Pediatric craniocerebral gunshot injuries: A National Trauma Database study.

BACKGROUND: We aimed to determine the outcomes and prognostic factors in pediatric craniocerebral gunshot injury (CGI) patients. Pediatric patients may have significantly different physiology, neuroplasticity, and clinical outcomes in CGI than adults. There is limited literature on this topic, mainly case reports and small case series. METHODS: We queried the National Trauma Data Bank for all pediatric CGI between 2014 and 2017. Patients were identified using International Classification of Diseases, Ninth Revision, codes. Demographic, emergency department, and clinical data were analyzed. Subgroup analysis was attempted for groups with Glasgow Coma Scale (GCS) scores of 9 to 15 and ages 0 to 8 years. RESULTS: In a 3-year period, there were 209 pediatric patients (aged 0-18 years) presenting to American hospitals with signs of life. The overall mortality rate was 53.11%. A linear relationship was demonstrated showing a mortality rate of 79% by initial GCS in GCS score of 3, 56% in GCS scores of 4 to 8, 22% in GCS scores of 9 to 12, and 5% in GCS scores of 13 to 15. The youngest patients, aged 0 to 8 years, had dramatically better initial GCS and subsequently lower mortality rates. Regression analysis showed mortality benefit in the total population for intracranial pressure monitoring (odds ratio, 0.267) and craniotomy (odds ratio, 0.232). CONCLUSION: This study uses the National Trauma Data Bank to quantify the prevalence of pediatric intracranial gunshot wounds, with the goal to determine risk factors for prognosis in this patient population. Significant effects on mortality for invasive interventions including intracranial pressure monitoring and craniotomy for all patients suggest low threshold for use of these procedures if there is any clinical concern. The presence of a 79% mortality rate in patients with GCS score of 3 on presentation suggests that as long as there is not a declared neurologic death, intracranial pressure monitoring and treatment measures including craniotomy should be considered by the consulting clinician. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

The effects of antithrombotic therapy on head trauma and its management.

The number of patients with traumatic intracranial hemorrhage (tICH) that are taking antithrombotics (ATs), antiplatelets (APs) and/or anticoagulants (ACs), has increased, but the influence of it for outcome remains unclear. This study aimed to evaluate an influence of AT for tICH. We retrospectively reviewed all patients with tICH treated between 2012 and 2019, and analyzed demographics, neurological status, clinical course, radiological findings, and outcome data. A total of 393 patients with tICH were included; 117 were on AT therapy (group A) and 276 were not (group B). Fifty-one (43.6%) and 159 (57.6%) patients in groups A and B, respectively, exhibited mRS of 0-2 at discharge (p = 0.0113). Mortality at 30 days was significantly higher in group A than in group B (25.6% vs 16.3%, p = 0.0356). Multivariate analysis revealed that higher age (OR 32.7, p < 0.0001), female gender (OR 0.56, p = 0.0285), pre-injury vitamin K antagonist (VKA; OR 0.42, p = 0.0297), and hematoma enlargement (OR 0.27, p < 0.0001) were associated with unfavorable outcome. AP and direct oral anticoagulant were not. Hematoma enlargement was significantly higher in AC-users than in non-users. Pre-injury VKA was at high risk of poor prognosis for patients with tICH. To improve outcomes, the management of VKA seems to be important.

Differences in outcomes of mandatory motorcycle helmet legislation by country income level: A systematic review and meta-analysis.

