Levetiracetam Prophylaxis for Post-traumatic Brain Injury Seizures is Ineffective: A Propensity Score Analysis.

INTRODUCTION: Early seizures after severe traumatic brain injury (TBI) have a reported incidence of up to 15 %. Prophylaxis for early seizures using 1 week of phenytoin is considered standard of care for seizure prevention. However, many centers have substituted the anticonvulsant levetiracetam without good data on the efficacy of this approach. Our hypothesis was that the treatment with levetiracetam is not effective in preventing early post-traumatic seizures. METHODS: All trauma patients sustaining a TBI from January 2007 to December 2009 at an urban level-one trauma center were retrospectively analyzed. Seizures were identified from a prospectively gathered morbidity database and anticonvulsant use from the pharmacy database. Statistical comparisons were made by Chi square, t tests, and logistic regression modeling. Patients who received levetiracetam prophylaxis were matched 1:1 using propensity score matching with those who did not receive the drug. RESULTS: 5551 trauma patients suffered a TBI during the study period, with an overall seizure rate of 0.7 % (39/5551). Of the total population, 1795 were diagnosed with severe TBI (Head AIS score 3-5). Seizures were 25 times more likely in the severe TBI group than in the non-severe group [2.0 % (36/1795) vs. 0.08 % (3/3756); OR 25.6; 95 % CI 7.8-83.2; p < 0.0001]. Of the patients who had seizures after severe TBI, 25 % (9/36) received pharmacologic prophylaxis with levetiracetam, phenytoin, or fosphenytoin. In a matched cohort by propensity scores, no difference was seen in seizure rates between the levetiracetam group and no-prophylaxis group (1.9 vs. 3.4 %, p = 0.50). CONCLUSIONS: In this propensity score-matched cohort analysis, levetiracetam prophylaxis was ineffective in preventing seizures as the rate of seizures was similar whether patients did or did not receive the drug. The incidence of post-traumatic seizures in severe TBI patients was only 2.0 % in this study; therefore we question the benefit of routine prophylactic anticonvulsant therapy in patients with TBI.

Traumatic intracranial aneurysm in blunt trauma.

INTRODUCTION: Computed Tomography Angiography (CTA) is being used to identify traumatic intracranial aneurysms (TICA) in patients with findings such as skull fracture and intracranial haemorrhage on initial Computed Tomography (CT) scans after blunt traumatic brain injury (TBI). However, the incidence of TICA in patients with blunt TBI is unknown. The aim of this study is to report the incidence of TICA in patients with blunt TBI and to assess the utility of CTA in detecting these lesions. METHODS: A 10-year retrospective study (2003-2012) was performed at a Level 1 trauma centre. All patients with blunt TBI who had an initial non-contrasted head CT scan and a follow-up head CTA were included. Head CTAs were then reviewed by a single investigator and TICAs were identified. The primary outcome measure was incidence of TICA in blunt TBI. RESULTS: A total of 10 257 patients with blunt TBI were identified, out of which 459 patients were included in the analysis. Mean age was 47.3 ± 22.5, the majority were male (65.1%) and median ISS was 16 [9-25]. Thirty-six patients (7.8%) had intracranial aneurysm, of which three patients (0.65%) had TICAs. CONCLUSION: The incidence of traumatic intracranial aneurysm was exceedingly low (0.65%) over 10-years. This study adds to the growing literature questioning the empiric use of CTA for detecting vascular injuries in patients with blunt TBI.

Low-dose aspirin therapy is not a reason for repeating head computed tomographic scans in traumatic brain injury: a prospective study.

