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Hakimzadeh Z, Vahdati SS, Ala A, Rahmani F, Ghafouri RR, Jaberinezhad M. The predictive value of the Kampala Trauma Score (KTS) in the outcome of multi-traumatic patients compared to the estimated Injury Severity Score (eISS). BMC Emerg Med 2024; 24:82. [PMID: 38745146 PMCID: PMC11094877 DOI: 10.1186/s12873-024-00989-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/18/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE The classification of trauma patients in emergency settings is a constant challenge for physicians. However, the Injury Severity Score (ISS) is widely used in developed countries, it may be difficult to perform it in low- and middle-income countries (LMIC). As a result, the ISS was calculated using an estimated methodology that has been described and validated in a high-income country previously. In addition, a simple scoring tool called the Kampala Trauma Score (KTS) was developed recently. The aim of this study was to compare the diagnostic accuracy of KTS and estimated ISS (eISS) in order to achieve a valid and efficient scoring system in our resource-limited setting. METHODS We conducted a cross-sectional study between December 2020 and March 2021 among the multi-trauma patients who presented at the emergency department of Imam Reza hospital, Tabriz, Iran. After obtaining informed consent, all data including age, sex, mechanism of injury, GCS, KTS, eISS, final outcome (including death, morbidity, or discharge), and length of hospital stay were collected and entered into SPSS version 27.0 and analyzed. RESULTS 381 multi-trauma patients participated in the study. The area under the curve for prediction of mortality (AUC) for KTS was 0.923 (95%CI: 0.888-0.958) and for eISS was 0.910 (95% CI: 0.877-0.944). For the mortality, comparing the AUCs by the Delong test, the difference between areas was not statistically significant (p value = 0.356). The diagnostic odds ratio (DOR) for the prediction of mortality KTS and eISS were 28.27 and 32.00, respectively. CONCLUSION In our study population, the KTS has similar accuracy in predicting the mortality of multi-trauma patients compared to the eISS.
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Affiliation(s)
- Zahra Hakimzadeh
- Emergency and Trauma Care Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Samad Shams Vahdati
- Emergency and Trauma Care Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Ala
- Emergency and Trauma Care Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farzad Rahmani
- Emergency and Trauma Care Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rouzbeh Rajaei Ghafouri
- Emergency and Trauma Care Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehran Jaberinezhad
- Clinical Research Development Unit of Tabriz Valiasr Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Qiu H, Zador Z, Lannon M, Farrokhyar F, Duda T, Sharma S. Identification of clinically relevant patient endotypes in traumatic brain injury using latent class analysis. Sci Rep 2024; 14:1294. [PMID: 38221527 PMCID: PMC10788338 DOI: 10.1038/s41598-024-51474-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/05/2024] [Indexed: 01/16/2024] Open
Abstract
Traumatic brain injury (TBI) is a complex condition where heterogeneity impedes the advancement of care. Understanding the diverse presentations of TBI is crucial for personalized medicine. Our study aimed to identify clinically relevant patient endotypes in TBI using latent class analysis based on comorbidity data. We used the Medical Information Mart for Intensive Care III database, which includes 2,629 adult TBI patients. We identified five stable endotypes characterized by specific comorbidity profiles: Heart Failure and Arrhythmia, Healthy, Renal Failure with Hypertension, Alcohol Abuse, and Hypertension. Each endotype had distinct clinical characteristics and outcomes: The Heart Failure and Arrhythmia endotype had lower survival rates than the Renal Failure with Hypertension despite featuring fewer comorbidities overall. Patients in the Hypertension endotype had higher rates of neurosurgical intervention but shorter stays in contrast to the Alcohol Abuse endotype which had lower rates of neurosurgical intervention but significantly longer hospital stays. Both endotypes had high overall survival rates comparable to the Healthy endotype. Logistic regression models showed that endotypes improved the predictability of survival compared to individual comorbidities alone. This study validates clinical endotypes as an approach to addressing heterogeneity in TBI and demonstrates the potential of this methodology in other complex conditions.
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Affiliation(s)
- Hongbo Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Zsolt Zador
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
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Sagi L, Price J, Lachowycz K, Starr Z, Major R, Keeliher C, Finbow B, McLachlan S, Moncur L, Steel A, Sherren PB, Barnard EBG. Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study. Scand J Trauma Resusc Emerg Med 2023; 31:104. [PMID: 38124103 PMCID: PMC10731700 DOI: 10.1186/s13049-023-01167-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations. METHODS A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI). RESULTS 30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension. CONCLUSION Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.
