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Beucler N, Sellier A, Joubert C, Lesquen HD, Schlienger G, Caubere A, Holay Q, Desse N, Esnault P, Dagain A. Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept. J Neurosci Rural Pract 2022; 13:585-607. [PMID: 36743747 PMCID: PMC9893946 DOI: 10.25259/jnrp-2022-1-38-r1-(2348)] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods A scoping review was conducted on Medline database from inception to September 2021. Results The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.
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Affiliation(s)
- Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | - Aurore Sellier
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Christophe Joubert
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Henri De Lesquen
- Department of Thoracic and Vascular Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Ghislain Schlienger
- Department of Visceral Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Alexandre Caubere
- Department of Orthopaedic Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Quentin Holay
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
- Department of Diagnostic and Interventional Radiology, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Nicolas Desse
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Pierre Esnault
- Department of Intensive care unit, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Department of Val-de-Grâce Military Academy, Paris, France
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Beucler N, Sellier A, Joubert C, Bernard C, Desse N, Esnault P, Dagain A. Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study. Mil Med 2022; 187:1127-1135. [PMID: 35038725 DOI: 10.1093/milmed/usab555] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/06/2021] [Accepted: 12/23/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. MATERIALS AND METHODS We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. RESULTS The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). CONCLUSION Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, Ile-de-France 75230, France
| | - Aurore Sellier
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Christophe Joubert
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Cédric Bernard
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Nicolas Desse
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Pierre Esnault
- Intensive Care Unit, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Val-de-Grâce Military Academy, Paris, Ile-de-France 75230, France
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Noureldine MHA, Hartnett S, Zavadskiy G, Pressman E, Kim JK, Davis D, Ciesla D, Bull B, Agazzi S. Predicting neurosurgical clearance in the polytrauma patient with concomitant traumatic brain injury. J Clin Neurosci 2021; 89:51-55. [PMID: 34119294 DOI: 10.1016/j.jocn.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/02/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Abstract
The goal of this study is to develop a model based on previously used prognostic predictors in traumatic brain injury (TBI) patients with polytrauma, which will facilitate the decision-making of whether to clear these patients for non-cranial surgery. Data of eligible patients was obtained from a trauma database at a Level I trauma and academic tertiary referral center in the United States. The number of days seen by the neurosurgical service prior to clearance, injury severity score (ISS), post-trauma day 0 (PTD 0) of Glasgow Coma Score (GCS), intracranial pressure (ICP) score and computed tomography (CT) score, as well as the changes in GCS, ICP score and CT score between PTD 0 and day of clearance were the variables used in developing the model. The Neurosurgical Clearance Model (NCM) was developed using data from 50 patients included in the study. Patients were cleared by neurosurgeons 1.6 days later than it would appear possible based on a retrospective review of the patients' clinical conditions. A single model equation was developed, the ultimate result of which is a clearance probability value. The best cutoff clearance probability value was found to be 0.584 (or 58.4%) using Receiver Operator Characteristic curve analysis. Our data suggests that neurosurgeons are risk-averse in clearing polytrauma patients for non-cranial surgery. This pilot NCM, if reproduced and validated by other groups and in larger prospective studies, may become a useful tool to assist clinicians in this often-difficult decision-making process.
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Affiliation(s)
| | - Sara Hartnett
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Gleb Zavadskiy
- Muma College of Business, University of South Florida, Tampa, FL, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Joon Kyung Kim
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Donald Davis
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - David Ciesla
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Brooke Bull
- Division of Trauma and Acute Care Surgery, Department of Surgery, Tampa General Hospital, Tampa, FL, USA
| | - Siviero Agazzi
- Department of Surgery, University of South Florida, Tampa, FL, USA
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Timing of Extremity Fracture Fixation in Patients with Traumatic Brain Injury: A Meta-Analysis of Prognosis. World Neurosurg 2020; 133:227-236. [DOI: 10.1016/j.wneu.2019.09.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 01/23/2023]
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Zhang Y, Sun K, Wang Y, Qin Y, Li H. Early vs late fracture fixation in severe head and orthopedic injuries. Am J Emerg Med 2018; 36:1410-1417. [DOI: 10.1016/j.ajem.2017.12.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022] Open
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Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury. J Neurosurg Anesthesiol 2018; 29:228-235. [PMID: 26954768 DOI: 10.1097/ana.0000000000000292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery. MATERIALS AND METHODS We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure<90 mm Hg), intracranial hypertension (ICP>20 mm Hg), cerebral hypotension (cerebral perfusion pressure<50 mm Hg), hypercarbia (end-tidal CO2>40 mm Hg), hypocarbia (end-tidal CO2<30 mm Hg in absence of intracranial hypertension), hyperglycemia (glucose>200 mg/dL), hypoglycemia (glucose<60 mg/dL), and hyperthermia (temperature >38°C). RESULTS A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by ≥2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P<0.001). CONCLUSIONS Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.
