Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center.

BACKGROUND: Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children. HYPOTHESIS: We hypothese that due to adequate treatment of EDH in children and adolescence excellent clinical and functional outcome can be reached. PURPOSE: To evaluate retrospectively our treatment process of EDH and to elucidate the relationship between trauma mechanism, injury pattern, radiological presentation, subsequent therapy and functional outcome. PATIENTS AND METHODS: Hundred and twenty infants and children with traumatic brain injuries (TBI) were treated between 1992 and 2009 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow Outcome Scale (GOS) scores at hospital discharge and at follow-up visits were used. EDH was classified according to the Rotterdam score. RESULTS: Finally, 41 cases were diagnosed with an EDH and therefore included in our study. Twenty-one cases were treated surgically; however of these in 11 patients delayed surgery was necessary. Twenty patients were treated conservatively. Two patients (5%) died within 24hours, 39 patients (95%) survived. One of the operatively treated patients (2%) presented in a vegetative state, another one had severe disability, and however, 32 patients (78%) showed good recovery at latest follow-up. DISCUSSION: Age, severity of TBI, and neurological status were the main factors influencing outcome after TBI due to acute EDH. We found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases - however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached.

The impact of body mass index on severity, patterns and outcomes after traumatic brain injuries caused by low level falls.

PURPOSE: Low level falls are a common cause of traumatic brain injuries (TBI) and are associated with significant mortality and disability. The aim of this study was to analyse whether BMI, height and weight of patients were related to severity, patterns and outcomes of TBI caused by low level falls. METHODS: Data on patients with TBI where cause of injury was a low level fall (fall < 3 m) with known body mass index (BMI) (N = 683) were analysed. Patients were categorized into underweight, normal, pre-obese and obese based on BMI and demographic characteristics, injury severity, patterns and outcomes were compared. In addition, physiological status, comorbidities and length of hospitalization were analysed in a subset of patients where this information was available. RESULTS: The median BMI was 25.6. About 1/10 of patients were obese. The mean age and proportion of male sex of patients was increasing with increasing BMI. The patients in all BMI groups were of similar injury severity and neurological status. There was also no difference in mortality and functional outcome based on patient's BMI. Obese and pre-obese patients required longer stay at ICU and in hospital. CONCLUSION: We found no associations between BMI and severity or outcome of TBI caused by low level falls. More detailed data and further studies are needed to fully elucidate these complex relationships.

Timing and duration of intracranial hypertension versus outcomes after severe traumatic brain injury.

BACKGROUND: The goal of this paper was to investigate the association between patterns of intracranial hypertension (IH) and outcomes, to describe the treatment of patients with different patterns of IH, and to examine whether IH is an independent predictor of mortality and unfavourable outcome, respectively. METHODS: A retrospective analysis of data collected prospectively in 9 central European centers is presented. 204 patients with severe TBI who had intracranial pressure (ICP) monitoring were coded as having either early (within first 2 days), late (after first 2 days), or no IH. IH was defined as >60 min of ICP >20 mmHg/day. The total number of hours/day of IH was recorded. Treatment was followed closely for the first 10 days using the therapy intensity level (TIL) score. Associations between types of IH and demographic factors, trauma severity, or treatment factors as well as outcomes were analysed. RESULTS: Patients in the early IH group were the most severely injured. They had the highest TIL levels, had the highest mortality (48%) and the highest rate of unfavourable outcome (65%) followed by the late IH group (20% and 57%) and the no IH group (23% and 36%). Duration of IH correlated significantly with hospital mortality. IH was an independent predictor of mortality and unfavourable outcome after adjusting for age, Glasgow Coma Scale score, and Abbreviated Injury Score "head". CONCLUSION: Intracranial hypertension with early onset is independently associated with significantly worse outcome in patients with severe TBI. The total duration of IH shows a significant correlation to mortality.

Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury.

