does not allow individual prognostic conclusions to be made. Implantation of an intracranial pressure sensor alone for making a prognostic estimate is not advisable. The use of intracranial pressure measurements in the retrospective appraisal of disease progress is highly problematic. However, MRI diagnostic in patients with severe TBI improves prognostic potency of clinical parameters. Copyright © 2016 Elsevier Inc. All rights reserved.

Influence of the rehabilitation outcome on returning to drive after neurological impairment.

PubMed

Čižman, Urša Š; Vidmar, Gaj; Drnovšek, Petra

2017-06-01

In traumatic brain injury (TBI) and stroke rehabilitation, the question of reintegration of the driver into traffic is faced very often. Driving is an important domain and for some patients, return to driving represents a crucial event for community inclusion. The aim of our study was to examine the utility of Glasgow Coma Scale within the first 24 h of injury and the Functional Independence Measure (FIM) at rehabilitation admission for predicting the return to driving. We included 72 patients after TBI or stroke. Driving outcome was assessed in terms of being allowed to drive without restrictions as opposed to failing the test or being allowed to drive with restrictions. We examined two samples: the TBI patients only and the entire sample including patients after stroke. The results indicate that for TBI patients, Glasgow Coma Scale and motor FIM could be predictors of driving outcome; in the entire sample, the unrestricted driving outcome was also associated with a high score on the FIM motor scale. Early prediction of return to driving after TBI and stroke is important for the patients, their families and the rehabilitation teams to set realistic goals that enable the best possible reintegration after rehabilitation.

The clinical significance of isolated loss of lordosis on cervical spine computed tomography in blunt trauma patients: a prospective evaluation of 1,007 patients.

PubMed

Mejaddam, Ali Y; Kaafarani, Haytham M A; Ramly, Elie P; Avery, Laura L; Yeh, Dante D; King, David R; de Moya, Marc A; Velmahos, George C

2015-11-01

A negative computed tomographic (CT) scan may be used to rule out cervical spine (c-spine) injury after trauma. Loss of lordosis (LOL) is frequently found as the only CT abnormality. We investigated whether LOL should preclude c-spine clearance. All adult trauma patients with isolated LOL at our Level I trauma center (February 1, 2011 to May 31, 2012) were prospectively evaluated. The primary outcome was clinically significant injury on magnetic resonance imaging (MRI), flexion-extension views, and/or repeat physical examination. Of 3,333 patients (40 ± 17 years, 60% men) with a c-spine CT, 1,007 (30%) had isolated LOL. Among 841 patients with a Glasgow Coma Scale score of 15, no abnormalities were found on MRI, flexion-extension views, and/or repeat examinations, and all collars were removed. Among 166 patients with Glasgow Coma Scale less than 15, 3 (.3%) had minor abnormal MRI findings but no clinically significant injury. Isolated LOL on c-spine CT is not associated with a clinically significant injury and should not preclude c-spine clearance. Copyright © 2015 Elsevier Inc. All rights reserved.

Appropriateness and reliability testing of the modified Richmond Agitation-Sedation Scale in Spanish patients with advanced cancer.

PubMed

Benítez-Rosario, Miguel Angel; Castillo-Padrós, Manuel; Garrido-Bernet, Belen; González-Guillermo, Toribio; Martínez-Castillo, Luis Pedro; González, Aceysele

2013-06-01

A tool to quantify agitation severity and sedation level in patients with advanced cancer is needed. To test the appropriateness and reliability of the Richmond Agitation-Sedation Scale (RASS) in Spanish patients with advanced cancer. The original RASS was translated into Spanish according to the standard guidelines. Face validity was assessed by members of the palliative care team, and interrater reliability was assessed, using a weighted kappa, from observations of patients admitted to the palliative care unit. The association between scores of the RASS, Ramsay Sedation Scale, and Glasgow Coma Scale was evaluated using Spearman's ρ. Three hundred twenty-two observations were performed in 156 patients: 116 observations were performed for delirious patients, 76 observations for sedated patients, and 130 observations for patients admitted for other symptom control. The weighted kappa values were practically equal to or greater than 0.90 between nurses and nurses and physicians. The agreement level between observers for each RASS score was roughly 90%. The correlation between the RASS and the Ramsay and Glasgow Scale values was analyzed for 196 observations recorded in 80 patients. The sedation scale of the RASS had a strong correlation with both the Ramsay (Spearman's ρ, -0.89; P < 0.001) and the Glasgow Coma Scales (Spearman's ρ, 0.85; P < 0.001). These data support the use of the RASS in Spanish patients with advanced cancer. Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Glasgow Coma Scale Scores, Early Opioids, and 4-year Psychological Outcomes among Combat Amputees

DTIC Science & Technology

2014-01-01

psychological outcomes, loss of consciousness, military and VA health data, morphine , posttraumatic stress disorder, traumatic brain injury. INTRODUCTION...appropriate for postinjury analgesia [15–17]. Unfortu- nately, little research has compared the psychological benefits of morphine or fentanyl...that morphine reduced PTSD compared with fentanyl because mor- phine produced more long-lasting pain relief and/or was more effective at blocking

Concussion and Mild Traumatic Brain Injury: An Annotated Bibliography

DTIC Science & Technology

2013-08-01

GCS – Glasgow Coma Scale IED- improvised explosive device LOC - loss of consciousness mTBI- mild traumatic brain injury PCS- post-concussion...Journal of Sport Medicine, 9, 193-198. Hospital patients who experienced LOC following a concussion were compared to concussed individuals who did...not experience LOC . The neuropsychological test measures used by the hospital, found no significant differences between the two groups, suggesting

A comparison of patient characteristics and survival in two trauma centres located in different countries.

PubMed

Templeton, J; Oakley, P A; MacKenzie, G; Cook, A L; Brand, D; Mullins, R J; Trunkey, D D

2000-09-01

The aim of the study was to compare patient characteristics and mortality in severely injured patients in two trauma centres located in different countries, allowing for differences in case-mix. It represents a direct bench-marking exercise between the trauma centres at the North Staffordshire Hospital (NSH), Stoke-on-Trent, UK and the Oregon Health Sciences University (OHSU) Hospital, Portland, Oregon, USA. Patients of all ages admitted to the two hospitals during 1995 and 1996 with an Injury Severity Score >15 were included, except for those who died in the emergency departments. Twenty-three factors were studied, including the Injury Severity Score, Glasgow Coma Score, mechanism of injury and anatomical site of injury. Outcome analysis was based on mortality at discharge. The pattern of trauma differed significantly between Stoke and Portland. Patients from Stoke tended to be older, presented with a lower conscious level and a lower systolic blood pressure and were intubated less frequently before arriving at hospital. Mortality depended on similar factors in both centres, especially age, highest AIS score, systolic blood pressure and Glasgow Coma Score.The crude analysis of mortality showed a highly significant odds-ratio of 1.64 in Stoke compared with Portland. Single-factor adjustments were made for the above four factors, which had a similar influence on mortality in both centres. Adjusting for the first three factors individually did not alter the odds-ratio, which stayed in the range 1.53-1.59 and remained highly significant. Adjusting for the Glasgow Coma Score reduced the odds-ratio to 0.82 and rendered it non-significant. In a multi-factor logistic regression model incorporating all of the factors shown to influence mortality in either centre, the odds-ratio was 1.7 but was not significant. The analysis illustrates the limitations and pitfalls of making crude outcome comparisons between centres. Highly significant differences in crude mortality were rendered non-significant by case-mix adjustments, supporting the null hypothesis that the two centres were equally effective in terms of this short-term indicator of outcome. To achieve a meaningful comparison between centres, adjustments must be made for the factors which affect mortality.

Prognostic value of EEG in different etiological types of coma.

PubMed

Khaburzania, M; Beridze, M

2013-06-01

Study aimed at evaluation of prognostic value of standard EEG in different etiology of coma and the influence of etiological factor on the EEG patterns and coma outcome. Totally 175 coma patients were investigated. Patients were evaluated by Glasgow Coma Scale (GCS), clinically and by 16 channel electroencephalography. Auditory evoked potentials studied by EEG -regime for evoked potentials in patients with vegetative state (VS). Patients divided in 8 groups according to coma etiology. All patients were studied for photoreaction, brainstem reflexes, localization of sound and pain, length of coma state and outcome. Brain injury visualized by conventional CT. Outcome defined as death, VS, recovery with disability and without disability. Disability was rated by Disability Rating Scale (DRS). Recovered patients assessed by Mini Mental State Examination (MMSE) scale. Statistics performed by SPSS-11.0. From 175 coma patients 55 patients died, 23 patients found in VS, 97 patients recovered with and without disability. In all etiological groups of coma the background EEG patterns were established. Correspondence analysis of all investigated factors revealed that sound localization had the significant association with EEG delta and theta rhythms and with recovery from coma state (Chi-sqr. =31.10493; p= 0.000001). Among 23 VS patients 9 patients had the signs of MCS and showed the long latency waves (p300) after binaural stimulation. The high amplitude theta frequencies in frontal and temporal lobes significantly correlated with prolongation of latency of cognitive evoked potentials (r=+0.47; p<0.01). Etiological factor had the significant effect on EEG patterns' association with coma outcome only in hemorrhagic and traumatic coma (chi-sqr.=12.95; p<0.005; chi-sqr.=7.92; p<0.03 respectively). Significant correlations established between the delta and theta EEG patterns and coma outcome. Low amplitude decreased power delta and theta frequencies correlated with SND in survived coma patients (r=+0.21; p<0.001; r=+0.27; p<0.001 respectively). Standard EEG is the useful tool for elucidation of coma patients with a high probability to recover as well as those patients, who are at high risk of SND in case of recovery from coma state.

Outcome after decompressive craniectomy for the treatment of severe traumatic brain injury.

PubMed

Howard, Jerry Lee; Cipolle, Mark D; Anderson, Meredith; Sabella, Victoria; Shollenberger, Daniele; Li, P Mark; Pasquale, Michael D

2008-08-01

Using decompressive craniectomy as part of the treatment regimen for severe traumatic brain injury (STBI) has become more common at our Level I trauma center. This study was designed to examine this practice with particular attention to long-term functional outcome. A retrospective review of prospectively collected data was performed for patients with STBI admitted from January 1, 2003 to December 31, 2005. Our institution manages patients using the Brain Trauma Foundation Guidelines. Data collected from patients undergoing decompressive craniectomy included: age, Injury Severity Score, admission and follow-up Glasgow Coma Score, timing of, and indication for decompressive craniectomy, and procedure-related complications. The Extended Glasgow Outcome Scale (GOSE) was performed by a experienced trauma clinical research coordinator using a structured phone interview to assess long-term outcome in the survivors. Student's t test and chi2 were used to examine differences between groups. Forty STBI patients were treated with decompressive craniectomy; 24 were performed primarily in conjunction with urgent evacuation of extra-axial hemorrhage and 16 were performed primarily in response to increased intracranial pressure with 4 of these after an initial craniotomy. Decompressive craniectomy was very effective at lowering intracranial pressure in these 16 patients (35.0 mm Hg +/- 13.5 mm Hg to 14.6 mm Hg +/- 8.7 mm Hg, p = 0.005). Twenty-two decompressive craniectomy patients did not survive to hospital discharge, whereas admission Glasgow Coma Score and admission pupil size and reactivity correlated with outcome, age, and Injury Severity Score did not. At a mean of 11 months (range, 3-26 months) after decompressive craniectomy, 6 survivors had a poor functional outcome (GOSE 1-4), whereas 12 survivors had a good outcome (GOSE 5-8). Therefore, 70% of these patients had an unfavorable outcome (death or severe disability), and 30% had a favorable long-term functional outcome. Fifteen of 18 survivors went on to cranioplasty, whereas 4 of 18 had cerebrospinal infection. The majority of survivors after decompressive craniectomy have a good functional outcome as analyzed by GOSE. Overall, 30% of patients with STBI who underwent decompressive craniectomy had a favorable long-term outcome. Improving patient selection and optimizing timing of this procedure may further improve outcome in these very severely brain injured patients.

Glasgow Coma Scores, Early Opioids, and Posttraumatic Stress Disorder Among Combat Amputees

DTIC Science & Technology

2014-04-01

icz, Johnson, & Mosely, 2008). Little research has compared how morphine and fentanyl might impact later psychological outcomes such as PTSD. In the...Fox, Saunders, Menk, & Middaugh, 1995). Because the analgesic effect of fentanyl is approximately 100 times more than morphine , the median Level 2...dosages administered to patients for these opioids appeared equivalent for analgesic effectiveness (Fox et al., 1995). Of the morphine -treated pa

Daily FOUR score assessment provides accurate prognosis of long-term outcome in out-of-hospital cardiac arrest.

PubMed

Weiss, N; Venot, M; Verdonk, F; Chardon, A; Le Guennec, L; Llerena, M C; Raimbourg, Q; Taldir, G; Luque, Y; Fagon, J-Y; Guerot, E; Diehl, J-L

2015-05-01

The accurate prediction of outcome after out-of-hospital cardiac arrest (OHCA) is of major importance. The recently described Full Outline of UnResponsiveness (FOUR) is well adapted to mechanically ventilated patients and does not depend on verbal response. To evaluate the ability of FOUR assessed by intensivists to accurately predict outcome in OHCA. We prospectively identified patients admitted for OHCA with a Glasgow Coma Scale below 8. Neurological assessment was performed daily. Outcome was evaluated at 6 months using Glasgow-Pittsburgh Cerebral Performance Categories (GP-CPC). Eighty-five patients were included. At 6 months, 19 patients (22%) had a favorable outcome, GP-CPC 1-2, and 66 (78%) had an unfavorable outcome, GP-CPC 3-5. Compared to both brainstem responses at day 3 and evolution of Glasgow Coma Scale, evolution of FOUR score over the three first days was able to predict unfavorable outcome more precisely. Thus, absence of improvement or worsening from day 1 to day 3 of FOUR had 0.88 (0.79-0.97) specificity, 0.71 (0.66-0.76) sensitivity, 0.94 (0.84-1.00) PPV and 0.54 (0.49-0.59) NPV to predict unfavorable outcome. Similarly, the brainstem response of FOUR score at 0 evaluated at day 3 had 0.94 (0.89-0.99) specificity, 0.60 (0.50-0.70) sensitivity, 0.96 (0.92-1.00) PPV and 0.47 (0.37-0.57) NPV to predict unfavorable outcome. The absence of improvement or worsening from day 1 to day 3 of FOUR evaluated by intensivists provides an accurate prognosis of poor neurological outcome in OHCA. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Dysfunction of hypothalamic-hypophysial axis after traumatic brain injury in adults.

PubMed

Krahulik, David; Zapletalova, Jirina; Frysak, Zdenek; Vaverka, Miroslav

2010-09-01

Traumatic brain injury (TBI) is a major cause of serious morbidity and mortality. The incidence is 100-500/100,000 inhabitants/year. Chronic pituitary dysfunction is increasingly recognized after TBI. To define the incidence of endocrine dysfunction and risk factors, the authors describe a prospectively assessed group of patients in whom they documented hormonal functions, early diagnosis, and treatment of neuroendocrine dysfunction after TBI. Patients aged 18-65 years were prospectively observed from the time of injury to 1 year postinjury; the Glasgow Coma Scale score ranged from 3 to 14. Patients underwent evaluation of hormonal function at the time of injury and at 3, 6, and 12 months postinjury. Magnetic resonance imaging was also conducted at 1 year postinjury. During the study period, 89 patients were observed. The mean age of the patients was 36 years, there were 23 women, and the median Glasgow Coma Scale score was 7. Nineteen patients (21%) had primary hormonal dysfunction. Major deficits included growth hormone dysfunction, hypogonadism, and diabetes insipidus. Patients in whom the deficiency was major had a worse Glasgow Outcome Scale score, and MR imaging demonstrated empty sella syndrome more often than in patients without a deficit. To the authors' knowledge, this is the third largest study of its kind worldwide. The incidence of chronic hypopituitarism after TBI was higher than the authors expected. After TBI, patients are usually observed on the neurological and rehabilitative wards, and endocrine dysfunction can be overlooked. This dysfunction can be life threatening and other clinical symptoms can worsen the neurological deficit, extend the duration of physiotherapy, and lead to mental illness. The authors recommend routine pituitary hormone testing after moderate or severe TBI within 6 months and 1 year of injury.

Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury.

PubMed

Foreman, Brandon P; Caesar, R Ruth; Parks, Jennifer; Madden, Christopher; Gentilello, Larry M; Shafi, Shahid; Carlile, Mary C; Harper, Caryn R; Diaz-Arrastia, Ramon R

2007-04-01

Assessment of injury severity is important in the management of patients with brain trauma. We aimed to analyze the usefulness of the head abbreviated injury score (AIS), the injury severity score (ISS), and the Glasgow Coma Scale (GCS) as measures of injury severity and predictors of outcome after traumatic brain injury (TBI). Data were prospectively collected from 410 patients with TBI. AIS, ISS, and GCS were recorded at admission. Subjects' outcomes after TBI were measured using the Glasgow Outcome Scale (GOS-E) at 12 months postinjury. Uni- and multivariate analyses were performed. Outcome information was obtained from 270 patients (66%). ISS was the best predictor of GOS-E (rs = -0.341, p < 0.001), followed by GCS score (rs = 0.227, p < 0.001), and head AIS (rs = -0.222, p < 0.001). When considered in combination, GCS score and ISS modestly improved the correlation with GOS-E (R = 0.335, p < 0.001). The combination of GCS score and head AIS had a similar effect (R = 0.275, p < 0.001). Correlations were stronger from patients 8). GCS score, AIS, and ISS are weakly correlated with 12-month outcome. However, anatomic measures modestly outperform GCS as predictors of GOS-E. The combination of GCS and AIS/ISS correlate with outcome better than do any of the three measures alone. Results support the addition of anatomic measures such as AIS and ISS in clinical studies of TBI. Additionally, most of the variance in outcome is not accounted for by currently available measures of injury severity.

Moderate Traumatic Brain Injury: Clinical Characteristics and a Prognostic Model of 12-Month Outcome.

PubMed

Einarsen, Cathrine Elisabeth; van der Naalt, Joukje; Jacobs, Bram; Follestad, Turid; Moen, Kent Gøran; Vik, Anne; Håberg, Asta Kristine; Skandsen, Toril

2018-06-01

Patients with moderate traumatic brain injury (TBI) often are studied together with patients with severe TBI, even though the expected outcome of the former is better. Therefore, we aimed to describe patient characteristics and 12-month outcomes, and to develop a prognostic model based on admission data, specifically for patients with moderate TBI. Patients with Glasgow Coma Scale scores of 9-13 and age ≥16 years were prospectively enrolled in 2 level I trauma centers in Europe. Glasgow Outcome Scale Extended (GOSE) score was assessed at 12 months. A prognostic model predicting moderate disability or worse (GOSE score ≤6), as opposed to a good recovery, was fitted by penalized regression. Model performance was evaluated by area under the curve of the receiver operating characteristics curves. Of the 395 enrolled patients, 81% had intracranial lesions on head computed tomography, and 71% were admitted to an intensive care unit. At 12 months, 44% were moderately disabled or worse (GOSE score ≤6), whereas 8% were severely disabled and 6% died (GOSE score ≤4). Older age, lower Glasgow Coma Scale score, no day-of-injury alcohol intoxication, presence of a subdural hematoma, occurrence of hypoxia and/or hypotension, and preinjury disability were significant predictors of GOSE score ≤6 (area under the curve = 0.80). Patients with moderate TBI exhibit characteristics of significant brain injury. Although few patients died or experienced severe disability, 44% did not experience good recovery, indicating that follow-up is needed. The model is a first step in development of prognostic models for moderate TBI that are valid across centers. Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.

A systematic review finds methodological improvements necessary for prognostic models in determining traumatic brain injury outcomes.

PubMed

Mushkudiani, Nino A; Hukkelhoven, Chantal W P M; Hernández, Adrián V; Murray, Gordon D; Choi, Sung C; Maas, Andrew I R; Steyerberg, Ewout W

2008-04-01

To describe the modeling techniques used for early prediction of outcome in traumatic brain injury (TBI) and to identify aspects for potential improvements. We reviewed key methodological aspects of studies published between 1970 and 2005 that proposed a prognostic model for the Glasgow Outcome Scale of TBI based on admission data. We included 31 papers. Twenty-four were single-center studies, and 22 reported on fewer than 500 patients. The median of the number of initially considered predictors was eight, and on average five of these were selected for the prognostic model, generally including age, Glasgow Coma Score (or only motor score), and pupillary reactivity. The most common statistical technique was logistic regression with stepwise selection of predictors. Model performance was often quantified by accuracy rate rather than by more appropriate measures such as the area under the receiver-operating characteristic curve. Model validity was addressed in 15 studies, but mostly used a simple split-sample approach, and external validation was performed in only four studies. Although most models agree on the three most important predictors, many were developed on small sample sizes within single centers and hence lack generalizability. Modeling strategies have to be improved, and include external validation.

Quantifying white matter structural integrity with high-definition fiber tracking in traumatic brain injury.

PubMed

Presson, Nora; Krishnaswamy, Deepa; Wagener, Lauren; Bird, William; Jarbo, Kevin; Pathak, Sudhir; Puccio, Ava M; Borasso, Allison; Benso, Steven; Okonkwo, David O; Schneider, Walter

2015-03-01

There is an urgent, unmet demand for definitive biological diagnosis of traumatic brain injury (TBI) to pinpoint the location and extent of damage. We have developed High-Definition Fiber Tracking, a 3 T magnetic resonance imaging-based diffusion spectrum imaging and tractography analysis protocol, to quantify axonal injury in military and civilian TBI patients. A novel analytical methodology quantified white matter integrity in patients with TBI and healthy controls. Forty-one subjects (23 TBI, 18 controls) were scanned with the High-Definition Fiber Tracking diffusion spectrum imaging protocol. After reconstruction, segmentation was used to isolate bilateral hemisphere homologues of eight major tracts. Integrity of segmented tracts was estimated by calculating homologue correlation and tract coverage. Both groups showed high correlations for all tracts. TBI patients showed reduced homologue correlation and tract spread and increased outlier count (correlations>2.32 SD below control mean). On average, 6.5% of tracts in the TBI group were outliers with substantial variability among patients. Number and summed deviation of outlying tracts correlated with initial Glasgow Coma Scale score and 6-month Glasgow Outcome Scale-Extended score. The correlation metric used here can detect heterogeneous damage affecting a low proportion of tracts, presenting a potential mechanism for advancing TBI diagnosis. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

A Spanish validation of the Coma Recovery Scale-Revised (CRS-R).

PubMed

Tamashiro, Mercedes; Rivas, Maria Elisa; Ron, Melania; Salierno, Fernando; Dalera, Marisol; Olmos, Lisandro

2014-01-01

Analysis of inter-rater reliability and concurrent validity. To determine measurement properties of a Spanish version of The Coma Recovery Scale-Revised (CRS-R). A sample of 35 in-patients with severe acquired brain injury. To test concurrent validity of the translated scale, the Glasgow Coma Scale (GSC) and Disability Rating Scale (DRS) were also administered. Two experts in the field were recruited to assess inter-rater agreement. Inter-rater reliability was good for total CRS-R scores (Cronbach α = 0.973, p = 0.001). Sub-scale analysis showed moderate-to-high inter-rater agreement. Total CRS-R scores correlated significantly (p < 0.05) with total GCS (r = 0.74) and DRS (r = 0.54) scores, indicating acceptable concurrent validity. The Spanish version of CRS-R can be administered reliably by trained and experienced examiners. CRS-R appears capable of differentiating patients in Emergence from Minimally Conscious State (EMCS) or in Minimally Conscious State (MCS) from those in a Vegetative State (VS).

Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries

PubMed Central

Wani, Abrar Ahad; Ramzan, Altaf Umar; Dar, Tanveer Iqbal; Malik, Nayil K.; Khan, Abdul Quyoom; Wani, Mohd Afzal; Alam, Shafeeq; Nizami, Furqan A.

2012-01-01

Background: The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain. Methods: All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO). Results: We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome. Conclusions: In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries. PMID:23050203

Glasgow Coma Scale score, mortality, and functional outcome in head-injured patients.

PubMed

Udekwu, Pascal; Kromhout-Schiro, Sharon; Vaslef, Steven; Baker, Christopher; Oller, Dale

2004-05-01

Preresuscitation Glasgow Coma Scale (P-GCS) score is frequently obtained in injured patients and incorporated into mortality prediction. Data on functional outcome in head injury is sparse. A large group of patients with head injuries was analyzed to assess relationships between P-GCS score, mortality, and functional outcome as measured by the Functional Independence Measure (FIM). Records for patients with International Classification of Diseases, Ninth Revision diagnosis codes indicating head injury in a statewide trauma registry between 1994 and 2002 were selected. P-GCS score, mortality, and FIM score at hospital discharge were integrated and analyzed. Of 138,750 patients, 22,924 patients were used for the mortality study and 7,150 patients for the FIM study. A good correlation exists between P-GCS score and FIM, as determined by rank correlation coefficients, whereas mortality falls steeply between a P-GCS score of 3 and a P-GCS score of 7 followed by a shallow fall. Although P-GCS score is related to mortality in head-injured patients, its relationship is nonlinear, which casts doubt on its use as a continuous measure or an equivalent set of categorical measures incorporated into outcome prediction models. The average FIM scores indicate substantial likelihood of good outcomes in survivors with low P-GCS scores, further complicating the use of the P-GCS score in the prediction of poor outcome at the time of initial patient evaluation. Although the P-GCS score is related to functional outcome as measured by the FIM score and mortality in head injury, current mortality prediction models may need to be modified to account for the nonlinear relationship between P-GCS score and mortality. The P-GCS score is not a good clinical tool for outcome prediction in individual head-injured patients, given the variability in mortality rates and functional outcomes at all scores.

The effect of brain death and coma on gastric myoelectrical activity.

PubMed

Bor, Canan; Bordin, Dmitry; Demirag, Kubilay; Uyar, Mehmet

2016-05-01

Gastrointestinal motility problems and delayed gastric emptying in patients admitted to intensive care units are important because they can contribute to different problems. Herein we aimed to measure the changes in gastric myoelectrical activity with electrogastrography (EGG) following brain death (BD) and compare the results to those from patients in a deep coma without BD. Fifteen patients with BD and nine in a deep coma with a Glasgow Coma Score from 3 to 8 were included. An enteral nutrition solution was given via a nasogastric tube between 45 min of fasting and the postprandial periods. The mean dominant frequency (MnDF), normal gastric slow wave ratio (%), tachygastria and bradygastria (%), power ratio (PR: dominant power after test meal/fasting), and dominant frequency instability coefficient were evaluated. The median of MnDF was determined 3.20±0.6 (BD) vs 3.05±0.5 (control), p>0.05. Patients with BD displayed tachygastria, particularly during the fasting state, with this disturbance decreasing during the postprandial period (from 41% to 15%). However, none of the differences between the groups were statistically significant. PR was pathologic in 4/15 (26.7%) patients in the BD group and 4/9 (44.4%) patients in the control group (p=0.288). Patients with coma or BD bouth might have gastric myoelectrical activity disturbances. BD does not show more severe disturbance than coma wihouth BD. EGG might be useful as a non-invasive and easy-to-use technology; however, it needs further improvement.

Epidemiology and Outcomes of Non-compressible Torso Hemorrhage

DTIC Science & Technology

2013-01-01

a r t i c l e i n f o Article history : Received 4 January 2013 Received in revised form 15 April 2013 Accepted 30 May 2013 Available online 21 June...military definition of NCTH, which incorporates anatomic and physiological criteria, to a civilian population treated at trauma centers in the US. Methods...injury (Glasgow Coma Scale, injury type, Injury Severity Score, anatomic region), and clinical (major surgical procedure, need for transfusion, and

Clinical Trials Network / Building Infrastructure to Accelerate Transfer of Basic Research in Spinal Cord Injury (SCI) to Clinical Practice

DTIC Science & Technology

2015-05-01

Glasgow Coma Scale (GCS) and of associated injuries with the Abbreviated Injury Scale . The American Spinal Injury Association impairment scale (AIS) is...registry protocol includes: the AIS Impairment Scale , and where appropriate, the Functional Independence Measure FIM™, the Spinal Cord Independence...have been achieved with the registry. Enrollment of 762 participants has demonstrated that is feasible to acquire prospective standardized research

Intrinsic Functional Connectivity Patterns Predict Consciousness Level and Recovery Outcome in Acquired Brain Injury

PubMed Central

Wu, Xuehai; Zou, Qihong; Hu, Jin; Tang, Weijun; Mao, Ying; Gao, Liang; Zhu, Jianhong; Jin, Yi; Wu, Xin; Lu, Lu; Zhang, Yaojun; Zhang, Yao; Dai, Zhengjia; Gao, Jia-Hong; Weng, Xuchu; Northoff, Georg; Giacino, Joseph T.; He, Yong

2015-01-01

For accurate diagnosis and prognostic prediction of acquired brain injury (ABI), it is crucial to understand the neurobiological mechanisms underlying loss of consciousness. However, there is no consensus on which regions and networks act as biomarkers for consciousness level and recovery outcome in ABI. Using resting-state fMRI, we assessed intrinsic functional connectivity strength (FCS) of whole-brain networks in a large sample of 99 ABI patients with varying degrees of consciousness loss (including fully preserved consciousness state, minimally conscious state, unresponsive wakefulness syndrome/vegetative state, and coma) and 34 healthy control subjects. Consciousness level was evaluated using the Glasgow Coma Scale and Coma Recovery Scale-Revised on the day of fMRI scanning; recovery outcome was assessed using the Glasgow Outcome Scale 3 months after the fMRI scanning. One-way ANOVA of FCS, Spearman correlation analyses between FCS and the consciousness level and recovery outcome, and FCS-based multivariate pattern analysis were performed. We found decreased FCS with loss of consciousness primarily distributed in the posterior cingulate cortex/precuneus (PCC/PCU), medial prefrontal cortex, and lateral parietal cortex. The FCS values of these regions were significantly correlated with consciousness level and recovery outcome. Multivariate support vector machine discrimination analysis revealed that the FCS patterns predicted whether patients with unresponsive wakefulness syndrome/vegetative state and coma would regain consciousness with an accuracy of 81.25%, and the most discriminative region was the PCC/PCU. These findings suggest that intrinsic functional connectivity patterns of the human posteromedial cortex could serve as a potential indicator for consciousness level and recovery outcome in individuals with ABI. SIGNIFICANCE STATEMENT Varying degrees of consciousness loss and recovery are commonly observed in acquired brain injury patients, yet the underlying neurobiological mechanisms remain elusive. Using a large sample of patients with varying degrees of consciousness loss, we demonstrate that intrinsic functional connectivity strength in many brain regions, especially in the posterior cingulate cortex and precuneus, significantly correlated with consciousness level and recovery outcome. We further demonstrate that the functional connectivity pattern of these regions can predict patients with unresponsive wakefulness syndrome/vegetative state and coma would regain consciousness with an accuracy of 81.25%. Our study thus provides potentially important biomarkers of acquired brain injury in clinical diagnosis, prediction of recovery outcome, and decision making for treatment strategies for patients with severe loss of consciousness. PMID:26377477

Traumatic midline subarachnoid hemorrhage on initial computed tomography as a marker of severe diffuse axonal injury.

PubMed

Mata-Mbemba, Daddy; Mugikura, Shunji; Nakagawa, Atsuhiro; Murata, Takaki; Ishii, Kiyoshi; Kushimoto, Shigeki; Tominaga, Teiji; Takahashi, Shoki; Takase, Kei

2018-01-05

OBJECTIVE The objective of this study was to test the hypothesis that midline (interhemispheric or perimesencephalic) traumatic subarachnoid hemorrhage (tSAH) on initial CT may implicate the same shearing mechanism that underlies severe diffuse axonal injury (DAI). METHODS The authors enrolled 270 consecutive patients (mean age [± SD] 43 ± 23.3 years) with a history of head trauma who had undergone initial CT within 24 hours and brain MRI within 30 days. Six initial CT findings, including intraventricular hemorrhage (IVH) and tSAH, were used as candidate predictors of DAI. The presence of tSAH was determined at the cerebral convexities, sylvian fissures, sylvian vallecula, cerebellar folia, interhemispheric fissure, and perimesencephalic cisterns. Following MRI, patients were divided into negative and positive DAI groups, and were assigned to a DAI stage: 1) stage 0, negative DAI; 2) stage 1, DAI in lobar white matter or cerebellum; 3) stage 2, DAI involving the corpus callosum; and 4) stage 3, DAI involving the brainstem. Glasgow Outcome Scale-Extended (GOSE) scores were obtained in 232 patients. RESULTS Of 270 patients, 77 (28.5%) had DAI; tSAH and IVH were independently associated with DAI (p < 0.05). Of tSAH locations, midline tSAH was independently associated with both overall DAI and DAI stage 2 or 3 (severe DAI; p < 0.05). The midline tSAH on initial CT had sensitivity of 60.8%, specificity of 81.7%, and positive and negative predictive values of 43.7% and 89.9%, respectively, for severe DAI. When adjusted for admission Glasgow Coma Score, the midline tSAH independently predicted poor GOSE score at both hospital discharge and after 6 months. CONCLUSIONS Midline tSAH could implicate the same shearing mechanism that underlies severe DAI, for which midline tSAH on initial CT is a probable surrogate.

Predictive Utility of the Total Glasgow Coma Scale Versus the Motor Component of the Glasgow Coma Scale for Identification of Patients With Serious Traumatic Injuries.

PubMed

Chou, Roger; Totten, Annette M; Carney, Nancy; Dandy, Spencer; Fu, Rongwei; Grusing, Sara; Pappas, Miranda; Wasson, Ngoc; Newgard, Craig D

2017-08-01

The motor component of the Glasgow Coma Scale (mGCS) has been proposed as an easier-to-use alternative to the total GCS (tGCS) for field assessment of trauma patients by emergency medical services. We perform a systematic review and meta-analysis to compare the predictive utility of the tGCS versus the mGCS or Simplified Motor Scale in field triage of trauma for identifying patients with adverse outcomes (inhospital mortality or severe brain injury) or who underwent procedures (neurosurgical intervention or emergency intubation) indicating need for high-level trauma care. Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Health and Psychosocial Instruments, and the Cochrane databases were searched through June 2016 for English-language cohort studies. We included studies that compared the area under the receiver operating characteristic curve (AUROC) of the tGCS versus the mGCS or Simplified Motor Scale assessed in the field or shortly after arrival in the emergency department for predicting the outcomes described above. Meta-analyses were performed with a random-effects model, and subgroup and sensitivity analyses were conducted. We included 18 head-to-head studies of predictive utility (n=1,703,388). For inhospital mortality, the tGCS was associated with slightly greater discrimination than the mGCS (pooled mean difference in [AUROC] 0.015; 95% confidence interval [CI] 0.009 to 0.022; I 2 =85%; 12 studies) or the Simplified Motor Scale (pooled mean difference in AUROC 0.030; 95% CI 0.024 to 0.036; I 2 =0%; 5 studies). The tGCS was also associated with greater discrimination than the mGCS or Simplified Motor Scale for nonmortality outcomes (differences in AUROC from 0.03 to 0.05). Findings were robust in subgroup and sensitivity analyses. The tGCS is associated with slightly greater discrimination than the mGCS or Simplified Motor Scale for identifying severe trauma. The small differences in discrimination are likely to be clinically unimportant and could be offset by factors such as convenience and ease of use. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Total Intravenous Anesthesia Including Ketamine versus Volatile Gas Anesthesia for Combat-related Operative Traumatic Brain Injury

DTIC Science & Technology

2008-07-01

receiving VGA with regard to Injury Severity Score, Glasgow Coma Scale score, base deficit, Head Abbreviated Injury Score, and craniectomy or craniotomy ...1, 2, or 3. Craniectomy or craniotomy was performed at the discretion of the neurosurgeon based on type of skull injury, severity of injury, and...perfectly on GCS ( 8, 8), base deficit ( 6, 6), Head Abbreviated Injury Score ( 3, 3) and craniectomy versus craniotomy . From these, subsets

North American Clinical Trials Network (NACTN) for Treatment of Spinal Cord Injury: A Consortium of Military, Veterans Administration, and Civilian Hospitals

DTIC Science & Technology

2011-01-31

of the patient on arrival and includes a clinical evaluation, 5 measurement of state of consciousness with the Glasgow Coma Scale (GCS) and of...associated injuries with the Abbreviated Injury Scale . The American Spinal Injury Association impairment scale (AIS) is scored on admission and at key...the AIS Impairment Scale , and where appropriate, the Functional Independence Measure FIM™, the Spinal Cord Independence Measure (SCIM), and the

Mortality factors in geriatric blunt trauma patients.

PubMed

Knudson, M M; Lieberman, J; Morris, J A; Cushing, B M; Stubbs, H A

1994-04-01

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma. In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score. Three urban trauma centers. Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989). The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3. Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

The change of plasma galectin-3 concentrations after traumatic brain injury.

PubMed

Shen, Yong-Feng; Yu, Wen-Hua; Dong, Xiao-Qiao; Du, Quan; Yang, Ding-Bo; Wu, Gang-Qun; Zhang, Zu-Yong; Wang, Hao; Jiang, Li

2016-05-01

Galectin-3 plays a significant role in microglia activation. Its increased circulating concentration has been associated with some inflammatory diseases. In-hospital major adverse events (IMAEs), including acute traumatic coagulopathy, progressive hemorrhagic injury and posttraumatic cerebral infarction, have high prevalence and are strong predictors of mortality after severe traumatic brain injury (STBI). The present study was designed to investigate the relationships between plasma galectin-3 concentrations and trauma severity, in-hospital mortality and IMAEs following STBI. Plasma galectin-3 concentrations of 100 STBI patients and 100 controls were determined. Diagnosis of progressive hemorrhagic injury and posttraumatic cerebral infarction was made on the follow-up computerized tomography scan. Acute traumatic coagulopathy was defined based on coagulation test. Plasma galectin-3 concentrations were significantly higher in patients as compared to controls and also associated highly with Glasgow Coma Scale scores and plasma C-reactive protein concentrations. Galectin-3 emerged as an independent predictor for in-hospital mortality and IMAEs. Areas under receiver operating characteristic curve of plasma galectin-3 concentrations were similar to those of Glasgow Coma Scale scores for prediction of in-hospital morality and IMAEs. Plasma galectin-3 concentrations have close relation to inflammation, trauma severity and clinical outcome, suggesting that galectin-3 should have the potential to be a good prognostic biomarker after STBI. Copyright © 2016 Elsevier B.V. All rights reserved.

Effect of quinine and artesunate combination therapy on platelet count of children with severe malaria.

PubMed

Gupta, Parul; Narang, Manish; Gomber, Sunil; Saha, Rumpa

2017-05-01

There are several case reports of quinine-induced thrombocytopenia but no clinical trials to ascertain its incidence and significance in severe malaria. The primary objective was to assess the effect of quinine on the platelet count in children with severe malaria and to compare it with artesunate combination therapy (ACT), and the secondary objective was to assess outcome of treatment with quinine and ACT. An open-labelled, randomised, controlled trial was undertaken in 100 children aged 6 months to 12 years who were diagnosed with malaria by microscopy and/or rapid diagnostic test kits with at least one WHO clinical or laboratory criterion for severe malaria. All subjects were commenced on either quinine or ACT. Clindamycin was added to artesunate as a combination drug (ACT). It was also given to patients on quinine to avoid its confounding effect on the results. Platelet counts were undertaken every 24 hours for 7 consecutive days, temperature and coma score (Blantyre coma score ≥3 in children <4 years or Glasgow coma score ≥13 in children >4 years) was recorded 6-hourly and peripheral smears were taken 12-hourly until two consecutively negative smears were obtained. The primary outcome was a fall in the platelet count by ≥20% from the time of drug initiation until day 7. The secondary outcome was comparison of the efficacy, parasite clearance time, fever clearance time, coma recovery time and adverse effects of quinine vs ACT. 30.4% patients in the quinine group (n = 48) had ≥20% fall in platelet count and 10.8% of patients in the ACT group (n = 46) (P = 0.02). Despite the fall in platelet count, there was no bleeding. The efficacy of ACT was significantly better than quinine but the other treatment outcomes showed insignificant difference. Quinine should be used with caution in patients with severe malaria because of the potential risk of quinine-induced thrombocytopenia.

Prognostic value of intraventricular bleeding in spontaneous intraparenchymal cerebral hemorrhage of small volume: a prospective cohort study.

PubMed

Fortes Lima, Telmo Tiburcio; Prandini, Mirto Nelso; Gallo, Pasquale; Cavalheiro, Sérgio

2012-04-01

The literature is controversial on whether intraventricular bleeding has a negative impact on the prognosis of spontaneous intracerebral hemorrhage. Nevertheless, an association between intraventricular bleeding and spontaneous intracerebral hemorrhage volumes has been consistently reported. To evaluate the prognostic value of intraventricular bleeding in deep intraparenchymal hypertensive spontaneous hemorrhage with a bleeding volume <30 cm(3). Of the 320 patients initially evaluated, 33 met the inclusion criteria and were enrolled in this prospective study. The volume of intraparenchymal hemorrhage was calculated by brain computed tomography (CT) image analysis, and the volume of intraventricular bleeding was calculated by the LeRoux scale. Clinical data, including neurological complications, were collected daily during hospitalization. Neurological outcome was evaluated 30 days after the event by using the Glasgow outcome scale. Patients were assigned to 1 of 3 groups according to intraventricular bleeding: Control, no intraventricular bleeding; LR 1, intraventricular bleeding with LeRoux scale scores of 1 to 8; or LR 2, intraventricular bleeding with LeRoux scale scores >8. There were no significant differences among groups concerning age, mean blood pressure, and time from onset to brain CT scan. Patients with greater intraventricular bleeding presented lower initial Glasgow coma scale scores, increased ventricular index and width of temporal horns, increased number of clinical and neurological complications, and longer hospitalization. Furthermore, their relative risk for unfavorable clinical outcome was 1.9 (95% confidence interval 1.25-2.49). Intraventricular bleeding with a LeRoux scale score >8 appears to have a negative effect on deep spontaneous intraparenchymal cerebral hemorrhage of small volume.

A French validation study of the Coma Recovery Scale-Revised (CRS-R).

PubMed

Schnakers, Caroline; Majerus, Steve; Giacino, Joseph; Vanhaudenhuyse, Audrey; Bruno, Marie-Aurelie; Boly, Melanie; Moonen, Gustave; Damas, Pierre; Lambermont, Bernard; Lamy, Maurice; Damas, Francois; Ventura, Manfredi; Laureys, Steven

2008-09-01

The aim of the present study was to explore the concurrent validity, inter-rater agreement and diagnostic sensitivity of a French adaptation of the Coma Recovery Scale-Revised (CRS-R) as compared to other coma scales such as the Glasgow Coma Scale (GCS), the Full Outline of UnResponsiveness scale (FOUR) and the Wessex Head Injury Matrix (WHIM). Multi-centric prospective study. To test concurrent validity and diagnostic sensitivity, the four behavioural scales were administered in a randomized order in 77 vegetative and minimally conscious patients. Twenty-four clinicians with different professional backgrounds, levels of expertise and CRS-R experience were recruited to assess inter-rater agreement. Good concurrent validity was obtained between the CRS-R and the three other standardized behavioural scales. Inter-rater reliability for the CRS-R total score and sub-scores was good, indicating that the scale yields reproducible findings across examiners and does not appear to be systematically biased by profession, level of expertise or CRS-R experience. Finally, the CRS-R demonstrated a significantly higher sensitivity to detect MCS patients, as compared to the GCS, the FOUR and the WHIM. The results show that the French version of the CRS-R is a valid and sensitive scale which can be used in severely brain damaged patients by all members of the medical staff.

Surgery for bilateral large intracranial traumatic hematomas: evacuation in a single session.

PubMed

Kompheak, Heng; Hwang, Sun-Chul; Kim, Dong-Sung; Shin, Dong-Sung; Kim, Bum-Tae

2014-06-01

Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia. In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated. The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived. Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy.

Surgery for Bilateral Large Intracranial Traumatic Hematomas: Evacuation in a Single Session

PubMed Central

Kompheak, Heng; Kim, Dong-Sung; Shin, Dong-Sung; Kim, Bum-Tae

2014-01-01

Objective Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia. Methods In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated. Results The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived. Conclusion Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy. PMID:25237431

Antithrombotic agents intake prior to injury does not affect outcome after a traumatic brain injury in hospitalized elderly patients.

PubMed

Julien, Jessica; Alsideiri, Ghusn; Marcoux, Judith; Hasen, Mohammed; Correa, José A; Feyz, Mitra; Maleki, Mohammed; de Guise, Elaine

2017-04-01

The purpose of this study is to investigate the effect of risk factors including International Normalized Ratio (INR) as well as the Partial Thromboplastin Time (PTT) scores on several outcomes, including hospital length of stay (LOS) and The Extended Glasgow Outcome Scale (GOSE) following TBI in the elderly population. Data were retrospectively collected on patients (n=982) aged 65 and above who were admitted post TBI to the McGill University Health Centre-Montreal General Hospital from 2000 to 2011. Age, Injury Severity Score (ISS), Glasgow Coma Scale score (GCS), type of trauma (isolated TBI vs polytrauma including TBI), initial CT scan results according to the Marshall Classification and the INR and PTT scores and prescriptions of antiplatelet or anticoagulant agents (AP/AC) were collected. Results also indicated that age, ISS and GSC score have an effect on the GOSE score. We also found that taking AC/AP has an effect on GOSE outcome, but that this effects depends on PTT, with lower odds of a worse outcome for those taking AC/AP agents as the PTT value goes up. However, this effect only becomes significant as the PTT value reaches 60 and above. Age and injury severity rather than antithrombotic agent intake are associated with adverse acute outcome such as GOSE in hospitalized elderly TBI patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

Fat and neurosurgery: does obesity affect outcome after intracranial surgery?

PubMed

Schultheiss, Kim E; Jang, Yeon Gyoe; Yanowitch, Rachel N; Tolentino, Jocelyn; Curry, Daniel J; Lüders, Jürgen; Asgarzadie-Gadim, Farbod; Macdonald, R Loch

2009-02-01

Obesity has been linked to increased morbidity and mortality after some surgical procedures. The purpose of this study was to determine whether obesity affects outcome after general neurosurgery and subarachnoid hemorrhage (SAH). Three data sets were analyzed, including a retrospective review of 404 patients undergoing cranial and spinal neurosurgical procedures, a prospective collection of 100 patients with aneurysmal SAH, and data from 3567 patients with aneurysmal SAH who were entered into randomized clinical trials of tirilazad. For each data set, outcome was assessed by mortality, postoperative morbidity, and Glasgow Outcome Scale score. Prognostic factors, including body weight and body mass index, were tested for their effect on these outcomes using multivariable logistic regression. For patients undergoing general cranial and spinal neurosurgery, independent predictors of morbidity and mortality were age, American Society of Anesthesia class, disseminated malignancy, emergency surgery, and increased duration of surgery. For patients with SAH, score on the Glasgow Outcome Scale was associated with age and admission Glasgow Coma Scale score. In the tirilazad data set, multiple factors were associated with score on the Glasgow Outcome Scale, but, as with the other 2 data sets, body weight had no relationship to outcome. Obesity may have less effect on the outcome of patients with mainly cranial neurosurgical disease and aneurysmal SAH than it does on patients undergoing other types of surgery.

Prehospital Heart Rate and Blood Pressure Increase the Positive Predictive Value of the Glasgow Coma Scale for High-Mortality Traumatic Brain Injury

DTIC Science & Technology

2014-05-15

TBI versus those with abnormalities in GCS alone. This could be useful for mobilizing resources (e.g., neurosurgeons and operating rooms at the...have high-mortality TBI versus those with abnormalities in GCS alone. This could be useful for mobilizing resources (e.g., neurosurgeons and... neurosurgeon at the earliest juncture. Third, improved risk stratification could be used to develop more rational clinical de- cision-making algorithms for

Severe Pediatric Head Injury During the Iraq and Afghanistan Conflicts.

PubMed

Klimo, Paul; Ragel, Brian T; Jones, G Morgan; McCafferty, Randall

2015-07-01

Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented. To describe the epidemiologic features and outcomes associated with isolated severe head injury in children during Operations Enduring Freedom and Iraqi Freedom (OEF and OIF). A retrospective review of children (<18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code >3) and treated at a US combat support hospital in Iraq or Afghanistan (2004-2012). The primary outcome was in-hospital mortality. We identified 647 children with severe isolated head injuries: 337 from OEF, 268 from OIF, and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor. This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts.

[Interobserver reliability of the Glasgow coma scale in critically ill patients with neurological and/or neurosurgical disease].

PubMed

Sánchez-Sánchez, M M; Sánchez-Izquierdo, R; Sánchez-Muñoz, E I; Martínez-Yegles, I; Fraile-Gamo, M P; Arias-Rivera, S

2014-01-01

The Glasgow coma scale (GCS) is a common tool used for neurological assessment of critically ill patients. Despite its widespread use, the GCS has some limitations, as sometimes different observers may value differently the same response. To evaluate the interobserver agreement, among intensive care nurses with a minimum of 3 years experience, both in the overall estimate of GCS and for each of its components. Prospective observational study including 110 neurological and/or neurosurgical patients conducted in a critical care unit of 18 beds, from October 2010 until December 2012. Registered variables: Demographic characteristics, reason for admission, overall GCS and its components. The neurological evaluation was conducted by a minimum of 3 nurses. One of them applied an algorithm and consensual assessment technique and all, independently, valued response to stimuli. Interobserver agreement was measured using the intraclass correlation coefficient (ICC) for a confidence interval (CI) of 95%. The study was approved by the Ethics Committee for Clinical Trails. The intraclass correlation coefficient (confident interval) for scale was: Overall GCS: 0.989 (0.985-0.992); ocular response: 0.981 (0.974-0.986); verbal response: 0.971 (0.960-0.979); motor response: 0.987 (0.982-0.991). In our cohort of patients we observed a high level of consistency in the application of both the GCS as in each of its components. Copyright © 2013 Elsevier España, S.L. y SEEIUC. All rights reserved.

[The evaluation of the suitability of our cases for referral to a level I trauma center].

PubMed

Taviloğlu, K; Aydin, A; Cuhali, B D; Demiralp, T; Güloğlu, R; Ertekin, C

2001-07-01

This study was performed on 200 patients with a prospective method, between July and October 1998. The aim of the study was to analyze the patients who were admitted directly or referred from another hospital, if they were suitable with the transfer criteria to a level I trauma center. One hundred and seven patients (53.5%) were admitted without ambulance and 93 patients (46.5%) by ambulance to our center. 34% of those patients applied directly and 66% of them were sent from other hospitals. Private ambulances consisted 70%, and 30% the belonged to the national health service. Only 26% of the ambulances had doctor as staff. The most common trauma etiologies were: traffic accidents (42.5%), falling from a height (37.5%) and assaults (11.5%). The mean Glasgow coma score (GCS) of the patients was calculated as 13.9 and mean revised trauma score was 11.7. The Glasgow coma score, revised trauma score and appropriateness to the transfer criteria of the American College of Surgeons were statistically analyzed according to the Fischer Exact test. The results revealed that 96% of the patients with RTS, 86% of the patients with GCS and 60% of the patients with ACS were not appropriate to the transfer criteria to a level I trauma center. In conclusion; we believe that GCS will predict better results in the triage of trauma patients with head trauma in our country.

The Relationship Between Serum Neuron-Specific Enolase Levels and Severity of Bleeding and Functional Outcomes in Patients With Nontraumatic Subarachnoid Hemorrhage.

PubMed

Tawk, Rabih G; Grewal, Sanjeet S; Heckman, Michael G; Rawal, Bhupendra; Miller, David A; Edmonston, Drucilla; Ferguson, Jennifer L; Navarro, Ramon; Ng, Lauren; Brown, Benjamin L; Meschia, James F; Freeman, William D

2016-04-01

The value of neuron-specific enolase (NSE) in predicting clinical outcomes has been investigated in a variety of neurological disorders. To investigate the associations of serum NSE with severity of bleeding and functional outcomes in patients with subarachnoid hemorrhage (SAH). We retrospectively reviewed the records of patients with SAH from June 2008 to June 2012. The severity of SAH bleeding at admission was measured radiographically with the Fisher scale and clinically with the Glasgow Coma Scale, Hunt and Hess grade, and World Federation of Neurologic Surgeons scale. Outcomes were assessed with the modified Rankin Scale at discharge. We identified 309 patients with nontraumatic SAH, and 71 had NSE testing. Median age was 54 years (range, 23-87 years), and 44% were male. In multivariable analysis, increased NSE was associated with a poorer Hunt and Hess grade (P = .003), World Federation of Neurologic Surgeons scale score (P < .001), and Glasgow Coma Scale score (P = .003) and worse outcomes (modified Rankin Scale at discharge; P = .001). There was no significant association between NSE level and Fisher grade (P = .81) in multivariable analysis. We found a significant association between higher NSE levels and poorer clinical presentations and worse outcomes. Although it is still early for any relevant clinical conclusions, our results suggest that NSE holds promise as a tool for screening patients at increased risk of poor outcomes after SAH.

Using the abbreviated injury severity and Glasgow Coma Scale scores to predict 2-week mortality after traumatic brain injury.

PubMed

Timmons, Shelly D; Bee, Tiffany; Webb, Sharon; Diaz-Arrastia, Ramon R; Hesdorffer, Dale

2011-11-01

Prediction of outcome after traumatic brain injury (TBI) remains elusive. We tested the use of a single hospital Glasgow Coma Scale (GCS) Score, GCS Motor Score, and the Head component of the Abbreviated Injury Scale (AIS) Score to predict 2-week cumulative mortality in a large cohort of TBI patients admitted to the eight U.S. Level I trauma centers in the TBI Clinical Trials Network. Data on 2,808 TBI patients were entered into a centralized database. These TBI patients were categorized as severe (GCS score, 3-8), moderate (9-12), or complicated mild (13-15 with positive computed tomography findings). Intubation and chemical paralysis were recorded. The cumulative incidence of mortality in the first 2 weeks after head injury was calculated using Kaplan-Meier survival analysis. Cox proportional hazards regression was used to estimate the magnitude of the risk for 2-week mortality. Two-week cumulative mortality was independently predicted by GCS, GCS Motor Score, and Head AIS. GCS Severity Category and GCS Motor Score were stronger predictors of 2-week mortality than Head AIS. There was also an independent effect of age (<60 vs. ≥60) on mortality after controlling for both GCS and Head AIS Scores. Anatomic and physiologic scales are useful in the prediction of mortality after TBI. We did not demonstrate any added benefit to combining the total GCS or GCS Motor Scores with the Head AIS Score in the short-term prediction of death after TBI.

Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries.

PubMed

Demetriades, Demetrios; Kuncir, Eric; Murray, James; Velmahos, George C; Rhee, Peter; Chan, Linda

2004-08-01

We assessed the prognostic value and limitations of Glasgow Coma Scale (GCS) and head Abbreviated Injury Score (AIS) and correlated head AIS with GCS. We studied 7,764 patients with head injuries. Bivariate analysis was performed to examine the relationship of GCS, head AIS, age, gender, and mechanism of injury with mortality. Stepwise logistic regression analysis was used to identify the independent risk factors associated with mortality. The overall mortality in the group of head injury patients with no other major extracranial injuries and no hypotension on admission was 9.3%. Logistic regression analysis identified head AIS, GCS, age, and mechanism of injury as significant independent risk factors of death. The prognostic value of GCS and head AIS was significantly affected by the mechanism of injury and the age of the patient. Patients with similar GCS or head AIS but different mechanisms of injury or ages had significantly different outcomes. The adjusted odds ratio of death in penetrating trauma was 5.2 (3.9, 7.0), p < 0.0001, and in the age group > or = 55 years the adjusted odds ratio was 3.4 (2.6, 4.6), p < 0.0001. There was no correlation between head AIS and GCS (correlation coefficient -0.31). Mechanism of injury and age have a major effect in the predictive value of GCS and head AIS. There is no good correlation between GCS and head AIS.

Plasma copeptin level predicts acute traumatic coagulopathy and progressive hemorrhagic injury after traumatic brain injury.

PubMed

Yang, Ding-Bo; Yu, Wen-Hua; Dong, Xiao-Qiao; Du, Quan; Shen, Yong-Feng; Zhang, Zu-Yong; Zhu, Qiang; Che, Zhi-Hao; Liu, Qun-Jie; Wang, Hao; Jiang, Li; Du, Yuan-Feng

2014-08-01

Higher plasma copeptin levels correlate with poor clinical outcomes after traumatic brain injury. Nevertheless, their links with acute traumatic coagulopathy and progressive hemorrhagic injury are unknown. Therefore, we aimed to investigate the relationship between plasma copeptin levels, acute traumatic coagulopathy and progressive hemorrhagic injury in patients with severe traumatic brain injury. We prospectively studied 100 consecutive patients presenting within 6h from head trauma. Progressive hemorrhagic injury was present when the follow-up computerized tomography scan reported any increase in size or number of the hemorrhagic lesion, including newly developed ones. Acute traumatic coagulopathy was defined as an activated partial thromboplastic time greater than 40s and/or international normalized ratio greater than 1.2 and/or a platelet count less than 120×10(9)/L. We measured plasma copeptin levels on admission using an enzyme-linked immunosorbent assay in a blinded fashion. In multivariate logistic regression analysis, plasma copeptin level emerged as an independent predictor of progressive hemorrhagic injury and acute traumatic coagulopathy. Using receiver operating characteristic curves, we calculated areas under the curve for progressive hemorrhagic injury and acute traumatic coagulopathy. The predictive performance of copeptin was similar to that of Glasgow Coma Scale score. However, copeptin did not obviously improve the predictive value of Glasgow Coma Scale score. Thus, copeptin may help in the prediction of progressive hemorrhagic injury and acute traumatic coagulopathy after traumatic brain injury. Copyright © 2014 Elsevier Inc. All rights reserved.

Outcomes after environmental hyperthermia.

PubMed

LoVecchio, Frank; Pizon, Anthony F; Berrett, Christopher; Balls, Adam

2007-05-01

This study was conducted to describe the characteristics and outcomes of patients who presented to the emergency department (ED) with presumed environmental hyperthermia. A retrospective chart review was performed in 2 institutions with patients who were seen in the ED and had a discharge diagnosis of hyperthermia, heat stroke, heat exhaustion, or heat cramps. Exclusion criteria were an alternative diagnosis potentially explaining the hyperthermia (pneumonia, etc). Research assistants, who were blinded to the purpose of the study, performed a systematic chart review after a structured training session. If necessary, a third reviewer acted as a tiebreaker. Data regarding patient demographics, comorbidities, vital signs, laboratory results, and short-term outcome were collected. Data were analyzed with Excel and STATA software. We enrolled 52 patients with a mean age of 42.6 years (range, 0.4-81 years) from August 1, 2003 to August 31, 2005. The mean high daily temperature was 103.6 degrees F (range, 88-118 degrees F). At presentation, the mean body temperature was 105.1 degrees F (range, 100.2-111.2 degrees F) and the Glasgow Coma Scale score was less than 14 in 36 (69.2%) patients. Laboratory results demonstrated that 21 (40.4%) patients had a creatinine level of more than 1.5 mg/dL, 35 (67.3%) patients had a creatine kinase (CK) of more than 200 U/L, 30 patients (57.7%) had a prothrombin time of more than 13 seconds, 29 (55.8%) patients had an aspartate aminotransferase (AST) of more than 45 U/L, and only 3 patients (5.7%) had a glucose of less than 60 mg/dL. Ethanol or illicit drugs were involved in 18 (34.6%) cases. The mean hospital stay was 4.7 days (range, 1-30 days), and there were 15 deaths (28.8%). A kappa score for interreviewer reliability was 0.69. Major limitations were the retrospective nature and lack of homogeneity in patient evaluation and test ordering. Hyperthermic patients with higher initial temperatures, hypotension, or low Glasgow Coma Scale score were more likely to die.

Characteristics of Cervical Spine Injury in Pediatric Patients With Facial Fractures.

PubMed

Halsey, Jordan N; Hoppe, Ian C; Marano, Andrew A; Kordahi, Anthony M; Lee, Edward S; Granick, Mark S

2016-01-01

Cervical spine injury may present with pediatric patients having sustained fractures of the craniofacial skeleton. Management considerations of the cervical spine often take priority to the fractures of the facial skeleton. The goal of this study was to examine this subset of patients with a focus on initial presentation and need for intervention. A retrospective review from 2000 to 2012 of all facial fractures in patients ≤ 18 years at a level 1 trauma center was performed. Patient demographics, location of fractures, and the presence of a cervical spine injury were collected. During this time period, 285 patients met inclusion criteria. Ten patients were found to have a cervical spine injury. Fractures of the zygoma and orbit were significantly associated with a cervical spine injury. Patients with a cervical spine injury had a Glasgow Coma Scale of 11.2 compared with 13.8 in those without (P < 0.05). C1 was injured in 4 patients, C2 in 2 patients, and C3 to C7 in 4 patients. A surgical airway was required in 1 patient, and 6 were intubated in the trauma bay. Fractures of the mandible were significantly associated with injury to C2. Le Fort fractures and palate fractures approached significance with injury to C1. Only 1 patient had neurologic impairment at presentation, manifested as upper extremity parasthesias, and underwent decompression and fusion in the operating room. Those patients admitted (90%) were all admitted for reasons other than management of the cervical spine injury. The majority of patients (70%) were treated with collar immobilization. One patient expired. No patients had a neurologic deficit at the time of discharge. In this study only 1 cervical spine injury necessitated intervention, with an eventual full recovery. Cervical spine injuries presenting with fractures of the facial skeleton appear to be relatively benign in this series; however, care must be taken to identify all such injuries to avoid exacerbation during maneuvers commonly used for facial fracture treatment. Special caution should be used when examining patients with a depressed Glasgow Coma Scale or in those with upper midface fractures.

Management of intracranial hemorrhage in patients with left ventricular assist devices.

PubMed

Wilson, Thomas J; Stetler, William R; Al-Holou, Wajd N; Sullivan, Stephen E; Fletcher, Jeffrey J

2013-05-01

The authors conducted a study to review outcomes and management in patients in whom intracranial hemorrhage (ICH) develops during left ventricular assist device (LVAD) therapy. This retrospective cohort study included all adult patients (18 years of age or older) at a single institution who underwent placement of an LVAD between January 1, 2003, and March 1, 2012. The authors conducted a detailed medical chart review, and data were abstracted to assess outcomes in patients in whom ICH developed compared to those in patients in whom ICH did not develop; to compare management of antiplatelet agents and anticoagulation with outcomes; to describe surgical management employed and outcomes achieved; to compare subtypes of ICH (intraparenchymal, subdural, and subarachnoid hemorrhage) and their outcomes; and to determine any predictors of outcome. During the study period, 330 LVADs were placed and 36 patients developed an ICH (traumatic subarachnoid hemorrhage in 10, traumatic subdural hematoma in 8, spontaneous intraventricular hemorrhage in 1, and spontaneous intraparenchymal hemorrhage in 17). All patients were treated with aspirin and warfarin at the time of presentation. With suspension of these agents, no thromboembolic events or pump failures were seen and no delayed rehemorrhages occurred after resuming these medications. Intraparenchymal hemorrhages had the worst outcomes, with a 30-day mortality rate in 59% compared with a 30-day mortality rate of 0% in patients with traumatic subarachnoid hemorrhages and 13% in those with traumatic subdural hematomas. Five patients with intraparenchymal hemorrhages were managed with surgical intervention, 4 of whom died within 60 days. The only factor found to be predictive of outcome was initial Glasgow Coma Scale score. No patients with a Glasgow Coma Scale score less than 11 survived beyond 30 days. Overall, the development of an ICH significantly reduced survival compared with the natural history of patients on LVAD therapy. The authors' data suggest that withholding aspirin for 1 week and warfarin for 10 days is sufficient to reduce the risk of hemorrhage expansion or rehemorrhage while minimizing the risk of thromboembolic events and pump failure. Patients with intraparenchymal hemorrhage have poor outcomes, whereas patients with traumatic subarachnoid hemorrhage or subdural hematoma have better outcomes.

[Predictive factors of all-cause mortality in patients attending the medical emergency unit of Kinshasa University Hospital].

PubMed

Mbutiwi Ikwa Ndol, F; Dramaix-Wilmet, M; Meert, P; Lepira Bompeka, F; Nseka Mangani, N; Malengreau, M; Makaula, P

2014-02-01

The management of medical emergencies is poorly organized in the Democratic Republic of Congo. In addition, the mortality of patients attending the medical emergency unit of Kinshasa University Hospital is relatively high, with death of patients occurring rather early. To date, factors associated with this mortality have been poorly elucidated. This study aimed to identify predictive factors of all-cause mortality in patients admitted to the medical emergency unit of the Kinshasa University Hospital. Analytical prospective study of all patients admitted from 15th January to 15th February 2011 in the emergency unit of the internal medicine department of Kinshasa University Hospital (427 patients). Among these patients, 13 were dead at arrival and were excluded from this study. The 414 patients included were followed until discharge from the hospital. Demographic, clinical, biological, diagnostic, therapeutical and evolutive data were collected. Four multivariate logistic regression models were used to identify risk factors associated with mortality. Patients' median age was 40 years (interquartile range, 28-58 years), 54.5% were male, and 15.9% had a life-threatening pathological condition on admission. The overall mortality was 12.3%. According to multivariate analyses, transfer from other health care structures (OR: 3.5; 95% CI: 1.7-7.1), Glasgow Coma Scale score less than 14 on admission (OR: 11.1; 95% CI: 4.7-26.3), high creatinine level (OR: 4.2; 95% CI: 1.8-9.7), presence of cardiovascular (OR: 2.9; 95% CI: 1.5-5.7), renal (OR: 7.4; 95% CI: 3.2-17.3), hematologic and/or respiratory (OR: 6.1; 95% CI: 1.7-21.4) diseases, presence of sepsis and/or meningitis and encephalitis (OR: 5.2; 95% CI: 1.6-17.0) were significantly associated with a high risk of death. However, the Glasgow Coma Scale score less than 14 on admission and renal disease were the only predictive factors of mortality remaining after including demographic, clinical, diagnostic and therapeutical variables in the logistic regression model. Our study showed that transfer from another health care structure, low Glasgow Coma Scale score on admission, high creatinine level, cardiovascular, renal, hematologic and/or respiratory diseases, sepsis and/or meningitis and encephalitis were associated with an increased risk of death in Kinshasa University Hospital patients admitted in the medical emergency unit. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Randomized controlled trial comparing cerebral perfusion pressure-targeted therapy versus intracranial pressure-targeted therapy for raised intracranial pressure due to acute CNS infections in children.

PubMed

Kumar, Ramesh; Singhi, Sunit; Singhi, Pratibha; Jayashree, Muralidharan; Bansal, Arun; Bhatti, Anuj

2014-08-01

In children with acute CNS infection, management of raised intracranial pressure improves mortality and neuromorbidity. We compared cerebral perfusion pressure-targeted approach with the conventional intracranial pressure-targeted approach to treat raised intracranial pressure in these children. Prospective open-label randomized controlled trial. PICU in a tertiary care academic institute. Hundred ten children (1-12 yr) with acute CNS infections having raised intracranial pressure and a modified Glasgow Coma Scale score less than or equal to 8 were enrolled. Patients were randomized to receive either cerebral perfusion pressure-targeted therapy (n = 55) (maintaining cerebral perfusion pressure ≥ 60 mm Hg, using normal saline bolus and vasoactive therapy-dopamine, and if needed noradrenaline) or intracranial pressure-targeted therapy (n = 55) (maintaining intracranial pressure < 20 mm Hg using osmotherapy while ensuring normal blood pressure). The primary outcome was mortality up to 90 days after discharge from PICU. Secondary outcome was modified Glasgow Coma Scale score at 72 hours after enrollment, length of PICU stay, duration of mechanical ventilation, and hearing deficit and functional neurodisability at discharge and 90-day follow-up. A 90-day mortality in intracranial pressure group (38.2%) was significantly higher than cerebral perfusion pressure group (18.2%; relative risk = 2.1; 95% CI, 1.09-4.04; p = 0.020). The cerebral perfusion pressure group in comparison with intracranial pressure group had significantly higher median (interquartile range) modified Glasgow Coma Scale score at 72 hours (10 [8-11] vs 7 [4-9], p < 0.001), shorter length of PICU stay (13 d [10.8-15.2 d] vs. 18 d [14.5-21.5 d], p = 0.002) and mechanical ventilation (7.5 d [5.4-9.6 d] vs. 11.5 d [9.5-13.5 d], p = 0.003), lower prevalence of hearing deficit (8.9% vs 37.1%; relative risk = 0.69; 95% CI, 0.53-0.90; p = 0.005), and neurodisability at discharge from PICU (53.3% vs. 82.9%; relative risk = 0.37; 95% CI, 0.17-0.81; p = 0.005) and 90 days after discharge (37.8% vs. 70.6%; relative risk = 0.47; 95% CI, 0.27-0.83; p = 0.004). Cerebral perfusion pressure-targeted therapy, which relied on more frequent use of vasopressors and lesser use of hyperventilation and osmotherapy, was superior to intracranial pressure-targeted therapy for management of raised intracranial pressure in children with acute CNS infection in reducing mortality and morbidity.

Nonsurgical acute traumatic subdural hematoma: what is the risk?

PubMed

Bajsarowicz, Paul; Prakash, Ipshita; Lamoureux, Julie; Saluja, Rajeet Singh; Feyz, Mitra; Maleki, Mohammad; Marcoux, Judith

2015-11-01

The Brain Trauma Foundation has published guidelines on the surgical management of traumatic subdural hematoma (SDH). However, no data exist on the proportion of patients with SDH that can be selected for conservative management and what is the outcome of these patients. The goals of this study were as follows: 1) to establish what proportion of patients are initially treated conservatively; 2) to determine what proportion of patients will deteriorate and require surgical evacuation; and 3) to identify risk factors associated with deterioration and delayed surgery. All cases of acute traumatic SDH (869 when inclusion criteria were met) presenting over a 4-year period were reviewed. For all conservatively treated SDH, the proportion of delayed surgical intervention and the Glasgow Outcome Scale score were taken as outcome measures. Multiple factors were compared between patients who required delayed surgery and patients without surgery. Of the 869 patients with acute traumatic SDH, 646 (74.3%) were initially treated conservatively. A good outcome was achieved in 76.7% of the patients. Only 6.5% eventually required delayed surgery, and the median delay for surgery was 9.5 days. Factors associated with deterioration were as follows: 1) thicker SDH (p<0.001); 2) greater midline shift (p<0.001); 3) location at the convexity (p=0.001); 4) alcohol abuse (p=0.0260); and 5) history of falls (p=0.018). There was no significant difference in regard to age, sex, Glasgow Coma Scale score, Injury Severity Score, abnormal coagulation, use of blood thinners, and presence of cerebral atrophy or white matter disease. The majority of patients with SDH are treated conservatively. Of those, only 6.5% later required surgery, for raised intracranial pressure or SDH progression. Patients at risk can be identified and followed more carefully.

Disruption of posteromedial large-scale neural communication predicts recovery from coma

PubMed Central

de Pasquale, Francesco; Vuillaume, Corine; Riu, Beatrice; Loubinoux, Isabelle; Geeraerts, Thomas; Seguin, Thierry; Bounes, Vincent; Fourcade, Olivier; Demonet, Jean-Francois; Péran, Patrice

2015-01-01

Objective: We hypothesize that the major consciousness deficit observed in coma is due to the breakdown of long-range neuronal communication supported by precuneus and posterior cingulate cortex (PCC), and that prognosis depends on a specific connectivity pattern in these networks. Methods: We compared 27 prospectively recruited comatose patients who had severe brain injury (Glasgow Coma Scale score <8; 14 traumatic and 13 anoxic cases) with 14 age-matched healthy participants. Standardized clinical assessment and fMRI were performed on average 4 ± 2 days after withdrawal of sedation. Analysis of resting-state fMRI connectivity involved a hypothesis-driven, region of interest–based strategy. We assessed patient outcome after 3 months using the Coma Recovery Scale–Revised (CRS-R). Results: Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with PCC, globally notwithstanding etiology. The functional connectivity strength between PCC and medial prefrontal cortex (mPFC) was significantly different between comatose patients who went on to recover and those who eventually scored an unfavorable outcome 3 months after brain injury (Kruskal-Wallis test, p < 0.001; linear regression between CRS-R and PCC-mPFC activity coupling at rest, Spearman ρ = 0.93, p < 0.003). Conclusion: In both etiology groups (traumatic and anoxic), changes in the connectivity of PCC-centered, spontaneously synchronized, large-scale networks account for the loss of external and internal self-centered awareness observed during coma. Sparing of functional connectivity between PCC and mPFC may predict patient outcome, and further studies are needed to substantiate this potential prognosis biomarker. PMID:26561296

Disruption of posteromedial large-scale neural communication predicts recovery from coma.

PubMed

Silva, Stein; de Pasquale, Francesco; Vuillaume, Corine; Riu, Beatrice; Loubinoux, Isabelle; Geeraerts, Thomas; Seguin, Thierry; Bounes, Vincent; Fourcade, Olivier; Demonet, Jean-Francois; Péran, Patrice

2015-12-08

We hypothesize that the major consciousness deficit observed in coma is due to the breakdown of long-range neuronal communication supported by precuneus and posterior cingulate cortex (PCC), and that prognosis depends on a specific connectivity pattern in these networks. We compared 27 prospectively recruited comatose patients who had severe brain injury (Glasgow Coma Scale score <8; 14 traumatic and 13 anoxic cases) with 14 age-matched healthy participants. Standardized clinical assessment and fMRI were performed on average 4 ± 2 days after withdrawal of sedation. Analysis of resting-state fMRI connectivity involved a hypothesis-driven, region of interest-based strategy. We assessed patient outcome after 3 months using the Coma Recovery Scale-Revised (CRS-R). Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with PCC, globally notwithstanding etiology. The functional connectivity strength between PCC and medial prefrontal cortex (mPFC) was significantly different between comatose patients who went on to recover and those who eventually scored an unfavorable outcome 3 months after brain injury (Kruskal-Wallis test, p < 0.001; linear regression between CRS-R and PCC-mPFC activity coupling at rest, Spearman ρ = 0.93, p < 0.003). In both etiology groups (traumatic and anoxic), changes in the connectivity of PCC-centered, spontaneously synchronized, large-scale networks account for the loss of external and internal self-centered awareness observed during coma. Sparing of functional connectivity between PCC and mPFC may predict patient outcome, and further studies are needed to substantiate this potential prognosis biomarker. © 2015 American Academy of Neurology.

Long-lasting functional disabilities in patients who recover from coma after cardiac operations.

PubMed

Rodriguez, Rosendo A; Nair, Shona; Bussière, Miguel; Nathan, Howard J

2013-03-01

Uncertainty regarding the long-term functional outcome of patients who awaken from coma after cardiac operations is difficult for families and physicians and may delay rehabilitation. We studied the long-term functional status of these patients to determine if duration of coma predicted outcome. We followed 71 patients who underwent cardiac operations; recovered their ability to respond to verbal commands after coma associated with postoperative stroke, encephalopathy, and/or seizures; and were discharged from the hospital. The Glasgow Outcome Scale Extended (GOSE) was used to assess functional disability 2 to 4 years after discharge. Outcomes were classified as favorable (GOSE scores 7 and 8) and unfavorable (GOSE scores 1-6). Of 71 patients identified, 39 were interviewed, 15 died, 1 refused to be interviewed, and 16 were lost to follow-up. Of the 54 patients with completed GOSE evaluations, only 15 (28%) had favorable outcomes. Among patients with unfavorable outcomes, 15 (28%) died, 14 (26%) survived with moderate disabilities, and 10 (18%) had severe disabilities. Factors associated with unfavorable outcomes were increases in duration of coma (p = 0.007), time in intensive care (p = 0.006), length of hospitalization (p = 0.004), and postoperative serum creatine kinase levels (p = 0.006). Only duration of coma was an independent predictor of unfavorable outcome (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.008-1.537; p = 0.042). Patients with durations of coma greater than 4 days were more likely to have unfavorable outcomes (OR, 5.1; 95% CI, 1.3-21.3; p = 0.02). Two thirds of comatose patients who survived to discharge after cardiac operations had unfavorable long-term functional outcomes. A longer duration of unconsciousness is a predictor of unfavorable outcome. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Isolated brain stem edema in a pediatric patient with head trauma: a case report.

PubMed

Basarslan, K; Basarslan, F; Karakus, A; Yilmaz, C

2015-01-01

Brain stem is the most vital part of our body and is a transitional region of the brain that connects the cerebrum with the spinal cord. Though, being small in size, it is full of indispensible functions such as the breathing, heart beat. Injury to the brain stem has similar effects as a brain injury, but it is more fatal. Use of the Glasgow Coma Score as a prognostic indicator of outcome in patients with head injuries is widely accepted in clinical practice. Traumatic brain stem edema in children is rare, but is associated with poor outcome. The question is that whether it is being aware of computerized tomography appearance of the posterior fossa when initial evaluating pediatric patients with head trauma at emergency clinics. Normal and edematous brain stem without an additional pathology are slightly different and not distinguished easily. On the other hand, brain stem edema should be promptly identified and appropriately treated in a short time.

In situ free-floating craniectomy: an unusual cause of chronic post-traumatic cephalalgia

PubMed Central

Kaliaperumal, Chandrasekaran; Raveendran, Savitha

2012-01-01

We describe a case of post-traumatic cephalalgia in a 54-year-old man with chronic right parieto-occipital headache 3 years posthead injury. At the initial presentation, his Glasgow Coma Scale (GCS) was 13/15 and CT brain revealed an acute subdural haematoma with fronto-temporal contusions. After 24 h his GCS dropped to 8/15 and subsequently he underwent a right-sided craniotomy and evacuation of the subdural haematoma and contusionectomy and intracranial pressure monitoring. To manage the cerebral oedema, the cranial bone flap was left in situ free-floating and was managed in an intensive care setting. He made good clinical recovery and 3 months postoperatively he complained of right-sided headache not relieved with medication and occipital nerve block. Three years later he underwent an exploration of the previous craniotomy scalp wound and the free-floating bone flap under the scalp was immobilised. The headache completely resolved following the procedure and is currently asymptomatic. PMID:22891026

Pediatric blunt carotid injury--case report.

PubMed

Oshiro, Shinya; Ohnishi, Hirokazu; Ohta, Mika; Tsuchimochi, Hirohito

2003-03-01

A 5-year-old boy was struck by a pickup truck, and admitted with Glasgow Coma Scale score of 14. Initial computed tomography (CT) showed no evidence of intracerebral lesions except for a skull fracture. Repeat CT 5 hours later showed hyperdense middle cerebral artery (MCA) sign, but he did not show any focal signs. Eighteen hours after the accident, he developed left hemiparesis. CT revealed a fresh infarction in the right MCA territory, associated with definite hyperdense MCA sign. He was immediately transferred to our hospital for further evaluation. Emergent angiography revealed a rat tail-shaped occlusion of the right internal carotid artery at the C-3 level. Cross-filling of the right MCA territory was insufficient for collateral circulation. He was treated conservatively because of the significant risk of hemorrhagic change from the established infarction. His hemiparesis improved gradually, and he was discharged on foot. Hyperdense MCA sign in a child is an important clinical sign for the early detection of cerebral ischemia after blunt carotid injury, before any focal signs appear.

Initial CSF total tau correlates with 1-year outcome in patients with traumatic brain injury.

PubMed

Ost, M; Nylén, K; Csajbok, L; Ohrfelt, A Olsson; Tullberg, M; Wikkelsö, C; Nellgård, P; Rosengren, L; Blennow, K; Nellgård, B

2006-11-14

We investigated if tau, microtubular binding protein, in serum and ventricular CSF (vCSF) in patients with severe traumatic brain injury (TBI) during the initial posttraumatic days correlated to 1-year outcome. Patients with severe TBI (n = 39, Glasgow Coma Scale score 2,126 pg/mL on days 2 to 3 discriminated between dead and alive (sensitivity of 100% and a specificity of 81%). A vCSF total tau level of >702 pg/mL on days 2 to 3 discriminated between bad (GOSE 1 to 4) and good (GOSE 5 to 8) outcome (sensitivity of 83% and a specificity of 69%). Patients with GOSE 1 (dead) had higher vCSF total tau levels on days 2 to 3 (p < 0.001) vs both surviving patients (GOSE 2 to 8) and those with NPH. Total tau was not detected in serum throughout the study. The increase in ventricular CSF (vCSF) total tau probably reflects axonal damage, known to be a central pathologic mechanism in traumatic brain injury (TBI). These results suggest that vCSF total tau may be an important early biochemical neuromarker for predicting long-term outcome in patients with a severe TBI.

The reliability of the Glasgow Coma Scale: a systematic review.

PubMed

Reith, Florence C M; Van den Brande, Ruben; Synnot, Anneliese; Gruen, Russell; Maas, Andrew I R

2016-01-01

The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.

Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma.

PubMed

Borgman, Matthew A; Maegele, Marc; Wade, Charles E; Blackbourne, Lorne H; Spinella, Philip C

2011-04-01

To develop a validated mortality prediction score for children with traumatic injuries. We identified all children (<18 years of age) in the US military established Joint Theater Trauma Registry from 2002 to 2009 who were admitted to combat-support hospitals with traumatic injuries in Iraq and Afghanistan. We identified factors associated with mortality using univariate and then multivariate regression modeling. The developed mortality prediction score was then validated on a data set of pediatric patients (≤ 18 years of age) from the German Trauma Registry, 2002-2007. Admission base deficit, international normalized ratio, and Glasgow Coma Scale were independently associated with mortality in 707 patients from the derivation set and 1101 patients in the validation set. These variables were combined into the pediatric "BIG" score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Scale), which were each calculated to have an area under the curve of 0.89 (95% confidence interval: 0.83-0.95) and 0.89 (95% confidence interval: 0.87-0.92) on the derivation and validation sets, respectively. The pediatric trauma BIG score is a simple method that can be performed rapidly on admission to evaluate severity of illness and predict mortality in children with traumatic injuries. The score has been shown to be accurate in both penetrating-injury and blunt-injury populations and may have significant utility in comparing severity of injury in future pediatric trauma research and quality-assurance studies. In addition, this score may be used to determine inclusion criteria on admission for prospective studies when accurately estimating the mortality for sample size calculation is required.

MIS Score: Prediction Model for Minimally Invasive Surgery.