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Affiliation(s)
- Liam Sagi
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK.
| | - James Price
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Lachowycz
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Zachary Starr
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Rob Major
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | | | | | - Sarah McLachlan
- Essex and Herts Air Ambulance, Earls Colne, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Lyle Moncur
- Essex and Herts Air Ambulance, Earls Colne, UK
| | | | - Peter B Sherren
- Essex and Herts Air Ambulance, Earls Colne, UK
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ed B G Barnard
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
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Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Guerrette MC, McKerral M. Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways. J Neurotrauma 2023; 40:523-535. [PMID: 35974662 DOI: 10.1089/neu.2022.0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.
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Affiliation(s)
- Marie-Claude Guerrette
- Department of Psychology, Université de Montréal, Center for Interdisciplinary Research in Rehabilitation of Greater Montreal-IURDPM, Montreal, Quebec, Canada
| | - Michelle McKerral
- Department of Psychology, Université de Montréal, Center for Interdisciplinary Research in Rehabilitation of Greater Montreal-IURDPM, Montreal, Quebec, Canada
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Santiago-Castañeda C, Huerta de la Cruz S, Martínez-Aguirre C, Orozco-Suárez SA, Rocha L. Cannabidiol Reduces Short- and Long-Term High Glutamate Release after Severe Traumatic Brain Injury and Improves Functional Recovery. Pharmaceutics 2022; 14:pharmaceutics14081609. [PMID: 36015236 PMCID: PMC9414526 DOI: 10.3390/pharmaceutics14081609] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/16/2022] [Accepted: 07/29/2022] [Indexed: 12/04/2022] Open
Abstract
This study aimed to determine if orally administered cannabidiol (CBD) lessens the cortical over-release of glutamate induced by a severe traumatic brain injury (TBI) and facilitates functional recovery. The short-term experiment focused on identifying the optimal oral pretreatment of CBD. Male Wistar rats were pretreated with oral administration of CBD (50, 100, or 200 mg/kg) daily for 7 days. Then, extracellular glutamate concentration was estimated by cortical microdialysis before and immediately after a severe TBI. The long-term experiment focused on evaluating the effect of the optimal treatment of CBD (pre- vs. pre- and post-TBI) 30 days after trauma. Sensorimotor function, body weight, and mortality rate were evaluated. In the short term, TBI induced a high release of glutamate (738% ± 173%; p < 0.001 vs. basal). Oral pretreatment with CBD at all doses tested reduced glutamate concentration but with higher potency at when animals received 100 mg/kg (222 ± 33%, p < 0.01 vs. TBI), an effect associated with a lower mortality rate (22%, p < 0.001 vs. TBI). In the long-term experiment, the TBI group showed a high glutamate concentration (149% p < 0.01 vs. SHAM). In contrast, animals receiving the optimal treatment of CBD (pre- and pre/post-TBI) showed glutamate concentrations like the SHAM group (p > 0.05). This effect was associated with high sensorimotor function improvement. CBD pretreatment, but not pre-/post-treatment, induced a higher body weight gain (39% ± 2.7%, p < 0.01 vs. TBI) and lower mortality rate (22%, p < 0.01 vs. TBI). These results support that orally administered CBD reduces short- and long-term TBI-induced excitotoxicity and facilitated functional recovery. Indeed, pretreatment with CBD was sufficient to lessen the adverse sequelae of TBI.
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Affiliation(s)
- Cindy Santiago-Castañeda
- Department of Pharmacobiology, Center for Research and Advanced Studies (CINVESTAV), Mexico City 14330, Mexico; (C.S.-C.); (S.H.d.l.C.); (C.M.-A.)
| | - Saúl Huerta de la Cruz
- Department of Pharmacobiology, Center for Research and Advanced Studies (CINVESTAV), Mexico City 14330, Mexico; (C.S.-C.); (S.H.d.l.C.); (C.M.-A.)
| | - Christopher Martínez-Aguirre
- Department of Pharmacobiology, Center for Research and Advanced Studies (CINVESTAV), Mexico City 14330, Mexico; (C.S.-C.); (S.H.d.l.C.); (C.M.-A.)
| | - Sandra Adela Orozco-Suárez
- Unit for Medical Research in Neurological Diseases, Specialties Hospital, National Medical Center SXXI (CMN-SXXI), Mexico City 06720, Mexico;
| | - Luisa Rocha
- Department of Pharmacobiology, Center for Research and Advanced Studies (CINVESTAV), Mexico City 14330, Mexico; (C.S.-C.); (S.H.d.l.C.); (C.M.-A.)