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Abstract
The best time to operate on a fracture is governed in part by the nature of the fracture itself. It is also influenced by the premorbid condition of the patient and by the degree that associated injuries have disrupted normal processes. It is likely that some patients have a period of increased physiological risk for intervention, during which a second insult will result in further harm. The picture is not yet fully clear but relates to variations in the inflammatory response to trauma. One consistent lesson appears to resonate throughout the published literature. The most predictable risk factor for iatrogenic physiological disturbance is transfer to the operating theatre before adequate resuscitation of the patient has taken place.
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Affiliation(s)
- MP Revell
- SpR Trauma & Orthopaedics, West Midlands, UK
| | - KM Porter
- Consultant Trauma & Orthopaedic Surgeon, Selly Oak Hospital, Birmingham, UK
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Algarra NN, Sharma D. Perioperative Management of Traumatic Brain Injury. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0170-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Fujita Y, Algarra NN, Vavilala MS, Prathep S, Prapruettham S, Sharma D. Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury. Childs Nerv Syst 2014; 30:1201-8. [PMID: 24429505 DOI: 10.1007/s00381-014-2353-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 01/02/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited. METHODS We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C). RESULTS Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score. CONCLUSIONS Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.
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Affiliation(s)
- Yasuki Fujita
- Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Cranialization in a cohort of 154 consecutive patients with frontal sinus fractures (1987-2007): review and update of a compelling procedure in the selected patient. Ann Plast Surg 2014; 71:54-9. [PMID: 22918401 DOI: 10.1097/sap.0b013e3182468198] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Retrospective review of charts of 180 consecutive patients with frontal sinus fractures managed by plastic surgeons at the University of Kentucky between 1987 and 2007 was performed with institutional review board approval. Twenty-six charts did not meet the criteria. The remaining 154 records provided 1-to-20-year follow-up. The study included 34 patients who underwent cranialization and 120 patients who did not. A low-complication rate of 6% after cranialization is ascribed by the authors to meticulous sinus mucosal debridement; thorough obliteration of the frontal sinus outflow tract (with sterile gelatin sponge pledgets and bone chips from the outer cortex of the temporoparietal skull); and avoidance of avascular barriers, such as abdominal fat. As high-resolution computerized tomography with parasaggital views was introduced, an increasing ability to preoperatively define the extent of injury of the medial and lateral sinus floor was observed. The authors conclude selective use of cranialization is indicated.
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Mrozek S, Gaussiat F, Geeraerts T. The management of femur shaft fracture associated with severe traumatic brain injury. ACTA ACUST UNITED AC 2013; 32:510-5. [DOI: 10.1016/j.annfar.2013.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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12
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Halvorson JJ, Pilson HTP, Carroll EA, Li ZJ. Orthopaedic management in the polytrauma patient. Front Med 2012; 6:234-42. [PMID: 22956121 DOI: 10.1007/s11684-012-0218-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 07/10/2012] [Indexed: 01/26/2023]
Abstract
The past century has seen many changes in the management of the polytraumatized orthopaedic patient. Early recommendations for non-operative treatment have evolved into early total care (ETC) and damage control orthopaedic (DCO) treatment principles. These principles force the treating orthopaedist to take into account multiple patient parameters including hypothermia, coagulopathy and volume status before deciding upon the operative plan. This requires a multidisciplinary approach involving critical care physicians, anesthesiologists and others.
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Affiliation(s)
- Jason J Halvorson
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27103, USA
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Velly L, Pellegrini L, Bruder N. [Early or delayed peripheral surgery in patients with severe head injury?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2010; 29:e183-e188. [PMID: 20656447 DOI: 10.1016/j.annfar.2010.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Head injuries are present in up to 65 % of multiple trauma patients with a frequent association with orthopaedic injuries. The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1980s. However, optimal timing of long bone fracture fixation in trauma patients with associated severe traumatic brain injury has been a lively topic. The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. In recent years, some studies reported a worse outcome, with secondary brain damage, resulting from hypotension, hypoxia and increased intraoperative fluid administration. This review summarises the current evidence available regarding the management of these patients in particular the recent concept of early temporary surgical stabilization in the era of "damage control orthopaedic surgery".