PubMed

Hu, Yuanyuan; Cao, Jingwei; Hou, Xianzeng; Liu, Guangcun

2017-03-01

Reports suggest that patients with spontaneous intracerebral hemorrhage (ICH) can benefit from minimally invasive surgery, but the inclusion criterion for operation is controversial. This article analyzes factors affecting the 30-day prognoses of patients who have received minimally invasive surgery and proposes a simple grading scale that represents clinical operation effectiveness. The records of 101 patients with spontaneous ICH presenting to Qianfoshan Hospital were reviewed. Factors affecting their 30-day prognosis were identified by logistic regression. A clinical grading scale, the MIS score, was developed by weighting the independent predictors based on these factors. Univariate analysis revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.01), age ≥80 years (P < 0.05), blood glucose (P < 0.01), ICH volume (P < 0.01), operation time (P < 0.05), and presence of intraventricular hemorrhage (P < 0.001). Logistic regression revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.05), age (P < 0.05), ICH volume (P < 0.01), and presence of intraventricular hemorrhage (P < 0.05). The MIS score was developed accordingly; 39 patients with 0-1 MIS scores had favorable prognoses, whereas only 9 patients with 2-5 MIS scores had poor prognoses. The MIS score is a simple grading scale that can be used to select patients who are suited for minimal invasive drainage surgery. When MIS score is 0-1, minimal invasive surgery is strongly recommended for patients with spontaneous cerebral hemorrhage. The scale merits further prospective studies to fully determine its efficacy. Copyright © 2016 Elsevier Inc. All rights reserved.

Endoscopic Evacuation of Basal Ganglia Hematoma: Surgical Technique, Outcome, and Learning Curve.

PubMed

Ma, Lichao; Hou, Yuanzheng; Zhu, Ruyuan; Chen, Xiaolei

2017-05-01

Minimally invasive endoscopic hematoma evacuation is a promising treatment option for intracerebral hemorrhage. However, the technique still needs improvement. We report our clinical experience of using this technique to evacuate deep-seated basal ganglia hematomas. The frontal approach was used in most patients. The preoperative and postoperative hematoma volumes, Glasgow Coma Scale, hematoma evacuation rate, 30-day mortality, and long-term outcome defined by the modified Rankin Scale were analyzed retrospectively. The surgical duration per milliliter of clot (DPM) was calculated. The learning curve for this technique was determined based on the relation between the DPM and evacuation rate per the number of cases experienced. A total of 24 patients were enrolled. The evacuation rate was 87% ± 10%. The average Glasgow Coma Scale score recovered from 8 to 13 after surgery. Twenty-one patients had follow-up data. The follow-up time was 13 ± 6 months. The 30-day mortality after surgery was zero. Forty-eight percent of patients (10/21) achieved a favorable outcome. The DPM (P = 0.92) and evacuation rate (P = 0.64) did not change substantially with the number of cases experienced. Endoscopic port surgery for hematoma evacuation via the frontal approach is a safe surgical option for deep-seated basal ganglia hematomas. This technique is minimally invasive and may be helpful to provide better long-term outcomes for selected patients. For neurosurgeons, the learning curve for this technique is steep, which implies that the skills needed for our technique can be easily acquired. Copyright © 2017 Elsevier Inc. All rights reserved.

Does semiology of status epilepticus have an impact on treatment response and outcome?

PubMed

Baysal-Kirac, Leyla; Feddersen, Berend; Einhellig, Marion; Rémi, Jan; Noachtar, Soheyl

2018-06-01

This study investigated whether there is an association between semiology of status epilepticus (SE) and response to treatment and outcome. Two hundred ninety-eight consecutive adult patients (160 females, 138 males) with SE at the University of Munich Hospital were prospectively enrolled. Mean age was 63.2±17.5 (18-97) years. Patient demographics, SE semiology and electroencephalography (EEG) findings, etiology, duration of SE, treatment, and outcome measures were investigated. Status epilepticus semiology was classified according to a semiological status classification. Patient's short-term outcome was determined by Glasgow Outcome Scale (GOS). The most frequent SE type was nonconvulsive SE (NCSE) (39.2%), mostly associated with cerebrovascular etiology (46.6%). A potentially fatal etiology was found in 34.8% of the patients. More than half (60.7%) of the patients had poor short-term outcome (GOS≤3) with an overall mortality of 12.4%. SE was refractory to treatment in 21.5% of the patients. Older age, potentially fatal etiology, systemic infections, NCSE in coma, refractory SE, treatment with anesthetics, long SE duration (>24h), low Glasgow Coma Scale (GCS) (≤8) at onset, and high Status Epilepticus Severity Score (STESS-3) (≥3) were associated with poor short-term outcome and death (p<0.05). Potentially fatal etiology and low GCS were the strongest predictors of poor outcome (Exp [b]: 4.74 and 4.10 respectively, p<0.05). Status epilepticus semiology has no independent association with outcome, but potentially fatal etiology and low GCS were strong predictive factors for poor short-term outcome of SE. Copyright © 2018 Elsevier Inc. All rights reserved.

Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review.

PubMed

Reith, Florence Cm; Synnot, Anneliese; van den Brande, Ruben; Gruen, Russell L; Maas, Andrew Ir

2017-06-01

The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS. The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS. A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables. Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers. Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented. Copyright © 2017 by the Congress of Neurological Surgeons.

Multicenter Retrospective Cohort Study of "Talk and Die" After Traumatic Brain Injury.

PubMed

Shibahashi, Keita; Sugiyama, Kazuhiro; Okura, Yoshihiro; Hoda, Hidenori; Hamabe, Yuichi

2017-11-01

Patients who "talk and die" after traumatic brain injury (TBI) are potentially salvageable. The reported incidences and risk factors for the "talk and die" phenomenon are conflicting and do not take into account recent improvements in trauma care. The aim of this study was to determine the incidences of "talk and die" after TBI in a modern trauma care system, as well as associated risk factors. We identified patients who experienced TBI (abbreviated injury scale 3-5) between 2004 and 2015 who talked on admission (i.e., their verbal component on the Glasgow Coma Scale was ≥3 on admission) using a nationwide trauma registry (the Japan Trauma Data Bank). The end point was in-hospital mortality. We compared patients who talked and died with those who talked and survived. During the study period, 236,698 patients were registered in the database. Of the 24,833 patients who were eligible for analysis, 956 (4.0%) patients subsequently died in the hospital. The in-hospital mortality rate significantly decreased over the past 12 years. Older age; male sex; a higher injury severity score; a lower Glasgow Coma Scale score; comorbidities (congestive heart failure, chronic kidney disease, liver cirrhosis, and hematologic disorders); hypotension on arrival; subdural hemorrhage; contusion; and vault fracture were independently associated with higher in-hospital mortality. Even in modern trauma care systems, some patients still talk and die after TBI. We identified certain risk factors in patients with TBI that elicit the requirement for close observation, even if these patients talk after TBI. Copyright © 2017 Elsevier Inc. All rights reserved.

Missile injury to the pediatric brain in conflict zones.

PubMed

Wani, Abrar A; Ramzan, Altaf U; Malik, Nayil K; Qayoom, Abdul; Nizami, Furqan A; Kirmani, Altaf R; Wani, M Afzal

2011-03-01

This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world. Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well. On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability. There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

Spontaneous rapid reduction of a large acute subdural hematoma.

PubMed

Lee, Chul-Hee; Kang, Dong Ho; Hwang, Soo Hyun; Park, In Sung; Jung, Jin-Myung; Han, Jong Woo

2009-12-01

The majority of acute post-traumatic subdural hematomas (ASDH) require urgent surgical evacuation. Spontaneous resolution of ASDH has been reported in some cases. We report here on a case of a patient with a large amount of ASDH that was rapidly reduced. A 61-yr-old man was found unconscious following a high speed motor vehicle accident. On initial examination, his Glasgow Coma Score scale was 4/15. His pupils were fully dilated and non-reactive to bright light. Brain computed tomography (CT) showed a massive right-sided ASDH. The decision was made to treat him conservatively because of his poor clinical condition. Another brain CT approximately 14 hr after the initial scan demonstrated a remarkable reduction of the previous ASDH and there was the new appearance of high density in the subdural space adjacent to the falx and the tentorium. Thirty days after his admission, brain CT revealed chronic SDH and the patient underwent surgery. The patient is currently able to obey simple commands. In conclusion, spontaneous rapid resolution/reduction of ASDH may occur in some patients. The mechanisms are most likely the result of dilution by cerebrospinal fluid and the redistribution of hematoma especially in patients with brain atrophy.

Spontaneous Rapid Reduction of a Large Acute Subdural Hematoma

PubMed Central

Kang, Dong Ho; Hwang, Soo Hyun; Park, In Sung; Jung, Jin-Myung; Han, Jong Woo

2009-01-01

The majority of acute post-traumatic subdural hematomas (ASDH) require urgent surgical evacuation. Spontaneous resolution of ASDH has been reported in some cases. We report here on a case of a patient with a large amount of ASDH that was rapidly reduced. A 61-yr-old man was found unconscious following a high speed motor vehicle accident. On initial examination, his Glasgow Coma Score scale was 4/15. His pupils were fully dilated and non-reactive to bright light. Brain computed tomography (CT) showed a massive right-sided ASDH. The decision was made to treat him conservatively because of his poor clinical condition. Another brain CT approximately 14 hr after the initial scan demonstrated a remarkable reduction of the previous ASDH and there was the new appearance of high density in the subdural space adjacent to the falx and the tentorium. Thirty days after his admission, brain CT revealed chronic SDH and the patient underwent surgery. The patient is currently able to obey simple commands. In conclusion, spontaneous rapid resolution/reduction of ASDH may occur in some patients. The mechanisms are most likely the result of dilution by cerebrospinal fluid and the redistribution of hematoma especially in patients with brain atrophy. PMID:19949689

Predictors of outcome after treatment of mild traumatic brain injury: a pilot study.

PubMed

Leininger, Shelley; Strong, Carrie-Ann H; Donders, Jacobus

2014-01-01

To determine factors affecting outcome of comprehensive outpatient rehabilitation of individuals who sustained a mild traumatic brain injury. From a 4-year series of referrals, 49 nonconsecutive participants met criteria for mild traumatic brain injury (ie, loss of consciousness <30 minutes, Glasgow Coma Scale score >12). Outpatient, community-based postconcussion clinic at a rehabilitation hospital. Participants and therapy staff completed the Mayo-Portland Adaptability Inventory-Fourth Edition (MPAI-4) at the initiation and conclusion of treatment. Participants were also administered the Trail Making Test at the start of treatment. Participants generally gave poorer adaptability ratings than staff at the beginning and discharge of treatment. Regression analyses revealed that after controlling for baseline ratings, psychiatric history was associated with worse participant-rated MPAI-4 Adjustment scores at treatment discharge, whereas better Trail Making Test Part B performance at initiation of treatment predicted better participant-rated MPAI-4 Ability at treatment discharge. Premorbid demographic and baseline neurocognitive factors should be taken into account prior to comprehensive treatment of mild traumatic brain injury, as they can influence long-term outcomes. Adaptability ratings from both staff and participants can be useful in gaining different perspectives and assessing factors affecting recovery.

Intubation is not a marker for coma after in-hospital cardiac arrest: A retrospective study.

PubMed

Berg, Katherine M; Grossestreuer, Anne V; Uber, Amy; Patel, Parth V; Donnino, Michael W

2017-10-01

In-hospital cardiac arrest (IHCA) strikes over 200,000 people in the United States annually. Targeted temperature management (TTM) is considered beneficial in other settings, but there is no prospective data for IHCA. Recent work on TTM and IHCA found an association between TTM and worse outcome. However, the authors used intubation as a marker for coma to determine eligibility for TTM. The validity of this approach is unexplored. Retrospective, single center study of adult patients with IHCA occurring in an intensive care unit, intubated prior to or during the event, or immediately after ROSC. We evaluated the percentage of patients documented as comatose after arrest, defined as Glasgow Comas Score (GCS) <8 for the primary analysis. We also evaluated the difference in hospital survival in patients with GCS <8 versus ≥8. Two sensitivity analyses using different methods for defining coma using post-ROSC GCS were conducted. 29/102 (28%) intubated patients had a post-ROSC GCS≥8, and 22 (22%) were documented as following commands. Survival in patients with GCS≥8 vs.<8 was 62% (18/29) vs. 37% (27/73) in unadjusted analysis (p=0.02). The adjusted odds ratio for survival to hospital discharge was 3.81 (95%CI: 1.37-10.61, p=0.01). Results were similar in both sensitivity analyses. Intubation prior to or during IHCA was not a valid marker of coma after ROSC. Post-ROSC mental status was associated with hospital survival, and thus could be an important confounder when conducting observational studies on the association of TTM with outcomes in this patient population. Copyright © 2017 Elsevier B.V. All rights reserved.

A comparison of the diagnostic power of the Full Outline of Unresponsiveness scale and the Glasgow coma scale in the discharge outcome prediction of patients with traumatic brain injury admitted to the intensive care unit

PubMed Central

Gorji, Mohammad Ali Heidari; Hoseini, Seyed Hosein; Gholipur, Afshin; Mohammadpur, Reza Ali

2014-01-01

Background and Aim: This study aimed to determine whether the Full Outline of Unresponsiveness (FOUR) score is an accurate predictorof discharge outcome in traumatic brain injury (TBI) patients and to compare its performanceto Glasgow coma scale (GCS). Materials and Methods: Thisis diagnostic study conducted prospectively on 53 TBI patients admitted to ICU of education hospitals of Medical Science University of Mazandaran during February 2013 to June 2013. Data collection was done with a checklist including biographic, clinical information and outcome. The FOUR score and GCS were determined by the researcher in the first 24 hours. Outcomes considered as in-hospital mortality and poor neurologic outcome (Glasgow Outcome Scale (GOS) 1-3) in discharge time from the hospital. Results: In terms of predictive power for in-hospital mortality, the area under the receiver operating characteristic (ROC) curve was 0/92 (95% CI. 0/81-0/97) for FOUR score and 0/96 (95% CI. 0/87-0/99) for GCS. In terms of predictive power of poor neurologic outcome, the area under the ROC curve was 0/95 (95% CI. 0/86-0/99) for FOUR score and 0/90 (95% CI.0/79-0/96) for GCS as evidenced by GOS 1-3. The cut-off of 6 showed sensitivity and specificity of total four score predicting poor outcome at 0/86 and 0/87 while the cut-off of 4 showed the value of in hospital mortality at 0/90 and 0/90. The total GCS score showed sensitivity and specificity 0/100 and 0/61 at cut-off 7 in predicting poor outcome while in predicting mortality at cut-off of 4 this range was 0/100 and 0/92. Conclusion: The FOUR score is an accurate predictor of discharge outcome in TBI patients. Thus, researchers recommend for therapeutic Schematizationto use in neurosurgical patients at admission day. PMID:24843331

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4.

PubMed

Fulkerson, Daniel H; White, Ian K; Rees, Jacqueline M; Baumanis, Maraya M; Smith, Jodi L; Ackerman, Laurie L; Boaz, Joel C; Luerssen, Thomas G

2015-10-01

Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a "normal" outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.

[Value of computer tomography in the managment of brain injuries].

PubMed

Keita, A D; Toure, M; Sissako, A; Doumbia, S; Coulibaly, Y; Doumbia, D; Kane, M; Diallo, A K; Toure, A A; Traore, I

2005-11-01

The purpose of this prospective study conducted from January 2001 to December 2001 was to ascertain the value of computer tomography for evaluation of brain injuries. Computer tomography was performed using a Toshiba X VID system with contiguous 5 mm axial sections through the posterior fossa and 10 mm contiguous axial sections through the subtentorial region without contrast injection. A total of 107 patients with brain injuries were enrolled over the one-year study period. These patients accounted for 0.8% of all admissions to surgical emergency unit of Gabriel Toure Hospital in Bamako, Mali. The predominant age group for brain injuries was the 20- to 29-year-old group (35 cases). The male-to-female sex ratio was 5:1. Vehicular accident was the most frequent cause of brain injury (76 cases). Trauma was severe in 48 patients with a Glasgow score less than 8. Coma occurred immediately after injury in 90 cases. Ventricular hemorrhage led to coma in 100% of cases whereas brain hemorrhage and hematoma led to coma in 93.3% and 83.3% of cases respectively. Treatment was medical in 99 cases and neurosurgical in 8. The mortality rate was 34% and the morbidity rate (permanent sequels) was 36%. Computer tomography is a valuable tool for therapeutic decision-making in medico-surgical emergencies involving brain injuries.

Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study

PubMed Central

2010-01-01

Introduction The Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff. Methods In this prospective observational study, scoring of GCS and FOUR score was performed by neurologists and ICU staff on 267 consecutive patients admitted to intensive care. Results In a total of 437 pair wise ratings the exact inter-rater agreement for the GCS was 71%, and for the FOUR score 82% (P = 0.0016); the inter-rater agreement within a range of ± 1 score point for the GCS was 90%, and for the FOUR score 92% (P = ns.). The exact inter-rater agreement among neurologists was superior to that among ICU staff for the FOUR score (87% vs. 79%, P = 0.04) but not for the GCS (73% vs. 73%). Neurologists and ICU staff did not significantly differ in the inter-rater agreement within a range of ± 1 score point for both GCS (88% vs. 93%) and the FOUR score (91% vs. 88%). Conclusions The FOUR score performed better than the GCS for exact inter-rater agreement, but not for the clinically more relevant agreement within the range of ± 1 score point. Though neurologists outperformed ICU staff with regard to exact inter-rater agreement, the inter-rater agreement of ICU staff within the clinically more relevant range of ± 1 score point equalled that of the neurologists. The small advantage in inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS, a score with a long tradition in intensive care. PMID:20398274

Predictors of informal care burden 1 year after a severe traumatic brain injury: results from the PariS-TBI study.

PubMed

Bayen, Eleonore; Pradat-Diehl, Pascale; Jourdan, Claire; Ghout, Idir; Bosserelle, Vanessa; Azerad, Sylvie; Weiss, Jean-Jacques; Joël, Marie-Eve; Aegerter, Philippe; Azouvi, Philippe

2013-01-01

To investigate predictors of informal care burden 1 year after a severe traumatic brain injury (TBI). Patients (N = 66) aged 15 years or older with severe TBI (Glasgow Coma Scale score of 8 or less) and their primary informal caregivers. Multicenter inception cohort study over 22 months in Paris and the surrounding area (PariS-TBI study). Patients' preinjury characteristics; injury severity data; outcome measures at discharge from intensive care and 1 year after the injury; Dysexecutive Questionnaire; Medical Outcome Study Short Form-36; Zarit Burden Inventory. Among the 257 survivors at discharge from acute care, 66 patient-caregiver couples were included. Primary informal caregivers were predominantly women (73%), of middle age (age, 50 years), supporting male patients (79%), of mean age of 38 years. The majority (56%) of caregivers experienced significant burden, and 44% were at risk of depression. Caregivers' impaired health status and perceived burden significantly correlated with patients' global disability (as assessed with the Glasgow Outcome Scale-Extended) and impairments of executive functions (as assessed with the Dysexecutive Questionnaire). A focused principal component analysis suggested that disability and executive dysfunctions were independent predictors of perceived burden, whereas demographics, injury severity, and Glasgow Outcome Scale at discharge from acute care did not significantly correlate with caregiver's burden. Global handicap and impairments of executive functions are independent significant predictors of caregiver burden 1 year after TBI.

Predictors of outcome in myxoedema coma: a study from a tertiary care centre.

PubMed

Dutta, Pinaki; Bhansali, Anil; Masoodi, Shriq Rashid; Bhadada, Sanjay; Sharma, Navneet; Rajput, Rajesh

2008-01-01

With the easy availability of thyroid hormone assays, thyroid disorders are now recognised even in a subclinical state. However, patients are still seen with advanced manifestations of the disease, particularly in developing countries. This observational study analysed the predictors of outcome in patients with myxoedema coma and tested the validity of different modules to define morbidity and mortality in these patients. Twenty-three consecutive patients with myxoedema coma who presented from January 1999 to August 2006 were studied. The thyroid function test and random serum cortisol were measured in all patients at the time of admission. Patients were given oral or intravenous (i.v.) thyroxine with intention to treat with the latter according to availability. Various modules that predict outcome, including Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment (SOFA) score, were analysed. SOFA score was repeated every 2 days until the time of discharge or demise. Twenty-three patients (20 women; 87%) of 59.5 +/- 14.4 years of age (range, 30 to 89 years) were seen during the study period. Nine (39%) patients were diagnosed with hypothyroidism for the first time at the time of presentation of myxoedema coma, whereas 14 (70%) were diagnosed with hypothyroidism previously. However, the treatment defaulters presented early to the hospital and had more severe manifestations than de novo subjects. Nineteen (82%) had thyroprivic (primary) and 4 (17%) had trophoprivic (secondary) hypothyroidism. Fifteen (65%) patients presented in the winter and in 17 (74%) sepsis was the major accompanying comorbidity. Twelve (52%) had a history of diuretic use, thereby delaying the initial diagnosis. Patients who received oral L-thyroxine had no difference in outcome from those receiving i.v. thyroxine. Twelve (52%) subjects died and sepsis was the predominant cause of death. Various predictors of mortality included hypotension (p = 0.01) and bradycardia (p = 0.03) at presentation, need for mechanical ventilation (p = 0.00), hypothermia unresponsive to treatment (p = 0.01), sepsis (p = 0.01), intake of sedative drugs (p = 0.02), lower GCS (p = 0.03), high APACHE II score (p = 0.04), and high SOFA score (p = 0.00). However, SOFA score was more effective than other predictive models as baseline and day 3 SOFA scores of more than 6 were highly predictive of poor outcome. L-Thyroxine treatment defaulters had more severe manifestations compared with de novo subjects. Outcome was not influenced by either aetiology or route of administration of L-thyroxine, and SOFA score was the best outcome predictor model.

The Assessment of the Risk of Unplanned Extubation in an Adult Intensive Care Unit.

PubMed

Aydoğan, Semine; Kaya, Nurten

In order to plan and implement nursing intervention to reduce the incidence rate of unplanned extubation problem in the intensive care unit (ICU), it is necessary to determine the risk factors of unplanned extubation and the patients under risk. This study was undertaken with the aim of evaluating the risk of unplanned extubation of endotracheal tube in adult ICU. This was a case-control study. The population constituted patients hospitalized in the adult ICU during 1-year period in a university hospital. The sample from this population was composed of patients whose extubation was unplanned (30 patients) and the randomly selected patients (60 patients) who were intubated at the same time in the ICU for each patient whose extubation was unplanned. In data collection, the Richmond Agitation-Sedation Scale, Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation II were utilized. According to the findings, the variables such as sex, age, mechanical ventilation period, and Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale scores did not have any effect on the unplanned extubation, but variables such as internal medicine diseases and Richmond Agitation-Sedation Scale did have an effect. It was also revealed that there was no extubation plan in most of the unplanned extubation group, the nurse was anticipating the unplanned extubation, the patient was intubated again, and a complication occurred. The patients who are provided inadequate sedation and analgesia and who have problems in their respiratory system are under risk of unplanned extubation. In order to prevent unplanned extubation, an adequate amount of sedation and private nursing care should be provided to patients in the ICU.

Reduced brain/serum glucose ratios predict cerebral metabolic distress and mortality after severe brain injury.

PubMed

Kurtz, Pedro; Claassen, Jan; Schmidt, J Michael; Helbok, Raimund; Hanafy, Khalid A; Presciutti, Mary; Lantigua, Hector; Connolly, E Sander; Lee, Kiwon; Badjatia, Neeraj; Mayer, Stephan A

2013-12-01

The brain is dependent on glucose to meet its energy demands. We sought to evaluate the potential importance of impaired glucose transport by assessing the relationship between brain/serum glucose ratios, cerebral metabolic distress, and mortality after severe brain injury. We studied 46 consecutive comatose patients with subarachnoid or intracerebral hemorrhage, traumatic brain injury, or cardiac arrest who underwent cerebral microdialysis and intracranial pressure monitoring. Continuous insulin infusion was used to maintain target serum glucose levels of 80-120 mg/dL (4.4-6.7 mmol/L). General linear models of logistic function utilizing generalized estimating equations were used to relate predictors of cerebral metabolic distress (defined as a lactate/pyruvate ratio [LPR] ≥ 40) and mortality. A total of 5,187 neuromonitoring hours over 300 days were analyzed. Mean serum glucose was 133 mg/dL (7.4 mmol/L). The median brain/serum glucose ratio, calculated hourly, was substantially lower (0.12) than the expected normal ratio of 0.40 (brain 2.0 and serum 5.0 mmol/L). In addition to low cerebral perfusion pressure (P = 0.05) and baseline Glasgow Coma Scale score (P < 0.0001), brain/serum glucose ratios below the median of 0.12 were independently associated with an increased risk of metabolic distress (adjusted OR = 1.4 [1.2-1.7], P < 0.001). Low brain/serum glucose ratios were also independently associated with in-hospital mortality (adjusted OR = 6.7 [1.2-38.9], P < 0.03) in addition to Glasgow Coma Scale scores (P = 0.029). Reduced brain/serum glucose ratios, consistent with impaired glucose transport across the blood brain barrier, are associated with cerebral metabolic distress and increased mortality after severe brain injury.

Effect of Memantine on Serum Levels of Neuron-Specific Enolase and on the Glasgow Coma Scale in Patients With Moderate Traumatic Brain Injury.

PubMed

Mokhtari, Majid; Nayeb-Aghaei, Hossein; Kouchek, Mehran; Miri, Mir Mohammad; Goharani, Reza; Amoozandeh, Arash; Akhavan Salamat, Sina; Sistanizad, Mohammad

2018-01-01

Traumatic brain injury (TBI) is a major cause of disability and death globally. Despite significant progress in neuromonitoring and neuroprotection, pharmacological interventions have failed to generate favorable results. We examined the effect of memantine on serum levels of neuron-specific enolase (NSE), a marker of neuronal damage, and the Glasgow Coma Scale (GCS) in patients with moderate TBI. Patients were randomly assigned to the control group (who received standard TBI management) and the treatment group (who, alongside their standard management, received enteral memantine 30 mg twice daily for 7 days). Patients' clinical data, GCS, findings of head computed tomography, and serum NSE levels were collected during the study. Forty-one patients were randomized into the control and treatment groups, 19 and 22 patients respectively. Baseline characteristics and serum NSE levels were not significantly different between the 2 groups. The mean serum NSE levels for the memantine and the control groups on day 3 were 7.95 ± 2.86 and 12.33 ± 7.09 ng/mL, respectively (P = .05), and on day 7 were 5.03 ± 3.25 and 10.04 ± 5.72 ng/mL, respectively (P = .003). The mean GCS on day 3 was 12.3 ± 2.0 and 10.9 ± 1.9 in the memantine and control groups, respectively (P = .03). Serum NSE levels and GCS changes were negatively correlated (r = -0.368, P = .02). Patients with moderate TBI who received memantine had significantly reduced serum NSE levels by day 7 and marked improvement in their GCS scores on day 3 of the study. © 2017, The American College of Clinical Pharmacology.

Glasgow Coma Scale and Outcomes after Structural Traumatic Head Injury in Early Childhood

PubMed Central

Heather, Natasha L.; Derraik, José G. B.; Beca, John; Hofman, Paul L.; Dansey, Rangi; Hamill, James; Cutfield, Wayne S.

2013-01-01

Objective To assess the association of the Glasgow Coma Scale (GCS) with radiological evidence of head injury (the Abbreviated Injury Scale for the head region, AIS-HR) in young children hospitalized with traumatic head injury (THI), and the predictive value of GCS and AIS-HR scores for long-term impairment. Methods Our study involved a 10-year retrospective review of a database encompassing all patients admitted to Starship Children’s Hospital (Auckland, New Zealand, 2000–2010) with THI. Results We studied 619 children aged <5 years at the time of THI, with long-term outcome data available for 161 subjects. Both GCS and AIS-HR scores were predictive of length of intensive care unit and hospital stay (all p<0.001). GCS was correlated with AIS-HR (ρ=-0.46; p<0.001), although mild GCS scores (13–15) commonly under-estimated the severity of radiological injury: 42% of children with mild GCS scores had serious–critical THI (AIS-HR 3–5). Increasingly severe GCS or AIS-HR scores were both associated with a greater likelihood of long-term impairment (neurological disability, residual problems, and educational support). However, long-term impairment was also relatively common in children with mild GCS scores paired with structural THI more severe than a simple linear skull fracture. Conclusion Severe GCS scores will identify most cases of severe radiological injury in early childhood, and are good predictors of poor long-term outcome. However, young children admitted to hospital with structural THI and mild GCS scores have an appreciable risk of long-term disability, and also warrant long-term follow-up. PMID:24312648

[Spanish versions of the Simplified Motor Score and the Glasgow Coma Scale in out-of-hospital treatment of head injury in adults: a preliminary study of each scale's ability to predict adverse events].

PubMed

Roca, Guillem; Mayol, Sergi; García, Esteban; Casajuana, Edgar; Quintana, Salvador

2015-06-01

To determine the ability of the modified (Spanish) version of the Simplified Motor Score (mSMS) to predict adverse events during hospitalization and to compare its predictive ability to that of the Glasgow Coma Scale (GCS) in adults with head injuries treated outside the hospital. Observational study of retrospective cohorts including all patients over the age of 14 years attended for head injuries occurring within 24 hours of treatment by an advanced life-support unit staffed by nurses between May 1, 2013, and May 1, 2014. The mSMS was a translation of the English original, created through a process of discussions of direct and back translations to arrive at consensus. Out-of-hospital patient records were searched to find GCS and mSMS scores. To predict the ability of each scale to predict brain injuries, neurosurgery, intubation, and/or inhospital death, we calculated the area under the receiving operator characteristic curves (AUCs). Of the total of 115 head-injury patients attended, 64 met the inclusion criteria. The mean (SD) age was 47 (24) years. Twelve (18.8%) patients developed some form of adverse event during hospitalization; 91.6% had brain damage, 58.3% required intubation, 8.3% required surgery, and 41.6% died. The AUC for the GCS was 0.907 (95% CI, 0.81-1.00; P<.001); the AUC for the mSMS was 0.796 (95% CI, 0.64-0.95; P=.001). Although the ability of the mSMS to predict in-hospital adverse outcomes is good, it is inferior to the GCS in adults with head injuries attended outside the hospital.

The influence of damage distribution on serious brain injury in occupants in frontal motor vehicle crashes.

PubMed

Coimbra, Raul; Conroy, Carol; Hoyt, David B; Pacyna, Sharon; May, MarSue; Erwin, Steve; Tominaga, Gail; Kennedy, Frank; Sise, Michael; Velky, Tom

2008-07-01

In spite of improvements in motor vehicle safety systems and crashworthiness, motor vehicle crashes remain one of the leading causes of brain injury. The purpose of this study was to determine if the damage distribution across the frontal plane affected brain injury severity of occupants in frontal impacts. Occupants in "head on" frontal impacts with a Principal Direction of Force (PDOF) equal to 11, 12, or 1o'clock who sustained serious brain injury were identified using the Crash Injury Research Engineering Network (CIREN) database. Impacts were further classified based on the damage distribution across the frontal plane as distributed, offset, and extreme offset (corner). Overall, there was no significant difference for brain injury severity (based on Glasgow Coma Scale<9, or brain injury AIS>2) comparing occupants in the different impact categories. For occupants in distributed frontal impacts, safety belt use was protective (odds ratio (OR)=0.61) and intrusion at the occupant's seat position was four times more likely to result in severe (Glasgow Coma Scale (GCS)<9) brain injury (OR=4.35). For occupants in offset frontal impacts, again safety belt use was protective against severe brain injury (OR=0.25). Possibly due to the small number of brain-injured occupants in corner impacts, safety belts did not significantly protect against increased brain injury severity during corner impacts. This study supports the importance of safety belt use to decrease brain injury severity for occupants in distributed and offset frontal crashes. It also illustrates how studying "real world" crashes may provide useful information on occupant injuries under impact circumstances not currently covered by crash testing.

Management and outcome of mechanically ventilated neurologic patients.

PubMed

Pelosi, Paolo; Ferguson, Niall D; Frutos-Vivar, Fernando; Anzueto, Antonio; Putensen, Christian; Raymondos, Konstantinos; Apezteguia, Carlos; Desmery, Pablo; Hurtado, Javier; Abroug, Fekri; Elizalde, José; Tomicic, Vinko; Cakar, Nahit; Gonzalez, Marco; Arabi, Yaseen; Moreno, Rui; Esteban, Andres

2011-06-01

To describe and compare characteristics, ventilatory practices, and associated outcomes among mechanically ventilated patients with different types of brain injury and between neurologic and nonneurologic patients. Secondary analysis of a prospective, observational, and multicenter study on mechanical ventilation. Three hundred forty-nine intensive care units from 23 countries. We included 552 mechanically ventilated neurologic patients (362 patients with stroke and 190 patients with brain trauma). For comparison we used a control group of 4,030 mixed patients who were ventilated for nonneurologic reasons. None. We collected demographics, ventilatory settings, organ failures, and complications arising during ventilation and outcomes. Multivariate logistic regression analysis was performed with intensive care unit mortality as the dependent variable. At admission, a Glasgow Coma Scale score ≤8 was observed in 68% of the stroke, 77% of the brain trauma, and 29% of the nonneurologic patients. Modes of ventilation and use of a lung-protective strategy within the first week of mechanical ventilation were similar between groups. In comparison with nonneurologic patients, patients with neurologic disease developed fewer complications over the course of mechanical ventilation with the exception of a higher rate of ventilator-associated pneumonia in the brain trauma cohort. Neurologic patients showed higher rates of tracheotomy and longer duration of mechanical ventilation. Mortality in the intensive care unit was significantly (p < .001) higher in patients with stroke (45%) than in brain trauma (29%) and nonneurologic disease (30%). Factors associated with mortality were: stroke (in comparison to brain trauma), Glasgow Coma Scale score on day 1, and severity at admission in the intensive care unit. In our study, one of every five mechanically ventilated patients received this therapy as a result of a neurologic disease. This cohort of patients showed a higher mortality rate than nonneurologic patients despite a lower incidence of extracerebral organ dysfunction.

Ketamine use for rapid sequence intubation in Australian and New Zealand emergency departments from 2010 to 2015: A registry study.

PubMed

Ferguson, Ian; Alkhouri, Hatem; Fogg, Toby; Aneman, Anders

2018-06-11

This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015. The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use. A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44-2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07-1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98-0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56-0.82), while trauma conferred an OR of 1.38 (95% CI 1.25-1.53). Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use. © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Role of Intracranial Pressure Monitoring in Management of Patients with Severe Traumatic Brain Injury: Results of a Large Level I Trauma Center in Southern Iran.

PubMed

Khalili, Hosseinali; Sadraei, Nazanin; Niakan, Amin; Ghaffarpasand, Fariborz; Sadraei, Amin

2016-10-01

To determine the role of intracranial pressure (ICP) monitoring in management of patients with severe traumatic brain injury (TBI) admitted to a large level I trauma center in Southern Iran. This was a cohort study performed during a 2-year period in a level I trauma center in Southern Iran including all adult patients (>16 years) with severe TBI (Glasgow Coma Scale [GCS] score, 3-8) who underwent ICP monitoring through ventriculostomy. The management was based on the recorded ICP values with threshold of 20 mm Hg. Decompressive craniectomy was performed in patients with intractable intracranial hypertension (persistent ICP ≥25 mm Hg). In unresponsive patients, barbiturate coma was induced. Patients were followed for 6 months and Glasgow Outcome Scale Extended was recorded. The determinants of favorable and unfavorable outcome were also determined. Overall, we included 248 patients with mean age of 34.6 ± 16.6 years, among whom there were 216 men (87.1%) and 32 women (12.9%). Eighty-five patients (34.2%) had favorable and 163 (65.8%) unfavorable outcomes. Those with favorable outcome had significantly lower age (P = 0.004), higher GCS score on admission (P < 0.001), lower Rotterdam score (P = 0.035), fewer episodes of intracranial hypertension (P < 0.001), and lower maximum recorded ICP (P = 0.041). These factors remained statistically significant after elimination of confounders by multivariate logistic regression model. Age, GCS score on admission, Rotterdam score, intracranial hypertension, and maximum recorded ICP are important determinants of outcome in patients with severe TBI. ICP monitoring assisted us in targeted therapy and management of patients with severe TBI. Copyright © 2016 Elsevier Inc. All rights reserved.

Reconsidering the logic of World Federation of Neurosurgical Societies grading in patients with severe subarachnoid hemorrhage.

PubMed

Fung, Christian; Inglin, Fabienne; Murek, Michael; Balmer, Mathias; Abu-Isa, Janine; Z'Graggen, Werner J; Ozdoba, Christoph; Gralla, Jan; Jakob, Stephan M; Takala, Jukka; Beck, Jürgen; Raabe, Andreas

2016-02-01

Current data show a favorable outcome in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) Grade V subarachnoid hemorrhage (SAH) and a rather poor prediction of worst cases. Thus, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. One reason for this lack of differentiation is the use of "negative" or "silent" diagnostic signs as part of the WFNS Grade V definition. The authors therefore reevaluated the WFNS scale by using "positive" clinical signs and the logic of the Glasgow Coma Scale as a progressive herniation score. The authors performed a retrospective analysis of 182 patients with SAH who had poor grades on the WFNS scale. Patients were graded according to the original WFNS scale and additionally according to a modified classification, the WFNS herniation (hWFNS) scale (Grade IV, no clinical signs of herniation; Grade V, clinical signs of herniation). The prediction of poor outcome was compared between these two grading systems. The positive predictive values of Grade V for poor outcome were 74.3% (OR 3.79, 95% CI 1.94-7.54) for WFNS Grade V and 85.7% (OR 8.27, 95% CI 3.78-19.47) for hWFNS Grade V. With respect to mortality, the positive predictive values were 68.3% (OR 3.9, 95% CI 2.01-7.69) for WFNS Grade V and 77.9% (OR 6.22, 95% CI 3.07-13.14) for hWFNS Grade V. Limiting WFNS Grade V to the positive clinical signs of the Glasgow Coma Scale such as flexion, extension, and pupillary abnormalities instead of including "no motor response" increases the prediction of mortality and poor outcome in patients with severe SAH.

Reliability of intensive care unit admitting and comorbid diagnoses, race, elements of Acute Physiology and Chronic Health Evaluation II score, and predicted probability of mortality in an electronic intensive care unit database.

PubMed

Wenner, Joshua B; Norena, Monica; Khan, Nadia; Palepu, Anita; Ayas, Najib T; Wong, Hubert; Dodek, Peter M

2009-09-01

Although reliability of severity of illness and predicted probability of hospital mortality have been assessed, interrater reliability of the abstraction of primary and other intensive care unit (ICU) admitting diagnoses and underlying comorbidities has not been studied. Patient data from one ICU were originally abstracted and entered into an electronic database by an ICU nurse. A research assistant reabstracted patient demographics, ICU admitting diagnoses and underlying comorbidities, and elements of Acute Physiology and Chronic Health Evaluation II (APACHE II) score from 100 random patients of 474 admitted during 2005 using an identical electronic database. Chamberlain's percent positive agreement was used to compare diagnoses and comorbidities between the 2 data abstractors. A kappa statistic was calculated for demographic variables, Glasgow Coma Score, APACHE II chronic health points, and HIV status. Intraclass correlation was calculated for acute physiology points and predicted probability of hospital mortality. Percent positive agreement for ICU primary and other admitting diagnoses ranged from 0% (primary brain injury) to 71% (sepsis), and for underlying comorbidities, from 40% (coronary artery bypass graft) to 100% (HIV). Agreement as measured by kappa statistic was strong for race (0.81) and age points (0.95), moderate for chronic health points (0.50) and HIV (0.66), and poor for Glasgow Coma Score (0.36). Intraclass correlation showed a moderate-high agreement for acute physiology points (0.88) and predicted probability of hospital mortality (0.71). Reliability for ICU diagnoses and elements of the APACHE II score is related to the objectivity of primary data in the medical charts.

Predictors of abdominal injuries in blunt trauma.

PubMed

Farrath, Samiris; Parreira, José Gustavo; Perlingeiro, Jacqueline A G; Solda, Silvia C; Assef, José Cesar

2012-01-01

To identify predictors of abdominal injuries in victims of blunt trauma. retrospective analysis of trauma protocols (collected prospectively) of adult victims of blunt trauma in a period of 15 months. Variables were compared between patients with abdominal injuries (AIS>0) detected by computed tomography or/and laparotomy (group I) and others (AIS=0, group II). Student's t, Fisher and qui-square tests were used for statistical analysis, considering p<0.05 as significant. A total of 3783 cases were included, with a mean age of 39.1 ± 17.7 years (14-99), 76.1% being male. Abdominal injuries were detected in 130 patients (3.4%). Patients sustaining abdominal injuries had significantly lower mean age (35.4 + 15.4 vs. 39.2 + 17.7), lower mean systolic blood pressure on admission (114.7 + 32.4 mmHg vs. 129.1 + 21.7 mmHg), lower mean Glasgow coma scale (12.9 + 3.9 vs. 14.3 + 2.0), as well as higher head AIS (0.95 + 1.5 vs. 0.67 + 1.1), higher thorax AIS (1.10 + 1.5 vs. 0.11 + 0.6) and higher extremities AIS (1.70 ± 1.8 vs. 1.03 ± 1.2). Patients sustaining abdominal injuries also presented higher frequency of severe injuries (AIS>3) in head (18.5% vs. 7.9%), thorax (29.2% vs. 2.4%) and extremities (40.0% vs. 13.7%). The highest odds ratios for the diagnosis of abdominal injuries were associated flail chest (21.8) and pelvic fractures (21.0). Abdominal injuries were more frequently observed in patients with hemodynamic instability, changes in Glasgow coma scale and severe lesions to the head, chest and extremities.

Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury.

PubMed

Algarra, Nelson N; Lele, Abhijit V; Prathep, Sumidtra; Souter, Michael J; Vavilala, Monica S; Qiu, Qian; Sharma, Deepak

2017-07-01

Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery. We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure<90 mm Hg), intracranial hypertension (ICP>20 mm Hg), cerebral hypotension (cerebral perfusion pressure<50 mm Hg), hypercarbia (end-tidal CO2>40 mm Hg), hypocarbia (end-tidal CO2<30 mm Hg in absence of intracranial hypertension), hyperglycemia (glucose>200 mg/dL), hypoglycemia (glucose<60 mg/dL), and hyperthermia (temperature >38°C). A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by ≥2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P<0.001). Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.

A Two-Center Validation of "Patient Does Not Follow Commands" and Three Other Simplified Measures to Replace the Glasgow Coma Scale for Field Trauma Triage.

PubMed

Hopkins, Emily; Green, Steven M; Kiemeney, Michael; Haukoos, Jason S

2018-05-02

Out-of-hospital personnel worldwide calculate the 13-point Glasgow Coma Scale (GCS) score as a routine part of field trauma triage. We wish to independently validate a simpler binary assessment to replace the GCS for this task. We analyzed trauma center registries from Loma Linda University Health (2003 to 2015) and Denver Health Medical Center (2009 to 2015) to compare the binary assessment "patient does not follow commands" (ie, GCS motor score <6) with GCS score less than or equal to 13 for the prediction of 5 trauma outcomes: emergency intubation, clinically significant brain injury, need for neurosurgical intervention, Injury Severity Score greater than 15, and mortality. As a secondary analysis, we similarly evaluated 3 other measures simpler than the GCS: GCS motor score less than 5, Simplified Motor Score, and the "alert, voice, pain, unresponsive" scale. In this analysis of 47,973 trauma patients, we found that the binary assessment "patient does not follow commands" was essentially identical to GCS score less than or equal to 13 for the prediction of all 5 trauma outcomes, with slightly superior positive likelihood ratios (eg, those for mortality 2.37 versus 2.13) offsetting slightly inferior negative ones (eg, those for mortality 0.25 versus 0.24) and its graphic depiction of sensitivity versus specificity superimposing the GCS prediction curve. We found similar results for the 3 other simplified measures. In this 2-center external validation, we confirmed that a simple binary assessment-"patient does not follow commands"-could effectively replace the more complicated GCS for field trauma triage. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Scoring severity in trauma: comparison of prehospital scoring systems in trauma ICU patients.

PubMed

Llompart-Pou, J A; Chico-Fernández, M; Sánchez-Casado, M; Salaberria-Udabe, R; Carbayo-Górriz, C; Guerrero-López, F; González-Robledo, J; Ballesteros-Sanz, M Á; Herrán-Monge, R; Servià-Goixart, L; León-López, R; Val-Jordán, E

2017-06-01

We evaluated the predictive ability of mechanism, Glasgow coma scale, age and arterial pressure (MGAP), Glasgow coma scale, age and systolic blood pressure (GAP), and triage-revised trauma Score (T-RTS) scores in patients from the Spanish trauma ICU registry using the trauma and injury severity score (TRISS) as a reference standard. Patients admitted for traumatic disease in the participating ICU were included. Quantitative data were reported as median [interquartile range (IQR), categorical data as number (percentage)]. Comparisons between groups with quantitative variables and categorical variables were performed using Student's T Test and Chi Square Test, respectively. We performed receiving operating curves (ROC) and evaluated the area under the curve (AUC) with its 95 % confidence interval (CI). Sensitivity, specificity, positive predictive and negative predictive values and accuracy were evaluated in all the scores. A value of p < 0.05 was considered significant. The final sample included 1361 trauma ICU patients. Median age was 45 (30-61) years. 1092 patients (80.3 %) were male. Median ISS was 18 (13-26) and median T-RTS was 11 (10-12). Median GAP was 20 (15-22) and median MGAP 24 (20-27). Observed mortality was 17.7 % whilst predicted mortality using TRISS was 16.9 %. The AUC in the scores evaluated was: TRISS 0.897 (95 % CI 0.876-0.918), MGAP 0.860 (95 % CI 0.835-0.886), GAP 0.849 (95 % CI 0.823-0.876) and T-RTS 0.796 (95 % CI 0.762-0.830). Both MGAP and GAP scores performed better than the T-RTS in the prediction of hospital mortality in Spanish trauma ICU patients. Since these are easy-to-perform scores, they should be incorporated in clinical practice as a triaging tool.

Aneurysmal subarachnoid hemorrhage causes injury of the ascending reticular activating system: relation to consciousness.

PubMed

Jang, S H; Kim, H S

2015-04-01

Little is known about the pathogenetic mechanism of impaired consciousness following subarachnoid hemorrhage. Using diffusion tensor imaging, we attempted to investigate the presence of injury of the lower portion of the ascending reticular activating system between the pontine reticular formation and the intralaminar thalamic nuclei, and the relation between this injury and consciousness level in patients with SAH. We recruited 24 consecutive patients with spontaneous SAH following aneurysmal rupture and 21 healthy control subjects. Consciousness level was rated by using the Glasgow Coma Scale. Using diffusion tensor tractography, we reconstructed the lower portion of the ascending reticular activating system between the pontine reticular formation and the intralaminar thalamic nuclei. Values of fractional anisotropy, apparent diffusion coefficient, and tract number of the ascending reticular activating system were measured. A significant difference in the tract number was observed between the patient and control groups (P < .05); however, there was no significant difference in terms of fractional anisotropy and apparent diffusion coefficient values (P > .05). In addition, regarding the tract number of the patient group, the Glasgow Coma Scale showed strong positive correlations with the tract number on the more affected side (r = 0.890, P < .05), the less affected side (r = 0.798, P < .05), and both sides (r = 0.919, P < .05), respectively. We found injury of the lower portion of the ascending reticular activating system between the pontine reticular formation and the thalamus in patients with SAH. In addition, we observed a close association between injury of the lower portion of the ascending reticular activating system and impaired consciousness in patients with SAH. © 2015 by American Journal of Neuroradiology.

Coma reversal with cerebral dysfunction recovery after repetitive hyperbaric oxygen therapy for severe carbon monoxide poisoning.

PubMed

Dean, B S; Verdile, V P; Krenzelok, E P

1993-11-01

The accepted beneficial effects of hyperbaric oxygen (HBO) include a greatly diminished carboxyhemoglobin (COHgb) half-life, enhanced tissue clearance of residual carbon monoxide (CO), reduced cerebral edema, and reversal of cytochrome oxidase inhibition, and prevention of central nervous system lipid peroxidation. Debate regarding the criteria for selection of HBO versus 100% normobaric oxygen therapy continues, and frequently is based solely on the level of COHgb saturation. Patients who manifest signs of serious CO intoxication (unconsciousness, neuropsychiatric symptoms, cardiac or hemodynamic instability) warrant immediate HBO therapy. An unresponsive 33-year-old woman was found in a closed garage, inside her automobile with the ignition on. Her husband admitted to seeing her 6 hours before discovery. 100% normobaric oxygen was administered in the prehospital and emergency department settings. The patient had an initial COHgb saturation of 46.7%, a Glasgow coma score of 3, and was transferred for HBO therapy. Before HBO therapy, the patient remained unresponsive and demonstrated decerebrate posturing and a positive doll's eyes (negative oculocephalic reflex). The electroencephalogram pattern suggested bilateral cerebral dysfunction consistent with a toxic metabolic or hypoxic encephalopathy. The patient underwent HBO therapy at 2.4 ATA for 90 minutes twice a day for 3 consecutive days. On day 7, the patient began to awaken, was weaned from ventilatory support, and was not soon verbalizing appropriately. A Folstein mental status examination showed a score of 26 of 30. Neurological examination demonstrated mild residual left upper extremity weakness and a normal gait. There was no evidence of significant neurological sequelae at 1 month follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Cobalt-55 positron emission tomography in traumatic brain injury: a pilot study.

PubMed Central

Jansen, H M; van der Naalt, J; van Zomeren, A H; Paans, A M; Veenma-van der Duin, L; Hew, J M; Pruim, J; Minderhoud, J M; Korf, J

1996-01-01

Traumatic brain injury is usually assessed with the Glasgow coma scale (GCS), CT, or MRI. After such injury, the injured brain tissue is characterised by calcium mediated neuronal damage and inflammation. Positron emission tomography with the isotope cobalt-55 (Co-PET) as a calcium tracer enables imaging of affected tissue in traumatic brain injury. The aim was to determine whether additional information can be gained by Co-PET in the diagnosis of moderate traumatic brain injury and to assess any prognostic value of Co-PET. Five patients with recent moderately severe traumatic brain injury were studied. CT was performed on the day of admission, EEG within one week, and MRI and Co-PET within four weeks of injury. Clinical assessment included neurological examination, GCS, neuropsychological testing, and Glasgow outcome scale (GOS) after one year. Co-PET showed focal uptake that extended beyond the morphological abnormalities shown by MRI and CT, in brain regions that were actually diagnosed with EEG. Thus Co-PET is potentially useful for diagnostic localisation of both structural and functional abnormalities in moderate traumatic brain injury. Images PMID:8708661

Nontraumatic Retroperitoneal Hematoma After Warfarin Administration: Fatal Case Report and Review of the Literature.

PubMed

Hosseini, Marzieh; Hosseinzadeh, Amin; Raufian, Kasra; Hedjazi, Arya

2015-12-01

Spontaneous retroperitoneal hematoma after warfarin therapy is an extremely rare event. Here, we report a 25-year-old man who was brought in to the emergency service with confusion. On arrival, the patient had hypotension, tachycardia, tachypnea, low-grade fever, and Glasgow Coma Scale score of 12. Abdominal examination revealed distention and mild tenderness in the right upper quadrant of the abdomen. The patient had a history of aortic valve replacement surgery and was on warfarin treatment at an international normalized ratio of 2.4. Our patient progressed to cardiorespiratory arrest. The resuscitation was initiated promptly. Despite all resuscitation measures, including transfusion and administration of high doses of catecholamine, the patient died of hypovolemic shock 3 hours after admission. At autopsy, the external surface of the abdominal great vessels (descending aorta and mesenteric vessels) showed scattered petechial hemorrhages without any visible site of perforation. After comprehensive exploration of the abdomen, no evidence of traumatic event was identified and the cause of internal blood loss was noted as warfarin adverse effect.

[Decompressive craniectomy in the management of sylvian infarction].

PubMed

Berhouma, Moncef; Khouja, Néjib; Jemel, Hafedh; Khaldi, Moncef

2006-09-01

Space-occupying middle cerebral artery infarction represents about 10 to 15% of supratentorial ischemic strokes. This syndrome carries a high rate of mortality and requires aggressive surgical decompression. The authors present 6 patients with signs of trans-tentorial herniation operated on between February 2001 and August 2003. Neurological preoperative status was evaluated with Glasgow coma scale score and postoperatively with Barthel index. Three patients had excellent recovery (Barthel Index up to 70), one remained dependant and two died. Younger patients had better prognosis. Decompressive surgery, when done early, should improve mortality rate and even functional outcome. Optimal selection of patients, with the help of Diffusion-Weighted imaging, could vouch good results.

Case 252: Acute Hyperammonemic Encephalopathy Resulting from Late-Onset Ornithine Transcarbamylase Deficiency.

PubMed

Hershman, Michelle; Carmody, Raymond; Udayasankar, Unni K

2018-04-01

History A 19-year-old woman with no pertinent medical history was brought to the emergency department after being found unconscious on her bathroom floor by her roommate. In the preceding weeks, she had reported intractable nausea and vomiting, for which she had been taking ondansetron. No other medications had been prescribed. The day prior to presentation, she had contacted her mother and described increasing confusion. Glasgow coma scale score on arrival in the emergency department was 4. Intravenous naloxone was administered, without immediate response. Initial blood glucose level was 232 mg/dL (12.8 mmol/L) (normal range, 79-140 mg/dL [4.4- 7.7 mmol/L]), and other routine laboratory test results were normal. Urine toxicology results were negative. Cerebrospinal fluid evaluation revealed levels were within normal limits. Neurologic examination revealed dilated pupils, which showed a sluggish response to light, and left lower extremity rigidity with intermittent tremors. Initial unenhanced cranial computed tomographic (CT) findings were negative. Magnetic resonance (MR) imaging of the brain was performed. The patient's condition deteriorated, with increasing cerebral edema over the next week, and she was declared brain dead. Her liver was transplanted into an adult recipient, who subsequently developed cerebral edema and elevated plasma ammonia levels, resulting in death in the immediate postoperative period.

Predictors of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a pilot study in a single Egyptian institute.

PubMed

Aboul-Ela, Hashem M; Salah El-Din, Ahmed M; Zaater, Ahmed A; Shehab, Mohamed; El Shahawy, Ossama A

2018-01-01

Acute hydrocephalus can cause neurological deterioration after aneurysmal subarachnoid hemorrhage (aSAH). Predicting which patient would require shunting is challenging. This prospective study was conducted upon twenty patients who suffered acute hydrocephalus due to subarachnoid hemorrhage of ruptured aneurysms. Surgical or non-surgical management of hydrocephalus was conducted. Glasgow Coma scale (GCS) was assessed, and hydrocephalus was graded by bicaudate index. Fisher grade was determined from CT scan. Aneurysm site was determined by conventional or CT angiography. Either surgical clipping or endovascular coiling of aneurysms was performed. Initially, 3 (15%) patients had emergency CSF diversion on admission due to poor GCS on arrival. Initially, the remaining 17 patients were managed conservatively. Five patients did not require any intervention. Twelve patients had external ventricular drainage placement, 4 were weaned, and 8 failed weaning. High bicaudate index (> 0.2) correlated with shunting. Aneurysm site correlated well with shunting (ACoA or PCoA). Patients with fair GCS can be managed conservatively. Any deterioration warrants shifting to CSF diversion. Higher bicaudate index will usually need CSF diversion. The value of Fisher carries no significant value. Aneurysm location (ACoA or PCoA) correlates with an increased incidence of ventriculoperitoneal shunt placement.

[Head injuries in Duckburg in 1959 and 2009].

PubMed

Juul, Agnete M; Rasmussen, Mads; Koch, Klaus Ulrik; Juul, Niels

2016-12-12

Comic books have been a part of popular culture through generations. Debates concerning their graphic depictions of violence have been ongoing for nearly as long. Our aim was to examine if the violence in "Donald Duck & Co." (a weekly published Danish comic book), illustrated through the number of head injuries, increased in the period from 1959 to 2009. The comic book vintages from the years 1959 and 2009 were read, and the number of head injuries noted. The head injuries were characterized by severity, in part by a modified Glasgow Coma Scale and in part by a newly developed Comic Book Coma Scale. The number of head injuries were equal in the examined years, however, the number of head injuries per page decreased from 1/10 pages to 1/20 pages. Donald Duck sustained a better part of the injuries increasing from 17% in 1959 to 33% in 2009. The study indicates that we, with peace of mind, can read a comic book while the rest of the family takes care of the dishes at Christmas.

Clinical, Radiologic, and Legal Significance of "Extensor Response" in Posttraumatic Coma.

PubMed

Firsching, Raimund; Woischneck, Dieter; Langejürgen, Alexander; Parreidt, Andreas; Bondar, Imre; Skalej, Martin; Röhl, Friedrich; Voellger, Benjamin

2015-11-01

The timely detection of neurologic deterioration can be critical for the survival of a neurosurgical patient following head injury. Because little reliable evidence is available on the prognostic value of the clinical sign "extensor response" in comatose posttraumatic patients, we investigated the correlation of this clinical sign with outcome and with early radiologic findings from magnetic resonance imaging (MRI). This retrospective analysis of prospectively obtained data included 157 patients who had remained in a coma for a minimum of 24 hours after traumatic brain injury. All patients received a 1.5-T MRI within 10 days (median: 2 days) of the injury. The correlations between clinical findings 12 and 24 hours after the injury-in particular, extensor response and pupillary function, MRI findings, and outcome after 1 year-were investigated. Statistical analysis included contingency tables, Fisher exact test, odds ratios (ORs) with confidence intervals (CIs), and weighted κ values. There were 48 patients with extensor response within the first 24 hours after the injury. Patients with extensor response (World Federation of Neurosurgical Societies coma grade III) statistically were significantly more likely to harbor MRI lesions in the brainstem when compared with patients in a coma who had no further deficiencies (coma grade I; p = 0.0004 by Fisher exact test, OR 10.8 with 95% CI, 2.7-42.5) and patients with unilateral loss of pupil function (coma grade II; p = 0.0187, OR 2.8 with 95% CI, 1.2-6.5). The correlation of brainstem lesions as found by MRI and outcome according to the Glasgow Outcome Scale after 1 year was also highly significant (p ≤ 0.016). The correlation of extensor response and loss of pupil function with an unfavorable outcome and with brainstem lesions revealed by MRI is highly significant. Their sudden onset may be associated with the sudden onset of brainstem dysfunction and should therefore be regarded as one of the most fundamental warning signs in the clinical monitoring of comatose patients. Georg Thieme Verlag KG Stuttgart · New York.

Influence of warfarin and low-dose aspirin on the outcomes of geriatric patients with traumatic intracranial hemorrhage resulting from ground-level fall.

PubMed

Inamasu, Joji; Nakatsukasa, Masashi; Miyatake, Satoru; Hirose, Yuichi

2012-10-01

Ground-level fall is the most common cause of traumatic intracranial hemorrhage (TICH) in the elderly, and is a major cause of morbidity and mortality in that population. A retrospective study was carried out to evaluate whether the use of warfarin/low-dose aspirin (LDA) is predictive of unfavorable outcomes in geriatric patients who sustain a fall-induced TICH. Charts of 76 geriatric patients (≥ 65 years-of-age) with fall-induced TICH were reviewed. The number of patients taking warfarin and LDA was 12 and 21, respectively, whereas the other 43 took neither medication (non-user group). The frequency of patients with unfavorable outcomes (Glasgow Outcome Scale score of 1-3) at discharge was calculated. Furthermore, variables predictive of unfavorable outcomes were identified by logistic regression analysis. The frequency of patients with unfavorable outcomes was 75% in the warfarin group, 33% in the LDA group and 27% in the non-user group, respectively. The risk of having unfavorable outcomes was significantly higher in the warfarin group compared with the LDA group (P = 0.03) and non-user group (P < 0.01). Logistic regression analysis showed that variables predictive of unfavorable outcomes were: age, initial Glasgow Coma Scale score ≤ 13 and presence of midline shift ≥ 5 mm. The use of warfarin, but not of LDA, might be associated with unfavorable outcomes in elderly with fall-induced TICH. The risk of TICH should be communicated properly to elderly taking warfarin. The information might be important not only to trauma surgeons who take care of injured elderly, but also to geriatric physicians who prescribe warfarin/LDA to them. © 2012 Japan Geriatrics Society.

[Sepsis associated encephalopathy is an independently risk factor for nosocomial coma in patients with supratentorial intracerebral hemorrhage: a retrospective cohort study of 261 patients].

PubMed

Wang, Guangsheng; Wang, Shaodan; Zhou, Yeting; Chen, Xiaodong; Ma, Xiaobo; Tong, Daoming

2016-08-01

To investigate whether the presence of sepsis associated encephalopathy (SAE) would predict nosocomial coma (NC) and poor outcome in patients with supratentorial intracerebral hemorrhage (SICH). A retrospective cohort study was conducted. The adult acute SICH patients with or without coma admitted to intensive care unit (ICU) of Shuyang People' Hospital Affiliated to Xuzhou Medical University from December 2012 to December 2015 were enrolled. Brain computed tomography (CT) scans were analyzed and the patients were divided into pre-hospital coma (PC) and NC groups. The clinical data and the incidence of SAE of patients in two groups were compared, and the 30-day prognosis was followed up. Univariate and Cox regression analyses were performed to analyze whether SAE would predict NC and poor outcome in patients with SICH. A total of 330 patients with acute SICH and coma were enrolled, excluding 60 cases of infratentorial cerebral hemorrhage, 3 cases of primary intraventricular hemorrhage, and 6 cases of unknown volume hematoma. Finally, 261 patients were included, with 111 patients of NC events, and 150 patients of PC events. 69 (62.2%) SAE in SICH with NC and 33 (22.2%) SAE in SICH with PC was diagnosed, and the incidence of SAE between two groups was statistically significant (P < 0.01). Compared with PC group, SICH patients in the NC group had lower incidence of hypertension (81.1% vs. 96.0%), longer time from onset to NC [days: 2.3 (23.9) vs. 0 (0.5)] and length of ICU stay [days: 5.0 (34.0) vs. 3.0 (12.0)], higher initial Glasgow coma score (GCS, 10.2±1.5 vs. 6.6±1.6) and sequential organ failure assessment (SOFA) score [4.0 (6.0) vs. 3.0 (3.0)], lower initial National Institutes of Health Stroke Scale (NIHSS) score (19.4±6.6 vs. 30.2±6.8), as well as more frequent sepsis (78.4% vs. 38.0%), vegetative state (24.3% vs. 14.0%), acute respiratory failure (24.3% vs. 10.0%), pneumonia (37.8% vs. 24.0%), septic shock (8.1% vs. 0), acute liver failure (5.4% vs. 0), hypernatremia (8.1% vs. 0), CT indicating that more frequent vasogenic edema (64.9% vs. 16.0%) and white matter lesion (13.5% vs. 2.0%), and less mannitol usage (94.6% vs. 100.0%), and less brain midline shift (32.4% vs. 68.0%) and hematoma enlargement (8.1% vs. 30.0%), less hematoma volume (mL: 28.0±18.8 vs. 38.3±24.4) in CT, and higher 30-day mortality (54.1% vs. 26.0%) with statistical differences (all P < 0.05). It was shown by Cox regression analyses that SAE [hazard ratio (HR) = 3.5, 95% confidence interval (95%CI) = 1.346-6.765, P = 0.000] and SOFA score (HR = 1.8, 95%CI = 1.073-1.756, P = 0.008) were independent risk factors of death of SICH patients with NC, and hematoma enlargement was independent risk factor of death of SICH patients with PC (HR = 3.0, 95%CI = 1.313-5.814, P = 0.000). SAE is the independent factor of inducing NC event and poor prognosis in SICH patients.

A Case of Myxedema Coma Presenting as a Brain Stem Infarct in a 74-Year-Old Korean Woman

PubMed Central

Ahn, Ji Yun; Kwon, Hyuk-Sool; Ahn, Hee Chol

2010-01-01

Myxedema coma is the extreme form of untreated hypothyroidism. In reality, few patients present comatose with severe myxedema. We describe a patient with myxedema coma which was initially misdiagnosed as a brain stem infarct. She presented to the hospital with alteration of the mental status, generalized edema, hypothermia, hypoventilation, and hypotension. Initially her brain stem reflexes were absent. After respiratory and circulatory support, her neurologic status was not improved soon. The diagnosis of myxedema coma was often missed or delayed due to various clinical findings and concomitant medical condition and precipitating factors. It is more difficult to diagnose when a patient has no medical history of hypothyroidism. A high index of clinical suspicion can make a timely diagnosis and initiate appropriate treatment. We report this case to alert clinicians considering diagnosis of myxedema coma in patients with severe decompensated metabolic state including mental change. PMID:20808690

A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman.

PubMed

Ahn, Ji Yun; Kwon, Hyuk-Sool; Ahn, Hee Chol; Sohn, You Dong

2010-09-01

Myxedema coma is the extreme form of untreated hypothyroidism. In reality, few patients present comatose with severe myxedema. We describe a patient with myxedema coma which was initially misdiagnosed as a brain stem infarct. She presented to the hospital with alteration of the mental status, generalized edema, hypothermia, hypoventilation, and hypotension. Initially her brain stem reflexes were absent. After respiratory and circulatory support, her neurologic status was not improved soon. The diagnosis of myxedema coma was often missed or delayed due to various clinical findings and concomitant medical condition and precipitating factors. It is more difficult to diagnose when a patient has no medical history of hypothyroidism. A high index of clinical suspicion can make a timely diagnosis and initiate appropriate treatment. We report this case to alert clinicians considering diagnosis of myxedema coma in patients with severe decompensated metabolic state including mental change.

Myxedema coma leading to respiratory depression in a dog.

PubMed

Atkinson, Kathryn; Aubert, Isabelle

2004-04-01

A 10-year-old, intact male, cocker spaniel was presented with hypothermia, without shivering, and progressive stupor leading to coma. Myxedema coma, potentially precipitated by diuretic therapy, was tentatively diagnosed and treatment initiated, but progressive respiratory depression led to the decision to euthanize. Postmortem findings supported the diagnosis of myxedema coma.

Myxedema coma leading to respiratory depression in a dog

PubMed Central

2004-01-01

Abstract A 10-year-old, intact male, cocker spaniel was presented with hypothermia, without shivering, and progressive stupor leading to coma. Myxedema coma, potentially precipitated by diuretic therapy, was tentatively diagnosed and treatment initiated, but progressive respiratory depression led to the decision to euthanize. Postmortem findings supported the diagnosis of myxedema coma. PMID:15144105

Post-operative re-bleeding in patients with hypertensive ICH is closely associated with the CT blend sign.

PubMed

Wu, Guofeng; Shen, Zhengkui; Wang, Likun; Sun, Shujie; Luo, Jinbiao; Mao, Yuanhong

2017-07-06

Intracranial post-operative re-haemorrhage is an important complication in patients with hypertensive intracerebral haemorrhage (ICH). The purpose of the present study was to determine the value of the computed tomography (CT) blend sign in predicting post-operative re-haemorrhage in patients with ICH. A total of 126 patients with ICH were included in the present study. All the patients underwent standard stereotactic minimally invasive surgery(MIS) to remove the ICH within 24 h following admission. There were 41 patients with a blend sign on initial CT and 85 patients without a blend sign on the initial CT. Multivariable logistic regression analyses were performed to assess the relationship between the presence of the blend sign on the non-enhanced admission CT scan and post-operative re-haemorrhage. Post-operative re-haemorrhage occurred in 24 of the 41 patients with the blend sign, and in 9 of the 85 patients without the blend sign. The incidence of re-haemorrhage was significantly different between the groups. The multivariate logistic regression analysis demonstrated that the initial Glasgow coma scale score (p = 0.002) and blend sign (P < 0.00) on the initial CT scan are independent predictors of post-operative re-haemorrhage. The sensitivity, specificity, and positive and negative predictive values of the blend sign for predicting post-operative re-haemorrhage were 72.7, 81.7, 58.5 and 89.4%, respectively. The presence of the blend sign on the initial CT scan is closely associated with post-operative re-haemorrhage in patients with ICH who undergo stereotactic MIS.

Predictors of outcome in myxoedema coma: a study from a tertiary care centre

PubMed Central

Dutta, Pinaki; Bhansali, Anil; Masoodi, Shriq Rashid; Bhadada, Sanjay; Sharma, Navneet; Rajput, Rajesh

2008-01-01

Background With the easy availability of thyroid hormone assays, thyroid disorders are now recognised even in a subclinical state. However, patients are still seen with advanced manifestations of the disease, particularly in developing countries. This observational study analysed the predictors of outcome in patients with myxoedema coma and tested the validity of different modules to define morbidity and mortality in these patients. Methods Twenty-three consecutive patients with myxoedema coma who presented from January 1999 to August 2006 were studied. The thyroid function test and random serum cortisol were measured in all patients at the time of admission. Patients were given oral or intravenous (IV) thyroxine with intention to treat with the latter according to availability. Various modules that predict outcome, including Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment (SOFA) score, were analysed. SOFA score was repeated every 2 days until the time of discharge or demise. Results Twenty-three patients (20 women; 87%) of 59.5 ± 14.4 years of age (range, 30 to 89 years) were seen during the study period. Nine (39%) patients were diagnosed with hypothyroidism for the first time at the time of presentation of myxoedema coma, whereas 14 (70%) were diagnosed with hypothyroidism previously. However, the treatment defaulters presented early to the hospital and had more severe manifestations than de novo subjects. Nineteen (82%) had thyroprivic (primary) and 4 (17%) had trophoprivic (secondary) hypothyroidism. Fifteen (65%) patients presented in the winter and in 17 (74%) sepsis was the major accompanying comorbidity. Twelve (52%) had a history of diuretic use, thereby delaying the initial diagnosis. Patients who received oral L-thyroxine had no difference in outcome from those receiving IV thyroxine. Twelve (52%) subjects died and sepsis was the predominant cause of death. Various predictors of mortality included hypotension (p = 0.01) and bradycardia (p = 0.03) at presentation, need for mechanical ventilation (p = 0.00), hypothermia unresponsive to treatment (p = 0.01), sepsis (p = 0.01), intake of sedative drugs (p = 0.02), lower GCS (p = 0.03), high APACHE II score (p = 0.04), and high SOFA score (p = 0.00). However, SOFA score was more effective than other predictive models as baseline and day 3 SOFA scores of more than 6 were highly predictive of poor outcome. Conclusion L-Thyroxine treatment defaulters had more severe manifestations compared with de novo subjects. Outcome was not influenced by either aetiology or route of administration of L-thyroxine, and SOFA score was the best outcome predictor model. PMID:18173846

Teaching NeuroImages: Ma2 encephalitis presenting as acute panhypopituitarism in a young man.

PubMed

Bergner, Caroline G; Lang, Christine; Spreer, Annette; Bähr, Mathias; Mohr, Alexander; Simons, Mikael

2013-11-05

A 21-year-old man presented with headache, hypotonia, hypothermia, and somnolence, deteriorating to a Glasgow Coma Scale score of 3 within days. Hormonal testing revealed panhypopituitarism. His cerebral MRI showed a gadolinium-enhancing lesion in the pituitary gland with adjacent changes to the hypothalamus, midbrain, and basal ganglia (figures 1 and 2). Therapy with prednisolone resulted in rapid improvement. Ma2 antibodies were found in the patient's serum and CSF. FDG-PET demonstrated a tumor mass in the superior mediastinum and histology revealed a mediastinal seminoma. Ma2 antibody-mediated paraneoplastic disease has to be considered as a rare differential diagnosis in patients presenting with acute panhypopituitarism.(1.)

Encephalopathy Associated with Influenza B in a Healthy Young Man.

PubMed

Shimamoto, Masaki; Okada, Satoshi; Terashima, Takeshi

2017-01-01

A 19-year-old man presented with a fever, convulsions, and loss of consciousness at our hospital. The patient had a Glasgow Coma Scale score of 12. Influenza B virus infection was diagnosed using the rapid test kit, and an eight-fold increase in the serum levels of anti-influenza B virus antibody was confirmed using the complement fixation test. Brain magnetic resonance imaging showed multifocal high-signal lesions, and an electroencephalogram showed diffuse slowing of the background activity, indicating acute encephalopathy. After treatment with peramivir and methylprednisolone for 3 days, the patient was discharged without any neurological impairment. This was a case of influenza B infection associated with acute encephalopathy in a healthy young man.

Clinical Course Score (CCS): a new clinical score to evaluate efficacy of neurotrauma treatment in traumatic brain injury and subarachnoid hemorrhage.

PubMed

Brandner, Sebastian; Kellermann, Isabel; Hore, Nirjhar; Bozhkov, Yavor; Buchfelder, Michael

2015-01-01

Neurotrauma continues to represent a challenging public health issue requiring continual improvement in therapeutic approaches. As no such current system exists, we present in this study the Clinical Course Score (CCS) as a new clinical score to evaluate the efficacy of neurotrauma treatment. The CCS was calculated in neurotrauma patients to be the difference between the grade of the Glasgow Outcome Scale 6 months after discharge from our department and the grade of a 1 to 5 point reduced Glasgow Coma Scale on admission. We assessed the CCS in a total of 248 patients (196 traumatic brain injury [TBI] patients and 52 subarachnoid hemorrhage [SAH] patients) who were treated in our Department of Neurosurgery between January 2011 and December 2012. We found negative CCS grades both in mild TBI and in mild SAH patients. In patients with severe TBI or SAH, we found positive CCS grades. In SAH patients, we found higher CCS scores in younger patients compared with elderly subjects in both mild and severe cases. The CCS can be useful in evaluating different therapeutic approaches during neurotrauma therapy. This new score might improve assessment of beneficial effects of therapeutic procedures.

Predicting outcome in severe traumatic brain injury using a simple prognostic model.

PubMed

Sobuwa, Simpiwe; Hartzenberg, Henry Benjamin; Geduld, Heike; Uys, Corrie

2014-06-17

Several studies have made it possible to predict outcome in severe traumatic brain injury (TBI) making it beneficial as an aid for clinical decision-making in the emergency setting. However, reliable predictive models are lacking for resource-limited prehospital settings such as those in developing countries like South Africa. To develop a simple predictive model for severe TBI using clinical variables in a South African prehospital setting. All consecutive patients admitted at two level-one centres in Cape Town, South Africa, for severe TBI were included. A binary logistic regression model was used, which included three predictor variables: oxygen saturation (SpO₂), Glasgow Coma Scale (GCS) and pupil reactivity. The Glasgow Outcome Scale was used to assess outcome on hospital discharge. A total of 74.4% of the outcomes were correctly predicted by the logistic regression model. The model demonstrated SpO₂ (p=0.019), GCS (p=0.001) and pupil reactivity (p=0.002) as independently significant predictors of outcome in severe TBI. Odds ratios of a good outcome were 3.148 (SpO₂ ≥ 90%), 5.108 (GCS 6 - 8) and 4.405 (pupils bilaterally reactive). This model is potentially useful for effective predictions of outcome in severe TBI.

Simultaneous cranioplasty and subdural-peritoneal shunting for contralateral symptomatic subdural hygroma following decompressive craniectomy.

PubMed

Lin, Muh-Shi; Chen, Tzu-Hsuan; Kung, Woon-Man; Chen, Shuo-Tsung

2015-01-01

Contralateral subdural hygroma caused by decompressive craniectomy tends to combine with external cerebral herniation, causing neurological deficits. Nine patients who underwent one-stage, simultaneous cranioplasty and contralateral subdural-peritoneal shunting were included in this study. Clinical outcome was assessed by Glasgow Outcome Scale as well as Glasgow Coma Scale, muscle power scoring system, and complications. Postoperative computed tomography scans demonstrated completely resolved subdural hygroma and reversed midline shifts, indicating excellent outcome. Among these 9 patients, 4 patients (44%) had improved GOS following the proposed surgery. Four out of 4 patients with lethargy became alert and orientated following surgical intervention. Muscle strength improved significantly 5 months after surgery in 7 out of 7 patients with weakness. Two out of 9 patients presented with drowsiness due to hydrocephalus at an average time of 65 days after surgery. Double gradient shunting is useful to eliminate the respective hydrocephalus and contralateral subdural hygroma. The described surgical technique is effective in treating symptomatic contralateral subdural hygroma following decompressive craniectomy and is associated with an excellent structural and functional outcome. However, subdural-peritoneal shunting plus cranioplasty thoroughly resolves the subdural hygroma collection, which might deteriorate the cerebrospinal fluid circulation, leading to hydrocephalus.

Does progesterone improve outcome in diffuse axonal injury?

PubMed

Soltani, Zahra; Shahrokhi, Nader; Karamouzian, Saeed; Khaksari, Mohammad; Mofid, Behshad; Nakhaee, Nouzar; Reihani, Hamed

2017-01-01

The benefits of progesterone have been demonstrated in the animal models of traumatic brain injury (TBI). However, the results of clinical studies are conflicting. Considering the heterogenic nature of TBI, the effect of progesterone in patients with diffuse axonal injury (DAI) was investigated in a clinical trial. In this study, 48 patients with DAI and Glasgow Coma Scale of 3-12, admitted within 4 hours after injury, were randomly assigned to the progesterone or control group. The dose of progesterone administration was 1 mg kg -1 per 12 hours for 5 days. The effect of progesterone was investigated using extended-Glasgow Outcome Scale (GOS-E), functional independence measure (FIM) scores and also mortality within the follow-up period. The progesterone group exhibited higher GOS-E and FIM scores in comparison to the control group at 6 months post-injury (p < 0.01 and p < 0.05, respectively). Mortality was also found in the control group (p < 0.05). The adverse events attributed to the progesterone administration were not found throughout the study. Findings of this study suggest that progesterone may be neuroprotective in patients with DAI. However, large clinical trials are needed to assess progesterone as a promising drug in DAI.

Benzodiazepine poisoning in elderly.

PubMed

Vukcević, Natasa Perković; Ercegović, Gordana Vuković; Segrt, Zoran; Djordjević, Snezana; Stosić, Jasmina Jović

2016-03-01

Benzodiazepines are among the most frequently ingested drugs in self-poisonings. Elderly may be at greater risk compared with younger individuals due to impaired metabolism and increased sensitivity to benzodiazepines. The aim of this study was to assess toxicity of benzodiazepines in elderly attempted suicide. A retrospective study of consecutive presentations to hospital after self-poisoning with benzodiazepines was done. Collected data consisted of patient's characteristics (age, gender), benzodiazepine ingested with its blood concentrations at admission, clinical findings including vital signs and Glasgow coma score, routine blood chemistry, complications of poisoning, details of management, length of hospital stay and outcome. According the age, patients are classified as young (15-40-year old), middle aged (41-65-year old) and elderly (older than 65). During a 2-year observational period 387 patients were admitted because of pure benzodiazepine poisoning. The most frequently ingested drug was bromazepam, the second was diazepam. The incidence of coma was significantly higher, and the length of hospital stay significantly longer in elderly. Respiratory failure and aspiration pneumonia occurred more frequently in old age. Also, flumazenil was more frequently required in the group of elderly patients. Massive benzodiazepines overdose in elderly may be associated with a significant morbidity, including deep coma with aspiration pneumonia, respiratory failure, and even death. Flumazenil is indicated more often to reduce CNS depression and prevent complications of prolonged unconsciousness, but supportive treatment and proper airway management of comatose patients is the mainstay of the treatment of acute benzodiazepine poisoning.

Reversible coma and Duret hemorrhage after intracranial hypotension from remote lumbar spine surgery: case report.

PubMed

Bonow, Robert H; Bales, James W; Morton, Ryan P; Levitt, Michael R; Zhang, Fangyi

2016-03-01

Intracranial hypotension is a rare condition caused by spontaneous or iatrogenic CSF leaks that alter normal CSF dynamics. Symptoms range from mild headaches to transtentorial herniation, coma, and death. Duret hemorrhages have been reported to occur in some patients with this condition and are traditionally believed to be associated with a poor neurological outcome. A 73-year-old man with a remote history of spinal fusion presented with syncope and was found to have small subdural hematomas on head CT studies. He was managed nonoperatively and discharged with a Glasgow Coma Scale score of 15, only to return 3 days later with obtundation, fixed downward gaze, anisocoria, and absent cranial nerve reflexes. A CT scan showed Duret hemorrhages and subtle enlargement of the subdural hematomas, though the hematomas remained too small to account for his poor clinical condition. Magnetic resonance imaging of the spine revealed a large lumbar pseudomeningocele in the area of prior fusion. His condition dramatically improved when he was placed in the Trendelenburg position and underwent repair of the pseudomeningocele. He was kept flat for 7 days and was ultimately discharged in good condition. On long-term follow-up, his only identifiable deficit was diplopia due to an internuclear ophthalmoplegia. Intracranial hypotension is a rare condition that can cause profound morbidity, including tonsillar herniation and brainstem hemorrhage. With proper identification and treatment of the CSF leak, patients can make functional recoveries.

Mortality prediction in patients with acute kidney injury requiring renal replacement therapy after cardiac surgery.

PubMed

Skarupskienė, Inga; Adukauskienė, Dalia; Kuzminskienė, Jurgita; Rimkutė, Laima; Balčiuvienė, Vilma; Žiginskienė, Edita; Kuzminskis, Vytautas; Adukauskaitė, Agnė; Pentiokinienė, Daiva; Bumblytė, Inga Arūnė

2017-01-01

Acute kidney injury (AKI) is a common and potentially serious postoperative complication after cardiac surgery, and it remains a cause of major morbidity and mortality. The aim of our study was to assess the prognostic illness severity score and to estimate the significant risk factors for poor outcome of patients with AKI requiring renal replacement therapy (RRT) after cardiac surgery. We retrospectively analyzed data of adult (>18 years) patients (n=111) who underwent open heart surgery and had developed AKI with need for RRT. Prognostic illness severity scores were calculated and perioperative risk factors of lethal outcome were assessed at the RRT initiation time. We defined three illness severity scores: Acute Physiology and Chronic Health Evaluation (APACHE II) as a general score, Sequential Organ Failure Assessment (SOFA) as an organ failure score, and Liano score as a kidney-specific disease severity score. Logistic regression was also used for the multivariate analysis of mortality risk factors. Hospital mortality was 76.5%. More than 7% of patients remained dialysis-dependent after their discharge from the hospital. The prognostic abilities of the scores were assessed for their discriminatory power. The area under the receiver-operating characteristic (ROC) curve of SOFA score was 0.719 (95% CI, 0.598-0.841), of Liano was 0.661 (95% CI, 0.535-0.787) and 0.668 (95% CI, 0.550-0.785) of APACHE II scores. From 16 variables analyzed for model selection, we reached a final logistic regression model, which demonstrated four variables significantly associated with patients' mortality. Glasgow coma score<14 points (OR=3.304; 95% CI, 1.130-9.662; P=0.003), mean arterial blood pressure (MAP)<63.5mmHg (OR=3.872; 95% CI, 1.011-13.616; P=0.035), serum creatinine>108.5μmol/L (OR=0.347; 95% CI, 0.123-0.998; P=0.046) and platelet count<115×10 9 /L (OR=3.731; 95% CI, 1.259-11.054; P=0.018) were independent risk factors for poor patient outcome. Our study demonstrated that SOFA score estimation is the most accurate to predict the fatal outcome in patients with AKI requiring RRT after cardiac surgery. Lethal patient outcome is related to Glasgow coma score, mean arterial blood pressure, preoperative serum creatinine and postoperative platelet count. Copyright © 2017 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Sp. z o.o. All rights reserved.

Implementation of a trauma registry in a Brazilian public hospital: the first 1,000 patients.

