Head-injured Patients Research Articles

Triage of Mild Head-Injured Intoxicated Patients Could Be Aided by Use of an Electroencephalogram-Based Biomarker.

Triage of Mild Head-Injured Intoxicated Patients Could Be Aided by Use of an Electroencephalogram-Based Biomarker.

Triage of Mild Head-Injured Intoxicated Patients Could Be Aided by Use of an Electroencephalogram-based Biomarker.

Triage of Mild Head-Injured Intoxicated Patients Could Be Aided by Use of an Electroencephalogram-based Biomarker.

Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study.

Tracheal suctioning is a routine procedure in mechanically ventilated children, however, in severe head-injured patients it can result in potential deleterious increase in intracranial pressure. We aimed to assess the effect of tracheal lidocaine administration on intracranial pressure during tracheal suctioning. Prospective randomized controlled crossover study. PICU of a tertiary hospital. Eleven patients with severe head trauma (Glasgow Coma Scale score 4-8) INTERVENTIONS:: Lidocaine (1.5 mg/kg) or saline solution was endotracheally instilled before a standardized tracheal suctioning maneuver. Each patient received both treatments in a crossover design. Cerebral hemodynamic and systemic and ventilatory effects were assessed at four time points: in baseline (T0), within 2 minutes (T1), 5 minutes (T2), and 15 minutes after tracheal instillation (T3). The 2-minute time interval around tracheal suctioning was used to assess each treatment efficacy MEASUREMENTS AND MAIN RESULTS:: The time course of intracranial pressure was different throughout the study in both treatment groups, with a significant increase of intracranial pressure from 14.82 ± 3.48 to 23.27 ± 9.06 with lidocaine (p = 0.003) and from 14.73 ± 2.41 to 30.45 ± 13.14 with saline (p = 0.02). The mean variation in intracranial pressure immediately after tracheal suctioning was smaller with lidocaine instillation than saline (8.45 vs 15.72 mm Hg; p = 0.006). Patients treated with lidocaine returned to baseline intracranial pressure value at 5 minutes after tracheal suctioning whereas those receiving saline solution returned to baseline intracranial pressure value at 15 minutes. Although patients treated with lidocaine had no significant hemodynamic changes, patients receiving saline solution experienced a higher mean value of mean arterial pressure (99.36 vs 81.73 mm Hg; p = 0.004) at T1. This preliminary study showed that tracheal lidocaine instillation can attenuate increase in intracranial pressure induced by tracheal suctioning and favor a faster return to the intracranial pressure baseline levels without significant hemodynamic and ventilatory changes.

Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study

ObjectivesPatients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness...

GENETIC INFLUENCE ON NEUROANATOMIC DEVELOPMENT BETWEEN CHILDHOOD AND ADULTHOOD

Health care disparities have been shown to negatively affect non-White people sustaining traumas, leading to increased morbidity and mortality. One possible explanation could be delays in emergent medical care. This study aims to assess if a disparity between races exists amongst acutely head-injured geriatric patients, as evidenced by the time it takes from emergency department (ED) presentation to performance of head computerized tomography (CT) imaging.A prospective cohort study was conducted from August 15, 2019 to August 14, 2020 at the two trauma centers in a south Florida county covering 1.5 million residents. Patients aged ≥ 65 years who sustained a head injury were identified daily. Patients who had a head injury >24 h prior, sustained penetrating trauma, or were transferred from another hospital were excluded. The primary outcome was time measured between ED presentation and CT head performance. Patients were grouped by race as selected from White, Black, Hispanic, and other. Comparisons were made using ANOVA analysis.4878 patients were included. 90% were White. The mean times to CT head were 90.3 min for White patients, 98.1 min for Black patients, and 86.6 min for Hispanic patients. There was a significant difference comparing time to CT between the three groups (F = 2.892, p = 0.034). Comparing each group to a combined others, there were no significant differences for White vs non-White (90.3 vs 91.3, F = 0.154, p = 0.695) or Hispanic vs non-Hispanic (86.6 vs 90.5, F = 0.918, p = 0.338); however Black vs non-Black (98.1 vs 89.9, F = 4.828, p = 0.028) was significant.Geriatric Black patients who sustained head trauma were found to have a longer time from ED presentation to performance of head CT than their non-Black counterparts.

