Prevention Of Secondary Injury Research Articles

Pediatric Trauma

Children have unique anatomy and physiologic responses to trauma that create different challenges for their management. It is important to follow the Advanced Trauma Life Support (ATLS) algorithm for assessing and treating a pediatric trauma patient, paying close attention to the primary survey. Once the primary survey is accomplished with adequate stabilization, the secondary survey proceeds with a focus on specific injuries. Head trauma is the leading cause of morbidity and mortality (M+M) in children. Early identification and prevention of secondary injury are important to optimize outcomes. The head and neck anatomic differences in a child cause a higher fulcrum of their cervical spine, leading to higher cervical spine injuries (CSIs). CSI is rare but carries a higher M+M due to higher spinal cord injuries. The National Emergency X-radiography Utilization Study (NEXUS) and Canadian C-spine Rule (CCR) are useful decision rules to clear cervical spines in adults but have limited strength in young children. PECARN has derived a pediatric cervical spine clearance rule, but this has yet to be prospectively validated. Similar to CSIs, thoracic injuries in children are rare but carry a higher M+M due to anatomic differences in children. A child’s chest anatomy and increased compliance cause more difficulty in injury identification. Abdominal trauma is common in children and can also be difficult to identify. Unlike adults, children can compensate for blood loss much longer while maintaining their blood pressure. Serial abdominal examinations are useful when imaging is negative and a patient has persistent symptoms. This review contains 5 highly rendered figures, 18 tables, and 92 references. Key words: abdominal trauma, Advanced Trauma Life Support (ATLS), cervical spine injury, head trauma, National Emergency X-radiography Utilization Study (NEXUS), Pediatric Emergency Care Applied Research Network (PECARN), thoracic trauma, traumatic brain injury

The changes of oxidative stress and caspase-3 in swine with traumatic hemorrhagic shock in dry-heat environment of desert

Objective To study the changes of oxidative stress and caspase-3 in swine with traumatic hemorrhagic shock in dry-heat environment of desert. Methods A total of 48 Landrace small swine were randomly(random number)divided into 2 groups(n=24 in each group), and then the traumatic hemorrhagic shock was established in room temperature environment[(25±1)℃, (35±5)% humidity] and in dry-heat environment[(40.5±0.5)℃, (10±2)% humidity]in swine. Dry-heat environment traumatic hemorrhagic shock group (DHS), which was made in an artificial experiment cabin mimic the reality included swine exposed in the dry-heat environment of desert for 3 h (T0, n=6), T1 (50 min after shock modeling, n=6), T2 (100 min after shock modeling, n=6), T3 (150 min after shock modeling, n=6). At each interval, blood sample was collected to detect urea nitrogen (BUN) and creatinine, urine sample was collected to detect neutrophil gelatinase-associated lipoprotein (NGAL), kidney tissue samples were collected to evaluate renal morphological and tubular scores, as well as to detect catalase (CAT), superoxide dismutase (SOD) and malondialdehyde (MDA). Western blot was used to detect the level of caspase-3. Traumatic hemorrhagic shock group of room temperature environment (RTS) was established and variety of assays were carried out as same as those deteced in the dry-heat environment group. Results Compared with the room temperature environment exposed group, kidney damage index, antioxidant and caspase-3 were increased in desert dry-heat environment exposed for 3 h group, but there were no statistically significant difference(P> 0.05). And from T1 then on, the levels of NGAL, CAT and SOD in DHS groups were increased which were significant different from those in RTS group (P<0.05 or P<0.01). There were significant differences in BUN and creatinine at T2 between two groups(P<0.05). At T3, caspase-3 protein content in DHS group was significantly different from that in RTS group (P<0.01). Correlation analysis showed that the NGAL level was correlated with the levels to MDA (rRTS= 0.935, rDHS = 0.858, P<0.01) in RTS group and DHS group. Compared with RTS group, renal tissue under light microscope showed that Bowman appeared dilated with degeneration and exfoliated epithelial cells, proximal tubule epithelial shedding, and interstitial edema in DHS group. Electron microscope showed that mitochondria became pleomorphic, endoplasmic reticulum with fold broadening. Conclusions When traumatic hemorrhagic shock happened in the desert dry-heat environment, desert dry-heat environment can aggravate kidney damage, possibly by reducing the renal tissue antioxidant enzyme content and increase renal tissue caspase-3 activity to promote renal tissue apoptosis. Antioxidant stress and apoptosis may be an important role in the prevention of the secondary kidney injury induced by traumatic hemorrhagic shock in dry-heat environment. Key words: Desert; Dry-heat environment; Traumatic hemorrhagic shock; Oxidative stress; Apoptosis; Acute kidney injury