PubMed

Carreiro, Paulo Roberto Lima; Drumond, Domingos André Fernandes; Starling, Sizenando Vieira; Moritz, Mônica; Ladeira, Roberto Marini

2014-01-01

Show the steps of a Trauma Registry (TR) implementation in a Brazilian public hospital and evaluate the initial data from the database. Descriptive study of the a TR implementation in João XXIII Hospital (Hospital Foundation of the state of Minas Gerais) and analysis of the initial results of the first 1,000 patients. The project was initiated in 2011 and from January 2013 we began collecting data for the TR. In January 2014 the registration of the first 1000 patients was completed. The greatest difficulties in the TR implementation were obtaining funds to finance the project and the lack of information within the medical records. The variables with the lowest completion percentage on the physiological conditions were: pulse, blood pressure, respiratory rate and Glasgow coma scale. Consequently, the Revised Trauma Score (RTS) could be calculated in only 31% of cases and the TRISS methodology applied to 30.3% of patients. The main epidemiological characteristics showed a predominance of young male victims (84.7%) and the importance of aggression as a cause of injuries in our environment (47.5%), surpassing traffic accidents. The average length of stay was 6 days, and mortality 13.7%. Trauma registries are invaluable tools in improving the care of trauma victims. It is necessary to improve the quality of data recorded in medical records. The involvement of public authorities is critical for the successful implementation and maintenance of trauma registries in Brazilian hospitals.

Cervical spine injuries associated with the incorrect use of airbags in motor vehicle collisions.

PubMed

Donaldson, William F; Hanks, Stephen E; Nassr, Ahmad; Vogt, Molly T; Lee, Joon Y

2008-03-15

Retrospective database review and analysis. The purpose of this study is to determine the rate of cervical spine injuries with correct and incorrect use of front driver and passenger-side airbags. Summary of Background Data. Although there are abundant literature showing reduced injury severity and fatalities from seatbelts and airbags, no recent studies have delineated the affect of incorrect use of airbags in cervical spine injuries. The database from the Pennsylvania Trauma Systems Foundation was searched for drivers and front-seat passenger injuries from 1990 to 2002. The resulting records were then grouped into those using both seatbelt and the airbag, airbag-only, seatbelt-only, and no restraints. The data were then analyzed for frequency of cervical spine fractures with or without spinal cord injury and injury severity indexes. The drivers using the airbag-only had significantly higher rate (54.1%) of cervical fractures than those using both airbag and a seatbelt (42.1%). Overall, drivers using the airbag-alone were 1.7 times more likely to suffer a cervical spine fracture than those using both protective devices. Likewise, passengers using the airbag-alone were 6.7 times more likely to suffer from a cervical spine fracture with spinal cord injury than those using both protective devices. In addition, the injury severity indexes (Glasgow coma scale, Injury Severity Score, Intensive Care Unit stays, and Total Hospital days) were significantly worse in patients who used an airbag-only. Airbag use without the concomitant use of a seatbelt is associated with a higher incidence of cervical spine fractures with or without spinal cord injuries. Airbag misuse is also associated with higher Injury Severity Score, lower Glasgow coma scale, and longer intensive care unit and total hospital stays, indicating that these patients suffer worse injury than those who use the airbag properly.

Hematoma Shape, Hematoma Size, Glasgow Coma Scale Score and ICH Score: Which Predicts the 30-Day Mortality Better for Intracerebral Hematoma?

PubMed Central

Wang, Chih-Wei; Liu, Yi-Jui; Lee, Yi-Hsiung; Hueng, Dueng-Yuan; Fan, Hueng-Chuen; Yang, Fu-Chi; Hsueh, Chun-Jen; Kao, Hung-Wen; Juan, Chun-Jung; Hsu, Hsian-He

2014-01-01

Purpose To investigate the performance of hematoma shape, hematoma size, Glasgow coma scale (GCS) score, and intracerebral hematoma (ICH) score in predicting the 30-day mortality for ICH patients. To examine the influence of the estimation error of hematoma size on the prediction of 30-day mortality. Materials and Methods This retrospective study, approved by a local institutional review board with written informed consent waived, recruited 106 patients diagnosed as ICH by non-enhanced computed tomography study. The hemorrhagic shape, hematoma size measured by computer-assisted volumetric analysis (CAVA) and estimated by ABC/2 formula, ICH score and GCS score was examined. The predicting performance of 30-day mortality of the aforementioned variables was evaluated. Statistical analysis was performed using Kolmogorov-Smirnov tests, paired t test, nonparametric test, linear regression analysis, and binary logistic regression. The receiver operating characteristics curves were plotted and areas under curve (AUC) were calculated for 30-day mortality. A P value less than 0.05 was considered as statistically significant. Results The overall 30-day mortality rate was 15.1% of ICH patients. The hematoma shape, hematoma size, ICH score, and GCS score all significantly predict the 30-day mortality for ICH patients, with an AUC of 0.692 (P = 0.0018), 0.715 (P = 0.0008) (by ABC/2) to 0.738 (P = 0.0002) (by CAVA), 0.877 (P<0.0001) (by ABC/2) to 0.882 (P<0.0001) (by CAVA), and 0.912 (P<0.0001), respectively. Conclusion Our study shows that hematoma shape, hematoma size, ICH scores and GCS score all significantly predict the 30-day mortality in an increasing order of AUC. The effect of overestimation of hematoma size by ABC/2 formula in predicting the 30-day mortality could be remedied by using ICH score. PMID:25029592

Utility of magnetic resonance imaging in diagnosing cervical spine injury in children with severe traumatic brain injury.

PubMed

Qualls, David; Leonard, Jeffrey R; Keller, Martin; Pineda, Jose; Leonard, Julie C

2015-06-01

Evaluation of children for cervical spine injuries (CSIs) after blunt trauma is complicated, particularly if the patient is unresponsive because of severe traumatic brain injury. Plain radiography and computed tomography (CT) are commonly used, but CT combined with magnetic resonance imaging (MRI) is still considered the gold standard in CSI detection. However, MRI is expensive and can delay cervical clearance. The purpose of this study is to determine the added benefit of MRI as an adjunct to CT in the clearance of children with severe head trauma. We performed a retrospective chart review of pediatric head trauma patients admitted to the pediatric intensive care unit at St. Louis Children's Hospital from 2002 to 2012. Patients who received both cervical spine CT and MRI and presented with a Glasgow Coma Scale score of 8 or lower were included in the study. Imaging was analyzed by two pediatric trauma subspecialists and classified as demonstrating "no injury," "stable injury," or "unstable injury." Results were compared, and discrepancies between CT and MRI findings were noted. A total of 1,196 head-injured children were admitted to the pediatric intensive care unit between January 2002 and December 2012. Sixty-three children underwent CT and MRI and met Glasgow Coma Scale criteria. Seven children were identified with negative CT and positive MRI findings, but none of these injuries were considered unstable by our criteria. Five children were determined to have unstable injuries, and all were detected on CT. The results of this study suggest that MRI does not detect unstable CSIs in the setting of negative CT imaging. Given the limited patient population for this study, further and more extensive studies investigating the utility of MRI in the head-injured pediatric patient are warranted. Diagnostic and care management study, level IV.

Efficacy of endoscopic third ventriculostomy in non-communicating hydrocephalus.

PubMed

ul Haq, Mian Iftikhar; Khan, Shahbaz Ali; Raja, Riaz A; Ahmed, Ehtisham

2012-01-01

Hydrocephalus is common problem requiring either extra-cranial (shunts) or intracranial (ventriculostomy) diversion of cerebrospinal fluid. Endoscopic third ventriculostomy obviates all the complications of shunts and has been accepted as the procedure of choice for the treatment of obstructed hydrocephalus in adults and children because of the minimally invasive nature. This study was conducted to determine the efficacy of endoscopic third ventriculostomy in the treatment of non-communicating hydrocephalus. This cross sectional descriptive study was done in neurosurgery department of Hayatabad Medical Complex, Peshawar, from 2nd February 2011 to 1st march 2012. A total of 171 patients with non-communicating hydrocephalous, irrespective of gender discrimination and Glasgow coma scale score of 10 and above were included in this study. Patients below one year of age, with lesion in the floor of the third ventricle or near basilar artery, and hydrocephalus with infected CSF or haemorrhage were excluded. Hydrocephalous was diagnosed on CT-scan brain. All the patients were followed up till 72 hours post-operatively for the determination of effectiveness in terms of improvement in Glasgow coma scale by at least 2 points. All the above mentioned information including name, age, gender and address were recorded in a predesigned proforma. The data was analysed using SPSS-17. Frequency and percentage was calculated for categorical variables. Mean +/- SD was calculated for age. A total of 171 patients with non-communicating hydrocephalous were included in the study. Out of 171 patients, there were 104 (60.8%) males and 67 (39.2%) females. Age ranged from 1-70 years with majority of the patients was below 10 years of age. Majority of the patients had hydrocephalus due to tuberculous meningitis 39.2% of the whole. In 134 (78.4%) patients the procedure was effective. Procedure was more effective in hydrocephalus due to space occupying lesion. Endoscopic third ventriculostomy is a very effective procedure for the treatment of non-communicating hydrocephalus.

A study to explore nurses' knowledge in using the Glasgow Coma Scale in an acute care hospital.

PubMed

Mattar, Ihsan; Liaw, Sok Ying; Chan, Moon Fai

2013-10-01

The Glasgow Coma Scale (GCS) is a neurological instrument, which measures the "depth and duration of impaired consciousness." The appeal of the GCS lies in its applicability in a wide variety of clinical situations as well as its ease of use by a range of healthcare staff. However, the GCS is not without its weaknesses and limitations. Its ease of use opens it up to misinterpretation and misapplication. Despite the propensity for incorrect assessment, the GCS remains in use in the clinical setting and enjoys an "unwarranted and privileged position." This creates an issue to patient care as the GCS is an important instrument in communicating an accurate assessment of the patient's condition between clinical staff. The aim of this study was to investigate nurses' knowledge in using the GCS and the demographic factors influencing knowledge of the GCS. This is a correlational observational study conducted in one acute care hospital in Singapore. The participants were registered nurses involving in bedside nursing care. A self-administered questionnaire was provided to the participants via ward managers. The quantitative responses were collated and analyzed using SPSS 16.0. Type of clinical discipline (i.e., neuroscience, general medicine, and neurointensive care unit; beta = 0.51, p < .001) and the length of experience in a neuroscience setting (beta = 0.22, p = .005) were significant in determining a nurses' knowledge of the GCS. Nurses in the neonatal intensive care unit scored the highest mean scores (12.7), whereas nurses from the general medicine wards scored the lowest mean scores (9.7). Nurses who worked in a neuroscience setting for 6 years or more scored higher mean scores (11.9) on the knowledge scale, whereas nurses who worked in a neuroscience setting for less than a year scored lower mean scores (10.0). Educational interventions and guidelines in performing GCS assessment are suggested to maintain and improve knowledge in performing the GCS.

Comparative analysis of multiple-casualty incident triage algorithms.

PubMed

Garner, A; Lee, A; Harrison, K; Schultz, C H

2001-11-01

We sought to retrospectively measure the accuracy of multiple-casualty incident (MCI) triage algorithms and their component physiologic variables in predicting adult patients with critical injury. We performed a retrospective review of 1,144 consecutive adult patients transported by ambulance and admitted to 2 trauma centers. Association between first-recorded out-of-hospital physiologic variables and a resource-based definition of severe injury appropriate to the MCI context was determined. The association between severe injury and Triage Sieve, Simple Triage and Rapid Treatment, modified Simple Triage and Rapid Treatment, and CareFlight Triage was determined in the patient population. Of the physiologic variables, the Motor Component of the Glasgow Coma Scale had the strongest association with severe injury, followed by systolic blood pressure. The differences between CareFlight Triage, Simple Triage and Rapid Treatment, and modified Simple Triage and Rapid Treatment were not dramatic, with sensitivities of 82% (95% confidence interval [CI] 75% to 88%), 85% (95% CI 78% to 90%), and 84% (95% CI 76% to 89%), respectively, and specificities of 96% (95% CI 94% to 97%), 86% (95% CI 84% to 88%), and 91% (95% CI 89% to 93%), respectively. Both forms of Triage Sieve were significantly poorer predictors of severe injury. Of the physiologic variables used in the triage algorithms, the Motor Component of the Glasgow Coma Scale and systolic blood pressure had the strongest association with severe injury. CareFlight Triage, Simple Triage and Rapid Treatment, and modified Simple Triage and Rapid Treatment had similar sensitivities in predicting critical injury in designated trauma patients, but CareFlight Triage had better specificity. Because patients in a true mass casualty situation may not be completely comparable with designated trauma patients transported to emergency departments in routine circumstances, the best triage instrument in this study may not be the best in an actual MCI. These findings must be validated prospectively before their accuracy can be confirmed.

False elevation of carboxyhemoglobin: case report.

PubMed

Mehrotra, Shruti; Edmonds, Marcia; Lim, Rodrick K

2011-02-01

Carbon monoxide toxicity in infants and children, like adults, produce nonspecific symptoms with normal vital signs necessitating the serum measurement of carboxyhemoglobin (COHb). In infants, the COHb may be falsely elevated. Our goal was to report a case of suspected carbon monoxide toxicity in an infant and the likely cause of the falsely elevated serum COHb. A previously healthy 3-month-old girl presented to the pediatric emergency department (ED) with smoke inhalation from a defective furnace. She was asymptomatic. On examination, she was alert, with Glasgow Coma Scale of 15 and normal vital signs. Cardiorespiratory and neurological examinations were completely normal. Because of concern regarding carbon monoxide poisoning, she was treated with normobaric oxygen therapy. Initial and subsequent serum COHb levels were persistently elevated, despite treatment and the infant appearing clinically well. As such, she had a prolonged stay in the ED. Further investigations found that fetal hemoglobin interferes with the spectrophotometric method used to analyze serum COHb levels. Carboxyhemoglobin serum level, in infants, may be falsely elevated due to the fetal hemoglobin interfering with standard methods of analysis. Knowledge of the false elevation using standard spectrophotometric methods of COHb in clinically well-appearing infants can decrease unnecessary oxygen therapy and monitoring time in the ED.

Magnesium, hemostasis, and outcomes in patients with intracerebral hemorrhage.

PubMed

Liotta, Eric M; Prabhakaran, Shyam; Sangha, Rajbeer S; Bush, Robin A; Long, Alan E; Trevick, Stephen A; Potts, Matthew B; Jahromi, Babak S; Kim, Minjee; Manno, Edward M; Sorond, Farzaneh A; Naidech, Andrew M; Maas, Matthew B

2017-08-22

We tested the hypothesis that admission serum magnesium levels are associated with hematoma volume, hematoma growth, and functional outcomes in patients with intracerebral hemorrhage (ICH). Patients presenting with spontaneous ICH were enrolled in an observational cohort study that prospectively collected demographic, clinical, laboratory, radiographic, and outcome data. We performed univariate and adjusted multivariate analyses to assess for associations between serum magnesium levels and initial hematoma volume, final hematoma volume, and in-hospital hematoma growth as radiographic measures of hemostasis, and functional outcome measured by the modified Rankin Scale (mRS) at 3 months. We included 290 patients for analysis. Admission serum magnesium was 2.0 ± 0.3 mg/dL. Lower admission magnesium levels were associated with larger initial hematoma volumes on univariate ( p = 0.02), parsimoniously adjusted ( p = 0.002), and fully adjusted models ( p = 0.006), as well as greater hematoma growth ( p = 0.004, p = 0.005, and p = 0.008, respectively) and larger final hematoma volumes ( p = 0.02, p = 0.001, and p = 0.002, respectively). Lower admission magnesium level was associated with worse functional outcomes at 3 months (i.e., higher mRS; odds ratio 0.14, 95% confidence interval 0.03-0.64, p = 0.011) after adjustment for age, admission Glasgow Coma Scale score, initial hematoma volume, time from symptom onset to initial CT, and hematoma growth, with evidence that the effect of magnesium is mediated through hematoma growth. These data support the hypothesis that magnesium exerts a clinically meaningful influence on hemostasis in patients with ICH. © 2017 American Academy of Neurology.

Natural Course of Initially Non-Operated Cases of Acute Subdural Hematoma : The Risk Factors of Hematoma Progression

PubMed Central

Son, Seong; Lee, Sang Gu; Kim, Eun Young; Park, Chan Woo; Kim, Woo Kyung

2013-01-01

Objective The objectives of the present study were to characterize the natural course of initially non-operated traumatic acute subdural hematoma (ASDH) and to identify the risk factors of hematoma progression. Methods Retrospective analysis was performed using sequential computed tomography (CT) images maintained in a prospective observational database containing 177 ASDH cases treated from 2005 to 2011. Patients were allocated to four groups as followings; 136 (76.8%) patients to the spontaneous resolution group, 12 (6.8%) who underwent operation between 4 hours and 7 days to the rapid worsening group (RWG), 24 (13.6%) who experienced an increase of hematoma and that underwent operation between 7 and 28 days to the subacute worsening group (SWG), and 5 (2.8%) who developed delayed aggravation requiring surgery from one month after onset to the delayed worsening group (DWG). Groups were compared with respect to various factors. Results No significant intergroup difference was found with respect to age, mechanism of injury, or initial Glasgow Coma Scale. The presence of combined cerebral contusion or subarachnoid hemorrhage was found to be a significant prognostic factor. Regarding CT findings, mixed density was common in the RWG and the SWG. Midline shifting, hematoma thickness, and numbers of CT slices containing hematoma were significant prognostic factors of the RWG and the SWG. Brain atrophy was more severe in the SWG and the DWG. Conclusion A large proportion of initially non-operated ASDHs worsen in the acute or subacute phase. Patients with risk factors should be monitored carefully for progression by repeat CT imaging. PMID:24278650

Dissection of the internal carotid artery and stroke after mandibular fractures: a case report and review of the literature.

PubMed

Tveita, Ingrid Aune; Madsen, Martin Ragnar Skjerve; Nielsen, Erik Waage

2017-06-02

We present a report of a patient with blunt trauma and mandibular fractures who developed a significant cerebral infarction due to an initially unrecognized injury of her left internal carotid artery. We believe that increased knowledge of this association will facilitate early recognition and hence prevention of a devastating outcome. A 41-year-old ethnic Norwegian woman presented to our Emergency Room after a bicycle accident that had caused a direct blow to her chin. At admittance, her Glasgow Coma Scale was 15. Initial trauma computed tomography showed triple fractures of her mandible, but no further pathology. She was placed in our Intensive Care Unit awaiting open reduction of her mandibular fractures. During the following 9 hours, she showed recurrent episodes of confusion and a progressive right-sided hemiparesis. Repeated cerebral computed tomography revealed no further pathology compared to the initial scan. She had magnetic resonance angiography 17 hours after admittance, which showed dissection and thrombus formation in her left internal carotid artery, total occlusion of her left medial cerebral artery, and left middle cerebral artery infarction was detected. Carotid artery dissection is a rare but life-threatening condition that can develop after trauma to the head and neck. There should be a high index of suspicion in patients with a mechanism of injury that places the internal carotid artery at risk because blunt vascular injury may show delayed onset with no initial symptoms of vascular damage. By implementing an algorithm for early detection and treatment of these injuries, serious brain damage may be avoided.

The impact of early hyperglycaemia on children with traumatic brain injury.

PubMed

Fu, Yue-Qiang; Chong, Shu-Ling; Lee, Jan Hau; Liu, Cheng-Jun; Fu, Sheng; Loh, Tsee Foong; Ng, Kee Chong; Xu, Feng

2017-01-01

Hyperglycaemia is common amongst children with traumatic brain injury (TBI). We aim to investigate the association between early hyperglycaemia and poor clinical outcomes in children with moderate to severe TBI. We performed a retrospective study in a tertiary paediatric hospital between May 2012 and October 2014 of all patients with TBI who were aged <16 years with a Glasgow Coma Scale (GCS) of ≤13. The primary outcome was death. Secondary outcomes were 14 ventilation-free, 14 paediatric intensive care unit (PICU)-free and 28 hospital-free days. We defined hyperglycaemia as glucose >11.1 mmol/L (200 mg/dL). There were 109 patients with a median age of 54 months [inter-quartile range (IQR): 17-82]. Median glucose on arrival was 6.1 mmol/L (IQR: 5.2-9.8). Median GCS in our cohort was 8 (IQR: 6-12). Multivariate logistic regression demonstrated that initial hyperglycaemia [odds ratio (OR): 15.23; 95% confidence interval (CI): 3.74-62.00; P < 0.001], and GCS <8 (OR: 13.02; 95% CI: 2.31-73.33; P = 0.004) were risk factors for mortality. Multivariate linear regression showed that initial hyperglycaemia was a risk factor for reduced ventilation-free, PICU-free and hospital-free days. Early hyperglycaemia predicts for in-hospital mortality, reduced ventilation-free, PICU-free and hospital-free days in children with moderate to severe TBI.

Cerebral Infarction after Traumatic Brain Injury: Incidence and Risk Factors

PubMed Central

Bae, Dong-Hyeon; Choi, Kyu-Sun; Chun, Hyoung-Joon; Ko, Yong; Bak, Koang Hum

2014-01-01

Objective Post-traumatic cerebral infarction (PTCI) is one of the most severe secondary insults after traumatic brain injury (TBI), and is known to be associated with poor outcome and high mortality rate. We assessed the practical incidence and risk factors for the development of PTCI. Methods We conducted retrospective study on 986 consecutive patients with TBI from the period May 2005 to November 2012 at our institution. The definition of PTCI was made on non-enhanced CT scan based on a well-demarcated or fairly discernible region of low attenuation following specific vascular territory with normal initial CT. Clinical and radiological findings that related to patients' outcome were reviewed and statistically compared. Results PTCI was observed in 21 (2.1%) patients. Of various parameters, age (p=0.037), initial Glasgow coma scale score (p<0.01), brain herniation (p=0.044), and decompressive craniectomy (p=0.012) were significantly higher in patients with PTCI than patients who do not have PTCI. Duration between accident and PTCI, patterns of TBI and vascular territory of PTCI were not specific. The mortality rates were significantly higher in patients with PTCI than without PTCI. Conclusion The development of PTCI is rare after TBI, but it usually results in serious outcome and high mortality. Early recognition for risks and aggressive managements is mandatory to prevent PTCI. PMID:27169031

Prognostic value of continuous electroencephalography monitoring in children with severe brain damage.

PubMed

Lan, Yan-huai; Zhu, Xiao-mei; Zhou, Yuan-feng; Qiu, Peng-ling; Lu, Guo-ping; Sun, Dao-kai; Wang, Yi

2015-06-01

The purpose of this study is to determine whether there is a relationship between continuous electroencephalography (EEG) monitoring patterns and prognosis for children with severe brain damage. Patients and The different patterns of EEG were analyzed for 103 children (Glasgow Coma Scale [GCS] score < 8) who were monitored with continuous video-EEG (CVEEG) within 72 hours after the onset of coma. The clinical outcomes were scored and evaluated at hospital discharge by the modified Pediatric Cerebral and Overall Performance Category Scale (PCOPCS). EEG parameters of the different prognosis groups were compared and risk factors for prognosis were identified. Of the 103 children, 36 were in the good prognosis group (PCOPCS scores 1 and 2) and 67 were in the poor prognosis group (PCOPCS scores 3-6). The poor prognosis group had the lower proportion of events in reactive EEG patterns and sleep architecture, and a higher proportion of low-voltage events. Multivariate analyses showed that the lower GCS score and no sleep architecture were significantly associated with poor prognosis. Comatose children with higher GCS score and sleep architecture have better clinical outcomes in terms of morbidity and mortality. Georg Thieme Verlag KG Stuttgart · New York.

Rapid Spontaneously Resolving Acute Subdural Hematoma

PubMed Central

Gan, Qi; Zhao, Hexiang; Zhang, Hanmei; You, Chao

2017-01-01

Introduction: This study reports a rare patient of a rapid spontaneously resolving acute subdural hematoma. In addition, an analysis of potential clues for the phenomenon is presented with a review of the literature. Patient Presentation: A 1-year-and-2-month-old boy fell from a height of approximately 2 m. The patient was in a superficial coma with a Glasgow Coma Scale of 8 when he was transferred to the authors’ hospital. Computed tomography revealed the presence of an acute subdural hematoma with a midline shift beyond 1 cm. His guardians refused invasive interventions and chose conservative treatment. Repeat imaging after 15 hours showed the evident resolution of the hematoma and midline reversion. Progressive magnetic resonance imaging demonstrated the complete resolution of the hematoma, without redistribution to a remote site. Conclusions: Even though this phenomenon has a low incidence, the probability of a rapid spontaneously resolving acute subdural hematoma should be considered when patients present with the following characteristics: children or elderly individuals suffering from mild to moderate head trauma; stable or rapidly recovered consciousness; and simple acute subdural hematoma with a moderate thickness and a particularly low-density band in computed tomography scans. PMID:28468224

First in vivo traumatic brain injury imaging via magnetic particle imaging

NASA Astrophysics Data System (ADS)

Orendorff, Ryan; Peck, Austin J.; Zheng, Bo; Shirazi, Shawn N.; Ferguson, R. Matthew; Khandhar, Amit P.; Kemp, Scott J.; Goodwill, Patrick; Krishnan, Kannan M.; Brooks, George A.; Kaufer, Daniela; Conolly, Steven

2017-05-01

Emergency room visits due to traumatic brain injury (TBI) is common, but classifying the severity of the injury remains an open challenge. Some subjective methods such as the Glasgow Coma Scale attempt to classify traumatic brain injuries, as well as some imaging based modalities such as computed tomography and magnetic resonance imaging. However, to date it is still difficult to detect and monitor mild to moderate injuries. In this report, we demonstrate that the magnetic particle imaging (MPI) modality can be applied to imaging TBI events with excellent contrast. MPI can monitor injected iron nanoparticles over long time scales without signal loss, allowing researchers and clinicians to monitor the change in blood pools as the wound heals.

Some new insights into the history of the Glasgow time ball and time guns

NASA Astrophysics Data System (ADS)

Clarke, David; Kinns, Roger

2012-03-01

The 1857 time ball machinery at the Glasgow Sailors' Home was supplied by Alexander McKenzie, mechanist, using a design that had much in common with the 1853 Edinburgh apparatus. It was operated using electrical connections to a mean time clock in the Home. This clock required adjustment by hand each day to compensate for its losing rate. Such manual intervention and lack of independent verification of accuracy under-mined the authority of the signal. The relative prestige of the Glasgow and Edinburgh Observatories was an important issue. There was no telegraphic link between Glasgow Observatory and the City until the end of 1863, but it had been demonstrated as early as October 1855 that a time ball could be dropped by telegraph from Edinburgh. Another Edinburgh initiative in September 1863 using time guns fired from Edinburgh caused offence in Glasgow and the trials were terminated in February 1864. Professor Grant, Director of Glasgow Observatory, argued successfully that a system of slave clocks controlled from Glasgow Observatory would be far superior to either a time ball or time guns which only provided a signal once per day. He won the debate in March 1864.

Impact of individual clinical outcomes on trial participants' perspectives on enrollment in emergency research without consent.

PubMed

Whitesides, Louisa W; Baren, Jill M; Biros, Michelle H; Fleischman, Ross J; Govindarajan, Prasanthi R; Jones, Elizabeth B; Pancioli, Arthur M; Pentz, Rebecca D; Scicluna, Victoria M; Wright, David W; Dickert, Neal W

2017-04-01

Evidence suggests that patients are generally accepting of their enrollment in trials for emergency care conducted under exception from informed consent. It is unknown whether individuals with more severe initial injuries or worse clinical outcomes have different perspectives. Determining whether these differences exist may help to structure post-enrollment interactions. Primary clinical data from the Progesterone for the Treatment of Traumatic Brain Injury trial were matched to interview data from the Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study. Answers to three key questions from Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study were analyzed in the context of enrolled patients' initial injury severity (initial Glasgow Coma Scale and Injury Severity Score) and principal clinical outcomes (Extended Glasgow Outcome Scale and Extended Glasgow Outcome Scale relative to initial injury severity). The three key questions from Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study addressed participants' general attitude toward inclusion in the Progesterone for the Treatment of Traumatic Brain Injury trial (general trial inclusion), their specific attitude toward being included in Progesterone for the Treatment of Traumatic Brain Injury trial under the exception from informed consent (personal exception from informed consent enrollment), and their attitude toward the use of exception from informed consent in the Progesterone for the Treatment of Traumatic Brain Injury trial in general (general exception from informed consent enrollment). Qualitative analysis of interview transcripts was performed to provide contextualization and to determine the extent to which respondents framed their attitudes in terms of clinical experience. Clinical data from Progesterone for the Treatment of Traumatic Brain Injury trial were available for all 74 patients represented in the Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study (including 46 patients for whom the surrogate was interviewed due to the patient's cognitive status or death). No significant difference was observed regarding acceptance of general trial inclusion or acceptance of general exception from informed consent enrollment between participants with favorable neurological outcomes and those with unfavorable outcomes relative to initial injury. Agreement with personal enrollment in Progesterone for the Treatment of Traumatic Brain Injury trial under exception from informed consent, however, was significantly higher among participants with favorable outcomes compared to those with unfavorable outcomes (89% vs 59%, p = 0.003). There was also a statistically significant relationship between more severe initial injury and increased acceptance of personal exception from informed consent enrollment ( p = 0.040) or general exception from informed consent use ( p = 0.034) in Progesterone for the Treatment of Traumatic Brain Injury trial. Many individuals referenced personal experience as a basis for their attitudes, but these references were not used to support negative views. Patients and surrogates of patients with unfavorable clinical outcomes were somewhat less accepting of their own inclusion in the Progesterone for the Treatment of Traumatic Brain Injury trial under exception from informed consent than were patients or surrogates of patients with favorable clinical outcomes. These findings suggest a need to identify optimal strategies for communicating with patients and their surrogates regarding exception from informed consent enrollment when clinical outcomes are poor.

The 90-day prognostic value of serum cyclophilin A in traumatic brain injury.

PubMed

Jin, Hang-Huang; Mao, Tian-Ming; Bai, Zhi-Qiang; Chen, Yuan; Ji, Hai-Long; Jin, Yong

2018-06-07

Cyclophilin A is involved in many inflammatory diseases and its expression is up-regulated after brain injury. We determined if serum cyclophilin A could be used as a marker for severity and 90-day outcome in patients with traumatic brain injury (TBI). Serum cyclophilin A concentrations were quantified in 105 severe TBI patients and 105 healthy individuals. Its association with Glasgow Coma Scale (GCS) score, 90-day mortality and 90-day poor outcome (Glasgow Outcome Scale score of 1-3) were investigated. Serum cyclophilin A concentrations were significantly higher in TBI patients than in healthy individuals. Cyclophilin A concentrations had a close relation to GCS scores and showed a high discriminatory ability for 90-day mortality and poor outcome according to area under receiver operating characteristic curve (AUC). Its AUC was in the range of GCS scores. Moreover, its combination with GCS scores significantly improved the predictive performance of GCS scores alone. In addition, serum cyclophilin A emerged as an independent predictor for 90-day mortality, overall survival and poor outcome. Increased serum cyclophilin A concentrations could reflect trauma severity and unfavorable outcome after head trauma, substantializing cyclophilin A as a potential biomarker for prognostic prediction of TBI. Copyright © 2018 Elsevier B.V. All rights reserved.

Traumatic Brain Injury in Children: Role of CDRs-PECARN as a Clinical Predictive Resource for Evaluation of Intracranical Lesions and Neuropsychiatric Outcomes.

PubMed

Ferrara, Pietro; Basile, Maria Cristina; Dell'Aquila, Livia; Vena, Flaminia; Coppo, Elena; Chiaretti, Antonio; Verrotti, Alberto; Paolini, Fabrizio; Caldarelli, Massimo

2016-01-01

Cranial computed tomography (CT) is considered the gold standard for the diagnosis of traumatic brain injury (TBI). The aim of this study was to evaluate if the clinical decision rules proposed by the Pediatric Emergency Care Applied Research Network (CDRs-PECARN) are really able to identify the patients who do not need cranial CT. This study investigates the neuropsychiatric outcome after TBI according to a pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds). We calculated the sensitivity, specificity, negative predictive value (NPV) and positive predictive value of the CDRs-PECARN in 2 age groups. Sensitivity was very high in both groups, and the NPV was very useful for predicting which subjects, of those who presented without CDRs- PECARN, would have a negative cranial CT. We also evaluated the correlations between the GOS-E Peds and Glasgow Coma Scale and between the GOS-E Peds and cranial CT scan. Our study confirms the validation of the PECARN TBI prediction rules as a clinical instrument which can play a significant role in CT decision-making for children with TBI. It also demonstrates that the GOS-E Peds is a valid pediatric outcome scale for children with TBI, despite some important limitations. © 2016 S. Karger AG, Basel.

Impact of extended monitoring-guided intensive care on outcome after severe traumatic brain injury: A prospective multicentre cohort study (PariS-TBI study).

PubMed

Mateo, Joaquim; Payen, Didier; Ghout, Idir; Vallée, Fabrice; Lescot, Thomas; Welschbillig, Stephane; Tazarourte, Karim; Azouvi, Philippe; Weiss, Jean-Jacques; Aegerter, Philippe; Vigué, Bernard

2017-01-01

We evaluated whether an integrated monitoring with systemic and specific monitoring affect mortality and disability in adults with severe traumatic brain injury (sTBI). Adults with severeTBI (Glasgow Coma Scale [GCS] ≤ 8) admitted alive in intensive care units (ICUs) were prospectively included. Primary endpoints were in-hospital 30-day mortality and extended Glasgow outcome score (GOSE) at 3 years. Association with the intensity of monitoring and outcome was studied by comparing a high level of monitoring (HLM) (systemic and ≥3 specific monitoring) and low level of monitoring (LLM) (systemic and 0-2 specific monitoring) and using inverse probability weighting procedure. 476 patients were included and IPW was used to improve the balance between the two groups of treatments (HLM/LMM). Overall hospital mortality (at 30 days) was 43%, being significantly lower in HLM than LLM group (27% vs. 53%: RR, 1.63: 95% CI: 1.23-2.15). The 14-day hospital mortality was also lower in the HLM group than expected, based upon the CRASH prediction model (35%). At 3 years, disability was not significantly different between the monitoring groups. After adjustment, HLM group improved short-term mortality but did not show any improvement in the 3-year outcome compared with LLM.

Cognitive Impairment after Severe Traumatic Brain Injury, Clinical Course and Impact on Outcome: A Swedish-Icelandic Study

PubMed Central

Stenberg, Maud; Godbolt, Alison K.; Nygren De Boussard, Catharina; Levi, Richard; Stålnacke, Britt-Marie

2015-01-01

Objective. To assess the clinical course of cognitive and emotional impairments in patients with severe TBI (sTBI) from 3 weeks to 1 year after trauma and to study associations with outcomes at 1 year. Methods. Prospective, multicenter, observational study of sTBI in Sweden and Iceland. Patients aged 18–65 years with acute Glasgow Coma Scale 3–8 were assessed with the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS). Outcome measures were Glasgow Outcome Scale Extended (GOSE) and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R). Results. Cognition was assessed with the BNIS assessed for 42 patients out of 100 at 3 weeks, 75 patients at 3 months, and 78 patients at 1 year. Cognition improved over time, especially from 3 weeks to 3 months. The BNIS subscales “orientation” and “visuospatial and visual problem solving” were associated with the GOSE and RLAS-R at 1 year. Conclusion. Cognition seemed to improve over time after sTBI and appeared to be rather stable from 3 months to 1 year. Since cognitive function was associated with outcomes, these results indicate that early screening of cognitive function could be of importance for rehabilitation planning in a clinical setting. PMID:26783381

Improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury.

PubMed

Corral, Luisa; Ventura, José Luis; Herrero, José Ignacio; Monfort, Jose Luis; Juncadella, Montserrat; Gabarrós, Andreu; Bartolomé, Carlos; Javierre, Casimiro F; García-Huete, Lucía

2007-11-01

To assess improvements in Glasgow Outcome Scale (GOS) and GOS extended (GOSE) scores between 6 months and 1 year following severe traumatic brain injury (TBI). One studied 214 adult patients with severe TBI with Glasgow Coma Scale (GCS) <9 admitted to Intensive Care Unit (ICU). GOS scores were obtained 6 and 12 months after injury in 195 subjects. Patients were predominantly male (84%) and median age was 35 years. Outcome (GOS and GOSE at 6 months and 1 year) was better in the high GCS score at admission (6-8) group than in the low score group (3-5). The improvement in GOS scores between 6 months and 1 year was greater in the high GCS score at admission group than in the low score group. At 6 months, 75 patients had died and 120 survived. None died between the 6-12-month assessments; at 12 months, 36% had improved GOS score. GOS scores improved between 6-12 months after severe TBI in 36% of survivors and it is concluded that the expectancy of improvement is incomplete at 6 months. This improvement was greater in patients with better GCS scores (6-8) at admission than in those with worse GCS scores (3-5).

Traumatic brain injuries from work accidents: a retrospective study.

PubMed

Salem, A M O; Jaumally, B A; Bayanzay, K; Khoury, K; Torkaman, A

2013-07-01

The United Arab Emirates is a rapidly developing country with recent expansion in construction and manufacturing. To investigate the occurrence and outcomes following occupational traumatic brain injury (TBI) requiring hospital admission. Records for all TBI cases admitted to an Abu Dhabi hospital between 2005 and 2009 were reviewed. Data on mechanisms of occupational injuries, Glasgow Coma Scale (GCS) on admission and Glasgow Outcome Scale (GOS) on follow-up, were analysed. Of 581 TBI cases reviewed, 56 (10%) cases were reported as occupational by either the patient or the informant accompanying the patient. All cases were male migrants, and 63% were aged 25-44. Falls accounted for 63% of cases, falling objects 34% and motor vehicle collisions 4%. Median GCS score was 13 for all cases. Median hospital stay was 7.5 days. Intensive care unit admission data were available in 47 cases, of which 34% (16) were admitted with a median stay of 5 days. GOS data were available in 95% (53) of cases, with good recovery in 81% cases, moderate-to-severe disability in 11% of cases and death in 8% (4) cases. Occupational TBI requiring hospitalization is most frequently due to falls and falling objects, with potentially grave consequences. This study further highlights the urgent need to implement preventative measures to improve construction worker safety.

Initial Diagnosis and Management of Coma.

PubMed

Traub, Stephen J; Wijdicks, Eelco F

2016-11-01

Coma represents a true medical emergency. Drug intoxications are a leading cause of coma; however, other metabolic disturbances and traumatic brain injury are also common causes. The general emergency department approach begins with stabilization of airway, breathing, and circulation, followed by a thorough physical examination to generate a limited differential diagnosis that is then refined by focused testing. Definitive treatment is ultimately disease-specific. This article presents an overview of the pathophysiology, causes, examination, and treatment of coma. Copyright © 2016 Elsevier Inc. All rights reserved.

Low-dose mannitol (0.3 g kg(-1)) improves the pulsatility index and minimum diastolic blood flow velocity in traumatic brain injury.

PubMed

Nincevic, Zeljko; Mestrovic, Julije; Nincevic, Jasna; Sundov, Zeljko; Kuscevic, Dorjan

2015-01-01

The aim of the study was to investigate the effects of using low-dose mannitol (0.3 g kg(-1)) on the pulsatility index (PI) and minimum diastolic blood flow velocity (FV-min) of the middle cerebral artery in a traumatic brain injury (TBI). Low-dose mannitol (0.3 g kg(-1)) was administered to a group of 20 patients with a TBI. Transcranial Doppler (TCD) ultrasonography was used to monitor the PI and FV-min. The study included patients with a diffuse traumatic brain injury and Glasgow coma score < 8. The initial TCD ultrasonography values were pathological (PI > 1.4 and FV-min < 20 cm s(-1)). TCD ultrasonography examinations were carried out before mannitol administration, immediately after administration and 1, 2 and 3 hours after the administration of mannitol. A one-way analysis of variance revealed significant changes in the PI (F = 8.392; p < 0.001) and FV-min (F = 8.291; p = 0.001) after the use of mannitol. Low-dose mannitol administration appears to be efficacious for improving the indicators of disturbed circulation in a TBI (FV-min increase, PI decrease). The maximum decrease in the PI was recorded 1 hour after the administration of mannitol and was 10.9% of the initial value. The maximum increase in the FV-min was recorded 1 hour after administration and was 29.7% of the initial value. These changes were significant ∼ 2 hours later.

The reliability of vital signs in estimating pain severity among adult patients treated by paramedics.

PubMed

Lord, Bill; Woollard, Malcolm

2011-02-01

The aim of this study was to examine the strength of correlation between initial pain severity score and systolic blood pressure, heart rate and respiratory rates among adults reporting pain in the prehospital setting as a means of validating the presence and severity of pain. A retrospective cohort study was conducted including all adults with a Glasgow Coma Score >12 assessed by paramedics in a metropolitan area over a 7 day period in 2005. Pain was self-scored by patients using a 0-10 numeric rating scale (NRS). Of the patients transported, 1766/3357 (53%) reported pain, and an NRS score was recorded for 1286. Median age was 57 years, 51% were women, and median initial NRS was six. Mean heart rate was 85 (95% CI 84 to 86), mean systolic blood pressure was 139 mmHg (95% CI 138 to 141) and mean respiratory rate was 18 (95% CI 18 to 18). There was no significant correlation between NRS and heart rate (r=0.002, p=0.61, 95% CI -0.007 to +0.011) or blood pressure (r=-0.0007, p=0.81, 95% CI -0.007 to +0.005), although this was statistically significant for initial pain score and respiratory rate (r 0.058, p=0.001, 95% CI 0.024 to 0.093). A lack of any meaningful correlation between pain scores and changes in vital signs in this population demonstrates that these signs cannot be used to validate the severity of pain reported by adult patients.

The role of middle latency evoked potentials in early prediction of favorable outcomes among patients with severe ischemic brain injuries.

PubMed

Zhang, Yan; Wang, Miao; Su, Ying Ying

2014-10-15

To explore the role of middle latency evoked potentials (EPs) as predictors for favorable outcome in patients with severe ischemic brain injuries by comparing the prognostic ability of short latency somatosensory and auditory evoked potentials (SLSEP and BAEP) with middle latency somatosensory and auditory evoked potentials (MLSEP and MLAEP). MLSEP, MLAEP, SLSEP and BAEP were recorded in 112 patients with severe ischemic brain injuries (Glasgow Coma Scale ≤ 8). Among them, 83 patients suffered from cerebral ischemic stroke and 29 suffered from anoxic-ischemic encephalopathy after cardiopulmonary resuscitation between 1 and 7 days after the onset of stroke. Outcomes were reviewed 6 months later using the Glasgow Outcome Scale (GOS). A GOS score of 4-5 was considered as a good outcome while a score of 1-3 was considered as poor. By using the prognostic authenticity analysis of predictors for good outcome, at least unilateral N20 of the SLSEP exit and at least unilateral N60 of the MLSEP exit showed the highest sensitivity which was 100% (95% CI: 86.7%-100%). The bilateral normal N60 showed a high specificity of 97.5% (95% CI: 90.4%-99.6%). It also showed the highest positive likelihood ratio of 6.25% (95% CI: 1.28%-30.59%), which was superior to N20 of SLSEP, V of BAEP, and Pa of MLAEP. The analysis demonstrated that the area under the curve for MLSEP grading was the highest (0.838) compared to that of SLSEP grading (0.784), MLAEP grading (0.659) and BAEP grading (0.621). Compared with using N20 of SLSEP analysis alone, adding MLSEP improves the outcome prediction in patients with severe ischemic brain injuries. When an outcome is uncertain after initial evaluation using short-latency EPs, MLSEP is valuable to be used from the first week to further improve prognostication in these patients. Copyright © 2014 Elsevier B.V. All rights reserved.

A traumatic asphyxia in a child.

PubMed

Nishiyama, T; Hanaoka, K

2000-11-01

Traumatic asphyxia in a child is rare and the pathophysiology is different from that occurring in an adult. We report a case of traumatic asphyxia in a child who recovered without specific treatment, even though chest and abdominal compression was severe. A three-year-old boy (14.2 kg) was run over by the rear wheel of a Jeep. He was under the tire for about three minutes and then was transferred to our hospital. When he arrived, he was lethargic with Glasgow Coma Scale of E3V4M6 (coma score of 13). He was cyanotic in his face and had a tire mark from the left shoulder to the right abdomen, petechiae on the head, face, conjunctiva and chest, oral bleeding, and facial edema. Serum concentrations of liver enzymes were increased and microhematuria was detected. However, no injuries were seen in the brain, eye, chest, or abdomen. Cyanosis disappeared in a few hours. Facial and thoracic petechiae disappeared in three days and that of the conjunctiva in five days. He was discharged from hospital on the 13th day without any disturbances. We present a three-year-old boy with traumatic asphyxia. He had no complications although he received severe thoraco-abdominal compression by a Jeep.

The usefulness of diffusion-weighted magnetic resonance imaging performed in the acute phase as an early predictor of delayed neuropsychiatric sequelae in acute carbon monoxide poisoning.

PubMed

Kim, Y S; Cha, Y S; Kim, M S; Kim, H J; Lee, Y S; Youk, H; Kim, H I; Kim, O H; Cha, K-C; Kim, H; Lee, K H; Hwang, S O

2018-06-01

Delayed onset of neuropsychiatric symptoms after apparent recovery from acute carbon monoxide (CO) poisoning has been described as delayed neuropsychiatric sequelae (DNS). No previous study has determined whether early use of diffusion-weighted magnetic resonance imaging (DWI) can predict which patients will develop DNS in the acute CO poisoning. This retrospective observational study was performed on adult patients with acute CO poisoning consecutively treated over a 17-month period. All included patients with acute CO poisoning underwent DWI to evaluate brain injury within 72 h after CO exposure. DWI was evaluated as follows: (1) presence of pathology, (2) number of pathologies, (3) asymmetry, and (4) location of pathology. Patients were divided into two groups. The DNS group was composed of patients with delayed sequelae, while the non-DNS group included patients with no sequelae. A total of 102 patients with acute CO poisoning were finally enrolled in this study. DNS developed in 10 patients (9.8%). Between the DNS group and the non-DNS group, presence of pathology on DWI and initial Glasgow Coma Scale (GCS) showed significant difference. There was also a statistical difference between the non-DNS group and DNS group in terms of CO exposure time, troponin I, rhabdomyolysis, acute kidney injury, and pneumonia. The presence of pathology in DWI and initial GCS (cutoff: <12) at the emergency department served as an early predictors of DNS.

Being a neighbor to Syria: a retrospective analysis of patients brought to our clinic for cranial gunshot wounds in the Syrian civil war.

PubMed

Aras, M; Altaş, M; Yilmaz, A; Serarslan, Y; Yilmaz, N; Yengil, E; Urfali, B

2014-10-01

Toward the end of 2010, the Arab spring, the waves of revolutionary demonstrations and protests influenced also Syria, where violent clashes turned into a civil war. Hundreds of thousands of people became refugees. The use of excessive force unfortunately culminated in numerous deaths and injuries in many cities. Being the closest city to Aleppo, Damascus and Homs, the biggest cities of Syria, Antioch/Hatay has been the city where initial emergency treatments were performed. For this reason, we examined and retrospectively analyzed the medical records of the patients treated in the clinics of our hospital due to cranial gunshot wounds during the war. The medical records of 186 patients who were injured in the Syrian War and brought to, followed up and treated in the Neurosurgery Clinic of Mustafa Kemal University, Faculty of Medicine in Hatay, a Turkish city on the Syrian border, between April 2011 and June 2013. A total of 186 patients were evaluated in a period of more than 2 years. Of all 91.4% of the patients were adults (male/female: 152/18) and 8.6% of them were pediatric patients (male/female: 14/2). The average age of the patients was 31 years, with an age range of between 2 months and 67 years. According to Glasgow coma score (GCS) of the patients at the time of admission, GCS was 3 in 32 patients (17.2%), between 4 and 7 in 70 patients (37.6%), and between 8 and 15 in 84 patients (45.1%). We observed that the patients with GCS of 4-7 had a significantly lower mortality among the 56 patients treated surgically compared with the 14 patients treated medically. Cranial gunshot wounds are responsible for high mortality and morbidity. A multiplicity of factors plays a role on morbidity and mortality. These are the duration of transport, the injury pattern, the velocities of the weapons used, and the Glasgow Coma Scales of the patients at the time of admission. The authors recommend that the patients with cranial gunshot wounds who has GCS of 4-7 should be aggressively treated including surgery as well. We do not recommend surgical treatment for patients with GCS of 3. All our experiences show that treatment of gunshot wounds will continue to be a matter of debate, about which there is more to learn. The data presented in this study will once again demonstrate the seriousness of the event, and will, perhaps, contribute to the peace negotiations to end the war. Copyright © 2014 Elsevier B.V. All rights reserved.

Radiation exposure in the young level 1 trauma patient: a retrospective review.

PubMed

Gottschalk, Michael B; Bellaire, Laura L; Moore, Thomas

2015-01-01

Computed tomography (CT) has become an increasingly popular and powerful tool for clinicians managing trauma patients with life-threatening injuries, but the ramifications of increasing radiation burden on individual patients are not insignificant. This study examines a continuous series of 337 patients less than 40 years old admitted to a level 1 trauma center during a 4-month period. Primary outcome measures included number of scans; effective dose of radiation from radiographs and CT scans, respectively; and total effective dose from both sources over patients' hospital stays. Several variables, including hospital length of stay, initial Glasgow Coma Scale score, and Injury Severity Score, correlated with greater radiation exposure. Blunt trauma victims were more prone to higher doses than those with penetrating or combined penetrating and blunt trauma. Location and mechanism of injury were also found to correlate with radiation exposure. Trauma patients as a group are exposed to high levels of radiation from X-rays and CT scans, and CT scans contribute a very high proportion (91.3% ± 11.7%) of that radiation. Certain subgroups of patients are at a particularly high risk of exposure, and greater attention to cumulative radiation dose should be paid to patients with the above mentioned risk factors.

[Clinical decision to perform cranial computed tomography in children with non-severe head injury].

PubMed

Franco-Koehrlen, Celine Alicia; Iglesias-Leboreiro, José; Bernárdez-Zapata, Isabel; Rendón-Macías, Mario Enrique

The main goal of this article was to evaluate if the decision to perform cranial computed tomography (CT) in children with minor head injury is determined by the presence or absence of the physician during assessment in the emergency room. Clinical files of 92 patients from 8 months to 4 years of age were selected. Those children were evaluated at the emergency department of the Spanish Hospital of Mexico due to non-severe traumatic brain injury. Glasgow Coma Scale (GCS) score was determined in all patients. Groups of patients were compared: 1) patients having CT, 2) patients with a physician who attended the initial assessment, 3) patients whose attending physician did not arrive to assess the patient and 4) patients assessed by the emergency room staff. 38% of patients with non-severe brain injury underwent CT, 8.6% had a brain injury visible on the CT. Moderate intensity impacts were greater in patients with CT. Regarding the ECG, it was found that most children scored 15 points (p=0.03). In patients without a physician, a greater trend was demonstrated for performing CT. Patients with minor head injury but without neurological signs should undergo a detailed clinical evaluation in order to avoid unwarranted CT. Copyright © 2015. Publicado por Masson Doyma México S.A.

[Polytrauma following a truck accident : How to save lives by guideline-oriented emergency care].

PubMed

Kippnich, M; Jelting, Y; Markus, C; Kredel, M; Wurmb, T; Kranke, P

2017-12-01

Identification and immediate treatment of life-threatening conditions is fundamental in patients with multiple trauma. In this context, the S3 guidelines on polytrauma and the S1 guidelines on emergency anesthesia provide the scientific background on how to handle these situations. This case report deals with a seriously injured driver involved in a truck accident. The inaccessible patient showed a scalping injury of the facial skeleton with massive bleeding and partially blocked airway but with spontaneous breathing as well as centralized cardiovascular circulation conditions and an initial Glasgow coma scale (GCS) of 8. An attempt was made to stop the massive bleeding by using hemostyptic-coated dressings. In addition, the patient was intubated via video laryngoscopy and received a left and right thoracic drainage as well as two entry points for intraosseous infusion. In modern emergency medical services, treatment based on defined algorithms is recommended and also increasingly established in dealing with critical patients. The guideline-oriented emergency care of patients with polytrauma requires invasive measures, such as intubation and thoracic decompression in the preclinical setting. The foundation for this procedure includes training in theory and practice both of the non-medical and medical rescue service personnel.

Cerebral fat embolism and the "starfield" pattern: a case report.

PubMed

Aravapalli, Amit; Fox, James; Lazaridis, Christos

2009-11-19

Nearly all long-bone fractures are accompanied by some form of fat embolism. The rare complication of clinically significant fat embolism syndrome, however, occurs in only 0.9-2.2% of cases. The clinical triad of fat embolism syndrome consists of respiratory distress, altered mental status, and petechial rash. Cerebral fat embolism causes the neurologic involvement seen in fat embolism syndrome. A 19-year-old African-American male was admitted with gunshot wounds to his right hand and right knee. He had diffuse hyperactive deep tendon reflexes, bilateral ankle clonus and decerebrate posturing with a Glasgow Coma Scale (GCS) score of 4T. Subsequent MRI of the brain showed innumerable punctate areas of restricted diffusion consistent with "starfield" pattern. On a 10-week follow up he has a normal neurological examination and he is discharged home. Despite the severity of the neurologic insult upon initial presentation, the majority of case reports on cerebral fat embolism illustrate that cerebral dysfunction associated with cerebral fat embolism is reversible. When neurologic deterioration occurs in the non-head trauma patient, then a systemic cause such as fat emboli should be considered. We describe a patient with non-head trauma who demonstrated the classic "starfield" pattern on diffusion-weighted MRI imaging.

[Myxedema coma].

PubMed

Rizzo, Leonardo F L; Mana, Daniela L; Bruno, Oscar D; Wartofsky, Leonard

2017-01-01

Hypothyroidism is a frequently diagnosed and simply treated disease. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. The term "myxedema coma" is generally seen as misleading since most patients do not initially present in a coma. The typical progression is lethargy evolving into stupor and, eventually, into coma with respiratory failure and hypothermia. It mainly affects elderly women, often occurring in winter and is relatively rare. It can be considered a form of decompensated hypothyroidism often triggered by a variety of non-thyroid conditions or diseases provoking an extremely severe condition of multiple system failure with lethal consequences unless an early diagnosis is made and an aggressive treatment is administered.

Community-acquired bacterial meningitis in elderly patients: experience over 30 years.

PubMed

Cabellos, Carmen; Verdaguer, Ricard; Olmo, Montse; Fernández-Sabé, Nuria; Cisnal, Maria; Ariza, Javier; Gudiol, Francesc; Viladrich, Pedro F

2009-03-01

Clinical characteristics, etiologies, evolution, and prognostic factors of community-acquired bacterial meningitis in elderly patients are not well known. To improve this knowledge, all episodes of community-acquired bacterial meningitis were prospectively recorded and cases occurring in patients >or=65 years old were selected. During the period 1977-2006, 675 episodes in adults (aged >or=18 yr) were recorded, with 185 (27%) in patients aged >or=65 years old; 76 were male and 109 were female, with a mean age of 73 +/- 6 years (range, 65-93 yr). Causative microorganisms were Streptococcus pneumoniae 74, Neisseria meningitidis 49, Listeria monocytogenes 17, other streptococcal 9, Escherichia coli 6, Haemophilus influenzae 4, Klebsiella pneumoniae and Staphylococcus aureus 2 each, Capnocytophaga canimorsus and Enterococcus faecalis 1 each, and unknown in 20. On admission 91% had had fever, 32% were in a coma (Glasgow Coma Scale or=65 yr), who showed a higher frequency of diabetes and malignancy as underlying disease; pneumonia, otitis, and pericranial fistula as predisposing factors; and S. pneumoniae and L. monocytogenes as etiology. There were also differences in clinical presentation, complications, sequelae, and mortality. Factors independently related with mortality were age, pneumonia as a predisposing factor, coma on admission, and heart failure and seizures after therapy. Dexamethasone therapy was a protective factor. In conclusion, bacterial meningitis in elderly patients is associated with greater diagnostic difficulties and neurologic severity and more complications, as well as with increased mortality. Antiseizure prophylaxis might be useful in these patients.

Phase Synchronization in Electroencephalographic Recordings Prognosticates Outcome in Paediatric Coma

PubMed Central

Nenadovic, Vera; Perez Velazquez, Jose Luis; Hutchison, James Saunders

2014-01-01

Brain injury from trauma, cardiac arrest or stroke is the most important cause of death and acquired disability in the paediatric population. Due to the lifetime impact of brain injury, there is a need for methods to stratify patient risk and ultimately predict outcome. Early prognosis is fundamental to the implementation of interventions to improve recovery, but no clinical model as yet exists. Healthy physiology is associated with a relative high variability of physiologic signals in organ systems. This was first evaluated in heart rate variability research. Brain variability can be quantified through electroencephalographic (EEG) phase synchrony. We hypothesised that variability in brain signals from EEG recordings would correlate with patient outcome after brain injury. Lower variability in EEG phase synchronization, would be associated with poor patient prognosis. A retrospective study, spanning 10 years (2000–2010) analysed the scalp EEGs of children aged 1 month to 17 years in coma (Glasgow Coma Scale, GCS, <8) admitted to the paediatric critical care unit (PCCU) following brain injury from TBI, cardiac arrest or stroke. Phase synchrony of the EEGs was evaluated using the Hilbert transform and the variability of the phase synchrony calculated. Outcome was evaluated using the 6 point Paediatric Performance Category Score (PCPC) based on chart review at the time of hospital discharge. Outcome was dichotomized to good outcome (PCPC score 1 to 3) and poor outcome (PCPC score 4 to 6). Children who had a poor outcome following brain injury secondary to cardiac arrest, TBI or stroke, had a higher magnitude of synchrony (R index), a lower spatial complexity of the synchrony patterns and a lower temporal variability of the synchrony index values at 15 Hz when compared to those patients with a good outcome. PMID:24752289

A pediatric FOUR score coma scale: interrater reliability and predictive validity.

PubMed

Czaikowski, Brianna L; Liang, Hong; Stewart, C Todd

2014-04-01

The Full Outline of UnResponsiveness (FOUR) Score is a coma scale that consists of four components (eye and motor response, brainstem reflexes, and respiration). It was originally validated among the adult population and recently in a pediatric population. To enhance clinical assessment of pediatric intensive care unit patients, including those intubated and/or sedated, at our children's hospital, we modified the FOUR Score Scale for this population. This modified scale would provide many of the same advantages as the original, such as interrater reliability, simplicity, and elimination of the verbal component that is not compatible with the Glasgow Coma Scale (GCS), creating a more valuable neurological assessment tool for the nursing community. Our goal was to potentially provide greater information than the formally used GCS when assessing critically ill, neurologically impaired patients, including those sedated and/or intubated. Experienced pediatric intensive care unit nurses were trained as "expert raters." Two different nurses assessed each subject using the Pediatric FOUR Score Scale (PFSS), GCS, and Richmond Agitation Sedation Scale at three different time points. Data were compared with the Pediatric Cerebral Performance Category (PCPC) assessed by another nurse. Our hypothesis was that the PFSS and PCPC should highly correlate and the GCS and PCPC should correlate lower. Study results show that the PFSS is excellent for interrater reliability for trained nurse-rater pairs and prediction of poor outcome and in-hospital mortality, under various situations, but there were no statistically significant differences between the PFSS and the GCS. However, the PFSS does have the potential to provide greater neurological assessment in the intubated and/or sedated patient based on the outcomes of our study.

[Events related with injury severity in pediatric multiple trauma].

PubMed

de Tomás, E; Navascués, J A; Soleto, J; Sánchez, R; Romero, R; García-Casillas, M A; Molina, E; de Agustín, J C; Matute, J; Aguilar, F; Vázquez, J

2004-01-01

Epidemiological analysis of main factors affecting multiple trauma in children in our environment. We reviewed the data collected from the patients (n = 2.166) admitted to our hospital because of trauma and included in our Registry from January 1995 to December 2000. Among this group 79 patients were considered severely injured trauma patients according Injury Severity Score (ISS) (ISS > 15) and selected for the study. Statistical analysis was done using chi2 and Student t test, p values under 0.01 were considered significant. Group gender distribution was 49 males and 30 females, age average was 9.7 years (range 0-15 years) Traffic related injuries were the leading cause of trauma in this group (77,2%). Initial triage by using the Pediatric Trauma Score allowed identifying the injury severity in 73,4% of patients (58 children obtained a PTS < or = 8). In 32,9% of the cases the patient was in coma at admission in the Emergency (Glasgow Coma Scale < or = 8, n = 26). ISS average was 23.4 (range 16-75). Most patients suffered from multiple injuries (87,3%), average of injuries number was 4,7 (range 1-9). The most frequent trauma localization was cranial trauma. Admission in the intensive care unit was necessary in 65,8% of patients, and any kind of surgical procedure was done in 35,4%. Average length of stay was 17,1 days (range 0-214 days). Injury severity was higher in automotive patients without restraining systems (I.S.S. average 27,2, mortality 16,6%). Overall mortality was 11,4% (n = 9), and 94.3% of patients presented any functional or anatomic disability. Traffic related injuries are the main cause of multiple trauma in children. The severity and high mortality of these injuries make imperative polytonal education systems and the use of restraining devices.

A tale of two cities: a review of homicide in Melbourne and Glasgow in 2005.

PubMed

Lynch, Matthew; Black, Marjorie

2008-01-01

The Departments of Forensic Medicine and Science at the University of Glasgow and the Victorian Institute of Forensic Medicine in Melbourne are academic university-based forensic medicine units providing a medico-legal death investigation service to the Strathclyde region of Scotland and the State of Victoria, Australia, respectively. We reviewed and compared homicides in the two jurisdictions for the year 2005. Whilst gross numbers were comparable, the homicide rate per capita was significantly higher in Glasgow. Death due to stabbing comprised a greater proportion of homicides in Glasgow, reflective of a well recognised social epidemic of knife-related trauma amongst young males. Blunt force trauma was the most prevalent cause of homicidal injury in the Australian cases. The cities shared a low incidence of firearm- related homicide, reflective of strict legislative initiatives.

Emergency department transport rates of children from the scene of motor vehicle collisions: do booster seats make a difference?

PubMed

House, Darlene R; Huffman, Gretchen; Walthall, Jennifer D H

2012-11-01

Motor vehicle collisions (MVCs) are the leading cause of death and disability among children older than 1 year. Many states currently mandate all children between the ages of 4 and 8 years be restrained in booster seats. The implementation of a booster-seat law is generally thought to decrease the occurrence of injury to children. We hypothesized that appropriate restraint with booster seats would also cause a decrease in emergency department (ED) visits compared with children who were unrestrained. This is an important measure as ED visits are a surrogate marker for injury. The main purpose of this study was to look at the rate of ED visits between children in booster seats compared with those in other or no restraint systems involved in MVCs. Injury severity was compared across restraint types as a secondary outcome of booster-seat use after the implementation of a state law. A prospective observational study was performed including all children 4 to 8 years old involved in MVCs to which emergency medical services was dispatched. Ambulance services used a novel on-scene computer charting system for all MVC-related encounters to collect age, sex, child-restraint system, Glasgow Coma Scale score, injuries, and final disposition. One hundred fifty-nine children were studied with 58 children (35.6%) in booster seats, 73 children in seatbelts alone (45.2%), and 28 children (19.1%) in no restraint system. 76 children (47.7%), 74 by emergency medical services and 2 by private vehicle, were transported to the ED with no significant difference between restraint use (P = 0.534). Utilization of a restraint system did not significantly impact MVC injury severity. However, of those children who either died (n = 2) or had an on-scene decreased Glasgow Coma Scale score (n = 6), 75% (6/8) were not restrained in a booster seat. The use of booster-seat restraints does not appear to be associated with whether a child will be transported to the ED for trauma evaluation.

Comparison of Glasgow Coma Scale, Full Outline of Unresponsiveness and Acute Physiology and Chronic Health Evaluation in Prediction of Mortality Rate Among Patients With Traumatic Brain Injury Admitted to Intensive Care Unit

PubMed Central

Hosseini, Seyed Hossein; Ayyasi, Mitra; Akbari, Hooshang; Heidari Gorji, Mohammad Ali

2016-01-01

Background Traumatic brain injury (TBI) is a common cause of mortality and disability worldwide. Choosing an appropriate diagnostic tool is critical in early stage for appropriate decision about primary diagnosis, medical care and prognosis. Objectives This study aimed to compare the Glasgow coma scale (GCS), full outline of unresponsiveness (FOUR) and acute physiology and chronic health evaluation (APACHE II) with respect to prediction of the mortality rate of patients with TBI admitted to intensive care unit. Patients and Methods This diagnostic study was conducted on 80 patients with TBI in educational hospitals. The scores of APACHE II, GCS and FOUR were recorded during the first 24 hours of admission of patients. In this study, early mortality means the patient death before 14 days and delayed mortality means the patient death 15 days after admitting to hospital. The collected data were analyzed using descriptive and inductive statistics. Results The results showed that the mean age of the patients was 33.80 ± 12.60. From a total of 80 patients with TBI, 16 (20%) were females and 64 (80%) males. The mortality rate was 15 (18.7%). The results showed no significant difference among three tools. In prediction of early mortality, the areas under the curve (AUCs) were 0.92 (CI = 0.95. 0.81 - 0.97), 0.90 (CI = 0.95. 0.74 - 0.94), and 0.96 (CI = 0.95. 0.87 - 0.9) for FOUR, APACHE II and GCS, respectively. In delayed mortality, the AUCs were 0.89 (CI = 0.95. 0.81-0.94), 0.94 (CI = 0.95. 0.74 - 0.97) and 0.90 (CI = 0.95. 0.87 - 0.95) for FOUR, APACHE II and GCS, respectively. Conclusions Considering that GCS is easy to use and the FOUR can diagnose a locking syndrome along same values of subscales. These two subscales are superior to APACHI II in prediction of early mortality. Conversation APACHE II is more punctual in the prediction of delayed mortality. PMID:29696116

Which score should be used in intubated patients’ Glasgow coma scale or full outline of unresponsiveness?

PubMed Central

Gorji, Mohammad Ali Heidari; Gorji, Ali Morad Heidari; Hosseini, Seyed Hossein

2015-01-01

Background and Aims: Today Glasgow coma scale (GCS) is the most well-known and common score for evaluation of the level of consciousness and outcome predict after traumatic brain injuries in the world. Regarding to some advantages of the full outline of unresponsiveness (FOUR) score over GCS in intubated patients, we’re going to compare the precision of these two scores in predicting the outcome predict in intubated patients. Methods: This research was a diagnostic-based study, which was conducted prospectively on 80 patients with Traumatic brain injury who were intubated and admitted to Intensive Care Unit (ICU) of Educational Hospitals of Mazandaran University of Medical Science during February 2013 to August 2013. The scores of FOUR and GCS were measured by the researcher in the first 24 h of admission in ICU. The information's recorded in the check list including the mortality rate of early and late inside of the hospital interred to excel. The findings were analyzed using SPSS software, through descriptive statistics and regression logistic. Results: The results showed of 80 patients 21 patients (20%) were female and 59 patients (80%) were male. The age average of the samples was 33.80 ± 12.60 ranging from 16 to 60 years old. 21 patients (26.2%) died during treatment. Of 21 patients, 15 patients died during first 14 days (18.7%) and 6 patients died after 14 years (7.5%). The area under curve (AUC) of FOUR score in early mortality was 0.90 (C1 = 0.95, 0.88–0.90). The amount AUC for GCS was 0.80 (C1 = 0.95, 0.78–0.84), which in delayed mortality it was ordered as 0.86 (C1 = 0.95, 0.84–0.90) and 0.89 (C1 = 0.95, 0.78–0.88). Conclusion: The research results indicated that FOUR score is more exact and more practical in intubated patients regarding lack of verbal response factor in early mortality prediction in GCS. Hence, it is recommended for health professionals to use the FOUR score to predict the early outcome of intubated patients with traumatic brain injuries. PMID:26097814

Optimization of brain metabolism using metabolic-targeted therapeutic hypothermia can reduce mortality from traumatic brain injury.

PubMed

Feng, Jin-Zhou; Wang, Wen-Yuan; Zeng, Jun; Zhou, Zhi-Yuan; Peng, Jin; Yang, Hao; Deng, Peng-Chi; Li, Shi-Jun; Lu, Charles D; Jiang, Hua

2017-08-01

Therapeutic hypothermia is widely used to treat traumatic brain injuries (TBIs). However, determining the best hypothermia therapy strategy remains a challenge. We hypothesized that reducing the metabolic rate, rather than reaching a fixed body temperature, would be an appropriate target because optimizing metabolic conditions especially the brain metabolic environment may enhance neurologic protection. A pilot single-blind randomized controlled trial was designed to test this hypothesis, and a nested metabolomics study was conducted to explore the mechanics thereof. Severe TBI patients (Glasgow Coma Scale score, 3-8) were randomly divided into the metabolic-targeted hypothermia treatment (MTHT) group, 50% to 60% rest metabolic ratio as the hypothermia therapy target, and the body temperature-targeted hypothermia treatment (BTHT) control group, hypothermia therapy target of 32°C to 35°C body temperature. Brain and circulatory metabolic pool blood samples were collected at baseline and on days 1, 3, and 7 during the hypothermia treatment, which were selected randomly from a subgroup of MTHT and BTHT groups. The primary outcome was mortality. Using H nuclear magnetic resonance technology, we tracked and located the disturbances of metabolic networks. Eighty-eight severe TBI patients were recruited and analyzed from December 2013 to December 2014, 44 each were assigned in the MTHT and BTHT groups (median age, 42 years; 69.32% men; mean Glasgow Coma Scale score, 6.17 ± 1.02). The mortality was significantly lower in the MTHT than the BTHT group (15.91% vs. 34.09%; p = 0.049). From these, eight cases of MTHT and six cases from BTHT group were enrolled for metabolomics analysis, which showed a significant difference between the brain and circulatory metabolic patterns in MTHT group on day 7 based on the model parameters and scores plots. Finally, metabolites representing potential neuroprotective monitoring parameters for hypothermia treatment were identified through H nuclear magnetic resonance metabolomics. MTHT can significantly reduce the mortality of severe TBI patients. Metabolomics research showed that this strategy could effectively improve brain metabolism, suggesting that reducing the metabolic rate to 50% to 60% should be set as the hypothermia therapy target. Therapeutic study, Level I.

Factors influencing pediatric Injury Severity Score and Glasgow Coma Scale in pediatric automobile crashes: results from the Crash Injury Research Engineering Network.

PubMed

Ehrlich, Peter F; Brown, J Kristine; Sochor, Mark R; Wang, Stewart C; Eichelberger, Martin E

2006-11-01

Motor vehicle crashes account for more than 50% of pediatric injuries. Triage of pediatric patients to appropriate centers can be based on the crash/injury characteristics. Pediatric motor vehicle crash/injury characteristics can be determined from an in vitro laboratory using child crash dummies. However, to date, no detailed data with respect to outcomes and crash mechanism have been presented with a pediatric in vivo model. The Crash Injury Research Engineering Network is comprised of 10 level 1 trauma centers. Crashes were examined with regard to age, crash severity (DeltaV), crash direction, restraint use, and airbag deployment. Multiple logistic regression analysis was performed with Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) as outcomes. Standard age groupings (0-4, 5-9, 10-14, and 15-18) were used. The database is biases toward a survivor population with few fatalities. Four hundred sixty-one motor vehicle crashes with 2500 injuries were analyzed (242 boys, 219 girls). Irrespective of age, DeltaV > 30 mph resulted in increased ISS and decreased GCS (eg, for 0-4 years, DeltaV < 30: ISS = 10, GCS = 13.5 vs DeltaV > 30: ISS = 19.5, GCS = 10.6; P < .007, < .002, respectively). Controlling for DeltaV, children in lateral crashes had increased ISS and decreased GCS versus those in frontal crashes. Airbag deployment was protective for children 15 to 18 years old and resulted in a lower ISS and higher GCS (odds ratio, 2.1; 95% confidence interval, 0.9-4.6). Front-seat passengers suffered more severe (ISS > 15) injuries than did backseat passengers (odds ratio, 1.7; 95% confidence interval, 0.7-3.4). A trend was noted for children younger than 12 years sitting in the front seat to have increased ISS and decreased GCS with airbag deployment but was limited by case number. A reproducible pattern of increased ISS and lower GCS characterized by high severity, lateral crashes in children was noted. Further analysis of the specific injuries as a function and the crash characteristic can help guide management and prevention strategies.

23.4% saline decreases brain tissue volume in severe hepatic encephalopathy as assessed by a quantitative computed tomography marker

PubMed Central

Liotta, Eric M; Lizza, Bryan D; Romanova, Anna L; Guth, James C; Berman, Michael D; Carroll, Timothy J; Francis, Brandon; Ganger, Daniel; Ladner, Daniela P; Maas, Matthew B; Naidech, Andrew M

2016-01-01

Objective Cerebral edema is common in severe hepatic encephalopathy and may be life-threatening. Bolus 23.4% hypertonic saline (HTS) improves surveillance neuromonitoring scores, although its mechanism of action is not clearly established. We investigated the hypothesis that bolus HTS decreases cerebral edema in severe hepatic encephalopathy utilizing a quantitative technique to measure brain and CSF volume changes. Design Retrospective analysis of serial computed tomography (CT) scans and clinical data for a case-control series was performed. Setting Intensive care units of a tertiary care hospital. Patients Patients with severe hepatic encephalopathy treated with 23.4% HTS and control patients who did not receive 23.4% HTS. Methods We used clinically obtained CT scans to measure volumes of the ventricles, intracranial CSF, and brain using a previously validated semi-automated technique (Analyze Direct; Overland Park, KS). Volumes before and after 23.4% HTS were compared with Wilcoxon signed-rank test. Associations between total CSF volume, ventricular volume, serum sodium, and Glasgow Coma Scale Scores were assessed using Spearman correlation. Results Eleven patients with 18 administrations of 23.4% HTS met inclusion criteria. Total CSF (median 47.6 [35.1–69.4] to 61.9 [47.7–87.0] mL, p<0.001) and ventricular volumes (median 8.0 [6.9–9.5] to 9.2 [7.8–11.9] mL, p=0.002) increased and Glasgow Coma Scale Scores improved (median 4 [3–6] to 7 [6–9], p=0.008) after 23.4% HTS. In contrast, total CSF and ventricular volumes decreased in untreated control patients. Serum sodium increase was associated with increase in total CSF volume (r=0.83, p<0.001) and change in total CSF volume was associated with ventricular volume change (r=0.86, p<0.001). Conclusions Total CSF and ventricular volumes increased after 23.4% HTS, consistent with a reduction in brain tissue volume. Total CSF and ventricular volume change may be useful quantitative measures to assess cerebral edema in severe hepatic encephalopathy. PMID:26308431

Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity.

PubMed

Brennan, Paul M; Murray, Gordon D; Teasdale, Graham M

2018-06-01

OBJECTIVE Glasgow Coma Scale (GCS) scores and pupil responses are key indicators of the severity of traumatic brain damage. The aim of this study was to determine what information would be gained by combining these indicators into a single index and to explore the merits of different ways of achieving this. METHODS Information about early GCS scores, pupil responses, late outcomes on the Glasgow Outcome Scale, and mortality were obtained at the individual patient level by reviewing data from the CRASH (Corticosteroid Randomisation After Significant Head Injury; n = 9,045) study and the IMPACT (International Mission for Prognosis and Clinical Trials in TBI; n = 6855) database. These data were combined into a pooled data set for the main analysis. Methods of combining the Glasgow Coma Scale and pupil response data varied in complexity from using a simple arithmetic score (GCS score [range 3-15] minus the number of nonreacting pupils [0, 1, or 2]), which we call the GCS-Pupils score (GCS-P; range 1-15), to treating each factor as a separate categorical variable. The content of information about patient outcome in each of these models was evaluated using Nagelkerke's R 2 . RESULTS Separately, the GCS score and pupil response were each related to outcome. Adding information about the pupil response to the GCS score increased the information yield. The performance of the simple GCS-P was similar to the performance of more complex methods of evaluating traumatic brain damage. The relationship between decreases in the GCS-P and deteriorating outcome was seen across the complete range of possible scores. The additional 2 lowest points offered by the GCS-Pupils scale (GCS-P 1 and 2) extended the information about injury severity from a mortality rate of 51% and an unfavorable outcome rate of 70% at GCS score 3 to a mortality rate of 74% and an unfavorable outcome rate of 90% at GCS-P 1. The paradoxical finding that GCS score 4 was associated with a worse outcome than GCS score 3 was not seen when using the GCS-P. CONCLUSIONS A simple arithmetic combination of the GCS score and pupillary response, the GCS-P, extends the information provided about patient outcome to an extent comparable to that obtained using more complex methods. The greater range of injury severities that are identified and the smoothness of the stepwise pattern of outcomes across the range of scores may be useful in evaluating individual patients and identifying patient subgroups. The GCS-P may be a useful platform onto which information about other key prognostic features can be added in a simple format likely to be useful in clinical practice.

Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury.

PubMed

Brenner, Megan; Stein, Deborah M; Hu, Peter F; Aarabi, Bizhan; Sheth, Kevin; Scalea, Thomas M

2012-05-01

Vital signs, particularly blood pressure, are often manipulated to maximize perfusion and optimize recovery from severe traumatic brain injury (sTBI). We investigated the utility of automated continuously recorded vital signs to predict outcomes after sTBI. Sixty patients with head Abbreviated Injury Scale score ≥ 3, age >14 years, "isolated" TBI, and need for intracranial pressure monitoring were prospectively enrolled at a single, large urban tertiary care facility. Outcome was measured by mortality and extended Glasgow Outcome Scale (GOSE) at 12 months. Continuous, automated, digital data were collected every 6 seconds for 72 hours after admission, and 5-minute means of systolic blood pressure (SBP) were recorded. We calculated SBP as pressure × time dose (PTD) to describe the cumulative amplitude and duration of episodes above and below clinical thresholds. The extent and duration of the insults were calculated as percent time (%time), PTD, and PTD per day (PTD/D) of defined thresholds (SBP: <90 mm Hg, <100 mm Hg, <110 mm Hg, and <120 mm Hg; mean arterial pressure: <60 mm Hg and <70 mm Hg; heart rate: >100 bpm and >120 bpm; and SpO(2): <88% and <92%) for the first 12 hours, 24 hours, and 48 hours of intensive care unit admission. We analyzed their ability to predict mortality and GOSE by receiver operator characteristics. Mean age was 33.9 (range, 16-83) years, mean admission Glasgow Coma Scale score 6.4 ± 3, and mean head Abbreviated Injury Scale score 4.2 ± 0.72. The 30-day mortality rate was 13.3%. Of the 45 patients in whom GOSE at 12 months was available, 28 (62%) had good neurologic outcomes (GOSE score >4). Traditional markers of poor outcome (admission SBP, admission Glasgow Coma Scale, and Marshall score) were not different between groups with good or poor outcome. PTD, PTD/D, and %time SBP <110 mm Hg and SBP <120 mm Hg predicted mortality at 12 hours, 24 hours, and 48 hours (p < 0.04). Percent time SBP <110 mm Hg in the first 24 hours was predictive of 12-month GOSE (p = 0.02). PTD/D SBP <120 mm Hg in the first 24 hours and PTD and PTD/D in the first 48 hours were also predictive of 12-month GOSE (p < 0.05). Within the first 48 hours of intensive care unit admission, hypotension was found to be predictive of mortality and functional outcomes at higher thresholds than traditionally defined. Systemic blood pressure targets closer to 120 mm Hg may be more efficacious in minimizing secondary insults and particularly useful in settings without invasive intracranial monitoring capabilities. III, prognostic study.

Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury.

PubMed

Stein, Deborah M; Hu, Peter F; Brenner, Megan; Sheth, Kevin N; Liu, Keng-Hao; Xiong, Wei; Aarabi, Bizhan; Scalea, Thomas M

2011-08-01

Management strategies after severe traumatic brain injury (TBI) target prevention and treatment of intracranial hypertension (ICH) and cerebral hypoperfusion (CH). We have previously established that continuous automated recordings of vital signs (VS) are more highly correlated with outcome than manual end-hour recordings. One potential benefit of automated vital sign data capture is the ability to detect brief episodes of ICH and CH. The purpose of this study was to establish whether a relationship exists between brief episodes of ICH and CH and outcome after severe TBI. Patients at the R Adams Cowley Shock Trauma Center were prospectively enrolled over a 2-year period. Inclusion criteria were as follows: age >14 years, admission within the first 6 hours after injury, Glasgow Coma Scale score <9 on admission, and placement of a clinically indicated ICP monitor. From high-resolution automated VS data recording system, we calculated the 5-minute means of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Brain Trauma Index (BTI = CPP/ICP). Patients were stratified by mortality and 6-month Extended Glasgow Outcome Score (GOSE). Sixty subjects were enrolled with a mean admission Glasgow Coma Scale score of 6.4 ± 3.1, a mean Head Abbreviated Injury Severity Scale score of 4.2 ± 0.7, and a mean Marshall CT score of 2.5 ± 0.9. Significant differences in the mean number of brief episodes of CPP <50 and BTI <2 in patients with a GOSE 1-4 versus GOSE 5-8 (9.4 vs. 4.7, p = 0.02 and 9.3 vs. 4.9, p = 0.03) were found. There were significantly more mean brief episodes per day of ICP >30 (0.52 vs. 0.29, p = 0.02), CPP <50 (0.65 vs. 0.28, p < 0.001), CPP <60 (1.09 vs. 0.7, p = 0.03), BTI <2 (0.66 vs. 0.31, p = 0.002), and BTI <3 (1.1 vs. 0.64, p = 0.01) in those patients with GOSE 1-4. Number of brief episodes of CPP <50, CPP <60, BTI <2, and BTI <3 all demonstrated high predictive power for unfavorable functional outcome (area under the curve = 0.65-0.75, p < 0.05). This study demonstrates that the number of brief 5-minute episodes of ICH and CH is predictive of poor outcome after severe TBI. This finding has important implications for management paradigms which are currently targeted to treatment rather than prevention of ICH and CH. This study demonstrates that these brief episodes may play a significant role in outcome after severe TBI.

Diagnostic Simulations of the Lunar Exosphere using Coma and Tail

NASA Astrophysics Data System (ADS)

Lee, Dong Wook; Kim, Sang J.

2017-10-01

The characteristics of the lunar exosphere can be constrained by comparing simulated models with observational data of the coma and tail (Lee et al., JGR, 2011); and thus far a few independent approaches on this issue have been performed and presented in the literature. Since there are two-different observational constraints for the lunar exosphere, it is interesting to find the best exospheric model that can account for the observed characteristics of the coma and tail. Considering various initial conditions of different sources and space weather, we present preliminary time-dependent simulations between the initial and final stages of the development of the lunar tail. Based on an updated 3-D model, we are planning to conduct numerous simulations to constrain the best model parameters from the coma images obtained from coronagraph observations supported by a NASA monitoring program (Morgan, Killen, and Potter, AGU, 2015) and future tail data.

Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.