- Correspondence: ; Tel.: +52-55-5483-2800
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Merz T, McCook O, Denoix N, Radermacher P, Waller C, Kapapa T. Biological Connection of Psychological Stress and Polytrauma under Intensive Care: The Role of Oxytocin and Hydrogen Sulfide. Int J Mol Sci 2021; 22:9192. [PMID: 34502097 PMCID: PMC8430789 DOI: 10.3390/ijms22179192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 12/12/2022] Open
Abstract
This paper explored the potential mediating role of hydrogen sulfide (H2S) and the oxytocin (OT) systems in hemorrhagic shock (HS) and/or traumatic brain injury (TBI). Morbidity and mortality after trauma mainly depend on the presence of HS and/or TBI. Rapid "repayment of the O2 debt" and prevention of brain tissue hypoxia are cornerstones of the management of both HS and TBI. Restoring tissue perfusion, however, generates an ischemia/reperfusion (I/R) injury due to the formation of reactive oxygen (ROS) and nitrogen (RNS) species. Moreover, pre-existing-medical-conditions (PEMC's) can aggravate the occurrence and severity of complications after trauma. In addition to the "classic" chronic diseases (of cardiovascular or metabolic origin), there is growing awareness of psychological PEMC's, e.g., early life stress (ELS) increases the predisposition to develop post-traumatic-stress-disorder (PTSD) and trauma patients with TBI show a significantly higher incidence of PTSD than patients without TBI. In fact, ELS is known to contribute to the developmental origins of cardiovascular disease. The neurotransmitter H2S is not only essential for the neuroendocrine stress response, but is also a promising therapeutic target in the prevention of chronic diseases induced by ELS. The neuroendocrine hormone OT has fundamental importance for brain development and social behavior, and, thus, is implicated in resilience or vulnerability to traumatic events. OT and H2S have been shown to interact in physical and psychological trauma and could, thus, be therapeutic targets to mitigate the acute post-traumatic effects of chronic PEMC's. OT and H2S both share anti-inflammatory, anti-oxidant, and vasoactive properties; through the reperfusion injury salvage kinase (RISK) pathway, where their signaling mechanisms converge, they act via the regulation of nitric oxide (NO).
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Affiliation(s)
- Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
- Clinic for Psychosomatic Medicine and Psychotherapy, Medical Center, Ulm University, 89081 Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Nuremberg General Hospital, Paracelsus Medical University, 90471 Nuremberg, Germany;
| | - Thomas Kapapa
- Clinic for Neurosurgery, Medical Center, Ulm University, 89081 Ulm, Germany;
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Freeman AD, Fitzgerald CA, Baxter KJ, Neff LP, McCracken CE, Bryan LN, Morsberger JL, Zahid AM, Santore MT. Does hypertension at initial presentation adversely affect outcomes in pediatric traumatic brain injury? J Pediatr Surg 2020; 55:702-706. [PMID: 31277980 PMCID: PMC6925357 DOI: 10.1016/j.jpedsurg.2019.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 06/04/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Adults with traumatic brain injury (TBI) who present hypertensive suffer worse outcomes and increased mortality compared to normotensive patients. The purpose of this study is to determine if age-adjusted hypertension on presentation is associated with worsened outcomes in pediatric TBI. METHODS A retrospective chart review was conducted on pediatric patients with severe TBI admitted to a single system pediatric tertiary care center. The primary outcome was mortality. Secondary outcomes included length of stay, need for neurosurgical intervention, duration of mechanical ventilation, and the need for inpatient rehabilitation. RESULTS Of 150 patients, 70% were hypertensive and 30% were normotensive on presentation. Comparing both