Spinal clearance practices at a regional Australian hospital: A window to major trauma management performance outside metropolitan trauma centres

Background: Prevention of secondary spinal injury via spinal protection measures is a standard component of trauma management, and a high-quality spinal clearance process is imperative in achieving this aim. To evaluate the current practice with a view to achieving best practice, we sought to examine the spinal clearance process and outcomes at a regional Australian referral hospital, which services a large geographical catchment area. Methods: A retrospective review of medical records of all patients with major trauma who presented to an Australian regional hospital during 2014 was conducted. The primary outcome measure was missed or delayed diagnosis of spinal injury. Secondary outcome measures included compliance with internationally accepted spinal clearance process measures, timing and choice of appropriate imaging modalities, rates of spinal injury and documentation of spinal clearance. Results: Of the 112 patients with major trauma who met the study eligibility criteria and were discharged from hospital during the study period from 1 January to 31 December 2014, 11 spinal injuries were missed or delayed in diagnosis. The injuries occurred in 3.6% of patients and all were thoracolumbar spine (TLS) injuries. The predominant reasons for missed or delayed diagnosis were reduced sensitivity of plain X-ray compared with computed tomography for spinal injury screening and incomplete full spinal imaging to detect non-contiguous fractures. Conclusion: Evidence-based clinical decision rules are imperative in ascertaining the need for imaging in the TLS and would be enhanced by an internationally recognised definition of clinical significance based on injury morphology rather than clinician management decision alone. In addition, regional hospitals may have limited capacity to achieve spinal clearance, and other trauma quality assurance standards commensurate with national and international benchmarks without the valuable performance feedback provided by state trauma registries, as is currently the case in Queensland.

Update on traumatic acute spinal cord injury. Part 1

Traumatic spinal cord injury requires a multidisciplinary approach both for specialized treatment of the acute phase and for dealing with the secondary complications. A suspicion or diagnosis of spinal cord injury is the first step for a correct management.A review is made of the prehospital management and characteristics of the acute phase of spinal cord injury. Respiratory monitoring for early selective intubation, proper identification and treatment of neurogenic shock are essential for the prevention of secondary spinal cord injury. The use of corticosteroids is currently not a standard practice in neuroprotective treatment, and hemodynamic monitoring and early surgical decompression constitute the cornerstones of adequate management.Traumatic spinal cord injury usually occurs as part of multiple trauma, and this can make diagnosis difficult. Neurological examination and correct selection of radiological exams prevent delayed diagnosis of spinal cord injuries, and help to establish the prognosis.

Proximal Neuromuscular Control Protects Against Hamstring Injuries in Male Soccer Players: A Prospective Study With Electromyography Time-Series Analysis During Maximal Sprinting