PubMed

Vavilala, Monica S; Kernic, Mary A; Wang, Jin; Kannan, Nithya; Mink, Richard B; Wainwright, Mark S; Groner, Jonathan I; Bell, Michael J; Giza, Christopher C; Zatzick, Douglas F; Ellenbogen, Richard G; Boyle, Linda Ng; Mitchell, Pamela H; Rivara, Frederick P

2014-10-01

The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. Retrospective multicenter cohort study. Five regional pediatric trauma centers affiliated with academic medical centers. Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. None. Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86). Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.

Efficacy and safety of key hole craniotomy for the evacuation of spontaneous cerebellar hemorrhage.

PubMed

Tokimura, Hiroshi; Tajitsu, Kenichiro; Taniguchi, Ayumi; Yamahata, Hitoshi; Tsuchiya, Masahiro; Takayama, Kenji; Shinsato, Tomomi; Arita, Kazunori

2010-01-01

The efficacy and safety of cerebellar hemorrhage evacuation by key hole craniotomy and the importance of thorough evacuation and irrigation of the hematoma in the fourth ventricle to resolve obstructive hydrocephalus were assessed in 23 patients with spontaneous cerebellar hemorrhage (SCH) greater than 3 cm or with brainstem compression and hydrocephalus. A 5-cm elongated S-shaped scalp incision was made, and a 3-cm key hole craniotomy was performed over a cerebellar convexity area. The hematoma was immediately evacuated through a small corticotomy. The hematoma in the fourth ventricle was gently removed through the hematoma cavity, followed by thorough saline irrigation to release obstructive hydrocephalus. Patients classified retrospectively into favorable and poor outcome groups using the Glasgow Outcome Scale (GOS) scores of 4-5 vs. 1-3 showed significant differences with respect to the preoperative Glasgow Coma Scale, hematoma size and volume, and brainstem compression. Only 2 of the 23 patients required ventricular drainage and no postoperative complications were recorded. Patients treated by experienced and inexperienced surgeons showed no significant differences in the hematoma evacuation rate, postoperative GOS, and interval from skin incision to start of hematoma evacuation. Our simplified method of key hole craniotomy to treat SCH was less invasive but easy to perform, as even inexperienced neurosurgeons could obtain good surgical results. Thorough cleaning of the fourth ventricle minimized the necessity for ventricular drainage.

Monitoring of Intracranial Pressure in Meningitis.

PubMed

Depreitere, Bart; Bruyninckx, Dominike; Güiza, Fabian

2016-01-01

The literature on intracranial pressure (ICP) monitoring in meningitis is limited to case reports and a handful of descriptive series. The aim of this study is to investigate relationships among ICP, cerebral perfusion pressure (CPP), and outcome in meningitis and to identify whether ICP affected clinical decisions. Between 1999 and 2011, a total of 17 patients with meningitis underwent ICP monitoring at the University Hospitals Leuven. Charts were reviewed for clinical history, ICP/CPP data, imaging findings, and Glasgow Outcome Scale score. Univariate correlations were computed for outcome and ICP/CPP variables, computed tomography characteristics, and Corticosteroid Randomization After Significant Head Injury outcome model variables. Treatment decisions were assessed regarding whether or not they were based on ICP. At drain placement, Glasgow Coma Scale scores showed a median of 8 (range 3-12). Six of 17 patients had either one or two nonreactive pupils. Significant correlations with outcome were found for the highest documented ICP value (r = -0.70), the number of episodes when CPP <50 mmHg (r =-0.50), the lowest documented CPP value (r = 0.61), and pupil reactivity (r = 0.57). Treatment was influenced by ICP in all patients. The results support the notion that in meningitis high ICP and low CPP represent secondary insults. The poor condition of the patients illustrates that the level of suspicion for increased ICP in meningitis may not be high enough.

Frontal assessment battery (FAB) performance following traumatic brain injury hospitalized in an acute care setting.

PubMed

Rojas, Natalia; Laguë-Beauvais, Maude; Belisle, Arielle; Lamoureux, Julie; AlSideiri, Ghusn; Marcoux, Judith; Maleki, Mohammed; Alturki, Abdulrahman Y; Anchouche, Sonia; Alquraini, Hanan; Feyz, Mitra; Guise, Elaine de

2018-01-19

The Frontal Assessment Battery (FAB) has been shown to be useful in several clinical settings. The aim of the present study was to examine the performance of patients with traumatic brain injury (TBI) on the FAB and to predict their acute outcome. The FAB was administered to 89 patients with mild (27 = uncomplicated and 39 = complicated) and moderate (n = 23) TBI during hospitalization in an acute care setting. The length of stay in days (LOS), Glasgow Outcome Scale-Revised score (GOSE) and Disability Rating Scale (DRS) score were collected. Results showed no significant differences between the three groups on the FAB score, but age and education were significantly associated with the FAB score. Parietal lesions were associated with lower total FAB score, and with the Similarities, Motor series and Conflicting instructions subscales, while frontal lesions were associated with lower performance on the Motor series and Conflicting instructions subscales. Total FAB score was significantly correlated with all outcome measures, and together the FAB total score and the Glasgow Coma Scale (GCS) score explained 30.8% of the variance in the DRS score. The FAB may be useful clinically to acutely assess frontal and parietal lobe functions at bedside in patients with TBI and, in combination with the GCS score to measure TBI severity, can enable clinicians to predict early outcome.

Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre.

PubMed

Chen, Lei; Bao, Yinghui; Liang, Yumin; Wang, Yong; Jiang, Jiyao

2016-01-01

To retrospectively analyse the surgical management and outcomes of non-missile open head injuries (NMOHI). Forty-four patients who suffered from NMOHI were included. The Glasgow outcome score (GOS), computed tomography (CT), aetiology and outcomes and complications at discharge and during a 6-month follow-up were analysed. All patients underwent debridement. Intracranial haematoma evacuation, decompressive craniectomy (DC) or replacement were performed. Motor vehicle accident and struck by/against were the most common causes (43.2% each). At admission, 33 patients had Glasgow coma scores (GCS) > 8 and 27 of them had a GCS score of > 13. Mean follow-up was 8.7 ± 4.3 months. All patients underwent debridement, 20 underwent bone fracture replacement and 27 underwent haematoma evacuation; 11 patients underwent haematoma evacuation and DC and one had bilateral DC. Twenty-seven patients showed good recovery; 11 patients had moderate disability; three patients had severe disability; and three patients died. After 6 months, 32 patients had good recovery and the morbidity of severe disability had decreased to 13.6%. Thirteen patients developed intracranial infection. Post-traumatic epilepsy and hydrocephalus was detected in three patients. Cerebrospinal fluid fistula was found in five patients. Only one patient developed a brain abscess after 6 months. NMOHI yielded satisfactory recovery and achieved good outcomes.

Multivariate outcome prediction in traumatic brain injury with focus on laboratory values.

PubMed

Nelson, David W; Rudehill, Anders; MacCallum, Robert M; Holst, Anders; Wanecek, Michael; Weitzberg, Eddie; Bellander, Bo-Michael

2012-11-20

Traumatic brain injury (TBI) is a major cause of morbidity and mortality. Identifying factors relevant to outcome can provide a better understanding of TBI pathophysiology, in addition to aiding prognostication. Many common laboratory variables have been related to outcome but may not be independent predictors in a multivariate setting. In this study, 757 patients were identified in the Karolinska TBI database who had retrievable early laboratory variables. These were analyzed towards a dichotomized Glasgow Outcome Scale (GOS) with logistic regression and relevance vector machines, a non-linear machine learning method, univariately and controlled for the known important predictors in TBI outcome: age, Glasgow Coma Score (GCS), pupil response, and computed tomography (CT) score. Accuracy was assessed with Nagelkerke's pseudo R². Of the 18 investigated laboratory variables, 15 were found significant (p<0.05) towards outcome in univariate analyses. In contrast, when adjusting for other predictors, few remained significant. Creatinine was found an independent predictor of TBI outcome. Glucose, albumin, and osmolarity levels were also identified as predictors, depending on analysis method. A worse outcome related to increasing osmolarity may warrant further study. Importantly, hemoglobin was not found significant when adjusted for post-resuscitation GCS as opposed to an admission GCS, and timing of GCS can thus have a major impact on conclusions. In total, laboratory variables added an additional 1.3-4.4% to pseudo R².

Brain pathology after mild traumatic brain injury: an exploratory study by repeated magnetic resonance examination.

PubMed

Lannsjö, Marianne; Raininko, Raili; Bustamante, Mariana; von Seth, Charlotta; Borg, Jörgen

2013-09-01

To explore brain pathology after mild traumatic brain injury by repeated magnetic resonance examination. A prospective follow-up study. Nineteen patients with mild traumatic brain injury presenting with Glasgow Coma Scale (GCS) 14-15. The patients were examined on day 2 or 3 and 3-7 months after the injury. The magnetic resonance protocol comprised conventional T1- and T2-weighted sequences including fluid attenuated inversion recovery (FLAIR), two susceptibility-weighted sequences to reveal haemorrhages, and diffusion-weighted sequences. Computer-aided volume comparison was performed. Clinical outcome was assessed by the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Hospital Anxiety and Depression Scale (HADS) and Glasgow Outcome Scale Extended (GOSE). At follow-up, 7 patients (37%) reported ≥  3 symptoms in RPQ, 5 reported some anxiety and 1 reported mild depression. Fifteen patients reported upper level of good recovery and 4 patients lower level of good recovery (GOSE 8 and 7, respectively). Magnetic resonance pathology was found in 1 patient at the first examination, but 4 patients (21%) showed volume loss at the second examination, at which 3 of them reported < 3 symptoms and 1 ≥ 3 symptoms, all exhibiting GOSE scores of 8. Loss of brain volume, demonstrated by computer-aided magnetic resonance imaging volumetry, may be a feasible marker of brain pathology after mild traumatic brain injury.

A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients.

PubMed

Lin, Chien-Min; Lin, Ming-Chin; Huang, Sheng-Jean; Chang, Cheng-Kuei; Chao, Dan-Ping; Lui, Tai-Ngar; Ma, Hsin-I; Liu, Ming-Ying; Chung, Wen-Yuh; Shih, Yang-Hsin; Tsai, Shin-Han; Chiou, Hung-Yi; Lin, Mau-Roung; Jen, Sen-Li; Wei, Li; Wu, Chung-Che; Lin, En-Yuan; Liao, Kuo-Hsing; Chiang, Yung-Hsiao; Chiu, Wen-Ta; Lin, Jia-Wei

2015-01-01

The purpose of this study was to compare the effect of PbtO2-guided therapy with traditional intracranial pressure- (ICP-) guided treatment on the management of cerebral variables, therapeutic interventions, survival rates, and neurological outcomes of moderate and severe traumatic brain injury (TBI) patients. From 2009 to 2010, TBI patients with a Glasgow coma scale <12 were recruited from 6 collaborative hospitals in northern Taiwan, excluding patients with severe systemic injuries, fixed and dilated pupils, and other major diseases. In total, 23 patients were treated with PbtO2-guided management (PbtO2 > 20 mmHg), and 27 patients were treated with ICP-guided therapy (ICP < 20 mmHg and CPP > 60 mmHg) in the neurosurgical intensive care unit (NICU); demographic characteristics were similar across groups. The survival rate in the PbtO2-guided group was also significantly increased at 3 and 6 months after injury. Moreover, there was a significant correlation between the PbtO2 signal and Glasgow outcome scale-extended in patients from 1 to 6 months after injury. This finding demonstrates that therapy directed by PbtO2 monitoring is valuable for the treatment of patients with moderate and severe TBI and that increasing PaO2 to 150 mmHg may be efficacious for preventing cerebral hypoxic events after brain trauma.

Out-of-Hospital Hypertonic Resuscitation Following Severe Traumatic Brain Injury: A Randomized Controlled Trial

PubMed Central

Bulger, Eileen M.; May, Susanne; Brasel, Karen J.; Schreiber, Martin; Kerby, Jeffrey D.; Tisherman, Samuel A.; Newgard, Craig; Slutsky, Arthur; Coimbra, Raul; Emerson, Scott; Minei, Joseph P.; Bardarson, Berit; Kudenchuk, Peter; Baker, Andrew; Christenson, Jim; Idris, Ahamed; Davis, Daniel; Fabian, Timothy C.; Aufderheide, Tom P.; Callaway, Clifton; Williams, Carolyn; Banek, Jane; Vaillancourt, Christian; van Heest, Rardi; Sopko, George; Hata, J. Steven; Hoyt, David B.

2010-01-01

Context Hypertonic fluids restore cerebral perfusion with reduced cerebral edema and modulate inflammatory response to reduce subsequent neuronal injury and thus have potential benefit in resuscitation of patients with traumatic brain injury (TBI). Objective To determine whether out-of-hospital administration of hypertonic fluids improves neurologic outcome following severe TBI. Design, Setting, and Participants Multicenter, double-blind, randomized, placebo-controlled clinical trial involving 114 North American emergency medical services agencies within the Resuscitation Outcomes Consortium, conducted between May 2006 and May 2009 among patients 15 years or older with blunt trauma and a prehospital Glasgow Coma Scale score of 8 or less who did not meet criteria for hypovolemic shock. Planned enrollment was 2122 patients. Intervention A single 250-mL bolus of 7.5% saline/6% dextran 70 (hypertonic saline/dextran), 7.5% saline (hypertonic saline), or 0.9% saline (normal saline) initiated in the out-of-hospital setting. Main Outcome Measure Six-month neurologic outcome based on the Extended Glasgow Outcome Scale (GOSE) (dichotomized as >4 or ≤4). Results The study was terminated by the data and safety monitoring board after randomization of 1331 patients, having met prespecified futility criteria. Among the 1282 patients enrolled, 6-month outcomes data were available for 1087 (85%). Baseline characteristics of the groups were equivalent. There was no difference in 6-month neurologic outcome among groups with regard to proportions of patients with severe TBI (GOSE ≤4) (hypertonic saline/dextran vs normal saline: 53.7% vs 51.5%; difference, 2.2% [95% CI, −4.5% to 9.0%]; hypertonic saline vs normal saline: 54.3% vs 51.5%; difference, 2.9% [95% CI, −4.0% to 9.7%]; P=.67). There were no statistically significant differences in distribution of GOSE category or Disability Rating Score by treatment group. Survival at 28 days was 74.3% with hypertonic saline/dextran, 75.7% with hypertonic saline, and 75.1% with normal saline (P=.88). Conclusion Among patients with severe TBI not in hypovolemic shock, initial resuscitation with either hypertonic saline or hypertonic saline/dextran, compared with normal saline, did not result in superior 6-month neurologic outcome or survival. Trial Registration clinicaltrials.gov Identifier: NCT00316004 PMID:20924011

ULTRA-COMPACT DWARFS IN THE COMA CLUSTER

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chiboucas, Kristin; Tully, R. Brent; Marzke, R. O.

2011-08-20

We have undertaken a spectroscopic search for ultra-compact dwarf galaxies (UCDs) in the dense core of the dynamically evolved, massive Coma cluster as part of the Hubble Space Telescope/Advanced Camera for Surveys (HST/ACS) Coma Cluster Treasury Survey. UCD candidates were initially chosen based on color, magnitude, degree of resolution within the ACS images, and the known properties of Fornax and Virgo UCDs. Follow-up spectroscopy with Keck/Low-Resolution Imaging Spectrometer confirmed 27 candidates as members of the Coma cluster, a success rate >60% for targeted objects brighter than M{sub R} = -12. Another 14 candidates may also prove to be Coma members,more » but low signal-to-noise spectra prevent definitive conclusions. An investigation of the properties and distribution of the Coma UCDs finds these objects to be very similar to UCDs discovered in other environments. The Coma UCDs tend to be clustered around giant galaxies in the cluster core and have colors/metallicity that correlate with the host galaxy. With properties and a distribution similar to that of the Coma cluster globular cluster population, we find strong support for a star cluster origin for the majority of the Coma UCDs. However, a few UCDs appear to have stellar population or structural properties which differentiate them from the old star cluster populations found in the Coma cluster, perhaps indicating that UCDs may form through multiple formation channels.« less

Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency.

PubMed

Lee, Christopher H; Wira, Charles R

2009-10-01

Myxedema coma is the most lethal manifestation of hypothyroidism. It is a true medical emergency and can result in profound hemodynamic instability and airway compromise. Myxedema coma currently remains a diagnostic challenge due to the rarity of cases seen today, and failure to promptly initiate therapy with replacement thyroid hormone can be fatal. As thyroid hormone therapy can take days or weeks to reverse the manifestations of myxedema coma, interim supportive therapy is critical while awaiting clinical improvement. Some patients will require endotracheal intubation in the emergency department (ED), and physicians should be aware that unanticipated posterior pharyngeal edema in myxedema coma could severely complicate airway management. Although mechanical ventilation is a well-described adjunctive therapy for myxedema coma, reports of the potential difficulty in securing a definitive airway in these patients are rare. We describe a case of an unidentified woman who presented to the ED with myxedema coma requiring urgent endotracheal intubation and was found to have extensive posterior pharyngeal angioedema inconsistent with her relatively benign external examination. This case highlights the typical features of myxedema coma and discusses our necessity for a rescue device in definitive endotracheal tube placement. Emergency physicians should anticipate a potentially difficult airway in all myxedema coma patients regardless of the degree of external facial edema present.

Prognostic accuracy of five simple scales in childhood bacterial meningitis.

PubMed

Pelkonen, Tuula; Roine, Irmeli; Monteiro, Lurdes; Cruzeiro, Manuel Leite; Pitkäranta, Anne; Kataja, Matti; Peltola, Heikki

2012-08-01

In childhood acute bacterial meningitis, the level of consciousness, measured with the Glasgow coma scale (GCS) or the Blantyre coma scale (BCS), is the most important predictor of outcome. The Herson-Todd scale (HTS) was developed for Haemophilus influenzae meningitis. Our objective was to identify prognostic factors, to form a simple scale, and to compare the predictive accuracy of these scales. Seven hundred and twenty-three children with bacterial meningitis in Luanda were scored by GCS, BCS, and HTS. The simple Luanda scale (SLS), based on our entire database, comprised domestic electricity, days of illness, convulsions, consciousness, and dyspnoea at presentation. The Bayesian Luanda scale (BLS) added blood glucose concentration. The accuracy of the 5 scales was determined for 491 children without an underlying condition, against the outcomes of death, severe neurological sequelae or death, or a poor outcome (severe neurological sequelae, death, or deafness), at hospital discharge. The highest accuracy was achieved with the BLS, whose area under the curve (AUC) for death was 0.83, for severe neurological sequelae or death was 0.84, and for poor outcome was 0.82. Overall, the AUCs for SLS were ≥0.79, for GCS were ≥0.76, for BCS were ≥0.74, and for HTS were ≥0.68. Adding laboratory parameters to a simple scoring system, such as the SLS, improves the prognostic accuracy only little in bacterial meningitis.

Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 as Outcome Predictors in Traumatic Brain Injury.

PubMed

Takala, Riikka S K; Posti, Jussi P; Runtti, Hilkka; Newcombe, Virginia F; Outtrim, Joanne; Katila, Ari J; Frantzén, Janek; Ala-Seppälä, Henna; Kyllönen, Anna; Maanpää, Henna-Riikka; Tallus, Jussi; Hossain, Md Iftakher; Coles, Jonathan P; Hutchinson, Peter; van Gils, Mark; Menon, David K; Tenovuo, Olli

2016-03-01

Biomarkers ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) may help detect brain injury, assess its severity, and improve outcome prediction. This study aimed to evaluate the prognostic value of these biomarkers during the first days after brain injury. Serum UCH-L1 and GFAP were measured in 324 patients with traumatic brain injury (TBI) enrolled in a prospective study. The outcome was assessed using the Glasgow Outcome Scale (GOS) or the extended version, Glasgow Outcome Scale-Extended (GOSE). Patients with full recovery had lower UCH-L1 concentrations on the second day and patients with favorable outcome had lower UCH-L1 concentrations during the first 2 days compared with patients with incomplete recovery and unfavorable outcome. Patients with full recovery and favorable outcome had significantly lower GFAP concentrations in the first 2 days than patients with incomplete recovery or unfavorable outcome. There was a strong negative correlation between outcome and UCH-L1 in the first 3 days and GFAP levels in the first 2 days. On arrival, both UCH-L1 and GFAP distinguished patients with GOS score 1-3 from patients with GOS score 4-5, but not patients with GOSE score 8 from patients with GOSE score 1-7. For UCH-L1 and GFAP to predict unfavorable outcome (GOS score ≤ 3), the area under the receiver operating characteristic curve was 0.727, and 0.723, respectively. Neither UCHL-1 nor GFAP was independently able to predict the outcome when age, worst Glasgow Coma Scale score, pupil reactivity, Injury Severity Score, and Marshall score were added into the multivariate logistic regression model. GFAP and UCH-L1 are significantly associated with outcome, but they do not add predictive power to commonly used prognostic variables in a population of patients with TBI of varying severities. Copyright © 2016 Elsevier Inc. All rights reserved.

Serum neuron-specific enolase as an early predictor of delayed neuropsychiatric sequelae in patients with acute carbon monoxide poisoning.

PubMed

Cha, Y S; Kim, H; Do, H H; Kim, H I; Kim, O H; Cha, K-C; Lee, K H; Hwang, S O

2018-03-01

Delayed onset of neuropsychiatric symptoms after apparent recovery from acute carbon monoxide (CO) poisoning has been described as delayed neuropsychiatric sequelae (DNS). To date, there have been no studies on the utility of serum neuron-specific enolase (NSE), a marker of neuronal cell damage, as a predictive marker of DNS in acute CO poisoning. This retrospective observational study was performed on adult patients with acute CO poisoning consecutively treated over a 9-month period. Serum NSE was measured after emergency department arrival, and patients were divided into two groups. The DNS group comprised patients with delayed sequelae, while the non-DNS group included patients with none of these sequelae. A total of 98 patients with acute CO poisoning were enrolled in this study. DNS developed in eight patients. The median NSE value was significantly higher in the DNS group than in the non-DNS group. There was a statistical difference between the non-DNS group and the DNS group in terms of CO exposure time, Glasgow Coma Scale (GCS), loss of consciousness, creatinine kinase, and troponin I. GCS and NSE were the early predictors of development of DNS. The area under the curve according to the receiver operating characteristic curves of GCS, serum NSE, and GCS combined with serum NSE were 0.922, 0.836, and 0.969, respectively. In conclusion, initial GCS and NSE served as early predictors of development of DNS. Also, NSE might be a useful additional parameter that could improve the prediction accuracy of initial GCS.

Severe carbon monoxide poisoning complicated by hypothermia: a case report.

PubMed

Kamijo, Yoshito; Ide, Toshimitsu; Ide, Ayako; Soma, Kazui

2011-03-01

It is proposed that the significant elevation of interleukin-6 (>400 pg/mL) in cerebrospinal fluid during the early phase of carbon monoxide poisoning may be a predictive biomarker for the development of delayed encephalopathy. A 52-year-old man presented to the emergency department with severe carbon monoxide poisoning. On arrival, the patient was comatose with decorticate rigidity (Glasgow Coma Scale, E1V1M3). His core body temperature, measured in the urinary bladder, was 32.4°C. Laboratory blood analysis revealed elevated CO-Hb (36.0%) and metabolic acidosis with elevated lactate (pH 7.081; base excess [BE], -19.2 mmol/L; HCO3, -9.8 mmol/L; lactate, 168.8 mg/dL). After treatment with hyperbaric oxygen and several different rewarming techniques, he became alert and his core body temperature increased to normal. Interleukin-6 in cerebrospinal fluid at 5.5 hours after his last exposure to carbon monoxide was significantly elevated (752 pg/mL). However, he did not develop delayed encephalopathy. In this case, hypothermia in the range of therapeutic hypothermia (32°C to 34°C) may have suppressed formation of reactive oxygen species and subsequent lipid peroxydation, preventing the development of delayed encephalopathy. Therapeutic hypothermia initiated soon after the last exposure to carbon monoxide may be an effective prophylactic method for preventing the development of delayed encephalopathy.

Neurogenic fever after traumatic brain injury: an epidemiological study

PubMed Central

Thompson, H; Pinto-Martin, J; Bullock, M

2003-01-01

Objectives: To determine the incidence of neurogenic fever (NF) in a population of patients in the acute phase following severe traumatic brain injury (TBI); to identify factors associated with the development of NF following severe TBI in adults. Methods: Charts of patients admitted from 1996 to 1999 with severe TBI at a large, urban mid-Atlantic teaching hospital were retrospectively evaluated based on diagnostic criteria for each episode of hyperthermia to determine the diagnosis of NF. Data were collected regarding mechanism and area of injury, severity of injury, and demographic factors to determine potential predictors of NF. Results: Diffuse axonal injury (DAI) (OR 9.06, 95% CI 0.99 to 82.7) and frontal lobe injury of any type (OR 6.68, 95% CI 1.1 to 39.3) are independently predictive of an increased risk of development of NF following severe TBI. The presence of a skull fracture and lower initial Glasgow Coma Score (GCS) were individual predictors of development of NF, but did not contribute to the final model. Conclusions: These findings examine known and novel risk factors for this phenomenon in comparison to previously published literature on NF. A set of predictor variables was identified to help clinicians target patients at high risk for development of NF following severe TBI. It is hoped that earlier diagnosis and appropriate intervention for fever in the TBI patient will lead to improved outcomes. PMID:12700304

Early Rebleeding after Brain Arteriovenous Malformation Rupture, Clinical Impact and Predictive Factors: A Monocentric Retrospective Cohort Study.

PubMed

Shotar, Eimad; Pistocchi, Silvia; Haffaf, Idriss; Bartolini, Bruno; Jacquens, Alice; Nouet, Aurélien; Chiras, Jacques; Degos, Vincent; Sourour, Nader-Antoine; Clarençon, Frédéric

2017-01-01

Brain arteriovenous malformations (BAVMs) are a leading cause of intracranial hemorrhage in young adults. This study aimed to identify individual predictive factors of early rebleeding after BAVM rupture and determine its impact on prognosis. Early rebleeding was defined as a spontaneous intracranial hemorrhage within 30 days of BAVM rupture in patients with nonobliterated BAVMs. One hundred fifty one patients with 158 BAVM hemorrhagic events admitted to a tertiary care center during 14 years were included. Univariate followed by multivariate logistic regression was performed to assess the impact of early rebleeding on in-hospital mortality and modified Rankin Scale (mRS) score beyond 3 months and to identify independent predictors of early rebleeding. Eight early rebleeding events were observed, 6 of which occurred during the first 7 days. Early rebleeding was independently and significantly associated with poor outcome (mRS ≥3 beyond 3 months, p = 0.004) but not with in-hospital mortality (p = 0.9). Distal flow-related aneurysms (p = 0.009) and altered consciousness with a Glasgow coma scale score of 3 (p = 0.01) were independently associated with early rebleeding. Early rebleeding is a severe complication that can occur after BAVM-related hemorrhage. Distal flow-related aneurysms and initial altered consciousness are associated with early rebleeding. © 2017 S. Karger AG, Basel.

Examining acute rehabilitation outcomes for children with total functional dependence after traumatic brain injury: a pilot study.

PubMed

Kramer, Megan E; Suskauer, Stacy J; Christensen, James R; DeMatt, Ellen J; Trovato, Melissa K; Salorio, Cynthia F; Slomine, Beth S

2013-01-01

To examine in a pilot cohort factors associated with functional outcome at discharge and 3-month follow-up after discharge from inpatient rehabilitation in children with severe traumatic brain injury (TBI) who entered rehabilitation with the lowest level of functional skills. Thirty-nine children and adolescents (3-18 years old) who sustained a severe TBI and had the lowest possible rating at rehabilitation admission on the Functional Independence Measure for Children (total score = 18). Retrospective review of data collected as part of routine clinical care. At discharge, 59% of the children were partially dependent for basic activities, while 41% remained dependent for basic activities. Initial Glasgow Coma Scale score, time to follow commands, and time from injury to rehabilitation admission were correlated with functional status at discharge. Time to follow commands and time from injury to rehabilitation admission were correlated with functional status at 3-month follow-up. Changes in functional status during the first few weeks of admission were associated with functional status at discharge and follow-up. Even children with the most severe brain injuries, who enter rehabilitation completely dependent for all daily activities, have the potential to make significant gains in functioning by discharge and in the following few months. Assessment of functional status early in the course of rehabilitation contributes to the ability to predict outcome from severe TBI.

Consequences of Underestimating Impalement Bicycle Handlebar Injuries in Children.

PubMed

Ramos-Irizarry, Carmen T; Swain, Shakeva; Troncoso-Munoz, Samantha; Duncan, Malvina

Impalement bicycle handlebar trauma injuries are rare; however, on initial assessment, they have the potential of being underestimated. We reviewed our prospective trauma database of 3,894 patients for all bicycle injuries from January 2010 to May 2015. Isolated pedal bike injuries were reported in 2.6% (N = 101) of the patients who were admitted to the trauma service. Fifteen patients suffered direct handlebar trauma. Patients were grouped into blunt trauma (n = 12) and impalement trauma (n = 3). We examined gender, age, injury severity score (ISS), Glasgow Coma Scale score, use of protective devices, need for surgical intervention, need for intensive care (ICU), and hospital length of stay. Mean age was 9.6 years. All children with penetrating injuries were males. Mean ISS was less than 9 in both groups. None of the children were wearing bicycle helmets. Three patients who sustained blunt injuries required ICU care due to associated injuries. All of the children with impalement injuries required several surgical interventions. These injuries included a traumatic direct inguinal hernia, a medial groin and thigh laceration with resultant femoral hernia, and a lateral deep thigh laceration. Impalement bicycle handlebar injuries must be thoroughly evaluated, with a similar importance given to blunt injuries. A high index of suspicion must be maintained when examining children with handlebar impalement injuries, as they are at risk for missed or underestimation of their injuries.

Developing Physiologic Models for Emergency Medical Procedures Under Microgravity

NASA Technical Reports Server (NTRS)

Parker, Nigel; O'Quinn, Veronica

2012-01-01

Several technological enhancements have been made to METI's commercial Emergency Care Simulator (ECS) with regard to how microgravity affects human physiology. The ECS uses both a software-only lung simulation, and an integrated mannequin lung that uses a physical lung bag for creating chest excursions, and a digital simulation of lung mechanics and gas exchange. METI s patient simulators incorporate models of human physiology that simulate lung and chest wall mechanics, as well as pulmonary gas exchange. Microgravity affects how O2 and CO2 are exchanged in the lungs. Procedures were also developed to take into affect the Glasgow Coma Scale for determining levels of consciousness by varying the ECS eye-blinking function to partially indicate the level of consciousness of the patient. In addition, the ECS was modified to provide various levels of pulses from weak and thready to hyper-dynamic to assist in assessing patient conditions from the femoral, carotid, brachial, and pedal pulse locations.

Developing Physiologic Models for Emergency Medical Procedures Under Microgravity

NASA Technical Reports Server (NTRS)

Parker, Nigel; OQuinn, Veronica

2012-01-01

Several technological enhancements have been made to METI's commercial Emergency Care Simulator (ECS) with regard to how microgravity affects human physiology. The ECS uses both a software-only lung simulation, and an integrated mannequin lung that uses a physical lung bag for creating chest excursions, and a digital simulation of lung mechanics and gas exchange. METI's patient simulators incorporate models of human physiology that simulate lung and chest wall mechanics, as well as pulmonary gas exchange. Microgravity affects how O2 and CO2 are exchanged in the lungs. Procedures were also developed to take into affect the Glasgow Coma Scale for determining levels of consciousness by varying the ECS eye-blinking function to partially indicate the level of consciousness of the patient. In addition, the ECS was modified to provide various levels of pulses from weak and thready to hyper-dynamic to assist in assessing patient conditions from the femoral, carotid, brachial, and pedal pulse locations.

Results of single burr hole drainage for acute subdural hematoma with non-reactive pupil.

PubMed

Yanagawa, Youichi; Sakamoto, Toshihisa

2012-01-01

To investigate the effects of emergency burr hole drainage for acute subdural hematoma (ASDH) with bilateral non-reactive pupils. A retrospective study was conducted by reviewing medical records from 1998 to 2007. Patients meeting the following criteria were included: 1) head injury with unconsciousness (Glasgow Coma Scale score 8); 2) bilateral non-reactive pupils on arrival; 3) ASDH with disappearance of basal cistern on computed tomography (CT); and 4) performance of emergency single burr hole drainage. Subjects were divided into survival and non-survival groups. Pupil size on the small side was significantly smaller in the survival group than in the non-survival group. All pupils on the small side in the survival group were 4 mm. Emergency burr hole drainage should still be considered in patients with ASDH showing bilateral non-reactive pupils and one pupil 4 mm.

Head Injuries in School-Age Children Who Play Golf.

PubMed

Reuter-Rice, Karin; Krebs, Madelyn; Eads, Julia K

2016-04-01

Traumatic brain injury (TBI) is the leading cause of death and disability in children. We conducted a prospective study, which examined injury characteristics and outcomes of school-age children of 5.0-15.0 years (N = 10) who were admitted to hospital for a TBI. This study evaluated the role of age, gender, the Glasgow Coma Scale, mechanisms and severity of injury, and functional outcomes. Seventy percent of the children sustained a TBI from a fall. We also found that playing golf was associated with 40% of the TBIs, with three (30%) children being unrestrained passengers in a moving golf cart and another one (10%) was struck by a golf club. Injury awareness could have benefited or prevented most injuries, and school nurses are in the best position to provide preventative practice education. In golf-centric communities, prevention of golf-related injuries should include education within the schools. © The Author(s) 2015.

Head Injuries in School-Age Children Who Play Golf

PubMed Central

Reuter-Rice, Karin; Krebs, Madelyn; Eads, Julia K.

2015-01-01

Traumatic brain injury (TBI) is the leading cause of death and disability in children. We conducted a prospective study, which examined injury characteristics and outcomes of school-age children of 5.0–15.0 years (N = 10) who were admitted to hospital for a TBI. This study evaluated the role of age, gender, the Glasgow Coma Scale, mechanisms and severity of injury, and functional outcomes. Seventy percent of the children sustained a TBI from a fall. We also found that playing golf was associated with 40% of the TBIs, with three (30%) children being unrestrained passengers in a moving golf cart and another one (10%) was struck by a golf club. Injury awareness could have benefited or prevented most injuries, and school nurses are in the best position to provide preventative practice education. In golf-centric communities, prevention of golf-related injuries should include education within the schools. PMID:25899097

Brain dead or not? CT angiogram yielding false-negative result on brain death confirmation.

PubMed

Johnston, Robyn; Kaliaperumal, Chandrasekaran; Wyse, Gerald; Kaar, George

2013-01-08

We describe a case of severe traumatic brain injury with multiple facial and skull fractures where CT angiogram (CTA) failed to yield a definite result of brain death as an ancillary test. A 28-year-old man was admitted following a road traffic accident with a Glasgow Coma Score (GCS) of 3/15 and fixed pupils. CT brain revealed uncal herniation and diffuse cerebral oedema with associated multiple facial and skull fractures. 72 h later, his clinical condition remained the same with high intracranial pressure refractory to medical management. Clinical confirmation on brain death was not feasible owing to facial injuries. A CTA, performed to determine brain perfusion, yielded a 'false-negative' result. Skull fractures have possibly led to venous prominence in the cortical and deep venous drainage system. This point needs to be borne in mind while considering CTA as an ancillary test to confirm brain death.

Neurosurgical management of L-asparaginase induced haemorrhagic stroke

PubMed Central

Ogbodo, Elisha; Kaliaperumal, Chandrasekaran; O’Sullivan, Michael

2012-01-01

The authors describe a case of L-asparaginase induced intracranial thrombosis and subsequent haemorrhage in a newly diagnosed 30-year-old man with acute lymphoblastic leukaemia who was successfully managed by surgical intervention. At presentation, he had a Glasgow Coma Score of 7/15, was aphasic and had dense right hemiplegia. Neuroimaging revealed an acute anterior left middle cerebral artery infarct with parenchymal haemorrhagic conversion, mass effect and subfalcine herniation. He subsequently underwent left frontal craniotomy and evacuation of large frontal haematoma and decompressive craniectomy for cerebral oedema. Six months postoperatively he underwent titanium cranioplasty. He had made good clinical recovery and is currently mobilising independently with mild occasional episodes of expressive dysphasia, difficulty with fine motor movement on the right side, and has remained seizure free. This is the first documented case of L-asparaginase induced haemorrhagic stroke managed by neurosurgical intervention. The authors emphasise the possible role of surgery in managing chemotherapy induced intracranial complications. PMID:22605598

Brain dead or not? CT angiogram yielding false-negative result on brain death confirmation

PubMed Central

Johnston, Robyn; Kaliaperumal, Chandrasekaran; Wyse, Gerald; Kaar, George

2013-01-01

We describe a case of severe traumatic brain injury with multiple facial and skull fractures where CT angiogram (CTA) failed to yield a definite result of brain death as an ancillary test. A 28-year-old man was admitted following a road traffic accident with a Glasgow Coma Score (GCS) of 3/15 and fixed pupils. CT brain revealed uncal herniation and diffuse cerebral oedema with associated multiple facial and skull fractures. 72 h later, his clinical condition remained the same with high intracranial pressure refractory to medical management. Clinical confirmation on brain death was not feasible owing to facial injuries. A CTA, performed to determine brain perfusion, yielded a ‘false-negative’ result. Skull fractures have possibly led to venous prominence in the cortical and deep venous drainage system. This point needs to be borne in mind while considering CTA as an ancillary test to confirm brain death. PMID:23302550

Airway complications in the head injured.

PubMed

Woo, P; Kelly, G; Kirshner, P

1989-07-01

Fifty head-injured patients who had tracheostomy were followed during rehabilitation by video fiberoptic laryngoscopy examination. Complications of aspiration (23/50), airway stenosis (13/50), and phonation dysfunction (16/24) were followed. Spontaneous resolution of aspiration may require a prolonged course. A majority of patients (37/50) had improvement and could be decannulated. Prognostic factors correlated to eventual decannulation included age, level on the Glasgow Coma Outcome Scale, and type of head injury. Those with poor neurologic improvement and glottic incompetence (13/50) are poor candidates for decannulation. Significant airway stenosis can involve both laryngeal and tracheal sites. Neurologic dysfunction may complicate the decannulation process after airway anatomy has been restored by surgery. Dysphonia resulting from intubation, peripheral laryngeal and nerve injury, or central laryngeal movement dysfunction are common. Preventive maintenance with ongoing evaluation can avoid airway crises such as aspiration pneumonia, hemoptysis, and innominate artery.

Mild brain injury and anticoagulants: Less is enough.

PubMed

Campiglio, Laura; Bianchi, Francesca; Cattalini, Claudio; Belvedere, Daniela; Rosci, Chiara Emilia; Casellato, Chiara Livia; Secchi, Manuela; Saetti, Maria Cristina; Baratelli, Elena; Innocenti, Alessandro; Cova, Ilaria; Gambini, Chiara; Romano, Luca; Oggioni, Gaia; Pagani, Rossella; Gardinali, Marco; Priori, Alberto

2017-08-01

Despite the higher theoretical risk of traumatic intracranial hemorrhage (ICH) in anticoagulated patients with mild head injury, the value of sequential head CT scans to identify bleeding remains controversial. This study evaluated the utility of 2 sequential CT scans at a 48-hour interval (CT1 and CT2) in patients with mild head trauma (Glasgow Coma Scale 13-15) taking oral anticoagulants. We retrospectively evaluated the clinical records of all patients on chronic anticoagulation treatment admitted to the emergency department for mild head injury. A total of 344 patients were included, and 337 (97.9%) had a negative CT1. CT2 was performed on 284 of the 337 patients with a negative CT1 and was positive in 4 patients (1.4%), but none of the patients developed concomitant neurologic worsening or required neurosurgery. Systematic routine use of a second CT scan in mild head trauma in patients taking anticoagulants is expensive and clinically unnecessary.

Assessment of injury severity in patients with major trauma.

PubMed

Stanford, Penelope; Booth, Nicola; Suckley, Janet; Twelvetree, Timothy; Thomas, Debbie

2016-08-03

Major trauma centres provide specialised care for patients who have experienced serious traumatic injury. This article provides information about major trauma centres and outlines the assessment tools used in this setting. Since patients in major trauma centres will be transferred to other settings, including inpatient wards and primary care, this article is relevant for both nurses working in major trauma centres and in these areas. Traumatic injuries require rapid assessment to ensure the patient receives prompt, adequate and appropriate treatment. A range of assessment tools are available to assist nurses in major trauma centres and emergency care to assess the severity of a patient's injury. The most commonly used tools are triage, Catastrophic Haemorrhage Airway to Exposure assessment, pain assessment and the Glasgow Coma Scale. This article summarises the use of these assessment tools in these settings, and discusses the use of the Injury Severity Score (ISS) to determine the severity of patient injuries.

Bilateral traumatic facial paralysis. Case report.

PubMed

Undabeitia, Jose; Liu, Brian; Pendleton, Courtney; Nogues, Pere; Noboa, Roberto; Undabeitia, Jose Ignacio

2013-01-01

Although traumatic injury of the facial nerve is a relatively common condition in neurosurgical practice, bilateral lesions related to fracture of temporal bones are seldom seen. We report the case of a 38-year-old patient admitted to Intensive Care Unit after severe head trauma requiring ventilatory support (Glasgow Coma Scale of 7 on admission). A computed tomography (CT) scan confirmed a longitudinal fracture of the right temporal bone and a transversal fracture of the left. After successful weaning from respirator, bilateral facial paralysis was observed. The possible aetiologies for facial diplegia differ from those of unilateral injury. Due to the lack of facial asymmetry, it can be easily missed in critically ill patients, and both the high resolution CT scan and electromyographic studies can be helpful for correct diagnosis. Copyright © 2012 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm.

PubMed

Torné, Ramon; Rodríguez-Hernández, Ana; Romero-Chala, Fabián; Arikan, Fuat; Vilalta, Jordi; Sahuquillo, Juan

2016-04-01

Acute subdural hematomas (aSDH) secondary to intracranial aneurysm rupture are rare. Most patients present with coma and their functional prognosis has been classically considered to be very poor. Previous studies mixed good-grade and poor-grade patients and reported variable outcomes. We reviewed our experience by focusing on patients in coma only and hypothesized that aSDH might worsen initial mortality but not long-term functional outcome. Between 2005 and 2013, 440 subarachnoid hemorrhage (SAH) patients were admitted to our center. Nineteen (4.3%) were found to have an associated aSDH and 13 (2.9%) of these presented with coma. Their prospectively collected clinical and outcome data were reviewed and compared with that of 104 SAH patients without aSDH who presented with coma during the same period. Median aSDH thickness was 10mm. Four patients presented with an associated aneurysmal cortical laceration and only one had good recovery. Overall, we observed good long-term outcomes in both SAH patients in coma with aSDH and those without aSDH (38.5% versus 26.4%). Associated aSDH does not appear to indicate a poorer long-term functional prognosis in SAH patients presenting with coma. Anisocoria and brain herniation are observed in patients with aSDH thicknesses that are smaller than those observed in trauma patients. Despite a high initial mortality, early surgery to remove the aSDH results in a good outcome in over 60% of survivors. Aneurysmal cortical laceration appears to be an independent entity which shows a poorer prognosis than other types of aneurysmal aSDH. Copyright © 2015 Elsevier Ltd. All rights reserved.

Outcomes following prehospital airway management in severe traumatic brain injury.

PubMed

Sobuwa, Simpiwe; Hartzenberg, Henry B; Geduld, Heike; Uys, Corrie

2013-07-29

Prevention of hypoxia and thus secondary brain injury in traumatic brain injury (TBI) is critical. However there is controversy regarding the role of endotracheal intubation in the prehospital management of TBI. To describe the outcome of TBI with various airway management methods employed in the prehospital setting in the Cape Town Metropole. The study was a cohort descriptive observational analysis of 124 consecutively injured adult patients who were admitted for severe TBI (Glasgow Coma Score ≤8) to Groote Schuur and Tygerberg hospitals between 1 January 2009 and 31 August 2011. Patients were categorised by their method of airway management: rapid sequence intubation (RSI), sedation-assisted intubation, failed intubation, basic airway management, and intubated without drugs. Good outcomes were defined by a Glasgow Outcome Score of 4 - 5. There was a statistically significant association between airway management and outcome (p=0.013). Patients who underwent basic airway management had a higher proportion of a good outcome (72.9%) than patients who were intubated in the prehospital setting. A good outcome was observed with 61.8% and 38.4% of patients who experienced sedation-assisted intubation and RSI, respectively. Patients intubated without drugs had the poorest outcome (88%), followed by rapid sequence intubation (61.5%) and by the sedation assisted group (38.2%). Prehospital intubation did not demonstrate improved outcomes over basic airway management in patients with severe TBI. A large prospective, randomised trial is warranted to yield some insight into how these airway interventions influence outcome in severe TBI.

Variation in PPP3CC Genotype Is Associated with Long-Term Recovery after Severe Brain Injury.

PubMed

Osier, Nicole D; Bales, James W; Pugh, Bunny; Shin, Samuel; Wyrobek, Julie; Puccio, Ava M; Okonkwo, David O; Ren, Dianxu; Alexander, Sheila; Conley, Yvette P; Dixon, C Edward

2017-01-01

After experimental traumatic brain injury (TBI), calcineurin is upregulated; blocking calcineurin is associated with improved outcomes. In humans, variation in the calcineurin A-gamma gene (PPP3CC) has been associated with neuropsychiatric disorders, though any role in TBI recovery remains unknown. This study examines associations between PPP3CC genotype and mortality, as well as gross functional status assessed at admission using the Glasgow Coma Scale (GCS) and at 3, 6, and 12 months after severe TBI using the Glasgow Outcome Score (GOS). The following tagging single nucleotide polymorphisms (tSNPs) in PPP3CC were genotyped: rs2443504, rs2461491, rs2469749, and rs10108011. The rs2443504 AA genotype was univariately associated with GCS (p = 0.022), GOS at 3, 6, and 12 months (p = 0.002, p = 0.034, and p = 0.004, respectively), and mortality (p = 0.007). In multivariate analysis controlling for age, sex, and GCS, the AA genotype of rs2443504 was associated with GOS at 3 (p = 0.02), and 12 months (p = 0.01), with a trend toward significance at 6 months (p = 0.05); the AA genotype also was associated with mortality in the multivariate model (p = 0.04). Further work is warranted to better understand the role of calcineurin, as well as the genes encoding it and their relevance to outcomes after brain injury.

The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study.

PubMed

Konstantinidis, Agathoklis; Plurad, David; Barmparas, Galinos; Inaba, Kenji; Lam, Lydia; Bukur, Marko; Branco, Bernardino C; Demetriades, Demetrios

2011-09-01

A distracting injury mandates cervical spine (c-spine) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine. The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the standard clinical examination of the c-spine. This is a prospective observational study conducted at a Level I Trauma Center from January 1, 2008, to December 31, 2009. After institutional review board approval, all evaluable (Glasgow Coma Scale score ≥13) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled. A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed. Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management. During the study period, 101 evaluable patients sustained a c-spine injury. Distracting injuries were present in 88 patients (87.1%). The most common was rib fracture (21.6%), followed by lower extremity fracture (20.5%) and upper extremity fracture (12.5%). Only four (4.0%) patients had no pain or tenderness on the initial examination of the c-spine. All four patients had bruising and tenderness to the upper anterior chest. None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization. C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest. Further definition of distracting injuries is mandated to avoid unnecessary utilization of resources and to reduce the imaging burden associated with the evaluation of the c-spine.

A comparison of the Full Outline of UnResponsiveness (FOUR) score and Glasgow Coma Score (GCS) in predictive modelling in traumatic brain injury.

PubMed

Kasprowicz, Magdalena; Burzynska, Malgorzata; Melcer, Tomasz; Kübler, Andrzej

2016-01-01

To compare the performance of multivariate predictive models incorporating either the Full Outline of UnResponsiveness (FOUR) score or Glasgow Coma Score (GCS) in order to test whether substituting GCS with the FOUR score in predictive models for outcome in patients after TBI is beneficial. A total of 162 TBI patients were prospectively enrolled in the study. Stepwise logistic regression analysis was conducted to compare the prediction of (1) in-ICU mortality and (2) unfavourable outcome at 3 months post-injury using as predictors either the FOUR score or GCS along with other factors that may affect patient outcome. The areas under the ROC curves (AUCs) were used to compare the discriminant ability and predictive power of the models. The internal validation was performed with bootstrap technique and expressed as accuracy rate (AcR). The FOUR score, age, the CT Rotterdam score, systolic ABP and being placed on ventilator within day one (model 1: AUC: 0.906 ± 0.024; AcR: 80.3 ± 4.8%) performed equally well in predicting in-ICU mortality as the combination of GCS with the same set of predictors plus pupil reactivity (model 2: AUC: 0.913 ± 0.022; AcR: 81.1 ± 4.8%). The CT Rotterdam score, age and either the FOUR score (model 3) or GCS (model 4) equally well predicted unfavourable outcome at 3 months post-injury (AUC: 0.852 ± 0.037 vs. 0.866 ± 0.034; AcR: 72.3 ± 6.6% vs. 71.9%±6.6%, respectively). Adding the FOUR score or GCS at discharge from ICU to predictive models for unfavourable outcome increased significantly their performances (AUC: 0.895 ± 0.029, p = 0.05; AcR: 76.1 ± 6.5%; p < 0.004 when compared with model 3; and AUC: 0.918 ± 0.025, p < 0.05; AcR: 79.6 ± 7.2%, p < 0.009 when compared with model 4), but there was no benefit from substituting GCS with the FOUR score. Results showed that FOUR score and GCS perform equally well in multivariate predictive modelling in TBI.

The BRAIN TRIAL: a randomised, placebo controlled trial of a Bradykinin B2 receptor antagonist (Anatibant) in patients with traumatic brain injury.

PubMed

Shakur, Haleema; Andrews, Peter; Asser, Toomas; Balica, Laura; Boeriu, Cristian; Quintero, Juan Diego Ciro; Dewan, Yashbir; Druwé, Patrick; Fletcher, Olivia; Frost, Chris; Hartzenberg, Bennie; Mantilla, Jorge Mejia; Murillo-Cabezas, Francisco; Pachl, Jan; Ravi, Ramalingam R; Rätsep, Indrek; Sampaio, Cristina; Singh, Manmohan; Svoboda, Petr; Roberts, Ian

2009-12-03

Cerebral oedema is associated with significant neurological damage in patients with traumatic brain injury. Bradykinin is an inflammatory mediator that may contribute to cerebral oedema by increasing the permeability of the blood-brain barrier. We evaluated the safety and effectiveness of the non-peptide bradykinin B2 receptor antagonist Anatibant in the treatment of patients with traumatic brain injury. During the course of the trial, funding was withdrawn by the sponsor. Adults with traumatic brain injury and a Glasgow Coma Scale score of 12 or less, who had a CT scan showing an intracranial abnormality consistent with trauma, and were within eight hours of their injury were randomly allocated to low, medium or high dose Anatibant or to placebo. Outcomes were Serious Adverse Events (SAE), mortality 15 days following injury and in-hospital morbidity assessed by the Glasgow Coma Scale (GCS), the Disability Rating Scale (DRS) and a modified version of the Oxford Handicap Scale (HIREOS). 228 patients out of a planned sample size of 400 patients were randomised. The risk of experiencing one or more SAEs was 26.4% (43/163) in the combined Anatibant treated group, compared to 19.3% (11/57) in the placebo group (relative risk = 1.37; 95% CI 0.76 to 2.46). All cause mortality in the Anatibant treated group was 19% and in the placebo group 15.8% (relative risk 1.20, 95% CI 0.61 to 2.36). The mean GCS at discharge was 12.48 in the Anatibant treated group and 13.0 in the placebo group. Mean DRS was 11.18 Anatibant versus 9.73 placebo, and mean HIREOS was 3.94 Anatibant versus 3.54 placebo. The differences between the mean levels for GCS, DRS and HIREOS in the Anatibant and placebo groups, when adjusted for baseline GCS, showed a non-significant trend for worse outcomes in all three measures. This trial did not reach the planned sample size of 400 patients and consequently, the study power to detect an increase in the risk of serious adverse events was reduced. This trial provides no reliable evidence of benefit or harm and a larger trial would be needed to establish safety and effectiveness. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN23625128.

Multicenter observational prehospital resuscitation on helicopter study.

PubMed

Holcomb, John B; Swartz, Michael D; DeSantis, Stacia M; Greene, Thomas J; Fox, Erin E; Stein, Deborah M; Bulger, Eileen M; Kerby, Jeffrey D; Goodman, Michael; Schreiber, Martin A; Zielinski, Martin D; O'Keeffe, Terence; Inaba, Kenji; Tomasek, Jeffrey S; Podbielski, Jeanette M; Appana, Savitri N; Yi, Misung; Wade, Charles E

2017-07-01

Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched. Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population. Level II.

Accuracy of Canadian CT head rule in predicting positive findings on CT of the head of patients after mild head injury in a large trauma centre in Saudi Arabia

PubMed Central

Arab, Ala Faisal; Ahmed, Anwar E; Hussein, Mohamed Ahmed; Khankan, Azzam A; Alokaili, Riyadh Nasser

2015-01-01

Background Investigation of unjustified computed tomography (CT) scan in patients with minor head injury is lacking in Saudi Arabia. The purpose of the study was to evaluate the compliance and effectiveness of the Canadian computed tomography head rule (CCHR) in our emergency department (ED) and trauma centre and also to reduce the number of unjustified CT studies of the head in the centre. Methods A retrospective study of 368 ED patients with minor head injury was conducted. Patients who underwent CT scan between July 2010 and June 2011were selected from the ED head trauma registry by systematic randomisation. The CCHR was retrospectively applied on the patients’ charts to calculate the prevalence of unjustified head CT scans. A separate survey was conducted to evaluate three emergency physicians’ level of awareness about the CCHR and their ability to determine the necessity of CT scans with various clinical scenarios of head injury. Results The prevalence of unjustified CT scans as per the CCHR was 61.8% (95% confidence interval (CI) 56.5–66.9%). Approximately 5% of the sample had positive CT findings with 95% CI 2.9–7.6%. The CCHR correctly identified 12 cases with positive CT findings with 66.67% sensitivity. Only 24 (6.7%) had Glasgow coma scale scores less than 15 (13/14). The Glasgow coma scale correctly identified only two cases with positive CT findings with 11.11% sensitivity. The percentage of skull fracture (0.9% vs 5%, P = 0.030) was significantly lower in patients with unjustified CT scans than in patients with clinically justified CT scans. There was fair to substantial agreement between the ED physicians and the CCHR (κ = 35–61%). Two ED physicians identified all cases of justified CT scan with 100% sensitivity (95% CI 71.51–100%). Conclusion The level of education regarding the CCHR was found to be optimal among emergency physicians using a case-based scenario survey. The CCHR was found to have a poor compliance potential in the busy ED of our trauma centre and the prevalence of unjustified cranial CT scans remained high. PMID:26471399

Thyroid Emergencies

PubMed Central

Leung, Angela M

2017-01-01

Myxedema coma and thyroid storm are thyroid emergencies associated with increased mortality. Prompt recognition of these states—which represent the severe, life-threatening conditions of extremely reduced or elevated circulating thyroid hormone concentrations, respectively—is necessary to initiate treatment. Management of myxedema coma and thyroid storm requires both medical and supportive therapies and should be treated in an intensive care unit setting. PMID:27598067

Recovery of consciousness and an injured ascending reticular activating system in a patient who survived cardiac arrest: A case report.

PubMed

Jang, Sung Ho; Hyun, Yi Ji; Lee, Han Do

2016-06-01

We report on a patient who survived cardiac arrest and showed recovery of consciousness and an injured ARAS at the early stage of hypoxic-ischemic brain injury (HI- BI) for 3 weeks, which was demonstrated by diffusion tensor tractography (DTT).A 52-year-old male patient who had suffered cardiac arrest caused by acute coronary syndrome was resuscitated immediately by a layman and paramedics for ∼25 minutes. He was then transferred immediately to the emergency room of a local medical center. When starting rehabilitation at 2 weeks after onset, his consciousness was impaired, with a Glasgow Coma Scale (GCS) score of 8 and Coma Recovery Scale-Revised (GRS-R) score of 8. He underwent comprehensive rehabilitative therapy, including drugs for recovery of consciousness. He recovered well and rapidly so that his consciousness had recovered to full scores in terms of GCS:15 and GRS-R:23 at 5 weeks after onset.The left lower dorsal and right lower ventral ARAS had become thicker on 5-week DTT compared with 2-week DTT (Fig. 1B). Regarding the change of neural connectivity of the thalamic ILN, increased neural connectivity to the basal forebrain and prefrontal cortex was observed in both hemispheres on 5-week DTT compared with 2-week DTT.Recovery of an injured ARAS was demonstrated in a patient who survived cardiac arrest and his consciousness showed rapid and good recovery for 3 weeks at the early stage of HI-BI.

Exploratory Use of Decision Tree Analysis in Classification of Outcome in Hypoxic-Ischemic Brain Injury.

PubMed

Phan, Thanh G; Chen, Jian; Singhal, Shaloo; Ma, Henry; Clissold, Benjamin B; Ly, John; Beare, Richard

2018-01-01

Prognostication following hypoxic ischemic encephalopathy (brain injury) is important for clinical management. The aim of this exploratory study is to use a decision tree model to find clinical and MRI associates of severe disability and death in this condition. We evaluate clinical model and then the added value of MRI data. The inclusion criteria were as follows: age ≥17 years, cardio-respiratory arrest, and coma on admission (2003-2011). Decision tree analysis was used to find clinical [Glasgow Coma Score (GCS), features about cardiac arrest, therapeutic hypothermia, age, and sex] and MRI (infarct volume) associates of severe disability and death. We used the area under the ROC (auROC) to determine accuracy of model. There were 41 (63.7% males) patients having MRI imaging with the average age 51.5 ± 18.9 years old. The decision trees showed that infarct volume and age were important factors for discrimination between mild to moderate disability and severe disability and death at day 0 and day 2. The auROC for this model was 0.94 (95% CI 0.82-1.00). At day 7, GCS value was the only predictor; the auROC was 0.96 (95% CI 0.86-1.00). Our findings provide proof of concept for further exploration of the role of MR imaging and decision tree analysis in the early prognostication of hypoxic ischemic brain injury.

Complete recovery after severe myxoedema coma complicated by status epilepticus

PubMed Central

Fjølner, Jesper; Søndergaard, Esben; Kampmann, Ulla; Nielsen, Søren

2015-01-01

We report a case of life-threatening myxoedema presenting with hypothermia, hypotension, bradycardia, pericardial effusion and deep coma. The condition was complicated by prolonged status epilepticus. The optimal treatment strategy has been debated over the years and the literature is briefly reviewed. Treatment with l-thyroxine (LT4) monotherapy without initial loading dose and with no l-triiodothyronine (LT3) treatment was successful with full recovery after hospitalisation for more than a month. Myxoedema coma is a rare, reversible condition with a high mortality and should be considered as a differential diagnosis in medical emergencies. PMID:25809434

Complete recovery after severe myxoedema coma complicated by status epilepticus.

PubMed

Fjølner, Jesper; Søndergaard, Esben; Kampmann, Ulla; Nielsen, Søren

2015-03-25

We report a case of life-threatening myxoedema presenting with hypothermia, hypotension, bradycardia, pericardial effusion and deep coma. The condition was complicated by prolonged status epilepticus. The optimal treatment strategy has been debated over the years and the literature is briefly reviewed. Treatment with l-thyroxine (LT4) monotherapy without initial loading dose and with no l-triiodothyronine (LT3) treatment was successful with full recovery after hospitalisation for more than a month. Myxoedema coma is a rare, reversible condition with a high mortality and should be considered as a differential diagnosis in medical emergencies. 2015 BMJ Publishing Group Ltd.

[Process indicators: tools for monitoring the management of severe trauma cases in Catalonia].

PubMed

Prat, Salvi; Muñoz-Ortiz, Laura; Navarro, Salvador; Koo, Maylin; Jiménez-Fábrega, Xavier; Martínez-Cruz, Olga; Espallargues, Mireia

2016-10-01

Process indicators have been widely used to monitor the way trauma care is provided. We aimed to analyze whether data from a hospital's severe trauma register could facilitate the evaluation of aspects of the initial management of severe injuries. Observational, retrospective population-based study. A working group of experts selected a set of trauma care process indicators relevant to some aspects of initial care, diagnosis, and treatment of severely injured patients. Four of the indicators referred to prehospital care and 5 to hospital care. We calculated the observed and expected compliance rates for all the indicators. A total of 1526 cases (44.4%) were analyzed for 2013; 1908 (55.6%) were analyzed for 2014. We were able to evaluate 3 of the 4 prehospital process indicators: endotracheal intubation in patients with a score of 8 on the Glasgow coma scale (GCS) (84% compliance), venous access established before hospital arrival (83.4%), and placement of a neck collar to immobilize the cervical spine (72.7%). Compliance for the hospital-phase indicators were as follows: performance of a computed tomography scan of the head within 60 minutes in cases with a GCS of 13 (5.3% compliance, craniotomy in candidate patients within 2 hours of diagnosis (65%), diagnostic examination for abdominal injuries within 60 minutes in patients with systolic blood pressure 90 mm Hg (89.3%), and therapeutic laparotomy or angiography within 4 hours of abdominal injury in candidate patients with systolic blood pressure 90 mm Hg (51.7%). Compliance was 69.9% for the last process indicator: surgical treatment of open fractures within 8 hours of an accident. Our findings show that a hospital trauma register provides data about care process indicators that can allow us to monitor the quality of care of severely injured patients.

Electroencephalography leads placed by nontechnologists using a template system produce signals equal in quality to technologist-applied, collodion disk leads.

PubMed

Kolls, Brad J; Olson, Daiwai M; Gallentine, William B; Skeen, Mark B; Skidmore, Christopher T; Sinha, Saurabh R

2012-02-01

The purpose of this study was to compare the quality of the electroencephalographic (EEG) data obtained with a BraiNet template in a practical use setting, to that obtained with standard 10/20 spaced, technologist-applied, collodion-based disk leads. Pairs of 8-hour blocks of EEG data were prospectively collected from 32 patients with a Glasgow coma score of ≤9 and clinical concern for underlying nonconvulsive status epilepticus over a 6-month period in the Neurocritical Care Unit at the Duke University Medical Center. The studies were initiated with the BraiNet template system applied by critical care nurse practitioners or physicians, followed by standard, collodion leads applied by registered technologists using the 10/20 system of placement. Impedances were measured at the beginning and end of each block recorded and variance in impedance, mean impedance, and the largest differences in impedances found within a given lead set were compared. Physicians experienced in reading EEG performed a masked review of the EEG segments obtained to assess the subjective quality of the recordings obtained with the templates. We found no clinically significant differences in the impedance measures. There was a 3-hour reduction in the time required to initiate EEG recording using the templates (P < 0.001). There was no difference in the overall subjective quality distributions for template-applied versus technologist-applied EEG leads. The templates were also found to be well accepted by the primary users in the intensive care unit. The findings suggest that the EEG data obtained with this approach are comparable with that obtained by registered technologist-applied leads and represents a possible solution to the growing clinical need for continuous EEG recording availability in the critical care setting.

Total and ionized plasma magnesium concentrations in children after traumatic brain injury.

PubMed

Mendez, Donna Reyes; Corbett, Ronald; Macias, Charles; Laptook, Abbot

2005-03-01

This study examined 1) whether plasma total Mg (TMg) and ionized Mg (IMg) concentrations in children are reduced by traumatic brain injury (TBI) and 2) whether the extent of reduction correlates with severity of trauma assessed by the Glasgow Coma Scale (GSC) score. This was a prospective cohort study of 98 pediatric patients who had TBI and were admitted through the emergency department. A GCS score was assigned and blood was obtained upon presentation and 24 h later. Plasma was analyzed for TMg and IMg. Patients were grouped into three categories-GCS scores 13-15, 8-12, and <8-to designate mild (n=21), moderate (n=37), and severe (n=40) TBI, respectively. Blood was obtained from 50 healthy children before elective surgery as controls. Control subjects had a TMg and an IMg of 0.94 +/- 0.08 and 0.550 +/- 0.06 mM. TBI patients had an initial TMg and IMg of 0.83 +/- 0.09 and 0.520 +/- 0.05 mM, respectively. Initial TMg for mild, moderate, and severe TBI subgroups (0.87 +/- 0.16, 0.81 +/- 0.15, and 0.83 +/- 0.14 mM, respectively) was reduced from control subjects (p <0.01). IMg was reduced only in the severe TBI subgroup (0.516 +/- 0.07 mM; p=0.016). Twenty-four hours later, TMg remained lower than in control subjects for all subgroups of TBI; however, IMg normalized. TBI in children is associated with a reduction in TMg, whereas IMg decreased only with severe TBI. IMg returned to control values by 24 h despite a continued lower TMg, suggesting mechanisms to maintain IMg. Changes in plasma IMg may serve as a marker for TBI but only over a limited time interval.

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma

PubMed Central

Hong, Zhi-Jie; Chen, Cheng-Jueng; Yu, Jyh-Cherng; Chan, De-Chuan; Chou, Yu-Ching; Liang, Chia-Ming; Hsu, Sheng-Der

2016-01-01

Abstract We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT. Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome. Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients’ time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06–0.75, P = 0.016). Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma. PMID:27631215

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma: A retrospective cohort study.

PubMed

Hong, Zhi-Jie; Chen, Cheng-Jueng; Yu, Jyh-Cherng; Chan, De-Chuan; Chou, Yu-Ching; Liang, Chia-Ming; Hsu, Sheng-Der

2016-09-01

We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT.Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome.Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients' time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06-0.75, P = 0.016).Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma.

Emergency airway management in critically injured patients: a survey of U.S. aero-medical transport programs.

PubMed

James, Dorsha N; Voskresensky, Igor V; Jack, Meg; Cotton, Bryan A

2009-06-01

Pre-hospital airway management represents the intervention most likely to impact outcomes in critically injured patients. As such, airway management issues dominate quality improvement (QI) reviews of aero-medical programs. The purpose of this study was to evaluate current practice patterns of airway management in trauma among U.S. aero-medical service (AMS) programs. The Association of Air Medical Services (AAMS) Resource Guide from 2005 to 2006 was utilized to identify the e-mail addresses of all directors of U.S. aero-medical transport programs. Program directors from 182 U.S. aero-medical programs were asked to participate in an anonymous, web-based survey of emergency airway management protocols and practices. Non-responders to the initial request were contacted a second time by e-mail. 89 programs responded. 98.9% have rapid sequence intubation (RSI) protocols. 90% use succinylcholine, 70% use long-acting neuromuscular blockers (NMB) within their RSI protocol. 77% have protocols for mandatory in-flight sedation but only 13% have similar protocols for maintenance paralytics. 60% administer long-acting NMB immediately after RSI, 13% after confirmation of neurological activity. Given clinical scenarios, however, 97% administer long-acting NMB to patients with scene and in-flight Glasgow Coma Scale (GCS) of 3, even for brief transport times. The majority of AMS programs have well defined RSI and in-flight sedation protocols, while protocols for in-flight NMB are uncommon. Despite this, nearly all programs administer long-acting NMB following RSI, irrespective of GCS or flight time. Given the impact of in-flight NMB on initial assessment, early intervention, and injury severity scoring, a critical appraisal of current AMS airway management practices appears warranted.

Using external lumbar CSF drainage to treat communicating external hydrocephalus in adult patients after acute traumatic or non-traumatic brain injury.

PubMed

Manet, Romain; Payen, Jean-François; Guerin, Romain; Martinez, Orianne; Hautefeuille, Serge; Francony, Gilles; Gergelé, Laurent

2017-10-01

Despite various treatments to control intracranial pressure (ICP) after brain injury, patients may present a late onset of high ICP or a poor response to medications. External lumbar drainage (ELD) can be considered a therapeutic option if high ICP is due to communicating external hydrocephalus. We aimed at describing the efficacy and safety of ELD used in a cohort of traumatic or non-traumatic brain-injured patients. In this multicentre retrospective analysis, patients had a delayed onset of high ICP after the initial injury and/or a poor response to ICP treatments. ELD was considered in the presence of radiological signs of communicating external hydrocephalus. Changes in ICP values and side effects following the ELD procedure were reported. Thirty-three patients with a median age of 51 years (25-75th percentile: 34-61 years) were admitted after traumatic (n = 22) or non-traumatic (n = 11) brain injuries. Their initial Glasgow Coma Scale score was 8 (4-11). Eight patients underwent external ventricular drainage prior to ELD. Median time to ELD insertion was 5 days (4-8) after brain insult. In all patients, ELD was dramatically effective in lowering ICP: 25 mmHg (20-31) before versus 7 mmHg (3-10) after (p < 0.001). None of the patients showed adverse effects such as pupil changes or intracranial bleeding after the procedure. One patient developed an ELD-related infection. These findings indicate that ELD may be considered potentially effective in controlling ICP, remaining safe if a firm diagnosis of communicating external hydrocephalus has been made.

Chemical Recycling of HCN in Cometary Comae

NASA Astrophysics Data System (ADS)

Boice, Daniel C.; Kawakita, Hideyo; Shinnaka, Yoshiharu; Mumma, Michael J.; Kobayashi, Hitomi; Ogawa, Sayuri

2014-11-01

Modeling is essential to understand the important physical and chemical processes that occur in cometary comae, especially the relationship between putative parent and daughter molecules, such as, HCN and CN. Photochemistry is a major source of ions and electrons that further initiate key gas-phase reactions, contributing to the plethora of molecules and atoms observed in comets. The effects of photoelectrons that interact via impacts are important to the overall excitation and dissociation processes in the inner coma. We consider the relevant processes in the collision-dominated, inner coma of a comet within a global modeling framework to understand observations of HCN and CN. The CN source(s) must be able to produce highly collimated jets, be consistent with the observed CN parent scale length, and have a production rate consistent with the observed CN production. HCN fulfills these conditions in some comets (e.g., 1P/Halley, Hale-Bopp) while it does not in others (e.g., 8P/Tuttle, 6P/d’Arrest, 73P/S-W3, 2P/Encke, 9P/Temple 1 and C/2007 W1).We investigate the chemistry of HCN with our chemical kinetics coma model including a network with other possible CN parents, as well as a dust component that may be a potential source of CN. It is seen that the major destruction pathways of HCN are via photo dissociation (into H and CN) and protonation with water group ions - primarily H3O+. We point out the intriguing “recycling” of HCN via protonation reactions with H3O+, H2O+, OH+, and subsequent dissociative recombination. It seems that HCN molecules observed in the coma can consist of those initially released from the nucleus and those that are freshly formed at different locations in the coma via these protonation/dissociation reactions. We will investigate implications for reconciling discrepancies between observations of HCN and CN in cometary comae.Acknowledgements: We appreciate support from the NSF Planetary Astronomy Program. This program is partially supported by the MEXT Supported Program for the Strategic Research Foundation at Private Universities, 2014-2018.

Cerebrospinal Fluid Markers of Macrophage and Lymphocyte Activation after Traumatic Brain Injury in Children

PubMed Central

Newell, Elizabeth; Shellington, David K.; Simon, Dennis W.; Bell, Michael J.; Kochanek, Patrick M.; Feldman, Keri; Bayır, Hülya; Aneja, Rajesh K.; Carcillo, Joseph A.; Clark, Robert S. B.

2015-01-01

Objective The magnitude and role of the cellular immune response following pediatric traumatic brain injury (TBI) remains unknown. We tested the hypothesis that macrophage/microglia and T-cell activation occurs following pediatric TBI by measuring cerebrospinal fluid (CSF) levels of sCD163 and ferritin, and sIL-2Rα, respectively, and determined whether these biomarkers were associated with relevant clinical variables and outcome. Design Retrospective analysis of samples from an established, single-center CSF bank. Setting Pediatric Intensive Care Unit (PICU) in a tertiary Children’s Hospital Patients Sixty-six pediatric patients after severe TBI (Glasgow coma scale score [GCS]<8) age 1 mo-16 y and 17 control patients age 1 mo-14 y. Measurements and Main Results CSF levels of sCD163, ferritin, and sIL-2Rα were determined by ELISA at 2 time points (t1=17±10, t2=72±15 h) for each TBI patient. CSF sCD163, ferritin, and sIL2Rα levels after TBI were compared with controls and analyzed for associations with age, patient sex, initial GCS, diagnosis of abusive head trauma (AHT), the presence of hemorrhage on computerized tomography scan, and Glasgow outcome scale score (GOS). CSF sCD163 was increased in TBI patients at t2 vs. t1 and controls (95.4[21.8–134.0] vs. 31.0[5.7–77.7] and 27.8[19.1–43.1] ng/ml, respectively; median[IQ]; P<0.05). CSF ferritin was increased in TBI patients at t2 and t1 vs. controls (8.3[7.5–19.8] and 8.9[7.5–26.7] vs. [7.5[0.0–0.0] ng/ml, respectively; P<0.05). CSF sIL-2Rα in TBI patients at t2 and t1 were not different vs. controls. Multivariate regression revealed associations between high ferritin and age ≤ 4 y, lower GCS, AHT, and unfavorable GOS. Conclusions Children with TBI demonstrate evidence for macrophage activation after TBI, and in terms of CSF ferritin, this appears more prominent with young age, initial injury severity, AHT, and unfavorable outcome. Further study is needed to determine whether biomarkers of macrophage activation may be used to discriminate between aberrant and adaptive immune responses, and whether inflammation represents a therapeutic target after TBI. PMID:25850867

Overview of traumatic brain injury patients at a tertiary trauma centre.

PubMed

de Guise, Elaine; Feyz, Mitra; LeBlanc, Joanne; Richard, Sylvain-Luc; Lamoureux, Julie

2005-05-01

The goal of this study was to provide a general descriptive and cognitive portrait of a population with traumatic brain injury (TBI) at the time of their acute care stay. Three hundred and forty-eight TBI patients were assessed. The following data were collected for each patient: age, level of education, duration of post-traumatic amnesia, Galveston Orientation Amnesia Test score, Glasgow Coma Scale score, results of cerebral imaging, Neurobehavioral Rating Scale score, the Functional Independence Measure cognitive score and the Glasgow Outcome Scale score. The clinical profile of the population revealed a mean age of 40.2 (+/-18.7) and a mean of 11.5 (+/-3.6) years of education. Most patients presented with frontal (57.6%) and temporal (40%) lesions. Sixty-two percent had post-traumatic amnesia of less than 24 hours. Seventy percent presented with mild TBI, 14% with moderate and 15% with severe TBI. The cognitive deficits most frequently observed on the Neurobehavioral Rating Scale were in the areas of attention, memory and mental flexibility as well as slowness and mental fatigability. Most patients had good cognitive outcome on the Functional Independence Measure and scores of 2 and 3 were frequent on the GOS. Forty-five percent of the patients returned home after discharge, 51.7% were referred to in or out patient rehabilitation and 3.2% were transferred to long-term care facilities. Because of the specialized mandate of acute care institutions, the information provided here concerning characteristics of our TBI population is essential for more efficient decision-making and planning/programming with regards to care and service delivery.

The Outcome and Patterns of Traumatic Brain Injury in the Paediatric Population of a Developing Country Secondary to TV Trolley Tip-Over.

PubMed

Waqas, Muhammad; Javed, Gohar; Nathani, Karim Rizwan; Ujjan, Badar; Quadri, Syed A; Tahir, Muhammad Zubair

2018-01-01

Television (TV) trolley tip-over incidences are common and can cause significant morbidity and mortality in children. This study was aimed at analyzing the pattern and outcomes of head injuries resulting from TV trolley tip-over. We conducted a medical chart review of children with TV trolley tip-over head injuries from January 2009 to April 2016. We collected data on demographics, the mechanism of injury, clinical and radiological features of the injury, and outcomes. Outcomes were measured by means of the Glasgow Outcome Scale (GOS) at 6 months (except in 1 case). A descriptive analysis was carried out using SPSS v19. Twenty-two children were included in the study (median age 23.5 months). Sixteen children were male. Most of the children (n = 16) were aged 12-35 months. The median Glasgow Coma Scale score on admission was 15. The median Rotterdam Score for the patients was 2.0. Common symptoms upon admission were vomiting, irritability, scalp laceration, and bruises. Median length of hospital stay was 3 days. Skull bone fractures were present in 12 children. Other CT findings included contusions, extradural and subdural haematomas, intraventricular haemorrhage, and pneumocranium. Surgical intervention was required in 4 cases. Although most of the patients made a good recovery (GOS = 5), 1 patient developed a mild disability and another died in hospital. TV trolley tip-over is most common in toddlers and can lead to significant head injury and mortality. This can be avoided by parental supervision and adjustments in the household. © 2017 S. Karger AG, Basel.

The Effectiveness of Subdural Drains Using Urokinase after Burr Hole Evacuation of Subacute Subdural Hematoma in Elderly Patients: A Prelimilary Report

PubMed Central

Yeo, Chang-Gi; Jeon, Woo-Yeol; Kim, Seong-Ho; Kim, Oh-Lyong

2016-01-01

Objective A subdural drain using urokinase after a burr hole hematoma evacuation was performed for subacute subdural hematoma (SASDH), and its effectiveness and safety in elderly patients were evaluated. Methods Between January 2013 and May 2015, subdural drains using urokinase after burr hole hematoma evacuation were performed in 19 elderly patients. The inclusion criteria were as follows: 1) a subdural hematoma occurring between 4 and 20 days after injury; 2) worsening neurological symptoms, from mild to moderate or severe, due to injury during the subacute stage; 3) a mix of solid clots (high-density lighter shadow) and fluid hematoma (low-density darker shadow) on the computed tomography (CT) scan; 4) a score of ≥9 on the Glasgow Coma Scale (GCS) assessed immediately before surgery; and 5) an age of ≥65 years. When the majority of the hematoma was evacuated on the CT, we removed the catheter. Results Under local anesthesia, a catheter was inserted into the hematoma through a burr hole. The mean age of the patients was 73.7 years (range, 65-87 years). The mean preoperative GCS score was 11.2 (range, 10-13), and the mean Glasgow Outcome Scale score for all patients was 5 at discharge. No recurrences of hematomas or surgical complications were observed. Conclusion A subdural drain using urokinase after burr hole hematoma evacuation under local anesthesia is thought to be an effective and safe method of blood clot removal with low morbidity. This surgical method is less invasive for treating elderly patients with SASDH. PMID:27857916

Traumatic Brain Injury Caused by Missile Wounds in the North of Palestine: A Single Institution's Experience with 520 Consecutive Civilian Patients.

PubMed

Darwazeh, Rami; Darwazeh, Mazhar; Sbeih, Ibrahim; Yan, Yi; Wang, Jianmin; Sun, Xiaochuan

2018-05-05

Literature about traumatic brain injury caused by missile wounds is scanty. We shed some light on this field. This retrospective study was carried out, between September 2000 and September 2010, on 520 civilian patients who sustained traumatic brain injury from missiles in the north of Palestine. Thorough detailed analyses were made of patients' admission Glasgow Coma Scale (GCS) scores, pupillary reactivity to light, site and mode of injuries, type of injurious agents, missile trajectory, method of treatment, radiologic manifestations, complications, and outcome. The GCS score was used to assess the level of consciousness, whereas the Glasgow Outcome Scale score was used to evaluate the outcome. Patients' age ranged from 6 months to 75 years. Only 50 (9.6%) patients were female. Patients injured by metallic bullets, rubber bullets, and shrapnel from bomb explosions numbered 351, 139, and 30, respectively. Of 384 patients who were treated conservatively, no mortality was detected, whereas of 136 surgically treated patients, 66 (48.5%) died of their injuries. Although our management of patients was not optimal because of many factors, the overall mortality was 12.7% (n = 66). The promptness of transport to hospital was a decisive factor with a major bearing on decreasing mortality. Brain computed tomography was invaluable in the diagnosis and follow-up of our patients. In addition, age, pupillary reactivity, admission GCS score, missile trajectory, ventricular involvement, and site and mode of injury were important prognostic factors. Copyright © 2018 Elsevier Inc. All rights reserved.

Does head CT scan pathology predict outcome after mild traumatic brain injury?

PubMed

Lannsjö, M; Backheden, M; Johansson, U; Af Geijerstam, J L; Borg, J

2013-01-01

More evidence is needed to forward our understanding of the key determinants of poor outcome after mild traumatic brain injury (MTBI). A large, prospective, national cohort of patients was studied to analyse the effect of head CT scan pathology on the outcome. One-thousand two-hundred and sixty-two patients with MTBI (Glasgow Coma Scale score 15) at 39 emergency departments completed a study protocol including acute head CT scan examination and follow-up by the Rivermead Post Concussion Symptoms Questionnaire and the Glasgow Outcome Scale Extended (GOSE) at 3 months after MTBI. Binary logistic regression was used for the assessment of prediction ability. In 751 men (60%) and 511 women (40%), with a mean age of 30 years (median 21, range 6-94), we observed relevant or suspect relevant pathologic findings on acute CT scan in 52 patients (4%). Patients aged below 30 years reported better outcome both with respect to symptoms and GOSE as compared to patients in older age groups. Men reported better outcome than women as regards symptoms (OR 0.64, CI 0.49-0.85 for ≥3 symptoms) and global function (OR 0.60, CI 0.39-0.92 for GOSE 1-6). Pathology on acute CT scan examination had no effect on self-reported symptoms or global function at 3 months after MTBI. Female gender and older age predicted a less favourable outcome. The findings support the view that other factors than brain injury deserve attention to minimize long-term complaints after MTBI. © 2012 The Author(s) European Journal of Neurology © 2012 EFNS.

Psychosocial adjustment and life satisfaction until 5 years after severe brain damage.

PubMed

Sörbo, Ann K; Blomqvist, Maritha; Emanuelsson, Ingrid M; Rydenhag, Bertil

2009-06-01

The objectives of this study were to describe psychosocial adjustment and outcome over time for severely brain-injured patients and to find suitable outcome measures for clinical practice during the rehabilitation process and for individual rehabilitation planning after discharge from hospital. The methods include a descriptive, prospective, population-based study. The participants were assessed at 6 months and annually until 5 years after traumatic brain injury or nontraumatic subarachnoid haemorrhage. Inclusion criteria were age 16-65 years, severe traumatic brain injury or nontraumatic subarachnoid haemorrhage defined as Glasgow Coma Scale 8 or worse and need for neurointensive care for at least 5 days. The main outcome measures were Head Injury Evaluation Chart, Glasgow Outcome Scale Extended (GOSE) and Life Satisfaction Questionnaire (LiSat)-11 checklist. Change over time for the group and the individuals, as measured with the GOSE, was analyzed by a statistical method that is suitable for small datasets and takes into account the nonmetric properties of the data. Eighteen patients were included. Three died and one was excluded for the long-term follow-up (n=14). The group had a good outcome with no participant remaining in a vegetative state, 93% (12 of 13) went home and 60% (six of 10) returned to work. Eighty percent (eight of 10) of participants rated 'life as a whole' as satisfactory 5 years after the injury. The change at group level was significant (GOSE) until 1 year after the injury. The GOSE and the LiSat-11 were most clinically useful as they were easy to use for the rater/participants.

