Radiologic predictors of in-hospital mortality after traumatic craniocervical dissociation.

BACKGROUND: Traumatic craniocervical dissociation (CCD) is the forcible dislocation of the skull from the vertebral column. Because most CCD patients die on scene, prognostication for those who arrive alive to hospital is challenging. The study objective was to determine if greater dissociation, based on radiologic measurements of CCD, is predictive of in-hospital mortality among patients surviving to the emergency department. METHODS: All trauma patients arriving to our Level 1 trauma center (January 2008 to April 2019) with CCD were retrospectively identified and included. Transfers and patients without computed tomography head/cervical spine were excluded. Study patients were dichotomized into groups based on in-hospital mortality. Radiologic measurements of degree of CCD were performed based on the index computed tomography scan by an attending radiologist with Emergency Radiology fellowship training. Measurements were compared between patients who died in-hospital versus those who survived. RESULTS: After exclusions, 36 patients remained: 12 (33%) died and 24 (67%) survived. Median age was 55 years (30-67 years) versus 44 (20-61 years) (p = 0.199). Patients who died had higher Injury Severity Score (39 [31-71] vs. 27 [14-34], p = 0.019) and Abbreviated Injury Scale head/neck score (5 [5-5] vs. 4 [3-4], p = 0.001) than survivors. The only radiologic measurement that differed between groups was greater soft tissue edema at mid C1 among patients who died (12.37 [7.60-14.95] vs. 7.86 [5.25-11.61], p = 0.013). Receiver operating characteristic curve analysis of soft tissue edema at mid C1 and mortality revealed 10.86 mm or greater of soft tissue width predicted mortality with sensitivity and specificity of 0.75. All other radiologic parameters, including the basion-dens interval, were comparable between groups (p > 0.05). CONCLUSION: Among patients who arrive alive to hospital after traumatic CCD, greater radiologic dissociation is not associated with increased mortality. However, increased soft tissue edema at the level of mid C1, particularly 10.86 mm or greater, is associated with in-hospital death. These findings improve our understanding of this highly lethal injury and impart the ability to better prognosticate for patients arriving alive to hospital with CCD. LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level III.

The evolution of trauma care in the Netherlands over 20 years.

INTRODUCTION: In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures). MATERIALS AND METHODS: In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated. RESULTS: It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement. CONCLUSION: Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential.

[Hypocalcemia is an "accelerator" for the death of patients with nervous system injury].

OBJECTIVE: In clinical diagnosis and treatment, the occurrence of hypocalcemia during severe nervous system damage is not uncommon but is easily neglected so that delayed treatment, further injurie and even death. It can provide theoretical support for the evaluation of the early identification in calcium ion imbalance and the development of standard calcium ion monitoring program for patients with critical disease by integrating the clinical symptoms induced by low blood calcium based on severe nervous system injury and analyzing the correlation among them.

Outcome and risk factors associated with extent of central nervous system injury due to exertional heat stroke.

To explore the relationship between the extent of central nervous system (CNS) injury and patient outcomes meanwhile research the potential risk factors associated with neurologic sequelae. In this retrospective cohort study, we analyzed data from 117 consecutive patients (86 survivors, 31 nonsurvivors) with exertional heat stroke (EHS) who had been admitted to intensive care unit (ICU) at 48 Chinese hospitals between April 2003 and July 2015. Extent of CNS injury was dichotomized according to Glasgow coma scale (GCS) score (severe 3-8, not severe 9-15). We then assessed differences in hospital mortality based on the extent of CNS injury by comparing 90-day survival time between the patient groups. Exploring the risk factors of neurologic sequelae. The primary outcomewas the 90-day survival ratewhich differed between the 2 groups (P = .023). The incidence of neurologic sequelae was 24.4%. For its risk factors, duration of recurrent hyperthermia (OR = 1.73, 95% CI: 1.20-2.49, P = .003), duration of CNS injury (OR = 1.39, 95% CI: 1.04-1.85, P = .025), and low GCS in the first 24 hours after admission (OR = 2.39, 95% CI: 1.11-5.15, P = .025) were selected by multivariable logistic regression. Cooling effect was eliminated as a factor (OR = 2641.27, 95% CI 0.40-1.73_107, P = .079). Significant differences in 90-day survival ratewere observed based on the extent of CNS injury in patients with EHS, and incidence was 24.4% for neurologic sequelae. Duration of recurrent hyperthermia, duration of CNS injury, and low GCS score in the first 24 hours following admission may be independent risk factors of neurologic sequelae. Cooling effect should be validated in the further studies.