Lung Ultrasound as a Bedside Tool for Assessment of Extravascular Lung Water in Critically Ill Head Injured Patients: An Observational Study.

ABSTRACTIntroductionExtra vascular lung water (EVLW) is defined as the amount of fluid in the interstitial and alveolar spaces. Primary aim of this study was to assess EVLW using lung USG (B lines >3 per lung field) in critically ill head injured patients.Materials and methodsIntubated adult patients admitted in Trauma ICU with head injury (GCS 4-15) were assessed by daily chest X-ray and lung ultrasonography. Lung water content was graded based on the number of B lines per ICS with score ranging from 0-32 and categorized as low pulmonary fluid burden (0-10), moderate fluid burden (11-20) and high fluid burden (21-32).Results140 critically ill head injured patients were assessed for eligibility and 20 excluded. Incidence of increased EVLW using lung USG was 61.66% (74/120) and the incidence reported using chest x ray was 40.83%(49/120) and the difference was statistically significant (p value <0.001). Increased EVLW significantly increased the duration of weaning, mechanical ventilation and ICU stay (p value <0.05). Significant association was observed between APACHE II, SAPS II and GCS at admission to ICU with presence of EVLW (p value ≤0.001). Mean delay in identification of EVLW by chest X-ray (CXR) compared to lung ultrasound was 1.42±0.76 days.ConclusionLung ultrasound is better than CXR for early detection of increased EVLW in critically ill head injured patients and has prognostic relevance as increased EVLW prolongs duration of mechanical ventilation and ICU stay.How to cite this articleGattupalli V, Jain K, et al. Lung Ultrasound as a Bedside Tool for Assessment of Extravascular Lung Water in Critically Ill Head Injured Patients: An Observational Study. Indian J Crit Care Med 2019;23(3):131-134.

Impact of the SIGN head injury guidelines and NHS 4-hour emergency target on hospital admissions for head injury in Scotland: an interrupted times series

ObjectivesHead injury is a common reason for emergency department (ED) attendance. Around 1% of patients have life-threatening injuries, while 80% of patients are discharged. National guidelines (Scottish Intercollegiate Guidelines Network...

Critically Head Injured Patients: Improving Nurses` Awareness and Self – Efficacy to Control Extremities Muscles Contracture

Aim: This study aimed to evaluate the effect of improving nurses` awareness and self – efficacy to control extremities muscles contracture in critically head injured patients. Subjects and Method : A quasi-experimental design was utilized for the conduction of this study in the Surgical Hospital affiliated to Ain Shams University in the following Critical Care Units (Neuro- Surgery , ICU and Emergency ). Sample: A purposive sample was composed of 50 nurses with different ages, education and experiences. In addition, 40 critically head injured patients from the above mentioned settings. Tools of data collection : 1) Self administered questionnaire (pre / post tests ) to assess the studied nurses` knowledge as regards controlling extremities muscles contracture . 2) An observation checklist (pre / post tests) to evaluate studied nurses ' practices in relation to care of patient's withcritically head injury to control extremitiesmuscle contracture. 3) General self-efficacy scale (pre / post tests) to assess studied nurses` self – efficacy level. 4) Patients` condition assessment sheet (pre / posttests): a) Glasgow Coma Scale to assess level of consciousness . b) Muscle contracture assessment sheet. Results: Mean ages of studied nurses were (16.7± 9.6). More than half of them had diploma nursing with less than five years of experience. In addition, there were unsatisfactory level of nurses ` knowledge, practices and self – efficacy in pre test . As regards the studied patients , significant improvement was indicated in post and follow- up tests for muscle contracture . Conclusion : In light of the present study, improving nurses` awareness ( knowledge and practices ) and self – efficacy through educational guidelines was helpful on controlling extremities muscles contracture in critically head injured patients , whereas significant improvement was indicated in post tests compared to pre. Moreover, patients` health condition assessment (incidence of extremities muscles contracture) was reduced in post - tests. Recommendations: Further studies should be carried out on a large number of critical care nurses with evidence of results and generalization.