BACKGROUND: The recent Lancet Commission on Legal Determinants of Global Health argues that governance can provide the framework for achieving sustainable development goals. Even though over 90% of fatal road traffic injuries occur in low- and middle-income countries (LMICs) primarily affecting motorcyclists, the utility of helmet laws outside of high-income settings has not been well characterized. We sought to evaluate the differences in outcomes of mandatory motorcycle helmet legislation and determine whether these varied across country income levels. METHODS AND FINDINGS: A systematic review and meta-analysis were completed using the PRISMA checklist. A search for relevant articles was conducted using the PubMed, Embase, and Web of Science databases from January 1, 1990 to August 8, 2021. Studies were included if they evaluated helmet usage, mortality from motorcycle crash, or traumatic brain injury (TBI) incidence, with and without enactment of a mandatory helmet law as the intervention. The Newcastle-Ottawa Scale (NOS) was used to rate study quality and funnel plots, and Begg's and Egger's tests were used to assess for small study bias. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were stratified by high-income countries (HICs) versus LMICs using the random-effects model. Twenty-five articles were included in the final analysis encompassing a total study population of 31,949,418 people. There were 17 retrospective cohort studies, 2 prospective cohort studies, 1 case-control study, and 5 pre-post design studies. There were 16 studies from HICs and 9 from LMICs. The median NOS score was 6 with a range of 4 to 9. All studies demonstrated higher odds of helmet usage after implementation of helmet law; however, the results were statistically significantly greater in HICs (OR: 53.5; 95% CI: 28.4; 100.7) than in LMICs (OR: 4.82; 95% CI: 3.58; 6.49), p-value comparing both strata < 0.0001. There were significantly lower odds of motorcycle fatalities after enactment of helmet legislation (OR: 0.71; 95% CI: 0.61; 0.83) with no significant difference by income classification, p-value: 0.27. Odds of TBI were statistically significantly lower in HICs (OR: 0.61, 95% CI 0.54 to 0.69) than in LMICs (0.79, 95% CI 0.72 to 0.86) after enactment of law (p-value: 0.0001). Limitations of this study include variability in the methodologies and data sources in the studies included in the meta-analysis as well as the lack of available literature from the lowest income countries or from the African WHO region, in which helmet laws are least commonly present. CONCLUSIONS: In this study, we observed that mandatory helmet laws had substantial public health benefits in all income contexts, but some outcomes were diminished in LMIC settings where additional measures such as public education and law enforcement might play critical roles.

Incidence and predictors of mortality among patients with head injury admitted to Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: A retrospective follow-up study.

INTRODUCTION: Head injury is the leading cause of morbidity and mortality throughout the world, especially in resource-limited countries including Ethiopia. However, little is known about the mortality rate and its predictors among these patients in Ethiopia. Thus, the study aims to assess the incidence rate of mortality and its predictors among patients with head injury admitted at Hawassa University Comprehensive Specialized Hospital. METHODS: Institutional based retrospective follow-up study was conducted among 1220 randomly selected head injury patients admitted from July 2017 to July 2019. Bivariable and multivariable Cox regression models were fitted to identify the predictors of mortality. Proportionality assumption was tested by a global test based on the Schoenfeld residuals test. RESULTS: The incidence of the mortality rate was 2.26 (95%CI: 1.9-2.6) per 100-person day observation. The independent predictors of time to death were age above 65 years (AHR:3.49, 95%CI:1.63, 7.48), severe TBI (AHR: 8.8, 95%CI:5.13, 15.0), moderate TBI (AHR:3, 95%CI:1.73,5.31), hypotension (AHR:1.72, 95%CI: 1.11,2.66), hypoxia (AHR:1.92, 95%CI: 1.33,2.76), hyperthermia (AHR:1.8, 95%CI: 1.23,2.63) and hypoglycemic (AHR:1.94, 95%CI: 1.34, 2.81) positively associated with mortality, while underwent neurosurgery was negatively associated with mortality (AHR: 0.25, 95% CI: 0.11,0.53). CONCLUSION: The incidence of mortality rate among head injury patients was high. Older age, moderate and severe TBI, hypotension and hypoxia at admission, neurosurgical procedure, and the episode of hyperthermia and hypoglycemia during hospitalization were the independent predictors of mortality among head injury patients. Therefore, intervention to reduce earlier deaths should focus on the prevention of secondary brain insults.

Self-Inflicted Gun Shot Wounds: A Retrospective, Observational Study of U.S. Trauma Centers.