Possible mechanisms for delayed neurological damage in lightning and electrical injury.

AIM: This article provides and reviews hypotheses to help explain the poorly understood phenomenon of delayed neurological injury following lightning or electrical injury. METHOD: A review of extant literature provides a starting point to integrate what is already known in an attempt to provide new hypotheses for this phenomenon, as well as to discuss existing hypotheses. RESULT: The author proposes two theories which stem from the literature on the damaging effects of oxidative stress, and also reviews an existing hypothesis, the electroporation hypothesis. The former two theories can account for delayed damage which is either of vascular or nonvascular origin. The electroporation hypothesis can explain changes both in cases where there is cellular loss as well as cases where there only appears to be change in function after lightning or electrical injury. CONCLUSION: Although all theories discussed are speculative, the formation of hypotheses is always a starting point in the scientific process. In cases where there is delayed neurological damage with a vascular origin, it is possible that free radicals resulting from oxidative stress may gradually damage spinal vascular endothelial cells, cutting off blood supply, and ending in death of spinal neurons. When the delayed condition is demyelination without vascular damage, it is possible that the free radicals from oxidative stress are formed directly from the lipids found in abundance in myelin cells. The electroporation hypothesis, the formation of additional pores in neurons, may best explain immediate or progressive changes in structure and function after lightning or electrical injury.

Lessons learned from war: a comprehensive review of the published experiences of the Iranian neurosurgeons during the Iraq-Iran conflict and review of the related literature.

BACKGROUND: This study sought to review the articles published by Iranian neurosurgeons regarding their experiences during the Iraq-Iran conflict and compare them with reports from other conflicts. METHODS: We searched databases (MEDLINE and 2 Iranian databases, namely IranMedex and Scientific Information Database, up to December 2011) and references for relevant studies. The search terms included Iran, Iraq, conflict, battle, war, traumatic aneurysm (TA), posttraumatic epilepsy (PTE), brain infection, penetrating head wound (PHW), cerebrospinal fluid (CSF) leakage, spine injury, and peripheral nerve injury. RESULTS: Twenty-eight articles were found that presented PHW, development of TA, infections, PTE, and peripheral nerve injuries. There were 2 different protocols for management of PHWs: radical surgery and minimal debridement protocol. The overall central nervous system infection rate was 10%. The cumulated incidence of TA was 6%. CONCLUSIONS: Conservative minimal debridement of the wounds is indicated in patients with small entrance wounds, or those with Glasgow Coma Scale score ≥ 8 and no progressive neurological deficit. To diagnose TA before rupture, angiography is indicated in patients who have shells or bone fragments pass through the crowded vasculature, or have large/delayed hematoma, or if the surgeon has high index of suspicion based on neuroimaging and early debridement surgery. Surgery in a well-equipped nearby hospital after quick and safe evacuation of the victims by trained salvaging ancillary groups and the administration of broad-spectrum antibiotics and proper antiepileptics decrease the morbidity and mortality of casualties after PHW in war situations. The biases of the case selection, data collection, and confounders, and decreasing biases by conducting blinded controlled clinical trials, are discussed.

Volume-outcome relationship in neurotrauma care.

OBJECT: A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers. METHODS: The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression. RESULTS: In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6-11, 12-23, 24-59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29-0.68), 0.56 (0.38-0.81), 0.63 (0.44-0.90), and 0.59 (0.41-0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay. CONCLUSIONS: A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.

Identifying survivors with traumatic craniocervical dissociation: a retrospective study.

BACKGROUND: Traumatic craniocervical dissociation (CCD), which includes atlanto-occipital dissociation and vertical distraction between C1-C2, is often an immediately fatal injury that has increasingly been associated with survival to the hospital. Our aim was to identify survivors of CCD based on clinical presentation. METHODS: We retrospectively reviewed the Harborview Medical Center Trauma Registry and the King County Medical Examiners database from 2001 to 2006. Patients>or=12 y old were identified by ICD-9 code, radiographic diagnosis on lateral cervical spine films, and CT. We examined age, gender, mechanism of injury, presentation and prehospital and hospital interventions, and radiographic findings to distinguish survivors and non-survivors. RESULTS: Of 69 patients with CCD, 47 were diagnosed post mortem, 22 were diagnosed in hospital, and seven survived to discharge. When comparing survivors and non-survivors, age, gender, and injury severity score were not significant. Survivors had significantly higher GCS, and were more likely to be normotensive; none had cervical cord injury; 80% of non-survivors had a basion-dental interval (BDI) of >or=16mm. CONCLUSIONS: Trauma patients diagnosed with CCD in the ED, with cervical cord injury, requiring CPR, and with GCS of 3 will not survive their injury. Wider BDI is associated with mortality.

