Traumatic brain injury and hemorrhagic shock: evaluation of different resuscitation strategies in a large animal model of combined insults.

Traumatic brain injury (TBI) and hemorrhagic shock (HS) are the leading causes of trauma-related mortality and morbidity. Combination of TBI and HS (TBI + HS) is highly lethal, and the optimal resuscitation strategy for this combined insult remains unclear. A critical limitation is the lack of suitable large animal models to test different treatment strategies. We have developed a clinically relevant large animal model of TBI + HS, which was used to evaluate the impact of different treatments on brain lesion size and associated edema. Yorkshire swine (42-50 kg) were instrumented to measure hemodynamic parameters and intracranial pressure. A computer-controlled cortical impact device was used to create a TBI through a 20-mm craniotomy: 15-mm cylindrical tip impactor at 4 m/s velocity, 100-ms dwell time, and 12-mm penetration depth. Volume-controlled hemorrhage was started (40% blood volume) concurrent with the TBI. After 2 h of shock, animals were randomized to one of three resuscitation groups (n = 5/group): (a) normal saline (NS); (b) 6% hetastarch, Hextend (Hex); and (c) fresh frozen plasma (FFP). Volumes of Hex and FFP matched the shed blood, whereas NS was three times the volume. After 6 h of postresuscitation monitoring, brains were sectioned into 5-mm slices and stained with TTC (2,3,5-triphenyltetrazolium chloride) to quantify the lesion size and brain swelling. Combination of 40% blood loss with cortical impact and a period of shock (2 h) resulted in a highly reproducible brain injury. Total fluid requirements were lower in the Hex and FFP groups. Lesion size and brain swelling in the FFP group (2,160 ± 202.63 mm and 22% ± 1.0%, respectively) were significantly smaller than those in the NS group (3,285 ± 130.8 mm3 and 37% ± 1.6%, respectively) (P < 0.05). Hex treatment decreased the swelling (29% ± 1.6%) without reducing the lesion size. Early administration of FFP reduces the size of brain lesion and associated swelling in a large animal model of TBI + HS. In contrast, artificial colloid (Hex) decreases swelling without reducing the actual size of the brain lesion.

Early mobilization in critically ill patients: patients' mobilization level depends on health care provider's profession.

OBJECTIVE: To evaluate whether the level of mobilization achieved and the barriers for progressing to the next mobilization level differ between nurses and physical therapists. DESIGN: Prospective, observational study. SETTING: Twenty-bed surgical intensive care unit (SICU) of the Massachusetts General Hospital. PARTICIPANTS: Sixty-three critically ill patients. METHODS: Physical therapists and nurses performed 179 mobilization therapies with 63 patients. OUTCOME MEASUREMENT: Mobilization was defined as the process of enhancing mobility in the SICU, including bed mobility, edge of bed activities, transfers out of bed to a chair, and gait training; the mobilization level was measured on the SICU optimal mobilization scale, a 5-point (0-4) numerical rating scale. RESULTS: Patients' level of mobilization achieved by physical therapists was significantly higher compared with that achieved by nurses (2.3 ± 1.2 mean ± SD versus 1.2 ± 1.2, respectively P < .0001). Different barriers for mobilization were identified by physical therapists and nurses: hemodynamic instability (26% versus 12%, P = .03) and renal replacement therapy (12% versus 1%, P = .03) were barriers rated higher by nurses, whereas neurologic impairment was rated higher by physical therapists providers (18% versus 38%, P = .002). No mobilization-associated adverse events were observed in this study. CONCLUSIONS: This study showed that physical therapists mobilize their critically ill patients to higher levels compared with nurses. Nurse and physical therapists identify different barriers for mobilization. Routine involvement of physical therapists in directing mobilization treatment may promote early mobilization of critically ill patients.

Indications for routine repeat head computed tomography (CT) stratified by severity of traumatic brain injury.

BACKGROUND: Controversy exists as to the role of a routine repeat head computed tomography (CT) for patients with traumatic brain injury and an initially abnormal head CT. The specific aim of this study is to identify patients with head injuries who would benefit from a routine repeat head CT. METHODS: This was a 2-year (2003 and 2004) prospective study of all patients with blunt trauma admitted to an urban, Level I trauma center that presented with an abnormal head CT. Results of initial head CT and indications for repeat head CT (routine vs. neurologic change) were recorded. Interventions were both medical (diuresis, hyperventilation, barbiturates) and surgical (intracranial pressure monitor placement or craniotomy). Patients were categorized by Glasgow Coma Scale (GCS) score as having mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS < or = 8) head injury. RESULTS: There were 354 patients admitted with an initially abnormal head CT. The 37 (10%) patients who went directly to craniotomy and the 43 (12%) patients who died within 24 hours of admission were excluded from analysis. The remaining 274 patients (44 years old, 70% male, mean injury severity score = 19, mean GCS = 10) are the focus of this analysis. After admission, 163 patients underwent a total of 241 repeat CT scans. Of the repeat scans obtained, 102 scans (43%) were unchanged, 54 scans (22%) were better, and 85 scans (35%) were worse. Neurologic deterioration prompted 45 repeat scans (19%), and 196 repeat scans (81%) were obtained routinely after admission without change in neurologic status. The 45 CT scans obtained for neurologic change led to medical or surgical intervention in 38% (n = 17) of cases, whereas scans obtained led to an intervention in only two patients (1%). Both patients who underwent an intervention after a routine scan had a GCS score < or =8 at admission and at the time of routine repeat head CT. One patient had an intracranial pressure monitor placed and the other was taken for craniotomy. No patient with a mild or moderate traumatic brain injury underwent an intervention after a routine repeat head CT. CONCLUSIONS: Patients with any head injury (mild, moderate, or severe) should undergo a repeat head CT after neurologic deterioration, because it leads to intervention in over one-third of patients. Routine repeat head CT is indicated for patients with a GCS score < or =8, as results might lead to intervention without neurologic change.

Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation.

BACKGROUND: Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. METHODS: Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. RESULTS: Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1). CONCLUSIONS: Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.