BACKGROUND: Most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate the utility of repeat head computed tomography (RHCT) and outcomes in patients on low-dose aspirin (acetylsalicylic acid; ASA) therapy. METHODS: Patients with traumatic brain injury with intracranial hemorrhage on initial head computed tomography (CT) were prospectively enrolled. Patients on prehospital low-dose (81 mg) aspirin therapy were matched with patients exclusive of antiplatelet and anticoagulation therapy using propensity score matching in a 1:1 ratio for age, Glasgow Coma Scale, head Abbreviated Injury Scale score, Injury Severity Score, and neurological examination. Outcome measures were progression on RHCT and subsequent neurosurgical intervention. RESULTS: A total of 144 patients who had intracranial hemorrhage on initial CT scan (ASA group: 72; No-ASA group: 72) were enrolled. The mean age was 72.8 ± 11.7 years, 59.7% were male, and median head Abbreviated Injury Scale was 3 (2-3). There was no difference in progression on RHCT (25% in ASA versus 16.6% in no-ASA), change in management as a result of RHCT (1.4% versus 1.4%), RHCT as a result of neurological decline (0 versus 1.4%), discharge Glasgow Coma Scale (15 [14-15] versus 15 [14-15]), and mortality (0 versus 1.4%) between the two groups. CONCLUSIONS: Low-dose aspirin therapy is not associated with progression of initial insult on RHCT or clinical deterioration. Prehospital low-dose aspirin therapy as a sole criterion should not warrant a routine repeat head CT in traumatic brain injury.

Telephotography in trauma: a 2-year clinical experience.

INTRODUCTION: Smartphones can be used to record and transmit high-quality clinical photographs. The aim of this study was to describe our experience with smartphone telephotography in the care of trauma patients. We hypothesized that smartphone telephotography can be safely and effectively implemented on a trauma service. SUBJECTS AND METHODS: We performed a 2-year (January 2011-December 2012) prospective analysis of all patient photographs recorded by members of our trauma team at our Level I trauma center. All members of the trauma team recorded patient photographs and e-mailed them to a secure e-mail account. An administrative assistant uploaded a copy of each photgrapho into the patient's electronic medical record. We assessed the number of photographs collected and uploaded, as well as the success, failure, and complication rates. RESULTS: Our trauma team sent 7,200 photographs to a secure e-mail account. Of those, 6,120 (85%) were considered, after an initial review, to be of good quality. Of these, 3,320 photographs (54%) were successfully uploaded into a patient's electronic medical record; the remaining 2,800 photographs lacked adequate labeling and could not be uploaded. The average interval to uploading was 3 months. In total, 10 photographs were uploaded into the wrong patient's electronic medical record, for an error rate of 0.003%. We received only three complaints during the study period. CONCLUSIONS: Telephotography can be safely and effectively implemented in trauma clinical practice. Fears of Health Insurance Portability and Accountability Act violations are not valid, as the incidence of patient complaints is minimal when telephotography is implemented under strict guidelines and rules. Dedicated administrative personnel are essential for effective implementation of smartphone photography.

Rehabilitation after trauma; does age matter?

BACKGROUND: Variability exits in the ability to predict overall recovery after trauma and inpatient rehabilitation. The aim of this study was to identify factors predicting functional improvement in trauma patients undergoing inpatient rehabilitation. METHODS: We performed a 3-y retrospective cohort analysis on a prospectively collected database of all trauma patients discharged from a level I trauma center to a single inpatient rehabilitation center. Patient's Functional Independence Measures (FIM) scores on hospital discharge and on discharge from the rehabilitation center were collected. Delta FIM was defined as the difference in FIM between rehabilitation center discharge and hospital discharge. Multiple linear regressions were performed to identify hospital admission factors associated with delta FIM. RESULTS: We included 160 patients, 69% were male, mean age 54.6 ± 22 y, and median Injury Severity Score 14 [10-50]. Based on rehabilitation admission FIM scores, 29 were totally dependent and 131 were partially dependent. The mean change in FIM was 39.4 ± 13. Age, gender, Glasgow Coma Scale on presentation, Injury Severity Score, systolic blood pressure on presentation, and intensive care unit length of stay were not predictive of delta FIM. Hospital length of stay and head Abbreviated Injury Score on hospital admission were negative predictors of delta FIM. CONCLUSIONS: In our study, age as an independent factor was not predictive of functional outcome after injury. The extent of head injury continues to negatively affect the overall functional improvement based on FIM.

