The features of the typical traumatic brain injury patient in the ICU are changing: what will this mean for the intensivist?

Criteria to clear polytrauma patients with traumatic brain injury for safe definitive surgery (<24 h)

INTRODUCTION

Optimizing treatment strategies in polytrauma patients is a key focus in trauma research and timing of major fracture care remains one of the most actively discussed topics. Besides physiologic factors, associated injuries, and injury patterns also require consideration. For instance, the exact impact and relevance of traumatic brain injury on the timing of fracture care have not yet been fully investigated.

METHODS

In this retrospectively cohort study at a level one trauma center, patients requiring trauma team activations from 2015 to 2020 were screened. Patients with an injury severity score >16 and at least one body region requiring operative fixation were included. Patients who underwent their first definitive surgery <24 h were stratified as group SDS (Safe Definitive Surgery) and >24 h as group DFC (Delayed Fracture Care). Outcomes were early mortality (<72 h), SIRS and sepsis, timing to first definitive surgery and completed reconstruction, total number of surgeries, and factors influencing the surgical strategy (e.g., unstable physiology). Odds ratios for treatment strategies and influencing factors were calculated using the Fisher`s exact test with conditional maximum likelihood estimate.

RESULTS

From a total of 901 patients screened, 239 were included in the analyzes (Group DFC: 151, Groups SDS: 88). Groups did not significantly differ regarding early mortality, SIRS and sepsis. Group SDS had a significantly lower mean number of operations (4.3 vs. 5.3; p = 0.037) and a significantly shorter mean time until completion of reconstructive operations (10 days vs. 15 days; p = 0.013). Unstable physiology and intracranial trauma sequelae with the necessity for neurosurgical interventions (NSI) were identified as most significant factors for delaying definitive fracture care (OR: 2.85; 95 % CIs: 1.56 to 5.33 and OR: 5.59; 95 % CIs: 1.63 to 29.85), while the presence of intracranial bleeding (IB) without NSI did not have a significant influence (OR: 1.21; 95 % CIs: 0.63 to 2.34).

CONCLUSION

The necessity of NSI and unstable physiology are highly relevant factors for delaying definitive fracture care in polytrauma patients, while the presence of IB without NSI had less impact. In this cohort, early definitive fracture care in physiologically stable patients without NSI, was not associated with increased patient morbidity.

Nanoparticle targeting strategies for traumatic brain injury

Nanoparticle (NP)-based drug delivery systems hold immense potential for targeted therapy and diagnosis of neurological disorders, overcoming the limitations of conventional treatment modalities. This review explores the design considerations and functionalization strategies of NPs for precise targeting of the brain and central nervous system. This review discusses the challenges associated with drug delivery to the brain, including the blood-brain barrier and the complex heterogeneity of traumatic brain injury. We also examine the physicochemical properties of NPs, emphasizing the role of size, shape, and surface characteristics in their interactions with biological barriers and cellular uptake mechanisms. The review concludes by exploring the options of targeting ligands designed to augment NP affinity and retention to specific brain regions or cell types. Various targeting ligands are discussed for their ability to mimic receptor-ligand interaction, and brain-specific extracellular matrix components. Strategies to mimic viral mechanisms to increase uptake are discussed. Finally, the emergence of antibody, antibody fragments, and antibody mimicking peptides are discussed as promising targeting strategies. By integrating insights from these scientific fields, this review provides an understanding of NP-based targeting strategies for personalized medicine approaches to neurological disorders. The design considerations discussed here pave the way for the development of NP platforms with enhanced therapeutic efficacy and minimized off-target effects, ultimately advancing the field of neural engineering.

Dynamic Prediction of Patient Outcomes in the Intensive Care Unit: A Scoping Review of the State-of-the-Art

INTRODUCTION

Intensive care units (ICUs) are high-pressure, complex, technology-intensive medical environments where patient physiological data are generated continuously. Due to the complexity of interpreting multiple signals at speed, there are substantial opportunities and significant potential benefits in providing ICU staff with additional decision support and predictive modeling tools that can support and aid decision-making in real-time.This scoping review aims to synthesize the state-of-the-art dynamic prediction models of patient outcomes developed for use in the ICU. We define "dynamic" models as those where predictions are regularly computed and updated over time in response to updated physiological signals.