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Affiliation(s)
- L Velly
- Service d'anesthésie-réanimation, CHU Timone-Adultes, 264 rue Saint-Pierre, Marseille, France.
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Nowinski D, Di Rocco F, Roujeau T, Meyer P, Renier D, Arnaud E. Complex Pediatric Orbital Fractures Combined With Traumatic Brain Injury. J Craniofac Surg 2010; 21:1054-9. [DOI: 10.1097/scs.0b013e3181e573be] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
The ideal timing and modality of femur shaft fracture fixation in head-injured patients remains a topic of debate. Several groups advocate the immediate definitive fixation of femur fractures ("early total care"), whereas others support the concept of "damage control orthopaedics" with temporary fracture fixation by means of external fixation and staged, planned conversion to internal fixation. The present review was designed to address this unresolved controversy by outlining the underlying immunopathophysiology of traumatic brain injury and providing clinical recommendations on the timing of femur shaft fracture fixation in patients with severe head injuries.
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Optimal Timing of Fracture Fixation: Have We Learned Anything In the Past 20 Years? ACTA ACUST UNITED AC 2008; 65:253-60. [DOI: 10.1097/ta.0b013e31817fa475] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lorich DG, Gardner MJ, Helfet DL. Trauma to the Pelvis and Extremities. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Role of biological modifiers regulating the immune response after trauma. Injury 2007; 38:1409-22. [PMID: 18048034 DOI: 10.1016/j.injury.2007.09.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Accepted: 09/24/2007] [Indexed: 02/02/2023]
Abstract
Trauma induces a profound immunological dysfunction. This is characterised by an early state of hyperinflammation, followed by a phase of immunosuppression with increased susceptibility to infection and multiple organ failure. Therapeutic strategies directed at restoring immune homeostasis after traumatic injuries have largely failed in translation from "bench to bedside". The present review illustrates the role of biological modifiers of the posttraumatic immune response by portraying different modalities of therapeutic immune modulation. The emphasis is placed on anti-inflammatory (steroids) and immune-stimulatory (interferon) pharmacological strategies and modified resuscitative strategies, as well as more unconventional immunomodulatory approaches, such as immunonutrition.
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Shibuya TY, Karam AM, Doerr T, Stachler RJ, Zormeier M, Mathog RH, McLaren CL, Li KT. Facial Fracture Repair in the Traumatic Brain Injury Patient. J Oral Maxillofac Surg 2007; 65:1693-9. [PMID: 17719385 DOI: 10.1016/j.joms.2006.06.309] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Revised: 12/14/2005] [Accepted: 06/13/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE To review the surgical complications of patients who had facial fractures repairs in the setting of a traumatic brain injury (TBI). PATIENTS AND METHODS A review of all individuals admitted with the diagnosis of TBI based on an evaluation by the neurotrauma service who also underwent facial fracture repair was performed. More than 600 charts were reviewed and 99 patients met study criteria. Univariate and mulitvariate logistic regression model analysis were performed comparing the complication rate in the immediate postoperative period to the patients' age, gender, mechanism of injury, zone of facial injury, preoperative Glasgow Coma score, presence of multisystem injury, mechanism of TBI and treatment, length of time from injury to surgical repair and length of surgical procedure. RESULTS Of the 99 individuals studied, there was an 11% complication rate (8 minor, 3 major) in the immediate postoperative period. After univariate analysis, the length of time from injury to surgical repair, zone 1 facial injury and low Glasgow Coma score were all factors associated with increased complications. Multivariate logistic regression model analysis revealed that the odds of a patient sustaining a postoperative complication was 1.298 as the hour of procedure increased by 1 hour (95% CI, 1.065-1.582) and was 1.152 as the days of repair increased by 1 day (95% CI, 1.030-1.288). CONCLUSIONS The overall complication rate of facial fracture repair in the TBI patient was 11%. A prolonged surgical procedure and delay in surgical repair were associated with higher complication rates as identified by multivariate logistical regression analysis.
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Affiliation(s)
- Terry Y Shibuya
- Department of Head and Neck Surgery, Southern California Kaiser-Permanente Medical Group, Orange County, CA 92807, USA.