Continuous noninvasive hemoglobin monitor from pulse ox: ready for prime time?

BACKGROUND: Advances in technology have allowed for continuous noninvasive hemoglobin monitoring (SpHb), which may enable earlier detection of hemorrhage and more efficient surgical and/or blood transfusion management. The use of SpHb has not been described in the trauma population. The purpose of the present study was to evaluate the accuracy of a SpHb measurement device in severely injured trauma patients. METHODS: We performed a prospective cohort analysis of severely injured trauma patients admitted to the intensive care unit (ICU) at our level I trauma center over a 6 month period. Serial IHb (invasive hemoglobin) levels and SpHb for the first 72 h were measured. Each SpHb measurement was matched with a corresponding IHb measurement. We defined normal Hgb as >8 mg/dL and low Hgb as <8 mg/dL. Data were then grouped based on Hgb level. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and Spearman correlation coefficient plot were calculated. RESULTS: A total of 23 trauma patients with 89 data pairs were reviewed. Eighty-six percent of the patients were male with a mean age of 32 years and a mean injury severity score (ISS) of 21.1 ± 14. Invasive hemoglobin had a range of 7.2-16.9 and SpHb had a range of 3.3-15.2. The average mean and difference between IHb and SpHb were 10.7 and 1, respectively. Continuous noninvasive hemoglobin measurement did not record data points 13.5% of the time. The Spearman correlation plot revealed a correlation of R = 0.670 (p < 0.001). After dichotomization with Hgb > 8, SpHb was found to have a sensitivity of 91%, PPV 96%, specificity 40%, NPV 20%, and an accuracy of 88%. CONCLUSIONS: The continuous noninvasive hemoglobin monitor does not appear to represent serum hemoglobin levels accurately in severely injured trauma patients. However, we were able to identify utility for this noninvasive tool when Hgb was dichotomized into normal or low levels.

Improving communication in level 1 trauma centers: replacing pagers with smartphones.

INTRODUCTION: Communication among healthcare providers continues to change, and 90% of healthcare providers are now carrying cellular phones. Compared with pagers, the rate and amount of information immediately available via cellular phones are far superior. Wireless devices such as smartphones are ideal in acute trauma settings as they can transfer patient information quickly in a coordinate manner to all the team members responsible for patient care. SUBJECTS AND METHODS: A questionnaire survey was distributed among all the trauma surgeons, surgery residents, and nurse practitioners who were a part of the trauma surgery team at a Level 1 trauma center. Answers to each question were recorded on a 5-point Likert scale. The completed survey questionnaires were analyzed using Statistical Package for Social Sciences software (SPSS version 17; SPSS, Inc., Chicago, IL). RESULTS: The respondents had an overall positive experience with the usage of the third-generation (3G) smartphones, with 94% of respondents in favor of having wireless means of communication at a Level 1 trauma center. Of respondents, 78% found the device very user friendly, 98% stated that use of smartphones had improved the speed and quality of communication, 96% indicated that 3G smartphones were a useful teaching tool, 90% of the individuals felt there was improvement in the physician's response time to both routine and critical patients, and 88% of respondents were aware of the rules and regulations of the Health Insurance Portability and Accountability Act. CONCLUSIONS: Smartphones in an acute trauma setting are easy to use and improve the means of communication among the team members by providing accurate and reliable information in real time. Smartphones are effective in patient follow-up and as a teaching tool. Strict rules need to be used to govern the use of smartphones to secure the safety and secrecy of patient information.

Sleep disruptions and nocturnal nursing interactions in the intensive care unit.