OBJECTIVE: To analyse the association between the Glasgow Coma Scale (GCS) score at intensive care unit (ICU) discharge and the 1-year outcome of patients with severe traumatic brain injury (TBI). DESIGN: Retrospective analysis of prospectively collected observational data. PATIENTS: Between 01/2001 and 12/2005, 13 European centres enrolled 1,172 patients with severe TBI. Data on accident, treatment and outcomes were collected. According to the GCS score at ICU discharge, survivors were classified into four groups: GCS scores 3-6, 7-9, 10-12 and 13-15. Using the Glasgow Outcome Scale (GOS), 1-year outcomes were classified as "favourable" (scores 5, 4) or "unfavourable" (scores <4). Factors that may have contributed to outcomes were compared between groups and for favourable versus unfavourable outcomes within each group. MAIN RESULTS: Of the 538 patients analysed, 308 (57 %) had GCS scores 13-15, 101 (19 %) had scores 10-12, 46 (9 %) had scores 7-9 and 83 (15 %) had scores 3-6 at ICU discharge. Factors significantly associated with these GCS scores included age, severity of trauma, neurological status (GCS, pupils) at admission and patency of the basal cisterns on the first computed tomography (CT) scan. Favourable outcome was achieved in 74 % of all patients; the rates were significantly different between GCS groups (93, 83, 37 and 10 %, respectively). Within each of the GCS groups, significant differences regarding age and trauma severity were found between patients with favourable versus unfavourable outcomes; neurological status at admission and CT findings were not relevant. CONCLUSION: The GCS score at ICU discharge is a good predictor of 1-year outcome. Patients with a GCS score <10 at ICU discharge have a poor chance of favourable outcome.

One-year outcome and course of recovery after severe traumatic brain injury.

GOAL: To describe the outcome of patients with severe traumatic brain injury (TBI) 3, 6 and 12 months after trauma. METHODS: Between January 2001 and December 2005, 13 European centres enrolled 1,172 patients with severe TBI defined as Glasgow Coma Scale (GCS) score < 9. Demographic data, trauma severity, results of computed tomography (CT) scans, data on status, treatment and outcome were recorded. The five-level Glasgow Outcome Scale (GOS) score was used to classify patients as having a "favourable" (GOS scores 5 and 4) or an "unfavourable outcome" (GOS scores 3, 2 and 1). RESULTS AND CONCLUSIONS: Of the 1,172 patients, 37% died in the intensive care unit (ICU) and 8.5% died after ICU discharge. At 12 months after trauma, almost half of the outcomes (46.6%) were classified as "favourable" (33% "good recovery", 13.6% "moderate disability") and 7.9% were classified as "unfavourable" (6.1% "severe disability", 1.8% "vegetative status"). As in previous studies, long-term outcomes were influenced by age, severity of trauma, first GCS score, pupillary status and CT findings (e.g. subdural haematoma and closed basal cistern on the first CT scan). Patients with "good recovery" had a high likelihood to remain in that category (91%). Patients with "moderate disability" had a 50% chance to improve to "good recovery". Patients with "severe disability" had a 40% chance to improve and had a 4% chance of death. Patients with "vegetative status" were more likely to die (42%) than to improve (31%). Changes were more likely to occur during the first than during the second half-year after trauma.

Evaluation of traumatic brain injury guidelines using AGREE instrument.

BACKGROUND: This study aims to assess the quality of four selected traumatic brain injuries management guidelines used mainly in the US and in Europe. METHODS: The instrument Appraisal of Guidelines Research & Evaluation was selected to provide a framework for guidelines appraisal. Four guidelines addressing a specific topic related to the treatment of traumatic brain injury were selected for evaluation: three developed in the United States of America and one from the United Kingdom. A trauma surgeon, one anaesthesiologist, one emergency physician and a public health specialist evaluated the guidelines. RESULTS: In the overall assessment of all guidelines, the United Kingdom guidelines attracted the best score, achieving the highest score of all four guidelines in five of six domains. The scientific quality of collected evidence was excellent and well documented in all four guidelines. Overall, the domains of Stakeholder involvement and Applicability were the lowest scoring for all the guidelines. CONCLUSION: A Broad spectrum of stakeholders should be represented in the brain trauma management guidelines development. The potential organizational and financial barriers for the application of guidelines need to be considered during their development. The paper provides suggestions for those who develop new guidelines for the management of patients with head injuries (Tab. 8, Ref. 29). Full Text (Free, PDF) www.bmj.sk.

