Glascow Coma Score Research Articles

On-Field Rule Out of Mild Traumatic Brain Injury: Can Blood-Based Biomarker Testing Change Outcome of Major Sporting Events?

Mild traumatic brain injury (mTBI) is defined as a Glascow Coma Score of between 13 and 15. The diagnosis and rule out of individuals suffering from mTBI on an acute basis is imperfect and involves subjective measures. Serum biomarkers that exhibit narrow within-individual biological variation can be used for the early rule-out of mTBI, when baseline levels are compared during health. This is a descriptive study that applies published biological variation data of serum mTBI biomarkers for early rule out of sports-related injury. Laboratory tests such as glial fibrillary acidic protein, fatty acid binding protein 7, and phosphorylated protein enriched in astrocytes have low within-individual variances and are potential candidates. Aldolase C also rises early in blood but the biological variation is of this marker is currently unknown. The use of blood-based biomarkers, measured in real time using point-of-care testing devices when compared to a pre-competition baseline instead of a population-based reference interval, can provide early rule out of mTBI, and possibly enable on-field evaluations and a medical decision for a return to competition.

Factors affecting seizure recurrence in the emergency department

BackgroundInformation on Emergency Department (ED) follow-up of patients presenting with epileptic seizures is limited. ObjectivesIt was planned to investigate the factors affecting the recurrence of epileptic seizures in the follow-up of patients presenting to the ED with the complaint of epileptic seizures. Materials and methodsThis prospective, observational, single-center study was carried out in an adult population presenting to the ED. The study included patients older than 18 years of age presenting to the ED with the complaint of epileptic seizures. ResultsOf the 205 patients included in the study, 68 (33.2%) had seizure recurrence during the 6 h. In the univariable analysis, advanced age, prolonged post-ictal duration, increased seizure duration, generalized tonic clonic seizure, alcohol consumption within past 24 h, hypertension, coronary artery disease, Alzheimer's disease, prior ischemic cerebrovascular disease, low Glascow Coma Scale (GCS), high glucose, high C-Reactive Protein, high phosphorus, low potassium, high blood urea nitrogen, high lactate, increased anion gap, high osmolarity were statistically significant in predicting recurrent seizure recurrence within 6 h. According to the logistic regression, postictal duration, GCS score, and age were independent predictors in our model. The cut-off value of postictal duration in predicting seizure recurrence at the highest sensitivity (66.2%) and specificity (89.8%) was 22.5 min. ConclusionA prolonged postictal state, low GCS score, advanced age may be an indication of seizure recurrence. Therefore, patients with a long postictal duration, low GCS score, advanced age should be followed up more carefully in terms of recurrent seizures in the ED.

Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial

BackgroundTranexamic acid (TXA) has been hypothesized to mitigate coagulopathy in patients after traumatic injury. Despite previous prehospital clinical trials demonstrating a TXA survival benefit, none have demonstrated correlated changes in...

Analysis of Extracranial Cerebrovascular Injuries: Clinical Predictors of Management and Outcomes