INTRODUCTION: Intentional self-harm (suicide) by firearms is a growing problem in the United States. Currently, there are no large studies that have identified risk factors for patients who die from self-inflicted gunshot wounds. Our objectives are to 1) identify risk factors for patients with the highest morbidity and mortality from self-inflicted gunshot wounds (SIGSWs) at trauma centers 2) present the outcomes of victims of SIGSW by handguns (HG) versus all other specified guns (AOG) and 3) compare the presentations and outcomes of victims with head or face (HF) injuries to other regions of the body. METHODS: We performed a retrospective analysis from the National Trauma Database (NTDB) data between 2012 and 2013 of all SIGSW patients who presented to trauma centers. Categorical data included patient characteristics upon presentation and outcomes which were compared between patients with HG injury versus AOG injury using the Chi-Squared test, where AOG includes shotguns, hunting rifles, and military firearms. Additionally, analysis of head and face (HF) injuries versus other bodily injuries (OBI) were compared between the HG group versus AOG group using Chi-squared test. RESULTS: There were 7,828 SIGSWs, of those, 78% (6,115) were white and 84.3% (6,600) were male. There were 5,139 HG injuries, 1,130 AOG injuries, and 1,405 unidentified gun injuries. The HG group was likely to be older (>55 years old), hypotensive (systolic blood pressure < 90), have a lower Glasgow Coma Score (GCS < 9), use illegal, or use prescription drugs. In comparing HF injuries (4,799) versus other bodily injuries (OBI) (3,028), HF group was more likely to use handguns, expire in ED, require ICU, and have a higher percent of overall mortality. Of the total OBI, the thorax, upper extremities, and abdomen were the most commonly injured. CONCLUSION: In our retrospective study of SIGSWs, we were able to demonstrate that SIGSW by handguns are associated with higher rates of mortality versus all other types of firearms. SIGSWs in older white males with handguns are the most at-risk for severe complications. Future efforts should improve screening methods for handguns in suicidal patients and at developing prevention programs.

Clinical predictors of poor 30-day headache outcomes after an emergency department visit for acute post-traumatic headache.

PURPOSE: We investigated clinical risk factors that predict poor 30-day headache outcomes among patients evaluated in the emergency department (ED) for post-traumatic headache (PTH). METHODS: This was an analysis of data from a randomized, placebo-controlled study of IV metoclopramide + diphenhydramine for acute PTH. Patients were enrolled during an ED visit and received telephone follow-up with a structured questionnaire 30 days later. The primary outcome was frequency of headaches 30 days after ED discharge. We used multivariable logistic regression models to determine which clinical variables were associated with frequent headaches at 30 days. RESULTS: In total, 160 patients were enrolled in the study. 134 (84%) patients completed the 30-day questionnaire and were included in the analysis, including 90 females and 44 males. 30 patients (22%, 95% CI = 0.16 to 0.30) reported frequent headaches at 30-day follow-up. In the multivariable analysis, female sex (OR = 4.03, 95% CI = 1.23±13.13), patients who blamed themselves for their injury (OR = 0.13, 95% CI = 0.04±0.45), and patients who were unsure if they sustained loss of consciousness during the traumatic incident (OR = 5.63, 95% CI = 1.89±16.78) were found to be associated with poor 30-day outcomes. Medication received in the ED and age were not associated. CONCLUSIONS: More than 1 out of five patients treated in the ED for acute PTH experienced frequent headaches 30 days later. Women and patients who were uncertain as to whether they had experienced loss of consciousness were at increased risk of frequent PTH. Blaming oneself for the head trauma was associated with less frequent PTH.

Increased complement activation 3 to 6 h after trauma is a predictor of prolonged mechanical ventilation and multiple organ dysfunction syndrome: a prospective observational study.