BACKGROUND: Sleep deprivation, common in intensive care unit (ICU) patients, may be associated with increased morbidity and/or mortality. We previously demonstrated that significant numbers of nocturnal nursing interactions (NNIs) occur during the routine care of surgical ICU patients. For this study, we assessed the quantity and type of NNIs in different ICU types: medical, surgical, cardiothoracic, pediatric, and neonatal. We hypothesized that the number and type of NNIs vary among different ICU types. MATERIAL AND METHODS: We performed a prospective observational cohort study at our academic medical center examining potential sleep disruption in ICU patients secondary to NNIs from the hours 2200-0600 nightly. From May through November 2011, bedside nursing staff in five different ICUs collected data on NNIs, including the frequency and nature of each event (patient care activity, nursing intervention, nursing assessment, or patient-initiated contact) as well as the length of time of each event and whether the bedside care provider thought that the event could have been safely omitted without negatively affecting patient care. Additional data collected included patient demographics, the need for mechanical ventilation, and sedative/narcotic use. RESULTS: Two hundred ICU patients were enrolled over 51 separate nocturnal time periods (3.9 patients/nocturnal time period). Of those 200 patients, 53 (26.5%) were mechanically ventilated; 12.5% underwent sedative infusion; and 23.0% underwent narcotic infusion. There were a total of 1831 NNIs; most (67%) were due to nursing assessment or patient care activity. The surgical ICU had the most frequent NNIs (11.8 ± 9.0), although they were the shortest (6.66 ± 6.06 min), as well as the highest proportion of NNIs that could have been safely omitted (20.9%). Nursing staff estimated that, of all NNIs in all ICU types, 13.9% could have been safely omitted. CONCLUSIONS: NNIs occur frequently and vary across different ICU types. Many NNIs are due to nursing assessment and patient care activities, much of which could be safely omitted or clustered. A protocol for nocturnal sleep promotion is warranted in order to standardize ICU NNIs and minimize nighttime sleep disruptions.

Pediatric all-terrain vehicle trauma: the epidemic continues unabated.

OBJECTIVES: The popularity of all-terrain vehicles (ATVs) continues to increase, but this form of recreation is not as well regulated and can impact children disproportionately. This study examines the epidemiology of ATV injuries in Arizona with emphasis on pediatric injuries and compares ATV injuries to those associated with motorcycle (MCC) and motor vehicle crashes (MVC). METHODS: The trauma registry of a level 1 trauma center was used to identify all ATV crashes during a 5-year period (2004-2008) in patients younger than 16 years. Registration data of ATV were obtained from the state DMV. All-terrain vehicle-related injuries were compared with both MVC and MCC. RESULTS: A total of 250 pediatric ATV crashes were observed during the 5-year period, rising from 29 in 2004 to 53 in 2008. The median age of patients with ATV-related injuries was 13 years, which is higher than that of patients with MVC-related injuries (9 years). Only 34% of the patients with ATV-related injuries were helmeted, compared with 55% of patients with MCC-related injuries. All-terrain vehicle-related crashes were at least 30 times more likely than MVCs and almost 20 times more likely than MCCs. Statewide pediatric ATV deaths rose during the study period. CONCLUSIONS: All-terrain vehicle-related crashes have increased during this study period and have become a significant source of injuries. Public education and awareness of the dangers associated with ATV use need to be targeted toward both parents and children likely to use ATVs.

Intensive laparoscopic training course for surgical residents: program description, initial results, and requirements.