Optimal management of traumatic extracranial cerebrovascular injuries (ECVIs) remains undefined. We sought to evaluate the factors that influence management and neurologic outcomes (stroke and brain death) following traumatic ECVI. A retrospective review of a single level 1 trauma center's prospectively maintained data registry of patients older than 18years of age with a diagnosis of ECVI was performed from 2013 to 2019. Injuries limited to the external carotid artery were excluded. Patient demographics, type of injury, timing of presentation, Biffl Classification of Cerebrovascular Injury Grade, Injury Severity Score (ISS), and Abbreviated Injury Scale were documented. Ultimate treatments (medical management and procedural interventions) and brain-related outcomes (stroke and brain death) were recorded. ECVIs were identified in 96 patients. The primary mechanism of injury was blunt trauma (89.5% vs. 10.5%, blunt versus penetrating), with 70 cases (66%) of vertebral artery injury and 37 cases of carotid artery injury. Treatments included vascular intervention (6.5%) and medical management (93.5%). Overall outcomes included ipsilateral ischemic stroke (29%) and brain death (6.5%). In the carotid group, vascular intervention was associated with higher Biffl grades (mean Biffl 3.17 vs. 2.23; P=0.087) and decreased incidence of brain death (0% vs. 19%, P=0.006), with no difference seen in ISS scores. Brain death was associated with higher ISS scores (40.29 vs. 24.17, P=0.01), lower glascow coma score on arrival (3.57 vs. 10.63, P<0.001), and increased rates of ischemic stroke (71% vs. 30%, P=0.025). In the vertebral group, neither Biffl grade nor ISS were associated with treatment or outcomes. Regarding the timing of stroke in ECVI, there was no significant difference in the time from presentation to cerebral infarction between the carotid and vertebral artery groups (24.7hr vs. 21.20hr, P=0.739). After this window, 98% of the ECVI cases demonstrated no further aneurysmal degeneration or new neurological deficits beyond the early time period (mean follow-up 9.7months). Blunt cerebrovascular injuries should be viewed distinctly in the carotid and vertebral territories. In cases of injury to the carotid artery, Biffl grade and ISS score are associated with surgical intervention and neurologic events, respectively; vertebral artery injuries did not share this association. Neurologic deficits were detected in a similar time frame between the carotid artery and the vertebral artery injury groups and both groups had rare late neurologic events.

The Impact of Antithrombotic Agents on In-Patient and Post-Discharge Mortality after Trauma Brain Injury (P7-1.009)

<h3>Objective:</h3> Determine the impact AA have on IPM and PDM TBI patients <h3>Background:</h3> Antithrombotic agents (AA) protect against thrombotic events with high risk of bleeding. It is unclear whether risks associated with TBI should impact decisions to start AA in the elderly, a group with the highest incidence of head injury. We hypothesize AA increase inpatient mortality (IPM) and 1y post-discharge mortality (PDM) rates in elderly TBI patients. <h3>Design/Methods:</h3> Elderly (age &gt;65) and adult (age 18–64) TBI patients were identified in a level I Trauma registry 2008–2017. Patients were sorted by AA exposure (+AA and −AA). The Trauma registry was merged with the National Death Index. Mortality was evaluated by chi-square, Fisher’s exact, and Wilcoxon rank-sum tests. Logistic regression determined the effect of AA on IPM and PDM. <h3>Results:</h3> Of 1,265 patients, 625 were using antithrombotic agents at the time of injury (+AA) and 640 were not (−AA). There were 537 adults and 687 elderly patients. AA was associated with older age, presence of a comorbidity (p-value ≤0.0001), and higher Glascow Coma Score on arrival (+AA Median=15 and -AA Median=14, p-value ≤0.0001). There was no difference in AIS head (+AA=4, −AA=4 p-value 0.12), or IPM (+AA=14.9%, −AA=16.4% p-value &lt;0.4551). The +AA had higher PDM (+AA=36.0%, −AA=24.7%, p-value ≤ 0.0001) and was older at death (+AA Median=84 and −AA Median=64, p-value ≤0.0001). To control for age, the data were grouped into adult and elderly populations. Logistic regression showed AA had no impact on elderly IPM (AUC=0.8890), PDM (Odds Ratio=0.970, p-value &lt;0.8937, AUC=0.7230), or adult IPM (AUC=0.9405). AA-adults had decreased PDM (OR= 0.155, p-value=0.0008, AUC=0.7716). <h3>Conclusions:</h3> Antithrombotic therapy is a confounder for age and co-morbidities, and not associated with IPM or PDM. These data should be considered when discussing risks and benefits of AA in the elderly. Functional outcomes may be more pertinent and require future study. <b>Disclosure:</b> Miss DeStefano has nothing to disclose. Mr. Vedula has nothing to disclose. Dr. Stodghill has nothing to disclose. Dr. Gillen has nothing to disclose. Dr. Nussbaum has nothing to disclose. Dr. Bower has nothing to disclose. Tonja Locklear has nothing to disclose. Dr. Collier has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Law Firm.

Auditory Steady-State Response and Hearing Impairment in Survivors of Childhood Bacterial Meningitis in Luanda, Angola.