groups, no statistically significant differences were noted in mortality (13.3% for both groups), need for neurosurgical intervention (51.4% vs 48.8%, p = 0.776), length of stay (6 vs 8 days, p = 0.732), duration of mechanical ventilation (2 vs 3 days, p = 0.912), or inpatient rehabilitation rates (48.6% vs 48.9%, p = 0.972). In comparing just the hypertensive patients, there was a trend toward increased mortality in the 95th and 99th percentile groups at 15.8% and 14.1%, versus the 90th percentile group at 6.7% but the difference was not statistically significant (p = 0.701). CONCLUSIONS Contrary to the adult literature, pediatric patients with severe TBI and hypertension on presentation do not appear to have worsened outcomes compared to those who are normotensive. However, a trend toward increased mortality did exist at extremes of age adjusted hypertension. Larger scale studies are needed to validate these findings. STUDY TYPE Retrospective cohort study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Ashley D. Freeman
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States,Corresponding author at: 1405 Clifton Rd NE, Division of Critical Care Medicine, 4 Floor Tower 1, Atlanta, GA 30322. Tel.: +1 404 785 4751; fax: +1 404 785 6233. (A.D. Freeman)
| | - Caitlin A. Fitzgerald
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Katherine J. Baxter
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Lucas P. Neff
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
| | - Courtney E. McCracken
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
| | - Leah N. Bryan
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
| | - Jill L. Morsberger
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Arslan M. Zahid
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Matthew T. Santore
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
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Williams AM, Bhatti UF, Dennahy IS, Graham NJ, Nikolian VC, Chtraklin K, Chang P, Zhou J, Biesterveld BE, Eliason J, Alam HB. Traumatic brain injury may worsen clinical outcomes after prolonged partial resuscitative endovascular balloon occlusion of the aorta in severe hemorrhagic shock model. J Trauma Acute Care Surg 2019; 86:415-423. [PMID: 30605139 PMCID: PMC6715315 DOI: 10.1097/ta.0000000000002149] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The use of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) in combined hemorrhagic shock (HS) and traumatic brain injury (TBI) has not been well studied. We hypothesized that the use of pREBOA in the setting of TBI would be associated with worse clinical outcomes. METHODS Female Yorkshire swine were randomized to the following groups: HS-TBI, HS-TBI-pREBOA, and HS-pREBOA (n = 5/cohort). Animals in the HS-TBI group were left in shock for a total of 2 hours, whereas animals assigned to pREBOA groups were treated with supraceliac pREBOA deployment (60 minutes) 1 hour into the shock period. All animals were then resuscitated, and physiologic parameters were monitored for 6 hours. Further fluid resuscitation and vasopressors were administered as needed. At the end of the observation period, brain hemispheric swelling (%) and lesion size (mm) were assessed. RESULTS Mortality was highest in the HS-TBI-pREBOA group (40% [2/5] vs. 0% [0/5] in the other groups, p = 0.1). Severity of shock was greatest in the HS-TBI-pREBOA group, as defined by peak lactate levels and pH nadir (p < 0.05). Fluid resuscitation and norepinephrine requirements were significantly higher in the HS-TBI-pREBOA group (p < 0.05). No significant differences were noted in brain hemispheric swelling and lesion size between the groups. CONCLUSION Prolonged application of pREBOA in the setting of TBI does not contribute to early worsening of brain lesion size and edema. However, the addition of TBI to HS-pREBOA may worsen the severity of shock. Providers should be aware of the potential physiologic sequelae induced by TBI.