BACKGROUND: Complement activation is a central mechanism in systemic inflammation and remote organ dysfunction following major trauma. Data on temporal changes of complement activation early after injury is largely missing. We aimed to describe in detail the kinetics of complement activation in individual trauma patients from admission to 10 days after injury, and the association with trauma characteristics and outcome. METHODS: In a prospective cohort of 136 trauma patients, plasma samples obtained with high time resolution (admission, 2, 4, 6, 8 h, and thereafter daily) were assessed for terminal complement complex (TCC). We studied individual TCC concentration curves and calculated a summary measure to obtain the accumulated TCC response 3 to 6 h after injury (TCC-AUC3-6). Correlation analyses and multivariable linear regression analyses were used to explore associations between individual patients' admission TCC, TCC-AUC3-6, daily TCC during the intensive care unit stay, trauma characteristics, and predefined outcome measures. RESULTS: TCC concentration curves showed great variability in temporal shapes between individuals. However, the highest values were generally seen within the first 6 h after injury, before they subsided and remained elevated throughout the intensive care unit stay. Both admission TCC and TCC-AUC3-6 correlated positively with New Injury Severity Score (Spearman's rho, p-value 0.31, 0.0003 and 0.21, 0.02) and negatively with admission Base Excess (- 0.21, 0.02 and - 0.30, 0.001). Multivariable analyses confirmed that deranged physiology was an important predictor of complement activation. For patients without major head injury, admission TCC and TCC-AUC3-6 were negatively associated with ventilator-free days. TCC-AUC3-6 outperformed admission TCC as a predictor of Sequential Organ Failure Assessment score at day 0 and 4. CONCLUSIONS: Complement activation 3 to 6 h after injury was a better predictor of prolonged mechanical ventilation and multiple organ dysfunction syndrome than admission TCC. Our data suggest that the greatest surge of complement activation is found within the first 6 h after injury, and we argue that this time period should be in focus in the design of future experimental studies and clinical trials using complement inhibitors.

Head injury and 25-year risk of dementia.

INTRODUCTION: Head injury is associated with significant morbidity and mortality. Long-term associations of head injury with dementia in community-based populations are less clear. METHODS: Prospective cohort study of 14,376 participants (mean age 54 years at baseline, 56% female, 27% Black, 24% with head injury) enrolled in the Atherosclerosis Risk in Communities (ARIC) Study. Head injury was defined using self-report and International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) codes. Dementia was defined using cognitive assessments, informant interviews, and ICD-9/10 and death certificate codes. RESULTS: Head injury was associated with risk of dementia (hazard ratio [HR] = 1.44, 95% confidence interval [CI] = 1.3-1.57), with evidence of dose-response (1 head injury: HR = 1.25, 95% CI = 1.13-1.39, 2+ head injuries: HR = 2.14, 95% CI = 1.86-2.46). There was evidence for stronger associations among female participants (HR = 1.69, 95% CI = 1.51-1.90) versus male participants (HR = 1.15, 95% CI = 1.00-1.32), P-for-interaction < .001, and among White participants (HR = 1.55, 95% CI = 1.40-1.72) versus Black participants (HR = 1.22, 95% CI = 1.02-1.45), P-for-interaction = .008. DISCUSSION: In this community-based cohort with 25-year follow-up, head injury was associated with increased dementia risk in a dose-dependent manner, with stronger associations among female participants and White participants.

Perfil epidemiológico do traumatismo cranioencefálico no Nordeste do Brasil / Epidemiological profile of traumatic brain injury in Northeastern Brazil

O traumatismo cranioencefálico (TCE) se apresenta na realidade brasileira como importante causa de incapacitações e óbitos, sendo de especial interesse da saúde pública, também, devido à alta demanda de recursos para o tratamento de suas vítimas. Nesse contexto, análises sistemáticas sobre o tema são de grande relevância para o direcionamento de políticas preventivas. O presente trabalho tem por objetivo analisar o perfil do TCE na região Nordeste do Brasil, através de estudo exploratório, descritivo, epidemiológico, de série temporal, de janeiro de 2009 a dezembro de 2019, com dados secundários do DATASUS - Ministério da Saúde do Brasil. Foi constatado um aumento no número de internações e óbitos no período, sendo a maioria das vítimas do sexo masculino, da raça parda, com idade entre 20 e 39 anos. Os custos com internações são elevados e se encontram em ascensão.