Comparison of bystander trauma care for moderate versus severe injury.

At the scene of an accident, the most severely injured patients need trauma care urgently. Bystanders are often present before the emergency medical service arrives and may be able to limit trauma-related damage by providing trauma care at the scene. The aim of this prospective study conducted in Mainz, Germany, and Vienna, Austria, was to compare the frequency and quality of bystander trauma care in moderately versus severely injured patients. Five specific measures (making the scene readily visible for oncoming traffic, extrication and positioning of the trauma patient, control of haemorrhage, and hypothermia protection) were assessed in a questionnaire and evaluated statistically. Bystanders were present at the scene in 58.7% of all accidents. Making the scene readily visible for oncoming traffic, patient extrication and patient positioning were initiated significantly more often than haemorrhage control and hypothermia protection. Extrication, patient positioning and hypothermia protection were initiated significantly more often in moderately (NACA I-II) compared to severely (NACA III-VII) injured patients. In severely injured patients, bystanders attempted measures less frequently and the measures performed were more often incorrect compared to those in moderately injured patients. Our findings show that severely injured patients received less and less appropriate bystander trauma care than moderately injured patients. In an effort to correct this serious problem and to improve trauma care on-scene, we advocate offering lay persons more extensive training in bystander trauma care.

Ultrasonographic findings of the axillary part of the brachial plexus.

UNLABELLED: In this prospective study we sought to determine anatomic variations of the main brachial plexus nerves in the axilla and upper arm via high-resolution ultrasonography (US) examination. Positions of nerves were studied via US in three sectional levels of the upper arm in 69 healthy volunteers (31 men and 38 women, median age 28 yr). Analysis was done by subdividing the US picture into eight pie-chart sectors and matching sectors for the position of the ulnar, radial, and median nerves. Shortly after the nerves pass the pectoralis minor muscle, they begin to diverge. At the middle level 9%-13%, and at the distal level, 30%-81% of the nerves are not seen together with the artery in the US picture. At the usual level of axillary block approach, we found the ulnar nerve in the posterior medial position in 59% of the volunteers. The other two nerves had two peaks in distribution: the radial nerve in posterior lateral (38%) and anterior lateral (20%) position, and the median nerve in anterior medial (30%) and posterior medial (26%) position. Applying light pressure distally can displace nerves to the side, especially when they are positioned anterior to the axillary artery. We conclude that an axillary block should be attempted as proximal as possible to the axilla. IMPLICATIONS: This prospective ultrasonography study demonstrates significant anatomic variations of the main brachial plexus nerves in the axilla and upper arm, which may increase the difficulty in identifying neural structures. Applying light pressure on the plexus can move nerves to the side, especially when they are positioned anterior to the axillary artery.

[The treatment of severe head-brain injuries in Austria] . / Die Behandlung des schweren Schädel-Hirntraumas in Osterreich.

INTRODUCTION: We performed this study in order to assess epidemiology and current practice of treatment of severe traumatic brain injury in Austria. Our survey followed the methods of a study published by J. Ghajar et al in the USA in 1995 and we compared the results to the Brain Trauma Foundation's "Guidelines For The Management Of Severe Head Injury". METHODS: The collected data represent answers to telephone interviews of 60 surgical intensive care units. We were able to evaluate data from all departments which treat severe brain traumas (Glasgow Coma Scale < or = 8) in Austria. RESULTS: At the time the treatment modalities of severe head injuries are not homogeneous and there are also big interdisciplinary management differences (trauma surgeons versus neurosurgeons). CONCLUSIONS: Results showed that there is a need for a brain trauma databank in Austria. We also recommend formation of an interdisciplinary brain trauma working group in order to control whether guidelines and standardized therapeutic modalities are being followed.