INTRODUCTION: The Department of Surgery at the University of Arizona has created an intensive laparoscopic training course for surgical residents featuring a combined simulation laboratory and live swine model. We herein report the essential components to design and implement a rigorous training course for developing laparoscopic skills in surgical residents. MATERIALS AND METHODS: At our institution, we developed a week-long pilot intensive laparoscopic training course. Six surgical residents (ranging from interns to chief residents) participate in the structured, multimodality course, without any clinical responsibilities. It consists of didactic instruction, laboratory training, practice in the simulation laboratory, and performance (under the direction of attending laparoscopic surgeons) of surgical procedures on pigs. The pigs are anesthetized and attended by veterinarians and technicians, and then euthanized at the end of each day. Three teams of two different training-level residents are paired. Daily briefing, debriefing, and analysis are performed at the close of each session. A written paper survey is completed at the end of the course. RESULTS: This report describes the results of first 36 surgical residents trained in six courses. Preliminary data reveal that all 36 now feel more comfortable handling laparoscopic instruments and positioning trocars; they now perform laparoscopic surgery with greater confidence and favor having the course as part of their educational curriculum. CONCLUSION: A multimodality intensive laparoscopic training course should become a standard requirement for surgical residents, enabling them to acquire basic and advanced laparoscopic skills on a routine basis.

Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend.

BACKGROUND: The traditional treatment of patients with traumatic hemopneumothorax has been an insertion of a chest tube (CT). But CT, because of its large caliber and significant trauma during an insertion, can cause pain, prevent full lung expansion, and worsen pulmonary outcome. Pigtail catheters (PCs) are smaller and less invasive; they have worked well in patients with nontraumatic pneumothorax (PTX). The purpose of this study was to review our early experience of PC use in trauma patients. METHODS: We retrospectively reviewed the charts of trauma patients who required CT or PC placement over a 2-year period (January 2008 through December 2009) at a Level I trauma center. The PCs were 14-French (14-F) Cook catheters placed by the trauma team, using a Seldinger technique. We compared outcome for the subgroups that had CT or PC placed for a PTX. For our statistical analysis, we used the unpaired Student t-test, χ(2) test, and Wilcoxon rank-sum test; we considered a p value < 0.05 as significant. RESULTS: Of 9,624 trauma patients evaluated, 94 were treated with PC and 386 with CT. Of the PC patients, 89% was inserted for PTX. When comparing patients with PC and CT inserted for PTX, demographics, tube days, need for mechanical ventilation, and insertion-related complications were similar. The tube failure rate, defined by a requirement for an additional tube or by recurrence that needed intervention, was higher in PC (11%) than in CT (4%) (p = 0.06), but the difference was not statistically significant. We observed a trend of increased PC use over time. CONCLUSION: PC is safe and can be performed at the bedside. It has a comparable efficacy to CT in patients with PTX. A prospective study is needed to determine the precise role of PC placement, including its indication, the associated tube-site pain, and any significant clinical advantages.

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review.

BACKGROUND: Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice. METHODS: Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence. RESULTS: Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing? CONCLUSIONS: Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Damage control laparotomy: a vital tool once overused.

BACKGROUND: Trauma surgery is in constant evolution as is the use of damage control laparotomy (DCL). The purpose of this study was to report the change in usage of DCL over time and its effect on outcome. METHODS: Trauma patients requiring laparotomies during a 3-year (2006-2008) period were reviewed. DCL was defined as laparotomy when fascia was not closed at the first operation. RESULTS: There were 14,534 trauma patients evaluated, and 843 laparotomies were performed on 532 patients during the study period. The number of patients requiring open laparotomies slightly increased while the demographics and Injury Severity Score were similar during the study period. The number of patient requiring DCL significantly decreased from 36.3% (53 of 146) in 2006 to 8.8% (15 of 170) in 2008 (p < 0.001). During this same time period, the mortality rate for patients requiring open laparotomy significantly decreased from 21.9% in 2006 to 12.9% in 2008 (p = 0.05). The decreased use of DCL resulted in a 33.3% reduction in the number of laparotomies performed. The decrease in average costs and charges is projected to result in savings of $2.2 million and $5.8 million, respectively. CONCLUSIONS: The use of DCL was significantly decreased by 78% during the study with significantly improved outcome. The improved outcome and decreased resource utilization can reduce health care costs and charges. Although DCL may be a vital aspect of trauma surgery, it can be used more selectively with improved outcome.

