Severe brain injury ICU outcomes are associated with Cranial-Arterial Pressure Index and noninvasive Bispectral Index and transcranial oxygen saturation: a prospective, preliminary study.

INTRODUCTION: The purpose of this study was to determine if noninvasive transcranial oxygen saturation (StcO2) and Bispectral Index (BIS) correlate with severe traumatic brain injury intensive care unit (ICU) outcomes. METHODS: This is a prospective observational study. Values of intracranial pressure (ICP), mean arterial pressure (MAP), BIS, and StcO2 were recorded hourly for the first six, post-injury days in 18 patients with severe brain injury. Included in the analyses was the Cranial-Arterial Pressure (CAP) Index, which is ICP/(MAP-ICP). RESULTS: After 1,883 hours of data were analyzed, we found that StcO2 and BIS are associated with survival, good neurological outcome, ICP or =60, and CAP index < or =0.30 (p < or = 0.001). Survival and good outcome are independently associated with BIS > or =60, StcO2 > or =70, and ICP < or =20 (p < 0.0001). BIS > or =60 or StcO2 > or =70 is associated with survival, good outcome, CPP > or =60, ICP < or =20, CAP index < or =0.30, and fewer ICP interventions (p < 0.0001). With BIS > or =60 or StcO2 > or =70, the rate of CPP > or =60 is 97.2% and the rate of ICP< or = 25 is 97.1%. An increased CAP index is associated with death, poor neurological outcome, and increased ICP interventions (p < 0.0001). With CAP index >0.25, MAP is not related to ICP (p = 0.16). CONCLUSION: Numerous significant associations with ICU outcomes indicate that BIS and StcO2 are clinically relevant. The independent associations of BIS, StcO2, and ICP with outcomes suggest that noninvasive multi-modal monitoring may be beneficial. Future studies of patients with BIS > or =60 or StcO2 > or =70 will determine if select patients can be managed without ICP monitoring and whether marginal ICP can be observed. An increased CAP index is associated with poor outcome.

Helical computed tomographic angiography: an excellent screening test for blunt cerebrovascular injury.

BACKGROUND: Blunt cerebrovascular injury (BCVI) carries a high morbidity and mortality, especially when diagnosis is delayed. Recent studies have shown that increased recognition of these injuries is achieved with prompt screening, allowing for early treatment and better outcome. Controversy still exists, however, on the best screening test. This study was used to evaluate the role of helical computed tomographic angiography (CTA) of the carotid and vertebral arteries in the early screening of BCVI. METHODS: All patients deemed at risk for BCVI underwent CTA within 24 hours of admission. Patients with a negative CTA test underwent no further radiologic evaluation of the cerebral vasculature. Those patients with positive or equivocal CTA results underwent four-vessel cerebral arteriography as a confirmatory test. Data were collected on the radiologic interpretation of all studies and patient clinical course. RESULTS: Four hundred eighty-six patients fulfilled the criteria for screening and underwent CTA. Nineteen patients were diagnosed with 25 BCVIs during the period of study. There were 7 carotid injuries and 18 vertebral injuries. Eighteen of 19 patients with BCVI were screened with CTA. Seventeen patients were asymptomatic at the time of screening. Results of CTA for BCVI were as follows: sensitivity, 100%; specificity, 94.0%; prevalence (screened patients), 3.7%; positive predictive value, 37.5%; and negative predictive value, 100%. Except for one patient in whom the CTA was clearly misinterpreted by the radiologist, no patient with a negative CTA examination was subsequently found to have a missed injury. CONCLUSION: CTA is an excellent test with which to screen for BCVI.

Erythromycin reduces delayed gastric emptying in critically ill trauma patients: a randomized, controlled trial.