Civilian Penetrating Gunshot Injury to the Neurocranium in Enugu

PubMed Central

Onyia, Ephraim Eziechina; Chikani, Mark C; Mezue, Wilfred C; Uche, Enoch O; Iloabachie, Izuchukwu; Mesi, Matthew; Ejembi, Sunday; Agunwa, Chuka

2017-01-01

Introduction: Civilian penetrating gunshot injuries to the neurocranium are no longer uncommon in Nigeria. Such injuries are however poorly reported. They are associated with poor outcome and, at close range, are frequently fatal, especially when inflicted by high-velocity weapons. Prompt transfer to neurosurgical service and urgent intervention may improve outcome in those that are not mortally wounded. Materials and Methods: Fifty-two patients with civilian penetrating gunshot wounds seen over a 10-year period (2004–2014) at the University of Nigeria Teaching Hospital and Memfys Hospital for Neurosurgery Enugu were reviewed retrospectively, and their data were analyzed to evaluate factors that impacted on outcome. Only patients with clinical and imaging evidence of cranial gunshot injuries who reached hospital alive were included in the study. The overall mortality and Glasgow outcome score were analyzed. Results: Fifty-two patients with isolated civilian penetrating gunshot wounds were identified (M:F = 7.7:1); mean (standard deviation) age was 32.8 (11.9) years. There was a high correlation (0.983) between the sex of the patients and the outcome. The overall mortality was 30.8%, whereas the mortality for patients with postresuscitation Glasgow coma scale (GCS) score ≤8 was 57%, as against 12.9% in those in whom postresuscitation GCS was >8; meaning that 87.1% of patients in whom postresuscitation GCS was >8 survived. Thirty-one patients (59.6%) had papillary abnormalities. Majority of patients with monohemispheric lesions survived while all those with diencephalic, transventricular, and posterior fossa involvement had 100% mortality. Conclusions: Admitting GCS and bullet trajectory were predictive of outcome. PMID:28584512

Civilian Penetrating Gunshot Injury to the Neurocranium in Enugu.

PubMed

Onyia, Ephraim Eziechina; Chikani, Mark C; Mezue, Wilfred C; Uche, Enoch O; Iloabachie, Izuchukwu; Mesi, Matthew; Ejembi, Sunday; Agunwa, Chuka

2017-01-01

Civilian penetrating gunshot injuries to the neurocranium are no longer uncommon in Nigeria. Such injuries are however poorly reported. They are associated with poor outcome and, at close range, are frequently fatal, especially when inflicted by high-velocity weapons. Prompt transfer to neurosurgical service and urgent intervention may improve outcome in those that are not mortally wounded. Fifty-two patients with civilian penetrating gunshot wounds seen over a 10-year period (2004-2014) at the University of Nigeria Teaching Hospital and Memfys Hospital for Neurosurgery Enugu were reviewed retrospectively, and their data were analyzed to evaluate factors that impacted on outcome. Only patients with clinical and imaging evidence of cranial gunshot injuries who reached hospital alive were included in the study. The overall mortality and Glasgow outcome score were analyzed. Fifty-two patients with isolated civilian penetrating gunshot wounds were identified (M:F = 7.7:1); mean (standard deviation) age was 32.8 (11.9) years. There was a high correlation (0.983) between the sex of the patients and the outcome. The overall mortality was 30.8%, whereas the mortality for patients with postresuscitation Glasgow coma scale (GCS) score ≤8 was 57%, as against 12.9% in those in whom postresuscitation GCS was >8; meaning that 87.1% of patients in whom postresuscitation GCS was >8 survived. Thirty-one patients (59.6%) had papillary abnormalities. Majority of patients with monohemispheric lesions survived while all those with diencephalic, transventricular, and posterior fossa involvement had 100% mortality. Admitting GCS and bullet trajectory were predictive of outcome.

Mortality and Epidemiology in 256 Cases of Pediatric Traumatic Brain Injury: Korean Neuro-Trauma Data Bank System (KNTDBS) 2010-2014.

PubMed

Jeong, Hee-Won; Choi, Seung-Won; Youm, Jin-Young; Lim, Jeong-Wook; Kwon, Hyon-Jo; Song, Shi-Hun

2017-11-01

Among pediatric injury, brain injury is a leading cause of death and disability. To improve outcomes, many developed countries built neurotrauma databank (NTDB) system but there was not established nationwide coverage NTDB until 2009 and there have been few studies on pediatric traumatic head injury (THI) patients in Korea. Therefore, we analyzed epidemiology and outcome from the big data of pediatric THI. We collected data on pediatric patients from 23 university hospitals including 9 regional trauma centers from 2010 to 2014 and analyzed their clinical factors (sex, age, initial Glasgow coma scale, cause and mechanism of head injury, presence of surgery). Among all the 2617 THI patients, total number of pediatric patients was 256. The average age of the subjects was 9.07 (standard deviation±6.3) years old. The male-to female ratio was 1.87 to 1 and male dominance increases with age. The most common cause for trauma were falls and traffic accidents. Age ( p =0.007), surgery ( p <0.001), mechanism of trauma ( p =0.016), subdural hemorrhage (SDH) ( p <0.001), diffuse axonal injury (DAI) ( p <0.001) were statistically significant associated with severe brain injury. Falls were the most common cause of trauma, and age, surgery, mechanism of trauma, SDH, DAI increased with injury severity. There is a critical need for effective fall and traffic accidents prevention strategies for children, and we should give attention to these predicting factors for more effective care.

Sickle cell crisis: A crisis of a different sort?

PubMed

Kumar, Gurinder; Al Muwaijei, Ayesha Ateeq; Sohal, Aman Preet Singh

2018-01-20

: A 9-year-old boy with sickle cell disease (SCD) was presented to the emergency department with acute headache and swelling over his bilateral temporoparietal region. There was no history of antecedent trauma, fever, vomiting or other features of an intercurrent illness. On arrival, his blood pressure was 112/62 mm Hg, heart rate was 98/min and his Glasgow Coma Scale score was 15/15. There was evidence of significant scalp tenderness over the bilateral temporoparietal region. A complete neurological examination including direct and consensual pupillary response was unremarkable. Initial investigations revealed haemoglobin of 9.6 g/dL, leucocyte count of 6.8/mm 3 , platelet count of 219/mm 3 and a normal coagulation profile. His current medications included hydroxyurea and penicillin prophylaxis. He underwent an urgent CT of the head followed by MRI of the brain, which revealed abnormalities as depicted in figures 1,2.edpract;archdischild-2017-313899v1/F1F1F1Figure 1CT head.edpract;archdischild-2017-313899v1/F2F2F2Figure 2MRI brain. QUESTION 1: Is this one of the most common neurological presentation seen in sickle cell crisis? QUESTION 2: How common is this presentation in paediatric SCD? QUESTION 3: What is the best way to manage this child? © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study.

PubMed

Wang, Shang-Yu; Liao, Chien-Hung; Fu, Chih-Yuan; Kang, Shih-Ching; Ouyang, Chun-Hsiang; Kuo, I-Ming; Lin, Jr-Rung; Hsu, Yu-Pao; Yeh, Chun-Nan; Chen, Shao-Wei

2014-04-28

We present a series of patients with blunt abdominal trauma who underwent damage control laparotomy (DCL) and introduce a nomogram that we created to predict survival among these patients. This was a retrospective study. From January 2002 to June 2012, 91 patients underwent DCL for hemorrhagic shock. We excluded patients with the following characteristics: a penetrating abdominal injury, age younger than 18 or older than 65 years, a severe or life-threatening brain injury (Abbreviated Injury Scale [AIS] ≥ 4), emergency department (ED) arrival more than 6 hours after injury, pregnancy, end-stage renal disease, or cirrhosis. In addition, we excluded patients who underwent DCL after ICU admission or later in the course of hospitalization. The overall mortality rate was 61.5%: 35 patients survived and 56 died. We identified independent survival predictors, which included a preoperative Glasgow Coma Scale (GCS) score < 8 and a base excess (BE) value < -13.9 mEq/L. We created a nomogram for outcome prediction that included four variables: preoperative GCS, initial BE, preoperative diastolic pressure, and preoperative cardiopulmonary cerebral resuscitation (CPCR). DCL is a life-saving procedure performed in critical patients, and devastating clinical outcomes can be expected under such dire circumstances as blunt abdominal trauma with exsanguination. The nomogram presented here may provide ED physicians and trauma surgeons with a tool for early stratification and risk evaluation in critical, exsanguinating patients.

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia.

PubMed

Mounier, Roman; Lobo, David; Voulgaropoulos, Julia; Martin, Mathieu; Aït-Mamar, Bouziane; Bitot, Valérie; Jost, Paul-Henri; Birnbaum, Ron; Nebbad, Biba; Cook, Fabrice; Dhonneur, Gilles

2017-01-01

We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21-64]) with severe trauma (initial Simplified Acute Score II = 42 [32-52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient's characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults.

Myxedema coma.

PubMed

Wartofsky, Leonard

2006-12-01

Myxedema coma is the term given to the most severe presentation of profound hypothyroidism and is often fatal in spite of therapy. Decompensation of the hypothyroid patient into a coma may be precipitated by a number of drugs, systemic illnesses (eg, pneumonia), and other causes. It typically presents in older women in the winter months and is associated with signs of hypothyroidism, hypothermia, hyponatremia, hypercarbia, and hypoxemia. Treatment must be initiated promptly in an intensive care unit setting. Although thyroid hormone therapy is critical to survival, it remains uncertain whether it should be administered as thyroxine, triiodothyronine, or both. Adjunctive measures, such as ventilation, warming, fluids, antibiotics, pressors, and corticosteroids, may be essential for survival.

Cerebrospinal fluid penetration of high-dose daptomycin in suspected Staphylococcus aureus meningitis.

PubMed

Riser, M Shawn; Bland, Christopher M; Rudisill, Celeste N; Bookstaver, P Brandon

2010-11-01

To report a case of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia with suspected MSSA meningitis treated with high-dose daptomycin assessed with concurrent serum and cerebrospinal fluid (CSF) concentrations. A 54-year-old male presented to the emergency department with generalized weakness and presumed health-care-associated pneumonia shown on chest radiograph. Treatment was empirically initiated with vancomycin, levofloxacin, and piperacillin/tazobactam. Blood cultures revealed S. aureus susceptible to oxacillin. Empiric antibiotic treatment was narrowed to nafcillin on day 4. On day 8, the patient developed acute renal failure (serum creatinine 1.9 mg/dL, increased from 1.2 mg/dL the previous day and 0.8 mg/dL on admission). The patient's Glasgow Coma Score was 3, with normal findings shown on computed tomography scan of the head 72 hours following an episode of cardiac arrest on day 10. The patient experienced relapsing MSSA bacteremia on day 9, increasing the suspicion for a central nervous system (CNS) infection. Nafcillin was discontinued and daptomycin 9 mg/kg daily was initiated for suspected meningitis and was continued until the patient's death on day 16. Daptomycin serum and CSF trough concentrations were 11.21 μg/mL and 0.52 μg/mL, respectively, prior to the third dose. Lumbar puncture results were inconclusive and no further blood cultures were positive for MSSA. Creatine kinase levels were normal prior to daptomycin therapy and were not reassessed. Daptomycin was initiated in our patient secondary to possible nafcillin-induced acute interstitial nephritis and relapsing bacteremia. At a dose of 9 mg/kg, resultant penetration of 5% was higher than in previous reports, more consistent with inflamed meninges. High-dose daptomycin may be an alternative option for MSSA bacteremia with or without a CNS source in patients who have failed or cannot tolerate standard therapy. Further clinical evaluation in patients with confirmed meningitis is warranted.

Cryoprecipitate use in the PROMMTT study.

PubMed

Holcomb, John B; Fox, Erin E; Zhang, Xuan; White, Nathan; Wade, Charles E; Cotton, Bryan A; del Junco, Deborah J; Bulger, Eileen M; Cohen, Mitchell J; Schreiber, Martin A; Myers, John G; Brasel, Karen J; Phelan, Herb A; Alarcon, Louis H; Muskat, Peter; Rahbar, Mohammad H

2013-07-01

There are few clinical data to guide the use of cryoprecipitate in severely injured trauma patients. Cryoprecipitate is a rich source of fibrinogen and has been associated with improved survival in animal as well as limited human studies. Our objectives were to identify patterns and predictors of cryoprecipitate use and determine whether transfusing cryoprecipitate was associated with improved survival. This secondary analysis of 1,238 of 1,245 PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study patients who had timed transfusion data included 359 (29%) who received cryoprecipitate. For this analysis, one dose of cryoprecipitate was defined as 10 U. Unadjusted predictors of cryoprecipitate use were identified using logistic regression. Multivariable time-dependent Cox models were performed to examine the association of cryoprecipitate on time to in-hospital death. Cryoprecipitate use varied significantly by center, ranging from 7% to 82%. Among patients who received cryoprecipitate, the median number of units infused by 24 hours was 10 (interquartile range, 10-20). The median time from admission to first cryoprecipitate unit was 2.7 hours (interquartile range, 1.7-4.4 hours). Of those who died of a hemorrhagic death within 6 hours of admission, 72% received no cryoprecipitate. Other unadjusted predictors of cryoprecipitate use included Injury Severity Score (ISS), initial fibrinogen levels, base deficit, international normalized ratio, prothrombin time/partial thromboplastin time, hemoglobin, damage-control surgery, and surgical intervention of the chest and abdomen. Cryoprecipitate use was not associated with in-hospital mortality after adjusting for initial pH, initial hemoglobin, emergency department systolic blood pressure, emergency department Glasgow Coma Scale (GCS) score, blood product use, ISS, and center. Ten US Level 1 trauma centers vary greatly in their timing and use of cryoprecipitate in severely injured trauma patients. We could not identify any association of cryoprecipitate use with in-hospital mortality, although most patients did not receive this product. Randomized controlled studies are needed to determine if cryoprecipitate (or fibrinogen concentrates) have a beneficial effect.

Do Age and Anticoagulants Affect the Natural History of Acute Subdural Hematomas?

PubMed

Lucke-Wold, Brandon P; Turner, Ryan C; Josiah, Darnell; Knotts, Chelsea; Bhatia, Sanjay

2016-01-01

Acute subdural hematoma is a serious complication following traumatic brain injury. Large volume hematomas or those with underlying brain injury can cause mass effect, midline shift, and eventually herniation of the brain. Acute subdural hematomas in the young are associated with high-energy trauma and often have underlying contusions, while acute subdural hematomas in the elderly are associated with minor trauma and an absence of underlying contusions, even though the elderly are more likely to be on anticoagulants or anti-platelet therapy. In the young patients with high impact injuries the hematomas tend to be small and the underlying brain injury and swelling is responsible for the increased intracranial pressure and midline shift. In the elderly, the injuries are low impact (e.g fall from standing), the underlying brain is intact, and the volume of the hematoma itself produces symptoms. In addition the use of anticoagulants and antiplatelet agents in the elderly population has been thought to be a poor prognostic indicator and is considered to be responsible for larger hematomas and poor outcome. When managed conservatively, acute subdural hematomas can sometimes progress to chronic subdural hematoma formation, further enlargement, seizures, and progressive midline shift. Another potential difference in the young and the elderly is brain atrophy, which increases the potential space to accommodate a larger hematoma. It is not known if these two groups differ in other ways that might have implications for treatment or prognosis. In this paper, we investigate the clinical course of 80 patients admitted to our institution with acute subdural hematomas, to identify differences in patients above or below the age of 65 years. The natural progression/resolution of acute subdural hematomas was mapped by measuring volume expansion/regression over time. In this retrospective chart review, we investigated clinical baseline metrics and subsequent volumetric expansion outcomes between patients < 65 years old (N=44) and those > 65 years old (N=36). Volume was estimated by the ABC/2 method. We observed a statistically significant difference between groups in use of anticoagulants χ 2 =40.305 with p < 0.001, corrective platelet administration χ 2 =19.380 with p < 0.001, gender χ 2 =14.573 with p < 0.001, and Glasgow Coma Scale with χ 2 =23.125 (p=0.026). Overall outcomes were similar in the two groups. Younger patients on average had worse presenting GCS scores, but recovered comparable to older patients. No significant difference in rate of volume expansion, resolution time, or need for surgical treatment was seen between these two groups. We conclude that the initial volume, size, and severity of subdural hematoma determined by the Glasgow Coma Scale score is more likely to predict surgery or future expansion than age of the patient. Patients on oral anti-coagulants that are given appropriate medical reversal agents early do quite well and no impact on the eventual outcome could be demonstrated. Further work is needed to establish better predictors of future volume expansion, and progression to chronic subdural hematoma based on improved severity scales.

Do Age and Anticoagulants Affect the Natural History of Acute Subdural Hematomas?

PubMed Central

Lucke-Wold, Brandon P.; Turner, Ryan C.; Josiah, Darnell; Knotts, Chelsea; Bhatia, Sanjay

2016-01-01

Acute subdural hematoma is a serious complication following traumatic brain injury. Large volume hematomas or those with underlying brain injury can cause mass effect, midline shift, and eventually herniation of the brain. Acute subdural hematomas in the young are associated with high-energy trauma and often have underlying contusions, while acute subdural hematomas in the elderly are associated with minor trauma and an absence of underlying contusions, even though the elderly are more likely to be on anticoagulants or anti-platelet therapy. In the young patients with high impact injuries the hematomas tend to be small and the underlying brain injury and swelling is responsible for the increased intracranial pressure and midline shift. In the elderly, the injuries are low impact (e.g fall from standing), the underlying brain is intact, and the volume of the hematoma itself produces symptoms. In addition the use of anticoagulants and antiplatelet agents in the elderly population has been thought to be a poor prognostic indicator and is considered to be responsible for larger hematomas and poor outcome. When managed conservatively, acute subdural hematomas can sometimes progress to chronic subdural hematoma formation, further enlargement, seizures, and progressive midline shift. Another potential difference in the young and the elderly is brain atrophy, which increases the potential space to accommodate a larger hematoma. It is not known if these two groups differ in other ways that might have implications for treatment or prognosis. In this paper, we investigate the clinical course of 80 patients admitted to our institution with acute subdural hematomas, to identify differences in patients above or below the age of 65 years. The natural progression/resolution of acute subdural hematomas was mapped by measuring volume expansion/regression over time. In this retrospective chart review, we investigated clinical baseline metrics and subsequent volumetric expansion outcomes between patients < 65 years old (N=44) and those > 65 years old (N=36). Volume was estimated by the ABC/2 method. We observed a statistically significant difference between groups in use of anticoagulants χ2 =40.305 with p < 0.001, corrective platelet administration χ2 =19.380 with p < 0.001, gender χ2 =14.573 with p < 0.001, and Glasgow Coma Scale with χ2 =23.125 (p=0.026). Overall outcomes were similar in the two groups. Younger patients on average had worse presenting GCS scores, but recovered comparable to older patients. No significant difference in rate of volume expansion, resolution time, or need for surgical treatment was seen between these two groups. We conclude that the initial volume, size, and severity of subdural hematoma determined by the Glasgow Coma Scale score is more likely to predict surgery or future expansion than age of the patient. Patients on oral anti-coagulants that are given appropriate medical reversal agents early do quite well and no impact on the eventual outcome could be demonstrated. Further work is needed to establish better predictors of future volume expansion, and progression to chronic subdural hematoma based on improved severity scales. PMID:27857999

Can focused trauma education initiatives reduce mortality or improve resource utilization in a low-resource setting?

PubMed

Petroze, Robin T; Byiringiro, Jean Claude; Ntakiyiruta, Georges; Briggs, Susan M; Deckelbaum, Dan L; Razek, Tarek; Riviello, Robert; Kyamanywa, Patrick; Reid, Jennifer; Sawyer, Robert G; Calland, J Forrest

2015-04-01

Over 90% of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ(2) and Fisher's exact test. A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3%, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3-8 had the highest injury-related mortality, which significantly decreased from 58.5% (n = 55) to 37.1% (n = 23), (p = 0.009, OR 0.42, 95% CI 0.22-0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3-5 in the post-intervention period had higher utilization of head CT scans and chest X-rays. The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.

‘Miracle baby’: an outcome of multidisciplinary approach to neurotrauma in pregnancy

PubMed Central

Neville, Grace; Kaliaperumal, Chandrasekaran; Kaar, George

2012-01-01

Traumatic brain injury (TBI) warranting neurosurgical intervention in the pregnant population is a rarity. We describe a case of a 27-year-old woman who at 13 weeks of gestation presented with multiple traumas having been involved in a near fatal road traffic accident. Glasgow Coma Scale was 6/15. CT brain showed extensive haemorrhagic contusions, diffuse brain swelling and multiple skull and facial fractures. Decompressive craniectomy was performed to control her intracranial pressure during her management in the intensive care. A viable intrauterine pregnancy was confirmed and progressed as maternal stabilisation and rehabilitation continued. At 35+3 weeks a 2770 g male child was delivered via emergency caesarean section after spontaneous onset of labour. The child had no detectable abnormalities and is clinically well. Eight months post-TBI the patient continues to make gradual improvements but is left with severe cognitive impairment and currently undergoing rehabilitation. A multidisciplinary approach was adopted in the management of this patient. PMID:22805738

Subpial Hematoma and Extravasation in the Interhemispheric Fissure with Subarachnoid Hemorrhage

PubMed Central

Matsuoka, Go; Abe, Kayoko; Okada, Yoshikazu; Sakai, Shuji

2015-01-01

A recent report on computed tomography (CT) findings of contrast extravasation in subarachnoid hemorrhage (SAH) with Sylvian hematoma suggests that the occurrence of the hematoma is secondary to bleeding in the subpial space. Our patient was in his sixties and was admitted to the hospital because of loss of consciousness (Glasgow Coma Scale E4V1M4). SAH was diagnosed in plain head CT, and growing hematomas were observed in the Sylvian and interhemispheric fissures following a subarachnoid hemorrhage. CT angiography (CTA) using a dual-phase scan protocol revealed contrast extravasation in both the fissures in the latter phase, and hematoma in the interhemispheric fissure contained multiple bleeding points. This case indicates that the occurrence of subpial hematoma such as Sylvian hematoma can be a secondary event following subpial bleeding from damaged small vessels elsewhere in the cranium. Instead of four-dimensional (4D) CT, the dual-phase CTA technique may help detect minor extravasations with usual helical CT scanner. PMID:25963159

[The efficacy of the native flumazenil for acute poisoning with benzodiazepines].

PubMed

Zhu, X H; Li, J X; Wang, F

2000-12-28

To evaluate the efficacy of the native flumazenil for acute self-poisoning with benzodiazepines. One hundred and twenty-six patients with unconsciousness from benzodiazepines-induced self-poisoning were randomly divided into two groups: flumazenil group(Group II, 63 cases) were treated with flumazenil, and conventional-medicine group(Group I, 63 cases) with placebo(glucose, vitamin C, KCl). A modified Glasgow Coma Scale(MGCS) and Observer's Assessment of Alertness/Sedation Scale(OAA/S) were used in the assessment of consciousness. MGCS were increased by 5.3, 8.0, 9.4 and 7.3 at 15 min, 30 min, 60 min and 180 min after intravenous flumazenil(P < 0.01) and by 5.2, 7.7, 8.7 and 6.9 in comparison with conventional-medicine group(P < 0.01). OAA/S increased by 1.9 compared with conventional-medicine group(P < 0.01). No severe side-effects were found in the treatment. Flumazenil might improve benzodiazepines-induced unconsciousness markedly and may be the most effective antagonist of benzodiazepines.

Streptococcus agalactiae septicemia in a patient with diabetes and hepatic cirrhosis

PubMed Central

Ferreira, Cristiane Rúbia

2015-01-01

Streptococcus agalactiae is a well-known pathogen during pregnancy and in neonates. Among non-pregnant adults, invasive infection, although rare, is showing increasing frequency, especially in chronically ill, immunosuppressed, or older patients. Although rare, the clinical features of meningeal infection caused by S. agalactiae are similar to other bacterial meningitis. The authors report the case of a middle-aged man previously diagnosed with hypertension, diabetes mellitus, and alcoholic liver cirrhosis, who was admitted at the emergency department with a Glasgow Coma Scale of 11/12, generalized spasticity, bilateral Babinski sign, and hypertension. The clinical outcome was bad, with refractory shock and death within 24 hours of hospitalization. The bacteriological work-up isolated S. agalactiae in the cerebral spinal fluid (CSF), blood, and urine. An autopsy revealed meningoencephalitis, acute myocardial infarction, and pyelonephritis due to septic emboli. The authors point out the atypical CSF findings, the rapid fatal outcome, and the importance of including this pathogen among the etiologic possibilities of invasive infections in this group of patients. PMID:26894044

Preliminary Validation of a New Measure of Negative Response Bias: The Temporal Memory Sequence Test.

PubMed

Hegedish, Omer; Kivilis, Naama; Hoofien, Dan

2015-01-01

The Temporal Memory Sequence Test (TMST) is a new measure of negative response bias (NRB) that was developed to enrich the forced-choice paradigm. The TMST does not resemble the common structure of forced-choice tests and is presented as a temporal recall memory test. The validation sample consisted of 81 participants: 21 healthy control participants, 20 coached simulators, and 40 patients with acquired brain injury (ABI). The TMST had high reliability and significantly high positive correlations with the Test of Memory Malingering and Word Memory Test effort scales. Moreover, the TMST effort scales exhibited high negative correlations with the Glasgow Coma Scale, thus validating the previously reported association between probable malingering and mild traumatic brain injury. A suggested cutoff score yielded acceptable classification rates in the ABI group as well as in the simulator and control groups. The TMST appears to be a promising measure of NRB detection, with respectable rates of reliability and construct and criterion validity.

Postoperative Chylothorax of Unclear Etiology in a Patient with Right-sided Subclavian Central Venous Catheter Placement

PubMed Central

Asghar, Samie; Shamim, Faisal

2017-01-01

A young male underwent decompressive craniotomy for an intracerebral bleed. A right-sided subclavian central venous catheter was placed in the operating room after induction of anesthesia. Postoperatively, he was shifted to Intensive Care Unit (ICU) for mechanical ventilation due to low Glasgow coma scale. He had an episode of severe agitation and straining on the tracheal tube in the evening same day. On the 2nd postoperative day in ICU, his airway pressures were high, and chest X-ray revealed massive pleural effusion on right side. Under ultrasound guidance, 1400 milky white fluid was aspirated. It was sent for analysis (triglycerides) that confirmed chyle and hence, chylothorax was made as diagnosis. A duplex scan was done which ruled out thrombosis in subclavian vein. The catheter had normal pressure tracing with free aspiration of blood from all ports. Enteral feeding was continued as it is a controversial matter in the literature and he was monitored clinically and radiologically. PMID:29284881

Postoperative Chylothorax of Unclear Etiology in a Patient with Right-sided Subclavian Central Venous Catheter Placement.

PubMed

Asghar, Samie; Shamim, Faisal

2017-01-01

A young male underwent decompressive craniotomy for an intracerebral bleed. A right-sided subclavian central venous catheter was placed in the operating room after induction of anesthesia. Postoperatively, he was shifted to Intensive Care Unit (ICU) for mechanical ventilation due to low Glasgow coma scale. He had an episode of severe agitation and straining on the tracheal tube in the evening same day. On the 2 nd postoperative day in ICU, his airway pressures were high, and chest X-ray revealed massive pleural effusion on right side. Under ultrasound guidance, 1400 milky white fluid was aspirated. It was sent for analysis (triglycerides) that confirmed chyle and hence, chylothorax was made as diagnosis. A duplex scan was done which ruled out thrombosis in subclavian vein. The catheter had normal pressure tracing with free aspiration of blood from all ports. Enteral feeding was continued as it is a controversial matter in the literature and he was monitored clinically and radiologically.

Perioperative and acute care outcomes in morbidly obese patients with acetabular fractures at a Level 1 trauma center

PubMed Central

Vincent, Heather K.; Haupt, Edward; Tang, Sonya; Egwuatu, Adaeze; Vlasak, Richard; Horodyski, MaryBeth; Carden, Donna; Sadisivan, Kalia K.

2014-01-01

Background Controversy exists regarding obesity-related injury severity and clinical outcomes after orthopedic trauma. Purpose The purposes of this study were to expand our understanding of the effect of morbid obesity on perioperative and acute care outcomes after acetabular fracture. Methods This was a retrospective review of patients with acetabular fracture after trauma. Non-morbidly obese (BMI < 35 kg/m2) and morbidly obese (BMI ≥ 35 kg/m2; N = 81). Injury severity scores and Glasgow Coma Scale scores (GCS) were collected. Perioperative and acute care outcomes were positioning and operative time, extra fractures, estimated blood loss, complications, hospital charges, ventilator days, transfusions, length of stay (LOS) and discharge destination. Positioning and operative times were longer in morbidly obese patients (p < 0.05). No other differences existed between groups. Conclusions Orthopedic trauma surgeons and care teams can expect similar acute care outcomes in morbidly obese and non-morbidly obese patients with acetabular fracture. PMID:25104886

Clinical evaluation of post-operative cerebral infarction in traumatic epidural haematoma.

PubMed

Zhang, Suojun; Wang, Sheng; Wan, Xueyan; Liu, Shengwen; Shu, Kai; Lei, Ting

2017-01-01

Patients with traumatic epidural haematoma, undergoing the prompt and correct treatment, usually have favourable outcomes. However, secondary cerebral infarction may be life-threatening condition, as it is difficult to be identified before neurological impairment occurs. To evaluate the clinical data of patients with traumatic EDH and assess potential risk factors for post-operative cerebral infarction. The clinical data of patients with traumatic EDH were collected and analysed retrospectively. The univariate analysis revealed 10 potential risk factors (the haematoma location, volume, the largest thickness and mid-line shift, basal cisterns compression, traumatic subarachnoid haemorrhage, pupil dilatation, pre-operative Glasgow Coma Scale score, ∆GCS and intraoperative brain pressure) for cerebral infarction with statistically significant difference. Of these factors, haematoma volume and basal cistern compression turned out to be the most significant risk factors through final multivariate logistic regression analysis. The findings of this study can provide predictive factors for development of cerebral infarction and information for clinical decision-making and future studies.

[Myxedema coma as a rare differential diagnosis of severe consciousness disturbance].

PubMed

Kollmar, R; Schellinger, P D; Bardutzky, J; Meisel, F; Schwaninger, M

2002-12-01

Myxedema coma is a rare and life-threatening complication of untreated hypothyroidism. Therefore, it must be part of the differential diagnosis in comatose patients. We report one patient who presented with CO(2) narcosis,hypothermia, bradycardia,hyporeflexia, tetraparesis, ascitis, pleural effusions, and heart insufficiency. Examination of the CSF, cranial CT, MRI, and MR angiography were normal. In suspicion of myxedema coma,the patient was treated with high dose L-thyroxine and hydrocortisone for preventing secondary adrenal insufficiency. A fast clinical recovery, decreased T4 (7.2 ng/l) and T3 (0.93 ng/l), and increased TSH (20.19 mU/l) together with the following anamnesis of radio iodine therapy and insufficient thyroxine intake confirmed the diagnosis. In conclusion, treatment of the myxedema coma must be started as soon as the laboratory results are confirmatory, since its course depends on the time of initiation of treatment.

Routine intracranial pressure monitoring in acute coma.

PubMed

Forsyth, Rob J; Raper, Joseph; Todhunter, Emma

2015-11-02

We know that the brain damage resulting from traumatic and other insults is not due solely to the direct consequences of the primary injury. A significant and potentially preventable contribution to the overall morbidity arises from secondary hypoxic-ischaemic damage. Brain swelling accompanied by raised intracranial pressure (ICP) prevents adequate cerebral perfusion with well-oxygenated blood.Detection of raised ICP could be useful in alerting clinicians to the need to improve cerebral perfusion, with consequent reductions in brain injury. To determine whether routine ICP monitoring in severe coma of any cause reduces the risk of all-cause mortality or severe disability at final follow-up. We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL Plus, ISI Web of Science (SCI-EXPANDED & CPCI-S), clinical trials registries and reference lists. We ran the most recent search on 22 May 2015. All randomised controlled studies of real-time ICP monitoring by invasive or semi-invasive means in acute coma (traumatic or non-traumatic aetiology) versus clinical care without ICP monitoring (that is, guided only by clinical or radiological inference of the presence of raised ICP). Two authors (ET and RF) worked independently to identify the one study that met inclusion criteria. JR and RF independently extracted data and assessed risk of bias. We contacted study authors for additional information, including details of methods and outcome data. One randomized controlled trial (RCT) meeting the selection criteria has been identified to date.The included study had 324 participants. We judged risk of bias to be low for all categories except blinding of participants and personnel, which is not feasible for this intervention. There were few missing data, and we analysed all on an intention-to-treat basis.Participants could be 13 years of age or older (mean age of sample 29; range 22 to 44), and all had severe traumatic brain injury, mostly due to traffic incidents. All were receiving care within intensive care units (ICUs) at one of six hospitals in either Bolivia or Ecuador. Investigators followed up 92% of participants for six months or until death. The trial excluded patients with a Glasgow Coma Score (GCS) less than three and fixed dilated pupils on admission on the basis that they had sustained brain injury of an unsalvageable severity.The study compared people managed using either an intracranial monitor or non-invasive monitoring (imaging and clinical examination) to identify potentially harmful raised intracranial pressure. Both study groups used imaging and clinical examination measures.Mortality at six months was 56/144 (39%) in the ICP-monitored group and 67/153 (44%) in the non-invasive group.Unfavourable outcome (defined as death or moderate to severe disability at six months) as assessed by the extended Glasgow Outcome Scale (GOS-E) was 80/144 (56%) in the ICP-monitored group and 93/153 (61%) in the non-invasive group.Six percent of participants in the ICP monitoring group had complications related to the monitoring, none of which met criteria for being a serious adverse event. There were no complications relating to the non-invasive group.Other complications and adverse events were comparable between treatment groups, 70/157 (45%) in the ICP-monitored group and 76/167 (46%) in the non-invasive group.Late mortality in both the monitored and non-invasive groups was high, with 35% of deaths occurring > 14 days after injury. The authors comment that this high late mortality may reflect inadequacies in post-ICU services for disabled survivors requiring specialist rehabilitation care. The data from the single RCT studying the role of routine ICP monitoring in acute traumatic coma fails to provide evidence to support the intervention.Research in this area is complicated by the fact that RCTs necessarily assess the combined impact of measurement of ICP with the clinical management decisions made in light of this data. Future studies will need to assess the added value of ICP data alongside other information from the multimodal monitoring typically performed in intensive care unit settings. Additionally, even within traumatically acquired brain injury (TBI), there is great heterogeneity in mechanisms, distribution, location and magnitude of injury, and studies within more homogeneous subgroups are likely to be more informative.

Hypoplastic anaemia complicating myxoedema coma.

PubMed

Song, S H; McCallum, C J; Campbell, I W

1998-10-01

The case of a 68 year old women presenting in myxoedema coma is described. She was found to be anaemic with a haemoglobin of 8.2 g/dl. Further investigations showed a pancytopenia and a hypoplastic anaemia confirmed by bone marrow. The patient recovered and became euthyroid following initial treatment with intravenous tri-iodothyronine (T3) and later oral thyroxine (T4) replacement with resolution of pancytopenia and return of bone marrow to normal.

[Severe fat embolism in perioperative abdominal liposuction and fat grafting].

PubMed

de Lima E Souza, Rodrigo; Apgaua, Bruno Tavares; Milhomens, João Daniel; Albuquerque, Francisco Tadeu Motta; Carneiro, Luiz Antônio; Mendes, Márcio Henrique; Garcia, Tiago Carvalho; Paiva, Clerisson; Ladeia, Felipe; Jeunon, Deiler Célio

2016-01-01

Fat embolism syndrome (FES) may occur in patients suffering from multiple trauma (long bone fractures) or plastic surgery (liposuction), compromising the circulatory, respiratory and/or central nervous systems. This report shows the evolution of severe FES after liposuction and fat grafting. SSS, 42 years old, ASA 1, no risk factors for thrombosis, candidate for abdominal liposuction and breast implant prosthesis. Subjected to balanced general anesthesia with basic monitoring and controlled ventilation. After 45minutes of procedure, there was a sudden and gradual decrease of capnometry, severe hypoxemia and hypotension. The patient was immediately monitored for MAP and central catheter, treated with vasopressors, inotropes, and crystalloid infusion, stabilizing her condition. Arterial blood sample showed pH = 7.21; PCO2 = 51mmHg; PO2 = 52mmHg; BE = -8; HCO3 = 18 mEq/L, and lactate = 6.0 mmol/L. Transthoracic echocardiogram showed PASP = 55mmHg, hypocontractile VD and LVEF = 60%. Diagnosis of pulmonary embolism. After 24h of intensive treatment, the patient developed anisocoria and coma (glasgow coma scale = 3). A brain CT was performed which showed severe cerebral hemispheric ischemia with signs of fat emboli in right middle cerebral artery; transesophageal echocardiography showed a patent foramen ovale. Finally, after 72h of evolution, the patient progressed to brain death. FES usually occurs in young people. Treatment is based mainly on the infusion of fluids and vasoactive drugs, mechanical ventilation, and triggering factor correction (early fixation of fractures or suspension of liposuction). The multiorgânico involvement indicates a worse prognosis. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Demographic profile and extent of healthcare resource utilisation of patients with severe traumatic brain injury: still a major public health problem.

PubMed

Wee, Jing Zhong; Yang, Yun Rui Jasmine; Lee, Qian Yi Ruth; Cao, Kelly; Chong, Chin Ted

2016-09-01

Trauma is the fifth principal cause of death in Singapore, with traumatic brain injury (TBI) being the leading specific subordinate cause. This study was an eight-year retrospective review of the demographic profiles of patients with severe TBI who were admitted to the neurointensive care unit (NICU) of the National Neuroscience Institute at Tan Tock Seng Hospital, Singapore, between 2004 and 2011. A total of 780 TBI patients were admitted during the study period; 365 (46.8%) patients sustained severe TBI (i.e. Glasgow Coma Scale score ≤ 8), with the majority (75.3%) being male. The ages of patients with severe TBI ranged from 14-93 years, with a bimodal preponderance in young adults (i.e. 21-40 years) and elderly persons (i.e. > 60 years). Motor vehicle accidents (48.8%) and falls (42.5%) were the main mechanisms of injury. Invasive line monitoring was frequently employed; invasive arterial blood pressure monitoring and central venous pressure monitoring were used in 81.6% and 60.0% of the patients, respectively, while intracranial pressure (ICP) measurement was required in 47.4% of the patients. The use of tiered therapy to control ICP (e.g. sedation, osmotherapy, cerebrospinal fluid drainage, moderate hyperventilation and barbiturate-induced coma) converged with international practices. The high-risk groups for severe TBI were young adults and elderly persons involved in motor vehicle accidents and falls, respectively. In the NICU, the care of patients with severe TBI requires heavy utilisation of resources. The healthcare burden of these patients extends beyond the acute critical care phase.

Monte Carlo Particle Trajectory Models for Neutral Cometary Gases. II. The Spatial Morphology of the Lyman-Alpha Coma

NASA Astrophysics Data System (ADS)

Combi, Michael R.; Smyth, William H.

1988-04-01

The Monte Carlo particle-trajectory model (MCPTM) developed in Paper 1 is applied to explain the observed morphology of the spatially extended Lyα comae of comets. The physical processes and assumptions used in the model as they relate to the photodissociation of H2O and OH and the solar radiation pressure acceleration are presented herein. For this first application, the rocket and Skylab images of the Lyα coma of comet Kohoutek were chosen for study. The self-consistent modeling analysis of these data consisted of two parts. The first part entailed using a steady state spherically symmetric inner coma MCPTM coupled with a simple gas-dynamic model to calculate the physical development of the coma, i.e., the dependence of coma temperature and outflow speed on radial distance to the center of the nucleus, as a function of the (time) heliocentric distance of the comet. The inner coma MCPTM was used to calculate correctly the photo-chemical heating of the coma due to the partial collisional thermalization of the hot hydrogen atoms produced in the photodissociation of water molecules. In the second part of the analysis the results from the first part were used in a fully time-dependent and three-dimensional extended coma MCPTM which includes the explicit calculation of partial thermalization of the H atoms by multiple collisions with coma molecules. The same physical model yielded very good matches between the modeled Lycα isophotes and those observed in both of the two very different images of comet Kohoutek. The production rate was varied in time as implied by the shape of the visual light curve. All other physical parameters were varied only according to their naturally expected heliocentric distance and velocity dependencies. The complete physical description of the inner coma provided by the coupled gas-dynamic/MCPTM calculation was needed to obtain a good fit to the data. The correct inner coma description is important since it provides not only the initial conditions for the photodissociated H atoms but also (and most importantly) the collisional targets for the H atoms produced in the innermost regions of the coma. Simplistic descriptions for the coma (single speed and perfectly radial molecular motion) do not yield realistic isophote contours. The implications of the model results as they apply to other comets, species, and a variety of conditions are also discussed.

Computed tomography-guided aspiration versus key-hole craniotomy for spontaneous putaminal haemorrhage: a prospective comparison of minimally invasive procedures.

PubMed

Zhao, J Z; Zhou, L F; Zhou, D B; Wang, R Z; Wang, M; Wang, D J; Wang, S; Yuan, G; Kang, S; Ji, N; Zhao, Y L; Ye, X

2009-08-01

To compare the effectiveness of two minimally invasive procedures, namely computed tomography-guided aspiration and the key-hole approach, in the neurosurgical management for spontaneous putaminal haemorrhage, and to explore the indications for the two approaches. A multicentre, single-blinded controlled trial. Hospitals taking part in this trial and the sources for patients were from China. Among others, the hospitals involved in the interventions included: the Beijing Tiantan Hospital (of the Capital University of Medical Sciences), the General Hospital of People's Liberation Army, the Peking Union Hospital, and the Shanghai Huashan Hospital (of the Fudan University medical school). From September 2001 to November 2003, data were available for analysis from a total of 841 patients with spontaneous putaminal haemorrhage from 135 hospitals all over China (except Tibet, Hong Kong, Taiwan, and Macao). All follow-up data were for at least 3 months. Mortality, Glasgow Coma Scale score, postoperative complications, Kanofsky Performance Scale score, and Barthel Index. There were 563 patients who underwent computed tomography-guided aspiration, and 165 were treated by the key-hole approach. Respective mortality rates 1 month after the operation were 17.9% and 18.3%; at 3 months they were 19.4% and 19.4%. In those undergoing computed tomography-guided aspiration, mortality rates at 3 months after the operation were 28.2% in patients with Glasgow Coma Scale scores of 8 or below, as opposed to 8.2% in those with higher scores. This amounted to a 3.4-fold difference. In those treated by the key-hole approach, the corresponding rates were 30.2% and 7.6%, which amounted to a 4-fold difference. The corresponding mortality at 3 months in patients with complications was 3.9 times as great as in those without complications. In those with haematoma volumes of 70 mL or greater, it was 2.7 times as much as in those in whom the volumes below 30 mL. The postoperative complication rate of computed tomography-guided aspiration (23.7%) did not differ significantly from that in those having the key-hole approach (25.7%) [P=0.420]. Computed tomography-guided aspiration is not superior to the key-hole approach for treating spontaneous putaminal haemorrhage in terms of favourable outcomes, mortality, and morbidity. However, it could be the first-choice approach for those with bleeds of 50 mL or less, while the key-hole approach may be more suitable for those with larger haematomas.

Child health-related quality of life following neurocritical care for traumatic brain injury: an analysis of preference-weighted outcomes.

PubMed

Tilford, John M; Aitken, Mary E; Goodman, Allen C; Fiser, Debra H; Killingsworth, Jeffrey B; Green, Jerril W; Adelson, P David

2007-01-01

Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking. This study seeks to describe the preference-weighted health outcomes of children following a traumatic brain injury at 3- and 6-months following pediatric intensive care unit (ICU) discharge. Children aged 5-17 who required ICU admission and endotracheal intubation or mechanical ventilation. The Quality of Well-being (QWB) score was used to describe preference-weighted outcomes. Clinical measures from the intensive care unit stay were used to estimate risk of mortality. Risk of mortality, Glasgow coma scores, patient length of stay in the intensive care unit, and parent-reported items from the Child Health Questionnaire (CHQ) were used to test construct validity. Subject data were obtained from nine pediatric intensive care units with consent procedures approved by representative institutional review boards. Medical records containing clinical information from the ICU stay were abstracted by the study coordinating center. Caregivers of children were contacted by telephone for follow-up interviews at 3- and 6-months following ICU discharge. All interviews were conducted by telephone with the primary caregiver of the injured child. Preference score statistics are presented overall and in relation to characteristics of the patient and their ICU admission. A response rate of 59% was achieved for the 3-month interviews (N = 56) and 67% for the 6-month interviews (N = 65) for caregivers of children aged 5 years and above that consented to participate. Overall, QWB scores averaged 0.508 (95% CI: 0.454-0.562) at the 3-month interview and 0.582 (95% CI: 0.526-0.639) at the 6-month interview. For both interview periods, scores ranged from 0.093 to 1.0 on a 0-1 value scale, where 0 represents death and 1 represents perfect health. Specific acute and chronic health problems from the QWB scale were present more often in patients with higher injury severity. Mortality risk, ICU length of stay, Glasgow Coma Scales, and parental reported summary scores from the CHQ all correlated correctly with the QWB scores. The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.

Use of recombinant factor VIIa in US military casualties for a five-year period.

PubMed

Wade, Charles E; Eastridge, Brian J; Jones, John A; West, Susan A; Spinella, Philip C; Perkins, Jeremy G; Dubick, Michael A; Blackbourne, Lorne H; Holcomb, John B

2010-08-01

Two prospective randomized trauma trials have shown recombinant factor VIIa (rFVIIa) to be safe and to decrease transfusion requirements. rFVIIa is presently used in 22% of massively transfused civilian trauma patients. The US Military has used rFVIIa in combat trauma patients for five years, and two small studies of massively transfused patients described an association with improved outcomes. This study was undertaken to assess how deployed physicians are using rFVIIa and its impact on casualty outcomes. US combat casualties (n = 2,050) receiving any blood transfusion from 2003 to 2009 were reviewed to compare patients receiving rFVIIa (n = 506) with those who did not (n = 1,544). Propensity-score matching (primary analysis) and multivariable logistic regression were used to compare outcomes. Differences were determined at p < 0.05. Twenty-five percent of patients received rFVIIa. Significant differences were noted between groups in indices of injury severity (Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Scale score), admission physiology (systolic blood pressure, diastolic blood pressure, heart rate, temperature, base deficit, hemoglobin, and international normalization ratio), and use of blood products, indicating that patients treated with rFVIIa were more severely injured, in shock, and coagulopathic. For propensity-score matching, factors associated with death were used: Injury Severity Score, Glasgow Coma Scale score, heart rate, systolic blood pressure, diastolic blood pressure, Hgb, and total packed red blood cell. A total of 266 patients per group were matched; 52% of the rFVIIa group. After pairing, there were no significant differences in any of the demographics, including incidence of massive transfusion (53% vs. 51%). There was no difference in the rate of complications (21% vs. 21%) or mortality (14% vs. 20%) for patients not treated or receiving rFVIIa, respectively. In military casualties, rFVIIa is used in the most severely injured patients based on physician selection rather than on guideline criteria. Use of rFVIIa is not associated with an improvement in survival or an increase in complications. The undetected bias of physician selection of patients for treatment with rFVIIa, likely, has an impact on case matching to achieve equivalence similar to that of randomized control studies. This inability to match populations, thus, prevents definitive interpretation of this study and others studies of similar design. This problem emphasizes the need to develop entry criteria to identify patients who could potentially benefit from use of rFVIIa and the need to subsequently perform efficacy studies.

Pediatric intracranial gunshot wounds: the Memphis experience.

PubMed

DeCuypere, Michael; Muhlbauer, Michael S; Boop, Frederick A; Klimo, Paul

2016-05-01

OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.

Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge.

PubMed

Kesinger, Matthew Ryan; Kumar, Raj G; Wagner, Amy K; Puyana, Juan Carlos; Peitzman, Andrew P; Billiar, Timothy R; Sperry, Jason L

2015-02-01

Long-term outcomes following traumatic brain injury (TBI) correlate with initial head injury severity and other acute factors. Hospital-acquired pneumonia (HAP) is a common complication in TBI. Limited information exists regarding the significance of infectious complications on long-term outcomes after TBI. We sought to characterize risks associated with HAP on outcomes 5 years after TBI. This study involved data from the merger of an institutional trauma registry and the Traumatic Brain Injury Model Systems outcome data. Individuals with severe head injuries (Abbreviated Injury Scale [AIS] score ≥ 4) who survived to rehabilitation were analyzed. Primary outcome was Glasgow Outcome Scale-Extended (GOSE) at 1, 2, and 5 years. GOSE was dichotomized into low (GOSE score < 6) and high (GOSE score ≥ 6). Logistic regression was used to determine adjusted odds of low GOSE score associated with HAP after controlling for age, sex, head and overall injury severity, cranial surgery, Glasgow Coma Scale (GCS) score, ventilation days, and other important confounders. A general estimating equation model was used to analyze all outcome observations simultaneously while controlling for within-patient correlation. A total of 141 individuals met inclusion criteria, with a 30% incidence of HAP. Individuals with and without HAP had similar demographic profiles, presenting vitals, head injury severity, and prevalence of cranial surgery. Individuals with HAP had lower presenting GCS score. Logistic regression demonstrated that HAP was independently associated with low GOSE scores at follow-up (1 year: odds ratio [OR], 6.39; 95% confidence interval [CI], 1.76-23.14; p = 0.005) (2 years: OR, 7.30; 95% CI, 1.87-27.89; p = 0.004) (5-years: OR, 6.89; 95% CI, 1.42-33.39; p = 0.017). Stratifying by GCS score of 8 or lower and early intubation, HAP remained a significant independent predictor of low GOSE score in all strata. In the general estimating equation model, HAP continued to be an independent predictor of low GOSE score (OR, 4.59; 95% CI, 1.82-11.60; p = 0.001). HAP is independently associated with poor outcomes in severe TBI extending 5 years after injury. This suggests that precautions should be taken to reduce the risk of HAP in individuals with severe TBI. Prognostic study, level III.

Hospital Acquired Pneumonia is an Independent Predictor of Poor Global Outcome in Severe Traumatic Brain Injury up to 5 Years after Discharge

PubMed Central

Kesinger, Matthew R.; Kumar, Raj G.; Wagner, Amy K.; Puyana, Juan C.; Peitzman, Andrew P.; Billiar, Timothy R.; Sperry, Jason L.

2016-01-01

Objectives Long-term outcomes following traumatic brain injury (TBI) correlate with initial head injury severity and other acute factors. Hospital-acquired pneumonia (HAP) is a common complication in TBI. Little information exists regarding the significance of infectious complications on long-term outcomes post-TBI. We sought to characterize risks associated with HAP on outcomes 5 years post-TBI. Methods Ddata from the merger of an institutional trauma registry and the TBI Model Systems outcome data. Individuals with severe head injuries (Abbreviated Injury Scale≥4), who survived to rehabilitation were analyzed. Primary outcome was Glasgow Outcome Scaled-Extended (GOSE) at 1, 2, and 5 years. GOSE was dichotomized into LOW (GOSE<6) and HIGH (GOSE≥6). Logistic regression was utilized to determine adjusted odds of LOW-GOSE associated with HAP after controlling for age, sex, head and overall injury severity, cranial surgery, Glasgow Coma Scale (GCS), ventilation days, and other important confounders. A general estimating equation (GEE) model was used to analyze all outcome observations simultaneously while controlling for within-patient correlation. Results A total of 141 individuals met inclusion criteria, with a 30% incidence of HAP. Individuals with and without HAP had similar demographic profiles, presenting vitals, head injury severity, and prevalence of cranial surgery. Individuals with HAP had lower presenting GCS. Logistic regression demonstrated that HAP was independently associated with LOW-GOSE scores at follow-up (1year: OR=6.39, 95%CI: 1.76-23.14, p=0.005; 2-years: OR=7.30, 95%CI 1.87-27.89, p=0.004; 5-years: OR=6.89, 95%CI: 1.42-33.39, p=0.017). Stratifying by GCS≤8 and early intubation, HAP remained a significant independent predictor of LOW-GOSE in all strata. In the GEE model, HAP continued to be an independent predictor of LOW-GOSE (OR: 4.59; 95%CI: 1.82-11.60′ p=0.001). Conclusion HAP is independently associated with poor outcomes in severe-TBI extending 5 years post-injury. This suggests precautions should be taken to reduce the risk of HAP in individuals with severe-TBI. Level III Retrospective Study Pneumonia TBI PMID:25757128

A prospective controlled study: Minimally invasive stereotactic puncture therapy versus conventional craniotomy in the treatment of acute intracerebral hemorrhage

PubMed Central

2011-01-01

Background Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke with the high mortality twofold to sixfold higher than that for ischemic stroke. But the treatment of haematomas within the basal ganglia continues to be a matter of debate among neurologists and neurosurgeons. The purpose of this study is to judge the clinical value of minimally invasive stereotactic puncture therapy (MISPT) on acute ICH. Methods A prospective controlled study was undertaken. The clinical trial was in compliance with the WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. According to the enrollment criterion, there were 168 acute ICH cases analyzed, of which 90 cases were performed by MISPT ( MISPT group, MG) and 78 cases by Conventional craniotomy (CC group, CG), by means of compare of Glasgow Coma Scale(GCS) score, postoperative complications(PC) and rebleeding incidence(RI), moreover, long-term outcome of 1 year postoperation judged by Glasgow Outcome Scale (GOS), Barthel Index (BI), modified Rankin Scale (mRS) and case fatality(CF). Results MG patients showed obvious amelioration in GCS score compared with that of CG. The total incidence of PC in MG decreased obviously compared with that of CG. The incidences of rebleeding in MG and CG were 10.0% and 15.4% respectively. There was no obvious difference between CFs of MG and CG. For three parameters representing long-term outcome, the GOS, BI and mRS in MG were ameliorated significantly than that of CG. Conclusion These data suggested that the advantage of MISPT was displayed in minute trauma and safety, and seemed to be feasible and to had a trend towards improved long-term outcome. Trial Registration The Australian New Zealand Clinical Trials Registry (ANZCTR), the registration number:ACTRN12610000945022. PMID:21699716

Decompressive Craniectomy for Traumatic Brain Injury: The Role of Cranioplasty and Hydrocephalus on Outcome.

PubMed

Nasi, Davide; Dobran, Mauro; Di Rienzo, Alessandro; di Somma, Lucia; Gladi, Maurizio; Moriconi, Elisa; Scerrati, Massimo; Iacoangeli, Maurizio

2018-05-14

After severe traumatic brain injury (sTBI) associated with uncontrollable high intracranial pressure (ICP), today the main challenge for neurosurgeons remains to identify who may obtain benefit from decompressive craniectomy (DC) and which factors after DC influence the prognosis of these patients. The aim of this paper was to identify the pre- and postoperative determinants of outcome after DC. This retrospective study included all patients undergoing DC for sTBI from 2003 to 2011. The 6-month outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS scores 4 and 5) and unfavorable (GOS scores 1-3) outcome. Predictors of outcome were identified by uni- and multivariate analysis. There were 190 patients who underwent DC for sTBI in this study. Sixty patients (31.6%) died within 30 days after DC. Independent prognostic factors for survival after 30 days were Glasgow Coma Scale score at admission greater than 5 (P = 0.002) and bilateral pupil reactivity (P < 0.0001). Thirty days after DC, 67 patients (51.5%) out of 130 had unfavorable outcome (GOS scores 1-3) and 63 patients (49.5%) presented favorable outcome (GOS scores 4 and 5). The independent preoperative prognostic factors for poor outcome were age over 65 years (P < 0.0001) and bilateral absence of pupil reactivity (P = 0.0165). After DC, onset of postoperative hydrocephalus and delayed cranioplasty (3 months after DC) was associated with unfavorable outcome at multivariate analysis (P = 0.002 and P < 0.0001, respectively). In our study, the development of hydrocephalus after DC for sTBI and delayed cranial reconstruction were associated with unfavorable outcome. Copyright © 2018 Elsevier Inc. All rights reserved.

A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol.

PubMed

Chesnut, Randall M; Temkin, Nancy; Dikmen, Sureyya; Rondina, Carlos; Videtta, Walter; Petroni, Gustavo; Lujan, Silvia; Alanis, Victor; Falcao, Antonio; de la Fuenta, Gustavo; Gonzalez, Luis; Jibaja, Manuel; Lavarden, Arturo; Sandi, Freddy; Mérida, Roberto; Romero, Ricardo; Pridgeon, Jim; Barber, Jason; Machamer, Joan; Chaddock, Kelley

2018-01-01

The imaging and clinical examination (ICE) algorithm used in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) randomized controlled trial is the only prospectively investigated clinical protocol for traumatic brain injury management without intracranial pressure (ICP) monitoring. As the default literature standard, it warrants careful evaluation. We present the ICE protocol in detail and analyze the demographics, outcome, treatment intensity, frequency of intervention usage, and related adverse events in the ICE-protocol cohort. The 167 ICE protocol patients were young (median 29 years) with a median Glasgow Coma Scale motor score of 4 but with anisocoria or abnormal pupillary reactivity in 40%. This protocol produced outcomes not significantly different from those randomized to the monitor-based protocol (favorable 6-month extended Glasgow Outcome Score in 39%; 41% mortality rate). Agents commonly employed to treat suspected intracranial hypertension included low-/moderate-dose hypertonic saline (72%) and mannitol (57%), mild hyperventilation (adjusted partial pressure of carbon dioxide 30-35 mm Hg in 73%), and pressors to maintain cerebral perfusion (62%). High-dose hyperosmotics or barbiturates were uncommonly used. Adverse event incidence was low and comparable to the BEST TRIP monitored group. Although this protocol should produce similar/acceptable results under circumstances comparable to those in the trial, influences such as longer pre-hospital times and non-specialist transport personnel, plus an intensive care unit model of aggressive physician-intensive care by small groups of neurotrauma-focused intensivists, which differs from most high-resource models, support caution in expecting the same results in dissimilar settings. Finally, this protocol's ICP-titration approach to suspected intracranial hypertension (vs. crisis management for monitored ICP) warrants further study.

External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom

PubMed Central

Griggs, Kathryn A.; Prabhu, Gita; Gomes, Manuel; Lecky, Fiona E.; Hutchinson, Peter J. A.; Menon, David K.; Rowan, Kathryn M.

2015-01-01

Abstract This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Scale score of less than 15 were recruited. The primary outcomes were mortality and unfavorable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3626 critical care unit admissions, 2975 were analyzed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavorable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven and colleagues, the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head Injury (CRASH) Trial Collaborators, and the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) group. The model with the best discrimination was the IMPACT “Lab” model (C index, 0.779 for mortality and 0.713 for unfavorable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavorable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavorable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research. PMID:25898072

Clinical Course and Outcomes of Small Supratentorial Intracerebral Hematomas.

PubMed

Behrouz, Réza; Misra, Vivek; Godoy, Daniel A; Topel, Christopher H; Masotti, Luca; Klijn, Catharina J M; Smith, Craig J; Parry-Jones, Adrian R; Slevin, Mark A; Silver, Brian; Willey, Joshua Z; Masjuán Vallejo, Jaime; Nzwalo, Hipólito; Popa-Wagner, Aurel; Malek, Ali R; Hafeez, Shaheryar; Di Napoli, Mario

2017-06-01

Intracerebral hemorrhage (ICH) volume, particularly if ≥30 mL, is a major determinant of poor outcome. We used a multinational ICH data registry to study the characteristics, course, and outcomes of supratentorial hematomas with volumes <30 mL. Basic characteristics, clinical and radiological course, and 30-day outcomes of these patients were recorded. Outcomes were categorized as early neurological deterioration (END), hematoma expansion, Glasgow Outcome Scale (GOS), and in-hospital death. Poor outcome was defined as composite of in-hospital death and severe disability (GOS ≤ 3). Comparison was conducted based on hemorrhage location. Logistic regression using dichotomized outcome scales was applied to determine predictors of poor outcome. Among 375 cases of supratentorial ICH with volumes <30 mL, expansion and END rates were 19.2% and 7.5%, respectively. Hemorrhage growth was independently associated with END (odds ratio: 28.7, 95% confidence interval [CI]: 8.51-96.5; P < .0001). Expansion rates did not differ according to ICH location. Overall, 13.9% (exact binomial 95% CI: 10.5-17.8) died in the hospital and 29.1% (CI: 24.5-34.0) had severe disability at 30 days; there was a cumulative poor outcome rate of 42.9% (CI: 37.9-48.1). Age, admission Glasgow Coma Scale, intraventricular extension, and END were independently associated with poor outcome. There was no difference in poor outcome rates between lobar and deep locations (40.2% versus 43.8%, P = .56). Patients with supratentorial ICH <30 mL have high rates of poor outcome at 30 days, regardless of location. Nearly 1 in 5 hematomas <30 mL expands, leading to END or death. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Serum levels of S100B from jugular bulb as a biomarker of poor prognosis in patients with severe acute brain injury.

PubMed

Ballesteros, María A; Rubio-Lopez, María I; San Martín, María; Padilla, Ana; López-Hoyos, Marcos; Llorca, Javier; Miñambres, Eduardo

2018-02-15

To evaluate the correlation between protein S100B concentrations measured in the jugular bulb as well as at peripheral level and the prognostic usefulness of this marker. A prospective study of all patients admitted to the intensive care unit with acute brain damage was carried out. Peripheral and jugular bulb blood samples were collected upon admission and every 24h for three days. The endpoints were brain death diagnosis and the Glasgow Outcome Scale score after 6months. A total of 83 patients were included. Jugular protein S100B levels were greater than systemic levels upon admission and also after 24 and 72h (mean difference>0). Jugular protein S100B levels showed acceptable precision in predicting brain death both upon admission [AUC 0.67 (95% CI 0.53-0.80)] and after 48h [AUC 0.73 (95% CI 0.57-0.89)]. Similar results were obtained regarding the capacity of jugular protein S100B levels upon admission to predict an unfavourable outcome (AUC 0.69 (95% CI 0.56-0.79)). The gradient upon admission (jugular-peripheral levels) showed its capacity to predict the development of brain death [AUC 0.74 (95% CI 0.62-0.86)] and together with the Glasgow Coma Scale constituted the independent factors associated with the development of brain death. Regional protein S100B determinations are higher than systemic determinations, thus confirming the cerebral origin of protein S100B. The transcranial protein S100B gradient is correlated to the development of brain death. Copyright © 2017. Published by Elsevier B.V.

Acute Gonadotroph and Somatotroph Hormonal Suppression after Traumatic Brain Injury

PubMed Central

Wagner, Justin; Dusick, Joshua R.; McArthur, David L.; Cohan, Pejman; Wang, Christina; Swerdloff, Ronald; Boscardin, W. John

2010-01-01

Abstract Hormonal dysfunction is a known consequence of moderate and severe traumatic brain injury (TBI). In this study we determined the incidence, time course, and clinical correlates of acute post-TBI gonadotroph and somatotroph dysfunction. Patients had daily measurement of serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, estradiol, growth hormone, and insulin-like growth factor-1 (IGF-1) for up to 10 days post-injury. Values below the fifth percentile of a healthy cohort were considered abnormal, as were non-measurable growth hormone (GH) values. Outcome measures were frequency and time course of hormonal suppression, injury characteristics, and Glasgow Outcome Scale (GOS) score. The cohort consisted of 101 patients (82% males; mean age 35 years; Glasgow Coma Scale [GCS] score ≤8 in 87%). In men, 100% had at least one low testosterone value, and 93% of all values were low; in premenopausal women, 43% had at least one low estradiol value, and 39% of all values were low. Non-measurable GH levels occurred in 38% of patients, while low IGF-1 levels were observed in 77% of patients, but tended to normalize within 10 days. Multivariate analysis revealed associations of younger age with low FSH and low IGF-1, acute anemia with low IGF-1, and older age and higher body mass index (BMI) with low GH. Hormonal suppression was not predictive of GOS score. These results indicate that within 10 days of complicated mild, moderate, and severe TBI, testosterone suppression occurs in all men and estrogen suppression occurs in over 40% of women. Transient somatotroph suppression occurs in over 75% of patients. Although this acute neuroendocrine dysfunction may not be TBI-specific, low gonadal steroids, IGF-1, and GH may be important given their putative neuroprotective functions. PMID:20214417

External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom.

PubMed

Harrison, David A; Griggs, Kathryn A; Prabhu, Gita; Gomes, Manuel; Lecky, Fiona E; Hutchinson, Peter J A; Menon, David K; Rowan, Kathryn M

2015-10-01

This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Scale score of less than 15 were recruited. The primary outcomes were mortality and unfavorable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3626 critical care unit admissions, 2975 were analyzed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavorable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven and colleagues, the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head Injury (CRASH) Trial Collaborators, and the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) group. The model with the best discrimination was the IMPACT "Lab" model (C index, 0.779 for mortality and 0.713 for unfavorable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavorable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavorable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research.

Characteristics of Firearm Brain Injury Survivors in the Traumatic Brain Injury Model Systems (TBIMS) National Database: A Comparison of Assault and Self-Inflicted Injury Survivors.

PubMed

Bertisch, Hilary; Krellman, Jason W; Bergquist, Thomas F; Dreer, Laura E; Ellois, Valerie; Bushnik, Tamara

2017-11-01

To characterize and compare subgroups of survivors with assault-related versus self-inflicted traumatic brain injuries (TBIs) via firearms at the time of inpatient rehabilitation and at 1-, 2-, and 5-year follow-up. Secondary analysis of data from the Traumatic Brain Injury Model Systems National Database (TBIMS NDB), a multicenter, longitudinal cohort study. Retrospective analyses of a subset of individuals enrolled in the TBIMS NDB. Individuals 16 years and older (N=399; 310 via assault, 89 via self-inflicted injury) with a primary diagnosis of TBI caused by firearm injury enrolled in the TBIMS NDB. Not applicable. Disability Rating Scale, Glasgow Outcome Scale-Extended, sociodemographic variables (sex, age, race, marital status), injury-related/acute care information (posttraumatic amnesia, loss of consciousness, time from injury to acute hospital discharge), and mental health variables (substance use history, psychiatric hospitalizations, suicide history, incarcerations). Individuals who survived TBI secondary to a firearm injury differed by injury mechanism (assault vs self-inflicted) on critical demographic, injury-related/acute care, and mental health variables at inpatient rehabilitation and across long-term recovery. Groups differed in terms of geographic area, age, ethnicity, education, marital status, admission Glasgow Coma Scale score, and alcohol abuse, suicide attempts, and psychiatric hospitalizations at various time points. These findings have implications for prevention (eg, mental health programming and access to firearms in targeted areas) and for rehabilitation planning (eg, by incorporating training with coping strategies and implementation of addictions-related services) for firearm-related TBI, based on subtype of injury. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Prostacyclin influences the pressure reactivity in patients with severe traumatic brain injury treated with an ICP-targeted therapy.

PubMed

Koskinen, Lars-Owe D; Eklund, Anders; Sundström, Nina; Olivecrona, Magnus

2015-02-01

This prospective consecutive double-blinded randomized study investigated the effect of prostacyclin on pressure reactivity (PR) in severe traumatic brain injured patients. Other aims were to describe PR over time and its relation to outcome. Blunt head trauma patients, Glasgow coma scale ≤8, age 15-70 years were included and randomized to prostacyclin treatment (n = 23) or placebo (n = 25). Outcome was assessed using the extended Glasgow outcome scale (GOSE) at 3 months. PR was calculated as the regression coefficient between the hourly mean values of ICP versus MAP. Pressure active/stable was defined as PR ≤0. Mean PR over 96 h (PRtot) was 0.077 ± 0.168, in the prostacyclin group 0.030 ± 0.153 and in the placebo group 0.120 ± 0.173 (p < 0.02). There was a larger portion of pressure-active/stable patients in the prostacyclin group than in the placebo group (p < 0.05). Intra-individual changes over time were common. PRtot correlated negatively with GOSE score (p < 0.04). PRtot was 0.117 ± 0.182 in the unfavorable (GOSE 1-4) and 0.029 ± 0.140 in the favorable outcome group (GOSE 5-8). Area under the curve for prediction of death (ROC) was 0.742 and for favorable outcome 0.628. Prostacyclin influenced the PR in a direction of increased pressure stability and a lower PRtot was associated with improved outcome. The individual PR varied substantially over time. The predictive value of PRtot for outcome was not solid enough to be used in the clinical situation.

Revisiting the “Golden Hour”: An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury

PubMed Central

Newgard, Craig D.; Meier, Eric N.; Bulger, Eileen M.; Buick, Jason; Sheehan, Kellie; Lin, Steve; Minei, Joseph P.; Barnes-Mackey, Roxy A.; Brasel, Karen

2015-01-01

Study Objective We evaluated shock and traumatic brain injury (TBI) patients previously enrolled in an out-of-hospital clinical trial to test the association between out-of-hospital time and outcome. Methods This was a secondary analysis of shock and TBI patients ≥ 15 years enrolled in a Resuscitation Outcomes Consortium out-of-hospital clinical trial by 81 EMS agencies transporting to 46 Level I and II trauma centers in 11 sites (May 2006 through May 2009). Inclusion criteria were: SBP ≤ 70 mmHg or SBP 71 - 90 mmHg with heart rate ≥ 108 beats per minute (shock cohort) and Glasgow Coma Scale score ≤ 8 (TBI cohort); patients meeting both criteria were placed in the shock cohort. Primary outcomes were 28-day mortality (shock cohort) and 6-month Glasgow Outcome Scale - Extended (GOSE) ≤ 4 (TBI cohort). Results There were 778 patients in the shock cohort (26% 28-day mortality) and 1,239 patients in the TBI cohort (53% 6-month GOSE ≤ 4). Out-of-hospital time > 60 minutes was not associated with worse outcomes after accounting for important confounders in the shock cohort (adjusted odds ratio [aOR] 1.42, 95% CI 0.77-2.62) or TBI cohort (aOR 0.80, 95% CI 0.52-1.21). However, shock patients requiring early critical hospital resources and arriving > 60 minutes had higher 28-day mortality (aOR 2.37, 95% CI 1.05-5.37); this finding was not observed among a similar TBI subgroup. Conclusions Among out-of-hospital trauma patients meeting physiologic criteria for shock and TBI, there was no association between time and outcome. However, the subgroup of shock patients requiring early critical resources arriving after 60 minutes had higher mortality. PMID:25596960

Implementation of Neurocritical Care Is Associated With Improved Outcomes in Traumatic Brain Injury.

PubMed

Sekhon, Mypinder S; Gooderham, Peter; Toyota, Brian; Kherzi, Navid; Hu, Vivien; Dhingra, Vinay K; Hameed, Morad S; Chittock, Dean R; Griesdale, Donald E

2017-07-01

Background Traditionally, the delivery of dedicated neurocritical care (NCC) occurs in distinct NCC units and is associated with improved outcomes. Institution-specific logistical challenges pose barriers to the development of distinct NCC units; therefore, we developed a consultancy NCC service coupled with the implementation of invasive multimodal neuromonitoring, within a medical-surgical intensive care unit. Our objective was to evaluate the effect of a consultancy NCC program on neurologic outcomes in severe traumatic brain injury patients. We conducted a single-center quasi-experimental uncontrolled pre- and post-NCC study in severe traumatic brain injury patients (Glasgow Coma Scale ≤8). The NCC program includes consultation with a neurointensivist and neurosurgeon and multimodal neuromonitoring. Demographic, injury severity metrics, neurophysiologic data, and therapeutic interventions were collected. Glasgow Outcome Scale (GOS) at 6 months was the primary outcome. Multivariable ordinal logistic regression was used to model the association between NCC implementation and GOS at 6 months. A total of 113 patients were identified: 76 pre-NCC and 37 post-NCC. Mean age was 39 years (standard deviation [SD], 2) and 87 of 113 (77%) patients were male. Median admission motor score was 3 (interquartile ratio, 1-4). Daily mean arterial pressure was higher (95 mmHg [SD, 10]) versus (88 mmHg [SD, 10], p<0.001) and daily mean core body temperature was lower (36.6°C [SD, 0.90]) versus (37.2°C [SD, 1.0], p=0.001) post-NCC compared with pre-NCC, respectively. Multivariable regression modelling revealed the NCC program was associated with a 2.5 increased odds (odds ratios, 2.5; 95% confidence interval, 1.1-5.3; p=0.022) of improved 6-month GOS. Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.

The Outcomes of Targeted Temperature Management After Cardiac Arrest at Emergency Department: A Real-World Experience in a Developing Country.

PubMed

Srivilaithon, Winchana; Muengtaweepongsa, Sombat

2017-03-01

Targeted temperature management (TTM) is indicated for comatose survivors of cardiac arrest to improve outcomes. However, the benefit of TTM was verified by rigid controlled clinical trials. This study aimed at evaluating its effects in real-world practices. A prospective observational study was done at the emergency department of tertiary care, Thammasat Hospital, from March 2012 until October 2015. We included all who did not obey verbal commands after being resuscitated from cardiac arrest regardless of initial cardiac rhythm. We excluded patients with traumatic arrest, uncontrolled bleeding, younger than 15 years old, and of poor neurological status (Glasgow coma scale below 14) before cardiac arrest. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcome (Cerebral Performance Categories 1 or 2 within 30 days). We used the logistic regression model to estimate the propensity score (PS) that will be used as a weight in the analysis. To analyze outcomes, the PS was introduced as a factor in the final logistic regression model in conjunction with other factors. A total of 192 cases, 61 and 131 patients, were enrolled in TTM and non-TTM groups, respectively. Characteristics believed to be related to initiation of TTM: gender, age, cardiac etiology, out-of-hospital cardiac arrest, witness arrest, collapse time, initial rhythm, received defibrillation, and advanced airway insertion, were included in multivariable analysis and estimated PS. After adjusted regression analysis with PS, the TTM group had a better result in survival to hospital discharge (34.43% vs. 12.21%; adjusted incidence risk ratio (IRR), 2.95; 95% confidence interval (CI), 1.49-5.84; p = 0.002). For neurological outcome, the TTM group had a higher number of favorable neurological outcomes (24.59% vs. 6.87%; IRR, 3.96; 95% CI, 1.67-9.36; p = 0.002). In real-world practices without a strictly controlled environment, TTM can improve survival and favorable neurological outcome in postcardiac arrest patients regardless of initial rhythm.

Active music therapy in the rehabilitation of severe brain injured patients during coma recovery.

PubMed

Formisano, R; Vinicola, V; Penta, F; Matteis, M; Brunelli, S; Weckel, J W

2001-01-01

Active improvised music therapy may offer an adjuvant from of treatment in the early rehabilitation of severe brain-injured patients. Active music therapy consists of musical improvisation between patient and therapist by singing or by playing different musical instruments, according to the vital functions, the neurological conditions and the motor abilities of the patients. We studied 34 severe brain-injured patients with a mean coma duration of 52 days +/- 37.21 and a mean interval from coma onset to the beginning of rehabilitation of 154 days on average. Our preliminary results show a significant improvement of the collaboration of the severe brain-injured patients and a reduction of undesired behaviours such as inertia (reduced psychomotor initiative) or psychomotor agitation.

Effects of platelet and plasma transfusion on outcome in traumatic brain injury patients with moderate bleeding diatheses.

PubMed

Anglin, Catherine O; Spence, Jeffrey S; Warner, Matthew A; Paliotta, Christopher; Harper, Caryn; Moore, Carol; Sarode, Ravi; Madden, Christopher; Diaz-Arrastia, Ramon

2013-03-01

Object Coagulopathy and thrombocytopenia are common after traumatic brain injury (TBI), yet transfusion thresholds for mildly to moderately abnormal ranges of international normalized ratio and platelet count remain controversial. This study evaluates associations between fresh frozen plasma (FFP) and platelet transfusions with long-term functional outcome and survival in TBI patients with moderate hemostatic laboratory abnormalities. Methods This study is a retrospective review of prospectively collected data of patients with mild to severe TBI. Data include patient demographics, several initial injury severity metrics, daily laboratory values, Glasgow Outcome Score- Extended (GOSE) scores, Functional Status Examination (FSE) scores, and survival to 6 months. Correlations were evaluated between these variables and transfusion of FFP, platelets, packed red blood cells (RBCs), cryoprecipitate, recombinant factor VIIa, and albumin. Ordinal regression was performed to account for potential confounding variables to further define relationships between transfusion status and long-term outcome. By analyzing collected data, mild to moderate coagulopathy was defined as an international normalized ratio 1.4-2.0, moderate thrombocytopenia as platelet count 50 × 10(9)/L to 107 × 10(9)/L, and moderate anemia as 21%-30% hematocrit. Results In patients with mild to moderate laboratory hematological abnormalities, univariate analysis shows significant correlations between poor outcome scores and FFP, platelet, or packed RBC transfusion; the volume of FFP or packed RBCs transfused also correlated with poor outcome. Several measures of initial injury and laboratory abnormalities also correlated with poor outcome. Patient age, initial Glasgow Coma Scale score, and highest recorded serum sodium were included in the ordinal regression model using backward variable selection. In the moderate coagulopathy subgroup, patients transfused with FFP were more likely to have a lower GOSE score relative to those who did not receive a transfusion (OR 5.20 [95% CI 1.72-15.73]). Patients with moderate coagulopathy who received FFP and packed RBCs were even more likely to be have a lower GOSE score (OR 7.17 [95% CI 2.12-24.12]). Moderately anemic patients who received packed RBCs alone were more likely to have a worse long-term functional outcome as determined by GOSE and FSE scores (GOSE: OR 2.41 [95% CI 1.51-3.85]; and FSE: OR 3.27 [95% CI 2.00-5.35]). No transfusion types or combinations were noted to significantly correlate with the 6-month mortality in ordinal regression. Conclusions In TBI patients with moderate coagulopathy, FFP transfusions alone or a combination of FFP and packed RBCs were associated with poorer long-term functional outcomes as measured by the GOSE. Red blood cell transfusions were associated with poor long-term functional outcome in TBI patients with moderate anemia. Platelet transfusion in patients with moderate thrombocytopenia was not significantly associated with outcome. Although transfusion is beneficial to many patients with severe hematological abnormalities, it is not without risk, and the indications for transfusion should be carefully considered in patients with moderate hematological abnormalities.

Changing paradigms in the management of 2184 patients with traumatic brain injury.

PubMed

Joseph, Bellal; Haider, Ansab A; Pandit, Viraj; Tang, Andrew; Kulvatunyou, Narong; OʼKeeffe, Terence; Rhee, Peter

2015-09-01

The aim of this study was to assess the change in trends in the management of traumatic brain injury (TBI) at a level I trauma center and the utilization of resources as a result of this change in management. The management of TBI has been evolving with trends toward management of minimally injured patients with intracranial hemorrhage exclusively by trauma surgeons. A 5-year (2009-2014) prospective database on all patients with TBI (skull fracture/intracranial hemorrhage on head computed tomography) presenting to a level I trauma center was analyzed for patient demographics, injuries, admission physiology, computed tomographic scan results, and hospital outcomes. These records were matched to the institutional registry and hospital financial database. A total of 2184 patients were included with median (interquartile range) Glasgow Coma Scale score of 15 (12-15), and median (interquartile range) head-abbreviated injury scale score of 3 (2-4). The distribution of types and size of intracranial bleeds remained unchanged throughout the study period. The proportion of TBI managed exclusively by trauma surgeons increased significantly over the years from 6.8% to 40.1% (P < 0.001). Proportion of patients who received neurosurgical consultations (P < 0.001) and repeat head computed tomographic scans (P < 0.001), hospital length of stay (P = 0.028), and costs (P < 0.001) decreased significantly over time. The overall mortality rate (18.5%) and rate of intervention (14.1%) remained unchanged. TBI patients can be selectively managed without initially involving neurosurgeons safely in a cost-effective manner, resulting in more effective use of precious resources.

The definition of polytrauma revisited: An international consensus process and proposal of the new 'Berlin definition'

PubMed

Pape, Hans-Christoph; Lefering, Rolf; Butcher, Nerida; Peitzman, Andrew; Leenen, Luke; Marzi, Ingo; Lichte, Philip; Josten, Christoph; Bouillon, Bertil; Schmucker, Uli; Stahel, Philip; Giannoudis, Peter; Balogh, Zsolt

2014-11-01

The nomenclature for patients with multiple injuries with high mortality rates is highly variable, and there is a lack of a uniform definition of the term polytrauma. A consensus process was therefore initiated by a panel of international experts with the goal of assessing an improved, database-supported definition for the polytraumatized patient. The consensus process involved the following: RESULTS: A total of 28,211 patients in the trauma registry met the inclusion criteria. The mean (SD) age of the study cohort was 42.9 (20.2) years (72% males, 28% females). The mean (SD) ISS was 30.5 (12.2), with an overall mortality rate of 18.7% (n = 5,277) and an incidence of 3% of penetrating injuries (n = 886). Five independent physiologic variables were identified, and their individual cutoff values were calculated based on a set mortality rate of 30%: hypotension (systolic blood pressure ≤ 90 mm Hg), level of consciousness (Glasgow Coma Scale [GCS] score ≤ 8), acidosis (base excess ≤ -6.0), coagulopathy (international normalized ratio ≥ 1.4/partial thromboplastin time ≥ 40 seconds), and age (≥70 years). Based on several consensus meetings and a database analysis, the expert panel proposes the following parameters for a definition of "polytrauma": significant injuries of three or more points in two or more different anatomic AIS regions in conjunction with one or more additional variables from the five physiologic parameters. Further validation of this proposal should occur, favorably by mutivariate analyses of these parameters in a separate data set.

Heroin and pharmaceutical opioid overdose events: Emergency medical response characteristics.

PubMed

Banta-Green, Caleb J; Coffin, Phillip O; Schoeppe, Jennie A; Merrill, Joseph O; Whiteside, Lauren K; Ebersol, Abigail K

2017-09-01

Emergency Medical Services (EMS) data may provide insight into opioid overdose incidence, clinical characteristics, and medical response. This analysis describes patient characteristics, clinical features, and EMS response to opioid overdoses, comparing heroin and pharmaceutical opioid (PO) overdoses, using a structured opioid overdose case criteria definition. A case series study was conducted. EMS medical staff screened cases for possible overdoses and study staff categorized the likelihood of opioid overdose. Medical form data were abstracted. Patient characteristics, clinical presentation, and medical response to heroin and PO-involved overdoses were compared with bi-variate test statistics. We identified 229 definite or probable opioid overdose cases over six months: heroin in 98 (43%) cases (10 also involved PO), PO without heroin in 85 (37%) cases, and 46 (20%) that could not be categorized and were excluded from analyses. Heroin overdose patients were younger than PO (median age 33 v 41 (p<0.05)), more often male (80% v 61% (p=<0.01)), intubated less (8% v 22%, p<0.01) and more likely to be administered naloxone (72% v 51%, p<0.01). No significant differences were found between heroin and PO overdoses for initial respiratory rate, Glasgow Coma Scale score, or co-ingestants, but heroin users were more likely to have miotic pupils (p<0.01). While heroin and PO events presented similarly, heroin-involved cases were more likely to receive naloxone and less likely to be intubated. Standardized case definitions and data documentation could aid opioid overdose surveillance as well as provide data for measuring the impact of professional and lay interventions. Copyright © 2017 Elsevier B.V. All rights reserved.