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Affiliation(s)
| | - Umar F. Bhatti
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Nathan J. Graham
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Kiril Chtraklin
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Panpan Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jing Zhou
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Jonathan Eliason
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hasan B. Alam
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Wafaisade A, Caspers M, Bouillon B, Helm M, Ruppert M, Gäßler M. Changes in anaesthetic use for trauma patients in German HEMS - a retrospective study over a ten-year period. Scand J Trauma Resusc Emerg Med 2019; 27:23. [PMID: 30808371 PMCID: PMC6390324 DOI: 10.1186/s13049-019-0603-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 02/17/2019] [Indexed: 11/29/2022] Open
Abstract
Background Airway management and use of intravenous anaesthetics to facilitate tracheal intubation after major trauma remains controversial. Numerous agents are available and used for pre-hospital rapid-sequence induction (RSI). The aim was to investigate usage and potential changes in administration of intravenous anaesthetics for pre-hospital RSI in trauma patients over a ten-year period. Methods Based on a large helicopter emergency medical service (HEMS) database in Germany between 2006 and 2015, a total of 9720 HEMS missions after major trauma leading to RSI on scene were analysed. Administration practice of sedatives and opioids were investigated, while neuromuscular blocking agents were not documented in the database. Results With respect to administration of sedatives, independent from trauma mechanism and specific injury patterns the use of Etomidate decreased dramatically (52 to 6%) in favour of a more frequent use of Propofol (3 to 32%) and Ketamine (9 to 24%; all p < 0.001) from 2006 to 2015. The use of Benzodiazepines increased slightly, while the utilization rate of Barbiturates remained constant. In patients with Shock Index > 1 at initial contact, the administration rate of Etomidate dropped significantly as well. This decline was mainly substituted by Ketamine and particularly Propofol. In patients with GCS ≤ 8 upon initial contact, a similar distribution compared to the general trauma population could be observed. With respect to opioids, mainly Fentanyl has been administered for RSI in trauma patients (2006: 69,6% to 2015: 60.2%; p < 0.001), while the use of sufentanyl showed a significant increase (0.2 to 8.8%; p < 0.001). Conclusions This large study analysed prehospital administration of anaesthetics in trauma patients, showing a substantial change from 2006 to 2015 despite the lack of any high-level evidence. Etomidate has shifted from the main sedative substance to virtual absence, indicating that the recommendation of an established national guideline was transferred into clinical practice, although based on weak evidence as well. The pre-hospital use of Propofol showed a particular increase. Fentanyl has been the main opioid drug for RSI in trauma, however Sufentanyl has become increasingly popular. The mechanisms and advantages of the different substances still have to be elucidated, especially in head injury and bleeding trauma.
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Affiliation(s)
- Arasch Wafaisade
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - Michael Caspers
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.,The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Bertil Bouillon
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Matthias Helm
- Armed Forces Medical Centre Ulm, Department of Anaesthesiology and Intensive Care Medicine, Section Emergency Medicine - HEMS "Christoph 22", Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Matthias Ruppert
- Department of Medicine - ADAC Air Rescue Service, Hansastrasse 19, 80686, Munich, Germany
| | - Michael Gäßler
- Department of Medicine - ADAC Air Rescue Service, Hansastrasse 19, 80686, Munich, Germany
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Kaushal A, Bindra A, Kumar A, Goyal K, Kumar N, Rath GP, Gupta D. Long Term Outcome in Survivors of Decompressive Craniectomy following Severe Traumatic Brain Injury. Asian J Neurosurg 2019; 14:52-57. [PMID: 30937008 PMCID: PMC6417309 DOI: 10.4103/ajns.ajns_147_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Decompressive craniectomy (DC) is done for the management of intracranial hypertension due to severe traumatic brain injury (sTBI). Despite DC, a number of patients die and others suffer from severe neurological disability. We conducted this observational study to assess functional outcome as measured by Glasgow outcome scale-extended (GOSE) in survivors of DC. The correlation between various factors at admission and hospital with functional outcome was also obtained. Materials and Methods: Patients (15–65 years) posted for cranioplasty following DC due to sTBI were prospectively enrolled. Demographic profile, clinical data, and GOSE were noted at the time of admission for cranioplasty from the patient or nearest relative or both. Retrospective data noted from hospital records included admission Marshalls grading, Glasgow coma score (GCS), motor response, mean arterial pressure (MAP), and timing of DC at the time of initial admission following sTBI. Results: A total of 85 patients (71 males and 14 females) were enrolled over a period of 2 years. The mean age of the patients was 33.42 ± 12.70 years. The median GCS at the time of admission due to head injury, at the time of discharge, and at the time of cranioplasty was 8 (interquartile range [IQR] 3–15), 10 (IQR 4–15), and 15 (IQR 7–15), respectively. Thirty-one patients (36%) had good functional outcome (GOSE 5–8) and 54 patients (64%) had poor functional outcome (GOSE 1–4). On univariate analysis tracheostomy (P = 0.00), duration of hospital stay (P = 0.002), MAP at admission (P = 0.01), and GCS at discharge (P = 0.01) correlated with outcome [Table 1]. On multivariate analysis MAP at admission (odds ratio [OR] [95% confidence interval {CI}]; 0.07 [0.01–0.40] and tracheostomy (OR [95% CI]; 15 [1.45–162.9]) were found to be the independent predictors of functional outcome. Conclusion: Significant disability is seen among the survivors of DC. Tracheostomy and MAP at admission were found to be independently associated with the patient outcome.