Is age a key determinant of mortality and neurological outcome after acute traumatic spinal cord injury?

Given the potential impact of age on mortality, neurological outcomes and the extent of post-traumatic neural degeneration, we examined these issues using a large, prospectively accrued clinical database (n=485) supplemented by analysis of postmortem spinal cord tissue (n=12) to compare axonal survival and white matter degeneration in younger versus elderly individuals with spinal cord injury (SCI). Elderly individuals (> or = 65 years) had significantly greater mortality rates than younger individuals at 30 days, at 6 months and at 1 year following SCI (46.88% versus 4.86%, respectively; p<0.0001). However, among survivors, age was not significantly associated with motor and sensory outcomes at 6 weeks, 6 months and 1 year post-SCI in univariate and multivariate analyses. Correspondingly, neuroanatomical analysis of postmortem spinal cord tissue revealed no significant age-related differences for extent of myelin degeneration or number of intact axons within sensory, motor and autonomic spinal cord tracts post-SCI. Treatment protocols for SCI need to identify preventable predictors of mortality in the elderly post-SCI, recognizing that the potential for neurological recovery among elderly survivors of SCI is similar to that of younger individuals.

Pediatric blunt and penetrating trauma deaths in Ontario: a population-based study.

PURPOSE: The purpose of the study was to describe the mechanisms of injury and causes of death in children dying in a modern, integrated trauma system. METHOD: Records of all children (<16 years of age) who died in Ontario from 2001 through 2003 after blunt or penetrating trauma were obtained from the Chief Coroner. Demographics and the nature and causes of injury and the causes of death were recorded. Estimates of the mortality rate were determined using census data. RESULTS: There were 234 injury deaths (222 blunt, 12 penetrating) over the 3 years. Thirty (13%) resulted from intentional injury. The median age was 10 (range, 0-15.9) years; 62% were male. Sixty-eight percent resulted from incidents involving motor vehicles (passenger, pedestrian, or cyclist). Most (74%) died at the scene; only 5% survived for more than 24 hours. Devastating craniocervical injury (Abbreviated Injury Scale 5 or 6) was present in 84% and was the only life-threatening injury in 40%. The annual mortality rate averaged 3.2 per 100,000 children. CONCLUSIONS: In a modern, integrated trauma system, most pediatric injury deaths occur at the scene from severe head injuries. In this population, strategies to reduce the death rate from pediatric trauma must focus on primary and secondary injury prevention.

Is the trimodal pattern of death after trauma a dated concept in the 21st century? Trauma deaths in Auckland 2004.

OBJECTIVE: To determine whether the classical trimodal distribution of trauma deaths is still applicable in a contemporary urban New Zealand trauma system. METHODS: All trauma deaths in the greater Auckland region between 1 January 2004 and 31 December 2004 were identified and reviewed. Data was obtained from hospital trauma registries, coroner autopsy reports and police reports. RESULTS: There were 186 trauma deaths. The median age was 28.5 years and the median Injury Severity Score was 25. The predominant mechanisms of injury were hanging (36%), motor vehicle crashes (31.7%), falls (9.7%), pedestrian-vehicle injury (5.4%), stabbing (4.3%), motorcycle crashes (3.2%), and pedestrian-train injury (2.2%). Most deaths were from central nervous system injury (71.5%), haemorrhage (15.6%), and airway/ventilation compromise (3.8%). Multi-organ failure accounted for 1.6% of deaths. Most deaths occurred in the pre-hospital setting (80.6%) with a gradual decrease thereafter. CONCLUSION: There was a skew towards early deaths. The trimodal distribution of trauma deaths was not demonstrated in this group of patients.

Serum interleukin-10 in ICU patients with severe acute central nervous system injuries.