raumatic brain injury (TBI) appears in the Brazilian reality as an important cause of disabilities and deaths, being of special interest to public health, also, due to the high demand for resources for the treatment of its victims. Based on this, systematic analyzes on the topic are of great relevance for the direction of preventive policies. The present work aims to analyze the profile of the TBI in Northeastern Brazil, through an exploratory, descriptive, epidemiological, time series study, from January 2009 to December 2019, with secondary data from DATASUS - Ministry of Health of Brazil. There was an increase in the number of hospitalizations and deaths in the period, with the majority of male victims, of brown race, aged between 20 and 39 years. Hospitalization costs are high and on the rise.

Determinants of Outcome in Traumatic Head Injuries: A South East Nigeria Experience.

OBJECTIVES: The objectives of this study were to ascertain factors significantly responsible for mortality from traumatic head injuries and prescribe measures necessary to circumvent such outcome. METHODS: A retrospective cohort study of all traumatic head injuries seen at our facility from October 2013 to September 2015 was done utilizing data from patient's case notes, ward registers, and casualty department. Extracted data were analyzed using descriptive statistics. RESULTS: A total of 221 patient records were analyzed with 161 men and 60 women. It was observed that although the younger age group (19-30 years) was the most frequently affected by traumatic head injuries (36.2%), the elderly (>60 years) were 4.6 times more likely to die from traumatic head injuries than any other age group. Also, those with severe head injuries were 58 times more likely to die than any other category of head injury, even though the commonest category of head injuries seen were mild head injuries (68.7%). Patients with traumatic head injury from road traffic accidents were 5.8 times more likely to die than any other cause. The sex of the patient and the length of hospital stay had no significant influence on mortality from traumatic head injuries. CONCLUSIONS: The postresuscitation Glasgow Coma Scale score, age of the patient, and mechanism of head injuries are important determining factors of outcome in traumatic head injuries, with the Glasgow Coma Scale score being the single most important determining factor. Efforts should be made at preventing such causes, with prompt and aggressive care instituted for cases at risk of unfavorable outcome.

Classification of road traffic injury collision characteristics using text mining analysis: Implications for road injury prevention.

Road traffic injuries are a leading cause of morbidity and mortality globally. Understanding circumstances leading to road traffic injury is crucial to improve road safety, and implement countermeasures to reduce the incidence and severity of road trauma. We aimed to characterise crash characteristics of road traffic collisions in Victoria, Australia, and to examine the relationship between crash characteristics and fault attribution. Data were extracted from the Victorian State Trauma Registry for motor vehicle drivers, motorcyclists, pedal cyclists and pedestrians with a no-fault compensation claim, aged > = 16 years and injured 2010-2016. People with intentional injury, serious head injury, no compensation claim/missing injury event description or who died < = 12-months post-injury were excluded, resulting in a sample of 2,486. Text mining of the injury event using QDA Miner and Wordstat was used to classify crash circumstances for each road user group. Crashes in which no other was at fault included circumstances involving lost control or avoiding a hazard, mechanical failure or medical conditions. Collisions in which another was predominantly at fault occurred at intersections with another vehicle entering from an adjacent direction, and head-on collisions. Crashes with higher prevalence of unknown fault included multi-vehicle collisions, pedal cyclists injured in rear-end collisions, and pedestrians hit while crossing the road or navigating slow traffic areas. We discuss several methods to promote road safety and to reduce the incidence and severity of road traffic injuries. Our recommendations take into consideration the incidence and impact of road trauma for different types of road users, and include engineering and infrastructure controls through to interventions targeting or accommodating human behaviour.

Relationship of injuries detected in fatal falls with sex, body mass index, and fall height: An autopsy study.