Survivors of childhood bacterial meningitis (BM) often develop hearing impairment (HI). In low- and middle-income countries (LMICs), BM continues to be a significant cause of hearing disability. We assessed hearing among BM survivors using auditory steady-state responses (ASSR), providing frequency-specific estimated audiograms, and examined whether ASSR would provide a greater understanding of BM-induced HI. Survivors from two prospective BM trials (ISRCTN62824827; NCT01540838) from Luanda Children's Hospital were examined in a follow-up visit with a median duration of 26 months after BM. The hearing of 50 BM survivors and 19 control children was evaluated using ASSR and auditory brainstem response (ABR) after interview and neurological and otorhinolaryngological examinations. The median age of survivors was 80 (IQR 86) months. We diagnosed HI (better ear hearing ≥ 26 dB) in 9/50 (18%) children. Five of the fifty survivors (10%) and 14/100 ears (14%) had profound HI (>80 dB). Severe-to-profound HI affected all frequencies steadily, affecting only the ears of BM survivors (18/100 vs. 0/38, p = 0.003). When looking only at the severely or profoundly affected ears, young age, low Glascow coma score, pneumococcal aetiology, and ataxia were associated with a worse hearing outcome.

Ultrasonographic measurement of the optic nerve sheath diameter to detect intracranial hypertension: an observational study

ObjectivesTo evaluate the ultrasonographic measurement of optic nerve sheath diameter (ONSD) as a predictor of intracranial hypertension as compared to the invasive measurement of intracranial pressure (ICP).DesignCross-sectional observational study.SettingIntensive Care Unit (ICU) of two tertiary university hospitals in Montevideo, Uruguay.PatientsWe included 56 adult patients, over 18 years of age, who required sedation, mechanical ventilation, and invasive ICP monitoring as a result of a severe acute neurologic injury (traumatic or non-traumatic) and had a Glascow Coma Score (GCS) equal to or less than 8 on admission to the ICU.InterventionsUltrasonographic measurement of ONSD to detect intracranial hypertension.Measurements and main resultsIn our study, a logistic regression model was performed in which it was observed that the variable ONSD is statistically significant with a p value of 0.00803 (< 0.05). This model estimates and predicts the probability that a patient will have an ICP greater than 20 mmHg. From the analysis of the cut-off points, it is observed that a value of 5.7 mm of ONSD maximizes the sensitivity (92.9%) of the method (a greater number of individuals with ICP > 20 mmHg are correctly identified).ConclusionsIn sedated neurocritical patients, with structural Acute Brain Injury, the ONSD measurement correlates with the invasive measurement of ICP. It was observed that with ONSD values less than 5.7 mm, the probability of being in the presence of ICP above 20 mmHg is very low, while for ONSD values greater than 5.7 mm, said probability clearly increases.

Radiology Findings in a Case of Acute Methanol Intoxication Complicated with Intracranial Hemorrhage

Aim: Methanol intoxication is rare and it can be fatal. This case report aimed to describe the radiological findings in acute methanol intoxication complicated with intracranial hemorrhage in a young patient. Case Report: A 32 year-old man applied to emergency department with a major complaints of nausea, vomiting, double vision, and confusion. Glascow coma score (GCS) was 7 at the initial referral. Laboratory tests showed high anion gap metabolic acidosis. Acute methanol intoxication was diagnosed by aid of the patient anamnesis. Diffusion-weighted MRI (DW-MRI) showed similar diffusion restriction lesions in the putamen and cingulate gyrus of both cerebral hemispheres. The patient had a cardiac arrest during follow-up in the emergency department. He was converted to sinus rhythm with the interventions, intubated, and taken to the intensive care unit. GCS reduced to 3 during follow- up at the 4th day. Cerebral intraparanchimal hemorrhage at the level of left basal ganglia was observed in the brain computed tomography (CT). He was operated however remained comatose after the operation and died at the 8th day of admission. Conclusion: Possibility of methanol intoxication should be included in the differential diagnosis in patients with altered consciousness, vision disturbances and a high anion gap admitted to the emergency service. DW-MRI may be helpful in diagnosis by detecting symmetrical diffusion restrictions at the basal ganglia. Additionally radiologic methods like CT can be used to determine complications such as bleeding that may occur during the follow-up of the cases.