RATIONALE: IL-10, the main anti-inflammatory cytokine, may play a pivotal role in cerebral inflammation implicated in the development of brain edema and secondary brain damage after injury. AIM OF THE STUDY: 1) Determining absolute IL-10 serum level and its pattern in critically ill patients with traumatic and non-traumatic acute brain injury. 2) Assessment of prognostic value of serum IL-10 in those patients. MATERIALS AND METHODS: Serum IL-10 levels in 46 adults (multi-profile ICU, teaching hospital) with traumatic brain injury (TBI, N = 18), nontraumatic intracranial hemorrhage (SAH, N = 11) and polytrauma with concomitant brain injury (POL, N = 17) were measured using ELISA. Relationship of IL-10 and initial diagnosis, clinical state, outcome and risk of infection development was evaluated. RESULTS: IL-10 was detectable in the serum of all but one patient on ICU admission (56.6 +/- 91.9 pg/ml; mean +/- SD). No statistically significant differences in IL-10 between TBI, SAH and POL groups as well as between survivors and non-survivors on any day were found. No correlation between IL-10 and GCS or SAPS II was seen. Significant fall in serum IL-10 during the first 4 days of injury in patients of all subgroups was observed. Patients with initial serum IL-10 below 77 pg/ml were at significantly higher risk of development of any infection within the first week of injury. CONCLUSIONS: After acute brain injury, serum IL-10 in adults is detectable independent of CNS lesion type. Its systemic release is strongly individualized. Serum IL-10 on ICU admission may have some prognostic value to predict development of infection in patients with CNS lesions.

Las lecciones derivadas del ASA Closed Claims Project (ASACCP). Proyecto de la ASA acerca de las razones que promovieron demandas contra anestesiólogos cuyos casos estuviesen ya archivados: 4a. parte. Anestesia Regional. Análisis de las demandas sobre casos/hechos asociados con la anestesia regional en la sala de operaciones / Lessons learned fron the ASA Closed Claims Project (ASACCP). Project about the reasons for which claims against anesthesiologists were renewed in cases that had already been closed: part. 4. Regional Anesthesia. Analysis of claims concerning regional anesthesia in the OR

Cuando se comparan las consecuencias de los accidentes anestésicos reclamados que constan en la base de datos del ASA CCP (Closed Claims Project), es significativo señalar que hubo un alto porcentaje de lesiones temporarias o no incapacitantes en los casos de anestesia regional (64 por ciento vs 46 por ciento p<0,05). Entre las lesiones incapacitantes permanentes derivadas de injurias del sistema nervioso periférico se hallan manifestaciones como la paraplejía y la cuadriplejía. Catorce de las reclamaciones legales asociadas con la paraplejía se debieron a síndromes de la anestesia espinal anterior. Los daños neurológicos permanentes fueron la causa más común de los daños incapacitantes, el más frecuente de los cuales (23 por ciento) fue asociado a bloqueos nerviosos para anestesia ocular (13 retrobulbares, 3 peribulbares) en los que hubo pérdida de la visión del ojo afectado. De todas maneras, se debe señalar que las complicaciones neurológicas como manifestaciones secundarias a la utilización de anestésicos locales para anestesia regional son muy poco frecuentes (0,02 y 0,07 por ciento de los casos), aunque es bastante común observar la aparición de manifestaciones neurológicas transitorias (entre 0,01 y 0,8 por ciento). La parestesia y el dolor durante la inyección son señales peligrosas ya que anuncian la posibilidad de la complicación. Se han descripto también abscesos peridurales y meningitis, en especial cuando se realizan bloqueos centrales con catéteres de pequeño diámetro a fin de alcanzar analgesia central para el dolor crónico. En la base de datos de la Mutual de Médicos Anestesiólogos de Buenos Aires están registradas las demandas realizadas contra anestesiólogos y los casos en los cuales los médicos, enfrentados a un incidente crítico, notifican la situación en previsión de una eventual demanda. Al igual que en el estudio de la ASACCP, desconocemos el número total de anestesia realizadas por los colegas adheridos. Hasta el 2004 hubo 339 notificaciones que incluyen 74 demandas, 24 causas penales y 50 causas civiles; 124 casos correspondieron a la anestesia regional, mientras que 215 formaron el grupo de pacientes que recibieron anestesia general. En 8 de los pacientes que presentaron radiculopatías se realizó una anestesia subaracnoidea con bupivacaína al 0,5 por ciento en solución hiperbara, habiéndose inyectado 15 mg (3 ml) de la solución anestésica...(AU)

Risk factors of mortality and permanent neurologic injury in patients undergoing ascending aortic and arch repair.

