Prehospital Predictors of Emergent Intervention After Helicopter Transfer for Spontaneous Intraparenchymal Hemorrhage.

OBJECTIVE: Helicopter transport may shorten transportation times for emergent neurosurgical intervention. The usefulness of helicopter transport after spontaneous intraparenchymal hemorrhage is not well studied. This study seeks to clarify factors that are associated with urgent surgical intervention in patients with spontaneous intracerebral hemorrhage following helicopter transport. METHODS: Records were reviewed for patients with spontaneous intraparenchymal hemorrhage transported by helicopter to Dartmouth-Hitchcock Medical Center between January 2008 and December 2011. Records were evaluated for factors associated with emergent tertiary-level care intervention during the first 24 hours of admission. RESULTS: A total of 107 patients met inclusion criteria, with a mean age of 67.2 years. At presentation, 79 (75.24%) were hypertensive, 22 (21.57%) had an increased international normalized ratio, and 47 (45.19%) were intubated. Thirty-three patients (30.8%) underwent 1 or more neurosurgical interventions within 24 hours of arrival, with an additional 6 (5.6%) patients undergoing neurosurgical intervention after 24 hours after admission. On univariate analysis, age, Glasgow Coma Scale (GCS) score, and clot volume were significant predictors of neurosurgical intervention within 24 hours of interfacility helicopter transport. A lobar clot, presence of intraventricular hemorrhage, and presence of >1 cm of midline shift were also associated with neurosurgical intervention within 24 hours. On multivariate analysis, younger age, GCS score of 3-8, and lobar hemorrhage were independent predictors of neurosurgical intervention within 24 hours. CONCLUSIONS: Two thirds of patients did not undergo any surgical intervention during the first 24 hours of admission after interfacility helicopter transfer. Factors associated with urgent neurosurgical intervention included younger age, low GCS score, and presence of lobar hemorrhage.

Prehospital Glasgow Coma Score Predicts Emergent Intervention following Helicopter Transfer for Spontaneous Subarachnoid Hemorrhage.

BACKGROUND: Helicopter transport may shorten transport time to neurosurgical intervention; however, there are few data regarding its utility for nontraumatic emergencies. METHODS: Prehospital and hospital records of all patients transferred via helicopter to Dartmouth-Hitchcock Medical Center for spontaneous subarachnoid hemorrhage between January 2007 and December 2011 were reviewed. Primary outcome measure was emergent tertiary-level care intervention, defined as ventriculostomy, conventional angiography, endovascular treatment, or craniotomy within 3 hours of arrival. RESULTS: Fifty-one patients met inclusion criteria. Median helicopter transport time, defined as time from telephone referral to arrival, was 97 minutes (range, 61-214 minutes). Fifteen patients underwent intervention within 3 hours of arrival (29%), 19 patients underwent intervention between 3 and 6 hours (37%), 9 patients underwent intervention between 6 to 12 hours (18%), and 11 patients underwent intervention greater than 12 hours after arrival (16%). Univariate analysis of pretransfer clinical and radiographic findings showed significant correlations between Glasgow Coma Scale (GCS) score less than 15 (odds ratio [OR], 22.8; 95% confidence interval [CI], 4.2-122.5), World Federation of Neurologic Surgeons (WFNS) scale greater than 2 (OR, 46.75; 95% CI, 7.511-290.99), presence of intraparenchymal hemorrhage (OR, 4.7; 95% CI, 1.3-17.5), and intubation (OR, 12.4; 95% CI, 2.9-51.8) with emergent intervention. On logistic multivariate regression analysis, GCS score less than 15 and WFNS scale score greater than 2 independently predicted emergent intervention. CONCLUSIONS: A majority of patients with spontaneous subarachnoid hemorrhage who were transferred by interfacility helicopter ambulance did not require emergent intervention. GCS score less than 15 at an outside hospital was independently associated with emergent intervention on multivariate analysis.

Management of acute spinal cord injury in the neurocritical care unit.

Acute spinal cord injury (SCI) is associated with widespread disturbances not only affecting neurologic function but also leading to hemodynamic instability and respiratory failure. Traumatic SCI rarely occurs in isolation, and frequently is accompanied by trauma to other organ systems. Management of individuals with SCI is complex, requiring aggressive monitoring and prompt treatment when complications arise. Typically this level of care is provided in the neurocritical care unit. This article reviews the pathophysiology of the neurologic, cardiovascular, and pulmonary derangements following traumatic SCI and their management in the critical care setting.

How long should cerebrospinal fluid cultures be held to detect shunt infections? Clinical article.

OBJECT: Infections of CSF hardware may be indolent, and some patients have received antibiotic treatment for various reasons before CSF is obtained to check for a shunt infection. At present, there are few data in the literature to guide the decision as to how long to hold CSF specimens when attempting to diagnose hardware infections, and institutions vary in the duration at which cultures are considered "final." METHODS: The authors reviewed the microbiology data from CSF specimens obtained from shunts, ventriculostomies, reservoirs, and lumbar drains at their institution over a 36-month period to discover how long after collection cultures became positive. The authors also sought to discover whether this time was affected by prior treatment with antibiotics. RESULTS: Of 158 positive CSF specimens obtained from hardware, the time to recovery ranged between 1-10 days, with a mean of 3.02 days (SD 2.37 days, 95% CI 2.66-3.38 days). One hundred and twenty-seven positive specimens were associated with clinical infections, and approximately 25% of these grew organisms after > 3 days, with some as long as 10 days after specimens were obtained. The most common organisms grown from individual patients were coagulase-negative Staphylococcus spp (34 cultures), Propionibacterium spp (21), Bacillus spp (6), Pseudomonas aeruginosa (4), and Staphylococcus aureus (4 cultures). Mean and maximum days to recovery were different across species, with S. aureus showing the shortest and Propionibacterium spp showing the longest incubation times. There appeared to be no significant difference in the time to recovery between specimens obtained in patients who had received prior antibiotic treatment versus those who had not. CONCLUSIONS: A substantial number of positive CSF specimens obtained in patients with clinical infections grew bacteria after > 3 days, with some requiring as long as 10 days. Thus, a routine 10-day observation period for CSF specimens can be justified.