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Rixen D, Grass G, Sauerland S, Lefering R, Raum MR, Yücel N, Bouillon B, Neugebauer EAM. Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: "evidence-based medicine" versus "reality" in the trauma registry of the German Trauma Society. ACTA ACUST UNITED AC 2006; 59:1375-94; discussion 1394-5. [PMID: 16394911 DOI: 10.1097/01.ta.0000198364.50334.39] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Femur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database. METHODS A systematic literature analysis was performed. The German Trauma Society trauma registry was used to assess variables predictive of treatment concept. RESULTS Contradictory results in 63 controlled trials failed to support a "generalized management strategy." In all, 1,465 FSFTs in 8,057 trauma registry patients (age 39 +/- 19.5 years; Injury Severity Score [ISS] 23.5 +/- 14.9; 17.3% mortality) were treated initially (<24 hour) by EF, nail, or plate in 47.0%, 41.1%, and 11.9%, respectively. Despite large interhospital variability, EF was more likely with increasing severity of ISS, Glasgow Coma Score, thorax trauma, base excess, coagulation abnormalities, and initial probability of death. CONCLUSIONS Clinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.
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Affiliation(s)
- Dieter Rixen
- Department of Trauma/Orthopedic Surgery, University of Witten/Herdecke at the Hospital Merheim, Cologne, Germany.
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Zalavras C, Velmahos GC, Chan L, Demetriades D, Patzakis MJ. Risk factors for respiratory failure following femoral fractures: the role of multiple intramedullary nailing. Injury 2005; 36:751-7. [PMID: 15910828 DOI: 10.1016/j.injury.2005.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Revised: 01/22/2005] [Accepted: 01/22/2005] [Indexed: 02/02/2023]
Abstract
Controversy exists on the relationship between intramedullary nailing (IMN) and the timing of fixation in the development of respiratory failure (RF) following femoral fractures. The purpose of this study is to identify risk factors for RF and evaluate the role of multiple IMN in the above setting. We prospectively observed 126 consecutive patients with femoral fractures for the development of RF. Twenty-one patients (17%) developed RF. This occurred before fracture fixation in 11 patients and after IMN in 10 patients; five after multiple IMN and five after a single IMN procedure. Patients who underwent multiple IMN demonstrated a significant increase of RF after fracture fixation (5/8,) compared to patients with one IMN procedure (5/114, 4.4%, p<0.001). Stepwise regression analysis identified two independent RF risk factors: thoracic injury and multiple IMN (odds ratios: 40.6 and 25.6, respectively). Thoracic injury and multiple IMN procedures are independent risk factors for RF in patients with femoral fractures, and the combination of the above conditions is highly predictive of the development of RF.
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Affiliation(s)
- Charalampos Zalavras
- Keck School of Medicine, University of Southern California, orthopaedic Surgery, LAC+USC Medical Center, 1200 N State St GNH 3900, Los Angeles, CA 90033, USA.
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Grotz MRW, Giannoudis PV, Pape HC, Allami MK, Dinopoulos H, Krettek C. Traumatic brain injury and stabilisation of long bone fractures: an update. Injury 2004; 35:1077-86. [PMID: 15488496 DOI: 10.1016/j.injury.2004.05.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2004] [Indexed: 02/02/2023]
Abstract
In the era of "damage control orthopaedics", the timing and type of stabilisation of long bone fractures in patients with associated severe traumatic brain injury has been a topic of lively debate. This review summarises the current evidence available regarding the management of these patients. There appear to be no clear treatment guidelines. Irrespective of the treatment protocol followed, if secondary brain damage is to be avoided at all times, ICP monitoring should be used, both in the intensive care unit and in the operating theatre during surgical procedures, since aggressive ICP management appears to be related to improved outcomes. Treatment protocols should be based on the individual clinical assessment, rather than mandatory time policies for fixation of long bone fractures.