CARBAMAZEPINE-ASSOCIATED HYPERAMMONEMIC ENCEPHALOPATHY (HE)

CARBAMAZEPINE-ASSOCIATED HYPERAMMONEMIC ENCEPHALOPATHY (HE)

Adolescent blunt solid organ injury: Differences in management strategies and outcomes between pediatric and adult trauma centers

BackgroundAdolescents with blunt solid organ injuries (BSOI) are cared for at both pediatric trauma centers (PTC) and adult trauma centers (ATC). Over the past decade, treatment strategies have shifted towards non-operative management with reported favorable outcomes. The aim of this study was to compare management strategies and outcomes between PTC and ATC. MethodsWe queried the 2016–2018 Trauma Quality Improvement Program (TQIP) datasets to identify adolescents between the ages of 16 and 19 with BSOI. Characteristics were stratified by center type (pediatric or adult) for comparative analyses. Separate logistic regressions were used to assess the association of hospital type, location of injury, age, gender, weight, Glascow Coma Score (GCS), Injury Severity Score (ISS), and intensive care unit (ICU) admissions for outcomes of interest. ResultsAmong the 3,011,310 patients enrolled in the 2016–2018 TQIP datasets, 106,892 (3.5%) had a BSOI ICD9/10 code. Of those, 9,193 (8.6%) were between 16 and 19 years of age and included in this analysis. Within this cohort, 6,073 (66.1%) were managed at an ATC and 3,120 (33.9%) were managed at a PTC. While statistically different, there were no clinically relevant differences for age, weight, and sex between groups. A significantly higher ISS and lower GCS score were observed among those admitted to ATC compared to PTC. ICU admissions were more frequent at ATC. Number of blood transfusions by 4 h after presentation were also higher among those admitted to an ATC. Despite a lower ISS and higher GCS at presentation, mortality was higher among those treated at a PTC with an odds ratio (95% confidence interval) of 2.42 (1.31–4.53). After excluding adolescents with a traumatic brain injury, a common cause of mortality among adolescent trauma patients, these differences in outcomes persisted. ConclusionsOur data suggest that adolescents with BSOI managed at a PTC are less likely to receive blood transfusions by 4 h of admission or be admitted to the ICU than those managed at an ATC. However, this more conservative approach may come at the expense of higher overall mortality. Further work is needed to understand these differences and determine if PTC need to be more aggressive in managing BSOI.

Evacuation Strategies for U.S. Casualties with Traumatic Brain Injury (TBI) with and without Polytrauma.