The effect of ACGME duty hour restrictions on operative continuity of care.

Resident work restrictions limit participation in operations that address problems created by a prior operation, because complications occur at any time. We compared resident and attending surgeon staffing of operative complications. We reviewed all complications that required a second operation reported at our Morbidity and Mortality Conference over 1 year, noting surgeons present, their postgraduate year level, and call shift. Comparisons were done using chi2. Of 142 cases, 39 involved a second operation. The same attending surgeon was present for both in 79 per cent of cases, whereas the same resident was present in only 44 per cent (P = 0.002). Postgraduate year 4 to 5 were less likely to be present for second operations than attendings (48% vs 87%, P = 0.011). Resident shift (day, night float, and weekend) was known in 32 cases. When the first operation occurred during day hours, attendings and residents were equally likely to be present at the second (55% and 45%, P = 0.16). When original operations took place during night float or weekend shifts, residents were less likely to be present (33%) than attendings (83%) at second operations (P = 0.036). Duty hour restrictions interfere with operative continuity of care. Reoperations should be exempted from duty hour restrictions.

Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: A single academic center experience.

OBJECTIVES: Early diagnosis and emergent surgical debridement of necrotizing soft tissue infections (NSTIs) remains the cornerstone of care. We aimed to study the effect of early surgery on patients' outcomes and, in particular, on hospital length of stay (LOS) and Intensive Care Unit (ICU) LOS. MATERIALS AND METHODS: Over a 6-year period (January 2003 through December 2008), we analyzed the records of patients with NSTIs. We divided patients into two groups based on the time of surgery (i.e., the interval from being diagnosed and surgical intervention): Early (<6 h) and late (≥6 h) intervention groups. For these two groups, we compared baseline demographic characteristics, symptoms, and outcomes. For our statistical analysis, we used the Student's t-test and Pearson Chi-square (χ(2)) test. To evaluate the clinical predictors of early diagnosis of NSTIs, we performed multivariate logistic regression analysis. RESULTS: In the study population (n = 87; 62% males and 38% females), age, gender, wound locations, and comorbidities were comparable in the two groups. Except for higher proportion of crepitus, the clinical presentations showed no significant differences between the two groups. There were significantly shorter hospital LOS and ICU LOS in the early than late intervention group. The overall mortality rate in our study patients with NSTIs was 12.5%, but early intervention group had a mortality of 7.5%, but this did not reach statistical significance. CONCLUSIONS: Our findings show that early surgery, within the first 6 h after being diagnosed, improves in-hospital outcomes in patients with NSTIs.

Clinical outcomes in traumatic brain injury patients on preinjury clopidogrel: a prospective analysis.

BACKGROUND: Patients receiving antiplatelet medications are considered to be at an increased risk for traumatic intracranial hemorrhage after blunt head trauma. However, most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate clinical outcomes and the requirement of a repeat head computed tomography (RHCT) in patients on preinjury clopidogrel therapy. METHODS: Patients with traumatic brain injury with intracranial hemorrhage on initial head CT were prospectively enrolled. Patients on preinjury clopidogrel were matched with patients exclusive of antiplatelet and anticoagulation therapy using a propensity score in a 1:1 ratio for age, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (h-AIS), Injury Severity Score (ISS), neurologic examination, and platelet transfusion. Outcome measures were progression on RHCT scan and need for neurosurgical intervention. RESULTS: A total of 142 patients with intracranial hemorrhage on initial head CT scan (clopidogrel, 71; no clopidogrel, 71) were enrolled. The mean (SD) age was 70.5 (15.1) years, 66% were male, median GCS score was 14 (range, 3-15), and median h-AIS (ISS) was 3 (range, 2-5). The mean (SD) platelet count was 210 (101), and 61% (n = 86) of the patients received platelet transfusion. Patients on preinjury clopidogrel were more likely to have progression on RHCT (odds ratio [OR], 5.1; 95% confidence interval [CI], 3.1-7.1) and RHCT as a result of clinical deterioration (OR, 2.1; 95% CI, 1.8-3.5). The overall rate of neurosurgical intervention was 4.2% (n = 6). Patients on clopidogrel therapy were more likely to require a neurosurgical intervention (OR, 1.8; 95% CI, 1.4-3.1). CONCLUSION: Preinjury clopidogrel therapy is associated with progression of initial insult on RHCT scan and need for neurosurgical intervention. Preinjury clopidogrel therapy as an independent variable should warrant the need for a routine RHCT scan in patients with traumatic brain injury. LEVEL OF EVIDENCE: Prognostic study, level I; therapeutic study, level II.