Outcome of endovascular treatment for acute basilar artery occlusion in the modern era: a single institution experience.

PubMed

Li, Chuanhui; Zhao, Wenbo; Wu, Chuanjie; Shang, Shuyi; Chen, Jian; Ren, Ming; Duan, Jiangang; Ma, Qingfeng; Li, Guilin; Zhang, Yunzhou; Zhang, Hongqi; Jiao, Liqun; Ji, Xunming

2018-06-01

The beneficial effect of endovascular treatment (EVT) for patients with acute basilar artery occlusion (ABAO) remains uncertain. The purpose of the present study was to evaluate clinical outcome of EVT for patients with ABAO and analyze prognostic factors of good outcome. From our prospectively established database, we reviewed all patients with ABAO receiving EVT during January 2014 to December 2016. Baseline characteristics and outcomes were evaluated. Favorable functional outcome was defined as modified Rankin Scale score of 0 to 3 assessed at 3-month follow-up. The association between clinical and procedural characteristics and functional outcome was assessed. Of the 68 patients included, 50 patients (73.5%) received mechanical thrombectomy with stent retriever device. Successful reperfusion (thrombolysis in cerebral infarction grades 2b-3) was achieved in 61 patients (89.7%). Overall favorable functional outcome was reached by 31 patients (45.6%). In univariate analysis, Glasgow Coma Scale sum score, baseline National Institutes of Health stroke scale score (NIHSS), and baseline glycemia level were identified predicting good clinical outcome. Multivariate analysis showed that lower NIHSS was the only independent risk factor of favorable functional outcome (OR 0.832; 95% CI, 0.715-0.968; p = 0.018). No difference of favorable outcomes was observed between the subgroups of time to EVT < 6 h and ≽ 6 h. Data in the present study suggests that EVT for ABAO patients should be reasonable within 24 h of symptom onset. The most important factor determining clinical outcome is initial stroke severity.

Management of penetrating brain injury

PubMed Central

Kazim, Syed Faraz; Shamim, Muhammad Shahzad; Tahir, Muhammad Zubair; Enam, Syed Ather; Waheed, Shahan

2011-01-01

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients. PMID:21887033

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia

PubMed Central

Mounier, Roman; Lobo, David; Voulgaropoulos, Julia; Martin, Mathieu; Aït-Mamar, Bouziane; Bitot, Valérie; Jost, Paul-Henri; Birnbaum, Ron; Nebbad, Biba; Cook, Fabrice; Dhonneur, Gilles

2017-01-01

Object We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. Methods We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. Results Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21–64]) with severe trauma (initial Simplified Acute Score II = 42 [32–52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient’s characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. Conclusions Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults. PMID:29261721

Chemistry in cometary comae

NASA Technical Reports Server (NTRS)

Irvine, W. M.; Dickens, J. E.; Lovell, A. J.; Schloerb, F. P.; Senay, M.; Bergin, E. A.; Jewitt, D.; Matthews, H. E.

1998-01-01

Significant gas-phase chemistry occurs in the comae of bright comets, as is demonstrated here for the case of Comet Hale-Bopp. The abundance ratio of the two isomers, hydrogen cyanide and hydrogen isocyanide, is shown to vary with heliocentric distance in a way that is consistent with production of HNC by ion-molecule chemistry initiated by the photoionization of water. Likewise, the first maps of emission from HCO+ show an abundance and an extended distribution that are consistent with the same chemical model.

Cortisol evaluation during the acute phase of traumatic brain injury-A prospective study.

PubMed

Bensalah, Meriem; Donaldson, Malcolm; Aribi, Yamina; Iabassen, Malek; Cherfi, Lyes; Nebbal, Mustapha; Medjaher, Meriem; Haffaf, ElMehdi; Abdennebi, Benaissa; Guenane, Kamel; Djermane, Adel; Kemali, Zahra; OuldKablia, Samia

2018-05-01

Biochemical diagnosis of adrenal insufficiency (AI) is difficult in the context of traumatic brain injury (TBI). To assess the frequency and predictive factors of AI in victims of TBI from Algiers. Between November 2009 and December 2013, TBI victims had a single 8-9 am serum cortisol measurement during the acute postinjury period (0-7 days). AI was defined according to basal cortisol levels of 83, 276 and 414 nmol/L. Variables studied were TBI severity according to Glasgow coma scale, duration of intubation and coma, pupillary status, hypotension, anaemia, brain imaging findings, diabetes insipidus and medication. Insulin tolerance test was performed during the recovery phase, defining AI as peak cortisol <500 nmol/L. Cortisol samples were obtained at median 3 (1-7) days from 277 patients (257M: 20F) aged 32 (18-65) years. Acute AI frequency was 8 (2.8%), 20 (21%) and 35 (37%), respectively using the three cortisol cut-offs. Factors predicting AI were diastolic hypotension, sedative medication, diabetes insipidus, skull base fracture and intraparenchymal haematoma. Mortality was highest in patients with acute cortisol <276 nmol/L (44.6% with OR for death 1.64, 95% CI 0.92-3.0, P = .12). During the recovery phase, AI was present in 3 of 3, 12 of 24, 4 of 16 and 20 of 66 patients with week 1 cortisol <83, 83-276, 277-414 and >414 nmol/L. Hydrocortisone replacement is advised in TBI patients with morning cortisol <276 nmol/L or those <414 nmol/L with additional risk factors for AI. As acute and subsequent AI are poorly correlated, patients with moderate/severe TBI require adrenal re-evaluation during the recovery phase. © 2018 John Wiley & Sons Ltd.

Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality

PubMed Central

Lawrence, T; Bouamra, O; Woodford, M; Lecky, F; Hutchinson, P J

2016-01-01

Objectives To provide a comprehensive assessment of the management of traumatic brain injury (TBI) relating to epidemiology, complications and standardised mortality across specialist units. Design The Trauma Audit and Research Network collects data prospectively on patients suffering trauma across England and Wales. We analysed all data collected on patients with TBI between April 2014 and June 2015. Setting Data were collected on patients presenting to emergency departments across 187 hospitals including 26 with specialist neurosurgical services, incorporating factors previously identified in the Ps14 multivariate logistic regression (Ps14n) model multivariate TBI outcome prediction model. The frequency and timing of secondary transfer to neurosurgical centres was assessed. Results We identified 15 820 patients with TBI presenting to neurosurgical centres directly (6258), transferred from a district hospital to a neurosurgical centre (3682) and remaining in a district general hospital (5880). The commonest mechanisms of injury were falls in the elderly and road traffic collisions in the young, which were more likely to present in coma. In severe TBI (Glasgow Coma Score (GCS) ≤8), the median time from admission to imaging with CT scan is 0.5 hours. Median time to craniotomy from admission is 2.6 hours and median time to intracranial pressure monitoring is 3 hours. The most frequently documented complication of severe TBI is bronchopneumonia in 5% of patients. Risk-adjusted W scores derived from the Ps14n model indicate that no neurosurgical unit fell outside the 3 SD limits on a funnel plot. Conclusions We provide the first comprehensive report of the management of TBI in England and Wales, including data from all neurosurgical units. These data provide transparency and suggests equity of access to high-quality TBI management provided in England and Wales. PMID:27884843

Application of the FOUR Score in Intracerebral Hemorrhage Risk Analysis.

PubMed

Braksick, Sherri A; Hemphill, J Claude; Mandrekar, Jay; Wijdicks, Eelco F M; Fugate, Jennifer E

2018-06-01

The Full Outline of Unresponsiveness (FOUR) Score is a validated scale describing the essentials of a coma examination, including motor response, eye opening and eye movements, brainstem reflexes, and respiratory pattern. We incorporated the FOUR Score into the existing ICH Score and evaluated its accuracy of risk assessment in spontaneous intracerebral hemorrhage (ICH). Consecutive patients admitted to our institution from 2009 to 2012 with spontaneous ICH were reviewed. The ICH Score was calculated using patient age, hemorrhage location, hemorrhage volume, evidence of intraventricular extension, and Glasgow Coma Scale (GCS). The FOUR Score was then incorporated into the ICH Score as a substitute for the GCS (ICH Score FS ). The ability of the 2 scores to predict mortality at 1 month was then compared. In total, 274 patients met the inclusion criteria. The median age was 73 years (interquartile range 60-82) and 138 (50.4%) were male. Overall mortality at 1 month was 28.8% (n = 79). The area under the receiver operating characteristic curve was .91 for the ICH Score and .89 for the ICH Score FS . For ICH Scores of 1, 2, 3, 4, and 5, 1-month mortality was 4.2%, 29.9%, 62.5%, 95.0%, and 100%. In the ICH Score FS model, mortality was 10.7%, 26.5%, 64.5%, 88.9%, and 100% for scores of 1, 2, 3, 4, and 5, respectively. The ICH Score and the ICH Score FS predict 1-month mortality with comparable accuracy. As the FOUR Score provides additional clinical information regarding patient status, it may be a reasonable substitute for the GCS into the ICH Score. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Comparison of enteral ethanol and benzodiazepines for alcohol withdrawal in neurocritical care patients.

PubMed

Gipson, Gregory; Tran, Kim; Hoang, Cuong; Treggiari, Miriam

2016-09-01

We designed a study to evaluate the use of benzodiazepines and ethanol in patients being assessed for alcohol withdrawal and compare outcomes between the two agents. This is a retrospective chart review of patients admitted to neurocritical care or neurosurgical services who were at risk for ethanol withdrawal between June 2011 and September 2015. Patients were divided into two groups based on the first medication administered for alcohol withdrawal management, either benzodiazepine (n=50) or enteral ethanol (n=50). The primary endpoint was the maximum change in Clinical Institute Withdrawal Assessment of Alcohol scale (CIWA) score within the first 24hours. Secondary endpoints included maximum and minimum CIWA score in 5days, length of stay, and change in Glasgow Coma Scale. Study groups differed by mortality risk, level of coma at admission, and other clinical characteristics, with the ethanol group appearing less severely ill. There was no significant difference between the two groups in the maximum change in CIWA score at 24hours (-0.97, 95%CI: -3.21 to 1.27, p=0.39). Hospital and intensive care unit length of stay was 6.5 days and 1 day shorter for the ethanol group (p=0.03 and p=0.02, respectively). In summary, enteral ethanol was preferentially used in patients who are more likely to be capable of tolerating oral intake. We found that the change from baseline in CIWA score or other physiologic variables was not substantially different between the two agents. The overall utility of benzodiazepines and enteral ethanol remains unclear for this population and further study is needed to determine superiority. Copyright © 2016 Elsevier Ltd. All rights reserved.

Deliberate drug poisonings admitted to an emergency department in Paris area - a descriptive study and assessment of risk factors for intensive care admission.

PubMed

Beaune, S; Juvin, P; Beauchet, A; Casalino, E; Megarbane, B

2016-01-01

Each year, approximately 165,000 poisonings are managed in the emergency departments (ED) in France. We performed a descriptive analysis of self-poisoned patients admitted to a university hospital ED in the Paris metropolitan area (France) aimed at investigating their outcome and the risk factors for transfer to the intensive care unit (ICU). We retrospectively reviewed patients' records and performed multivariate logistic regression analysis to identify risk factors for ICU admission. During 4 years, 882 self-poisoned patients (median age, 38 years [IQR, 26-47]; sex-ratio, 1M/3F) were admitted to the ED, representing 0.7% of all referred patients. Poisonings mainly resulted from multidrug exposures (53%), including benzodiazepines (78%), serotonin reuptake inhibitors (17%), acetaminophen (13%), antipsychotics (9.5%), imidazopyridines (9.5%), antihypertensive drugs (3%), and polycyclic antidepressants (1.3%). Ethanol was involved in 20% of the exposures. Patients were briefly (<24h) monitored in the ED (55%), transferred to the psychiatric department (30%), medical ward (2%) or ICU (6%), and took an irregular discharge (7%). Among the patients transferred to the ICU, 25% were mechanically ventilated and only one died. Risk factors for ICU admission included antihypertensive (Odds ratio (OR), 40.6; 95%-confidence interval (CI), 7.5-221.9) or antipsychotic drug ingestion (OR, 5.3; CI, 2.0-14.4), male gender (OR, 3.3; CI, 1.30-8.8), and consciousness impairment (OR, 2.1; CI, 1.8-2.5 per point lost in Glasgow coma score). Deliberate drug exposure represents a frequent cause of ED admission. Psychotropic drugs are most commonly involved. Transfer to the ICU is rare and predicted by male gender, drug class, and coma depth.

Severe fat embolism in perioperative abdominal liposuction and fat grafting.

PubMed

de Lima E Souza, Rodrigo; Apgaua, Bruno Tavares; Milhomens, João Daniel; Albuquerque, Francisco Tadeu Motta; Carneiro, Luiz Antônio; Mendes, Márcio Henrique; Garcia, Tiago Carvalho; Paiva, Clerisson; Ladeia, Felipe; Jeunon, Deiler Célio

2016-01-01

Fat embolism syndrome may occur in patients suffering from multiple trauma (long bone fractures) or plastic surgery (liposuction), compromising the circulatory, respiratory and/or central nervous systems. This report shows the evolution of severe fat embolism syndrome after liposuction and fat grafting. SSS, 42 years old, ASA 1, no risk factors for thrombosis, candidate for abdominal liposuction and breast implant prosthesis. Subjected to balanced general anesthesia with basic monitoring and controlled ventilation. After 45min of procedure, there was a sudden and gradual decrease of capnometry, severe hypoxemia and hypotension. The patient was immediately monitored for MAP and central catheter, treated with vasopressors, inotropes, and crystalloid infusion, stabilizing her condition. Arterial blood sample showed pH=7.21; PCO2=51mmHg; PO2=52mmHg; BE=-8; HCO3=18mEqL(-1), and lactate=6.0mmolL(-1). Transthoracic echocardiogram showed PASP=55mmHg, hypocontractile VD and LVEF=60%. Diagnosis of pulmonary embolism. After 24h of intensive treatment, the patient developed anisocoria and coma (Glasgow coma scale=3). A brain CT was performed which showed severe cerebral hemispheric ischemia with signs of fat emboli in right middle cerebral artery; transesophageal echocardiography showed a patent foramen ovale. Finally, after 72h of evolution, the patient progressed to brain death. Fat embolism syndrome usually occurs in young people. Treatment is based mainly on the infusion of fluids and vasoactive drugs, mechanical ventilation, and triggering factor correction (early fixation of fractures or suspension of liposuction). The multiorgânico involvement indicates a worse prognosis. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Work-related injuries in a state trauma registry: relationship between industry and drug screening.

PubMed

Bunn, Terry L; Slavova, Svetla; Bernard, Andrew C

2014-08-01

Work-related injuries exert a great financial and economic burden on the US population. The study objectives were to identify the industries and occupations associated with worker injuries and to determine the predictors for injured worker drug screening in trauma centers. Work-related injury cases were selected using three criteria (expected payer source of workers' compensation, industry-related e-codes, and work-related indicator) from the Kentucky Trauma Registry data set for years 2008 to 2012. Descriptive analyses and multiple logistic regression were performed on the work-related injury cases. The "other services" and construction industry sectors accounted for the highest number of work-related cases. Drugs were detected in 55% of all drug-screened work-related trauma cases. Higher percentages of injured workers tested positive for drugs in the natural resources and mining, transportation and public utilities, and construction industries. In comparison, higher percentages of injured workers in the other services as well as transportation and public utilities industries were drug screened. Treatment at Level I trauma centers and Glasgow Coma Scale (GCS) scores indicating a coma or severe brain injury were both significant independent predictors for being screened for drugs; industry was not a significant predictor for being drug screened. The injured worker was more likely to be drug screened if the worker had a greater than mild injury, regardless of whether the worker was an interfacility transfer. These findings indicate that there may be elevated drug use or abuse in natural resources and mining, transportation and public utilities, as well as construction industry workers; improved identification of the specific drug types in positive drug screen results of injured workers is needed to better target prevention efforts. Epidemiologic study, level III.

Neurophysiological prediction of neurological good and poor outcome in post-anoxic coma.

PubMed

Grippo, A; Carrai, R; Scarpino, M; Spalletti, M; Lanzo, G; Cossu, C; Peris, A; Valente, S; Amantini, A

2017-06-01

Investigation of the utility of association between electroencephalogram (EEG) and somatosensory-evoked potentials (SEPs) for the prediction of neurological outcome in comatose patients resuscitated after cardiac arrest (CA) treated with therapeutic hypothermia, according to different recording times after CA. Glasgow Coma Scale, EEG and SEPs performed at 12, 24 and 48-72 h after CA were assessed in 200 patients. Outcome was evaluated by Cerebral Performance Category 6 months after CA. Within 12 h after CA, grade 1 EEG predicted good outcome and bilaterally absent (BA) SEPs predicted poor outcome. Because grade 1 EEG and BA-SEPs were never found in the same patient, the recording of both EEG and SEPs allows us to correctly prognosticate a greater number of patients with respect to the use of a single test within 12 h after CA. At 48-72 h after CA, both grade 2 EEG and BA-SEPs predicted poor outcome with FPR=0.0%. When these neurophysiological patterns are both present in the same patient, they confirm and strengthen their prognostic value, but because they also occurred independently in eight patients, poor outcome is predictable in a greater number of patients. The combination of EEG/SEP findings allows prediction of good and poor outcome (within 12 h after CA) and of poor outcome (after 48-72 h). Recording of EEG and SEPs in the same patients allows always an increase in the number of cases correctly classified, and an increase of the reliability of prognostication in a single patient due to concordance of patterns. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Delayed Traumatic Intracranial Haemorrhage and Progressive Traumatic Brain Injury in a Major Referral Centre Based in a Developing Country

PubMed Central

Jeng, Toh Charng; Haspani, Mohd Saffari Mohd; Adnan, Johari Siregar; Naing, Nyi Nyi

2008-01-01

A repeat Computer Tomographic (CT) brain after 24–48 hours from the 1st scanning is usually practiced in most hospitals in South East Asia where intracranial pressure monitoring (ICP) is routinely not done. This interval for repeat CT would be shortened if there was a deterioration in Glasgow Coma Scale (GCS). Most of the time the prognosis of any intervention may be too late especially in hospitals with high patient-to-doctor ratio causing high mortality and morbidity. The purpose of this study was to determine the important predictors for early detection of Delayed Traumatic Intracranial Haemorrhage (DTICH) and Progressive Traumatic Brain Injury (PTBI) before deterioration of GCS occurred, as well as the most ideal timing of repeated CT brain for patients admitted in Malaysian hospitals. A total of 81 patients were included in this study over a period of six months. The CT scan brain was studied by comparing the first and second CT brain to diagnose the presence of DTICH/PTBI. The predictors tested were categorised into patient factors, CT brain findings and laboratory investigations. The mean age was 33.1 ± 15.7 years with a male preponderance of 6.36:1. Among them, 81.5% were patients from road traffic accidents with Glasgow Coma Scale ranging from 4 – 15 (median of 12) upon admission. The mean time interval delay between trauma and first CT brain was 179.8 ± 121.3 minutes for the PTBI group. The DTICH group, 9.9% of the patients were found to have new intracranial clots. Significant predictors detected were different referral hospitals (p=0.02), total GCS status (p=0.026), motor component of GCS (p=0.043), haemoglobin level (p<0.001), platelet count (p=0.011) and time interval between trauma and first CT brain (p=0.022). In the PTBI group, 42.0% of the patients were found to have new changes (new clot occurrence, old clot expansion and oedema) in the repeat CT brain. Univariate statistical analysis revealed that age (p=0.03), race (p=0.035), types of admission (p=0.024), GCS status (p=0.02), pupillary changes (p=0.014), number of intracranial lesion (p=0.004), haemoglobin level (p=0.038), prothrombin time (p=0.016) as the best predictors of early detection of changes. Multiple logistics regression analysis indicated that age, severity, GCS status (motor component) and GCS during admission were significantly associated with second CT scan with changes. This study showed that 9.9% of the total patients seen in the period of study had DTICH and 42% had PTBI. In the early period after traumatic head injury, the initial CT brain did not reveal the full extent of haemorrhagic injury and associated cerebral oedema. Different referral hospitals of different trauma level, GCS status, motor component of the GCS, haemoglobin level, platelet count and time interval between trauma and the first CT brain were the significant predictors for DTICH. Whereas the key determinants of PTBI were age, race, types of admission, GCS status, pupillary changes, number of intracranial bleed, haemoglobin level, prothrombin time and of course time interval between trauma and first CT brain. Any patients who had traumatic head injury in hospitals with no protocol of repeat CT scan or intracranial pressure monitoring especially in developing countries are advised to have to repeat CT brain at the appropriate quickest time . PMID:22589639

Fatal Intracranial Hemorrhage in a Patient with Severe Dengue Fever

PubMed Central

Sam, Jo Ee; Gee, Teak Sheng; Wahab, Nasser Abdul

2018-01-01

Dengue fever has been a major cause of morbidity and mortality in subtropical and tropical countries. We report a rare case of severe dengue with spontaneous intracranial hemorrhage. A search of literature through PubMed revealed that the largest series analyzed so far only included five cases. A 47-year-old man presented with 7 days history of fever, headache, myalgia, and vomiting with hematemesis. On the day of presentation, he had reduced consciousness and an episode of generalized tonic-clonic seizure. His Glasgow Coma Scale was E1V1M3 with anisocoria. Postresuscitation computed tomography of the brain revealed a right subdural and left thalamic hemorrhage. His blood investigations revealed thrombocytopenia, dengue virus type 1 nonstructural protein antigen test was positive, dengue IgM negative, and dengue IgG positive. A right decompressive craniectomy was done. Unfortunately, the patient died soon after. Spontaneous intracranial hemorrhage in patients with dengue fever is an uncommon entity but usually carry a grave prognosis. To date, there has been no clear management guideline for such cases, as both operative and nonoperative approaches have their own inherent risks. PMID:29492121

Surgical Management of Supratentorial Intracerebral Hemorrhages: Endoscopic Versus Open Surgery.

PubMed

Eroglu, Umit; Kahilogullari, Gokmen; Dogan, Ihsan; Yakar, Fatih; Al-Beyati, Eyyub S M; Ozgural, Onur; Cohen-Gadol, Aaron A; Ugur, Hasan Caglar

2018-06-01

Intracerebral hemorrhage continues to be a major global problem. No standard treatment or surgical procedure has been identified for intracerebral hemorrhages. High morbidity and mortality rates caused by conventional approaches and the disease itself have necessitated more-invasive treatment methods. The endoscopic approach is a more minimally invasive method than craniotomy, which is another alternative surgical treatment. We compared intracerebral hematoma drainage in 2 groups of 17 patients each, treated with minimally invasive endoscopic method versus craniotomy. All the patients were treated for supratentorial spontaneous hemorrhage between December 2013 and February 2017 at the Neurosurgery Clinic of Ankara University Faculty of Medicine. We retrospectively evaluated 34 patients surgically treated between December 2013 and February 2017. All patients underwent surgery within the first 24 hours. Patients in the early surgery group had better surgical outcomes. In the neuroendoscopic group, Glasgow Coma Scale increased from 6 to 11 at 1 week postoperatively compared with 5 to 9 in the craniotomy group. Minimally invasive endoscopic hematoma evacuation may be a good alternative surgical method for treating supratentorial spontaneous cerebral hematomas. Copyright © 2018 Elsevier Inc. All rights reserved.

Principles for managing penetrating craniocerebral injuries caused by firearm missiles.

PubMed

Zhang, X; Yi, S Y; Liu, W P; Zhang, Z W; Wang, L G; Li, A M

1996-07-01

Penetrating craniocerebral firearm injuries remain one of the most lethal causes of all trauma and are common both in war or peace time. Data were reviewed for 4140 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3-8) treated at Xi-Jing Hospital between 1973 and 1993; 51 of these patients had acute penetrating craniocerebral injuries caused by firearm missiles. These patients consisted of 46 males (90.2%) and 5 females (9.8%) ranging in age from 3 months to 48 years (median 22.4 years). The lesion types included 2 tangential wounds, 37 tubular wounds and 12 through-and-through wounds. All cases were urgent with the patients in severe and unstable states. After emergency treatment and operation, 5 cases died (9.8%). Follow up studies at three months showed that 23 cases (45.1%) had made a good recovery. Moderate disability, severe disability and vegetative states in this series were 29.4%, 13.7% and 2.0% respectively. Long term follow up studies indicated that 32 were able to resume their occupation. The principles for managing penetrating craniocerebral firearm injuries and suggestions for operation are discussed.

Prevalence of seizures in cats after head trauma.

PubMed

Grohmann, Kristina S; Schmidt, Martin J; Moritz, Andreas; Kramer, Martin

2012-12-01

To determine the prevalence of seizures in cats after head trauma. Retrospective cross-sectional study. 52 cats with head trauma. Information was obtained from medical records of cats with head trauma and via telephone interviews of owners at least 2 years after cats had head trauma. Severity of head trauma in cats was classified with the modified Glasgow coma scale (mGCS), and the association between scores and development of seizures was determined. 9 cats had moderate head trauma (mGCS score, 9 to 14), and 43 cats had mild head trauma (mGCS score, 15 to 18). None of the cats developed seizures during the follow-up period (≥ 2 years after head injury). The calculated 95% confidence interval for prevalence of seizures in cats after head injury was 0% to 5.6%. There was no significant relationship between severity of head trauma and the risk of seizures in cats. Results indicated the probability that cats with mild to moderate head trauma would develop posttraumatic seizures was low. However, clinicians should monitor cats with a history of head trauma for development of secondary epilepsy.

Childhood meningitis in the conjugate vaccine era: a prospective cohort study.

PubMed

Sadarangani, Manish; Willis, Louise; Kadambari, Seilesh; Gormley, Stuart; Young, Zoe; Beckley, Rebecca; Gantlett, Katherine; Orf, Katharine; Blakey, Sarah; Martin, Natalie G; Kelly, Dominic F; Heath, Paul T; Nadel, Simon; Pollard, Andrew J

2015-03-01

Bacterial conjugate vaccines have dramatically changed the epidemiology of childhood meningitis; viral causes are increasingly predominant, but the current UK epidemiology is unknown. This prospective study recruited children under 16 years of age admitted to 3 UK hospitals with suspected meningitis. 70/388 children had meningitis-13 bacterial, 26 viral and 29 with no pathogen identified. Group B Streptococcus was the most common bacterial pathogen. Infants under 3 months of age with bacterial meningitis were more likely to have a reduced Glasgow Coma Score and respiratory distress than those with viral meningitis or other infections. There were no discriminatory clinical features in older children. Cerebrospinal fluid (CSF) white blood cell count and plasma C-reactive protein at all ages, and CSF protein in infants <3 months of age, distinguished between bacterial meningitis and viral meningitis or other infections. Improved diagnosis of non-bacterial meningitis is urgently needed to reduce antibiotic use and hospital stay. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Flexion and extension views are not cost-effective in a cervical spine clearance protocol for obtunded trauma patients.

PubMed

Anglen, Jeff; Metzler, Michael; Bunn, Paul; Griffiths, Harry

2002-01-01

Between 1994 and 1999, 837 flexion-extension cervical spine films (F/E) were ordered as part of a protocol to evaluate cervical stability in blunt trauma victims, particularly obtunded patients with otherwise normal films. After 5 years' experience with this protocol, a review of its efficiency and cost-effectiveness was performed. The radiology reports and charts were reviewed for positive or suggestive F/E series. Nearly a third of all series were inadequate to rule out instability. Only four patients were identified who had decreased admission Glasgow Coma Scale score, normal plain films and/or CT, and positive or suggestive findings on F/E. One was felt to be a false positive, and the others had minor or borderline findings; all were treated with continuation of the cervical collar. Although one patient was lost to follow-up, none of the other three required subsequent surgery or developed deformity or neurologic injury. Flexion-extension studies were not a cost-effective part of the protocol, and they were dropped.

Repeat cranial tomography in patients with mild head injury and stable neurological examination ---- a perspective from a developing country.

PubMed

Nasir, Sadaf; Hussain, Manzar

2011-01-01

To determine the frequency of altered findings on repeat cranial tomography (CT) in patients with mild head injury along with stable neurological examination at tertiary care hospital. Cross-sectional study was done in the Department of Radiology, Liaquat National Hospital, Karachi from January 2008 to September 2010. All patients with mild head injury in terms of Glasgow Coma Scale (GCS) who underwent repeat scan without clinical or neurological deterioration in the emergency department of a tertiary care centre were included. The collected data were accordingly entered and analyzed by the principal investigator using Statistical Package for Social Sciences (SPSS) version 16.0. In all 275 patients, only 17 (6%) of the patients were found worseing on repeat CT, 120 (43.63%) scans improved, 138 (50.18%) unchanged and 17 (6.18%) worsened. None of these patients showed signs of clinical deterioration. Our results suggest that for patients with mild head injury and stable neurological examination, only 6% of them show deterioration on repeat CT, especially when patients'GCS is below 13.

Death after discharge: predictors of mortality in older brain-injured patients.

PubMed

Peck, Kimberly A; Calvo, Richard Y; Sise, C Beth; Johnson, Jeffrey; Yen, Jessica W; Sise, Michael J; Dunne, Casey E; Badiee, Jayraan; Shackford, Steven R; Lobatz, Michael A

2014-12-01

Older patients with traumatic brain injury (TBI) may be at high risk of death after hospitalization. The purpose of this study was to characterize long-term mortality of older TBI patients who survived to discharge. We hypothesized that predictors of postdischarge mortality differed from those of inpatient mortality. A retrospective cohort study was performed on TBI patients older than 55 years admitted to our Level I trauma center between July 1, 2006, and December 31, 2011. Postdischarge deaths were identified by matching patient data with local vital records up to December 31, 2011, when data collection was terminated (censoring). Patients were categorized by age, comorbidities, history of preinjury anticoagulant/prescription antiplatelet agent therapy, injury severity indices, initial TBI type, prehospital living status, discharge location, and discharge condition. The effect of risk factors on postdischarge mortality was evaluated by Cox proportional hazards modeling. Of 353 patients, 322 (91.2%) survived to discharge. Postdischarge mortality was 19.8% (n = 63) for the study period. Of the postdischarge deaths, 54.0% died within 6 months of discharge, and 68.3% died within 1 year. Median days to death after discharge or censoring were 149 and 410, respectively. Factors associated with death after discharge included age, preinjury anticoagulant use, higher number of Charlson comorbidities, discharge to a long-term care facility, and severe disability. Factors related to injury severity (i.e., Injury Severity Score [ISS], initial Glasgow Coma Scale [GCS] score) and preinjury prescription antiplatelet agent use, previously found to predict inpatient death, did not predict postdischarge mortality. Older TBI patients who survive to discharge have a significant risk of death within 1 year. Predictors of postdischarge mortality and inpatient death differ. Death after discharge is largely a function of overall health status. Monitoring health status and continued aggressive management of comorbidities after discharge may be essential in determining long-term outcomes. Epidemiologic study, level III.

Noninvasive screening for intracranial hypertension in children with acute, severe traumatic brain injury.

PubMed

O'Brien, Nicole F; Maa, Tensing; Reuter-Rice, Karin

2015-10-01

The aim of this study was to determine the relationship between transcranial Doppler (TCD) derived pulsatility index (PI), end diastolic flow velocity (Vd), and intracranial pressure (ICP). The subjects in this study were 36 children admitted after severe traumatic brain injury (TBI) (postresuscitation Glasgow Coma Scale ≤ 8) undergoing invasive ICP monitoring. Subjects underwent a total of 148 TCD studies. TCD measurements of systolic flow velocity (Vs), Vd, and mean flow velocity (Vm) were performed on the middle cerebral artery (MCA) ipsilateral to the ICP monitor. The PI was calculated by the TCD software (Vs-Vd/Vm). ICP registrations were made in parallel with TCD measurements. Using a PI threshold of 1.3, postinjury Day 0-1 PI had 100% sensitivity and 82% specificity at predicting an ICP ≥ 20 mm Hg (n = 8). During this time frame, a moderately strong relationship was observed between the MCA PI and actual ICP (r = 0.611, p = 0.01). When using a threshold of < 25 cm/sec, postinjury Day 0-1 Vd had a 56% sensitivity to predict an ICP ≥ 20 mm Hg. Beyond the initial 24 hours from injury, the sensitivity of an MCA PI of 1.3 to detect an ICP ≥ 20 mm Hg was 47%, and a weak relationship between actual ICP values and MCA PI (r = 0.376, p = 0.01) and MCA Vd (r = -0.284, p = 0.01) was found. Postinjury Day 0-1 MCA PI > 1.3 has good sensitivity and specificity at predicting an ICP ≥ 20 mm Hg. In those children with TBI who initially do not meet clear criteria for invasive ICP monitoring but who are at risk for development of intracranial hypertension, TCD may be used as a noninvasive tool to screen for the development of elevated ICP in the first 24 hours following injury.

A Chemical Model of the Coma of Comet C/2009 P1 (Garradd)

NASA Astrophysics Data System (ADS)

Boice, Daniel C.; Kawakita, H.; Kobayashi, H.; Naka, C.; Phelps, L.

2012-10-01

Modeling is essential to understand the important physical and chemical processes that occur in cometary comae. Photochemistry is a major source of ions and electrons that further initiate key gas-phase reactions, leading to the plethora of molecules and atoms observed in comets. The effects of photoelectrons that react via impacts are important to the overall ionization. We identify the relevant processes within a global modeling framework to understand simultaneous observations in the visible and near-IR of Comet C/2009 (Garradd) and to provide valuable insights into the intrinsic properties of its nucleus. Details of these processes are presented in the collision-dominated, inner coma of the comet to evaluate the relative chemical pathways and the relationship between parent and sibling molecules. Acknowledgements: We appreciate support from the NSF Planetary Astronomy Program.

Lithium poisoning in the intensive care unit: predictive factors of severity and indications for extracorporeal toxin removal to improve outcome.

PubMed

Vodovar, Dominique; El Balkhi, Souleiman; Curis, Emmanuel; Deye, Nicolas; Mégarbane, Bruno

2016-09-01

Lithium is responsible for life-threatening poisoning, not consistently improved by extracorporeal toxin removal (ECTR). Our aim was to identify predictive factors on admission of poisoning severity and based on an evaluation of practice, report indications for ECTR susceptible to improve outcome Methods: We performed a retrospective cohort study including all lithium-poisoned patients admitted to the ICU in a university hospital. The usual clinical, biological and toxicological variables were collected. Poisoning severity was defined by seizures, catecholamine infusion, mechanical ventilation >48 h and/or fatality. Univariate followed by multiple logistic regression analyses were performed to identify prognosticators of poisoning severity and ECTR use. From 1992 to 2013, 128 lithium-poisoned patients including acutely (10%), acute-on-chronically (63%) and chronically poisoned patients (27%) were included. The presumed ingested dose of lithium was 17.0 g [8.0-24.5] (median [25th-75th percentiles]). Serum lithium concentrations were 2.6 mmol/l [1.5-4.6], 2.8 mmol/l [1.8-4.5] and 2.8 mmol/l [2.1-3.0] on admission, peaking at 3.6 mmol/l [2.6; 6.2], 4.3 mmol/l [2.4; 6.2] and 2.8 mmol/l [2.1; 3.1] in the three groups, respectively. Severe poisoning occurred in 48 patients (38%) including four fatalities. Using the regression analysis, predictive factors of poisoning severity were Glasgow coma score ≤10 (Odds ratio (OR), 11.1; 95% confidence interval (CI), [4.1-33.3], p < 0.0001) and lithium concentration ≥5.2 mmol/l (OR, 6.0; CI, [1.7-25.5], p = 0.005). Ninety-eight patients (77%) developed acute kidney injury according to KDIGO criteria and 22 (17%) were treated with ECTR. Peak lithium concentration ≥5.2 mmol/l (OR, 22.4; CI, [6.4-96.4]; p < 0.0001) and peak creatinine concentration ≥200 μmol/l (OR, 5.0; CI, [1.4-19.2]; p = 0.01) were associated with ECTR use. Only 21/46 patients who presented one of these two criteria were actually treated with ECTR. More significant neurological impairment persisted on discharge in patients not treated with ECTR (p = 0.0007) despite not significantly shorter length of ICU stay. Lithium poisoning is responsible for severe impairments but rare fatalities. Severity can be predicted on admission using Glasgow coma score and lithium concentration. Our results suggest that ECTR could be indicated if serum lithium ≥5.2 mmol/l or creatinine ≥200 μmol/l.

Traumatic subarachnoid hemorrhage due to motor vehicle crash versus fall from height: a 4-year epidemiologic study.

PubMed

Parchani, Ashok; El-Menyar, Ayman; Al-Thani, Hassan; El-Faramawy, Ahmed; Zarour, Ahmad; Asim, Mohammad; Latifi, Rifat

2014-11-01

Traumatic brain injury (TBI) is a common cause of morbidity and mortality worldwide. It is difficult to estimate the real incidence of traumatic subarachnoid hemorrhage (TSAH). Although TSAH after trauma is associated with poor prognoses, the impact of mechanism of injury (MOI) and the pathophysiology remains unknown. We hypothesized that outcome of TSAH caused by motor vehicle crash (MVC) or fall from height (FFH) varies based on the MOI. Data were collected retrospectively from a prospectively created database registry in the section of Trauma Surgery at Hamad General Hospital between January 2008 and July 2012. All patients presented with head trauma and TSAH were included. Patient data included age, gender, nationality, mechanism of injury, injury severity score (ISS), types of head injuries, and associated injuries. Ventilator days, intensive care unit length of stay, pneumonia, and mortality were also studied. A total of 1665 patients with TBI were identified, of them 403 had TSAH with a mean age of 35 ± 15 years. Of them 93% were male patients and 86% were expatriates. MVC (53%) and FFH (35%) were the major mechanisms of injury. The overall mean ISS and head abbreviated injury score were 19 ± 10.6 and 3.4 ± 0.96, respectively. Patients in MVC group sustained severe TSAH, had significantly greater head abbreviated injury score (3.5 ± 0.9 vs. 3.2 ± 0.9; P = 0.009) and ISS (21.6 ± 10.6 vs. 15.9 ± 9.5; P = 0.001), and lower scene Glasgow coma scale (10.8 ± 4.8 vs. 13.2 ± 3.4; P = 0.001) compared with the FFH group. In addition, the MVC group sustained more intraventricular hemorrhage (4.7 vs. 0.7; P = 0.001) and diffuse axonal injury (4.2 vs. 2.9; P = 0.001). In contrast, extradural hemorrhage (14.3% vs. 11.6%; P = 0.008) was higher in the FFH group. Lower extremities (14% vs. 4.3%; P = 0.004) injury was mainly associated with the MVC group. The overall mortality was 19 % among patients with TSAH. The mortality rate was higher in the MVC group when compared with the FFH group (24% vs. 10%; P = 0.001). In both groups, ISS and Glasgow coma scale at the scene were independent predictors of mortality. Patients with TSAH have a higher mortality rate. In this population, MVCs are associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can reduce the incidence and severity of TBI in Qatar. Copyright © 2014 Elsevier Inc. All rights reserved.

Combat Casualties and Severe Shock: Risk Factors for Death at Role 3 Military Facilities.

PubMed

Buehner, Michelle F; Eastridge, Brian J; Aden, James K; DuBose, Joseph J; Blackbourne, Lorne H; Cestero, Ramon F

2017-09-01

Although significant research has been conducted on combat casualties receiving blood products, there is limited data for the subpopulation presenting in shock. The purpose of this study was to evaluate combat casualties arriving to a role 3 facility with an initial systolic blood pressure (SBP) ≤ 90 in order to identify clinical characteristics and associations between presentation, transfusion therapy, and mortality outcomes. The Department of Defense Trauma Registry was queried from 2001 to 2010 for trauma-related casualties who arrived at a role 3 combat surgical facility with a SBP ≤ 90. Transfers from role 2 facilities were excluded. Data captured included demographics, admission vital signs, laboratory values, blood products, and mortality. Relationships between admission physiology, blood product utilization, and mortality were developed. Independent associations between variables were determined by logistic regression analysis. 1,703 patients were identified who met our inclusion criteria and composite mortality was 23%. Mortality in those receiving a balanced transfusion ratio was 18% versus 27% (p < 0.0001). Hypotensive casualties who survived were significantly more likely to have a higher presenting Glasgow Coma Score (GCS), temperature, SBP, shock index, and pH. In addition, this group was also more likely to have a lower international normalized ratio, pCO2, and base deficit (p < 0.001). Age, heart rate, and pulse pressure were not significantly different between groups. Independent predictors of mortality included Injury Severity Score, presentation GCS, and initial pH value (p < 0.0001). In contrast, independent predictors of survival included those with above-knee amputation and a balanced transfusion (p < 0.0001). Combat casualties hypotensive on arrival to surgical facilities have a significant expected mortality. Those receiving balanced transfusions demonstrated improved survival. Of the five independent risk factors, pH, GCS, and the presence of above-knee amputation are typically available during initial evaluation. These factors may be helpful in determining resource allocation and mortality risk, especially in triage or mass casualty settings. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

Amiodarone-induced myxoedema coma.

PubMed

Hassan, Syed; Ayoub, Walaa; Hassan, Mona; Wisgerhof, Max

2014-04-12

A 62-year-old man was found to have bradycardia, hypothermia and respiratory failure 3 weeks after initiation of amiodarone therapy for atrial fibrillation. Thyroid-stimulating hormone was found to be 168 μIU/mL (nl. 0.3-5 μIU/mL) and free thyroxine (FT4) was <0.2 ng/dL (nl. 0.8-1.8 ng/dL). He received intravenous fluids, vasopressor therapy and stress dose steroids; he was intubated and admitted to the intensive care unit. He received 500 μg of intravenous levothyroxine in the first 18 h of therapy, and 150 µg intravenous daily thereafter. Haemodynamic improvement, along with complete recovery of mental status, occurred after 48 h. Twelve hours after the initiation of therapy, FT4 was 0.96 ng/dL. The patient was maintained on levothyroxine 175 (g POorally daily. A thyroid ultrasound showed diffuse heterogeneity. The 24 hour excretion of iodine was 3657 (mcg (25-756 ( mcg). The only two cases of amiodarone-induced myxoedema coma in the literature report patient death despite supportive therapy and thyroid hormone replacement. This case represents the most thoroughly investigated case of amiodarone-induced myxoedema coma with a history significant for subclinical thyroid disease.

[Clinical efficacy observation of acupuncture at suliao (GV 25) on improving regain of consciousness from coma in severe craniocerebral injury].

PubMed

Xu, Kai-Sheng; Song, Jian-Hua; Huang, Tiao-Hua; Huang, Zhi-Hua; Yu, Lu-Chang; Zheng, Wei-Ping; Chen, Xiao-Shan; Liu, Chuan

2014-06-01

To compare the clinical therapeutic effects differences between acupuncture at Suliao (GV 25) and Shuigou (GV 26) on promoting regain of consciousness from coma in severe craniocerebral injury. Based on regular emergency treatments of neurosurgery, eighty-two cases of craniocerebral injury who were under stable condition were randomly divided into an observation group (42 cases) and a control group (40 cases). Suliao (GV 25) was selected as main aupoint, while Laogong (PC 8) and Yongquan (KI 1), etc. were selected as adjuvant acupoints and Neiguan (PC 6), Sanyinjiao (SP 6), Yifeng (TE 17) and Wangu (GB 12), etc. were selected as matching acupoints in the observation group where a strong needle manipulation was applied to improve the regain of consciousness. The main acupoint of Shuigou (GV 26) along with identical adjuvant acupoints and matching acupoints in the observation group were selected in the control group with identical strong needle manipulation. The treatment was given once a day in both groups, five times per week and ten times were considered as one session. The immediate clinical symptoms after acupuncture at Suliao (GV 25) and Shuigou (GV 26) were observed as well as Glasgow coma scale (GCS) before the treatment, after 45 days and 90 days of treatment to assess the resuscitation time and rate. Also the clinical efficacy was compared between both groups. The occurrence rate of sneezing reflex was 85.7% (36/42) in the observation group, which was higher than 25.0% (10/40) in the control group (P < 0.01). The average resuscitation time was (64.6 +/- 19.4) days in the observation group, which was obviously shorter than (73.8 +/- 14. 6) days in the control group (P < 0.05). The resuscitation rate was 88.1% (37/42) in the observation group, which was similar to 75.0% (30/40) in the control group (P > 0.05). Compared before the treatment, GCS were both improved after the treatment in two groups (both P < 0.01). The 90-day GCS was 9.52 +/- 2.32 in the observation group, which was superior to 8.47 +/-2.14 in the control group (P < 0.05). The curative and markedly effective rate was 45.2% (19/42) in the observation group, which was superior to 22.5% (9/40) in the control group (P < 0.05). The effect of acupuncture at Suliao (GV 25) on improving regain of consciousness from coma in severe craniocerebral injury is positive. It could specifically improve sneezing reflex and stimulate respiratory center, which has more obvious effect than acupuncture at Shuigou (GV 26).

The fragmentation of dust in the innermost comae of comets: Possible evidence from ground-based images

NASA Technical Reports Server (NTRS)

Combi, Michael R.

1994-01-01

Dust particles when released from the nucleus of a comet are entrained in the expanding gas flow created by the vaporization of ices (mainly water ice). Traditional approaches to dusty-gas dynamics in the inner comae of comets consider there to be an initial distribution of dust particle sizes which do not fragment or evaporate. The standard Finson-Probstein model (and subsequent variations) yields a one-to-one-to-one correspondence between the size of a dust particle, its terminal velocity owing to gas drag, and its radiation pressure acceleration which creates the notable cometary dust tail. The comparison of a newly developed dust coma model shows that the typical elongated shapes of isophotes in the dust comae of comets on the scale of greater than 10(exp 4) km from the nucleus requires that the one-to-one-to-one relationship between particle size, terminal velocity and radiation pressure acceleration cannot in general be correct. There must be a broad range of particles including those having a small velocity but large radiation pressure acceleration in order to explain the elongated shape. A straightforward way to create such a distribution is if particle fragmentation, or some combination of fragmentation with vaporization, routinely occurs within and/or just outside of the dusty-gas dynamic acceleration region (i.e., up to several hundred km). In this way initially large particles, which are accelerated to fairly slow velocities by gas-drag, fragment to form small particles which still move slowly but are subject to a relatively large radiation pressure acceleration. Fragmentation has already been suggested as one possible interpretation for the flattened gradient in the spatial profiles of dust extracted from Giotto images of Comet Halley. Grain vaporization has been suggested as a possible spatially extended source of coma gases. The general elongated isophote shapes seen in ground-based images for many years represents another possible signature of fragmentation.

Coma of unknown origin in the emergency department: implementation of an in-house management routine.

PubMed

Braun, Mischa; Schmidt, Wolf Ulrich; Möckel, Martin; Römer, Michael; Ploner, Christoph J; Lindner, Tobias

2016-04-27

Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines. We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in-house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed "coma alarm"). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP. During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1-4), then fluctuated between 84 and 94 % (months 5-24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period. We achieved a median door-to-CT time of 20 minutes. 85 % of patients needed subsequent ICU treatment, 40 % of which required specialised neuro-ICUs. Our results indicate that our new simple in-house triage criteria may be sufficient to identify eligible patients before arrival. We aimed at ensuring the fastest possible proceedings given high portions of underlying time-sensitive neurological and medical pathologies while using all available resources as purposefully as possible. Our SOP may provide an appropriate tool for efficient management of patients with non-traumatic coma. Our results justify the assignment of the initial diagnostic workup to neurologists and internal specialists in collaboration with anaesthesiologists.

Infant welfare, philanthropy and entrepreneurship in Glasgow: Sister Laura's Infant Food Company.

PubMed

Weaver, L T

2008-06-01

Laura Smith was sister-in-charge of the Children's Dispensary in Glasgow from 1897 to 1922. In 1911 she established Sister Laura's Infant Food Company to market a special milk formula of her own invention.The directors of the Dispensary were not amused. As the 'outdoor' department of the Royal Hospital for Sick Children (Yorkhill), the Dispensary was at the forefront of efforts to combat child ill health and malnutrition. This paper considers Laura Smith's initiative within the context of the health and care of infants of the time - high infant mortality, public and professional concerns for infant welfare, technological advances in food science, changing recommendations and practices of infant feeding and ambiguous relations between medicine and commerce.

Respiratory depression in the intoxicated trauma patient: are opioids to blame?

PubMed

Shenk, Eleni; Barton, Cassie A; Mah, Nathan D; Ran, Ran; Hendrickson, Robert G; Watters, Jennifer

2016-02-01

Providing effective pain management to acutely intoxicated trauma patients represents a challenge of balancing appropriate pain management with the risk of potential respiratory depression from opioid administration. The objective of this study was to quantify the incidence of respiratory depression in trauma patients acutely intoxicated with ethanol who received opioids as compared with those who did not and identify potential risk factors for respiratory depression in this population. Retrospective medical record review was conducted for subjects identified via the trauma registry who were admitted as a trauma activation and had a detectable serum ethanol level upon admission. Risk factors and characteristics compared included demographics, Injury Severity Score, Glasgow Coma Score, serum ethanol level upon arrival, urine drug screen results, incidence of respiratory depression, and opioid and other sedative medication use. A total of 233 patients were included (78.5% male). Patients who received opioids were more likely to have a higher Injury Severity Score and initial pain score on admission as compared with those who did not receive opioids. Blood ethanol content was higher in patients who did not receive opioids (0.205 vs 0.237 mg/dL, P = .015). Patients who did not receive opioids were more likely to be intubated within 4 hours of admission (1.7% vs 12.1%, P = .02). Opioid administration was not associated with increased risk of respiratory depression (19.7% vs 22.4%, P = .606). Increased cumulative fentanyl dose was associated with increased risk of respiratory depression. Increased cumulative fentanyl dose, but not opioid administration alone, was found to be a risk factor for respiratory depression. Copyright © 2015 Elsevier Inc. All rights reserved.

Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service.

PubMed

Lee, James S; O'Dochartaigh, Domhnall; MacKenzie, Mark; Hudson, Darren; Couperthwaite, Stephanie; Villa-Roel, Cristina; Rowe, Brian H

2015-06-01

Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS)<15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001). Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.

Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations.

PubMed

McNamara, Caitlin; Mironova, Irina; Lehman, Erik; Olympia, Robert P

2017-06-01

Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure. To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature. We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation. Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%). Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness. Copyright © 2016 Elsevier Inc. All rights reserved.

Patients who reattend after head injury: a high risk group.

PubMed Central

Voss, M.; Knottenbelt, J. D.; Peden, M. M.

1995-01-01

OBJECTIVE--To assess risk factors for important neurosurgical effects in patients who reattend after head injury. DESIGN--Retrospective study. SUBJECTS--606 patients who reattended a trauma unit after minor head injury. MAIN OUTCOME MEASURES--Intracranial abnormality detected on computed tomography or the need for neurosurgical intervention. RESULTS--Five patients died: two from unrelated causes and three from raised intracranial pressure. On multiple regression analysis the only significant predictor for both abnormality on computed tomography (14.4% of reattenders) and the need for operation (5% of reattenders) was vault fracture seen on the skull radiograph (P < 10(-6)); predictors for abnormal computed tomogram were a Glasgow coma scale score < 15 at either first or second attendance (P < 0.0001) and convulsion at second attendance (P < 0.05); predictive for operation only was penetrating injury of the skull (P < 10(-6)). On contingency table analysis these associations were confirmed. In addition significant associations with both abnormality on computed tomography and operation were focal neurological abnormality, weakness, or speech disturbance. Amnesia or loss of consciousness at the time of initial injury, personality change, and seizures were significantly associated only with abnormality on computed tomography. Headache, dizziness, nausea, and vomiting were common in reattenders but were found to have no independent significance. CONCLUSIONS--All patients who reattend after head injury should undergo computed tomography as at least 14% of scans can be expected to yield positive results. Where this facility is not available patients with predictors for operation should be urgently referred for neurosurgical opinion. Other patients can be readmitted and need referral only if symptoms persist despite symptomatic treatment or there is neurological deterioration while under observation. These patients are a high risk group and should be treated seriously. PMID:8520273

In-hospital mortality after pre-treatment with antiplatelet agents or oral anticoagulants and hematoma evacuation of intracerebral hematomas.

PubMed

Stein, Marco; Misselwitz, Björn; Hamann, Gerhard F; Kolodziej, Malgorzata; Reinges, Marcus H T; Uhl, Eberhard

2016-04-01

Pre-treatment with antiplatelet agents is described to be a risk factor for mortality after spontaneous intracerebral hemorrhage (ICH). However, the impact of antithrombotic agents on mortality in patients who undergo hematoma evacuation compared to conservatively treated patients with ICH remains controversial. This analysis is based on a prospective registry for quality assurance in stroke care in the State of Hesse, Germany. Patients' data were collected between January 2008 and December 2012. Only patients with the diagnosis of spontaneous ICH were included (International Classification of Diseases 10th Revision codes I61.0-I61.9). Predictors of in-hospital mortality were determined by univariate analysis. Predictors with P<0.1 were included in a binary logistic regression model. The binary logistic regression model was adjusted for age, initial Glasgow Coma Score (GCS), the presence of intraventricular hemorrhage (IVH), and pre-ICH disability prior to ictus. In 8,421 patients with spontaneous ICH, pre-treatment with oral anticoagulants or antiplatelet agents was documented in 16.3% and 25.1%, respectively. Overall in-hospital mortality was 23.2%. In-hospital mortality was decreased in operatively treated patients compared to conservatively treated patients (11.6% versus 24.0%; P<0.001). Patients with antiplatelet pre-treatment had a significantly higher risk of death during the hospital stay after hematoma evacuation (odds ratio [OR]: 2.5; 95% confidence interval [CI]: 1.24-4.97; P=0.010) compared to patients without antiplatelet pre-treatment treatment (OR: 0.9; 95% CI: 0.79-1.09; P=0.376). In conclusion a higher rate of in-hospital mortality after pre-treatment with antiplatelet agents in combination with hematoma evacuation after spontaneous ICH was observed in the presented cohort. Copyright © 2015 Elsevier Ltd. All rights reserved.

Beta-blocker use is associated with improved outcomes in adult trauma patients.

PubMed

Arbabi, Saman; Campion, Eric M; Hemmila, Mark R; Barker, Melissa; Dimo, Mary; Ahrns, Karla S; Niederbichler, Andreas D; Ipaktchi, Kyros; Wahl, Wendy L

2007-01-01

Beta-adrenoreceptor blocker (beta-blocker) therapy may improve outcomes in surgical patients by decreasing cardiac oxygen consumption and hypermetabolism. Because beta-blockers can lower the systemic blood pressure and cerebral perfusion pressure, there is concern regarding their use in patients with head injury. However, beta-blockers may protect beta-receptor rich brain cells by attenuating cerebral oxygen consumption and metabolism. We hypothesized that beta-blockers are safe in trauma patients, even if they have suffered a significant head injury. Using pharmacy and trauma registry data of a Level I trauma center, we identified a cohort of trauma patients who received beta-blockers during their hospital stay (beta-cohort). Trauma admissions who did not receive beta-blockers were in the control cohort. beta-blocker status, in combination with other variables associated with mortality, were placed in a stepwise multivariate logistic regression to identify independent predictors of fatal outcome. In all, 303 (7%) of 4,117 trauma patients received beta-blockers. In the beta-cohort, 45% of patients were on beta-blockers preinjury. The most common reason to initiate beta-blocker therapy was blood pressure (60%) and heart rate (20%) control. The overall mortality rate was 5.6% and head injury was considered to be the major cause of death. After adjusting for age, Injury Severity Scale score, blood pressure, Glasgow Coma Scale score, respiratory status, and mechanism of injury, the odds ratio for fatal outcome was 0.3 (p < 0.001) for beta-cohort as compared with control. Decreased risk of fatal outcome was more pronounced in patients with a significant head injury. beta-blocker therapy is safe and may be beneficial in selected trauma patients with or without head injury. Further studies looking at beta-blocker therapy in trauma patients and their effect on cerebral metabolism are warranted.

A Preliminary Observational Study of Anovulatory Uterine Bleeding After Aneurysmal Subarachnoid Hemorrhage.

PubMed

Brown, Suzanne M; Fifield, Susan W; Pizzi, Michael A; Alejos, David; Richie, Alexa N; Dinh, Tri A; Cheshire, William P; Meek, Shon E; Freeman, William D

2017-12-01

It was observed that women with aneurysmal subarachnoid hemorrhage (aSAH) tended to have earlier menses than a typical 21- to 28-day cycle. The goal was to determine whether there is an association between aSAH and early onset of menses. All cases of aSAH in women aged 18 to 55 years who were admitted to our facility's neuroscience intensive care unit from June 1, 2011, to June 30, 2012, were reviewed. The electronic healthcare record for each of these patients was examined for documentation of menses onset, computed tomography of the head, brain aneurysm characteristics, modified Fisher score and Glasgow Coma Scale on admission, presence/absence of vasospasm, medical/surgical history, and use of medications that affect the menstrual cycle. The mean onset of menses in this study population was compared with the mean of 21 to 28 days with the 1-sample t test. During the study period, 103 patients with subarachnoid hemorrhage were admitted. Sixty-one were women, and 15 were aged 18 to 55 years. Nine of the 15 (60%) had documentation of menses occurring during their initial week of hospitalization; 1 patient had documentation of menses on hospital day 12. There is a significant difference when the mean onset of menses in our patient population is compared with the approximate normal menstrual cycle of 21 to 28 days (P < .01). Early onset of menses or abnormal uterine bleeding after SAH may occur in women with aSAH and typically within the first 7 to 10 days after intracranial aneurysm rupture. The physiologic cause of early onset of menses after aSAH, whether primary or secondary, remains unknown.

Inhaled methoxyflurane and intranasal fentanyl for prehospital management of visceral pain in an Australian ambulance service.

PubMed

Johnston, Steven; Wilkes, Garry J; Thompson, Jennifer A; Ziman, Mel; Brightwell, Richard

2011-01-01

This study analysed the analgesic effect and changes in vital signs associated with administration of inhaled Methoxyflurane (MTX) and/or intranasal Fentanyl (INF) for prehospital management of visceral pain. A retrospective, observational study reviewing 1024 randomly selected records of patients with presumed visceral pain administered MTX (465), INF (397) or both (162) by the Western Australian Ambulance Service between January 2004 and February 2006. Clinical variables assessed included systolic blood pressure, pulse rate, respiration rate and Glasgow Coma Scale score. Pain was assessed utilising Visual/Verbal Analogue Scale pain scores. Overall effects on vital signs appeared favourable 5 min after use and at hospital arrival with either agent alone or in combination. As sole agents, MTX produced the greatest initial pain scores reduction (2.0 (1.7 to 2.2) vs 1.6 (1.4 to 1.8)) (mean (95% CI), and INF provided greater pain reduction by hospital arrival (3.2 (2.9 to 3.5) vs 2.5 (2.1 to 2.9)). While both agents were effective, INF provided a greater pain score reduction for cardiac (3.0 (2.6 to 3.4) vs 2.3 (1.8 to 2.8)), female (3.4 (2.9 to 4.0) v 2.5 (2.0 to 3.0)) and age 75+ patients (3.2 (2.5 to 3.8) vs 1.8 (1.0 to 2.5)). Combined use of agents was not advantageous. MTX and INF are effective agents for providing visceral pain analgesia in the prehospital setting. While MTX provided a more rapid onset of pain relief, INF provided superior analgesia after subsequent doses and in female, cardiac and older patients.

A case of thyroid storm with a markedly elevated level of circulating soluble interleukin-2 receptor complicated by multiple organ failure and disseminated intravascular coagulation syndrome.

PubMed

Shimoda, Yoko; Satoh, Tetsurou; Takahashi, Hiroki; Katano-Toki, Akiko; Ozawa, Atsushi; Tomaru, Takuya; Horiguchi, Norio; Kaira, Kyoichi; Nishioka, Masaki; Shibusawa, Nobuyuki; Hashimoto, Koshi; Wakino, Shu; Mori, Masatomo; Yamada, Masanobu

2014-01-01

Thyroid storm (TS) is a life-threatening endocrine emergency. However, the pathogenesis of TS is poorly understood. A 40-year-old man was admitted to a nearby hospital with body weight loss and jaundice. Five days after a contrasted abdominal computerized tomography (CT) scan, he exhibited high fever and disturbance of consciousness. He was diagnosed with TS originating from untreated Graves' disease and was transferred to the intensive care unit (ICU) of our hospital. The patient exhibited impaired consciousness (E4V1M4 in Glasgow coma scale), high fever (39.3°C), and atrial flutter with a pulse rate 162/min, and was complicated by heart failure, acute hepatic failure, and disseminated intravascular coagulation syndrome (DIC). His circulating level of soluble interleukin-2 receptor (sIL-2R), a serum marker of an activated immune response, was highly elevated (7,416 U/mL, reference range: 135-483). Multiple organ failure (MOF) and DIC were successfully managed by multimodality treatments using inorganized iodide, glucocorticoids, anti-thyroid drugs, beta-blockers, and diuretics as well as an anticoagulant agent and the transfusion of platelet concentrate and fresh frozen plasma. sIL-2R levels gradually decreased during the initial treatment, but were still above the reference range even after thyroidectomy. Mild elevations in serum levels of sIL-2R have previously been correlated with thyroid hormone levels in non-storm Graves' disease. The present study demonstrated, for the first time, that circulating sIL-2R levels could be markedly elevated in TS. The marked increase in sIL-2R levels was speculated to represent an inappropriate generalized immune response that plays an unknown role in the pathogenesis of TS.

A comparison of acute hemorrhagic stroke outcomes in 2 populations: the Crete-Boston study.

PubMed

Zaganas, Ioannis; Halpin, Amy P; Oleinik, Alexandra; Alegakis, Athanasios; Kotzamani, Dimitra; Zafiris, Spiros; Chlapoutaki, Chryssanthi; Tsimoulis, Dimitris; Giannakoudakis, Emmanouil; Chochlidakis, Nikolaos; Ntailiani, Aikaterini; Valatsou, Christina; Papadaki, Efrosini; Vakis, Antonios; Furie, Karen L; Greenberg, Steven M; Plaitakis, Andreas

2011-12-01

Although corticosteroid use in acute hemorrhagic stroke is not widely adopted, management with intravenous dexamethasone has been standard of care at the University Hospital of Heraklion, Crete with observed outcomes superior to those reported in the literature. To explore this further, we conducted a retrospective, multivariable-adjusted 2-center study. We studied 391 acute hemorrhagic stroke cases admitted to the University Hospital of Heraklion, Crete between January 1997 and July 2010 and compared them with 510 acute hemorrhagic stroke cases admitted to Massachusetts General Hospital, Boston, from January 2003 to September 2009. Of the Cretan cases, 340 received a tapering scheme of intravenous dexamethasone, starting with 16 to 32 mg/day, whereas the Boston patients were managed without steroids. The 2 cohorts had comparable demographics and stroke severity on admission, although anticoagulation was more frequent in Boston. The in-hospital mortality was significantly lower on Crete (23.8%, n=340) than in Boston (38.0%, n=510; P<0.001) as was the 30-day mortality (Crete: 25.4%, n=307; Boston: 39.4%, n=510; P<0.001). Exclusion of patients on anticoagulants showed even greater differences (30-day mortality: Crete 20.8%; n=259; Boston 37.0%; n=359; P<0.001). The improved survival on Crete was observed 3 days after initiation of intravenous dexamethasone and was pronounced for deep-seated hemorrhages. After adjusting for acute hemorrhagic stroke volume/location, Glasgow Coma Scale, hypertension, diabetes mellitus, smoking, coronary artery disease and statin, antiplatelet, and anticoagulant use, intravenous dexamethasone treatment was associated with better functional outcomes and significantly lower risk of death at 30 days (OR, 0.357; 95% CI, 0.174-0.732). This study suggests that intravenous dexamethasone improves outcome in acute hemorrhagic stroke and supports a randomized clinical trial using this approach.

Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population.

PubMed

Hsu, Jeremy Ming; Hitos, Kerry; Fletcher, John P

2013-09-01

Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not. Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9-95.8). The area under the receiver operating characteristic curve for the model was 0.859. From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation. Prognostic study, level III.

20 years of trauma documentation in Germany--actual trends and developments.

PubMed

2014-10-01

The TraumaRegister DGU(®) has been founded 20 years ago. Although initially supported by larger hospitals and universities, it has recently become a representative registry for the care of severely injured patients in Germany. Based on the registry data some important trends and developments of the recent decades are presented. German trauma patients with an Injury Severity Score (ISS)≥ 16 were eligible if primary admitted from the scene. All cases documented between 1993 and 2012 (20 years) were eligible. For selected variables, an average change per years was calculated using linear regression analysis. A total of 49,801 patients was analysed. The mean age was 46.3 years, and 72% were males. The following relevant trends could be observed: The average age increased dramatically from 38 to 50 years. Pre-hospital intubation rate was halfed in patients with Glasgow Coma Scale (GCS)>8 but remained constant in unconscious patients (GCS ≤ 8; 90% intubation rate). Pre-hospital volume administration decreased as well, which led to less blood transfusions (from 45% to 16%). The use of helicopters for transportation into a trauma centre decreased as well but today still 27% of all cases are transported by air. Whole-body CT was performed in about 80% of patients; this value is stable in the last four years. Hospital mortality could be reduced and was 2-3% lower than expected in recent years. The Revised Injury Severity Classification (RISC) score used as a reference here was based on TR-DGU data from the 1990s. Standardised prospective registration of severely injured patients over 20years allows to empirically monitor trends and developments in acute trauma care. Copyright © 2014 Elsevier Ltd. All rights reserved.

How much of the difference in life expectancy between Scottish cities does deprivation explain?

PubMed

Seaman, R; Mitchell, R; Dundas, R; Leyland, A H; Popham, F

2015-10-16

Glasgow's low life expectancy and high levels of deprivation are well documented. Studies comparing Glasgow to similarly deprived cities in England suggest an excess of deaths in Glasgow that cannot be accounted for by deprivation. Within Scotland comparisons are more equivocal suggesting deprivation could explain Glasgow's excess mortality. Few studies have used life expectancy, an intuitive measure that quantifies the between-city difference in years. This study aimed to use the most up-to-date data to compare Glasgow to other Scottish cities and to (i) evaluate whether deprivation could account for lower life expectancy in Glasgow and (ii) explore whether the age distribution of mortality in Glasgow could explain its lower life expectancy. Sex specific life expectancy was calculated for 2007-2011 for the population in Glasgow and the combined population of Aberdeen, Dundee and Edinburgh. Life expectancy was calculated for deciles of income deprivation, based on the national ranking of datazones, using the Scottish Index of Multiple Deprivation. Life expectancy in Glasgow overall, and by deprivation decile, was compared to that in Aberdeen, Dundee and Edinburgh combined, and the life expectancy difference decomposed by age using Arriaga's discrete method. Life expectancy for the whole Glasgow population was lower than the population of Aberdeen, Dundee and Edinburgh combined. When life expectancy was compared by national income deprivation decile, Glasgow's life expectancy was not systematically lower, and deprivation accounted for over 90 % of the difference. This was reduced to 70 % of the difference when carrying out sensitivity analysis using city-specific income deprivation deciles. In both analyses life expectancy was not systematically lower in Glasgow when stratified by deprivation. Decomposing the differences in life expectancy also showed that the age distribution of mortality was not systematically different in Glasgow after accounting for deprivation. Life expectancy is not systematically lower across the Glasgow population compared to Aberdeen, Dundee and Edinburgh combined, once deprivation is accounted for. This provides further evidence that tackling deprivation in Glasgow would probably reduce the health inequalities that exist between Scottish cities. The change in the amount of unexplained difference when carrying out sensitivity analysis demonstrates the difficulties in comparing socioeconomic deprivation between populations, even within the same country and when applying an established ecological measure. Although the majority of health inequality between Glasgow and other Scottish cities is explained by deprivation, the difference in the amount of unexplained inequality depending on the relative context of deprivation used demonstrates the challenges associated with attributing mortality inequalities to an independent 'place effect'.

Repeatability of the Dust and Gas Morphological Structures in the Coma of Comet

NASA Astrophysics Data System (ADS)

Lejoly, Cassandra; Samarasinha, N. H.; Ojha, L.; Schleicher, D. G.

2013-10-01

Comet 1P/Halley is the most famous comet in history and has been observed for over two millennia, making it one of the most extensively studied comets. The morphology in the coma of comet 1P/Halley originates due to the activity at the nucleus and could be used as a probe of the nuclear rotation and the activity. We will present the results from a study summarizing the evolution of coma morphology of comet 1P/Halley observed from ground between October 1985 and June 1986. The results to be presented include analysis of dust features as well as gas (CN) features in the coma and comparisons will be made between their spatial and temporal evolution. About 80 CN images and 300 continuum images from the Small Bodies Node of the NASA Planetary Data System were analyzed using image enhancement techniques that were not available n the 1980s. This enables us to see coma structure never observed before in comet 1P/Halley. Because of the comet's proximity to Earth, most of our best signal-to-noise images were taken in the March-April interval of 1986. Despite the limited coverage of preceding and following months, there is a sufficient number of images to monitor morphological evolution over many months. The initial synodic periods as a function of time used to phase the images together were extrapolated from the lightcurves of the active coma (Schleicher et al. 1990, AJ, 100, 896-912). We will present the periods of repeatability of individual coma features measured using the position angle at different spatial distances from the nucleus in adjacent cycles. Separate features appear to have slightly different periods of repeatability, perhaps depending on the corresponding source regions on the nucleus and/or projection effects. The periods of repeatability of coma morphologies will be presented as a function of time from the perihelion. These results will ultimately be used in detailed modeling of the coma morphologies of comet 1P/Halley over the 1985-1986 apparition in order to characterize the activity of the comet. This work is supported by NASA Planetary Atmospheres grant NNX11AD85G and C.L.'s participation at the meeting is supported by a gift to the Lunar and Planetary Laboratory at the University of Arizona.

A Comparison of the Near-Infrared Spectral Features of Early-Type Galaxies in the Virgo and Coma Clusters

NASA Astrophysics Data System (ADS)

Houdashelt, M. L.

1992-05-01

Initial results are presented from an examination of near-infrared spectra (6800 - 9200 Angstroms) of 34 early-type galaxies - 17 in the Virgo cluster, 10 in the Coma cluster and seven field members. It has previously been speculated that E/S0 galaxies of similar luminosity in the Virgo and Coma clusters have different red stellar populations. To explore this possibility, pseudo-equivalent widths of a number of near-IR spectral features have been measured. The important features studied include the TiO bands near 7100, 7890, 8197, 8500 and 8950 Angstroms, which are mainly produced by the late-type stars whose flux contributes only about 10-20\\ the near-IR. The strengths of the Ca triplet (8498, 8542, 8662 Angstroms) and Na I doublet (8183, 8195 Angstroms) are also measured, since these features are affected by the relative contribution of dwarf stars to the red light. Although the main focus of this work is the search for spectral differences among the Coma, Virgo and field E/S0 populations, each subgroup of galaxies (and the sample as a whole) are also examined for correlations among the feature strengths, galaxy color and luminosity.

Severe oligozoospermia in a patient with myxedema coma.

PubMed

Komiya, Akira; Watanabe, Akihiko; Kawauchi, Yoko; Takano, Atsuko; Fuse, Hideki

2012-10-01

A case of severe oligozoospermia with myxedema coma is herein presented. The patient was referred to a male infertility clinic with a 5-year history of primary infertility. Decreased serum testosterone and elevated serum prolactin without abnormal MRI findings in the hypothalamus, and decreased semen volume and sperm motility were noted. A GnRH test revealed a decreased luteinizing hormone response, whereas the HCG test showed a normal testosterone increase. Because a urinalysis after ejaculation indicated retrograde ejaculation, imipramine administration was started. However, the semen quality deteriorated, so the patient was referred to an ART clinic. Twenty-one months from the initial visit, the patient developed a loss of consciousness and edema due to myxedema coma, a life-threatening state of hypothyroidism. The patient recovered after 1 month of thyroid hormone replacement therapy (HRT) with corticosteroids. Three months after the myxedema coma, a semen analysis showed a decreased semen volume (0.2 mL) and severe oligozoospermia (two spermatozoa/ejaculate). Elevated prolactin and decreased testosterone levels were still present. These parameters gradually improved after restoration of euthyroidism by HRT. In conclusion, physicians should confirm the thyroid function in the management of male infertility, especially in patients with elevated prolactin levels.

Food deprivation and prior anoxic coma have opposite effects on the activity of a visual interneuron in the locust.

PubMed

Cross, Kevin P; Britton, Samantha; Mangulins, Rebecca; Money, Tomas G A; Robertson, R Meldrum

2017-04-01

We compared how different metabolic stressors, anoxic coma and food deprivation, affected signaling in neural tissue. We used the locust's Descending Contralateral Movement Detector (DCMD) interneuron because its large axon, high firing frequencies, and rapid conduction velocity make it energetically expensive. We exposed locusts to a 30min anoxic coma or 1day of food deprivation and found contrasting effects on signaling within the axon. After a prior anoxic coma, the DCMD fired fewer high-frequency (>200Hz) action potentials (APs) (Control: 12.4±1.6; Coma: 6.3±0.9) with a reduction in axonal conduction velocity (CV) at all frequencies (∼4-8%) when presented with a standard looming visual stimulus. Prior anoxic coma was also associated with a loss of supernormal conduction by reducing both the number of supernormal APs and the firing frequency with the highest CV. Initially, food deprivation caused a significant increase in the number of low- and high-frequency APs with no differences observed in CV. After controlling for isolation, food deprivation resulted in an increase in high-frequency APs (>200Hz: Control: 17.1±1.7; Food-deprived: 19.9±1.3) and an increase in relative conduction velocity for frequencies >150Hz (∼2%). Action potentials of food-deprived animals had a smaller half-width (Control: 0.45±0.02ms; Food-deprived: 0.40±0.01ms) and decay time (Control: 0.62±0.03ms; Food-deprived: 0.54±0.02ms). Our data indicate that the effects of metabolic stress on neural signaling can be stressor-dependent. Copyright © 2017 Elsevier Ltd. All rights reserved.

A Psychological Service Contribution to Nurture: Glasgow's Nurturing City

ERIC Educational Resources Information Center

March, Sam; Kearney, Maura

2017-01-01

This article details the work undertaken in Glasgow to develop a range of nurturing approaches across establishments. Glasgow Psychological Service (GPS), in conjunction with Glasgow education colleagues, used the nurture group principles as developed by the Nurture Group Network, and extended and adapted these to give more detail and direction as…

Measurement of height velocity is an useful marker for monitoring pituitary function in patients who had traumatic brain injury.

PubMed

Bellone, S; Einaudi, S; Caputo, M; Prodam, F; Busti, A; Belcastro, S; Parlamento, S; Zavattaro, M; Verna, F; Bondone, C; Tessaris, D; Gasco, V; Bona, G; Aimaretti, G

2013-12-01

To assess the incidence of abnormal neuroendocrine function post-traumatic brain injuriy (TBI) in a large group of paediatric patients and its correlations with clinical parameters (Glasgow coma scale-GCS, Glasgow outcome scale-GOS, TC marshall scale, height velocity). We evaluated 70 patients [58 M, 12 F; age at the time of TBI (mean ± SEM) 8.12 ± 4.23 years] previously hospitalized for TBI at the "Regina Margherita" Hospital, in Turin and "Maggiore della Carità Hospital" in Novara, Italy, between 1998 and 2008. All patients included underwent: auxological, clinical, hormonal and biochemical assessments at recall (after at least 1 year from TBI to T0); auxological visit after 6 months (T6) and hormonal assessments at 12 months (T12) in patients with height velocity (HV) below the 25th centile. At T0, 4 cases of hypothalamus-pituitary dysfunction had been diagnosed; At T6 20/70 patients had an HV <25th centile, but no one had HV < the 3rd centile limit. At T12, among the 20 patients with HV <25th centile, in 13 patients the HV was below the 25th centile and GHRH + Arginine test has been performed. Four subjects demonstrated an impaired GH peak and were classified as GH deficiency (GHD). Of these 4 subjects, 3 subjects showed isolated GHD, while one patient showed multiple hypopituitarism presenting also secondary hypocortisolism and hypothyroidism. The GCS at admission and GOS do not correlate with the onset of hypopituitarism. A simple measurement of the height velocity at least 1 year after the TBI, is enough to recognize patients with a pituitary impairment related to GH deficiency. We suggest to follow-up paediatric population who had TBI with auxological evaluations every 6 months, limiting hormonal evaluation in patients with a reduction of height velocity below the 25th centile limit.

Patients with Moderate and Severe Traumatic Brain Injury: Impact of Preinjury Platelet Inhibitor or Warfarin Treatment.

PubMed

Tollefsen, Marie Hexeberg; Vik, Anne; Skandsen, Toril; Sandrød, Oddrun; Deane, Susan Frances; Rao, Vidar; Moen, Kent Gøran

2018-06-01

We aimed to examine the effect of preinjury antithrombotic medication on clinical and radiologic neuroworsening in traumatic brain injury (TBI) and study the effect on outcome. A total of 184 consecutive patients ≥50 years old with moderate and severe TBI admitted to a level 1 trauma center were included. Neuroworsening was assessed clinically by using the Glasgow Coma Scale (GCS) score and radiologically by using the Rotterdam CT score on repeated time points. Functional outcome was assessed with the Glasgow Outcome Scale Extended 6 months after injury. The platelet inhibitor group (mean age, 77.3 years; n = 43) and the warfarin group (mean age, 73.2 years; n = 20) were significantly older than the nonuser group (mean age, 63.7 years; n = 121; P ≤ 0.001). In the platelet inhibitor group 74% and in the warfarin group, 85% were injured by falls. Platelet inhibitors were not significantly associated with clinical or radiologic neuroworsening (P = 0.37-1.00), whereas warfarin increased the frequency of worsening in GCS score (P = 0.001-0.028) and Rotterdam CT score (P = 0.004). In-hospital mortality was higher in the platelet inhibitor group (28%; P = 0.030) and the warfarin group (50%; P < 0.001) compared with the nonuser group (13%). Platelet inhibitors did not predict mortality or worse outcome after adjustment for age, preinjury disability, GCS score, and Rotterdam CT score, whereas warfarin predicted both mortality and worse outcome. In this study of patients with moderate and severe TBI, preinjury platelet inhibitors did not cause neuroworsening or predict higher mortality or worse outcome. In contrast, preinjury warfarin caused neuroworsening and was an independent risk factor for mortality and worse outcome at 6 months. Hence, fall prevention and liberal use of computed tomography examinations is important in this patient group. Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.

German validation of Quality of Life after Brain Injury (QOLIBRI) assessment and associated factors

PubMed Central

Sasse, Nadine; Wilson, Lindsay; Otto, Christiane; Mullins, Ryan; Behr, Robert; Deinsberger, Wolfgang; Martinez-Olivera, Ramon; Puschendorf, Wolfgang; Petereit, Werner; Rohde, Veit; Schmidt, Holger; Sehmisch, Stephan; Stürmer, Klaus Michael; von Wild, Klaus; Gibbons, Henning

2017-01-01

The consequences of traumatic brain injury (TBI) for health-related quality of life (HRQoL) are still poorly understood, and no TBI-specific instrument has hitherto been available. This paper describes in detail the psychometrics and validity of the German version of an internationally developed, self-rated HRQoL tool after TBI—the QOLIBRI (Quality of Life after Brain Injury). Factors associated with HRQoL, such as the impact of cognitive status and awareness, are specifically reported. One-hundred seventy-two participants after TBI were recruited from the records of acute clinics, most of whom having a Glasgow Coma Scale (GCS) 24-hour worst score and a Glasgow Outcome Scale (GOSE) score. Participants had severe (24%), moderate (11%) and mild (56%) injuries as assessed on the GCS, 3 months to 15 years post-injury. The QOLIBRI uses 37 items to measure “satisfaction” in the areas of “Cognition”, “Self”, “Daily Life and Autonomy”, and “Social Relationships”, and “feeling bothered” by “Emotions”and “Physical Problems”. The scales meet standard psychometric criteria (α = .84 to .96; intra-class correlation—ICC = .72 to .91). ICCs (0.68 to 0.90) and αs (.83 to .96) were also good in a subgroup of participants with lower cognitive performance. The six-subscale structure of the international sample was reproduced for the German version using confirmatory factor analyses and Rasch analysis. Scale validity was supported by systematic relationships observed between the QOLIBRI and the GOSE, Patient Competency Rating Scale for Neurorehabilitation (PCRS-NR), Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Short Form 36 (SF-36), and Satisfaction with Life Scale (SWLS). The German QOLIBRI contains novel information not provided by other currently available measures and has good psychometric criteria. It is potentially useful for clinicians and researchers, in post-acute and rehabilitation studies, on a group and individual level. PMID:28542226

Influence of apoptosis on neurological outcome following traumatic cerebral contusion.

PubMed

Nathoo, Narendra; Narotam, Pradeep K; Agrawal, Devendra K; Connolly, Catherine A; van Dellen, James R; Barnett, Gene H; Chetty, Runjan

2004-08-01

Apoptosis has increasingly been implicated in the pathobiology of traumatic brain injury (TBI). The present study was undertaken to confirm the presence of apoptosis in the periischemic zone (PIZ) of traumatic cerebral contusions and to determine the role of apoptosis, if any, in neurological outcome. Brain tissue harvested at Wentworth Hospital from the PIZ in 29 patients with traumatic supratentorial contusions was compared with brain tissue resected in patients with epilepsy. Immunohistochemical analyses were performed on the tissues to see if they contained the apoptosis-related proteins p53, bcl-2, bax, and caspase-3. The findings were then correlated to demographic, clinical, surgical, neuroimaging, and outcome data. In the PIZ significant increases of bax (18-fold; p < 0.005) and caspase-3 (20-fold; p < 0.005) were recorded, whereas bcl-2 was upregulated in only 14 patients (48.3%; 2.9-fold increase) compared with control tissue. Patients in the bcl-2-positive group exhibited improved outcomes at the 18-month follow-up examination despite an older mean age and lower mean admission Glasgow Coma Scale score (p < 0.03). Caspase-3 immunostaining was increased in those patients who died (Glasgow Outcome Scale [GOS] Score 1, 12 patients) when compared with those who experienced a good outcome (GOS Score 4 or 5, 17 patients) (p < 0.005). Regression analysis identified bcl-2-negative status (p < 0.04, odds ratio [OR] 5.5; 95% confidence interval [CI] 1.1-28.4) and caspase-3-positive status (p < 0.01, OR 1.4, 95% CI 1.1-1.8) as independent predictors of poor outcome. No immunostaining for p53 was recorded in the TBI specimens. The present findings confirm apoptosis in the PIZ of traumatic cerebral contusions and indicate that this form of cell death can influence neurological outcome following a TBI.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study.

PubMed

Ruet, Alexis; Jourdan, Claire; Bayen, Eléonore; Darnoux, Emmanuelle; Sahridj, Dalila; Ghout, Idir; Azerad, Sylvie; Pradat Diehl, Pascale; Aegerter, Philippe; Charanton, James; Vallat Azouvi, Claire; Azouvi, Philippe

2017-05-18

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors. A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected. The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis. At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score. This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Early rehabilitation for severe acquired brain injury in intensive care unit: multicenter observational study.