BACKGROUND: Early enteral feeding has been shown to be beneficial in improving outcome in critically injured trauma patients. Delayed gastric emptying occurs frequently in trauma patients, increasing the time to achieve nutritional goals, and limiting the benefit of early enteral feedings. Intravenous erythromycin is an effective agent for improving gastric motility in diabetics and postgastrectomy patients. The purpose of this study is to determine the effectiveness of erythromycin for improving gastric motility in critically injured trauma patients. METHODS: All critically injured patients who received gastric feedings within 72 hours of admission were candidates for the study. Those patients who failed to tolerate feedings at 48 hours (gastric residual > 150 mL) were eligible for enrollment. Patients were prospectively assigned to two treatment groups by randomization to receive either erythromycin (ERY) or placebo (PLA). Treatment was continued in patients who tolerated gastric feedings until the feedings were no longer required. Patients with continued intolerance for 48 hours after randomization were considered failures of therapy and given metoclopramide. RESULTS: Sixty-eight patients were enrolled and were well matched for age, sex, and Injury Severity Score. Mortality, intensive care unit length of stay, hospital length of stay, number of ventilator days, and rate of nosocomial infections were similar in each group. There was a significant difference between the ERY group and the PLA group in the amount of feedings tolerated at 48 hours (58% vs. 44%, p = 0.001). There was no difference in the amount of feedings tolerated (as a percentage of target goal volume) throughout the entire duration of the study (ERY [65% of target] vs. PLA [59%], p = 0.061). Overall success of therapy at 48 hours was 56% in the ERY group versus 39% in the PLA group, but this also did not reach statistical significance (p = 0.22). CONCLUSION: Intravenous erythromycin improves gastric motility and enhances early nutritional intake in critically injured patients.

A prehospital glasgow coma scale score < or = 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions.

BACKGROUND: Trauma team activation protocols should ideally minimize the undertriage of seriously injured patients and eliminate unnecessary activations for those patients that do not require hospitalization. This study examined which physiologic parameter(s) most reliably predicted the need for hospitalization after motor vehicle collisions (MVCs). METHODS: A prehospital triage tool using standard physiologic parameters was developed and prospectively analyzed for reliability in predicting subsequent patient admission at a Level II trauma center after MVCs. Data were collected on 4,014 consecutive patients, 2,880 (72%) of whom had all of the physiologic parameters reported and recorded. Patients who arrived in extremis, who were dead on arrival, or who died shortly after arrival despite appropriate trauma team activation were ineligible for the study. Multivariate stepwise logistic regression analysis was used to determine which parameters were associated with hospital admission. RESULTS: The Glasgow Coma Scale (GCS) score was the only prehospital physiologic parameter providing a clinically identifiable difference between those patients admitted (13 +/- 4) and those discharged to home (15 +/- 0.5) (mean + SD) (relative risk for hospitalization, 2.24; 95% confidence interval, 1.86-2.70 for GCS score < 14). CONCLUSION: The prehospital GCS score is a reliable physiologic parameter for predicting hospital admission after MVC. When obvious indicators (hypoxemia, multiple long bone fractures, focal neurologic deficits) for trauma team activation are lacking, the prehospital GCS score may be used to reduce overtriage and undertriage rates.

Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries.

BACKGROUND: Patients with traumatic intracranial hemorrhagic injuries (IHIs) are at high risk for venous thromboembolism (VTE). The safety of early anticoagulation for IHI has not been established. HYPOTHESIS: Enoxaparin can be safely administered to most patients with IHI for VTE prophylaxis. SETTING: Level I trauma center. DESIGN: Prospective, single-cohort, observational study. PATIENTS AND METHODS: One hundred fifty (85%) of 177 patients with blunt IHI received enoxaparin beginning approximately 24 hours after hospital admission until discharge. Brain computed tomographic (CT) scans were performed at admission, 24 hours after admission, and at variable intervals thereafter based on clinical course. Patients were excluded for coagulopathy, heparin allergy, expected brain death or discharge within 48 hours, and age younger than 14 years. Complications of enoxaparin prophylaxis were defined as Marshall CT grade progression of IHI, expansion of an existing IHI, or development of a new hemorrhagic lesion on follow-up CT after beginning enoxaparin use. RESULTS: Thirty-four patients (23%) had CT progression of IHI. Twenty-eight CT scans (19%) worsened before enoxaparin therapy and 6 (4%) worsened after beginning enoxaparin use. No differences between operative patient (2/24, 8%) and nonoperative patient (4/126, 3%) complications were identified (P =.23). Study group mortality was 7% (10/150). All 6 patients who developed progression of IHI after initiation of enoxaparin therapy survived hospitalization. A deep vein thrombosis was identified in 2 (2%) of 106 patients. CONCLUSION: Enoxaparin can be safely used for VTE prophylaxis in trauma patients with IHI when started 24 hours after hospital admission or after craniotomy.