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Affiliation(s)
- Ashutosh Kaushal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Ashish Bindra
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Abhyuday Kumar
- Department of Anesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Keshav Goyal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Niraj Kumar
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
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Krishnamoorthy V, Chaikittisilpa N, Kiatchai T, Vavilala M. Hypertension After Severe Traumatic Brain Injury: Friend or Foe? J Neurosurg Anesthesiol 2017; 29:382-387. [PMID: 27648804 PMCID: PMC5357208 DOI: 10.1097/ana.0000000000000370] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Traumatic brain injury (TBI) is a major public health problem, with severe TBI contributing to a large number of deaths and disability worldwide. Early hypotension has been linked with poor outcomes following severe TBI, and guidelines suggest early and aggressive management of hypotension after TBI. Despite these recommendations, no guidelines exist for the management of hypertension after severe TBI, although observational data suggests that early hypertension is also associated with an increased risk of mortality after severe TBI. The purpose of this review is to discuss the underlying pathophysiology of hypertension after TBI, provide an overview of the current clinical data on early hypertension after TBI, and discuss future research that should test the benefits and harms of treating high blood pressure in TBI patients.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology and Pain Medicine, University of Washington
- Harborview Injury Prevention and Research Center, University of Washington
| | - Nophanan Chaikittisilpa
- Department of Anesthesiology and Pain Medicine, University of Washington
- Harborview Injury Prevention and Research Center, University of Washington
| | - Taniga Kiatchai
- Department of Anesthesiology and Pain Medicine, University of Washington
- Harborview Injury Prevention and Research Center, University of Washington
| | - Monica Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington
- Harborview Injury Prevention and Research Center, University of Washington
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The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine multiple injuries model. J Trauma Acute Care Surg 2017. [PMID: 28632582 DOI: 10.1097/ta.0000000000001518] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite clinical reports of poor outcomes, the degree to which resuscitative endovascular balloon occlusion of the aorta (REBOA) exacerbates traumatic brain injury (TBI) is not known. We hypothesized that combined effects of increased proximal mean arterial pressure (pMAP), carotid blood flow (Qcarotid), and intracranial pressure (ICP) from REBOA would lead to TBI progression compared with partial aortic occlusion (PAO) or no intervention. METHODS Twenty-one swine underwent a standardized TBI via computer Controlled cortical impact followed by 25% total blood volume rapid hemorrhage. After 30 minutes of hypotension, animals were randomized to 60 minutes of continued hypotension (Control), REBOA, or PAO. REBOA and PAO animals were then weaned from occlusion. All animals were resuscitated with shed blood via a rapid blood infuser. Physiologic parameters were recorded continuously and brain computed tomography obtained at specified intervals. RESULTS There were no differences in baseline physiology or during the initial 30 minutes of hypotension. During the 60-minute intervention period, REBOA resulted in higher maximal pMAP (REBOA, 105.3 ± 8.8; PAO, 92.7 ± 9.2; Control, 48.9 ± 7.7; p = 0.02) and higher Qcarotid (REBOA, 673.1 ± 57.9; PAO, 464.2 ± 53.0; Control, 170.3 ± 29.4; p < 0.01). Increases in ICP were greatest during blood resuscitation, with Control animals demonstrating the largest peak ICP (Control, 12.8 ± 1.2; REBOA, 5.1 ± 0.6; PAO, 9.4 ± 1.1; p < 0.01). There were no differences in the percentage of animals with hemorrhage progression on CT (Control, 14.3%; 95% confidence interval [CI], 3.6-57.9; REBOA, 28.6%; 95% CI, 3.7-71.0; and PAO, 28.6%; 95% CI, 3.7-71.0). CONCLUSION In an animal model of TBI and shock, REBOA increased Qcarotid and pMAP, but did not exacerbate TBI progression. PAO resulted in physiology closer to baseline with smaller increases in ICP and pMAP. Rapid blood resuscitation, not REBOA, resulted in the largest increase in ICP after intervention, which occurred in Control animals. Continued studies of the cerebral hemodynamics of aortic occlusion and blood transfusion are required to determine optimal resuscitation strategies for multi-injured patients.