According to the Military Health System Traumatic Brain Injury (TBI) Center of Excellence, 51,261 service members suffered moderate to severe TBI in the last 21 years. Moderate to severe TBI in service members is usually related to blast injury in combat operations, which necessitates medical evacuation to higher levels of care. Prevention of secondary insult, and mitigation of the unique challenges associated with the transport of TBI patients in a combat setting are important in reducing the morbidity and mortality associated with this injury. The primary goal of this study was a secondary analysis comparing the impact of time to transport on clinical outcomes for TBI patients without polytrauma versus TBI patients with polytrauma transported out of the combat theater via Critical Care Air Transport Teams (CCATT). Our secondary objective was to describe the occurrence of in-flight events and interventions for TBI patients without polytrauma versus TBI with polytrauma to assist with mission planning for future transports. We performed a secondary analysis of a retrospective cohort of 438 patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Polytrauma was defined as abbreviated injury scale (AIS) of at least three to another region in addition to head/neck. Time to transport was defined as the time (in days) from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and examined the associations between time to transport and preflight characteristics, in-flight interventions and events, and clinical outcomes for TBI patients with and without polytrauma. We categorized patients into two groups, those who had a TBI without polytrauma (n = 179) and those with polytrauma (n = 259). Within each group, we further divided those that were transported within 1 day of injury, in 2 days, and 3 or more days. Patients with TBI without polytrauma transported in 1 or 2 days were more likely to have a penetrating injury, an open head injury, a preflight Glascow Coma Score (GCS) of 8 or lower, and be mechanically ventilated compared to those transported later. Patients without polytrauma who were evacuated in 1 or 2 days required more in-flight interventions compared to patients without polytrauma evacuated later. Patients with polytrauma who were transported in 2 days were more likely to receive blood products, and patients with polytrauma who were evacuated within 1 day were more likely to have had at least one episode of hypotension en route. Polytrauma patients who were evacuated in 2-3 days had higher hospital days compared to polytrauma with earlier evacuations. There was no significant difference in mortality between any of the groups. In patients with moderate to severe TBI transported via CCATT, early evacuation was associated with a higher rate of in-flight hypotension in polytrauma patients. Furthermore, those who had TBI without polytrauma that were evacuated in 1-2 days received more in-flight supplementary oxygen, blood products, sedatives, and paralytics. Given the importance of minimizing secondary insults in patients with TBI, recognizing this in this subset of the population may help systematize ways to minimize such events. Traumatic Brain Injury patients with polytrauma may benefit from further treatment and stabilization in theater prior to CCATT evacuation.

Five-year analysis of clinical presentations and predictors of stroke mortality in rural Southwestern Nigeria: A retrospective observational study.

IntroductionStroke mortality and its predictors are important outcome measures in stroke epidemiological studies and clinical trials. There is an observed paucity of data regarding the clinical presentations and predictors of stroke mortality in Southwestern Nigeria. Few available related studies have centred on hospitals in the urban and sub-urban areas; however, none in the rural settings. This study, therefore, focuses on the clinical presentations and predictors of stroke mortality at the adult Emergency Centre of a tertiary hospital situated in rural Southwestern Nigeria.MethodsA retrospective survey, using data form and standardized questionnaire, was used to study the patients admitted for stroke between January 2015 and December 2019. The data were analysed using SPSS Version 22.0. The results were presented in descriptive and tabular formats.ResultsA total of 276 patients were studied. Their mean age was 67.3 ± 11.1 years. The most common clinical presentations were hemiparesis and cranial nerve deficit. The case of fatality was 10.1%. The predictors of stroke mortality were age ≥65 years [(AOR = 12.752; 95% CI: (1.022–159.190), p = 0.048)], Glascow coma score <8 [(AOR = 50.348; 95% CI: (7.779–325.866), p < 0.001)], uncontrolled blood pressure [(AOR = 23.321; 95% CI: (2.449–221.927), p = 0.006)], presence of atrial fibrillation [(AOR = 16.456; 95% CI: (2.169–169.336), p = 0.009)], convulsion [(AOR = 25.889; 95% CI: (2.374–282.296), p = 0.008)], heart failure [(AOR = 30.284; 95% CI: (3.265–256.347), p < 0.001)], and a repeat stroke [(AOR = 32.617; 95% CI: (2.410–441.381), p = 0.009)].ConclusionThe 7-day fatality was 10.1%. The predictors of stroke mortality were poor Glascow coma score, uncontrolled blood pressure, atrial fibrillation, heart failure, convulsion and a repeat stroke. This study strengthens the argument on the higher prevalence of stroke and its mortality in rural Southwestern Nigeria. Our findings may provide an impetus for prospective research on this outcome.

Development of a Prediction Model for Donation after Circulatory Death Lung Donor Progression