Falls from height are the most common cause of blunt trauma after traffic accidents. The focus of this retrospective study was to analyze the relationship between injuries in fatal falls and fall height, body mass index (BMI), and sex in 206 autopsy reports. Age, sex, weight, height, place of the fall, fall height, period between the incidence and death, external examination findings in the autopsy, intracranial findings, fractures, internal organ injuries, and information about the causes of death were recorded. Accidents and men were the largest groups. Injuries to the upper and lower extremities were frequently detected in accidents. Lower extremity injuries were more common in women. The occurrence of head and neck injuries were rare in overweight individuals. When evaluated by manner of death, there were differences in extremities and posterior body injuries. There was no difference between sex in terms of autopsy findings. It was observed that the injuries increased as the height increased. There was a statistical difference between the BMI groups in terms of liver, rib and sternum injuries. The most common cause of death was head injuries. Many factors have been known to affect injury patterns in cases of falls from height. Fall height, BMI, and gender are just a few of these factors. This study will be beneficial to support the findings of this study with larger-scale studies and statistical modeling that consider more factors affecting injuries in cases of falls.

Implementation of Institutional Triaging Algorithms Decreases Head and Neck MDCT Use in Blunt Trauma.

Background Multidetector CT (MDCT) enables rapid and accurate diagnosis of head and neck (HN) injuries in patients with blunt trauma (BT). However, MDCT is overused, and appropriate selection of patients for imaging could improve workflow. Purpose To investigate the effect of implementing clinical triaging algorithms on use of MDCT in the HN in patients who have sustained BT. Materials and Methods In this retrospective study, patients aged 15 years or older with BT admitted between October 28, 2007, and December 31, 2013, were included. Patients were divided into pre- and postalgorithm groups. The institutional trauma registry and picture archiving and communication system reports were reviewed to determine which patients underwent MDCT of the head, MDCT of the cervical spine (CS), and MDCT angiography of the HN at admission and whether these examinations yielded positive results. Injury Severity Score, Acute Physiology and Chronic Health Evaluation II score (only those patients in the intensive care unit), length of hospital stay (LOS), length of intensive care unit stay (ICULOS), and mortality were obtained from the trauma registry. Results A total of 8999 patients (mean age, 45 years ± 20 [standard deviation]; age range, 15-101 years; 6027 male) were included in this study. A lower percentage of the postalgorithm group versus the prealgorithm group underwent MDCT of the head (55.8% [2774 of 4969 patients]; 95% CI: 54.4, 57.2 vs 64.2% [2589 of 4030 patients]; 95% CI: 62.8, 65.7; P < .001) and CS (49.4% [2452 of 4969 patients]; 95% CI: 48.0, 50.7 vs 60.5% [2438 of 4030 patients]; 95% CI: 59.0, 62.0; P < .001) but not MDCT angiography of the HN (9.7% [480 of 4969 patients]; 95% CI: 8.9, 10.5 vs 9.8% [393 of 4030 patients]; 95% CI: 8.9, 10.7; P > .99). Pre- versus postalgorithm groups did not differ in LOS (mean, 4.8 days ± 7.1 vs 4.5 days ± 7.1, respectively; P = .42), ICULOS (mean, 4.6 days ± 6.6 vs 4.8 days ± 6.7, respectively; P > .99), or mortality (2.9% [118 of 4030 patients]; 95% CI: 2.5, 3.5; vs 2.8% [141 of 4969 patients]; 95% CI: 2.4, 3.3; respectively; P > .99). Conclusion Implementation of a clinical triaging algorithm resulted in decreased use of multidetector CT of the head and cervical spine in patients who experienced blunt trauma, without increased adverse outcomes. © RSNA, 2021 See also the editorial by Munera and Martin in this issue.

Chinese Head Trauma Data Bank: Effect of Gender on the Outcome of Patients With Acute Traumatic Brain Injury.

Gender may be related with the outcome of patients with acute traumatic brain injury (TBI). We explored the effect of gender on the outcome of 7145 patients with acute TBI. There was no statistical difference between male and female sex in the causes of trauma, age, Glasgow Coma Scale score, computed tomgraphy findings, and surgical management. The mortality of 7145 patients with acute TBI in males and females was 7.48% and 7.22%, respectively, with the corresponding unfavorable outcomes of 16.05% and 17.23%, respectively (p > 0.05 in both cases). The mortality of 1626 patients with severe TBI in males and females was 19.68% and 20.72%, respectively, with the corresponding unfavorable outcomes of 46.96% and 48.85%, respectively (p > 0.05 in both cases). Our data suggest that sex does not play a role in the outcome of patients with acute TBI.