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14
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Garcia JM, Stillings SA, Leclerc JL, Phillips H, Edwards NJ, Robicsek SA, Hoh BL, Blackburn S, Doré S. Role of Interleukin-10 in Acute Brain Injuries. Front Neurol 2017; 8:244. [PMID: 28659854 PMCID: PMC5466968 DOI: 10.3389/fneur.2017.00244] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/17/2017] [Indexed: 12/23/2022] Open
Abstract
Interleukin-10 (IL-10) is an important anti-inflammatory cytokine expressed in response to brain injury, where it facilitates the resolution of inflammatory cascades, which if prolonged causes secondary brain damage. Here, we comprehensively review the current knowledge regarding the role of IL-10 in modulating outcomes following acute brain injury, including traumatic brain injury (TBI) and the various stroke subtypes. The vascular endothelium is closely tied to the pathophysiology of these neurological disorders and research has demonstrated clear vascular endothelial protective properties for IL-10. In vitro and in vivo models of ischemic stroke have convincingly directly and indirectly shown IL-10-mediated neuroprotection; although clinically, the role of IL-10 in predicting risk and outcomes is less clear. Comparatively, conclusive studies investigating the contribution of IL-10 in subarachnoid hemorrhage are lacking. Weak indirect evidence supporting the protective role of IL-10 in preclinical models of intracerebral hemorrhage exists; however, in the limited number of clinical studies, higher IL-10 levels seen post-ictus have been associated with worse outcomes. Similarly, preclinical TBI models have suggested a neuroprotective role for IL-10; although, controversy exists among the several clinical studies. In summary, while IL-10 is consistently elevated following acute brain injury, the effect of IL-10 appears to be pathology dependent, and preclinical and clinical studies often paradoxically yield opposite results. The pronounced and potent effects of IL-10 in the resolution of inflammation and inconsistency in the literature regarding the contribution of IL-10 in the setting of acute brain injury warrant further rigorously controlled and targeted investigation.
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Affiliation(s)
- Joshua M Garcia
- College of Medicine, University of Florida, Gainesville, FL, United States
| | | | - Jenna L Leclerc
- Department of Anesthesiology, College of Medicine, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States.,Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Harrison Phillips
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Nancy J Edwards
- Department of Neurology, University of California, San Francisco, CA, United States.,Department of Neurosurgery, University of California, San Francisco, CA, United States
| | - Steven A Robicsek
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States.,Department of Neurosurgery, University of Florida, Gainesville, FL, United States.,Department of Neuroscience, University of Florida, Gainesville, FL, United States
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Spiros Blackburn
- Department of Neurosurgery, University of Texas, Houston, TX, United States
| | - Sylvain Doré
- Department of Anesthesiology, College of Medicine, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States.,Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, United States.,Department of Neurology, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Psychology, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Psychiatry, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Pharmaceutics, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States
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15
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Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care 2015; 19:134. [PMID: 25879683 PMCID: PMC4391675 DOI: 10.1186/s13054-015-0872-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 03/11/2015] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Rapid Sequence Induction of anaesthesia (RSI) is the recommended method to facilitate emergency tracheal intubation in trauma patients. In emergency situations, a simple and standardised RSI protocol may improve the safety and effectiveness of the procedure. A crucial component of developing a standardised protocol is the selection of induction agents. The aim of this study is to compare the safety and effectiveness of a traditional RSI protocol using etomidate and suxamethonium with a modified RSI protocol using fentanyl, ketamine and rocuronium. METHODS We performed a comparative cohort study of major trauma patients undergoing pre-hospital RSI by a physician-led Helicopter Emergency Medical Service. Group 1 underwent RSI using etomidate and suxamethonium and Group 2 underwent RSI using fentanyl, ketamine and rocuronium. Apart from the induction agents, the RSI protocol was identical in both groups. Outcomes measured included laryngoscopy view, intubation success, haemodynamic response to laryngoscopy and tracheal intubation, and mortality. RESULTS Compared to Group 1 (n = 116), Group 2 RSI (n = 145) produced significantly better laryngoscopy views (p = 0.013) and resulted in significantly higher first-pass intubation success (95% versus 100%; p = 0.007). A hypertensive response to laryngoscopy and tracheal intubation was less frequent following Group 2 RSI (79% versus 37%; p < 0.0001). A hypotensive response was uncommon in both groups (1% versus 6%; p = 0.05). Only one patient in each group developed true hypotension (SBP < 90 mmHg) on induction. CONCLUSIONS In a comparative, cohort study, pre-hospital RSI using fentanyl, ketamine and rocuronium produced superior intubating conditions and a more favourable haemodynamic response to laryngoscopy and tracheal intubation. An RSI protocol using fixed ratios of these agents delivers effective pre-hospital trauma anaesthesia.