METHODS

Studies describing the development of predictive models for use in the ICU were searched, using PubMed. The studies were screened as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and the data regarding predicted outcomes, methods used to develop the predictive models, preprocessing the data and dealing with missing values, and performance measures were extracted and analyzed.

RESULTS

A total of n = 36 studies were included for synthesis in our review. The included studies focused on the prediction of various outcomes, including mortality (n = 17), sepsis-related complications (n = 12), cardiovascular complications (n = 5), and other complications (respiratory, renal complications, and bleeding, n = 5). The most common classification methods include logistic regression, random forest, support vector machine, and neural networks.

CONCLUSION

The included studies demonstrated that there is a strong interest in developing dynamic prediction models for various ICU patient outcomes. Most models reported focus on mortality. As such, the development of further models focusing on a range of other serious and well-defined complications-such as acute kidney injury-would be beneficial. Furthermore, studies should improve the reporting of key aspects of model development challenges.

Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study

INTRODUCTION

Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization.

METHODS

Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported.

RESULTS

In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]).

CONCLUSIONS

Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

BACKGROUND

Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care.

METHODS

A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted.

RESULTS

A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided.

CONCLUSIONS

This consensus provides practical recommendations to support clinician's decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

BACKGROUND

Patients with moderate and severe traumatic brain injury (TBI) are admitted to general hospitals (GHs) without neurosurgical services, but few studies have addressed the management of these patients. This study aimed to describe these patients, the rate of and reasons for managing patients entirely at the GH, and differences between patients managed entirely at the GH (GH group) and patients transferred to the regional trauma centre (RTC group). We specifically examined the characteristics of elderly patients.

METHODS

Patients with moderate (Glasgow Coma Scale score 9-13) and severe (score ≤ 8) TBIs who were admitted to one of the seven GHs without neurosurgical services in central Norway between 01.10.2004 and 01.10.2014 were retrospectively identified. Demographic, injury-related and outcome data were collected from medical records. Head CT scans were reviewed.

RESULTS

Among 274 patients admitted to GHs, 137 (50%) were in the GH group. The transferral rate was 58% for severe TBI and 40% for moderate TBI. Compared to the RTC group, patients in the GH group were older (median age: 78 years vs. 54 years, p < 0.001), more often had a preinjury disability (50% vs. 39%, p = 0.037), and more often had moderate TBI (52% vs. 35%, p = 0.005). The six-month case fatality rate was low (8%) in the GH group when transferral was considered unnecessary due to a low risk of further deterioration and high (90%, median age: 87 years) when neurosurgical intervention was considered nonbeneficial. Only 16% of patients ≥ 80 years old were transferred to the RTC. For this age group, the in-hospital case fatality rate was 67% in the GH group and 36% in the RTC group and 84% and 73%, respectively, at 6 months.

CONCLUSIONS

Half of the patients were managed entirely at a GH, and these were mainly patients considered to have a low risk of further deterioration, patients with moderate TBI, and elderly patients. Less than two of ten patients ≥ 80 years old were transferred, and survival was poor regardless of the transferral status.

The effect of targeted hyperoxemia in a randomized controlled trial employing a long-term resuscitated, model of combined acute subdural hematoma and hemorrhagic shock in swine with coronary artery disease: An exploratory, hypothesis-generating study

Controversial evidence is available regarding suitable targets for the arterial O₂ tension (P_aO₂) after traumatic brain injury and/or hemorrhagic shock (HS). We previously demonstrated that hyperoxia during resuscitation from hemorrhagic shock attenuated cardiac injury and renal dysfunction in swine with coronary artery disease. Therefore, this study investigated the impact of targeted hyperoxemia in a long-term, resuscitated model of combined acute subdural hematoma (ASDH)-induced brain injury and HS. The prospective randomized, controlled, resuscitated animal investigation consisted of 15 adult pigs. Combined ASDH plus HS was induced by injection of 0.1 ml/kg autologous blood into the subdural space followed by controlled passive removal of blood. Two hours later, resuscitation was initiated comprising re-transfusion of shed blood, fluids, continuous i.v. noradrenaline, and either hyperoxemia (target P_aO₂ 200 – 250 mmHg) or normoxemia (target P_aO₂ 80 – 120 mmHg) during the first 24 h of the total of 54 h of intensive care. Systemic hemodynamics, intracranial and cerebral perfusion pressures, parameters of brain microdialysis and blood biomarkers of brain injury did not significantly differ between the two groups. According to the experimental protocol, P_aO₂ was significantly higher in the hyperoxemia group at the end of the intervention period, i.e., at 24 h of resuscitation, which coincided with a higher brain tissue PO₂. The latter persisted until the end of observation period. While neurological function as assessed using the veterinary Modified Glasgow Coma Score progressively deteriorated in the control group, it remained unaffected in the hyperoxemia animals, however, without significant intergroup difference. Survival times did not significantly differ in the hyperoxemia and control groups either. Despite being associated with higher brain tissue PO₂ levels, which were sustained beyond the intervention period, targeted hyperoxemia exerted neither significantly beneficial nor deleterious effects after combined ASDH and HS in swine with pre-existing coronary artery disease. The unavailability of a power calculation and, thus, the limited number of animals included, are the limitations of the study.