OBJECTIVES: To analyze outcome in elderly patients after surgical repair of the ascending aorta and the aortic arch as compared with their younger counterparts and to determine risk factors of mortality and permanent neurologic injury. Patients and methods Between January 1995 and February 2003, a total of 369 patients underwent ascending aortic and arch repair. Indications for surgical intervention were acute type A dissections in 174 (47%) patients (<75 years, n = 147; > or =75 years, n = 27) and chronic atherosclerotic aneurysms in 195 (53%) patients (<75 years, n = 168; > or =75 years, n = 27). Emergency surgery was performed in 167 (45%) patients; 202 patients (54.7%) underwent surgery requiring deep hypothermic circulatory arrest. Pre- and intraoperative factors were evaluated by means of stepwise logistic regression analysis to determine risk factors of mortality and permanent neurologic injury. RESULTS: Overall in-hospital mortality was 11.6%. In-hospital mortality with regard to indication for surgical intervention was comparable in both age groups (type A dissection: <75 years, 15.6%; > or =75 years, 18.5%; P =.731; chronic atherosclerotic aneurysm: <75 years, 7.7%; > or =75 years, 7.4%; P =.933). Permanent neurologic injury was observed in 5.0%. Permanent neurologic injury with regard to surgical intervention was comparable in both age groups (type A dissection: <75 years, 8.8%; > or =75 years, 3.7%; P =.359; chronic atherosclerotic aneurysm: <75 years, 3.0%; > or =75 years, 3.7%; P =.843). Stepwise logistic regression analysis revealed preoperative hemodynamic instability (odds ratio 4.3; P =.000), duration of cardiopulmonary bypass (odds ratio 2.1; P =.001), and permanent neurologic injury (odds ratio 1.7; P =.033) but not age as independent predictors affecting mortality. Utilization of but not duration of deep hypothermic circulatory arrest was the only independent predictor of permanent neurologic injury (odds ratio 2.8; P =.019). CONCLUSIONS: Age shows a trend toward a higher risk of mortality but does not predict a higher incidence of permanent neurologic injury after ascending aortic and arch repair. As utilization of deep hypothermic circulatory arrest remains the only independent predictor of permanent neurologic injury, alternative approaches to maintain cerebral perfusion during ascending aortic and arch repair are warranted.

The relationship between facial fractures and death from neurologic injury.

PURPOSE: The purpose of this study was to review patients who failed to survive blunt trauma and to determine whether there is a relationship between specific facial fracture patterns and death. PATIENTS AND METHODS: This was a retrospective record review of patients with facial fractures admitted to a level I trauma center between January 1, 1993 and December 31, 1996. Records were reviewed for gender, age, injury severity score (ISS), Glasgow Coma Scale (GCS), revised probability of survival (RPS), cause of death, and facial fracture pattern. Facial fracture patterns were grouped as lower face (mandible), midface (maxilla, zygoma, nose, and orbits), and upper face (frontal bone). Causes of death were grouped into neurologic, visceral, combined neurologic and visceral, and other. Surviving and nonsurviving groups were compared. Parametric data were analyzed with a pooled or separate variance t-test, nonparametric data with a Mann-Whitney U-test, and categorical variables with a chi-square test (P < or = .05). The odds ratio with corresponding 95% confidence intervals was used to show the association between facial fracture patterns and death. RESULTS: During the 4-year period, 6,117 patients were admitted with blunt trauma, 661 (11%) of whom had facial fractures. Those who died were more likely to be older than those who survived, with a lower GCS, lower RPS, and higher ISS. Although there was a male predominance in the patient population, there was no gender difference between those who died and those who survived. Surviving patients were more likely to have only isolated mandible injuries. Nonsurvivors were more likely to have isolated midface fractures or combinations of midface and other facial fractures. The odds ratio showed a 13 to 75 times greater risk of patients dying of neurologic injury with patterns other than isolated mandible injury than with any mid- or upper-facial fracture patterns. CONCLUSIONS: Compared with survivors, nonsurviving patients with facial fractures were older and had a lower GCS, higher ISS, and lower RPS. Nonsurviving patients had a dramatic predilection for mid- and upper-facial fracture patterns and death of neurologic injury.