<h3>Purpose</h3> Although use of donation-after-circulatory-death (DCD) donors has significantly increased lung transplant (LTx) rates, 25-40% of intended DCD do not convert to actual donors due to non-progression to asystole in the required 90 minute time frame from withdrawal of cardio-respiratory support (WCRS). Predicting which intended DCD patient will progress remains problematic & impacts resourcing. <h3>Methods</h3> This retrospective study reviewed intended DCD lung donors referred between 2014-2018 to our program, to determine specific factors that may predict the likelihood of progression to death in ≤90mins. Donor demographics, relevant medical history, reason for WCRS, ICU hemodynamic/ventilation/admission data were compared between non-progresses and LTx DCD donor cohorts. Significant variables were included in multivariable logistic regression analysis and construction of a classification and regression tree (CART) prediction model. <h3>Results</h3> 159 of 334 referred DCD donors were accepted for LTx: 100 (63%) progressed to donation, 59 (37%) did not progress. Comparing non-progressed & LTx DCD donors, significant factors associated with death ≤90mins were: length of ICU stay ≤4 days, Glascow Coma Score=3, ventilation mode and severe infra-tentorial brain damage on imaging by CT/MRI . These factors were used to develop a CART predictive model for progression ≤90mins post-WCRS, which had a sensitivity of 0.95 and predictive value of 0.69 (Figure 1). Of the 59 who did not progress, 26 patients (44%) died within the subsequent 6 hours. <h3>Conclusion</h3> Intended DCD lung donors referred early after ICU admission, in a deep coma with severe infra-tentorial damage suggesting a significant neurological injury, are to most likely to progress within 90-minute post-WCRS. This CART prediction model is now being utilized prospectively to assist LTx team re decisions on potential DCD lung donor retrievals & resource allocation. Use of a time-extended DCD lung protocol up to 6 hours post WCRS, further expands the lung donor pool.

Abstract P400: Racial Disparities in Subarachnoid Hemorrhage Outcomes-A Single Center Experience

Introduction: Subarachnoid hemorrhage (SAH) has high morbidity and mortality, and prior studies have reported outcome disparities between African American (AA) and Caucasian patients. We compared demographics, risk factors, and discharge outcomes among different ethnicities treated at our comprehensive stroke center. Methods: We used data on all SAH patients admitted between July 2014 and March 2020 to our university hospital in the Southeast United States. Race was categorized into AA, Caucasian, and “other.” Pearson chi-square test and analysis of variance were used to compare these variables between the different groups. Results: A total of 578 SAH patients were identified (39% AA patients, 54% Caucasian, and 7% other). Admission Glascow Coma Score (GCS) and Hunt &amp; Hess scores were comparable between the 3 groups. AA patients were significantly younger (51 vs 59 in Caucasian group vs 56 years in Other, p-value &lt;0.001) and had higher BP at admission (systolic BP 152 vs 144 vs 145, p=0.002, diastolic BP 86 vs 80 vs 81, p&lt;0.001). AA patients were more likely to have a history of hypertension (p&lt;0.001) and had higher BMI (30 vs 28.1 vs 26, p=0.003) and Hemoglobin A1c (5.8 vs 5.6 vs 6.1, p=0.013). Modified Rankin scale (mRS) at discharge, in-hospital mortality, and discharge destination were similar between the groups, but AA patients had a longer mean hospital length of stay (19 vs 14 vs 17 days, p=0.035). Conclusion: In our cohort, AA SAH patients were significantly younger and had more comorbidities at admission. Although they had a higher length of stay, discharge outcomes were comparable to other races.

P1699 A case of atrial myxoma presenting with acute stroke

Abstract A 73-year-old female presented with sudden reduced level of consciousness on the background of rheumatoid arthritis and dyslipidaemia. On examination she had a Glascow Coma Score of 12 and an irregularly irregular pulse. The electrocardiograph confirmed atrial fibrillation and showed widespread T wave inversion. A computed tomography cerebral angiogram showed an acute basilar artery occlusion. She was transferred to a tertiary centre where she had successful endovascular clot retrieval. An urgent transthoracic echocardiogram (figure 1) showed apical hypertrophy, normal systolic function and a large right atrial mass. The left atrial size was normal. A transoesophageal echocardiogram (figure 3) confirmed a large pedunculated mobile mass with a hypermobile septum consistent with a patent foramen ovale. There was no right to left doppler flow, however the atrial mass obstructed the course, and a bubble study was positive. The cardiac magnetic resonance image (figure 2) showed a 47 x 48 mm pedunculated lesion within the right atrium, arising from the intraventricular septum, demonstrating moderate T2 signal intensity, and intermediate T1 signal intensity, with avid enhancement, consistent with a right atrial myxoma. There was increased apical wall thickening at 15mm which confirmed apical hypertrophic cardiomyopathy. An open surgical resection and left atrial appendage ligation was performed on day 11 of admission. Histopathology confirmed an atrial myxoma. She had an excellent neurological recovery with only mild diplopia. The mechanism of stroke was likely atrial fibrillation secondary to increased left atrial pressure from apical hypertrophic cardiomyopathy. However, the unexpected finding of a right atrial myxoma with a corresponding patent foramen ovale provides a second possible mechanism. Abstract P1699 Figure. Right atrial Myxoma