THE DEAD OF MILD AND MODERATE HEAD INJURY

The head injury is one of the accidents causing death and disability. Head injuries include in the top 10 most surgical diseases in the Emergency Department of Ulin Hospital Banjarmasin. From January to September 2017, head injured patients amounted to 974 cases. Patients dominated by mild head injury with GCS were 13-15. Patients with head injuries come with severe GCS and some die on the same day of head injury occurrence, but others get intensive care. This research to find out the relationship between GCS on admission and outcome of head injury patient in Emergency Department (ED) of Ulin Hospital Banjarmasin, ED of Idaman Hospital Banjarbaru and ED of Ratu Zalecha Martapura. This research used non-experiment method in cohort way with consecutive sampling for its sample collecting technique from 56 respondents who are the head injury patients in 3 hospital emergency departments. The analysis of relationship between GCS score on admission and outcome of head injury patient using fisher exact test obtained the significance value (2-tailed) of 0.006 &lt; 0.5 which means that H0 is rejected, so there is relationship between GCS score on admission and outcome. The higher the score of GCS on admission, the better outcome received.

ANALYSIS OF THE EFFECTIVENESS OF NATIONAL EARLY WARNING SCORE (NEWS) USAGE ON THE OUTCOMES OF HEAD INJURY

NEWS (National Early Warning Score) is a new developmental instrument for early detection of declining patient conditions. Head injury is still a problem in Indonesia and so far its assessment is still based on GCS to know the category of head injury. Therefore, an appropriate early assessment instrument is needed to detect outcomes thus a management plan can be done quickly and accurately. This study aims to know the effectiveness of NEWS use against the outcome of head injury patients. The design of this study is a prospective cohort. Samples were taken by consecutive sampling in 48 head injured patients in three hospitals. The study was conducted from 27 November 2017 to 08 January 2018 with observation and documentation study. The result of analysis shows that p-value is 0,013 &lt;0,05 (H0 is rejected), meaning that there is difference of outcome according to NEWS category. Significant differences were seen in mild and severe category of NEWS (0.013 &lt;0.05). The percentage of NEWS influence on outcome is 78.34%. This suggests that NEWS is effectively used for initial assessment of outcomes of partients with head injury.

An International Interprofessional Study of Mental Models and Factors Delaying Neuroimaging of Critically Head-Injured Children Presenting to Emergency Departments.

Thousands of head-injured children are cared for by interprofessional teams in emergency departments every day. Teams must balance performing time-consuming interventions with safe transport for neuroimaging. This study aims to describe and compare providers' perspectives on the transfer of head-injured children to neuroimaging and factors contributing to delays. Participants were interprofessional health care providers involved in the care of head-injured children at sites in the United Kingdom, the United States, and New Zealand. They first viewed a 3-minute video of a child with a severe head injury presenting to their resuscitation bay. Next, they were presented with 5 physiologically different simulated scenarios and asked to report whether interventions were required before transporting each patient to neuroimaging. Then, they reported team and system factors contributing to delays in neuroimaging. Two hundred forty of 296 providers completed the intervention. The percentage of providers reporting that they would directly transport to neuroimaging without intervention was 89% for "stable," 49% for "Cushing's triad," 26% for "hypoxic," 25% for "tachycardic," and 5% for "extremis." There were differences noted in responses by profession for the hypoxia and tachycardia cases. No differences were noted between trainees and attending physicians for any cases. The most frequent factors reported as delaying neuroimaging were team decision making and waiting for equipment, medications, and scanner availability. There is variability in providers' perspectives on the interventions required before transporting severely head-injured patients for imaging. Diverse team and system factors contribute to delays in imaging.