The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons.

BACKGROUND: It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation. METHODS: In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. RESULTS: A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. κ statistic is equal to 0.98. CONCLUSION: We have proposed BIG based on patient's history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Improving survival rates after civilian gunshot wounds to the brain.

BACKGROUND: Gunshot wounds to the brain are the most lethal of all firearm injuries, with reported survival rates of 10% to 15%. The aim of this study was to determine outcomes in patients with gunshot wounds to the brain, presenting to our institution over time. We hypothesized that aggressive management can increase survival and the rate of organ donation in patients with gunshot wounds to the brain. STUDY DESIGN: We analyzed all patients with gunshot wounds to the brain presenting to our level 1 trauma center over a 5-year period. Aggressive management was defined as resuscitation with blood products, hyperosmolar therapy, and/or prothrombin complex concentrate (PCC). The primary outcome was survival and the secondary outcome was organ donation. RESULTS: There were 132 patients with gunshot wounds to the brain, and the survival rates increased incrementally every year, from 10% in 2008 to 46% in 2011, with the adoption of aggressive management. Among survivors, 40% (16 of 40) of the patients had bi-hemispheric injuries. Aggressive management with blood products (p = 0.02) and hyperosmolar therapy (p = 0.01) was independently associated with survival. Of the survivors, 20% had a Glasgow Coma Scale score ≥ 13 at hospital discharge. In patients who died (n = 92), 56% patients were eligible for organ donation, and they donated 60 organs. CONCLUSIONS: Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. The bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save patients with gunshot wound to the brain.

The physiological effects of hyperosmolar resuscitation: 5% vs 3% hypertonic saline.

BACKGROUND: Use of 5% normal saline (NS) is gaining renewed interest. The primary aim of our study was to compare the physiological effects after the administration of different concentrations of hypertonic saline (3% vs 5%NS) in the initial resuscitation of trauma. METHODS: We performed a retrospective analysis of a prospectively collected database of all trauma patients who received hypertonic saline during initial resuscitation. Medical records were reviewed for serum electrolytes and serum osmolarity, coagulation parameters, complications, and mortality. RESULTS: A total of 212 patients were included in the study, of which 170 patients received 5%NS and 42 patients received 3%NS. Both groups were similar in age (41.16 ± 19 vs 44.17 + 23.6; P = .45) and ISS score (26 [17 to 29] vs 25 [16 to 27]; P = .6). Mean serum osmolarity (316 ± 20.3 vs 294 ± 22.5; P = .02) and serum sodium levels (143 ± 8.6 vs 137 ± 10.9; P < .001) remained higher in the 5%NS group within 72 hours of admission. The pH was lower in the 5%NS group compared with the 3%NS group at 24 hours (7.29 ± .12 vs 7.33 ± .12; P = .01); however, at 48 and 72 hours (7.40 ± .07 vs 7.41 ± .07; P = .7), no difference was found. There was no difference in blood products requirement (1,734 vs 2,253 mL; P = .11) between the 2 groups. CONCLUSIONS: The 5%NS has sustained higher serum osmolarity and serum sodium concentration within the first 72 hours without any increase in adverse effects in comparison with 3%NS.