PubMed

Bartolo, Michelangelo; Bargellesi, Stefano; Castioni, Carlo A; Bonaiuti, Donatella; Antenucci, Roberto; Benedetti, Angelo; Capuzzo, Valeria; Gamna, Federica; Radeschi, Giulio; Citerio, Giuseppe; Colombo, Carolina; Del Casale, Laura; Recubini, Elena; Toska, Saimir; Zanello, Marco; D'Aurizio, Carlo; Spina, Tullio; Del Gaudio, Alredo; Di Rienzo, Filomena; Intiso, Domenico; Dallocchio, Giulia; Felisatti, Giovanna; Lavezzi, Susanna; Zoppellari, Roberto; Gariboldi, Valentina; Lorini, Luca; Melizza, Giovanni; Molinero, Guido; Mandalà, Giorgio; Pignataro, Amedeo; Montis, Andrea; Napoleone, Alessandro; Pilia, Felicita; Pisu, Marina; Semerjian, Monica; Pagliaro, Giuseppina; Nardin, Lorella; Scarponi, Federico; Zampolini, Mauro; Zava, Raffaele; Massetti, Maria A; Piccolini, Carlo; Aloj, Fulvio; Antonelli, Sergio; Zucchella, Chiara

2016-02-01

The increased survival after a severe acquired brain injury (sABI) raise the problem of making most effective the treatments in Intensive Care Unit (ICU)/Neurointensive Care Unit (NICU), also integrating rehabilitation care. Despite previous studies reported that early mobilization in ICU was effective in preventing complications and reducing hospital stay, few studies addressed the rehabilitative management of sABI patients in ICU/NICU. To collect clinical and functional data about the early rehabilitative management of sABI patients during ICU/NICU stay. Prospective, observational, multicenter study. Fourteen facilities supplied by intensive neurorehabilitation units and ICU/NICUs. Consecutive sABI patients admitted to ICU/NICU. Patients were evaluated at admission and then every 3-5 days. Clinical, functional and rehabilitative data, including Glasgow Coma Scale (GCS), Disability Rating Scale (DRS), The Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), Early Rehabilitation Barthel Index (ERBI), Glasgow Outcome scale (GOS) and Functional Independence Measure (FIM) were collected. One hundred and two patients (F/M 44/58) were enrolled. The mean duration of ICU stay was 24.7±13.9 days and the first rehabilitative evaluation occurred after 8.7±8.8 days. Regular postural changes and multijoint mobilization were prescribed in 63.7% and 64.7% cases, respectively. The mean session duration was 38±11.5 minutes. Swallowing evaluation was performed in 14.7% patients, psychological support was provided to 12.7% of patients' caregivers, while 17.6% received a psycho-educational intervention, and 28.4% were involved in interdisciplinary team meetings. The main discharge destinations were Severe Acquired Brain Injury rehabilitation units for 43.7%, intensive neurorehabilitation units for 20.7%. Data showed that early rehabilitation was not diffusely performed in sABI subjects in ICU/NICU and rehabilitative interventions were variable; one-third of subjects were not referred to dedicated rehabilitation unit at discharge. The study stresses the need to spread and implement a rehabilitative culture also for critical ill patients due to neurological diseases.

German validation of Quality of Life after Brain Injury (QOLIBRI) assessment and associated factors.

PubMed

von Steinbüchel, Nicole; Real, Ruben G L; Sasse, Nadine; Wilson, Lindsay; Otto, Christiane; Mullins, Ryan; Behr, Robert; Deinsberger, Wolfgang; Martinez-Olivera, Ramon; Puschendorf, Wolfgang; Petereit, Werner; Rohde, Veit; Schmidt, Holger; Sehmisch, Stephan; Stürmer, Klaus Michael; von Wild, Klaus; Gibbons, Henning

2017-01-01

The consequences of traumatic brain injury (TBI) for health-related quality of life (HRQoL) are still poorly understood, and no TBI-specific instrument has hitherto been available. This paper describes in detail the psychometrics and validity of the German version of an internationally developed, self-rated HRQoL tool after TBI-the QOLIBRI (Quality of Life after Brain Injury). Factors associated with HRQoL, such as the impact of cognitive status and awareness, are specifically reported. One-hundred seventy-two participants after TBI were recruited from the records of acute clinics, most of whom having a Glasgow Coma Scale (GCS) 24-hour worst score and a Glasgow Outcome Scale (GOSE) score. Participants had severe (24%), moderate (11%) and mild (56%) injuries as assessed on the GCS, 3 months to 15 years post-injury. The QOLIBRI uses 37 items to measure "satisfaction" in the areas of "Cognition", "Self", "Daily Life and Autonomy", and "Social Relationships", and "feeling bothered" by "Emotions"and "Physical Problems". The scales meet standard psychometric criteria (α = .84 to .96; intra-class correlation-ICC = .72 to .91). ICCs (0.68 to 0.90) and αs (.83 to .96) were also good in a subgroup of participants with lower cognitive performance. The six-subscale structure of the international sample was reproduced for the German version using confirmatory factor analyses and Rasch analysis. Scale validity was supported by systematic relationships observed between the QOLIBRI and the GOSE, Patient Competency Rating Scale for Neurorehabilitation (PCRS-NR), Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Short Form 36 (SF-36), and Satisfaction with Life Scale (SWLS). The German QOLIBRI contains novel information not provided by other currently available measures and has good psychometric criteria. It is potentially useful for clinicians and researchers, in post-acute and rehabilitation studies, on a group and individual level.

[Mortality in patients with potentially severe trauma in a tertiary care hospital emergency department and evaluation of risk prediction with the GAP prognostic scale].

PubMed

Martín Quirós, Alejandro; Borobia Pérez, Alberto; Pertejo Fernández, Ana; Pérez Perilla, Patricia; Rivera Núñez, Angélica; Martínez Virto, Ana María; Quintana Díaz, Manuel

2015-01-01

To assess mortality in patients with potentially severe injuries and explore the correlation between mortality and the score on the GAP scale (Glasgow Coma Scale, age, and systolic blood pressure). Retrospective observational study of all patients with potentially severe injuries treated in an emergency department (ED) over a period of 15 months. We recorded epidemiologic variables, cause of injury, type of transport, need for prehospital orotracheal intubation, substance abuse, Charlson Comorbidity Index (CCI), variables for the GAP prognostic score, destination on discharge from the ED and at the end of the episode, and mortality. Data for 864 patients entered the final analysis. Mortality was higher in older patients (mean [SD] age, 57.9 [26.6] vs 41.1 [17.4], P<.05) and those with a higher mean CCI (3.3 [2.9] vs 0.9 [1.7]). Accident type was a precipitating factor associated with mortality (P<.001), but substance abuse was unrelated. Patients who died had lower mean Glasgow scores (9.1 [5.3] vs 14.8 [1.2], P<.001) and lower mean systolic and diastolic pressures (respectively, 113.8 [19.8] vs 131.3 [20.7] mm Hg, P=.012, and 60.1 [16.8] vs 77.7 [11.7] mm Hg, P=.002). Patients who died also had lower mean GAP scores than survivors (15.1 [4.8] vs 22.6 [1.7], P<.001). Risk factors that remained significant in the multivariate analysis were CCI (odds ratio [OR], 0.704; 95% CI, 0.52-0.96) and GAP score (OR, 1.8; 95% CI, 1.45-2.20). Mortality in our patient series was lower than rates in previously published reports. The GAP score was a useful tool for predicting mortality in the series we studied.

Community-acquired bacterial meningitis in adults in the Netherlands, 2006-14: a prospective cohort study.

PubMed

Bijlsma, Merijn W; Brouwer, Matthijs C; Kasanmoentalib, E Soemirien; Kloek, Anne T; Lucas, Marjolein J; Tanck, Michael W; van der Ende, Arie; van de Beek, Diederik

2016-03-01

We studied causative pathogens, clinical characteristics, and outcome of adult community-acquired bacterial meningitis after the introduction of adjunctive dexamethasone treatment and nationwide implementation of paediatric conjugate vaccines. In this cohort study, we prospectively assessed adults (age >16 years) with community-acquired bacterial meningitis in the Netherlands, identified through the National Reference Laboratory for Bacterial Meningitis or individual physicians between Jan 1, 2006, and July 1, 2014. We identified independent predictors of an unfavourable outcome (Glasgow Outcome Scale score 1-4) by logistic regression. We assessed 1412 episodes of community-acquired bacterial meningitis. Incidence declined from 1·72 cases per 100,000 adults per year in 2007-08, to 0·94 per 100,000 per year in 2013-14. Streptococcus pneumoniae caused 1017 (72%) of 1412 episodes. Rates of adult bacterial meningitis decreased most sharply among pneumococcal serotypes included in paediatric conjugate vaccine, and in meningococcal meningitis. We found no evidence of serotype or serogroup replacement. The overall case fatality rate was 244 (17%) of 1412 episodes and unfavourable outcome occurred in 531 (38%) of 1412 episodes. Predictors of unfavourable outcome were advanced age, absence of otitis or sinusitis, alcoholism, tachycardia, lower score on the Glasgow Coma Scale, cranial nerve palsy, a cerebrospinal fluid white-cell count lower than 1000 cells per μL, a positive blood culture, and a high serum C-reactive protein concentration. Adjunctive dexamethasone was administered for 1234 (89%) of 1384 assessed episodes. The multivariable adjusted odds ratio of dexamethasone treatment for unfavourable outcome was 0·54 (95% CI 0·39-0·73). The incidence of adult bacterial meningitis has decreased substantially, which is partly explained by herd protection by paediatric conjugate vaccines. Adjunctive dexamethasone treatment was associated with substantially improved outcome. European Research Council, National Institute of Public Health and the Environment, European Union, Academic Medical Center, and Netherlands Organization for Health Research and Development. Copyright © 2016 Elsevier Ltd. All rights reserved.

Post-Traumatic Hypoxia Is Associated with Prolonged Cerebral Cytokine Production, Higher Serum Biomarker Levels, and Poor Outcome in Patients with Severe Traumatic Brain Injury

PubMed Central

Yan, Edwin B.; Satgunaseelan, Laveniya; Paul, Eldho; Bye, Nicole; Nguyen, Phuong; Agyapomaa, Doreen; Kossmann, Thomas; Rosenfeld, Jeffrey V.

2014-01-01

Abstract Secondary hypoxia is a known contributor to adverse outcomes in patients with traumatic brain injury (TBI). Based on the evidence that hypoxia and TBI in isolation induce neuroinflammation, we investigated whether TBI combined with hypoxia enhances cerebral cytokine production. We also explored whether increased concentrations of injury biomarkers discriminate between hypoxic (Hx) and normoxic (Nx) patients, correlate to worse outcome, and depend on blood–brain barrier (BBB) dysfunction. Forty-two TBI patients with Glasgow Coma Scale ≤8 were recruited. Cerebrospinal fluid (CSF) and serum were collected over 6 days. Patients were divided into Hx (n=22) and Nx (n=20) groups. Eight cytokines were measured in the CSF; albumin, S100, myelin basic protein (MBP) and neuronal specific enolase (NSE) were quantified in serum. CSF/serum albumin quotient was calculated for BBB function. Glasgow Outcome Scale Extended (GOSE) was assessed at 6 months post-TBI. Production of granulocye macrophage-colony stimulating factor (GM-CSF) was higher, and profiles of GM-CSF, interferon (IFN)-γ and, to a lesser extent, tumor necrosis factor (TNF), were prolonged in the CSF of Hx but not Nx patients at 4–5 days post-TBI. Interleukin (IL)-2, IL-4, IL-6, and IL-10 increased similarly in both Hx and Nx groups. S100, MBP, and NSE were significantly higher in Hx patients with unfavorable outcome. Among these three biomarkers, S100 showed the strongest correlations to GOSE after TBI-Hx. Elevated CSF/serum albumin quotients lasted for 5 days post-TBI and displayed similar profiles in Hx and Nx patients. We demonstrate for the first time that post-TBI hypoxia is associated with prolonged neuroinflammation, amplified extravasation of biomarkers, and poor outcome. S100 and MBP could be implemented to track the occurrence of post-TBI hypoxia, and prompt adequate treatment. PMID:24279428

Amiodarone-induced myxoedema coma

PubMed Central

Hassan, Syed; Ayoub, Walaa; Hassan, Mona; Wisgerhof, Max

2014-01-01

A 62-year-old man was found to have bradycardia, hypothermia and respiratory failure 3 weeks after initiation of amiodarone therapy for atrial fibrillation. Thyroid-stimulating hormone was found to be 168 μIU/mL (nl. 0.3–5 μIU/mL) and free thyroxine (FT4) was <0.2 ng/dL (nl. 0.8–1.8 ng/dL). He received intravenous fluids, vasopressor therapy and stress dose steroids; he was intubated and admitted to the intensive care unit. He received 500 μg of intravenous levothyroxine in the first 18 h of therapy, and 150 µg intravenous daily thereafter. Haemodynamic improvement, along with complete recovery of mental status, occurred after 48 h. Twelve hours after the initiation of therapy, FT4 was 0.96 ng/dL. The patient was maintained on levothyroxine 175 (g POorally daily. A thyroid ultrasound showed diffuse heterogeneity. The 24 hour excretion of iodine was 3657 (mcg (25–756 ( mcg). The only two cases of amiodarone-induced myxoedema coma in the literature report patient death despite supportive therapy and thyroid hormone replacement. This case represents the most thoroughly investigated case of amiodarone-induced myxoedema coma with a history significant for subclinical thyroid disease. PMID:24729111

The use of stable xenon-enhanced computed tomographic studies of cerebral blood flow to define changes in cerebral carbon dioxide vasoresponsivity caused by a severe head injury.

PubMed

Marion, D W; Bouma, G J

1991-12-01

Previous studies using the xenon-133 cerebral blood flow (CBF) method have documented the impairment of CO2 vasoresponsivity after a severe head injury, but only global values can be obtained reliably with this technique. We studied CO2 vasoresponsivity using the stable xenon-enhanced computed tomographic CBF method, which provided information about well-defined cortical regions and deep brain structures not available with the xenon-133 method. In 17 patients with admission Glasgow Coma Scale scores of 8 or less, hemispheric CO2 vasoresponsivity ranged from 1.3 to 8.5% per mm Hg change in partial CO2 pressure. Lobar, cerebellar, basal ganglia, and brain stem CO2 vasoresponsivity frequently varied from the mean global value by more than 25%. In all but one patient, local CO2 vasoresponsivity in one or more of these areas differed from the mean global value by more than 50%. The greatest variability occurred in patients with acute subdural hematomas and diffuse (bihemispheric) injuries. This variability in CO2 vasoresponsivity has important implications for the effective and safe management of intracranial hypertension that frequently accompanies severe head injury.

Human exposures to immobilising agents: results of an online survey.

PubMed

Haymerle, A; Fahlman, A; Walzer, C

2010-08-28

Cases of human exposure to veterinary injectable anaesthetics were reviewed following a literature search and completion of an online questionnaire in an attempt to provide an objective approach to the problem. The modified Glasgow Coma Scale was used to rank cases according to their severity. From the cases examined, results showed that intoxication with potent opioids, such as etorphine, carfentanil and thiafentanil, need to be treated with antagonists such as naloxone, nalmefene or naltrexone, and not with antagonists with agonistic properties, such as diprenorphine. With regard to the alpha(2)-agonists xylazine, detomidine, medetomidine and romifidine, no antagonist is currently accredited for human use. Atipamezole, a specific alpha(2)-antagonist, is widely used in veterinary medicine and has been used experimentally to reverse dexmetomidine in a study in human medicine. The high concentrations of alpha(2)-agonists being used in zoo and wildlife medicine warrant the accreditation of atipamezole for use in cases of human exposure. Knowledge and availability of the appropriate antagonist are essential in cases of human intoxication with injectable anaesthetics. Preventive measures, such as wearing gloves and eye protection, need to be used more regularly to reduce the risk of exposure.

Clinical emergency treatment of 68 critical patients with severe organophosphorus poisoning and prognosis analysis after rescue.

PubMed

Dong, Hui; Weng, Yi-Bing; Zhen, Gen-Shen; Li, Feng-Jie; Jin, Ai-Chun; Liu, Jie

2017-06-01

This study reports the clinical emergency treatment of 68 critical patients with severe organophosphorus poisoning, and analyzes the prognosis after rescue.The general data of 68 patients with severe organophosphorus poisoning treated in our hospital were retrospectively analyzed. These patients were divided into 2 groups: treatment group, and control group. Patients in the control group received routine emergency treatment, while patients in the treatment group additionally received hemoperfusion plus hemodialysis on the basis of routine emergency treatment. The curative effects in these 2 groups and the prognosis after rescue were compared.Compared with the control group, atropinization time, recovery time of cholinesterase activity, recovery time of consciousness, extubation time, and length of hospital stay were shorter (P < .05); the total usage of atropine was significantly lower (P < .05); Glasgow Coma Score was significantly higher (P < .05); acute physiology and chronic health score (APACHE II) was significantly lower (P < .05); and mortality and poisoning rebound rate was significantly lower (P < .05) in the treatment group.Hemoperfusion and hemodialysis on the basis of routine emergency treatment for critical patients with organophosphorus poisoning can improve rescue outcomes and improve the prognosis of patients, which should be popularized.

Serum Levels of Substance P and Mortality in Patients with a Severe Acute Ischemic Stroke

PubMed Central

Lorente, Leonardo; Martín, María M.; Almeida, Teresa; Pérez-Cejas, Antonia; Ramos, Luis; Argueso, Mónica; Riaño-Ruiz, Marta; Solé-Violán, Jordi; Hernández, Mariano

2016-01-01

Substance P (SP), a member of tachykinin family, is involved in the inflammation of the central nervous system and in the appearance of cerebral edema. Higher serum levels of SP have been found in 18 patients with cerebral ischemia compared with healthy controls. The aim of our multi-center study was to analyze the possible association between serum levels of SP and mortality in ischemic stroke patients. We included patients with malignant middle cerebral artery infarction (MMCAI) and a Glasgow Coma Scale (GCS) lower than 9. Non-surviving patients at 30 days (n = 31) had higher serum concentrations of SP levels at diagnosis of severe MMCAI than survivors (n = 30) (p < 0.001). We found in multiple regression an association between serum concentrations of SP higher than 362 pg/mL and mortality at 30 days (Odds Ratio = 5.33; 95% confidence interval = 1.541–18.470; p = 0.008) after controlling for age and GCS. Thus, the major novel finding of our study was the association between serum levels of SP and mortality in patients suffering from severe acute ischemic stroke. PMID:27338372

Recurrent hemorrhage in hemangioblastoma involving the posterior fossa: Case report

PubMed Central

Marvin, Eric; Akhter, Asad S.; Coppens, Jeroen R.

2017-01-01

Background: Hemangioblastomas (HGBs) are the most common primary intra-axial posterior fossa tumor in adults. Although spontaneous hemorrhage of these tumors is exceedingly rare, despite their vascular nature, we describe a case of recurrent hemorrhage with associated tonsillar herniation, and demonstrate that a surgical approach can provide a suitable outcome. Case Description: A 54-year-old female with von Hippel-Lindau (VHL) syndrome presented with acute loss of consciousness and Glasgow Coma Scale (GCS) was 4. Computed tomographic (CT) images demonstrated large volume subarachnoid hemorrhage of the posterior fossa with intraventricular extension and intraparenchymal hemorrhage involving the right cerebellar tonsil. Magnetic resonance imaging (MRI) displayed three lesions in the posterior fossa, two near the hemorrhage site. Patient underwent suboccipital craniectomy with a decent recovery followed by radiosurgery as she refused resection. A second hemorrhage occurred ultimately prompting surgical resection of the three posterior fossa lesions, with a reasonable postoperative course. Conclusion: Hemorrhage of HGBs of the posterior fossa can present in conjunction of tonsillar herniation. Re-hemorrhage appears to be likely if prior acute hemorrhage has occurred. A stepwise approach of surgical decompression and resection may provide the best outcome. PMID:28713626

Hypothermia is a frequent sign of severe hypoglycaemia in patients with diabetes.

PubMed

Tran, C; Gariani, K; Herrmann, F R; Juan, L; Philippe, J; Rutschmann, O T; Vischer, U M

2012-10-01

Hypothermia is a recognized complication of severe hypoglycaemia, but its prevalence and characteristics are poorly studied. For this reason, this study aimed to evaluate hypothermia in severely hypoglycaemic patients. A retrospective chart review was performed including all patients discharged between 2007 and 2010 from the Emergency Department of the Geneva University Hospital with a diagnosis of severe hypoglycaemia. Hypothermia was identified in 30 (23.4%) out of 128 patients with severe hypoglycaemia. Its incidence was not affected by age, type of diabetes, season or time of day (day/night). Using linear regression, the lowest recorded temperature was associated with the Glasgow coma scale (GCS) score (r2 = 13.8%, P < 0.0001) and inversely associated with the leukocyte count (r2 = 13.1%, P = 0.001). Hypothermia is a frequent sign of severe hypoglycaemia in patients with diabetes. The associations between hypothermia and the GCS score and the leukocyte count suggest that it is a marker of hypoglycaemia severity and/or duration. Hypothermia may represent an important compensatory mechanism in severe hypoglycaemia, reflecting a decrease in energy demand during glucose deprivation. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Acute alcohol intoxication, diffuse axonal injury and intraventricular bleeding in patients with isolated blunt traumatic brain injury.

PubMed

Matsukawa, Hidetoshi; Shinoda, Masaki; Fujii, Motoharu; Takahashi, Osamu; Murakata, Atsushi; Yamamoto, Daisuke

2013-01-01

The influence of blood alcohol level (BAL) on outcome remains unclear. This study investigated the relationships between BAL, type and number of diffuse axonal injury (DAI), intraventricular bleeding (IVB) and 6-month outcome. This study reviewed 419 patients with isolated blunt traumatic brain injury. First, it compared clinical and radiological characteristics between patients with good recovery and disability. Second, it compared BAL among DAI lesions. Third, it evaluated the correlation between the BAL and severity of IVB, number of DAI and corpus callosum injury lesions. Regardless of BAL, older age, male gender, severe Glasgow Coma Scale score (<9), abnormal pupil, IVB and lesion on genu of corpus callosum were significantly related to disability. There were no significant differences between the BAL and lesions of DAI. Simple regression analysis revealed that there were no significant correlation between BAL and severity of IVB, number of DAI and corpus callosum injury lesions. Acute alcohol intoxication was not associated with type and number of DAI lesion, IVB and disability. This study suggested that a specific type of traumatic lesion, specifically lesion on genu of corpus callosum and IVB, might be more vital for outcome.

Traumatic brain injury due to gunshot wounds: a single institution's experience with 442 consecutive patients.

PubMed

Solmaz, Ilker; Kural, Cahit; Temiz, Cağlar; Seçer, Halil Ibrahim; Düz, Bülent; Gönül, Engin; Izci, Yusuf

2009-07-01

Traumatic brain injury (TBI) caused by a gunshot wound is a complex injury with a broad spectrum of symptoms and high rates of mortality and morbidity. This study presents an evaluation of TBI caused by gunshot wounds presenting at a single institution and discusses possible predictive factors for the outcome of surgical intervention. The study sample consisted of 442 patients who underwent surgery for TBI over a 16-year period. All injuries were caused by gunshot wounds, such as bullets and shrapnel. All patients underwent surgical intervention. Almost all patients (99.3%) were male, and the mean patient age was 22.3 years. Wounds were caused by shrapnel in 68 percent of patients. The Glasgow Coma Scale (GCS) score at admission was below 8 in 116 patients (26.2%) and above 8 in 326 patients (73.8%). In total, 47 patients (10.6%) died despite surgical management, with diffuse brain injury the most common cause of death. Low GCS scores, ventricular injuries and bihemispheric injuries are correlated with poor prognosis. Early and less invasive surgery in conjunction with short transportation time to the hospital could decrease mortality rates.

V-akt murine thymoma viral oncogene homolog 3 (AKT3) contributes to poor disease outcome in humans and mice with pneumococcal meningitis.

PubMed

Valls Serón, Mercedes; Ferwerda, Bart; Engelen-Lee, JooYeon; Geldhoff, Madelijn; Jaspers, Valery; Zwinderman, Aeilko H; Tanck, Michael W; Baas, Frank; van der Ende, Arie; Brouwer, Matthijs C; van de Beek, Diederik

2016-05-18

Pneumococcal meningitis is the most common and severe form of bacterial meningitis. Fatality rates are substantial, and long-term sequelae develop in about half of survivors. Here, we have performed a prospective nationwide genetic association study using the Human Exome BeadChip and identified gene variants in encoding dynactin 4 (DCTN4), retinoic acid early transcript 1E (RAET1E), and V-akt murine thymoma viral oncogene homolog 3 (AKT3) to be associated with unfavourable outcome in patients with pneumococcal meningitis. No clinical replication cohort is available, so we validated the role of one of these targets, AKT3, in a pneumococcal meningitis mouse model. Akt3 deficient mice had worse survival and increased histopathology scores for parenchymal damage (infiltration) and vascular infiltration (large meningeal artery inflammation) but similar bacterial loads, cytokine responses, compared to wild-type mice. We found no differences in cerebrospinal fluid cytokine levels between patients with risk or non-risk alleles. Patients with the risk genotype (rs10157763, AA) presented with low scores on the Glasgow Coma Scale and high rate of epileptic seizures. Thus, our results show that AKT3 influences outcome of pneumococcal meningitis.

Paediatric head injuries in the Kwazulu-Natal Province of South Africa: a developing country perspective.

PubMed

Okyere-Dede, Ebenezer K; Nkalakata, Munyaradzi C; Nkomo, Tshepo; Hadley, G P; Madiba, Thandinkosi E

2013-01-01

We investigated the causes, management and outcome of head injuries in paediatric patients admitted to the paediatric surgery unit at King Edward VIII Hospital over a 3-year period, from 1999 to 2001. There were 506 patients (331 male; M:F ratio 2:1) and the mean age was 71.99 +36.8 months (2 weeks to 180 months). The injuries were due to: motor vehicle crashes (324); falls (121); assault (30); inadvertent injury (23); and unknown (11). Forty-nine patients (9%) were admitted with a Glasgow Coma Scale ≤8. The most common intracranial pathology on computed tomography was: intracranial haematoma/haemorrhage (44); contusion (16); and brain oedema (10). Nineteen patients (3.4%) underwent neurosurgical intervention and the rest were managed conservatively. Eighteen died in hospital (3.6%). The mean hospital stay was 5 ± 12 days. Twenty-three patients (4.5%) were discharged with neurological sequelae. Few paediatric patients are admitted with severe head injury: the majority from blunt injury caused by motor vehicle crashes. Management mainly requires simple neurological observation in a general ward with a surprisingly good prognosis. Specific protocols for paediatric head injuries have been proposed based on these findings.

[Clinical features and prognostic factors of meningococcal disease: a case series study in Chile during the 2012-2013 outbreak].

PubMed

Matute, Isabel; Olea, Andrea; López, Darío; Loayza, Sergio; Nájera, Manuel; González, Claudia; Poffald, Lucy; Hirmas, Macarena; Delgado, Iris; Pedroni, Elena; Alfaro, Tania; Gormaz, Ana María; Sanhueza, Gabriel; Vial, Pablo; Dabanch, Jeannette; Gallegos, Doris; Aguilera, Ximena

2015-10-01

Meningococcal disease (MD) is a major global problem because of its case fatality rate and sequels. Since 2012 cases of serogroup W have increased in Chile, with nonspecific clinical presentation, high case fatality rate and serious consequences. To characterize the evolution and outcome of MD cases between January 2012 and March 2013 in Chile. Case series considering 149 MD cases of 7 regions. A questionnaire was applied and clinical records were reviewed, including individual, agent, clinical course and healthcare process variables. The analysis allowed to obtain estimates of the OR as likelihood of dying. 51.5% was meningococcemia, the case fatality rate reached 27%, prevailing serogroup W (46.6%). Factors that increased the probability of dying: > age, belonging to indigenous people, having lived a stressful event, having diarrhea, impaired consciousness, cardiovascular symptoms, low oxygen saturation and low Glasgow coma scale score. The case fatality rate exceeded normal levels and was higher in serogroup W. Increasing in this serogroup, associated to the increased presence of nonspecific symptoms or rapid progression to septicemia, hit a health system accustomed to more classic meningococcal disease presentation, which could partly explain the observed increased fatality rate.

Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction.

PubMed

Wang, Qiang-Ping; Ma, Jun-Peng; Zhou, Zhang-Ming; Yang, Min; You, Chao

2016-08-01

Several studies have investigated the incidence and risk factors of hydrocephalus after decompressive craniectomy (DC) for malignant hemispheric cerebral infarction. However, the results are controversial. Therefore, the following is a retrospective cohort study to determine the incidence and risk factors of hydrocephalus after DC for malignant hemispheric cerebral infarction. From January 2004 to June 2014, patients at two medical centres in south-west China, who underwent DC for malignant hemispheric cerebral infarction, were included. The patients' clinical and radiologic findings were retrospectively reviewed. A chi-square test, Mann-Whitney U-test and logistic regression model were used to identify the risk factors. A total of 128 patients were included in the study. The incidence of ventriculomegaly and shunt-dependent hydrocephalus were 42.2% (54/128) and 14.8% (19/128), respectively. Lower preoperative Glasgow Coma Scale (GCS) score and presence of subarachnoid haemorrhage (SAH) were factors significantly associated with the development of post-operative hydrocephalus after DC. Cerebral infarction patients receiving DC have a moderate tendency to suffer from post-operative hydrocephalus. A poor GCS score and the presence of SAH were significantly associated with the development of hydrocephalus after DC.

[Prognostic factors after cardiac arrest. Usefulness of early video-electroencephalogram].

PubMed

Arméstar, Fernando; Becerra Cuñat, Juan Luis; León Chan, Yariela; Mesalles Sanjuan, Eduard; Moreno, José Antonio; Jiménez González, Marta; Roca, Josep

2015-05-08

Predictors of unfavorable outcome in patients after cardiopulmonary arrest (CPA) are important to make decisions about the limitation of therapeutic efforts. The aim was to analyze the clinical variables in the prognosis of patients recovered after CPA. Retrospective study on comatose patients with recovered CPA. The variables were: age, sex, Glasgow Coma Score (GCS), pupillary light reflex, other variables related to CPA (cause, duration, witnessed or not witnessed), myoclonic status and electroencephalographic (EEG) patterns. Fifty patients were studied. The variables associated with mortality were the absence of pupillary light reflex (hazard ratio [HR] 0.277, 95% confidence interval [95% CI] 0.103-0.741, P=.01), a low GCS (HR 0.701, 95% CI 0.542-0.908, P=.007) and myoclonic state (HR 0.38, 95% CI 0.176-0.854, P=.01). We evaluated the EEG patterns in 22 patients. No statistical significance was observed. The absence of pupillary light reflex, a low GCS and myoclonic state are prognostic factors in patients recovered after a CPA. The EEG patterns showed a nonsignificant association with prognosis. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.

Brainstem encephalitis and acute polyneuropathy associated with hepatitis E infection.

PubMed

Salim, Omar Jabbar; Davidson, Amy; Li, Kathy; Leach, John Paul; Heath, Craig

2017-09-11

A 59-year-old man presented with feverish illness. His Glasgow Coma Scale was 15, had reduced visual acuity in the left eye with partial left ptosis and mild left hemiparesis with an extensor left plantar. Over 48 hours, he accrued multiple cranial nerves palsies and progressed to a flaccid paralysis necessitating admission to an intensive care unit.Cerebrospinal fluid (CSF) study showed 20 lymphocytes and raised protein. Viral and bacterial PCRs were negative. Samples for Lyme, blood-borne viruses, syphilis and autoantibodies were also negative. MRI brain showed T2 abnormalities within the brainstem. Nerve conduction studies revealed an acute motor and sensory axonal neuropathy pattern of Guillian Barre Syndrome (GBS). The patient was treated for both infective and inflammatory causes of brainstem encephalitis and GBS.Retrospective studies confirmed the presence of hepatitis E virus (HEV) RNA in CSF and serum studies showed positive HEV IgG and IgM prior to intravenous infusion. After 3 months of intensive rehabilitation, the patient was discharged home walking with a frame. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

The atmosphere of 2060 Chiron

NASA Technical Reports Server (NTRS)

Meech, Karen J.; Belton, Michael J. S.

1990-01-01

An explanation for 2060 Chiron's behavior, which focuses on the influence of Chiron's mass on the development of its dust coma, is presented. It is suggested that dust is entrained by the flow of CO or another gas of similar volatility from an active region. It remains gravitationally bound on orbits confined to a region, roughly 5000 km in extent, that lies between the surface and an exopause imposed by radiation pressure forces. The influence of radiation pressure transforms the initial particle trajectories into satellite orbits with a characteristic period of 20 days and orbital residence time of about 25 revolutions. The particle population in the coma slowly increases, explaining Chiron's photometric behavior.

Synergistic regulation of competence development in Bacillus subtilis by two Rap-Phr systems.

PubMed

Bongiorni, Cristina; Ishikawa, Shu; Stephenson, Sophie; Ogasawara, Naotake; Perego, Marta

2005-07-01

The 11 Rap proteins of Bacillus subtilis comprise a conserved family of tetratricopeptide (TPR)-containing regulatory proteins. Their activity is inhibited by specific Phr pentapeptides produced from the product of phr genes through an export-import maturation process. We found that one of the proteins, namely RapF, is involved in the regulation of competence to DNA transformation. The ComA response regulator and transcription factor for initiation of competence development is the target of RapF. Specific binding of RapF to the carboxy-terminal DNA-binding domain of ComA inhibits the response regulator's ability to bind its target DNA promoters. The PhrF C-terminal pentapeptide, QRGMI, inhibits RapF activity. The activity of RapF and PhrF in regulating competence development is analogous to the previously described activity of RapC and PhrC (L. J. Core and M. Perego, Mol. Microbiol. 49:1509-1522, 2003). In fact, the RapF and PhrF pair of proteins acts synergistically with RapC and PhrC in the overall regulation of the ComA transcription factor. Since the transcription of the RapC- and RapF-encoding genes is positively regulated by their own target ComA, an autoregulatory circuit must exist for the competence transcription factor in order to modulate its activity.

Chemical Recycling of Molecules in Cometary Comae

NASA Astrophysics Data System (ADS)

Boice, Daniel C.; Kawakita, Hideyo; Shinnaka, Yoshiharu; Kobayashi, Hitomi

2015-08-01

Modeling is essential to understand the important physical and chemical processes that occur in cometary comae, especially the relationship between native and sibling molecules, such as, HCN and CN. Photochemistry is a major source of ions and electrons that further initiate key gas-phase reactions, leading to the plethora of molecules and atoms observed in comets. The effects of photoelectrons that react via impacts are important to the overall ionization in the inner coma. We have found that many molecules undergo protonation reactions with primarily water, followed by electron recombination resulting in the original molecules in a vibrationally excited state. These excited molecules spontaneously emit photons back to the ground state. We identify this series of reactions as chemical “recycling.” We discuss the importance of this mechanism for HCN, NH3, and water in comets. We also identify other relevant processes in the collision-dominated, inner coma of a comet within a global modeling framework to better understand observations and in situ measurements of cometary species, especially relationships between native and sibling molecules for the Rosetta Mission to Comet 67P/Churyumov-Gerasimenko.Acknowledgements: We appreciate support from the NSF Planetary Astronomy Program under Grant No. 0908529. This program is partially supported by the MEXT Supported Program for the Strategic Research Foundation at Private Universities, 2014-2018.

Immediate, irreversible, posttraumatic coma: a review indicating that bilateral brainstem injury rather than widespread hemispheric damage is essential for its production.

PubMed

Rosenblum, William I

2015-03-01

Traumatic brain injury may result in immediate long-lasting coma. Much attention has been given to predicting this outcome from the initial examination because these predictions can guide future treatment and interactions with the patient's family. Reports of diffuse axonal injury in these cases have ascribed the coma to widespread damage in the deep white matter that disconnects the hemispheres from the ascending arousal system (AAS). However, brainstem lesions are also present in such cases, and the AAS may be interrupted at the brainstem level. This review examines autopsy and imaging literature that assesses the presence, extent, and predictive value of lesions in both sites. The evidence suggests that diffuse injury to the deep white matter is not the usual cause of immediate long-lasting posttraumatic coma. Instead, brainstem lesions in the rostral pons or midbrain are almost always the cause but only if the lesions are bilateral. Moreover, recovery is possible if critical brainstem inputs to the AAS are spared. The precise localization of the latter is subject to ongoing investigation with advanced imaging techniques using magnets of very high magnetic gradients. Limited availability of this equipment plus the need to verify the findings continue to require meticulous autopsy examination.

Brain MRS glutamine as a biomarker to guide therapy of hyperammonemic coma.

PubMed

O'Donnell-Luria, Anne H; Lin, Alexander P; Merugumala, Sai K; Rohr, Frances; Waisbren, Susan E; Lynch, Rebecca; Tchekmedyian, Vatche; Goldberg, Aaron D; Bellinger, Andrew; McFaline-Figueroa, J Ricardo; Simon, Tracey; Gershanik, Esteban F; Levy, Bruce D; Cohen, David E; Samuels, Martin A; Berry, Gerard T; Frank, Natasha Y

2017-05-01

Acute idiopathic hyperammonemia in an adult patient is a life-threatening condition often resulting in a rapid progression to irreversible cerebral edema and death. While ammonia-scavenging therapies lower blood ammonia levels, in comparison, clearance of waste nitrogen from the brain may be delayed. Therefore, we used magnetic resonance spectroscopy (MRS) to monitor cerebral glutamine levels, the major reservoir of ammonia, in a gastric bypass patient with hyperammonemic coma undergoing therapy with N-carbamoyl glutamate and the ammonia-scavenging agents, sodium phenylacetate and sodium benzoate. Improvement in mental status mirrored brain glutamine levels, as coma persisted for 48h after plasma ammonia normalized. We hypothesize that the slower clearance for brain glutamine levels accounts for the delay in improvement following initiation of treatment in cases of chronic hyperammonemia. We propose MRS to monitor brain glutamine as a noninvasive approach to be utilized for diagnostic and therapeutic monitoring purposes in adult patients presenting with idiopathic hyperammonemia. Copyright © 2017 Elsevier Inc. All rights reserved.

Antibiotic Therapy in Comatose Mechanically Ventilated Patients Following Aspiration: Differentiating Pneumonia From Pneumonitis.

PubMed

Lascarrou, Jean Baptiste; Lissonde, Floriane; Le Thuaut, Aurélie; Bachoumas, Konstantinos; Colin, Gwenhael; Henry Lagarrigue, Matthieu; Vinatier, Isabelle; Fiancette, Maud; Lacherade, Jean Claude; Yehia, Aihem; Joret, Aurélie; Lebert, Christine; Bourdon, Sandra; Martin Lefèvre, Laurent; Reignier, Jean

2017-08-01

To determine the proportion of patients with documented bacterial aspiration pneumonia among comatose ICU patients with symptoms suggesting either bacterial aspiration pneumonia or non-bacterial aspiration pneumonitis. Prospective observational study. University-affiliated 30-bed ICU. Prospective cohort of 250 patients admitted to the ICU with coma (Glasgow Coma Scale score ≤ 8) and treated with invasive mechanical ventilation. None. The primary outcome was the proportion of patients with microbiologically documented bacterial aspiration pneumonia. Patients meeting predefined criteria for aspiration syndrome routinely underwent telescopic plugged catheter sampling during bronchoscopy before starting probabilistic antibiotic treatment. When cultures were negative, the antibiotic treatment was stopped. Of 250 included patients, 98 (39.2%) had aspiration syndrome, including 92 before mechanical ventilation discontinuation. Telescopic plugged catheter in these 92 patients showed bacterial aspiration pneumonia in 43 patients (46.7%). Among the remaining 49 patients, 16 continued to receive antibiotics, usually for infections other than pneumonia; of the 33 patients whose antibiotics were discontinued, only two subsequently showed signs of lung infection. In the six patients with aspiration syndrome after mechanical ventilation, and therefore without telescopic plugged catheter, antibiotic treatment was continued for 7 days. Mechanical ventilation duration, ICU length of stay, and mortality did not differ between the 43 patients with bacterial aspiration pneumonia and the 49 patients with non-bacterial aspiration pneumonitis. The 152 patients without aspiration syndrome did not receive antibiotics. Among comatose patients receiving mechanical ventilation, those without clinical, laboratory, or radiologic evidence of bacterial aspiration pneumonia did not require antibiotics. In those with suspected bacterial aspiration pneumonia, stopping empirical antibiotic therapy when routine telescopic plugged catheter sampling recovered no microorganisms was nearly always effective. This strategy may be a valid alternative to routine full-course antibiotic therapy. Only half the patients with suspected bacterial aspiration pneumonia had this diagnosis confirmed by telescopic plugged catheter sampling.

Comparative Analysis of Cervical Spine Management in a Subset of Severe Traumatic Brain Injury Cases Using Computer Simulation

PubMed Central

Carter, Kimbroe J.; Dunham, C. Michael; Castro, Frank; Erickson, Barbara

2011-01-01

Background No randomized control trial to date has studied the use of cervical spine management strategies in cases of severe traumatic brain injury (TBI) at risk for cervical spine instability solely due to damaged ligaments. A computer algorithm is used to decide between four cervical spine management strategies. A model assumption is that the emergency room evaluation shows no spinal deficit and a computerized tomogram of the cervical spine excludes the possibility of fracture of cervical vertebrae. The study's goal is to determine cervical spine management strategies that maximize brain injury functional survival while minimizing quadriplegia. Methods/Findings The severity of TBI is categorized as unstable, high risk and stable based on intracranial hypertension, hypoxemia, hypotension, early ventilator associated pneumonia, admission Glasgow Coma Scale (GCS) and age. Complications resulting from cervical spine management are simulated using three decision trees. Each case starts with an amount of primary and secondary brain injury and ends as a functional survivor, severely brain injured, quadriplegic or dead. Cervical spine instability is studied with one-way and two-way sensitivity analyses providing rankings of cervical spine management strategies for probabilities of management complications based on QALYs. Early collar removal received more QALYs than the alternative strategies in most arrangements of these comparisons. A limitation of the model is the absence of testing against an independent data set. Conclusions When clinical logic and components of cervical spine management are systematically altered, changes that improve health outcomes are identified. In the absence of controlled clinical studies, the results of this comparative computer assessment show that early collar removal is preferred over a wide range of realistic inputs for this subset of traumatic brain injury. Future research is needed on identifying factors in projecting awakening from coma and the role of delirium in these cases. PMID:21544239

The importance of polysomnography in the evaluation of prolonged disorders of consciousness: sleep recordings more adequately correlate than stimulus-related evoked potentials with patients' clinical status.

PubMed

de Biase, Stefano; Gigli, Gian Luigi; Lorenzut, Simone; Bianconi, Claudio; Sfreddo, Patrizia; Rossato, Gianluca; Basaldella, Federica; Fuccaro, Matteo; Corica, Antonio; Tonon, Davide; Barbone, Fabio; Valente, Mariarosaria

2014-04-01

The aim of our study was to evaluate the importance of sleep recordings and stimulus-related evoked potentials (EPs) in patients with prolonged disorders of consciousness (DOCs) by correlating neurophysiologic variables with clinical evaluation obtained using specific standardized scales. There were 27 vegetative state (VS) and 5 minimally conscious state (MCS) patients who were evaluated from a clinical and neurophysiologic perspective. Clinical evaluation included the Coma Recovery Scale-Revised (CRS-R), Disability Rating Scale (DRS), and Glasgow Coma Scale (GCS). Neurophysiologic evaluation included 24-h polysomnography (PSG), somatosensory EPs (SEPs), brainstem auditory EPs (BAEPs), and visual EPs (VEPs). Patients with preservation of each single sleep element (sleep-wake cycle, sleep spindles, K-complexes, and rapid eye movement [REM] sleep) always showed better clinical scores compared to those who did not have preservation. Statistical significance was only achieved for REM sleep. In 7 patients PSG showed the presence of all considered sleep elements, and they had a CRS-R score of 8.29±1.38. In contrast, 25 patients who lacked one or more of the sleep elements had a CRS-R score of 4.84±1.46 (P<.05). Our multivariate analysis clarified that concurrent presence of sleep spindles and REM sleep were associated with a much higher CRS-R score (positive interaction, P<.0001). On the other hand, no significant associations were found between EPs and CRS-R scores. PSG recordings have proved to be a reliable tool in the neurophysiologic assessment of patients with prolonged DOCs, correlating more adequately than EPs with the clinical evaluation and the level of consciousness. The main contribution to higher clinical scores was determined by the concomitant presence of REM sleep and sleep spindles. PSG recordings may be considered inexpensive, noninvasive, and easy-to-perform examinations to provide supplementary information in patients with prolonged DOCs. Copyright © 2014 Elsevier B.V. All rights reserved.

Predicting the mortality in geriatric patients with dengue fever

PubMed Central

Huang, Hung-Sheng; Hsu, Chien-Chin; Ye, Je-Chiuan; Su, Shih-Bin; Huang, Chien-Cheng; Lin, Hung-Jung

2017-01-01

Abstract Geriatric patients have high mortality for dengue fever (DF); however, there is no adequate method to predict mortality in geriatric patients. Therefore, we conducted this study to develop a tool in an attempt to address this issue. We conducted a retrospective case–control study in a tertiary medical center during the DF outbreak in Taiwan in 2015. All the geriatric patients (aged ≥65 years) who visited the study hospital between September 1, 2015, and December 31, 2015, were recruited into this study. Variables included demographic data, vital signs, symptoms and signs, comorbidities, living status, laboratory data, and 30-day mortality. We investigated independent mortality predictors by univariate analysis and multivariate logistic regression analysis and then combined these predictors to predict the mortality. A total of 627 geriatric DF patients were recruited, with a mortality rate of 4.3% (27 deaths and 600 survivals). The following 4 independent mortality predictors were identified: severe coma [Glasgow Coma Scale: ≤8; adjusted odds ratio (AOR): 11.36; 95% confidence interval (CI): 1.89–68.19], bedridden (AOR: 10.46; 95% CI: 1.58–69.16), severe hepatitis (aspartate aminotransferase >1000 U/L; AOR: 96.08; 95% CI: 14.11–654.40), and renal failure (serum creatinine >2 mg/dL; AOR: 6.03; 95% CI: 1.50–24.24). When we combined the predictors, we found that the sensitivity, specificity, positive predictive value, and negative predictive value for patients with 1 or more predictors were 70.37%, 88.17%, 21.11%, and 98.51%, respectively. For patients with 2 or more predictors, the respective values were 33.33%, 99.44%, 57.14%, and 98.51%. We developed a new method to help decision making. Among geriatric patients with none of the predictors, the survival rate was 98.51%, and among those with 2 or more predictors, the mortality rate was 57.14%. This method is simple and useful, especially in an outbreak. PMID:28906367

Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis.

PubMed

Nirula, Ram; Millar, D; Greene, Tom; McFadden, Molly; Shah, Lubdha; Scalea, Thomas M; Stein, Deborah M; Magnotti, Louis J; Jurkovich, Gregory J; Vercruysse, Gary; Demetriades, Demetrios; Scherer, Lynette A; Peitzman, Andrew; Sperry, Jason; Beauchamp, Kathryn; Bell, Scott; Feiz-Erfan, Iman; O'Neill, Patrick; Coimbra, Raul

2014-04-01

Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH. Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls. There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher. Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy. Therapeutic care/management, level III.

Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality.

PubMed

Lawrence, T; Helmy, A; Bouamra, O; Woodford, M; Lecky, F; Hutchinson, P J

2016-11-24

To provide a comprehensive assessment of the management of traumatic brain injury (TBI) relating to epidemiology, complications and standardised mortality across specialist units. The Trauma Audit and Research Network collects data prospectively on patients suffering trauma across England and Wales. We analysed all data collected on patients with TBI between April 2014 and June 2015. Data were collected on patients presenting to emergency departments across 187 hospitals including 26 with specialist neurosurgical services, incorporating factors previously identified in the Ps14 multivariate logistic regression (Ps14 n ) model multivariate TBI outcome prediction model. The frequency and timing of secondary transfer to neurosurgical centres was assessed. We identified 15 820 patients with TBI presenting to neurosurgical centres directly (6258), transferred from a district hospital to a neurosurgical centre (3682) and remaining in a district general hospital (5880). The commonest mechanisms of injury were falls in the elderly and road traffic collisions in the young, which were more likely to present in coma. In severe TBI (Glasgow Coma Score (GCS) ≤8), the median time from admission to imaging with CT scan is 0.5 hours. Median time to craniotomy from admission is 2.6 hours and median time to intracranial pressure monitoring is 3 hours. The most frequently documented complication of severe TBI is bronchopneumonia in 5% of patients. Risk-adjusted W scores derived from the Ps14 n model indicate that no neurosurgical unit fell outside the 3 SD limits on a funnel plot. We provide the first comprehensive report of the management of TBI in England and Wales, including data from all neurosurgical units. These data provide transparency and suggests equity of access to high-quality TBI management provided in England and Wales. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

[Surgical outcome of external decompression associated with anterior and medial temporal lobectomy for massive hemispheric infarction due to internal carotid artery occlusion].

PubMed

Yamazaki, Takaaki; Kamiyama, Kenji; Osato, Toshiaki; Sasaki, Takehiko; Nakagawara, Jyoji; Nakamura, Hirohiko

2010-01-01

Acute occlusion of the internal carotid artery (ICA) can lead the massive cerebral hemispheric infarction and cause massive cerebral edema and may result in tentorial herniation and death. The mortality rate is estimated at 80% with maximum conservative medical treatment. We have performed external decompression associated with anterior and medial temporal lobectomy (AMTL) as internal decompression for lifesaving. This study evaluated our surgical results and gives an analysis of the prognostic factors. Twenty one consecutive patients with massive cerebral infarction caused by internal carotid artery occlusion who underwent external decompression associated with AMTL for lifesaving between June 2000 and December 2005 were included in this retrospective analysis. Survivors were divided into two functional groups at three months after surgery: good (Barthel index; BI> or =50) and poor (B1<50). The characteristics of the two groups were compared using statistical analysis. The patients consisted of 11 males and 10 females aged from 28 to 81 years with a mean age of 65.0+/-11.6 years. Eight patients had an infarction restricted to the middle cerebral artery (MCA) territory, others had additional anterior cerebral artery (ACA) or posterior cerebral artery (PCA) territory infarctions. The mean time between stroke onset and operation was 43.5+/-30 hours and ranged from 7 to 148 hours. Two patients died, so the mortality was 9.5%. Elderly patients (> or =60 years) (P=0.038), high preoperative Japan coma scale (> or =3 digit) (P=0.013), low preoperative Glasgow coma scale (GCS<8) (P=0.044), and multiple arterial territory (MCA+ACA or PCA) infarction (P=0.045) were significantly associated with poor functional outcome. External decompression associated with AMTL can immediately relieve peduncle compression and could be effective in preserving life as effectively as "early" external decompression.

Predicting the mortality in geriatric patients with dengue fever.

PubMed

Huang, Hung-Sheng; Hsu, Chien-Chin; Ye, Je-Chiuan; Su, Shih-Bin; Huang, Chien-Cheng; Lin, Hung-Jung

2017-09-01

Geriatric patients have high mortality for dengue fever (DF); however, there is no adequate method to predict mortality in geriatric patients. Therefore, we conducted this study to develop a tool in an attempt to address this issue.We conducted a retrospective case-control study in a tertiary medical center during the DF outbreak in Taiwan in 2015. All the geriatric patients (aged ≥65 years) who visited the study hospital between September 1, 2015, and December 31, 2015, were recruited into this study. Variables included demographic data, vital signs, symptoms and signs, comorbidities, living status, laboratory data, and 30-day mortality. We investigated independent mortality predictors by univariate analysis and multivariate logistic regression analysis and then combined these predictors to predict the mortality.A total of 627 geriatric DF patients were recruited, with a mortality rate of 4.3% (27 deaths and 600 survivals). The following 4 independent mortality predictors were identified: severe coma [Glasgow Coma Scale: ≤8; adjusted odds ratio (AOR): 11.36; 95% confidence interval (CI): 1.89-68.19], bedridden (AOR: 10.46; 95% CI: 1.58-69.16), severe hepatitis (aspartate aminotransferase >1000 U/L; AOR: 96.08; 95% CI: 14.11-654.40), and renal failure (serum creatinine >2 mg/dL; AOR: 6.03; 95% CI: 1.50-24.24). When we combined the predictors, we found that the sensitivity, specificity, positive predictive value, and negative predictive value for patients with 1 or more predictors were 70.37%, 88.17%, 21.11%, and 98.51%, respectively. For patients with 2 or more predictors, the respective values were 33.33%, 99.44%, 57.14%, and 98.51%.We developed a new method to help decision making. Among geriatric patients with none of the predictors, the survival rate was 98.51%, and among those with 2 or more predictors, the mortality rate was 57.14%. This method is simple and useful, especially in an outbreak.

Effect of Age on Glasgow Coma Scale in Patients with Moderate and Severe Traumatic Brain Injury: An Approach with Propensity Score-Matched Population.

PubMed

Rau, Cheng-Shyuan; Wu, Shao-Chun; Chen, Yi-Chun; Chien, Peng-Chen; Hsieh, Hsiao-Yun; Kuo, Pao-Jen; Hsieh, Ching-Hua

2017-11-13

Background: The most widely used methods of describing traumatic brain injury (TBI) are the Glasgow Coma Scale (GCS) and the Abbreviated Injury Scale (AIS). Recent evidence suggests that presenting GCS in older patients may be higher than that in younger patients for an equivalent anatomical severity of TBI. This study aimed to assess these observations with a propensity-score matching approach using the data from Trauma Registry System in a Level I trauma center. Methods: We included all adult patients (aged ≥20 years old) with moderate to severe TBI from 1 January 2009 to 31 December 2016. Patients were categorized into elderly (aged ≥65 years) and young adults (aged 20-64 years). The severity of TBI was defined by an AIS score in the head (AIS 3‒4 and 5 indicate moderate and severe TBI, respectively). We examined the differences in the GCS scores by age at each head AIS score. Unpaired Student's t - and Mann-Whitney U -tests were used to analyze normally and non-normally distributed continuous data, respectively. Categorical data were compared using either the Pearson chi-square or two-sided Fisher's exact tests. Matched patient populations were allocated in a 1:1 ratio according to the propensity scores calculated using NCSS software with the following covariates: sex, pre-existing chronic obstructive pulmonary disease, systolic blood pressure, hemoglobin, sodium, glucose, and alcohol level. Logistic regression was used to evaluate the effects of age on the GCS score in each head AIS stratum. Results: The study population included 2081 adult patients with moderate to severe TBI. These patients were categorized into elderly ( n = 847) and young adults ( n = 1234): each was exclusively further divided into three groups of patients with head AIS of 3, 4, or 5. In the 162 well-balanced pairs of TBI patients with head AIS of 3, the elderly demonstrated a significantly higher GCS score than the young adults (14.1 ± 2.2 vs. 13.1 ± 3.3, respectively; p = 0.002). In the 362 well-balanced pairs of TBI patients with head AIS of 4, the elderly showed a significantly higher GCS score than the young adults (13.1 ± 3.3 vs. 12.2 ± 3.8, respectively; p = 0.002). In the 89 well-balance pairs of TBI patients with head AIS of 5, no significant differences were observed for the GCS scores. Conclusions: This study demonstrated that elderly patients with moderate TBI present higher GCS score than younger patients. This study underscores the importance of determining of TBI severity in this group of elderly patients based on the GCS score alone. A lower threshold of GCS cutoff should be adopted in the management of the elderly patients with TBI.

Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features.

PubMed

Kreitzer, Natalie; Lyons, Michael S; Hart, Kim; Lindsell, Cristopher J; Chung, Sora; Yick, Andrew; Bonomo, Jordan

2014-10-01

Emergency department (ED) management of mild traumatic brain injury (TBI) patients with any form of traumatic intracranial hemorrhage (ICH) is variable. Since 2000, our center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable. Whether this practice is safe is unknown. This study characterized clinical outcomes in mild TBI patients with acute traumatic ICH seen on initial ED neuroimaging. This retrospective cohort study included patients presenting to the ED with blunt mild TBI with Glasgow Coma Scale (GCS) scores of 14 or 15 and stable vital signs, during the period from January 2001 to January 2010. Patients with any ICH on initial head CT and repeat head CT within 24 hours were eligible. Cases were excluded for initial GCS < 14, injury > 24 hours old, pregnancy, concomitant nonminor injuries, and coagulopathy. A single investigator abstracted data from records using a standardized case report form and data dictionary. Primary endpoints included death, neurosurgical procedures, and for discharged patients, return to the ED within 7 days. Differences in proportions were computed with 95% confidence intervals (CIs). Of 1,011 patients who presented to the ED and had two head CTs within 24 hours, 323 (32%) met inclusion criteria. The median time between CT scans was 6 hours (interquartile range = 5 to 7 hours). A total of 153 (47%) patients had subarachnoid hemorrhage, 132 (41%) patients had subdural hemorrhage, 11 (3%) patients had epidural hemorrhage, 78 (24%) patients had cerebral contusions, and 59 (18%) patients had intraparenchymal hemorrhage. Four of 323 (1.2%, 95% CI = 0.3% to 3.2%) patients died within 2 weeks of injury. Three of the patients who died had been admitted from the ED on their initial visits, and one had been discharged home. There were 206 patients (64%) discharged from the ED, 28 (13.6%) of whom returned to the ED within 1 week. Of the 92 who were hospitalized, three (0.9%, 95% CI = 0.2% to 2.7%) required neurosurgical intervention. Discharge after a repeat head CT and brief period of observation in the ED allowed early discharge of a cohort of mild TBI patients with traumatic ICH without delayed adverse outcomes. Whether this justifies the cost and radiation exposure involved with this pattern of practice requires further study. © 2014 by the Society for Academic Emergency Medicine.

Routine repeat head CT may not be necessary for patients with mild TBI

PubMed Central

Rosen, Claire B; Luy, Diego D; Deane, Molly R; Scalea, Thomas M; Stein, Deborah M

2018-01-01

Background Routine repeat cranial CT (RHCT) is standard of care for CT-verified traumatic brain injury (TBI). Despite mixed evidence, those with mild TBI are subject to radiation and expense from serial CT scans. Thus, we investigated the necessity and utility of RHCT for patients with mild TBI. We hypothesized that repeat head CT in these patients would not alter patient care or outcomes. Methods We retrospectively studied patients suffering from mild TBI (Glasgow Coma Scale (GCS) score 13–15) and treated at the R Adams Cowley Shock Trauma Center from November 2014 through January 2015. The primary outcome was the need for surgical intervention. Outcomes were compared using paired Student’s t-test, and stratified by injury on initial CT, GCS change, demographics, and presenting vital signs (mean ± SD). Results Eighty-five patients met inclusion criteria with an average initial GCS score=14.6±0.57. Our center sees about 2800 patients with TBI per year, or about 230 per month. This includes patients with concussions. This sample represents about 30% of patients with TBI seen during the study period. Ten patients required operation (four based on initial CT and others for worsening GCS, headaches, large unresolving injury). There was progression of injury on repeat CT scan in only two patients that required operation, and this accompanied clinical deterioration. The mean brain Abbreviated Injury Scale (AIS) score was 4.8±0.3 for surgical patients on initial CT scan compared with 3.4±0.6 (P<0.001) for non-surgical patients. Initial CT subdural hematoma size was 1.1±0.6 cm for surgical patients compared with 0.49±0.3 cm (P=0.05) for non-surgical patients. There was no significant difference between intervention groups in terms of other intracranial injuries, demographics, vital signs, or change in GCS. Overall, 75 patients that did not require surgical intervention received RHCT. At $340 per CT, $51 000 was spent on unnecessary imaging ($367 000/year, extrapolated). Discussion In an environment of increased scrutiny on healthcare expenditures, it is necessary to question dogma and eliminate unnecessary cost. Our data questions the use of routine repeat head CT scans in every patient with anatomic TBI and suggests that clinically stable patients with small injury can simply be followed clinically. Level of evidence Level III. PMID:29766124

The HST/ACS Coma Cluster Survey. II. Data Description and Source Catalogs

NASA Technical Reports Server (NTRS)

Hammer, Derek; Kleijn, Gijs Verdoes; Hoyos, Carlos; Den Brok, Mark; Balcells, Marc; Ferguson, Henry C.; Goudfrooij, Paul; Carter, David; Guzman, Rafael; Peletier, Reynier F.;

A Two-Year Follow-up on Systematic Desensitization with Data Pertaining to the External Validity of Laboratory Fear Assessment

ERIC Educational Resources Information Center

Rosen, Gerald M.; And Others

1977-01-01

A 2-year follow-up questionnaire was sent to subjects originally tested by Rosen, Glasgow, and Barrera. Initial treatment gains for self- and therapist-directed desensitization subjects were maintained. Posttest behavior approach scores were not predictive of real-life behavioral change as reported at follow-up. (Author)

An Exploration of Smoking Behavior of African Male Immigrants Living in Glasgow

PubMed Central

Ezika, Ejiofor Augustine

2014-01-01

INTRODUCTION The aim of this research study was to explore the smoking behavior of adult African male immigrant smokers living in Glasgow to inform and contribute to primary health promotion frameworks. METHODS 25 adult African male immigrant smokers living in Glasgow were recruited via consecutive sampling by soliciting for participation through the use of flyers, posters and word of mouth. Data collection occurred via semi-structured face-to-face interviews. The interviews were audio taped, after which verbatim transcription was carried out and the data analyzed thematically. RESULTS The participants’ smoking habits were influenced by cold weather environment as well as societal norms that appear to make the smoking habit more acceptable in Glasgow than Africa. It appears the more educated the participants were, the fewer cigarettes they smoked. However, there was only a slight difference in the number of cigarettes smoked between participants with a degree and those with a postgraduate degree. CONCLUSION The participants’ smoking habits in Glasgow appear to have increased because of environmental variables associated with living in Glasgow, specifically the cold weather environment and high acceptability of smoking habits in Glasgow. PMID:25741179

The "Spirit of New Orleans": translating a model of intervention with maltreated children and their families for the Glasgow context.

PubMed

Minnis, Helen; Bryce, Graham; Phin, Louise; Wilson, Phil

2010-10-01

Children in care have higher rates of mental health problems than the general population and placement instability contributes to this. Children are both most vulnerable to the effects of poor quality care and most responsive to treatment in the early weeks and months of life yet, in the UK, permanency decisions are generally not in place until around the age of four. We aimed to understand the components of an innovative system for assessing and intervening with maltreated children and their families developed in New Orleans and to consider how it might be implemented in Glasgow, UK. During and after a visit to New Orleans by a team of Glasgow practitioners, eight key interviews and meetings with New Orleans and Glasgow staff were audio-recorded. Qualitative analysis of verbatim transcripts identified key themes. Themes highlighted shared aspects of the context and attitudes of the two teams, identified gaps in the Glasgow service and steps that would be needed to implement a version of the New Orleans model in Glasgow. Our discussions with the New Orleans team have highlighted concrete steps we can take, in Glasgow, to make better decision-making for vulnerable children a reality.

Combined motor disturbances following severe traumatic brain injury: an integrative long-term treatment approach.

PubMed

Keren, O; Reznik, J; Groswasser, Z

2001-07-01

Patients surviving severe traumatic brain injury (TBI) often suffer from residual impairments in motor control, communication skills, cognition and social behaviour. These distinctly hamper their capability to return to their 'pre-trauma' activity. Comprehensive and integrated rehabilitation programmes initiate, during the acute phase, a prolonged treatment process which starts at the most sophisticated medical systems. There is no clear end point for the treatment of these patients, since the recovery process and the rehabilitation activity may continue for years, even after patients return home to live with their families. The inherent inability to make a firm early prediction regarding outcome of patients and the late appearance of additional symptoms stress the need for a comprehensive close long-term follow-up. The following presentation concerns the description of the treatment strategy and long-term improvement of a 22-year-old male who suffered from very severe TBI. On admission to the emergency room, he was in the decerebrated position and his Glasgow Coma Scale (GCS) was at the lowest (3). The focus of this presentation is on the recovery of motor function. The initial motor disabilities included weakness in all four limbs, in particular left hemiplegia, and right hemiparesis with severe bilateral ataxic elements and a marked tremor of the right arm. Range of motion was limited in hips, and he suffered from stiff trunk and neck. Goals of physiotherapy were directed towards improving range of motion (ROM) and active movement. Casting, use of orthoses, biofeedback, hydrotherapy, hippotherapy, medication and nerve blocks for reducing spasticity were timely applied during the process. The motor improvement in this very severe TBI patient who is now over 3 years post-injury still continues and has a functional meaning. He has succeeded in being able to stand up by himself from a chair and is able to walk unaided and without orthoses for very short distances--up to five steps. He is able to drink soup without assistance and play a few notes on the piano. Marked cognitive improvement occurred as well. It is concluded that motor improvement may be evident over long periods of time and various timely interventions may assist in the process.

The atmosphere of 2060 Chiron

DOE Office of Scientific and Technical Information (OSTI.GOV)

Meech, K.J.; Belton, M.J.S.

An explanation for 2060 Chiron's behavior, which focuses on the influence of Chiron's mass on the development of its dust coma, is presented. It is suggested that dust is entrained by the flow of CO or another gas of similar volatility from an active region. It remains gravitationally bound on orbits confined to a region, roughly 5000 km in extent, that lies between the surface and an exopause imposed by radiation pressure forces. The influence of radiation pressure transforms the initial particle trajectories into satellite orbits with a characteristic period of 20 days and orbital residence time of about 25more » revolutions. The particle population in the coma slowly increases, explaining Chiron's photometric behavior. 74 refs.« less

The Three Sources of Gas in the Comae of Comets

NASA Technical Reports Server (NTRS)

Huebner, W. F.

1995-01-01

Surface water ice on a comet nucleus is the major source of coma gas. Dust, entrained by coma gas, fragments and vaporizes, forming a second, distributed source of coma gas constituents. Ice species more volatile than water ice below the surface of the nucleus are a third source of coma gas. Vapors from these ices, produced by heat penetrating into the nucleus, diffuse through pores outward into the coma. The second and third sources provide minor, but sometimes easily detectible, gaseous species in the coma. We present mixing ratios of observed minor coma constituents relative to water vapor as a function of heliocentric and cometocentric distances and compare these ratios with model predictions, assuming the sources of the minor species are either coma dust or volatile ices in the nucleus.

[Thyroid emergencies : Thyroid storm and myxedema coma].

PubMed

Spitzweg, C; Reincke, M; Gärtner, R

2017-10-01

Thyroid emergencies are rare life-threatening endocrine conditions resulting from either decompensated thyrotoxicosis (thyroid storm) or severe thyroid hormone deficiency (myxedema coma). Both conditions develop out of a long-standing undiagnosed or untreated hyper- or hypothyroidism, respectively, precipitated by an acute stress-associated event, such as infection, trauma, or surgery. Cardinal features of thyroid storm are myasthenia, cardiovascular symptoms, in particular tachycardia, as well as hyperthermia and central nervous system dysfunction. The diagnosis is made based on clinical criteria only as thyroid hormone measurements do not differentiate between thyroid storm and uncomplicated hyperthyroidism. In addition to critical care measures therapy focusses on inhibition of thyroid hormone synthesis and secretion (antithyroid drugs, perchlorate, Lugol's solution, cholestyramine, thyroidectomy) as well as inhibition of thyroid hormone effects in the periphery (β-blocker, glucocorticoids).Cardinal symptoms of myxedema coma are hypothermia, decreased mental status, and hypoventilation with risk of pneumonia and hyponatremia. The diagnosis is also purely based on clinical criteria as measurements of thyroid hormone levels do not differ between uncomplicated severe hypothyroidism and myxedema coma. In addition to substitution of thyroid hormones and glucocorticoids, therapy focusses on critical care measures to treat hypoventilation and hypercapnia, correction of hyponatremia and hypothermia.Survival of both thyroid emergencies can only be optimized by early diagnosis based on clinical criteria and prompt initiation of multimodal therapy including supportive measures and treatment of the precipitating event.

Synergistic Regulation of Competence Development in Bacillus subtilis by Two Rap-Phr Systems† ‡

PubMed Central

Bongiorni, Cristina; Ishikawa, Shu; Stephenson, Sophie; Ogasawara, Naotake; Perego, Marta

2005-01-01

The 11 Rap proteins of Bacillus subtilis comprise a conserved family of tetratricopeptide (TPR)-containing regulatory proteins. Their activity is inhibited by specific Phr pentapeptides produced from the product of phr genes through an export-import maturation process. We found that one of the proteins, namely RapF, is involved in the regulation of competence to DNA transformation. The ComA response regulator and transcription factor for initiation of competence development is the target of RapF. Specific binding of RapF to the carboxy-terminal DNA-binding domain of ComA inhibits the response regulator's ability to bind its target DNA promoters. The PhrF C-terminal pentapeptide, QRGMI, inhibits RapF activity. The activity of RapF and PhrF in regulating competence development is analogous to the previously described activity of RapC and PhrC (L. J. Core and M. Perego, Mol. Microbiol. 49:1509-1522, 2003). In fact, the RapF and PhrF pair of proteins acts synergistically with RapC and PhrC in the overall regulation of the ComA transcription factor. Since the transcription of the RapC- and RapF-encoding genes is positively regulated by their own target ComA, an autoregulatory circuit must exist for the competence transcription factor in order to modulate its activity. PMID:15968044

High dose phenobarbitone coma in pediatric refractory status epilepticus; a retrospective case record analysis, a proposed protocol and review of literature.

PubMed

Gulati, Sheffali; Sondhi, Vishal; Chakrabarty, Biswaroop; Jauhari, Prashant; Lodha, Rakesh; Sankar, Jhuma

2018-04-01

Ongoing refractory status epilepticus is associated with significant morbidity and mortality. Therapeutic coma induction with midazolam, thiopentone, phenobarbitone or propofol is indicated when conventional antiepileptics fail to abort seizure. Of these, the most extensively studied is midazolam. Amongst the remaining three, phenobarbitone has the most favourable pharmacological profile, but has not been studied adequately, more so in the pediatric age group. The current retrospective case records analysis is an attempt to describe use of phenobarbitone coma in pediatric refractory status epilepticus. Case records of patients, admitted with status epilepticus to the pediatric inpatient services of a tertiary care teaching hospital of North India between January 2014 and December 2016 were reviewed. Those with refractory status epilepticus who failed to respond to midaolam infusion and phenobarbitone coma was used were included for analysis. Overall, 108 children presented in status, of which 34 developed refractory status epilepticus. Of these 34, 21 responded to midazolam infusion and in 13 high dose phenobarbitone coma following a standardised protocol was used. Amongst these 13 (8 males and 5 females, median age 6 years, IQR: 2.5-9.5), 12 responded and 1 succumbed. The median time to clinical seizure resolution and desired electroencephalographic changes post phenobarbitone initiation were 16 (IQR: 12-25) and 72 h (IQR: 48-120) respectively. High dose phenobarbitone appears to be an effective therapeutic modality in pediatric refractory status epilepticus. The current study provides a protocol for its use which can be validated in future studies with larger sample size. Copyright © 2018 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

An adaptive and generalizable closed-loop system for control of medically induced coma and other states of anesthesia

NASA Astrophysics Data System (ADS)

Yang, Yuxiao; Shanechi, Maryam M.

2016-12-01

Objective. Design of closed-loop anesthetic delivery (CLAD) systems is an important topic, particularly for medically induced coma, which needs to be maintained for long periods. Current CLADs for medically induced coma require a separate offline experiment for model parameter estimation, which causes interruption in treatment and is difficult to perform. Also, CLADs may exhibit bias due to inherent time-variation and non-stationarity, and may have large infusion rate variations at steady state. Finally, current CLADs lack theoretical performance guarantees. We develop the first adaptive CLAD for medically induced coma, which addresses these limitations. Further, we extend our adaptive system to be generalizable to other states of anesthesia. Approach. We designed general parametric pharmacodynamic, pharmacokinetic and neural observation models with associated guidelines, and derived a novel adaptive controller. We further penalized large steady-state drug infusion rate variations in the controller. We derived theoretical guarantees that the adaptive system has zero steady-state bias. Using simulations that resembled real time-varying and noisy environments, we tested the closed-loop system for control of two different anesthetic states, burst suppression in medically induced coma and unconsciousness in general anesthesia. Main results. In 1200 simulations, the adaptive system achieved precise control of both anesthetic states despite non-stationarity, time-variation, noise, and no initial parameter knowledge. In both cases, the adaptive system performed close to a baseline system that knew the parameters exactly. In contrast, a non-adaptive system resulted in large steady-state bias and error. The adaptive system also resulted in significantly smaller steady-state infusion rate variations compared to prior systems. Significance. These results have significant implications for clinically viable CLAD design for a wide range of anesthetic states, with potential cost-saving and therapeutic benefits.

An adaptive and generalizable closed-loop system for control of medically induced coma and other states of anesthesia.

PubMed

Yang, Yuxiao; Shanechi, Maryam M

2016-12-01

Design of closed-loop anesthetic delivery (CLAD) systems is an important topic, particularly for medically induced coma, which needs to be maintained for long periods. Current CLADs for medically induced coma require a separate offline experiment for model parameter estimation, which causes interruption in treatment and is difficult to perform. Also, CLADs may exhibit bias due to inherent time-variation and non-stationarity, and may have large infusion rate variations at steady state. Finally, current CLADs lack theoretical performance guarantees. We develop the first adaptive CLAD for medically induced coma, which addresses these limitations. Further, we extend our adaptive system to be generalizable to other states of anesthesia. We designed general parametric pharmacodynamic, pharmacokinetic and neural observation models with associated guidelines, and derived a novel adaptive controller. We further penalized large steady-state drug infusion rate variations in the controller. We derived theoretical guarantees that the adaptive system has zero steady-state bias. Using simulations that resembled real time-varying and noisy environments, we tested the closed-loop system for control of two different anesthetic states, burst suppression in medically induced coma and unconsciousness in general anesthesia. In 1200 simulations, the adaptive system achieved precise control of both anesthetic states despite non-stationarity, time-variation, noise, and no initial parameter knowledge. In both cases, the adaptive system performed close to a baseline system that knew the parameters exactly. In contrast, a non-adaptive system resulted in large steady-state bias and error. The adaptive system also resulted in significantly smaller steady-state infusion rate variations compared to prior systems. These results have significant implications for clinically viable CLAD design for a wide range of anesthetic states, with potential cost-saving and therapeutic benefits.

Evaluation of novel computerized tomography scoring systems in human traumatic brain injury: An observational, multicenter study

PubMed Central

Kivisaari, Riku; Svensson, Mikael; Skrifvars, Markus B.

2017-01-01

Background Traumatic brain injury (TBI) is a major contributor to morbidity and mortality. Computerized tomography (CT) scanning of the brain is essential for diagnostic screening of intracranial injuries in need of neurosurgical intervention, but may also provide information concerning patient prognosis and enable baseline risk stratification in clinical trials. Novel CT scoring systems have been developed to improve current prognostic models, including the Stockholm and Helsinki CT scores, but so far have not been extensively validated. The primary aim of this study was to evaluate the Stockholm and Helsinki CT scores for predicting functional outcome, in comparison with the Rotterdam CT score and Marshall CT classification. The secondary aims were to assess which individual components of the CT scores best predict outcome and what additional prognostic value the CT scoring systems contribute to a clinical prognostic model. Methods and findings TBI patients requiring neuro-intensive care and not included in the initial creation of the Stockholm and Helsinki CT scoring systems were retrospectively included from prospectively collected data at the Karolinska University Hospital (n = 720 from 1 January 2005 to 31 December 2014) and Helsinki University Hospital (n = 395 from 1 January 2013 to 31 December 2014), totaling 1,115 patients. The Marshall CT classification and the Rotterdam, Stockholm, and Helsinki CT scores were assessed using the admission CT scans. Known outcome predictors at admission were acquired (age, pupil responsiveness, admission Glasgow Coma Scale, glucose level, and hemoglobin level) and used in univariate, and multivariable, regression models to predict long-term functional outcome (dichotomizations of the Glasgow Outcome Scale [GOS]). In total, 478 patients (43%) had an unfavorable outcome (GOS 1–3). In the combined cohort, overall prognostic performance was more accurate for the Stockholm CT score (Nagelkerke’s pseudo-R2 range 0.24–0.28) and the Helsinki CT score (0.18–0.22) than for the Rotterdam CT score (0.13–0.15) and Marshall CT classification (0.03–0.05). Moreover, the Stockholm and Helsinki CT scores added the most independent prognostic value in the presence of other known clinical outcome predictors in TBI (6% and 4%, respectively). The aggregate traumatic subarachnoid hemorrhage (tSAH) component of the Stockholm CT score was the strongest predictor of unfavorable outcome. The main limitations were the retrospective nature of the study, missing patient information, and the varying follow-up time between the centers. Conclusions The Stockholm and Helsinki CT scores provide more information on the damage sustained, and give a more accurate outcome prediction, than earlier classification systems. The strong independent predictive value of tSAH may reflect an underrated component of TBI pathophysiology. A change to these newer CT scoring systems may be warranted. PMID:28771476

Modelling of the inner gas and dust coma of comet 67P/Churyumov-Gerasimenko using ROSINA/COPS and OSIRIS data - First results

NASA Astrophysics Data System (ADS)

Marschall, R.; Su, C. C.; Liao, Y.; Thomas, N.; Wu, J. S.; Altwegg, K.; Sierks, H.; Ip, W.-H.; Keller, H. U.; Knollenberg, J.; Kührt, E.; Lai, I. L.; Rubin, M.; Skorov, Y.; Jorda, L.; Preusker, F.; Scholten, F.; Gicquel, A.; Gracia-Berná, A.; Naletto, G.

2015-10-01

The physics of the outflow above the surface of comets is somewhat complex. Ice sublimating into vacuum forms a non-equilibrium boundary layer, the "Knudsen layer" (Kn-layer), with a scale height of #20 mean free paths. If the production rate is low, the Kn-layer becomes infinitely thick and the velocity distribution function (VDF) remains strongly non-Maxwellian. Thus our preferred method for gas dynamics simulations of the coma is Direct Simulation Monte Carlo DSMC. Here we report on the first results of models of the outflow from the Rosetta target, comet67P/Churyumov-Gerasimenko (C-G). Our aims are to (1) determine the gas flow-field of H2O and CO2 in the innermost coma and compare the results to the in-situ measurements of the ROSINA/COPS instrument (2) produce artificial images of the dust brightnesses that can be compared to the OSIRIS cameras. The comparison with ROSINA/COPS and OSIRIS data help to constrain the initial conditions of the simulations and thus yield information on the surface processes.

Myxedema coma: A case report of pediatric emergency care.

PubMed

Zhu, Yueniu; Qiu, Wenjuan; Deng, Mengyan; Zhu, Xiaodong

2017-05-01

Myxedema coma (MC) is extremely rare but lethal in pediatric patients with hypothyroidism leading to altered mental status and hypothermia. But there is no clinical guideline for such cases. A 6-year-old Chinese girl presented with coma and hypothermia preceded by pneumonia. Her lab results were: free thyroxin (T4) 4.18 pmol/L and thyroid-stimulating hormone (TSH) > 150 μIU/mL with extremely elevated anti-thyroid peroxidase (TPO-Ab) and anti-thyroglobulin. Pneumonia, mild pleural, and pericardial effusion were seen on computed tomographic (CT) scan. MC, autoimmune hypothyroidism, pneumonia and sepsis were diagnosed. Gastric levothyroxine, intravenous dexamethasone and antibiotics were administered. Her consciousness was restored and temperature returned to normal 2 days after starting levothyroxine. She was discharged two weeks later. MC is rare but may be the initial presentation in pediatric patients with prolonged untreated hypothyroidism. Autoimmune thyroiditis could cause hypothyroidism in children. MC should be suspected in pediatric patients with altered mental status, hypothermia and cardiovascular instability. Treatment with 100 mg/m of gastric levothyroxine is an option for pediatric patients with MC.

Observing RAM Pressure Stripping and Morphological Transformation in the Coma Cluster

NASA Astrophysics Data System (ADS)

Gregg, Michael; West, Michael

2017-07-01

The two largest spirals in the Coma cluster, NGC4911 and NGC4921, are being vigorously ram-pressure stripped by the hot intracluster medium. Our HST ACS and WFC3 images have revealed galactic scale shock fronts, giant "Pillars of Creation", rivulets of dust, and spatially coherent star formation in these grand design spirals. We have now obtained HST WFC3 imaging of five additional large Coma spirals to search for and investigate the effects of ram pressure stripping across the wider cluster environment. The results are equally spectacular as the first two examples. The geometry of the interactions in some cases allows an estimation of the various time scales involved, including gas flows out of the disk leading to creation of the ICM, and the attendant triggered star formation in the galaxy disks. The global star formation patterns yield insights into the spatial and temporal ISM-ICM interactions driving cluster galaxy evolution and ultimately transforming morphologies from spiral to S0. These processes were much more common in the early Universe when the intergalactic and intracluster components were initially created from stripping and destruction of member galaxies.

The effects of hypoglycemic and alcoholic coma on the blood-brain barrier permeability

PubMed Central

Yorulmaz, Hatice; Seker, Fatma Burcu; Oztas, Baria

2011-01-01

In this investigation, the effects of hypoglycemic coma and alcoholic coma on the blood-brain barrier (BBB) permeability have been compared. Female adult Wistar albino rats weighing 180-230 g were divided into three groups: Control group (n=8), Alcoholic Coma Group (n=18), and Hypoglycemic Coma group (n=12). The animals went into coma approximately 3-4 hours after insulin administration and 3-5 minutes after alcohol administration. Evans blue (4mL/kg) was injected intravenously as BBB tracer. It was observed that the alcoholic coma did not significantly increase the BBB permeability in any of the brain regions when compared to control group. Changes in BBB permeability were significantly increased by the hypoglycemic coma in comparison to the control group values (p<0.01). Our findings suggest that hypoglycemic and alcoholic coma have different effects on the BBB permeability depending on the energy metabolism. PMID:21619558

Numerical simulations of the radiance from the limb measurements of dusty coma of the Comet 67P/Churyumov Gerasimenko

NASA Astrophysics Data System (ADS)

Błęcka, M. I.; Rinaldi, G.; Fink, U.; Capacioni, F.; Tozzi, G. P.