Assessment of predictors of one-month outcome in head injury in a Nigerian tertiary hospital

Abstract Background Current prognostic models for head injury were developed using data mostly from high income countries. A more useful model may be obtained from predictors designed from data obtained from low and middle income countries where trauma is said to be a neglected endemic condition. Methods This prospective study, after ethical and institutional clearance, examined 19 clinical and Computerized Tomographic (CT) scan parameters of all head injured patients who met the study's inclusion criteria. The significance of these parameters in predicting outcomes at 15 and 30 days post-injury using the Glasgow Outcome Scale (GOS) and mortality/survival was statistically determined using Univariate and Multivariate analysis. Results One hundred and fifty patients were prospectively recruited. The age range was 0.33 to 82 years. After univariate analysis, the clinical parameters that were significantly predictive of outcomes were pupillary response (p Conclusions This study suggests that GCS, pupillary response and multifocal contusions may independently predict outcome using GOS in head injury. A prediction model designed on these predictors needs to be considered and evaluated for this environment.

Is computed tomography of the head justified in patients with minor head trauma presenting with Glasgow Coma Scale 15/15?

BackgroundIn keeping with radiology departments in tertiary referral hospitals in developing countries offering computed tomography (CT) head scan services, the radiology department at Groote Schuur Hospital (GSH) in the Western Cape of South Africa undertakes several such scans annually. Of these scans, many are undertaken for post-trauma patients with minor head injury (MHI). While there is agreement that MHI patients with Glasgow Coma Scale (GCS) scores of 13–14/15 may well benefit, there is doubt as to the clinical utility of routine CT head scanning in MHI patients with GCS scores of 15/15.ObjectivesThis retrospective descriptive study of patient records was undertaken to determine the frequency and clinical significance of any abnormalities found on CT head scans of 460 patients with MHI and GCS scores of 15/15, scanned at GSH between 2012 and 2014.MethodEthical clearance was obtained and the records of 460 MHI patients with GCS scores of 15/15, loss of consciousness (LOC) and amnesia who underwent CT head scanning at GSH between 2012 and 2014 were then retrieved from the Philips picture archiving and communication system (PACS). Patient records, containing illegible referral forms or technically inadequate CT head scans, were excluded from the study. Patients’ biographical, clinical and CT head scan data were entered into sequentially numbered data collection forms. These data were tabulated and summed as percentage distributions. Patients’ CT head scan findings were reviewed and classified as either showing normal or abnormal features. Abnormalities detected on CT head scans were classified as being either clinically significant or clinically non-significant.ResultsReferral forms and CT scan reports were obtained for 460 MHI patients from a sample of 497 patients, calculated by using the equation for estimating a single proportion from a large sample (precision 1.5%). The sample obtained yielded an acceptable response rate of 460/497 (92.6%). Of 460 (100%) scan reports, 320 (69.6%) showed no abnormality, while 140 (30.4%) showed abnormality. Of the 140 abnormal scans, 107 (23.3%) showed clinically non-significant abnormality, while 33 (7.2%) revealed clinically significant abnormality. Twenty-two (4.8%) of these clinically significant scans showed brain contusion and 11(2.4%) showed skull fracture. No subdural or extradural haematoma, shift or herniation were reported and none of the 33 patients whose CT scans showed clinically significant abnormality underwent urgent neurosurgical intervention.ConclusionOf the 460 CT head scans performed at GSH for MHI with LOC but normal GCS between 2012 and 2014, none required urgent neurosurgical intervention. This is in accordance with the 2012 Kimberley Hospital Rule (KHR), a management protocol which indicates that CT head scanning in patients with MHI and GCS scores of 15/15 can safely be delayed for 8 h. An audit of the records of patients excluded from this study coupled with an analysis of data from other Western Cape hospital CT head scan databases could help ensure that this scarce resource is used cost-beneficially for all head-injured patients in the Western Cape catchment area.