"Recommendations for uniform reporting of data following major trauma--the Utstein style" (as of July 17, 1999). An International Trauma Anaesthesia and Critical Care Society (ITACCS).

Basic and advanced care of trauma patients has always been an important aspect of prehospital and immediate in-hospital emergency medicine, involving a broad spectrum of disciplines, specialties and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources and operation. This complex background has, at least in part, hindered the development of a uniform pattern or set of criteria and definitions. This in turn has hitherto rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be readily evaluated or compared with acceptable validity. Guided by previous consensus processes evolved by the ERC, the AHA and other International Organizations--represented in ILCOR--on 'Uniform reporting of data following out-of-hospital and in-hospital cardiac arrest--the Utstein style' an international working group of ITACCS has drafted a document, 'Recommendations for uniform reporting of data following major trauma--the Utstein style'. The reporting system is based on the following considerations: A structured reporting system based on an "Utstein style template" which would permit the compilation of data and statistics on major trauma care, facilitating and validating independent or comparative audit of performance and quality of care (and enable groups to challenge performance statistics which did not take account of all relevant information). The recommendations and template should encompass both out-of-hospital and in-hospital trauma care. The recommendations and template should further permit intra- and inter-system evaluation to improve the quality of delivered care and identification of the relative benefits of different systems and innovative initiatives. The template should facilitate studies setting out to improve epidemiological understanding of trauma; for example such studies might focus on the factors that determine survival. The document is structured along the lines of the original Utstein Style Guidelines publication on 'prehospital cardiac arrest'. It includes a glossary of terms used in the prehospital and early hospital phase and definitions, time points and intervals. The document uses an almost identical scheme for illustrating the different process time clocks--one for the patient, one for the dispatch centre, one for the ambulance and, finally, one for the hospital. For clarity, data should be reported as core data (i.e. always obtained) and optional data (obtained under specific circumstances). In contrast to the graphic approach used for the Utstein template for pre- or in-hospital cardiac arrest, respectively, the present template introduces, for the time being, at least, a number of terms and definitions and a semantic rather than a graphic report form. The document includes the following sections: The Section Introduction and background The Section on Trauma Data Structure Development: presents a general outline of the development of structured data using object-orientated modelling (which will be discussed in due course) and includes a set of explanatory illustrations. The Section on Terms and Definitions: outlines terms and definitions in trauma care, describing different types of trauma (blunt, penetrating, long bone, major/combined, multiple/polytrauma and predominant trauma). The Section on Factors relating to the circumstances of the injury describes the following items: cause of injury (e.g. type of injury (blunt or penetrating), burns, cold, crush, laceration, amputation, radiation, multiple, etc. Severity of Injury e.g. prehospital basic abbreviated injury score developed by the working group. The score contains anatomical and physiological disability data, with the anatomical scale ranging ordinally from 1. Head to 9. External; the physiological disability scale ranging ordinally from 0--unsurvivable. Mechanism of injury recording for transportation incidents etc. e.g. the type of impact, po

Prehospital trauma care.

Concepts regarding uniform reporting of data after trauma and regarding treatment of brain trauma patients at the scene have recently been agreed upon in consensus processes. Endotracheal intubation and alternatives are as controversially discussed as fluid resuscitation and helicopter transport of trauma victims. Long-term outcomes of trauma patients should more frequently be studied using the Quality of Wellbeing Scale.

Effects of half the tidal volume during cardiopulmonary resuscitation on acid-base balance and haemodynamics in pigs.