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study.

BACKGROUND: Intracranial hemorrhage (ICH) after head injury is a concern among older adult patients on anticoagulation. We evaluated the risk of ICH after an emergency department visit for head injury among patients 65 years and older taking warfarin or a direct oral anticoagulant (DOAC) compared with patients not taking anticoagulants. We also evaluated risk of 30-day mortality and neurosurgical intervention among patients with ICH. METHODS: In this retrospective cohort study, we used population-based data of patients 65 years and older seen in an Ontario emergency department with a head injury. We matched patients on the propensity score to create 3 pairwise-matched cohorts based on anticoagulation status (warfarin v. DOAC, warfarin v. no anticoagulant, DOAC v. no anticoagulant). For each cohort, we calculated the relative risk of ICH at the index emergency department visit and 30-day mortality. We also calculated the hazard of neurosurgical intervention among patients with ICH. RESULTS: We identified 77 834 patients with head injury, including 64 917 (83.4%) who were not on anticoagulation, 9214 (11.8%) who were on DOACs and 3703 (4.8%) who were on warfarin. Of these, 5.9% of patients had ICH at the index emergency department visit. Patients on warfarin had an increased risk of ICH compared with matched patients on DOACs (relative risk [RR] 1.43, 95% confidence interval [CI] 1.20-1.69) and patients not on anticoagulation (RR 1.36, 95% CI 1.15-1.61). We did not observe a difference in ICH between patients on DOACs compared with matched patients not on anticoagulation. In patients with ICH, 30-day mortality did not differ by anticoagulation status or type. Patients on warfarin had an increased hazard of neurosurgery compared with patients not on anticoagulation. INTERPRETATION: Patients on warfarin seen in the emergency department with a head injury had higher relative risks of ICH than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of ICH for patients on a DOAC was not significantly different compared with no anticoagulation. Further research should confirm that older adults using warfarin are the only group at higher risk of ICH after head injury.

Perfil epidemiológico de pacientes adultos com traumatismo cranioencefálico grave na rede SUS do Distrito Federal: um estudo retrospectivo / Epidemiological profile of adult patients with severe traumatic brain injury in the SUS network in the Federal District: a retrospective study

INTRODUÇÃO: O traumatismo cranioencefálico (TCE) é considerado uma epidemia silenciosa e um grande problema de saúde pública mundial. Dados epidemiológicos precisos podem ajudar na formulação de políticas públicas e em estratégias para reduzir a incidência do TCE. O objetivo deste estudo foi descrever a epidemiologia do TCE grave de pacientes admitidos na unidade de terapia intensiva (UTI). MÉTODOS: Trata-se de um estudo retrospectivo com coleta de dados em prontuário eletrônico na UTI de um hospital da rede SUS do Distrito Federal. Foram analisados o perfil epidemiológico e os principais desfechos clínicos e funcionais de pacientes com TCE internados entre janeiro e dezembro de 2015. Uma análise estatística descritiva foi conduzida e os dados foram expressos em médias, intervalo de confiança de 95% (IC95%) e taxas. RESULTADOS: 227 pacientes foram estudados com média de idade de 38 anos (IC95% 36 a 40), sendo 84% (191/227) do sexo masculino. O principal mecanismo de trauma foi o acidente motociclístico, 19% (43/227) seguido dos atropelamentos, 18% (40/227). O tempo médio de ventilação mecânica foi de 14 dias, (IC95% 12 a 15) e os tempos médios de internação na UTI e hospitalar foram de 16 dias, (IC95% 14 a 18) e 42 dias, (IC95% 36 a 47), respectivamente. Apenas 16% (36/227) dos pacientes conseguiu permanecer em ortostase na alta da UTI. A taxa de mortalidade na UTI foi de 25% (57/227). CONCLUSÃO: Os homens jovens são os mais acometidos por TCE grave sendo o principal mecanismo o acidente motociclístico. Estes pacientes apresentam internação hospitalar prolongada e altas taxas de mortalidade