Not all head injured patients on antiplatelet drugs need platelets: Integrating platelet reactivity testing into platelet transfusion guidelines

IntroductionAntiplatelet medication use continues to rise in an aging population, and these agents can have a deleterious effect for patients with traumatic intracranial hemorrhage (tICH). The purpose of the current investigation is to assess the safety and efficacy of using platelet reactivity testing (PRT) to direct platelet transfusion for tICH patients. Patients and MethodsA Level I trauma center adopted a targeted platelet transfusion guideline using PRT to determine whether platelets were inhibited by an antiplatelet medication (aspirin or P2Y12 inhibitors). Non-inhibited patients were monitored without platelet transfusion, regardless of severity of the head injury. The guideline was analyzed retrospectively to evaluate patient outcomes during the study period (June 2014–December 2016). All patients sustained blunt tICH and received a PRT for known or suspected antiplatelet medication use. Differences were assessed with Kruskal-Wallis and Fisher’s Exact tests. Results166 patients met study inclusion criteria. PRT results indicated that 48 patients (29%) were not inhibited by an antiplatelet medication, and 92% of those patients (n = 44) were spared platelet transfusion. Seven percent (n = 11) of all patients had a clinically significant progression of the head bleed, but this did not differ by inhibition or transfusion status. Implementation of this guideline reduced platelet transfusions by an estimated 30–50% and associated healthcare costs by 42%. ConclusionsA targeted platelet transfusion guideline using PRT reduced platelet usage for patients with tICH. If appropriately tested, results suggest that not all tICH patients taking or suspected of taking antiplatelet drugs need platelet transfusion. Platelet reactivity testing can significantly reduce healthcare costs and resource usage.

The relationship between pre-hospital factors and Glasgow outcome scale in head injured patients with Glasgow coma scale 9-13 in public hospital Dr. Saiful Anwar, Malang

The relationship between pre-hospital factors and Glasgow outcome scale in head injured patients with Glasgow coma scale 9-13 in public hospital Dr. Saiful Anwar, Malang

The relationship between pre-hospital factors and Glasgow outcome scale in head injured patients with Glasgow coma scale 9-13 in public hospital Dr. Saiful Anwar, Malang

The relationship between pre-hospital factors and Glasgow outcome scale in head injured patients with Glasgow coma scale 9-13 in public hospital Dr. Saiful Anwar, Malang

A clinical prediction model for raised intracranial pressure in patients with traumatic brain injuries.

Intracranial hypertension is believed to contribute to secondary brain insult in traumatically brain injured patients. Currently, the diagnosis of intracranial hypertension requires intracranial monitoring or advanced imaging. Unfortunately, prehospital transport times can be prolonged, delaying time to the initial radiographic assessment. The aim of this study was to identify clinical variables associated with raised intracranial pressure (ICP) prior to the completion of neuroimaging. We performed a retrospective cohort study of head injured patients over a 3-year period. Patients were labeled as having increased ICP if they had a single reading of ICP greater than 20 mm Hg within 1 hour of ICP monitor insertion or computed tomography findings suggestive of raised ICP. Patient and clinical characteristics were analyzed using stepwise multivariable logistic regression with ICP as the dependent variable. Of 701 head injured patients identified, 580 patients met inclusion criteria. Mean age was 48.65 ± 21 years, 73.3% were male. The mean Injury Severity Score was 22.71 ± 12.38, and the mean Abbreviated Injury Scale for body region head was 3.34 ± 1.06. Overall mortality was 14.7%. Only 46 (7.9%) patients had an ICP monitor inserted; however, a total of 107 (18%) patients met the definition of raised ICP. The mortality rate for patients with raised ICP was 50.4%. Independent predictors of raised ICP were as follows: age, older than 55 years (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.35-3.76), pupillary fixation (OR, 5.76; 95% CI, 3.16-10.50), signs of significant head trauma (OR, 2.431; 95% CI, 1.39-4.26), and need for intubation (OR, 3.589; 95% CI, 2.10-6.14). This study identified four independent variables associated with raised ICP and incorporated these findings into a preliminary risk assessment scale that can be implemented at the bedside to identify patients at significant risk of raised ICP. Future work is needed to prospectively validate these findings prior to clinical implementation. Prognostic, Epidemiological, level III.

A Retrospective Study of Intracranial Pressure in Head-Injured Patients Undergoing Decompressive Craniectomy: A Comparison of Hypertonic Saline and Mannitol.

