A review of the current management of severe traumatic brain injury

Health-related quality of life measures in patients undergoing decompressive craniectomy for severe traumatic brain injury: a 6-year follow-up analysis

PURPOSE

We aimed to assess the long-term neurological outcomes and the functionality and QoL in patients undergoing decompressive craniectomy for severe traumatic brain injury, respectively.

MATERIALS AND METHODS

Among the 120 patients who underwent decompressive craniectomy for severe TBI between 2002 and 2007, 101 were included based on the inclusion criteria. Long-term follow-up results (minimum 3 years) were available for 22 patients. The outcomes were assessed using the Glasgow Outcome Scale (GOS) and the functionality and HRQoL were assessed using the Short Form-36 (SF-36) (v2) and Quality of Life After Brain Injury (QoLIBRI) questionnaires.

RESULTS

Among the patients with severe TBI, 62 (61.4%) died and 39 (38.6%) were discharged to either home or a physical therapy facility. Eleven of the thirty-nine patients could not be reached and were excluded from the final analysis. The mean GOS of the remaining 28 patients was 4.14 ± 0.8 after 6.46 ± 1.64 years of follow-up. The HRQoL was assessed in 22 of the 28 patients. The HRQoL scores were lower in patients with TBI than in healthy controls. Furthermore, there was a significant difference in the HRQoL scores in patients with improved GOS scores than in those with unimproved GOS scores.

CONCLUSIONS

Health-related outcome scores could help clinicians understand the requirements of survivors of severe TBI to create a realistic rehabilitation target for them. QoLIBRI served as a good way of communication in these subjects.

Imaging assessment of traumatic brain injury

Traumatic brain injury (TBI) constitutes injury that occurs to the brain as a result of trauma. It should be appreciated as a heterogeneous, dynamic pathophysiological process that starts from the moment of impact and continues over time with sequelae potentially seen many years after the initial event. Primary traumatic brain lesions that may occur at the moment of impact include contusions, haematomas, parenchymal fractures and diffuse axonal injury. The presence of extra-axial intracranial lesions such as epidural and subdural haematomas and subarachnoid haemorrhage must be anticipated as they may contribute greatly to secondary brain insult by provoking brain herniation syndromes, cranial nerve deficits, oedema and ischaemia and infarction. Imaging is fundamental to the management of patients with TBI. CT remains the imaging modality of choice for initial assessment due to its ease of access, rapid acquisition and for its sensitivity for detection of acute haemorrhagic lesions for surgical intervention. MRI is typically reserved for the detection of lesions that may explain clinical symptoms that remain unresolved despite initial CT. This is especially apparent in the setting of diffuse axonal injury, which is poorly discerned on CT. Use of particular MRI sequences may increase the sensitivity of detecting such lesions: diffusion-weighted imaging defining acute infarction, susceptibility-weighted imaging affording exquisite data on microhaemorrhage. Additional advanced MRI techniques such as diffusion tensor imaging and functional MRI may provide important information regarding coexistent structural and functional brain damage. Gaining robust prognostic information for patients following TBI remains a challenge. Advanced MRI sequences are showing potential for biomarkers of disease, but this largely remains at the research level. Various global collaborative research groups have been established in an effort to combine imaging data with clinical and epidemiological information to provide much needed evidence for improvement in the characterisation and classification of TBI and in the identity of the most effective clinical care for this patient cohort. However, analysis of collaborative imaging data is challenging: the diverse spectrum of image acquisition and postprocessing limits reproducibility, and there is a requirement for a robust quality assurance initiative. Future clinical use of advanced neuroimaging should ensure standardised approaches to image acquisition and analysis, which can be used at the individual level, with the expectation that future neuroimaging advances, personalised to the patient, may improve prognostic accuracy and facilitate the development of new therapies.

Controversies in the management of adults with severe traumatic brain injury

Despite progress in the management of adults with severe traumatic brain injury, several controversies persist. Among the unresolved issues of greatest concern to neurocritical care clinicians and scientists are the following: (1) the best use of technological advances and the data obtained from multimodality monitoring; (2) the use of mannitol and hypertonic saline in the management of increased intracranial pressure; (3) the use of decompressive craniectomy and barbiturate coma in refractory increased intracranial pressure; (4) therapeutic hypothermia as a neuroprotectant; (5) anemia and the role of blood transfusion; and (6) venous thromboembolism prophylaxis in severe traumatic brain injury. Each of these strategies for managing severe traumatic brain injury, including the postulated mechanism(s) of action and beneficial effects of each intervention, adverse effects, the state of the science, and critical care nursing implications, is discussed.