2013-09-01

The work we present deals with the spectrometric measurements of the VIRTIS instrument part of the payload of the Rosetta mission to the Comet 67P/Churyumov-Gerasimenko. This spectrometer will monitor (VIRTIS M channel: 0.25μm - 0.98μm; Δκ=20cm-1 ; 0.980 - 5.0 μm; Δκ=5cm-1; VIRTIS H channel: 2.0 μm- 5.0 μm ; Δκ=5cm-1) the nucleus and the coma in order to provide a picture of coma's composition, the production of gas and dust, and the structure and variation of mineralogy of the nucleus surface. The dust is an important constituent of cometary environment and is always present on the surface of the nucleus and in the coma. The cometary spectra are strongly affected by the processes taking place in the coma and by the structure, composition and the spatial distribution of cometary solid particles. The particles of the dust, illuminated by solar light, scatter, absorb and emit radiation. The reflected and emitted radiation are transmitted through the coma region before being collected by instruments such as VIRTIS. The reflection, absorption, scattering, and emission processes in the coma depend on the Comet-Sun geometry. In the VIRTIS team we have initiated and effort to simulate the dust radiance using several radiative transfer models (see Rinaldi et al, this issue). In the present paper, which is the continuation of our previous works (e.g. AGU fall meeting 2011, EGU 2012, EPSC2012 -abstracts), we are mainly concentrated on the influence of optical parameters of dust on spectra we expect from the VIRTIS/Rosetta measurements. To this purposes the equation of radiative transfer in limb geometry through the assembly of various dust grains and gases is solved. The number density distribution of the dust grains around the coma and their size distribution are drawn from recent theoretical models (e.g.Tenishev et.al.2011). A few phenomenological scattering phase functions are taken into account. We have assumed in the simulation the presence on the surface of H2O ice, in which are embedded dust grains of various mineralogies. These grains, when freed by the gas sublimation, were considered as the main constituent of the dusty coma. At the beginning the particles are spherical. Such an assumption would be reasonable in many cases. We have confined ourselves to the compact dust particles only. But it should be noted here that fluffy grains would have different optical properties and their presence would lead to different conclusions. The main purposes of the paper are: 1) discussion of the influence of the mineralogical composition of cometary dust including mixtures with ices, the size distributions and optical parameters - using the various possible phase functions, extinction and symmetry factors 2) influence of cometary activity on parameters of the coma and then the signal to be measured by the VIRTIS spectrometer at various distances from the Sun (3.7AU; 3.5AU; 3.0AU; 1.24AU).

Trauma scoring systems and databases.

PubMed

Lecky, F; Woodford, M; Edwards, A; Bouamra, O; Coats, T

2014-08-01

This review considers current trauma scoring systems and databases and their relevance to improving patient care. Single physiological measures such as systolic arterial pressure have limited ability to diagnose severe trauma by reflecting raised intracranial pressure, or significant haemorrhage. The Glasgow coma score has the greatest prognostic value in head-injured and other trauma patients. Trauma triage tools and imaging decision rules-using combinations of physiological cut-off measures with mechanism of injury and other categorical variables-bring both increased sophistication and increased complexity. It is important for clinicians and managers to be aware of the diagnostic properties (over- and under-triage rates) of any triage tool or decision rule used in their trauma system. Trauma registries are able to collate definitive injury descriptors and use survival prediction models to guide trauma system governance, through individual patient review and case-mix-adjusted benchmarking of hospital and network performance with robust outlier identification. Interrupted time series allow observation in the changes in care processes and outcomes at national level, which can feed back into clinical quality-based commissioning of healthcare. Registry data are also a valuable resource for trauma epidemiological and comparative effectiveness research studies. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Effects of severity of traumatic brain injury and brain reserve on cognitive-control related brain activation.

PubMed

Scheibel, Randall S; Newsome, Mary R; Troyanskaya, Maya; Steinberg, Joel L; Goldstein, Felicia C; Mao, Hui; Levin, Harvey S

2009-09-01

Functional magnetic resonance imaging (fMRI) has revealed more extensive cognitive-control related brain activation following traumatic brain injury (TBI), but little is known about how activation varies with TBI severity. Thirty patients with moderate to severe TBI and 10 with orthopedic injury (OI) underwent fMRI at 3 months post-injury using a stimulus response compatibility task. Regression analyses indicated that lower total Glasgow Coma Scale (GCS) and GCS verbal component scores were associated with higher levels of brain activation. Brain-injured patients were also divided into three groups based upon their total GCS score (3-4, 5-8, or 9-15), and patients with a total GCS score of 8 or less produced increased, diffuse activation that included structures thought to mediate visual attention and cognitive control. The cingulate gyrus and thalamus were among the areas showing greatest increases, and this is consistent with vulnerability of these midline structures in severe, diffuse TBI. Better task performance was associated with higher activation, and there were differences in the over-activation pattern that varied with TBI severity, including greater reliance upon left-lateralized brain structures in patients with the most severe injuries. These findings suggest that over-activation is at least partially effective for improving performance and may be compensatory.

Predictors of Mortality in Patients with Penetrating Inferior Vena Cava Injuries Surviving to the Operating Room.

PubMed

Maciel, James D; Plurad, David; Gifford, Edward; deVirgilio, Christian; Koopmann, Matt; Neville, Angela; Putnam, Brant; Kim, Dennis Y

2015-10-01

Inferior vena cava (IVC) injuries are associated with significant morbidity and mortality. To identify clinical factors associated with mortality in patients undergoing operative intervention for penetrating IVC injuries, a retrospective review of 98 patients was performed, excluding blunt injuries (n = 20) and deaths before surgery (n = 16). The overall mortality was 58 per cent. Nonsurvivors more commonly presented with hypotension (50% vs 23%, P = 0.03) and underwent resuscitative thoracotomy more frequently (42% vs 4%, P = 0.01). Retrohepatic injuries were more common among nonsurvivors (P = 0.04). There was no difference in the use of ligation (7% vs 17%, P = 0.29) or the massive transfusion protocol (35% vs 25%, P = 0.41). On multivariate analysis, after controlling for mechanism of injury, admission hypotension, Glasgow Coma Scale score , preoperative cumulative fluids, resuscitative thoracotomy , absence of spontaneous tamponade, and location of IVC injury, the only independent predictor of mortality was the absence of spontaneous tamponade at the time of laparotomy (odds ratio = 5.4, 95% confidence interval: 1.11-25.95; P = 0.04). Penetrating IVC injuries continue to be associated with a high mortality, particularly among patients with free intraabdominal hemorrhage at laparotomy. Large multicenter studies are required to define the optimal resuscitative and operative management techniques in these severely injured patients.

Prognostic severity scores for patients with COPD exacerbations attending emergency departments.

PubMed

Quintana, J M; Esteban, C; Unzurrunzaga, A; Garcia-Gutierrez, S; Gonzalez, N; Lafuente, I; Bare, M; de Larrea, N Fernandez; Vidal, S

2014-12-01

Reported predictors of the adverse evolution of patients with chronic obstructive pulmonary disease exacerbations (eCOPD) are various and inconsistent in the bibliography. To develop clinical prediction rules for short-term outcomes in eCOPD patients attending an emergency department (ED). Prospective cohort study of patients with an eCOPD. Short-term outcomes were admission to an intensive care unit (ICU), admission to an intermediate respiratory care unit (IRCU) and death in these groups. Multivariate logistic regression models were developed for each of the outcomes. Predictors of ICU or IRCU admission were use of long-term home oxygen therapy (LT-HOT) or non-invasive mechanical ventilation (NIMV), elevated PCO2 and decreased pH upon ED arrival (area under the curve [AUC] 0.87 in the derivation sample; 0.89 in the validation sample). Among those admitted to an ICU or IRCU, predictors of death were increased age, use at home of LT-HOT or NIMV, use of inspiratory accessory muscles upon ED arrival and altered Glasgow Coma Scale (<15 points) (AUC 0.78). Three clinical predictors available in the ED can be used to create a simple score to predict the need for intensive treatment among eCOPD patients. Such a score can be a tool for clinical practice.

Blunt gastric injuries.

PubMed

Oncel, Didem; Malinoski, Darren; Brown, Carlos; Demetriades, Demetrios; Salim, Ali

2007-09-01

Gastric rupture after blunt abdominal trauma is a rare injury with few reports in the literature. The purpose of this study was to review our experience with blunt gastric injuries and compare outcomes with small bowel or colon injuries. All patients with hollow viscus perforations after blunt abdominal trauma from 1992 to 2005 at our level I trauma center were reviewed. Of 35,033 blunt trauma admissions, there were 268 (0.7%) patients with a total of 319 perforating hollow viscus injuries, 25 (0.07%) of which were blunt gastric injuries. When compared with the small bowel or colon injuries, the blunt gastric injury group had a higher Injury Severity Score (22 versus 17, P = 0.04), more patients with a chest Abbreviated Injury Score greater than 2 (36% versus 12%, P < 0.01), and a shorter interval from injury to laparotomy (221 versus 366 minutes, P = 0.017). Multivariate analysis identified five independent risk factors for mortality: age older than 55 years, head Abbreviated Injury Score greater than 2, chest Abbreviated Injury Score greater than 2, the presence of hypotension on admission, and Glasgow Coma Scale 8 or less. The results of this study suggest that mortality in patients with blunt hollow viscus injuries can be attributed to concurrent head and chest injuries, but not the specific hollow viscus organ that is injured.

Spectrum of neurosurgical complications following medical tourism: challenges of patients without borders.

PubMed

Idowu, Emmanuel Olufemi; Adewole, Oladipo Adeboluji

2015-03-01

The cost of medical care and availability of resources (human and facilities) which differs from nation to nation are amongst others, factors driving medical tourism (MT) despite its potential drawbacks. The aim of the study was to analyse all patients that presented with neurosurgical complications following MT. A single institution prospective study was carried out. Data which included patients' demographics, diagnosis, Glasgow coma scale score at admission, type of complication, and outcome were collected over a 3 year period and analysed. A total of 23 neurosurgical cases were seen during the study period with a median age of 42 years (17-70 years). India is the most common country visited by Nigerian patients. Nine patients died from various complications on arrival in Nigeria. There was no significant statistical difference between the outcome and patients clinical status prior to travel (p=0.107), country where the surgery was done (p=0.776), admission GCS in Nigeria (p=0.169), and redo surgery in Nigeria (0.181). Government in different nations should have legislations to ensure that medical tourists' receive appropriate care abroad, proper follow-up care upon their return, and also promulgate laws to regulate quasi and organised MT agencies that are operating in a regulatory vacuum.

Traumatic injury to the colon and rectum in Scotland: demographics and outcome.

PubMed

Brady, R R; O'Neill, S; Berry, O; Kerssens, J J; Yalamarthi, S; Parks, R W

2012-01-01

An analysis of a multi-centred database of trauma patients was performed. The study used data from a prospective multi-centre trauma database containing details of 52 887 trauma patients admitted to participating Scottish Hospitals over an 11-year period. Three hundred and forty (0.64%) of 52 887 trauma patients (284 male) with colorectal injuries were identified; 43.9% of colorectal injuries occurred following blunt trauma and 56.1% following penetrating injury. Patients in the latter group were younger, had less haemodynamic compromise and were less likely to die than those with blunt trauma (P < 0.01). The overall mortality rate was 25.6% and after rectal injury it was 21.2% (P > 0.05). Female gender, increased age, road traffic accidents and those admitted as a result of a blunt traumatic injury were associated with increased mortality. Age > 65 years (P = 0.01), increasing injury severity score (ISS) at presentation (P < 0.001), haemodynamic compromise (P = 0.045) and decreased Glasgow Coma Score (GCS) (P < 0.001) had the strongest independent associations with mortality. Colorectal injury after trauma has a high morbidity. Clinical features associated with death allow stratification of mortality risk. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

High-velocity gunshot wounds to the head: analysis of 135 patients.

PubMed

Bakir, Abdurrahman; Temiz, Cüneyt; Umur, Sukru; Aydin, Varol; Torun, Fuat

2005-06-01

Head injuries due to high-velocity missiles and shrapnel as a result of military conflicts have become a very important cause of death or severe neurological deficits. Military-type missiles have high velocities and transfer higher amounts of energy to neural tissue, compared to civil-type missiles. This physical phenomenon also causes greater neural tissue destruction. Shrapnel particles derive from blasts and cause less severe injury because of the irregular particle shape and low energy transmission. This study analyzed 135 patients with head trauma, 80 patients (59%) injured by missiles and 55 patients (41%) by shrapnel. Glasgow Coma Scale (GCS) scores at admission were 3 to 7 in 69 patients, 8 to 10 in 29 patients, and 11 to 15 in 37 patients. The most common anatomical localizations were the right frontoparietal region in 42 patients and the left frontoparietal region in 40 patients. One hundred patients (74%) were operated on immediately and 35 patients (26%) were treated conservatively in the intensive care unit. Ten of the 135 patients died (7.4%), seven from missile injury and three from shrapnel injury. In this study, we found that high mortality was associated with low GCS score at admission, presence of multilobar or skull base injuries, and involvement of ventricles. Early and aggressive surgical intervention decreased the mortality.

Comparison of transcutaneous contrast-enhanced ultrasound-guided injected hemostatic agents with traditional surgery treatment for liver, spleen and kidney trauma: a retrospective study.

PubMed

Wang, Dong; Lv, Faqin; Luo, Yukun; An, Lichun; Li, Junlai; Xie, Xia; Tian, Jiangke; Zhao, Weiyan; Tang, Jie

2012-10-01

There is lack of studies on the effectiveness of transcutaneous contrast-enhanced ultrasound-guided injections of hemostatic agents for liver. spleen and kidney trauma. We compared treatment by hemostatic agents to surgical treatment in a retrospective interventional human study. The study enrolled a total of 135 subjects from emergency unit of the Chinese People's Liberation Army General Hospital in Beijing. Within the cohort, 62 patients received contrast enhanced ultrasound-guided injection of hemostatic agents and the rest received surgical treatments. The injury severity score was lower in the hemostatic agent treatment group than surgical treatment group (p<0.05), but Glasgow coma scale scores did not reach statistical significance. The patients in the surgical treatment group had significantly higher hospital fees than those in the hemostatic treatment group (p<0.05), although the length of hospitalization did not significantly differ between two groups. Safety outcome variables pre- and post-treatment remained within normal limits in both groups. Hemostatic agents were more cost-effective than surgery to treat patients with liver, spleen and kidney trauma. However, given the limited sample size, subsequent studies drawing upon larger populations from multiple medical centers are necessary for follow-up.

A Single-Center Review of Facial Fractures as the Result of High-Speed Projectile Injuries

PubMed Central

Liu, Farrah C.; Halsey, Jordan N.; Hoppe, Ian C.; Ciminello, Frank S.; Lee, Edward S.; Granick, Mark S.

2018-01-01

Purpose: Gunshot injuries to the face that result in fractures of the underlying skeleton present a challenge in management. The goal of this study was to evaluate patterns of facial fractures as a result of gunshot injuries and strategies for management. Methods: A retrospective review of facial fractures resulting from gunshot injuries in a level 1 trauma center was performed for the years 2000 to 2012. Data were collected for patient demographics, fracture distribution, concomitant injuries, and surgical management strategies. Results: A total of 190 patients sustained facial fractures from a gunshot injury. The average age was 29.9 years, and 90% were male. Sixteen injuries were self-inflicted. The most common fractures were of the mandible and the orbit. Uncontrolled hemorrhage was noted on presentation in 68 patients; 100 patients were intubated on arrival. The average Glasgow Coma Scale score on arrival was 11.9. Concomitant injuries included skull fracture, intracranial hemorrhage, and intrathoracic injury. Surgical management was required in 89 patients. Nine patients required soft-tissue coverage. Thirty patients expired. Conclusion: Gunshot injuries to the face resulting in fractures of the underlying skeleton have high instances of morbidity and mortality. Life-threatening concomitant injuries can complicate management of facial fractures in this population. PMID:29713397

Loss to Follow-Up and Social Background in an Inception Cohort of Patients With Severe Traumatic Brain Injury: Results From the PariS-TBI Study.

PubMed

Jourdan, Claire; Bayen, Eleonore; Bahrami, Stephane; Ghout, Idir; Darnoux, Emmanuelle; Azerad, Sylvie; Ruet, Alexis; Vallat-Azouvi, Claire; Weiss, Jean-Jacques; Aegerter, Philippe; Mateo, Joaquim; Vigue, Bernard; Tazarourte, Karim; Pradat-Diehl, Pascale; Azouvi, Philippe

2016-01-01

To assess determinants of loss to follow-up (FU) at 2 time points of an inception traumatic brain injury (TBI) cohort. The PariS-TBI study consecutively included 504 adults with severe TBI on the accident scene (76% male, mean age 42 years, mean Glasgow Coma Scale 5). No exclusion criteria were used. Loss to FU at 1 and 4 years was defined among survivors as having no outcome data other than survival status. Among 257 1-year survivors, 118 (47%) were lost to FU at 1 year and 98 (40%) at 4 years. Main reasons for loss to FU were impossibility to achieve contact (109 at 1 year, 52 at 4 years) and refusal to participate (respectively 5 and 24). At 1 year, individuals not working preinjury or with nonaccidental traumas were more often lost to FU in univariate and multivariable analyses. At 4 years, loss to FU was significantly associated with preinjury alcohol abuse and unemployment. Relationship with injury severity was not significant. Socially disadvantaged persons are underrepresented in TBI outcome research. It could result in overestimation of outcome and biased estimates of sociodemographic characteristics' effects. These persons, particularly unemployed individuals, require special attention in clinical practice.

Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome.

PubMed

Mazzini, Letizia; Campini, Riccardo; Angelino, Elisabetta; Rognone, Felice; Pastore, Ilaria; Oliveri, Giuseppe

2003-11-01

To detect the clinical and radiologic characteristics of posttraumatic hydrocephalus (PTH), to define its prognostic value, and to assess the effects of shunt surgery. Correlational study on a prospective cohort. Brain injury rehabilitation center. One hundred forty patients with severe traumatic brain injury (TBI) referred to an inpatient intensive rehabilitation unit of primary care in a university-based system. Not applicable. The Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), FIM instrument, and Neurobehavioural Rating Scale (NRS), as well as single-photon emission computed tomography (SPECT) and magnetic resonance imaging. PTH was found in 45% of patients. Risk factors for PTH were as follows: age (P<.04), duration of coma (P<.0001), and decompressive craniectomy (P<.0001). PTH correlated with the degree of hypoperfusion in the temporal lobes (P<.001). Patients who showed clinical deterioration improved after surgery. PTH correlated significantly with GOS, DRS, FIM, and NRS (P<.0001) 1 year after the trauma, and it influenced the appearance of posttraumatic epilepsy (P<.02). PTH concerns about 50% of patients with severe TBI. It influences functional and behavioral outcome and the appearance of posttraumatic epilepsy. The selection of patients for surgery can be defined principally on a clinical basis. SPECT may be helpful for differentiating ventricular enlargement due to cortical atrophy and hydrocephalus.

Quality assurance for patients with head injuries admitted to a regional trauma unit.

PubMed

Schwartz, M L; Sharkey, P W; Andersen, J A

1991-07-01

The efficacy of trauma systems in reducing preventable deaths has been established but the methods of auditing care are still evolving. Various "audit filters" to identify which patients' charts should be reviewed have been proposed. An analysis of all patients admitted to the Regional Trauma Unit (RTU) over a 19-month period was conducted. Of 729 patients, 135 were identified as having suffered a traumatic intracranial hemorrhage (TICH). On review, neither delay in transfer from the emergency room to the operating room nor increasing time from the incident to the operating room correlated with increasing mortality. In contrast to delay, the Glasgow Coma Scale (GCS) score on admission correlated well with outcome. The charts of patients with anomalous outcomes based on admission GCS score were reviewed, and two possibly preventable deaths were identified. There were 48 patients with TICH who had no operations but there were no deaths attributable to a missed operation. There were 76 patients for whom the GCS score at the referring hospital and the GCS score on admission to the RTU were available. Seven of 19 patients who worsened on transfer declined because of significant pulmonary injuries. Anomalous outcomes based on admission GCS score and declining GCS scores are recommended as quality assurance filters.

Clearing the Cervical Spine in a War Zone: What Other Injuries Matter?

PubMed

Drew, Jennifer; Chou, Victoria B; Miller, Catriona; Borg, Bryson; Ingalls, Nichole; Shackelford, Stacy

2015-07-01

Cervical spine clearance requires clinicians to assess the reliability of physical examination based on a patient's mental status and distracting injuries. Distracting injuries have never been clearly defined in military casualties. Retrospective review was conducted of patients entered into Department of Defense Trauma Registry January 2008 to August 2013, identifying blunt trauma patients with cervical spine injury and Glasgow Coma Score ≥ 14. Physical examination and radiology results were abstracted from medical records and injury diagnoses were obtained from Department of Defense Trauma Registry. Groups were compared, p-value of < 0.05 was considered significant. A total of 149 patients met study criteria; 20 patients (13%) had a negative clinical examination of the cervical spine. Coexisting injuries identified in patients with negative physical examination included injuries in proximity to the neck (head, thoracic spine, chest, or humerus) in 17 (85%) patients. In 3 patients (15%), coexisting injuries were not in proximity to the neck and included pelvic, femur, and tibia fractures. All patients without coexisting injury (n = 37) had a positive physical examination. Physical examination of multitrauma casualties with neck injury may be unreliable when distracting injuries are present. When no distracting injuries were present, the physical examination was accurate in all patients. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Intracerebral hemorrhage with a favorable outcome in a patient with childhood primary angiitis of the central nervous system.

PubMed

Silva, Marco Felipe; Feitosa, Ana Raquel; Paz, José A; Aikawa, Nádia Emi; Silva, Clovis A

2016-01-01

Childhood primary angiitis of the central nervous system (cPACNS) is a rare inflammatory brain disease of unknown etiology. Of note, brain hemorrhage has been rarely reported in cPACNS patients, generally associated with a delayed clinical diagnosis, or with a diagnosis only at necropsy. We present the case of a boy with cPACNS that previously suffered an ischemic stroke. At the age of 7 years and 10 months, he presented a sudden and severe headache, vomiting and reduction in consciousness level (Glasgow coma scale 7), requiring prompt tracheal intubation. Brain computed tomography demonstrated intraparenchymal hematoma in the right parieto-occipital lobe and a small focus of bleeding in the right frontal lobe, vasogenic edema, herniation of the uncus and a 10mm deviation to the left from the midline. C-reactive protein (9.2mg/dL) and von Willebrand factor (vWF) antigen (202%) were elevated. Decompressive craniotomy was performed and methylprednisolone and cyclophosphamide were administered. One week later, the patient had left hemiparesis without other sequelae. Importantly, motor deficits have been improving progressively. Our case reinforces the inclusion of this vasculitis as a differential diagnosis in children and adolescents with CNS hemorrhage. Copyright © 2014 Elsevier Editora Ltda. All rights reserved.

Role of hormonal levels on hospital mortality for male patients with severe traumatic brain injury.

PubMed

Hohl, Alexandre; Ronsoni, Marcelo Fernando; Debona, Rodrigo; Ben, Juliana; Schwarzbold, Marcelo Liborio; Diaz, Alexandre Paim; Thais, Maria Emília Rodrigues de Oliveira; Linhares, Marcelo Neves; Latini, Alexandra; Prediger, Rui Daniel; Pizzol, Felipe Dal; Walz, Roger

2014-01-01

Changes in hormone blood levels during the acute phase of traumatic brain injury (TBI) have been described in the literature. The objective was to investigate the association among several hormones plasma levels in the acute phase of severe TBI and the hospital mortality rate of male patients. The independent association among plasma levels of TSH, LH, FSH, GH, free T4, cortisol, IGF-1 and total testosterone was measured 10 hours and 30 hours after severe TBI and the hospital mortality of 60 consecutive male patients was evaluated. At least one hormonal level abnormality was demonstrated in 3.6-73.1% of patients. The multiple logistic regressions showed a trend for an independent association among hospital mortality and normal or elevated LH levels measured at 10 hours (OR = 3.7, 95% CI = 0.8-16.3, p = 0.08) and 30 hours (OR = 3.9, 95% CI = 0.9-16.7, p = 0.06). Admission with abnormal pupils and a lower Glasgow Coma Score also were independently associated with hospital mortality. The hormonal changes are frequent in the acute phase of severe TBI. The hormones plasma levels, excepting the LH, are not highly consistent with the hospital mortality of male patients.

Characteristics of nontrauma scene flights for air medical transport.

PubMed

Krebs, Margaret G; Fletcher, Erica N; Werman, Howard; McKenzie, Lara B

2014-01-01

Little is known about the use of air medical transport for patients with medical, rather than traumatic, emergencies. This study describes the practices of air transport programs, with respect to nontrauma scene responses, in several areas throughout the United States and Canada. A descriptive, retrospective study was conducted of all nontrauma scene flights from 2008 and 2009. Flight information and patient demographic data were collected from 5 air transport programs. Descriptive statistics were used to examine indications for transport, Glasgow Coma Scale Scores, and loaded miles traveled. A total of 1,785 nontrauma scene flights were evaluated. The percentage of scene flights contributed by nontraumatic emergencies varied between programs, ranging from 0% to 44.3%. The most common indication for transport was cardiac, nonST-segment elevation myocardial infarction (22.9%). Cardiac arrest was the indication for transport in 2.5% of flights. One air transport program reported a high percentage (49.4) of neurologic, stroke, flights. The use of air transport for nontraumatic emergencies varied considerably between various air transport programs and regions. More research is needed to evaluate which nontraumatic emergencies benefit from air transport. National guidelines regarding the use of air transport for nontraumatic emergencies are needed. Copyright © 2014 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

Craniofacial Trauma in Pediatric Patients Following Winnowing Blade Injury-review of Literature

PubMed Central

Huliyappa, Harsha; Ojha, Balakrishna; Chandra, Anil; Singh, Sunil Kumar; Srivastava, Chhitij

2018-01-01

In developing countries, during the harvest season, winnower blade injuries occur very frequently in children and results in lifelong disability. Nine children were managed during 1 month, all resulting due to winnower blade induced craniofacial trauma. PubMed search for “fan blade injury” showed two case series and three case reports. In our study, 88% had compound depressed fracture; brain matter leak in 56%, cerebrospinal fluid (CSF) leak alone in 22%. 66.7% had injury involving the frontal bone. Two patients had eye injury with visual loss. Seven underwent debridement craniectomy, five augmentation duroplasty and three contusectomy. All had vegetable material, sand particles. Complications in 66.6% with two cases of CSF leak settled with lumbar drain, one case of CSF otorrohea, 22.2% of wound infection, 44.4% wound dehiscence requiring redebridement and suturing in five patients. Two patients had postoperative seizures, two patients had hemiparesis both improved. Two low Glasgow Coma Scale remained so on postoperative period. One case of subdural empyema needed debridement and duroplasty with glue. No mortality noted. These findings were consistent with previous reports. Follow-up at 1.5 months showed good functional recovery. Early surgery debridement, steps to minimize postoperative infections, identifying putative risk factors early in the management are the principles of a successful treatment regimen. PMID:29682010

Craniofacial Trauma in Pediatric Patients Following Winnowing Blade Injury-review of Literature.

PubMed

Huliyappa, Harsha; Ojha, Balakrishna; Chandra, Anil; Singh, Sunil Kumar; Srivastava, Chhitij

2018-01-01

In developing countries, during the harvest season, winnower blade injuries occur very frequently in children and results in lifelong disability. Nine children were managed during 1 month, all resulting due to winnower blade induced craniofacial trauma. PubMed search for "fan blade injury" showed two case series and three case reports. In our study, 88% had compound depressed fracture; brain matter leak in 56%, cerebrospinal fluid (CSF) leak alone in 22%. 66.7% had injury involving the frontal bone. Two patients had eye injury with visual loss. Seven underwent debridement craniectomy, five augmentation duroplasty and three contusectomy. All had vegetable material, sand particles. Complications in 66.6% with two cases of CSF leak settled with lumbar drain, one case of CSF otorrohea, 22.2% of wound infection, 44.4% wound dehiscence requiring redebridement and suturing in five patients. Two patients had postoperative seizures, two patients had hemiparesis both improved. Two low Glasgow Coma Scale remained so on postoperative period. One case of subdural empyema needed debridement and duroplasty with glue. No mortality noted. These findings were consistent with previous reports. Follow-up at 1.5 months showed good functional recovery. Early surgery debridement, steps to minimize postoperative infections, identifying putative risk factors early in the management are the principles of a successful treatment regimen.

Predictors of carbon monoxide poisoning-induced delayed neuropsychological sequelae.

PubMed

Ku, Hsiao-Lun; Yang, Kai-Chun; Lee, Ying-Chiao; Lee, Ming-Been; Chou, Yuan-Hwa

2010-01-01

Carbon monoxide poisoning (COP) commonly results in delayed neuropsychological sequelae (DNS). The aim of the article is to demonstrate the clinical characteristics and potential predictors of COP-induced DNS later. Retrospective medical record review was performed for patients who had COP in the past year at a National Medical Center in Taiwan. Sixty patients with COP were registered during a one-year period. Fifty-six of them (93.3%) were COP because of suicide attempt. Patients with COP who have a complete medical record of carboxyhemoglobin (COHb) and Glasgow Coma Scale (GCS) and Mini-Mental Status Examination (MMSE) scores were recruited. Multiple regression analysis was performed to search for the predictive factors of DNS. Forty-three patients were recruited. Most had attempted suicide (93.0%) using CO, and thirteen developed DNS later. A longer duration of admission, more sessions of hyperbaric oxygen therapy, and positive findings in brain computed tomography (CT) scans were more often found in patients with DNS than those without DNS. The GCS and MMSE scores and positive findings in brain CT scans were associated with the development of DNS but COHb was not. Our results identified several potential predictors of DNS. This finding may help clinicians understand and treat COP patients efficiently. Copyright 2010 Elsevier Inc. All rights reserved.

Cortical laminar necrosis in dengue encephalitis-a case report.

PubMed

Garg, Ravindra Kumar; Rizvi, Imran; Ingole, Rajan; Jain, Amita; Malhotra, Hardeep Singh; Kumar, Neeraj; Batra, Dhruv

2017-04-20

Dengue encephalitis is a rare neurological manifestation of dengue fever. Its clinical presentation is similar to other viral encephalitides and encephalopathy. No single specific finding on magnetic resonance imaging of dengue encephalitis has yet been documented. They are highly variable and atypical. A 15-year boy presented with fever, the headache and altered sensorium of 12-day duration. On neurological examination, his Glasgow Coma Scale score was 10 (E3M4V3). There was no focal neurological deficit. Laboratory evaluation revealed leukopenia and marked thrombocytopenia. Dengue virus IgM antibody was positive both in serum and cerebrospinal fluid. Magnetic resonance imaging of the brain revealed signal changes in bilateral parietooccipital and left frontal regions (left hemisphere more involved than the right hemisphere). There was gyriform enhancement bilateral parietooccipital regions consistent with cortical laminar necrosis. Bilaterally diffuse subcortical white matter was also involved and subtle T2 hyperintensity involving both basal ganglia was noted. Gradient echo sequence revealed presence of hemorrhage in the subcortical white matter. Patient was treated conservatively and received platelet transfusion. Patient became fully conscious after 7 days. In a patient with highly suggestive dengue e\\ephalitis, we describe an unusual magnetic resonance imaging finding. This report is possibly the first instance of cortical laminar necrosis in such a setting.

[Disturbances of cerebral perfusion in patients with bacterial meningoencephalitis].

PubMed

Garlicki, Aleksander; Podsiadło-Kleinrok, Beata; Bociaga-Jasik, Monika; Kleinrok, Krzysztof; Tomik, Barbara

2003-01-01

The investigations were done in acute and reconvalescent phase in 34 patients with bacterial meningoencephalitis. Neurologic condition, degree of the brain injury on the basis of Glasgow Coma Scale (GCS), protein level and pleocytosis in cerebrospinal fluid (CSF), and regional cerebral blood flow on dynamic computed tomography (CT) were assessed. The brain blood flow was measured in the white matter of the frontal and occipital horns of lateral ventricles, symmetrically in both hemispheres. Statistically significant reduction of the brain perfusion in acute phase of illness was improved. In reconvalescent phase normalisation of the brain blood supply was observed. 56% of patients had changes of consciousness. There was no significant correlation between these symptoms and parameters describing blood supply. The rest of patients had neurologic abnormalities: seizure, pyramidal syndrome, injury of the central nerves due to the reduction of blood flow in selected regions of the brain. Patients who aggregated low GCS score had high inflow of the blood. In patients who were in better condition, inflow was smaller. High pleocytosis in CSF was associated with small blood inflow and perfusion in investigated regions of the brain. Whereas high protein concentration correlated with higher inflow and increase in regional perfusion. We consider, that the brain blood supply correlate with intensification of inflammatory response in CSF.

Frequency of vital sign assessment and clinical deterioration in an Australian emergency department.

PubMed

Lambe, Katherine; Currey, Judy; Considine, Julie

2016-11-01

Understanding of clinical deterioration of emergency department patients is rapidly evolving. The aim of this study was to investigate the frequency and nature of vital sign collection and clinical deterioration in emergency care. A descriptive exploratory approach was used. Data were collected from the records of 200 randomly selected adults with presenting complaints of abdominal pain, shortness of breath, chest pain and febrile illness from 1 January to 31 December 2014 at a 22 bed emergency department in Melbourne, Australia. When controlled for length of stay, heart rate was the most frequently assessed vital sign per hour (median=0.9) whilst Glasgow Coma Score was the least frequently assessed vital sign per hour (median=0.5). Clinical deterioration (one or more vital signs fulfilling hospital medical emergency team activation criteria during emergency department care) occurred in 14.5% of patients. Of the 5466 vital sign measures, 19.6% were abnormal, 1.9% indicated clinical deterioration. Clinical deterioration occurred in one in seven patients, and one in five vital signs documented were outside of accepted normal ranges. Thus, emergency department physiological status has implications for patient safety and nursing practice, in particular clinical handover for patients requiring hospital admission. Copyright © 2016 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting.

PubMed

Garner, A; Crooks, J; Lee, A; Bishop, R

2001-07-01

To determine whether prehospital critical care teams (CCT) would result in improved functional outcomes for road trauma related severe head injury in the Australian setting, when compared with standard advanced life support measures provided by paramedics. Retrospective review of 250 patients treated by paramedics and 46 patients treated by CCT transported directly from the accident scene, with a prehospital Glasgow coma scale (GCS)< or =8. CCT-treated patients had longer median prehospital times (113 versus 45 min, P<0.001), and a higher prehospital intubation rate (100% versus 36%, P<0.001) than paramedic-treated patients. On multivariate analysis, revised trauma score > or =4.45 (odds ratio [OR] 2.31, 95% CI: 1.15-4.65), lower injury severity score (OR 1.04, 95% CI: 1.02-1.06), age< or =25 years (OR 1.76, 95% CI: 1.13-2.75), absence of an acute subdural haematoma (OR 3.36, 95% CI: 1.89-5.95) and prehospital treatment by a CCT (OR 2.70, 95% CI: 1.48-4.95) independently predicted better outcome. The range of advanced interventions provided by the CCT were associated with improved functional outcome. Further studies are required to determine the individual factors responsible.

Early rehabilitation results in a child who developed herpes simplex encephalitis

PubMed Central

Toy, Seyma; Ozdemir, Filiz; Kızılay, Fatma; Ersoy, Yuksel; Apaydın, Hakan

2017-01-01

In this case, a 4-year-old girl was admitted to the emergency service with the complaints of a sudden onset of fever, shortness of breath, jerking motions of the hands and feet and a sliding mouth. Her condition deteriorated, and she was kept under observation in the intensive care unit for 6 days. The Glasgow Coma Score of the patient was 1. Lumbar puncture revealed a white blood cell count of 0 and cerebrospinal fluid was positive for herpes simplex virus 1 and 2. Antiviral therapy was administered for 14 days. One month earlier, the patient had experienced a herpes labialis infection, which suggested herpes simplex encephalitis (HSE). Cranial magnetic resonance imaging indicated significant bilateral cerebral ischemic changes, which also supported suspicion of HSE. After antiviral treatment, the patient was referred to the department of physical therapy and rehabilitation. The Functional Independence Measure for Children (WeeFIM) scale was used to evaluate the patient. A 30-session rehabilitation program based on the Bobath concept of neurodevelopmental therapy was implemented. Before the treatment, the WeeFIM score was 20 points, and at its conclusion, the score was 88 points. The patient began to walk without limitation and the choreoathetosis was almost completely corrected. The patient was discharged with medical treatment and a home-based exercise training program. PMID:29270579

The value of the identification of predisposing factors for post-traumatic amnesia in management of mild traumatic brain injury.

PubMed

Fotakopoulos, George; Makris, Demosthenes; Tsianaka, Eleni; Kotlia, Polikceni; Karakitsios, Paulos; Gatos, Charalabos; Tzannis, Alkiviadis; Fountas, Kostas

2018-01-01

To identify the risk factors for post-traumatic amnesia (PTA) and to document the incidence of PTA after mild traumatic brain injuries. This was a prospective study, affecting mild TBI (mTBI) (Glasgow Coma Scale 14-15) cases attending to the Emergency Department between January 2009 and April 2012 (40 months duration). Patients were divided into two groups (Group A: without PTA, and Group B: with PTA, and they were assessed according to the risk factors. A total of 1762 patients (males: 1002, 56.8%) were meeting study inclusion criteria [Group A: n = 1678 (83.8%), Group B: n = 84 (4.2%)]. Age, CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs, and skull base fractures), anticoagulation therapy and seizures were independent factors of PTA. There was no statistically significant correlation between PTA and sex, convexity fractures, stroke event, mechanism of mTBI (fall +/or beating), hypertension, coronary heart disease, chronic smokers and diabetes (p > 0.005). CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs and skull base fractures), age, seizures and anticoagulation/antiplatelet therapy, were independent factors of PTA and could be used as predictive factors after mTBI.

Predictive value of the APACHE II, SAPS II, SOFA and GCS scoring systems in patients with severe purulent bacterial meningitis.

PubMed

Pietraszek-Grzywaczewska, Iwona; Bernas, Szymon; Łojko, Piotr; Piechota, Anna; Piechota, Mariusz

2016-01-01

Scoring systems in critical care patients are essential for predicting of the patient outcome and evaluating the therapy. In this study, we determined the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) and Glasgow Coma Scale (GCS) scoring systems in the prediction of mortality in adult patients admitted to the intensive care unit (ICU) with severe purulent bacterial meningitis. We retrospectively analysed data from 98 adult patients with severe purulent bacterial meningitis who were admitted to the single ICU between March 2006 and September 2015. Univariate logistic regression identified the following risk factors of death in patients with severe purulent bacterial meningitis: APACHE II, SAPS II, SOFA, and GCS scores, and the lengths of ICU stay and hospital stay. The independent risk factors of patient death in multivariate analysis were the SAPS II score, the length of ICU stay and the length of hospital stay. In the prediction of mortality according to the area under the curve, the SAPS II score had the highest accuracy followed by the APACHE II, GCS and SOFA scores. For the prediction of mortality in a patient with severe purulent bacterial meningitis, SAPS II had the highest accuracy.

Early Fever As a Predictor of Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury.

PubMed

Hinson, Holly E; Schreiber, Martin A; Laurie, Amber L; Baguley, Ian J; Bourdette, Dennis; Ling, Geoffrey S F

Paroxysmal sympathetic hyperactivity (PSH) is characterized by episodic, hyperadrenergic alterations in vital signs after traumatic brain injury (TBI). We sought to apply an objective scale to the vital sign alterations of PSH in order to determine whether 1 element might be predictive of developing PSH. We conducted an observational study of consecutive TBI patients (Glasgow Coma Scale score ≤12) and monitored the cohort for clinical evidence of PSH. PSH was defined as a paroxysm of 3 or more of the following characteristics: (1) tachycardia, (2) tachypnea, (3) hypertension, (4) fever, (5) dystonia (rigidity or decerebrate posturing), and (6) diaphoresis, with no other obvious causation (ie, alcohol withdrawal, sepsis). The Modified Clinical Feature Severity Scale (mCFSS) was applied to each participant once daily for the first 5 days of hospitalization. Nineteen (11%) of the 167 patients met criteria for PSH. Patients with PSH had a higher 5-day cumulative mCFSS score than those without PSH (median [interquartile range] = 36 [29-42] vs 29 [22-35], P = .01). Of the 4 components of the mCFSS, elevated temperature appeared to be most predictive of the development of PSH, especially during the first 24 hours (odds ratio = 1.95; 95% confidence interval, 1.12-3.40). Early fever after TBI may signal impending autonomic dysfunction.

Twelve-month prospective cohort study of patients with severe traumatic brain injury and their relatives: Coping, satisfaction with life and neurological functioning.

PubMed

Haller, Chiara S

2017-01-01

To examine the associations between the functioning of patients with severe traumatic brain injury (TBI), and their relatives' coping style and quality of life across 12 months post-injury. Prospective, population-based cohort study assessing 188 patients with severe TBI (Abbreviated Injury Scale of the head region [HAIS] score >3), and their relatives, 3, 6 and 12 months post-injury. Data were drawn from a larger national study run in Switzerland (2007-2011). Patient assessment: Glasgow Coma Outcome Scale Extended (GOSE), Patient Competency Rating Scale for Neurorehabilitation (PCRS-NR). Relative assessment: Health-Related Quality of Life (HRQoL; 12-item short form health survey [SF-12]), Coping Inventory for Stressful Situations (CISS). Mixed linear models were run separately for ages >50 and ≤50 (i.e. bimodal distribution). Patients' GOSE score was associated with relatives' reported mental SF-12 scores across age (ps < 0.01). Relatives' CISS was associated with patients' PCRS score (age > 50 years): Total and cognitive functioning decreased as emotion-oriented coping increased (ps = 0.01), while interpersonal functioning increased as task-oriented coping increased (p = 0.01) and decreased as avoidance-oriented coping increased (p = 0.02). Patients' functioning and relatives' mental HRQoL and coping strategies are associated with each other.

Adam Smith and the Moral Economy of the Classroom System.

ERIC Educational Resources Information Center

Hamilton, D.

1980-01-01

Traces the development of mass schooling to its origins in 19th-century Glasgow. Its importance as an intellectual and economic center enabled Glasgow to invent a solution to the problem of urban schooling, while the association of scholars like Adam Smith with Glasgow University made Scottish educational theories acceptable around the world. (DB)

Trigger Happy: The Troubling Trend of Primary School Closures in Glasgow City Schools

ERIC Educational Resources Information Center

Koch, Joshua F.

2010-01-01

This paper examines the continuing trend of school closures in Glasgow, Scotland. Particular attention will be paid to Stonedyke Primary School, which Glasgow City Council was proposing to close at the time of this research. Current statistical data and research is used to better examine the current crisis Stonedyke Primary faces. Furthermore,…

A brain-machine interface for control of medically-induced coma.

PubMed

Shanechi, Maryam M; Chemali, Jessica J; Liberman, Max; Solt, Ken; Brown, Emery N

2013-10-01

Medically-induced coma is a drug-induced state of profound brain inactivation and unconsciousness used to treat refractory intracranial hypertension and to manage treatment-resistant epilepsy. The state of coma is achieved by continually monitoring the patient's brain activity with an electroencephalogram (EEG) and manually titrating the anesthetic infusion rate to maintain a specified level of burst suppression, an EEG marker of profound brain inactivation in which bursts of electrical activity alternate with periods of quiescence or suppression. The medical coma is often required for several days. A more rational approach would be to implement a brain-machine interface (BMI) that monitors the EEG and adjusts the anesthetic infusion rate in real time to maintain the specified target level of burst suppression. We used a stochastic control framework to develop a BMI to control medically-induced coma in a rodent model. The BMI controlled an EEG-guided closed-loop infusion of the anesthetic propofol to maintain precisely specified dynamic target levels of burst suppression. We used as the control signal the burst suppression probability (BSP), the brain's instantaneous probability of being in the suppressed state. We characterized the EEG response to propofol using a two-dimensional linear compartment model and estimated the model parameters specific to each animal prior to initiating control. We derived a recursive Bayesian binary filter algorithm to compute the BSP from the EEG and controllers using a linear-quadratic-regulator and a model-predictive control strategy. Both controllers used the estimated BSP as feedback. The BMI accurately controlled burst suppression in individual rodents across dynamic target trajectories, and enabled prompt transitions between target levels while avoiding both undershoot and overshoot. The median performance error for the BMI was 3.6%, the median bias was -1.4% and the overall posterior probability of reliable control was 1 (95% Bayesian credibility interval of [0.87, 1.0]). A BMI can maintain reliable and accurate real-time control of medically-induced coma in a rodent model suggesting this strategy could be applied in patient care.

Validation of the modified Ranson versus Glasgow score for pancreatitis in a Singaporean population.

PubMed

Tan, Yong Hui Alvin; Rafi, Shumaila; Tyebally Fang, Mirriam; Hwang, Stephen; Lim, Ee Wen; Ngu, James; Tan, Su-Ming

2017-09-01

The characteristics of patients with acute pancreatitis in multi-ethnic Singapore differ from that of the populations used in formulating the modified Ranson and Glasgow scores. The use of these scoring systems has not previously been validated in the Singaporean setting. This study aims to validate and compare the prognostic use of the modified Ranson and Glasgow scores, and to determine the superiority of one score over the other in predicting the outcome for acute pancreatitis in the Singaporean population. This is a 3-year retrospective study of patients diagnosed with acute pancreatitis at our centre. Patients with chronic pancreatitis, acute on chronic pancreatitis, iatrogenic pancreatitis, pancreatic cancer as well as those with incomplete Ranson or Glasgow scores were excluded from the study. Case notes and computer records were reviewed for local complications of pancreatitis and organ failure. Receiver operator characteristic (ROC) curves of the Ranson and Glasgow scores were plotted for the prediction of severity and mortality. Between January 2010 and December 2012, 230 cases were diagnosed with acute pancreatitis. A majority of the patients had mild pancreatitis (n = 194, 84.3%), and the overall 30-day mortality rate was 3.5% (n = 8). ROC of the Ranson and Glasgow scoring systems for mortality showed an area under curve (AUC) of 0.854 (P = 0.001) and 0.776 (P = 0.008), respectively. For severity, the AUC for the modified Ranson and Glasgow score was calculated to be 0.694 and 0.668, respectively. The ROC curves of Ranson and Glasgow scores for mortality are comparable with that published in earlier studies. In a Singaporean population, the Ranson score is more accurate in the prediction of mortality. However, both scoring systems are poor predictors for severity of acute pancreatitis. © 2015 Royal Australasian College of Surgeons.

Traumatic axonal injury: the prognostic value of lesion load in corpus callosum, brain stem, and thalamus in different magnetic resonance imaging sequences.

PubMed

Moen, Kent G; Brezova, Veronika; Skandsen, Toril; Håberg, Asta K; Folvik, Mari; Vik, Anne

2014-09-01

The aim of this study was to explore the prognostic value of visible traumatic axonal injury (TAI) loads in different MRI sequences from the early phase after adjusting for established prognostic factors. Likewise, we sought to explore the prognostic role of early apparent diffusion coefficient (ADC) values in normal-appearing corpus callosum. In this prospective study, 128 patients (mean age, 33.9 years; range, 11-69) with moderate (n = 64) and severe traumatic brain injury (TBI) were examined with MRI at a median of 8 days (range, 0-28) postinjury. TAI lesions in fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and T2*-weighted gradient echo (T2*GRE) sequences were counted and FLAIR lesion volumes estimated. In patients and 47 healthy controls, mean ADC values were computed in 10 regions of interests in the normal-appearing corpus callosum. Outcome measure was the Glasgow Outcome Scale-Extended (GOS-E) at 12 months. In patients with severe TBI, number of DWI lesions and volume of FLAIR lesions in the corpus callosum, brain stem, and thalamus predicted outcome in analyses with adjustment for age, Glasgow Coma Scale score, and pupillary dilation (odds ratio, 1.3-6.9; p = <0.001-0.017). The addition of Rotterdam CT score and DWI lesions in the corpus callosum yielded the highest R2 (0.24), compared to all other MRI variables, including brain stem lesions. For patients with moderate TBI only the number of cortical contusions (p = 0.089) and Rotterdam CT score (p = 0.065) tended to predict outcome. Numbers of T2*GRE lesions did not affect outcome. Mean ADC values in the normal-appearing corpus callosum did not differ from controls. In conclusion, the loads of visible TAI lesions in the corpus callosum, brain stem, and thalamus in DWI and FLAIR were independent prognostic factors in patients with severe TBI. DWI lesions in the corpus callosum were the most important predictive MRI variable. Interestingly, number of cortical contusions in MRI and CT findings seemed more important for patients with moderate TBI.

Comparison of Gender Differences in Intracerebral Hemorrhage in a Multi-Ethnic Asian Population.

PubMed

Hsieh, Justin T; Ang, Beng Ti; Ng, Yew Poh; Allen, John C; King, Nicolas K K

2016-01-01

Intracerebral hemorrhage (ICH) accounts for 10-15% of all first time strokes and with incidence twice as high in the Asian compared to Western population. This study aims to investigate gender differences in ICH patient outcomes in a multi-ethnic Asian population. Data for 1,192 patients admitted for ICH were collected over a four-year period. Multivariate logistic regression was used to identify independent predictors and odds ratios were computed for 30-day mortality and Glasgow Outcome Scale (GOS) comparing males and females. Males suffered ICH at a younger age than females (62.2 ± 13.2 years vs. 66.3 ± 15.3 years; P<0.001). The occurrence of ICH was higher among males than females at all ages until 80 years old, beyond which the trend was reversed. Females exhibited increased severity on admission as measured by Glasgow Coma Scale compared to males (10.9 ± 4.03 vs. 11.4 ± 4.04; P = 0.030). No difference was found in 30-day mortality between females and males (F: 30.5% [155/508] vs. M: 27.0% [186/688]), with unadjusted and adjusted odds ratio (F/M) of 1.19 (P = 0.188) and 1.21 (P = 0.300). At discharge, there was a non-statistically significant but potentially clinically relevant morbidity difference between the genders as measured by GOS (dichotomized GOS of 4-5: F: 23.7% [119/503] vs. M: 28.7% [194/677]), with unadjusted and adjusted odds ratio (F/M) of 0.77 (P = 0.055) and 0.87 (P = 0.434). In our multi-ethnic Asian population, males developed ICH at a younger age and were more susceptible to ICH than women at all ages other than the beyond 80-year old age group. In contrast to the Western population, neurological status of female ICH patients at admission was poorer and their 30-day mortality was not reduced. Although the study was not powered to detect significance, female showed a trend toward worse 30-day morbidity at discharge.

COBI (COntinuous hyperosmolar therapy for traumatic Brain-Injured patients) trial protocol: a multicentre randomised open-label trial with blinded adjudication of primary outcome.

PubMed

Roquilly, Antoine; Lasocki, Sigismond; Moyer, Jean Denis; Huet, Olivier; Perrigault, Pierre François; Dahyot-Fizelier, Claire; Seguin, Philippe; Sharshar, Tarek; Geeraerts, Thomas; Remerand, Francis; Feuillet, Fanny; Asehnoune, Karim

2017-09-24

Traumatic brain injury (TBI) is a major cause of death and severe prolonged disability. Intracranial hypertension (ICH) is a critical risk factor of bad outcomes after TBI. Continuous infusion of hyperosmolar therapy has been proposed for the prevention and the treatment of ICH. Whether an early administration of continuous hyperosmolar therapy improves long-term outcomes of patients with TBI is uncertain. The aim of the COBI study (number clinicaltrial.gov 03143751, pre-results stage) is to assess the efficiency and the safety of continuous hyperosmolar therapy in patients with TBI. The COBI (COntinuous hyperosmolar therapy in traumatic Brain-Injured patients) trial is a multicentre, randomised, controlled, open-label, two-arms study with blinded adjudication of primary outcome. Three hundred and seventy patients hospitalised in intensive care unit with a TBI (Glasgow Coma Scale ≤12 and abnormal brain CT scan) are randomised in the first 24 hours following trauma to standard care or continuous hyperosmolar therapy (20% NaCl) plus standard care. Continuous hyperosmolar therapy is maintained for at least 48 hours in the treatment group and continued for as long as is necessary to prevent ICH. The primary outcome is the score on the Extended Glasgow Outcome Scale at 6 months. The treatment effect is estimated with ordinal logistic regression adjusted for prespecified prognostic factors and expressed as a common OR. The COBI trial protocol has been approved by the ethics committee of Paris Ile de France VIII and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The COBI trial is the first randomised controlled trial powered to investigate whether continuous hyperosmolar therapy in patients with TBI improve long-term recovery. Trial registration number is NCT03143751. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy.

PubMed

Barlow, Karen M; Thomson, Elaine; Johnson, David; Minns, Robert A

2005-08-01

There is limited information regarding the long-term outcome of inflicted traumatic brain injury (TBI), including shaken infant syndrome. The purpose of this study was to describe the long-term neurologic, behavioral, and cognitive sequelae seen in this population. A cross-sectional and prospective longitudinal study was conducted of 25 children with inflicted TBI in Scotland between 1980 and 1999. After consent was obtained, neurologic and cognitive examinations were performed on all participants and sequentially in the prospective cohort. Two global outcome measures were used: Glasgow Outcome Score (GOS) and Seshia's outcome score. Cognitive outcome was assessed using the Bayley Scales of Infant Development, British Ability Scales, and the Vineland Adaptive Behavior Scales. The mean length of follow-up was 59 months. A total of 68% of survivors were abnormal on follow-up, 36% had severe difficulties and were totally dependant, 16% had moderate difficulties, and 16% had mild difficulties on follow-up. A wide range of neurologic sequelae were seen, including motor deficits (60%), visual deficits (48%), epilepsy (20%), speech and language abnormalities (64%), and behavioral problems (52%). There was a wide range of cognitive abilities: the mean psychomotor index, 69.9 (SD: +/-25.73); and mean mental development index, 74.53 (SD: +/-28.55). Adaptive functioning showed a wide range of difficulties across all domains: communication domain (mean: 76.1; SD: +/-25.4), Daily living skills domain (mean: 76.9; SD: +/-24.3), and socialization domain (mean: 79.1; SD: +/-23.1). Outcome was found to correlate with the Pediatric Trauma Score and the Glasgow Coma Score but did not correlate with age at injury or mechanism of injury. Inflicted TBI has a very poor prognosis and correlates with severity of injury. Extended follow-up is necessary so as not to underestimate problems such as specific learning difficulties and attentional and memory problems that may become apparent only once the child is in school. Behavioral problems are present in 52% and begin to manifest clinically between the second and third years of life, although the consequences of frontal lobe injury may be underestimated unless follow-up is extended into adolescence and early adulthood.

Occurrence of pituitary dysfunction following traumatic brain injury.

PubMed

Bondanelli, Marta; De Marinis, Laura; Ambrosio, Maria Rosaria; Monesi, Marcello; Valle, Domenico; Zatelli, Maria Chiara; Fusco, Alessandra; Bianchi, Antonio; Farneti, Marco; degli Uberti, Ettore C I

2004-06-01

Traumatic brain injury (TBI) may be associated with impairment of pituitary hormone secretion, which may contribute to long-term physical, cognitive, and psychological disability. We studied the occurrence and risk factors of pituitary dysfunction, including growth hormone deficiency (GHD) in 50 patients (mean age 37.6 +/- 2.4 years; 40 males, age 20-60 years; 10 females, age 23-87 years) with TBI over 5 years. Cranial or facial fractures were documented in 12 patients, and neurosurgery was performed in 14. According to the Glasgow Coma Scale (GCS), 16 patients had suffered from mild, 7 moderate, and 27 severe TBI. Glasgow Outcome Scale (GOS) indicated severe disability in 5, moderate disability in 11, and good recovery in 34 cases. Basal pituitary hormone evaluation, performed once at times variable from 12 to 64 months after TBI, showed hypogonadotrophic hypogonadism in 7 (14%), central hypothyroidism in 5 (10%), low prolactin (PRL) levels in 4 (8%), and high PRL levels in 4 (8%) cases. All subjects had normal corticotrophic and posterior pituitary function. Seven patients showed low insulin-like growth factor-I (IGF-I) levels for age and sex. Results of GHRH plus arginine testing indicated partial GHD in 10 (20%) and severe GHD in 4 (8%) cases. Patients with GHD were older (p <0.05) than patients with normal GH secretion. Magnetic resonance imaging demonstrated pituitary abnormalities in 2 patients; altogether pituitary dysfunction was observed in 27 (54%) patients. Six patients (12%) showed a combination of multiple abnormalities. Occurrence of pituitary dysfunction was 37.5%, 57.1%, and 59.3% in the patients with mild, moderate, and severe TBI, respectively. GCS scores were significantly (p <0.02) lower in patients with pituitary dysfunction compared to those with normal pituitary function (8.3 +/- 0.5 vs. 10.2 +/- 0.6). No relationship was detected between pituitary dysfunction and years since TBI, type of injury, and outcome from TBI. In conclusion, subjects with a history of TBI frequently develop pituitary dysfunction, especially GHD. Therefore, evaluation of pituitary hormone secretion, including GH, should be included in the long-term follow-up of all TBI patients so that adequate hormone replacement therapy may be administered.

Application of the Ommaya Reservoir in Managing Ventricular Hemorrhage.

PubMed

Yang, Xi-Tao; Feng, Dong-Fu; Zhao, Liang; Sun, Zhao-Liang; Zhao, Gang

2016-05-01

Intraventricular hemorrhage (IVH) is associated with high morbidity and mortality. This study evaluated the safety and efficacy of the combined treatment of an Ommaya reservoir and conventional external ventricular drainage (EVD) using urokinase in the management of IVH. We performed a prospective controlled study. Sixty eligible patients with IVH received conventional EVD alone (group A) or combined EVD and Ommaya reservoir (group B) between January 2010 and January 2015. Clinical, cerebrospinal fluid, and radiographic data were used to assess clot clearance, clinical outcomes, and complications between the groups. There were no significant differences in gender, age, blood pressure, Glasgow Coma Scale, Graeb score, intracerebral hemorrhage volume on admission, and IVH volume before surgery between groups A and B (P > 0.05). The number of injections of urokinase (20,000 IU/dose) were significantly different in group B compared with group A (P < 0.05). Repeated computed tomography scans 3 days, 6 days, and 10 days after surgery revealed that clot clearance rates at each time point were significantly increased in group B compared with group A (P < 0.05). The conventional catheter-based EVD duration time was shortened to 5 (4-6) days in group B compared with 7 (5-9) days in group A (P < 0.05). The total drainage time was prolonged to 9 (8-11) days in group B compared with 7 (5-9) days in group A (P < 0.05). Ventriculitis was not significantly different between the 2 groups (P > 0.05). The hydrocephalus incidence and mortality revealed significant differences between the 2 groups (P < 0.05). The 30-day Glasgow Outcome Scale score was significantly increased in group B compared with group A (P < 0.05). The combined treatment approach of an Ommaya reservoir and EVD with intraventricular urokinase is safe and effective in patients with IVH. It increased clot clearance, shortened conventional catheter-based EVD duration, prolonged total drainage time, reduced the hydrocephalus incidence and mortality, and contributed to good clinical outcomes. The Ommaya reservoir provides a safe way to increase the injection times of urokinase, which accelerated clot resolution and did not increase the risk for ventriculitis infection. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparative evaluation of H&H and WFNS grading scales with modified H&H (sans systemic disease): A study on 1000 patients with subarachnoid hemorrhage.

PubMed

Aggarwal, Ashish; Dhandapani, Sivashanmugam; Praneeth, Kokkula; Sodhi, Harsimrat Bir Singh; Pal, Sudhir Singh; Gaudihalli, Sachin; Khandelwal, N; Mukherjee, Kanchan K; Tewari, M K; Gupta, Sunil Kumar; Mathuriya, S N

2018-01-01

The comparative studies on grading in subarachnoid hemorrhage (SAH) had several limitations such as the unclear grading of Glasgow Coma Scale 15 with neurological deficits in World Federation of Neurosurgical Societies (WFNS), and the inclusion of systemic disease in Hunt and Hess (H&H) scales. Their differential incremental impacts and optimum cut-off values for unfavourable outcome are unsettled. This is a prospective comparison of prognostic impacts of grading schemes to address these issues. SAH patients were assessed using WFNS, H&H (including systemic disease), modified H&H (sans systemic disease) and followed up with Glasgow Outcome Score (GOS) at 3 months. Their performance characteristics were analysed as incremental ordinal variables and different grading scale dichotomies using rank-order correlation, sensitivity, specificity, positive predictive value, negative predictive value, Youden's J and multivariate analyses. A total of 1016 patients were studied. As univariate incremental variable, H&H sans systemic disease had the best negative rank-order correlation coefficient (-0.453) with respect to lower GOS (p < 0.001). As univariate dichotomized category, WFNS grades 3-5 had the best performance index of 0.39 to suggest unfavourable GOS with a specificity of 89% and sensitivity of 51%. In multivariate incremental analysis, H&H sans systemic disease had the greatest adjusted incremental impact of 0.72 (95% confidence interval (CI) 0.54-0.91) against a lower GOS as compared to 0.6 (95% CI 0.45-0.74) and 0.55 (95% CI 0.42-0.68) for H&H and WFNS grades, respectively. In multivariate categorical analysis, H&H grades 4-5 sans systemic disease had the greatest impact on unfavourable GOS with an adjusted odds ratio of 6.06 (95% CI 3.94-9.32). To conclude, H&H grading sans systemic disease had the greatest impact on unfavourable GOS. Though systemic disease is an important prognostic factor, it should be considered distinctly from grading. Appropriate cut-off values suggesting unfavourable outcome for H&H and WFNS were 4-5 and 3-5, respectively, indicating the importance of neurological deficits in addition to level of consciousness.

Association of Lectin Pathway Protein Levels and Genetic Variants Early after Injury with Outcomes after Severe Traumatic Brain Injury: A Prospective Cohort Study.

PubMed

Osthoff, Michael; Walder, Bernhard; Delhumeau, Cécile; Trendelenburg, Marten; Turck, Natacha

2017-09-01

The lectin pathway of the complement system has been implicated in secondary ischemic/inflammatory injury after traumatic brain injury (TBI). However, previous experimental studies have yielded conflicting results, and human studies are scarce. In this exploratory study, we investigated associations of several lectin pathway proteins early after injury and single-nucleotide polymorphisms (SNP) with outcomes after severe TBI (mortality at 14 days [primary outcome] and consciousness assessed with the Glasgow Coma Scale [GCS] at 14 days, disability assessed with the Glasgow Outcome Scale Extended [GOSE] at 90 days). Forty-four patients with severe TBI were included. Plasma levels of lectin pathway proteins were sampled at 6, 12, 24, and 48 h after injury and eight mannose-binding lectin (MBL) and ficolin (FCN)2 SNPs were analyzed by enzyme-linked immunosorbent assay (ELISA) and genotyping, respectively. Plasma protein levels were stable with only a slight increase in mannose-binding protein-associated serine protease (MASP)-2 and FCN2 levels after 48 h (p < 0.05), respectively. Neither lectin protein plasma levels (6 h or mean levels) nor MBL2 genotypes or FCN2 variant alleles were associated with 14 day mortality or 14 day consciousness. However, FCN2, FCN3, and MASP-2 levels were higher in patients with an unfavorable outcome (GOSE 1-4) at 90 days (p < 0.05), whereas there was no difference in MBL2 genotypes or FCN2 variant alleles. In particular, higher mean MASP-2 levels over 48 h were independently associated with a GOSE score < 4 at 90 days after adjustment (odds ratio 3.46 [95% confidence interval 1.12-10.68] per 100 ng/mL increase, p = 0.03). No association was observed between the lectin pathway of the complement system and 14 day mortality or 14 day consciousness. However, higher plasma FCN2, FCN3, and, in particular, MASP-2 levels early after injury were associated with an unfavorable outcome at 90 days (death, vegetative state, and severe disability) which may be related to an increased activation of the lectin pathway.

Immediate Single-Stage Reconstruction of Complex Frontofaciobasal Injuries: Part I

PubMed Central

Awadalla, Akram Mohamed; Ezzeddine, Hichem; Fawzy, Naglaaa; Saeed, Mohammad Al; Ahmad, Mohammad R.

2014-01-01

Objective To determine if immediate (within 6 hours of adequate resuscitation) single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality taking into consideration the cosmetic appearance of the patient. Patients and Methods A total of 26 patients (19 men, 7 women) ranging in age from 8 to 58 years with Glasgow Coma Scale scores of 5 to 15 all had a combined single-stage repair of their complex craniofacial injuries within 6 hours of their admission. After initial assessment and adequate resuscitation, they were evaluated with three-dimensional computed tomography of the face and head. Coronal skin flap was used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, calvarial reconstruction, and titanium mesh placement. Results Neurosurgical outcome at both the early and late evaluations was judged as good in 22 of 26 patients (85%), moderate in 3 of 26 (11%), and poor in 1 of the 26 (3.8%). Cosmetic surgical outcome at the early evaluation showed 17 of 26 (65%) to be excellent, 4 of 26 (15.5%) to be good, 4 patients (15.5%) to be fair, and 1 patient (3.8%) to be poor. At the late reevaluation, the fair had improved to good with an additional reconstructive procedure, and the poor had improved to fair with another surgery. There was no calvarial osteomyelitis, graft resorption, or intracranial abscess. Complications included three patients (11%): one (3.8%) had tension pneumocephaly and meningitis, one (3.8%) had delayed cerebrospinal fluid leak with recurrent attacks of meningitis, and one had a maxillary sinus infection (3.8%) secondary to front maxillary fistula. Conclusion The immediate single-stage repair of complex craniofacial injuries can be performed with acceptable results, a decreased need for reoperation, and improved cosmetic and functional outcomes. PMID:25844296

Efficacy of inhaled HYdrogen on neurological outcome following BRain Ischemia During post-cardiac arrest care (HYBRID II trial): study protocol for a randomized controlled trial.

PubMed

Tamura, Tomoyoshi; Hayashida, Kei; Sano, Motoaki; Onuki, Shuko; Suzuki, Masaru

2017-10-23

Hydrogen gas inhalation (HI) improved survival and neurological outcomes in an animal model of post-cardiac arrest syndrome (PCAS). The feasibility and safety of HI for patients with PCAS was confirmed in a pilot study. The objective of this study is to evaluate the efficacy of HI for patients with PCAS. The efficacy of inhaled HYdrogen on neurological outcome following BRain Ischemia During post-cardiac arrest care (HYBRID II) trial is an investigator-initiated, randomized, double-blind, placebo-controlled trial designed to enroll 360 adult comatose (Glasgow Coma Scale score < 8) patients who will be resuscitated following an out-of-hospital cardiac arrest of a presumed cardiac cause. The patients will be randomized (1:1) to either the HI or control group. Patients in the HI group will inhale 2% hydrogen with 24% to 50% oxygen, and those in the control group will inhale 24% to 50% oxygen for 18 h after admission via mechanical ventilation. Multidisciplinary post-arrest care, including targeted temperature management (TTM) between 33 °C and 36 °C, will be provided in accordance with the latest guidelines. The primary outcome of interest is the 90-day neurological outcome, as evaluated using the Cerebral Performance Categories scale (CPC). The secondary outcomes of interest are the 90-day survival rate and other neurological outcomes. This study will provide 80% power to detect a 15% change in the proportion of patients with good neurological outcomes (CPCs of 1 and 2), from 50% to 65%, with an overall significance level of 0.05. The first multicenter randomized trial is underway to confirm the efficacy of HI on neurological outcomes in comatose out-of-hospital cardiac arrest survivors. Our study has the potential to address HI as an appealing and innovative therapeutic strategy for PCAS in combination with TTM. University Hospital Medical Information Network (UMIN), 000019820 . Registered on 17 November 2015.

The spot sign and tranexamic acid on preventing ICH growth--AUStralasia Trial (STOP-AUST): protocol of a phase II randomized, placebo-controlled, double-blind, multicenter trial.

PubMed

Meretoja, Atte; Churilov, Leonid; Campbell, Bruce C V; Aviv, Richard I; Yassi, Nawaf; Barras, Christen; Mitchell, Peter; Yan, Bernard; Nandurkar, Harshal; Bladin, Christopher; Wijeratne, Tissa; Spratt, Neil J; Jannes, Jim; Sturm, Jonathan; Rupasinghe, Jayantha; Zavala, Jorge; Lee, Andrew; Kleinig, Timothy; Markus, Romesh; Delcourt, Candice; Mahant, Neil; Parsons, Mark W; Levi, Christopher; Anderson, Craig S; Donnan, Geoffrey A; Davis, Stephen M

2014-06-01

No evidence-based acute therapies exist for intracerebral hemorrhage. Intracerebral hemorrhage growth is an important determinant of patient outcome. Tranexamic acid is known to reduce hemorrhage in other conditions. The study aims to test the hypothesis that intracerebral hemorrhage patients selected with computed tomography angiography contrast extravasation 'spot sign' will have lower rates of hematoma growth when treated with intravenous tranexamic acid within 4.5-hours of stroke onset compared with placebo. The Spot sign and Tranexamic acid On Preventing ICH growth--AUStralasia Trial is a multicenter, prospective, 1:1 randomized, double-blind, placebo-controlled, investigator-initiated, academic Phase II trial. Intracerebral hemorrhage patients fulfilling clinical criteria (e.g. Glasgow Coma Scale >7, intracerebral hemorrhage volume <70 ml, no identified secondary cause of intracerebral hemorrhage, no thrombotic events within the previous 12 months, no planned surgery) and demonstrating contrast extravasation on computed tomography angiography will receive either intravenous tranexamic acid 1 g 10-min bolus followed by 1 g eight-hour infusion or placebo. A second computed tomography will be performed at 24 ± 3 hours to evaluate intracerebral hemorrhage growth and patients followed up for three-months. The primary outcome measure is presence of intracerebral hemorrhage growth by 24 ± 3 hours, defined as either >33% or >6 ml increase from baseline, and will be adjusted for baseline intracerebral hemorrhage volume. Secondary outcome measures include growth as a continuous measure, thromboembolic events, and the three-month modified Rankin Scale score. This is the first trial to evaluate the efficacy of tranexamic acid in intracerebral hemorrhage patients selected based on an imaging biomarker of high likelihood of hematoma growth. The trial is registered as NCT01702636. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.

In vivo monitoring of neuronal loss in traumatic brain injury: a microdialysis study

PubMed Central

Tisdall, Martin M.; Girbes, Armand R.; Martinian, Lillian; Thom, Maria; Kitchen, Neil; Smith, Martin

2011-01-01

Traumatic brain injury causes diffuse axonal injury and loss of cortical neurons. These features are well recognized histologically, but their in vivo monitoring remains challenging. In vivo cortical microdialysis samples the extracellular fluid adjacent to neurons and axons. Here, we describe a novel neuronal proteolytic pathway and demonstrate the exclusive neuro-axonal expression of Pavlov’s enterokinase. Enterokinase is membrane bound and cleaves the neurofilament heavy chain at positions 476 and 986. Using a 100 kDa microdialysis cut-off membrane the two proteolytic breakdown products, extracellular fluid neurofilament heavy chains NfH476−986 and NfH476−1026, can be quantified with a relative recovery of 20%. In a prospective clinical in vivo study, we included 10 patients with traumatic brain injury with a median Glasgow Coma Score of 9, providing 640 cortical extracellular fluid samples for longitudinal data analysis. Following high-velocity impact traumatic brain injury, microdialysate extracellular fluid neurofilament heavy chain levels were significantly higher (6.18 ± 2.94 ng/ml) and detectable for longer (>4 days) compared with traumatic brain injury secondary to falls (0.84 ± 1.77 ng/ml, <2 days). During the initial 16 h following traumatic brain injury, strong correlations were found between extracellular fluid neurofilament heavy chain levels and physiological parameters (systemic blood pressure, anaerobic cerebral metabolism, excessive brain tissue oxygenation, elevated brain temperature). Finally, extracellular fluid neurofilament heavy chain levels were of prognostic value, predicting mortality with an odds ratio of 7.68 (confidence interval 2.15–27.46, P = 0.001). In conclusion, this study describes the discovery of Pavlov’s enterokinase in the human brain, a novel neuronal proteolytic pathway that gives rise to specific protein biomarkers (NfH476−986 and NfH476−1026) applicable to in vivo monitoring of diffuse axonal injury and neuronal loss in traumatic brain injury. PMID:21278408

Natural History of Perihematomal Edema and Impact on Outcome After Intracerebral Hemorrhage.

PubMed

Wu, Teddy Y; Sharma, Gagan; Strbian, Daniel; Putaala, Jukka; Desmond, Patricia M; Tatlisumak, Turgut; Davis, Stephen M; Meretoja, Atte

2017-04-01

Edema may worsen outcome after intracerebral hemorrhage (ICH). We assessed its natural history, factors influencing growth, and association with outcome. We estimated edema volumes in ICH patients from the Helsinki ICH study using semiautomated planimetry. We assessed the correlation between edema extension distance (EED) and time from ICH onset, creating an edema growth trajectory model up to 3 weeks. We interpolated expected EED at 72 hours and identified clinical and imaging characteristics associated with faster edema growth. Association of EED and mortality was assessed using logistic regression adjusting for predictors of ICH outcome. From 1013 consecutive patients, 861 were included. There was a strong inverse correlation between EED growth rate (cm/d) and time from onset (days): EED growth=0.162*days exp(-0.927), R 2 =0.82. Baseline factors associated with larger than expected EED were older age (71 versus 68; P =0.002), higher National Institutes of Health Stroke Scale score (14 versus 8; P <0.001), and lower Glasgow Coma scale score (13 versus 15; P <0.001), larger ICH volume (19.7 versus 12.7 mL; P <0.001), larger initial EED (0.42 versus 0.30; P <0.001), irregularly shaped hematoma (55% versus 42%; P <0.001), and higher glucose (7.6 versus 6.9 mmol/L; P =0.001). Patients with faster edema growth had more midline shift (50% versus 31%; P <0.001), herniation (12% versus 4%; P <0.001), and higher 6-month (46% versus 26%; P <0.001) mortality. In the logistic regression model, higher-than-expected EED was associated with 6-month mortality (odds ratio, 1.60; 95% confidence interval, 1.04-2.46; P =0.032). Edema growth can be readily monitored and is an independent determinant of mortality after ICH, providing an important treatment target for strategies to improve patient outcome. © 2017 American Heart Association, Inc.

Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern.

PubMed

Baerg, Joanne; Thirumoorthi, Arul; Vannix, Rosemary; Taha, Asma; Young, Amy; Zouros, Alexander

2017-05-01

The purpose of this study was to document the incidence and pattern of cervical spine (c-spine) injuries in children below 36months with inflicted trauma. An IRB approved, prospective cohort study was performed between July 2011 and January 2016. Inclusion criteria were: age below 36months, loss of consciousness after inflicted trauma, and one initial head computed tomography finding: a subdural, intraventricular, intraparenchymal, subarachnoid hemorrhage, diffuse axonal injury, hypoxic injury, or cerebral edema. A protocol of brain and neck magnetic resonance imaging and angiography was obtained within 48h. Variables were compared by t-test and Fisher-exact test. There were 53 children (median age: five months; range: 1-35months), 38 males (71.7%), of which seven died (13.2%). C-spine injury was identified in 8 (15.1%): ligamentous injury (2), vertebral artery shear injury (1), atlantooccipital dissociation (AOD) (1), cord injury with cord epidural hematoma (2), and isolated cord epidural hematoma (2). Retinal hemorrhages (p=0.02), shaking (p=0.04), lower Glasgow coma score (GCS) (p=0.01), brain infarcts (p=0.01), and hypoxic/ischemic injury (p=0.01) were associated with c-spine injury. One with AOD died. Six had significant disability. For small children with inflicted trauma, the c-spine injury incidence is 15.1%. The injury pattern includes retinal hemorrhages, shaking, lower GCS, and brain injury. Evaluation of shaken infants should include c-spine imaging. Level 2 A- This is a prospective cohort study with complete follow-up to hospital discharge or death. In all cases, inflicted trauma was confirmed. Owing to the nature of child abuse, the precise time of injury is not known. All children underwent a strict imaging protocol on arrival to hospital that was supervised on a prospective basis. Copyright © 2017 Elsevier Inc. All rights reserved.

Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service.

PubMed

Garner, Alan A; Barker, Claire L; Weatherall, Andrew D

2015-11-06

Drowning patients may benefit from the advanced airway management capabilities that can be provided by physician staffed helicopter emergency medical services. The aim of this study is to describe paediatric drowning patients treated by such a service examining tasking systems, initial physiology at the incident scene, survival and neurological outcome. Retrospective analysis of paediatric drowning victims over a 5- year period. Case identification system, patient age, site of drowning, presence or absence of cardiac output, first Glasgow Coma Scale (GCS) score and interventions were collected from prehospital notes, and survival and neurological outcomes from hospital and rehabilitation notes. The P-HEMS direct case identification system operating in parallel with a central control system identified all severe drowning cases but 3 of 7 cases (43%) were missed when the central control system operated in isolation. All severe drowning cases (22) identified for P-HEMS response were intubated and transported directly to a paediatric specialist centre. Intubation required adjuvant anaesthesia in 10 (45%) cases. All children with GCS greater than eight on arrival of the P-HEMS survived neurologically intact. Seven of eight children with a GCS between four and seven survived without neurological impairment and all children with a GCS greater than three survived. Four of twelve asystolic children survived including one child who at 18 months post drowning is neurologically normal. All children who survived had return of spontaneous circulation prior to arrival in the emergency department. P-HEMS played a significant role in the management of severe paediatric drowning in this case series. Requirement for P-HEMS only interventions were high and all identified cases were transferred directly to a paediatric specialist centre. Discontinuation of the P-HEMS direct case identication system that operated during the majority of the study period resulted in deterioration in system performance with some paediatric drowning cases subsequently not identified for P-HEMS response being transported to adult hospitals.

The Change in Nutritional Status in Traumatic Brain Injury Patients: A Retrospective Descriptive Study

NASA Astrophysics Data System (ADS)

Masha'al, Dina A.

There is a high prevalence in malnutrition among traumatic brain injury (TBI) due to the hypermetabolism and hypercatabolism which develop post injury. Traumatic brain injury patients are different, even among themselves, in their energy requirements and response to nutritional therapy. This implies that there are other factors that affect the energy intake of these patients and enhance the incidence of malnutrition. This dissertation study examines the nutritional status of TBI patients upon admission to the intensive care unit (ICU) and during their hospital stay to describe baseline status, detect changes in nutritional status over 7 days, and identify the factors affecting the adequacy of energy intake and the change in nutritional status as a consequence. Anthropometric measurements, biomedical measurements, measures of severity of illness, daily health status, level of brain injury severity, and other data were collected from the medical records of 50 patients, who were ≥ 18 years old, mechanically ventilated in the first 24 hours of ICU admission, and had a Glasgow Coma Scale score between 3-12. These data were used to examine the previous relationships. Although there was no statistically significant change found in body mass index and weight, there was a significant change detected in other nutritional markers, including hemoglobin, albumin, and total lymphocyte levels over the 7 days of ICU and hospital stay. No significant relationship was found between the adequacy of energy intake and total prescribed energy, severity of illness, level of brain injury severity, daily health status, patient age, intracranial pressure, or time of feeding initiation. Findings may be used to develop and test interventions to improve nutritional status during the acute phase of TBI. This will lay a foundation for health care providers, including nurses, to establish standards for practice and nutrition protocols to assure optimal nutrition assessment and intervention in a timely manner.

[Case of acute ischemic stroke due to cardiac myxoma treated by intravenous thrombolysis and endovascular therapy].

PubMed

Kamiya, Yuki; Ichikawa, Hiroo; Mizuma, Keita; Itaya, Kazuhiro; Shimizu, Yuki; Kawamura, Mitsuru

2014-01-01

A 48-year-old woman with no previous neurological diseases was transferred to our hospital because of sudden-onset unconsciousness. On arrival, she showed consciousness disturbance (E1V1M3 on the Glasgow Coma Scale), tetraplegia, right conjugate deviation and bilateral pathological reflexes. These symptoms resulted in a NIH stroke scale score of 32. Brain diffusion-weighted MR imaging (DWI) showed multiple hyper-intense lesions, and MR angiography revealed occlusions of the basilar artery (BA) and superior branch of the right middle cerebral artery (MCA). Transthoracic echocardiography disclosed a 51 × 24 mm myxoma in the left atrium. These findings led to diagnosis of acute ischemic stroke due to embolization from cardiac myxoma. Thrombolytic therapy with intravenous tissue plasminogen activator (IV tPA) was started 120 min after onset because there were no contraindications for this treatment. However, the symptoms did not resolve, and thus endovascular therapy was performed immediately after IV tPA. Angiography of the left vertebral artery initially showed BA occlusion, but a repeated angiogram resulted in spontaneous recanalization of the BA. However, the left posterior cerebral artery remained occluded by a residual embolus. Subsequently, occlusion found in the superior branch of the right MCA was treated by intra-arterial local thrombolysis using urokinase and thrombectomy with a foreign body retrieval device, but the MCA remained occluded. DWI after endovascular therapy showed new hyper-intense lesions in the bilateral medial thalamus and left occipital cortex. Clinically, neurological status did not improve, with a score of 5 on the modified Rankin Scale. IV tPA can be used for stroke due to cardiac myxoma, but development of brain aneurysms and metastases caused by myxoma is a concern. Given the difficulty of predicting an embolus composite from a thrombus or tumor particle, aspiration thrombectomy may be safer and more effective for stroke due to cardiac myxoma to avoid delayed formation of brain aneurysms and metastases.

Variation in seizure prophylaxis in severe pediatric traumatic brain injury.

PubMed

Ostahowski, Paige J; Kannan, Nithya; Wainwright, Mark S; Qiu, Qian; Mink, Richard B; Groner, Jonathan I; Bell, Michael J; Giza, Christopher C; Zatzick, Douglas F; Ellenbogen, Richard G; Boyle, Linda Ng; Mitchell, Pamela H; Vavilala, Monica S

2016-10-01

OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.

Ability of Ultrasonography in Detection of Different Extremity Bone Fractures; a Case Series Study

PubMed Central

Bozorgi, Farzad; Shayesteh Azar, Massoud; Montazer, Seyed Hossein; Chabra, Aroona; Heidari, Seyed Farshad; Khalilian, Alireza

2017-01-01

Introduction: Despite radiography being the gold standard in evaluation of orthopedic injuries, using bedside ultrasonography has several potential supremacies such as avoiding exposure to ionizing radiation, availability in pre-hospital settings, being extensively accessible, and ability to be used on the bedside. The aim of the present study is to evaluate the diagnostic accuracy of ultrasonography in detection of extremity bone fractures. Methods: This study is a case series study, which was prospectively conducted on multiple blunt trauma patients, who were 18 years old or older, had stable hemodynamic, Glasgow coma scale 15, and signs or symptoms of a possible extremity bone fracture. After initial assessment, ultrasonography of suspected bones was performed by a trained emergency medicine resident and prevalence of true positive and false negative findings were calculated compared to plain radiology. Results: 108 patients with the mean age of 44.6 ± 20.4 years were studied (67.6% male). Analysis was done on 158 sites of fracture, which were confirmed with plain radiography. 91 (57.6%) cases were suspected to have upper extremity fracture(s) and 67 (42.4%) to have lower ones. The most frequent site of injuries were forearm (36.7%) in upper limbs and leg (27.8%) in lower limbs. Prevalence of true positive and false negative cases for fractures detected by ultrasonography were 59 (64.8%) and 32 (35.52%) for upper and 49 (73.1%) and 18 (26.9%) for lower extremities, respectively. In addition, prevalence of true positive and false negative detected cases for intra-articular fractures were 24 (48%) and 26 (52%), respectively. Conclusion The present study shows the moderate sensitivity (68.3%) of ultrasonography in detection of different extremity bone fractures. Ultrasonography showed the best sensitivity in detection of femur (100%) and humerus (76.2%) fractures, respectively. It had low sensitivity in detection of in intra-articular fractures. PMID:28286822