INTRODUCTION: traumatic brain injury (TBI) has been considered a silent epidemic and a major worldwide public health problem. Accurate epidemiological data can assist in the formulation of public policies and strategies to reduce the incidence of TBI. The aim of this study was to describe the epidemiology of severe TBI in patients admitted to the intensive care unit (ICU). METHODS: this is a retrospective study with data collected from electronic medical records from the ICU of a SUS hospital in the Federal District. The epidemiological profile and the main clinical and functional outcomes of patients with TBI hospitalized between January and December 2015 were analyzed. A descriptive statistical analysis was conducted and data were expressed as averages, 95% confidence interval (95% CI) and rates. RESULTS: 227 patients were studied with a mean age of 38 (95% CI 36 to 40), 84% (191/227) being male. The main mechanism of trauma was motorcycle collision, 19% (43/227) followed by pedestrian collision, 18% (40/227). The mean time of mechanical ventilation was 14 days, (95% CI 12 to 15) and the average length of stay in the ICU and hospital was 16 days, (95% CI 14 to 18) and 42 days, (95% CI 36 to 47), respectively. Only 16% (36/227) of patients managed to remain in orthostasis upon discharge from the ICU. The mortality rate in the ICU was 25% (57/227). CONCLUSION: Young men are the most affected by severe TBI, and the main mechanism was motorcycle accidents. These patients have prolonged hospital stays and high mortality rates

Prognostic factors in craniocerebral gunshot wounds: Analysis of 30 patients from the neurosurgical viewpoint.

BACKGROUND: Craniocerebral gunshot wounds (CGW) are the most lethal injuries of the cranium. CGW is mostly secondary to military conflicts but may also be seen in civilian life. These injuries also have severe consequences, such as epilepsy, hydrocephalus, infection and late-term cognitive dysfunctions. The present study aims to present our series of CGW and to discuss the prognostic factors and consequences of these injuries. METHODS: The data of patients who were treated in our department for CGW between 2011 and 2019 were retrospectively reviewed in this study. The injury type, wounding site, surgical management and outcomes were analyzed. Radiological evaluation was also performed. RESULTS: Thirty patients were treated with the diagnosis of CGW. All of the patients were male and the mean age was 27.9 years. The frontal lobe was affected in 12 (40%) patients, while temporal lobe in eight, occipital lobe in six, parietal lobe in three, and posterior fossa in one patients. Twenty-three patients underwent surgical treatment, seven patients were treated conservatively. Thirteen (43.3%) patients died despite the treatment. CONCLUSION: Mortality in CGW is high. Ventricular injuries, bihemispheric or midline injuries, perforating injuries, brain stem injuries and low GCS score at admission are prognostic factors for CGW. Appropriate management is mandatory to obtain a better clinical outcome.

Pediatric head traumas: A different perspective.

BACKGROUND: We aim to present our series on pediatric head traumas and discuss our results with the current literature. METHODS: The data of children who underwent treatment for head trauma in our department between 2010 and 2019 were retrospectively reviewed. Their clinical condition at admission, radiological findings, treatment methods and outcomes were analyzed. RESULTS: Ninety children underwent treatment for head trauma, 60 of them were male and 30 were female. The mean age was 6.6 years. Linear skull fracture was seen 55 patients, while epidural hematoma in 15 patients. Twenty patients underwent surgical treatment, while 70 patients underwent conservative treatment. No patient died in our series, three patients underwent rehabilitation due to neurological deficits after discharge. CONCLUSION: Children were more prone to head trauma, but their mortality was less than the adults. Conservative treatment should be the first goal, but surgical management should be reserved for children with significant hematoma and declining neurological conditions.

Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis.

BACKGROUND: Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group. METHODS: An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies. RESULTS: 148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%). CONCLUSIONS: The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.