The effects of half the tidal volume during cardiopulmonary resuscitation (CPR) on haemodynamics, acid-base balance, and oxygenation were studied in anaesthetized pigs. The animals were ventilated with a mean tidal volume of 12.5 +/- 0.5 ml/kg at a rate of 14/minute resulting in a mean arterial pCO2 of 40 +/- 3 mmHg. They were randomly assigned to two groups: in one group ventilation was performed with half the pre-arrest tidal volume (50% group; n = 9), in the other group ventilation remained unchanged during CPR (100% group; n = 10). After 8 minutes of CPR attempts were made to restore spontaneous circulation with epinephrine and countershocks. There were no differences in advanced life support requirements, haemodynamic parameters, and resuscitability between the two groups. During CPR up to 5 minutes after restoration of spontaneous circulation (ROSC) dead space ventilation was significantly higher in the 50% group compared with the 100% group (p < 0.05). During CPR (at 3 and 7 minutes) arterial pO2 values were significantly lower (218 +/- 136 and 221 +/- 120 mmHg vs. 381 +/- 130 and 352 +/- 147 mmHg; FiO2 1.0) and hyperventilation was less pronounced (34.4 +/- 7.3 and 31.3 +/- 7.7 mmHg vs. 26.2 +/- 5.6 and 26.9 +/- 6.3 mmHg) in the 50% group. Our results suggest that half the tidal volume during CPR is likely to establish a more physiological acid-base balance and has no adverse effects on haemodynamics in intubated pigs ventilated with pure oxygen.

Treatment of refractory intracranial hypertension in severe traumatic brain injury with repetitive hypertonic/hyperoncotic infusions.

Rapid resuscitation of clinical and experimental traumatic brain injury (TBI) with hypertonic saline (HS) has been shown to improve neurological function and decrease intracranial pressure (ICP). The purpose of the present study was to test the efficacy of administration of HS (7.5%) combined with 6% hydroxyethyl starch (molecular weight 200,000/0.60-0.66; HHES) for the treatment of intracranial hypertension refractory to standard therapy in patients with severe TBI. With approval of the Institutional Ethics Committee six consecutive patients with severe TBI (GCS < 8) between 22 and 47 years of age (mean 32) who met the inclusion criteria (therapy resistant ICP > 25 mmHg, cerebral perfusion pressure (CPP) < 60 mmHg, plasma-Na+ < 150 mOsm and > 4 hours since the last HS/HHES treatment) were prospectively enrolled in the study. Patients received between one and ten bolus infusions of maximal 250 ml HS/HHES at a rate of 20 ml/min. A total of 32 infusions were given. ICP and CPP before treatment were 45 +/- 15 and 52 +/- 18 mmHg, respectively. Administration of HS/HHES significantly lowered ICP to 25 +/- 14 mmHg and improved CPP to 72 +/- 16 mmHg at 30 min without affecting arterial blood pressure or blood gases. Plasma sodium normalized within 30 min. HS/HES might become an interesting addition to conventional treatment maneuvers currently used for ICP therapy. It reduces otherwise therapy-resistant intracranial hypertension without negatively affecting blood pressure, blood gases and cerebral perfusion.

Hypertonic/hyperoncotic saline reliably reduces ICP in severely head-injured patients with intracranial hypertension.

Hypertonic saline (HS) has been shown to decrease intracranial pressure (ICP) and cerebral water content in experimental models of traumatic brain injury (TBI). The purpose of the present study was to test the efficacy of administration of HS (7.5%) combined with 6% hydroxyethyl starch (molecular weight 200.000/0.60-0.66; HHES) for the treatment of therapy-resistant intracranial hypertension in patients with severe TBI. Six patients with severe TBI (GCS < 8) who met the inclusion criteria (therapy resistant ICP > 25 mmHg, cerebral perfusion pressure (CPP) < 60 mmHg, plasma-Na+ < 150 mOsm and > 4 hours since the last HS/HHES treatment) were prospectively enrolled in the study and received between one and ten bolus infusions of maximal 250 ml HS/HHES at a rate of 20 ml/min. A total of 32 infusions were given. Administration of HS/HHES significantly lowered ICP by 44% and improved CPP by 38% to well above 70 mmHg at 30 min without affecting arterial blood pressure or blood gases. Plasma sodium normalized within 30 min. Experimental studies from our laboratory indicate that the ICP lowering effect is primarily due to dehydration of brain tissue and that cerebral blood volume remains largely unaffected by HS. In summary, HS/HHES reduces otherwise therapy-resistant intracranial hypertension and improves cerebral perfusion even after repeated administration without negatively affecting blood pressure or causing a rebound ICP increase.