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Affiliation(s)
- Richard M Lyon
- Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK.
| | - Zane B Perkins
- Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK.
- Centre for Trauma Sciences, Queen Mary, University of London, London, E1 2AT, UK.
| | - Debamoy Chatterjee
- Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK.
| | - David J Lockey
- School of Clinical Sciences University of Bristol & University of Stavanger Norway, North Bristol NHS Trust, Bristol, BS16 1LE, UK.
| | - Malcolm Q Russell
- Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK.
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16
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Bugaev N, Al-Hazmi M, Allcorn M, Arabian SS, Riesenburger R, Safain M, Burke S, Colangelo A, Rabinovici R. Blood pressure regulation to prevent progression of blunt traumatic intracranial hemorrhage in stable patients. Neurocrit Care 2015; 21:58-66. [PMID: 24493080 DOI: 10.1007/s12028-014-9957-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Target blood pressure (BP) in stable (non-hypotensive) patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) is unknown. To address this issue, our study correlated BP with radiological volumetric progression (RP) and neurological deterioration (ND) in these patients. METHODS A retrospective review of hemodynamically stable adults (n = 184) with isolated TICH not requiring emergent surgery consecutively admitted to a Level I trauma center. BPs before admission computed tomography (CT) scan (CT1) and between CT1 and a follow-up CT (CT2) were correlated with TICH volume and Glasgow Coma Scale (GCS) during these time periods. Predictors for deterioration were studied. Primary outcomes were increased measured TICH and decreased GCS at the CT1-CT2 interval. RESULTS Age (57 years), % male (73), ISS (17), % falls (77), comorbidities (1.2/pt), and % anticoagulation (20) were similar in patients with or without RP (n = 107, 58%) or ND (n = 34, 18%). By univariate analysis, RP patients had an average systolic (SBP), diastolic (DBP), and mean BP (MAP) similar to non-RP patients; whereas ND patients compared to non-ND patients had a higher mean admission DBP (p < 0.02) and MAP (p < 0.04), a higher mean admission peak MAP (p < 0.01) and DBP (p < 0.01), a higher CT1-CT2 interval peak DBP (p < 0.01) and peak MAP (p < 0.01), and a lower CT1-CT2 nadir SBP (p < 0.04). Spearman rank correlation test did not show association among average SBP, MAP, DBP, absolute or % change in BPs, and absolute or % change in TICH volumes in any phase. Multivariate analysis identified higher nadir admission SBP [adjusted odds ratio (AOR) 1.29 per 10 mmHg increase] and lower peak MAP during the CT1-CT2 period (AOR 0.71 per 10 mmHg decrease) as independent predictors of RP, and a peak DBP in the CT1-CT2 interval (AOR 1.48) as an independent predictor of ND. Other predictors of ND included bilateral admission TICH (AOR 3.31) and increased injury volume (AOR 1.36), while the number of comorbidities/patient (AOR 4.34), bilateral injury (AOR 3.12), and midline shift (AOR 4.34) predicted RD. CONCLUSIONS A comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration (injury volume and GCS) did not demonstrate a clinically relevant protective target BP value. Current practices of BP control in this specific group of patients should be further investigated. LEVEL OF EVIDENCE III Prognostic, Level II study.
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Affiliation(s)
- Nikolay Bugaev
- Department of Surgery, Tufts Medical Center, 800 Washington St., #4488, Boston, MA, 02111, USA
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Lugeder A. Differences between groups. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:288. [PMID: 23671474 PMCID: PMC3648897 DOI: 10.3238/arztebl.2013.0288a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Armin Lugeder
- *Klinik für Unfallchirurgie und Orthopädie, Johannes Wesling Klinikum Minden,
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Miersch D. In reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:288. [PMID: 23671475 PMCID: PMC3648898 DOI: 10.3238/arztebl.2013.0288b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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