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Affiliation(s)
- M R W Grotz
- Department of Trauma & Orthopaedics, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
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Chipman JG, Deuser WE, Beilman GJ. Early surgery for thoracolumbar spine injuries decreases complications. ACTA ACUST UNITED AC 2004; 56:52-7. [PMID: 14749565 DOI: 10.1097/01.ta.0000108630.34225.85] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The proper timing for surgical fracture repair is controversial. Early repair of long bone and cervical fractures reduces complications and is safe. Few studies exist to compare time to surgery with outcomes in thoracolumbar (TL) spine injuries. METHODS Patients with TL spine injuries were identified from the trauma registry and divided into two cohorts on the basis of Injury Severity Score (ISS). Cohorts were compared for infectious, respiratory, and total complications in patients who had early (<72 hours from injury) versus late (>72 hours from injury) surgical repair. A retrospective chart review was performed on High ISS patients (> or =15) to identify differences in resuscitation needs and neurologic, respiratory, and infectious complications. RESULTS Early surgery, Low ISS patients were younger, received fewer anterior repairs, and had shorter hospitalizations. Early patients in the High ISS cohort had significantly fewer total complications and shorter hospital and intensive care unit lengths of stay. Resuscitative requirements were similar for both surgery groups. More late surgery patients required ventilator support for noninfectious reasons. There was no difference in admission or postoperative neurologic status or the incidence of head injury. CONCLUSION Early surgery in severely injured patients with thoracolumbar spine trauma was associated with fewer complications and shorter hospital and intensive care unit lengths of stay, required less ventilator support for noninfectious reasons, and did not increase neurologic deficits.
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Affiliation(s)
- Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, 55455, USA
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Anglen JO, Luber K, Park T. The effect of femoral nailing on cerebral perfusion pressure in head-injured patients. THE JOURNAL OF TRAUMA 2003; 54:1166-70. [PMID: 12813339 DOI: 10.1097/01.ta.0000057232.66613.ac] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The timing of fracture fixation in patients with head trauma is controversial. Early fracture fixation may be associated with secondary brain injury. We undertook this study to investigate the effect of reamed intramedullary nailing on cerebral perfusion. METHODS Seventeen patients were identified who had placement of an intracranial pressure monitor and reamed rodding of the femur. Retrospective chart review was performed. RESULTS Average Injury Severity Score was 35 (range, 17-50). Cerebral perfusion pressure (CPP) decreased intraoperatively for all except one. The average decrease in CPP from pre- to intraoperative values was 17 mm Hg (p = 0.0012). Seventy percent had an average intraoperative CPP below 75 mm Hg, and all patients had a minimum CPP below 75 mm Hg. The decrease in CPP was mostly attributable to a corresponding decrease in mean arterial pressure. CONCLUSION Patients with head trauma undergoing femoral rodding need careful attention paid to managing blood pressure to minimize CPP decreases.
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Giannoudis PV, Veysi VT, Pape HC, Krettek C, Smith MR. When should we operate on major fractures in patients with severe head injuries? Am J Surg 2002; 183:261-7. [PMID: 11943123 DOI: 10.1016/s0002-9610(02)00783-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The widely accepted practice of early fracture fixation (EFF) in multiply injured patients has recently been challenged in the presence of head injury. DATA SOURCES English and German language articles on the subject were searched using Medline. Keywords included head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture. CONCLUSIONS The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. Treatment should therefore be tailored to the individual patient, with the assumption that full neurologic recovery will take place.
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Affiliation(s)
- Peter V Giannoudis
- Department of Trauma and Orthopaedics, St. James' University Hospital, Leeds, Beckett St., LS9 7TF, Leeds, United Kingdom
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Abstract
Although injury to the brain and spinal cord can have varied etiology and mechanisms, the common pathway appears to be mediated by occurrence of ischemia and secondary injury. Because the pathophysiology in traumatic brain injury is heterogeneous, improvement in outcome will come from better diagnosis and monitoring, so that targeted therapy can be tailored to the individual patient. This review focuses on traumatic injury to the brain and spinal cord, and highlights recent developments in this area.
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Affiliation(s)
- S Fletcher
- Department of Anesthesiology, Harborview Medical Center, University of Washington, Seattle, Washington 98104-2499, USA
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Abstract
Physicians are still largely ignorant of the underlying biology of SIRS and multiple organ failure. Nonetheless, strategies to prevent multiple organ failure are possible. These include aggressive resuscitation of hemodynamically unstable patients, careful assessment to avoid missing clinically significant injuries, early operative treatment of all possible injuries with debridement of all nonviable tissue, early nutritional support, and the early diagnosis and prompt treatment of infectious complications. Treatment of patients with established multiple organ failure is still largely supportive and has made little impact on the patient mortality rate over the past 20 years. Future treatment strategies must focus on multimodality combination therapy aimed at specifically suppressing excessive activation of the inflammatory response while preserving immune competence and normal antimicrobial defenses. Only then are physicians likely to begin to see a reduction in the mortality rate of patients with this complex and challenging condition.
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Affiliation(s)
- E A Deitch
- Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, USA.
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