Treatment of Hyponatremia in Patients with Acute Neurological Injury.

Little data exist regarding the practice of sodium management in acute neurologically injured patients. This study describes the practice variations, thresholds for treatment, and effectiveness of treatment in this population. This retrospective, multicenter, observational study identified 400 ICU patients, from 17 centers, admitted for ≥48h with subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), intraparenchymal hemorrhage, or intracranial tumors between January 1, 2011 and July 31, 2012. Data collection included demographics, APACHE II, Glascow Coma Score (GCS), serum sodium (Na+), fluid rate and tonicity, use of sodium-altering therapies, intensive care unit (ICU) and hospital length of stay, and modified Rankin score upon discharge. Data were collected for the first 21days of ICU admission or ICU discharge, whichever came first. Sodium trigger for treatment defined as the Na+ value prior to treatment with response defined as an increase of ≥4mEq/L at 24h. Sodium-altering therapy was initiated in 34% (137/400) of patients with 23% (32/137) having Na+ >135mEq/L at time of treatment initiation. The most common indications for treatment were declining serum Na+ (68/116, 59%) and cerebral edema with mental status changes (21/116, 18%). Median Na+ treatment trigger was 133mEq/L (IQR 129-139) with no difference between diagnoses. Incidence and treatment of hyponatremia was more common in SAH and TBI [SAH (49/106, 46%), TBI (39/97, 40%), ICH (27/102, 26%), tumor (22/95, 23%); p=0.001]. The most common initial treatment was hypertonic saline (85/137, 62%), followed by oral sodium chloride tablets (42/137, 31%) and fluid restriction (15/137, 11%). Among treated patients, 60% had a response at 24h. Treated patients had lower admission GCS (12 vs. 14, p=0.02) and higher APACHE II scores (12 vs. 10, p=0.001). There was no statistically significant difference in outcome when comparing treated and untreated patients. Sodium-altering therapy is commonly employed among neurologically injured patients. Hypertonic saline infusions were used first line in more than half of treated patients with the majority having a positive response at 24h. Further studies are needed to evaluate the impact of various treatments on patient outcomes.

The Thin Border between Life and Death

We aimed to represent the case of a gunshot injury which was so close to the center that it could have affected the vital functions. Here you will find the imaging studies regarding this case. A 17-year-old male patient presented to the emergency department with the claim of a gunshot injury. It was observed that the patient was conscious, cooperative, and oriented. During examination, a defect, consistent with a 5 × 5 mm bullet inlet, was seen in the left zygomatic region as an extracranial finding. Minimal tenderness was elicited with palpation on left zygomatic region and his Glascow coma score was 15/15. His pupils were isocoric, light reflex was bilaterally positive, eye movements and vision were normal, diplopia was not present, and otorrhea and rhinorea were absent. Cranial nerves and motor function examinations were intact. When the patient was admitted to the hospital, his vital signs were as follows: blood pressure, 100/60; pulse, 80/min; inspiration rate, 22/min; temperature, 26.6°C; and oxygen saturation, 97%. Laboratory revealed no significant pathological findings. Cranial and maxillofacial computed tomography revealed that the bullet inlet was located anteriorly in the left maxillary sinus, the bullet was located in the left suboccipital condyle, and the lateral wall was destroyed (Figure 1, 2a, b). The patient was referred to the neurology clinic. His neurological examination revealed no sign of any deficit. Radiological imaging revealed that the bullet was located in a place which could not be easily reached with surgical instruments; therefore, a conservative approach was thought to be suitable for this case (Figure 3a-c, 4). Surgery for a gunshot head injury is intended to achieveof revitalized in the entrance and exit wounds, evacuation of all significant mass lesions, hemostasis, and meticulous dural and scalp closure (1). The indication for surgery to remove a bullet is controversial because presence of retained bullets or bone fragments do not increase intracranial infection rate and removal of the same to prevent infection is unnecessary (1, 2). However, the common complications of retained intracranial foreign bodies are abscess formation, cerebrospinal fluid fistulas, post-traumatic epilepsy, hematomas, and infection (3). The patient was observed for 24 h in our emergency clinic and then discharged. He was instructed to come back for follow-up visits for 3 months. During the follow-up visits, no pathology was observed.