The 'hit by a stick' disease: an epidemiologic study of the causes of trauma in a non-profit hospital in rural Ethiopia

Traumatic injuries are one of the leading causes of death and disability worldwide and represent a very important public health problem in countries like Ethiopia, where there are insufficient centres of trauma care and where an interest in prevention has only relatively recently been awakened. The aim of this study was to investigate the causes of trauma at St Luke Catholic Hospital. We conducted a one-year retrospective study on 2969 patients who suffered from trauma. Every traumatized patient was classified by age, sex, cause and site of the trauma. The admission rate and hospital stays were also analysed. The most common causes of injury were: interpersonal conflict (32.2%); falling (15.1%); and road traffic incidents (RTIs; 14%). Men (71.7%) and young adults (37.6%; range 15-29 years) were the most affected, while head and neck were the most affected sites (33%). Half of the 377 admitted patients stay in hospital for more than a week. The 'hit by a stick' disease can be reduced with appropriate public health campaigns on trauma prevention. This is a priority in trauma prevention, especially in the rural areas.

Traumatic brain injury associated with combat ocular trauma

PURPOSE

To determine the impact of traumatic brain injury (TBI) on visual outcomes in combat ocular trauma (COT) and determine the association between TBI severity and types of ocular injuries.

PARTICIPANTS

One hundred fifty-two US casualties sustained 207 globe/oculoplastic combat injuries.

METHODS

Retrospective, hospital-based cross-sectional study of US service members injured during Operations Iraqi Freedom and Enduring Freedom were treated by the Ophthalmology Service at Walter Reed Army Medical Center and screened for TBI by the Defense and Veterans Brain Injury Center from August 2004 to October 2006.

MAIN OUTCOME MEASURES

The main outcome measure was best-corrected visual acuity (BCVA). Secondary outcome measures included the severity and frequency of TBI with globe, oculoplastic, and/or neuro-ophthalmic injury.

RESULTS

The frequency of COT with positive TBI screening was 101 of 152 cases (66%) in comparison with negative TBI screening, which was 51 of 152 (34%) cases. The Defense and Veterans Brain Injury Center found TBI with concomitant ocular trauma in 101 of 474 (21%) consecutive casualties. Explosive fragmentary munitions accounted for 79% of TBI-associated COT. The median follow-up was 185 days. Traumatic brain injury severity did not correlate with worse final BCVA (Spearman coefficient, r = 0.12). The odds that BCVA worse than 20/200 was present with TBI was not statistically significant (OR: 1.5; 95% CI, 0.9-2.6; P = .10). The presence of TBI in COT was not associated with worse visual outcome (Mann-Whitney U test, P = .10). Globe injuries were more common than oculoplastic or neuro-ophthalmic injury. Closed-globe injuries were more likely to have TBI than open-globe injuries (OR: 2.17; 95% CI, 1.12-4.21; P = .03). Traumatic brain injury severity associated with COT included mild TBI (31%), moderate TBI (30%), severe TBI (25%), and penetrating TBI (14%). Severe TBI is more frequently associated with COT.

CONCLUSION

Traumatic brain injury occurs in two thirds of all COT and ocular trauma is a common finding in all TBI cases. Closed-globe injuries are at highest risk for TBI while TBI does not appear to lead to poorer visual outcomes. Every patient with COT needs TBI screening. Those service members who are screened TBI positive need a referral to a TBI rehabilitation specialist.

Congenital and acquired brain injury. 1. Epidemiology, pathophysiology, prognostication, innovative treatments, and prevention

This self-directed learning module reviews the current epidemiology of traumatic brain injury (TBI), its pathophysiology, prognostication after injury, currently available innovative early approaches to diagnosis and treatment, and effective methods of prevention. It is intended to provide the rehabilitation clinician with current knowledge to accurately inform patients, families, significant others, referring physicians, and payers and to aid in clinical decision making while caring for patients after TBI.

OVERALL ARTICLE OBJECTIVE

To describe current knowledge in traumatic brain injury epidemiology, pathophysiology, prognostication, acute treatment, and prevention.

End tidal carbon dioxide monitoring in prehospital and retrieval medicine: a review

End tidal carbon dioxide (ETCO2) monitoring is the non-invasive measurement of exhaled CO2. The Intensive Care Society guidelines include (ETCO2) monitoring as one of the objective standards required for monitoring patients in transport, and the American Heart Association recommends that all intubations must be confirmed by some form of ETCO2 measurement. The physiological principles and technology underlying ETCO2 measurement and the clinical indication for its use in the prehospital environment are reviewed. ETCO2 monitoring has been widely established in the prehospital environment and is of particular use for verification of endotracheal tube placement. It is non-invasive and easy to apply to breathing circuits. The units now available are compact and rugged, with extended battery operating times, which are ideally suited for prehospital use and should be considered as an essential item for advanced airway management.