Objective: The impact of hypertonic saline (HTS) on the control of increased intracranial pressure (ICP) in head-injured patients undergoing decompressive craniectomy (DC) has yet to be established. The current retrospective study was conducted to compare the effect of HTS and mannitol on lowering the ICP burden of these patients.Methods: We reviewed data on patients who had sustained a traumatic brain injury (TBI) and were admitted to the First People's Hospital of Kunshan between January 1, 2012, and August 31, 2017. Patients who received only one type of hyperosmotic agent, 3% HTS or 20% mannitol, after DC were included. The daily ICP burden (h/day) and response to the hyperosmolar agent were used as primary outcome measures. The numbers of days in the intensive care unit and in the hospital, and the 2-weeks mortality rates were also compared between the groups.Results: The 30 patients who received 3% HTS only and the 30 who received 20% mannitol only were identified for approximate matching and additional data analyses. The demographic characteristics of the patients in the two groups were comparable, but the daily ICP burden was significantly lower in the HTS group than in the mannitol group (0.89 ± 1.02 h/day vs. 2.11 ± 2.95 h/day, respectively; P = 0.038). The slope of the reduction in ICP in response to a bolus dose at baseline was higher with HTS than with mannitol (P = 0.001). However, the between-group difference in the 2-weeks mortality rates was not statistically significant (2 [HTS] vs. 1 [mannitol]; P = 0.554).Conclusion: When used in equiosmolar doses, the reduction in the ICP of TBI patients achieved with 3% HTS was superior to that achieved with 20% mannitol after DC. However, this advantage did not seem to confer any additional benefit terms of short-term mortality.

Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta-analysis of prospective studies.

Guidelines advise performing a computed tomography head scan for all anticoagulated head injured patients, but the risk of intracranial haemorrhage (ICH) after a minor head injury is unclear. We conducted a systematic review and meta-analysis to determine the incidence of ICH in anticoagulated patients presenting with a minor head injury and a Glasgow Coma Score (GCS) of 15. We followed Meta-Analyses and Systematic Reviews of Observational Studies guidelines. We included all prospective studies recruiting consecutive anticoagulated emergency patients presenting with a head injury. Anticoagulation included vitamin-K antagonists (warfarin, fluindione), direct oral anticoagulants (apixaban, rivaroxaban, dabigatran and edoxaban) and low molecular weight heparin. A total of five studies (including 4080 anticoagulated patients with a GCS of 15) were included in the analysis. The majority of patients took vitamin K antagonists (98·3%). There was significant heterogeneity between studies with regards to mechanism of injury and methods. The random effects pooled incidence of ICH was 8·9% (95% confidence interval 5·0-13·8%). In conclusion, around 9% of patients on vitamin K antagonists with a minor head injury develop ICH. There is little data on the risk of traumatic intracranial bleeding in patients who have a GSC 15 post-head injury and are prescribed a direct oral anticoagulant.

Clinical study of continuous intracranial pressure monitoring after decompressive craniectomy in severe traumatic brain injury patient

Objective To clarify the relationship between intracranial pressure monitoring and prognosis of patients with traumatic brain injury after decompressive craniectomy. Methods From December 2015 to December 2017, 48 head-injured patients in Affiliated Suzhou Hospital of Nanjing Medical University were enrolled, who were underwent decompressive craniectomy in this retrospective study. The patients were subdivided into 2 groups based on whether postoperative was monitored (n=19) or not (n=29). The prognosis was evaluated by Glasgow Outcome Scale score, with 1 point of prognosis death, 2 to 3 points of poor prognosis, and 4 to 5 points of good prognosis. Count data were expressed as a percentage (%). Count data were expressed as percentage (%). The chi-square test was used to compare the difference in the rate of good prognosis and mortality between the two groups. Results The mortality of monitoring group (10.5%) was significantly lower than that of control group (37.9%) (χ2=4.365 5, P=0.036 7) during hospitalization, The rate of good prognosis in the monitoring group (68.4%) and the control group (44.8%) was not statistically significant (χ2=2.573 8, P=0.108 6). Conclusion The study showed that continuous monitoring in patients with severe craniocerebral injury could reduce the mortality of patients during hospitalization, but had no significant effect on the improvement of prognosis. Key words: Brain injuries; Intensive care; Intracranial pressure; Decompressive craniectomy