Clustering identifies endotypes of traumatic brain injury in an intensive care cohort: a CENTER-TBI study

BACKGROUND

While the Glasgow coma scale (GCS) is one of the strongest outcome predictors, the current classification of traumatic brain injury (TBI) as 'mild', 'moderate' or 'severe' based on this fails to capture enormous heterogeneity in pathophysiology and treatment response. We hypothesized that data-driven characterization of TBI could identify distinct endotypes and give mechanistic insights.

METHODS

We developed an unsupervised statistical clustering model based on a mixture of probabilistic graphs for presentation (< 24 h) demographic, clinical, physiological, laboratory and imaging data to identify subgroups of TBI patients admitted to the intensive care unit in the CENTER-TBI dataset (N = 1,728). A cluster similarity index was used for robust determination of optimal cluster number. Mutual information was used to quantify feature importance and for cluster interpretation.

RESULTS

Six stable endotypes were identified with distinct GCS and composite systemic metabolic stress profiles, distinguished by GCS, blood lactate, oxygen saturation, serum creatinine, glucose, base excess, pH, arterial partial pressure of carbon dioxide, and body temperature. Notably, a cluster with 'moderate' TBI (by traditional classification) and deranged metabolic profile, had a worse outcome than a cluster with 'severe' GCS and a normal metabolic profile. Addition of cluster labels significantly improved the prognostic precision of the IMPACT (International Mission for Prognosis and Analysis of Clinical trials in TBI) extended model, for prediction of both unfavourable outcome and mortality (both p < 0.001).

CONCLUSIONS

Six stable and clinically distinct TBI endotypes were identified by probabilistic unsupervised clustering. In addition to presenting neurology, a profile of biochemical derangement was found to be an important distinguishing feature that was both biologically plausible and associated with outcome. Our work motivates refining current TBI classifications with factors describing metabolic stress. Such data-driven clusters suggest TBI endotypes that merit investigation to identify bespoke treatment strategies to improve care. Trial registration The core study was registered with ClinicalTrials.gov, number NCT02210221 , registered on August 06, 2014, with Resource Identification Portal (RRID: SCR_015582).

Acute traumatic brain injury in frail patients: the next pandemic

PURPOSE OF REVIEW

To highlight recent findings on the evaluation and impact of frailty in the management of patients with traumatic brain injury (TBI).

RECENT FINDINGS

Frailty is not a direct natural consequence of aging. Rather, it commonly results from the intersection of age-related decline with chronic diseases and conditions. It is associated with adverse outcomes such as institutionalization, falls, and worsening health status. Growing evidence suggests that frailty should be a key consideration both in care planning and in adverse outcome prevention. The prevalence of elderly patients with TBI is increasing, and low-energy trauma (i.e., ground or low-level falls, which are typical in frail patients) is the major cause. Establishing the real incidence of frailty in TBI requires further studies. Failure to detect frailty potentially exposes patients to interventions that may not benefit them, and may even harm them. Moreover, considering patients as 'nonfrail' purely on the basis of their age is unacceptable. The future challenge is to shift to a new clinical paradigm characterized by more appropriate, goal-directed care of frail patients.

SUMMARY

The current review highlights the crucial importance of frailty evaluation in TBI, also given the changing epidemiology of this condition. To ensure adequate assessment, prevention and management, both in and outside hospital, there is an urgent need for a valid screening tool and a specific frailty-based and comorbidity-based clinical approach.