309 Predictors of Neurosurgical Interventions in Low Risk Patients With Isolated Traumatic Subarachnoid Hemorrhage

309 Predictors of Neurosurgical Interventions in Low Risk Patients With Isolated Traumatic Subarachnoid Hemorrhage

Predictors of the necessity for early tracheostomy in patients with acute cervical spinal cord injury: a 15-year experience

BackgroundThe need for mechanical ventilation (MV) after spinal cord injury (SCI) is a risk factor for prolonged critical care. The “purpose” of this study was to identify the level of cervical SCI that requires MV, thereby defining candidates for tracheostomy. MethodsPatients with cervical SCI over a 15-year period were reviewed. ResultsOne hundred sixty-three patients sustained cervical SCI. Of 76 complete injuries, 91% required MV for greater than 48 hours. By injury level, MV incidence was 100% for C2–4, 91% for C5, 79% for C6, and 80% for C7. Only one quarter of patients with incomplete SCI required MV for greater than 48 hours; Glascow Coma Score and Injury Severity Score were significantly worse compared with patients not requiring MV. ConclusionsFactors influencing the decision for tracheostomy in cervical SCI patients include the presence of a complete SCI, anatomic level of injury, Glascow Coma Score, Injury Severity Score, and associated thoracic injury. Patients with complete cervical SCI often require prolonged MV. Conversely, the minority of incomplete SCI required MV; the need for tracheostomy was likely performed for associated injuries. Utilizing identified factors permits a thoughtful approach to tracheostomy in this patient population.

Prehospital Use of Tranexamic Acid for Hemorrhagic Shock in Primary and Secondary Air Medical Evacuation

IntroductionMajor hemorrhage remains a leading cause of death in both military and civilian trauma. We report the use of tranexamic acid (TXA) as part of a trauma exanguination/massive transfusion protocol in the management of hemorrhagic shock in a civilian primary and secondary air medical evacuation (AME) helicopter EMS program. MethodsTXA was introduced into our CCP flight paramedic program in June 2011. Indications for use include age > 16 years, major trauma (defined a priori based on mechanism of injury or findings on primary survey), and heart rate (HR) > 110 beats per minute (bpm) or systolic blood pressure (SBP) < 90 mmHg. Our protocol, which includes 24-hour online medical oversight, emphasizes rapid initiation of transport, permissive hypotension in select patients, early use of blood products (secondary AME only), and infusion of TXA while en route to a major trauma center. ResultsOver a 4-month period, our CCP flight crews used TXA a total of 13 times. Patients had an average HR of 111 bpm [95% CI 90.71–131.90], SBP of 91 mmHg [95% CI 64.48–118.60], and Glascow Coma Score of 7 [95% CI 4.65–9.96]. For primary AME, average response time was 33 minutes [95% CI 19.03–47.72], scene time 22 minutes [95% CI 20.23–24.27], and time to TXA administration 32 minutes [95% CI 25.76–38.99] from first patient contact. There were no reported complications with the administration of TXA in any patient. ConclusionWe report the successful integration of TXA into a primary and secondary AME program in the setting of major trauma with confirmed or suspected hemorrhagic shock. Further studies are needed to assess the effect of such a protocol in this patient population.