Background: With their unremittingly high incidence rate and detrimental functional repercussions, hamstring injuries remain a substantial problem in male soccer. Proximal neuromuscular control (“core stability”) is considered to be of key importance in primary and secondary hamstring injury prevention, although scientific evidence and insights on the exact nature of the core-hamstring association are nonexistent at present. Hypothesis: The muscle activation pattern throughout the running cycle would not differ between participants based on injury occurrence during follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: Sixty amateur soccer players participated in a multimuscle surface electromyography (sEMG) assessment during maximal acceleration to full-speed sprinting. Subsequently, hamstring injury occurrence was registered during a 1.5-season follow-up period. Hamstring, gluteal, and trunk muscle activity time series during the airborne and stance phases of acceleration were evaluated and statistically explored for a possible causal association with injury occurrence and absence from sport during follow-up. Results: Players who did not experience a hamstring injury during follow-up had significantly higher amounts of gluteal muscle activity during the front swing phase (P = .027) and higher amounts of trunk muscle activity during the backswing phase of sprinting (P = .042). In particular, the risk of sustaining a hamstring injury during follow-up lowered by 20% and 6%, with a 10% increment in normalized muscle activity of the gluteus maximus during the front swing and the trunk muscles during the backswing, respectively (P < .024). Conclusion: Muscle activity of the core unit during explosive running appeared to be associated with hamstring injury occurrence in male soccer players. Higher amounts of gluteal and trunk muscle activity during the airborne phases of sprinting were associated with a lower risk of hamstring injuries during follow-up. Hence, the present results provide a basis for improved, evidence-based rehabilitation and prevention, particularly focusing on increasing neuromuscular control of the gluteal and trunk muscles during sport-specific activities (eg, sprint drills, agility drills).

PRE-SEASON ISOKINETIC SCREENING OF NEUROMUSCULAR RISK FACTORS IN ELITE FOOTBALL

BackgroundNeuromuscular isokinetic screening as a pre-season test may identify players at risk of injury or undertrained players.ObjectiveIdentify, assess and describe unilateral and bilateral knee muscular deficits in elite football players...

PREDICTING LOWER EXTREMITY INJURY RISK IN SPORT THROUGH MOVEMENT QUALITY SCREENING: A SYSTEMATIC REVIEW

BackgroundThe identification of risk factors for lower extremity musculoskeletal (MSK) injury in sport is required to inform primary and secondary injury prevention strategies.ObjectiveTo determine whether measures of poor movement quality...

Actualización en lesión medular aguda postraumática. Parte 1

Traumatic spinal cord injury requires a multidisciplinary approach both for specialized treatment of the acute phase and for dealing with the secondary complications. A suspicion or diagnosis of spinal cord injury is the first step for a correct management.A review is made of the prehospital management and characteristics of the acute phase of spinal cord injury. Respiratory monitoring for early selective intubation, proper identification and treatment of neurogenic shock are essential for the prevention of secondary spinal cord injury. The use of corticosteroids is currently not a standard practice in neuroprotective treatment, and hemodynamic monitoring and early surgical decompression constitute the cornerstones of adequate management.Traumatic spinal cord injury usually occurs as part of multiple trauma, and this can make diagnosis difficult. Neurological examination and correct selection of radiological exams prevent delayed diagnosis of spinal cord injuries, and help to establish the prognosis.

The critical care management of spontaneous intracranial hemorrhage: a contemporary review.

Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1432-0) contains supplementary material, which is available to authorized users.

The nature of the destructive, compensatory and regenerative processes in the brain of rats after experimental moderate traumatic brain injury and the possibility of their pharmacological correction.

Background. The most important task of intensive care patients with traumatic brain injury is prevention and treatment of secondary brain injury, including cerebral ischemia secondary, and neuroprotection, which reduces the impact of secondary damaging factors and allows the nerve cells to escape death. One of the most promising ways of neuroprotection in traumatic brain injury can be neurotrophic therapy. Among the drugs used as neuroprotective agents cerebrolysin occupies a special place. Objective. The aim of this work was to study the effect of the drug cerebrolysin on the morphological changes of brain structures in the early posttraumatic period. Methods. To simulate a traumatic brain injury spring drummer was used, it was experimentally calibrated to apply rats moderate injury. At the time of injury animals were briefly pressed to the foam lining, achieved than horizontal arrangement surface of the cranial vault. In the first subgroup of the main group of animals applied injury secondary to severe without further therapy cerebrolysin. In the second subgroup of the main group after the application of the medium-heavy injury in an experimental neuroprotective therapy used Cerebrolysin (0.1 ml once within 10 days). Calculated absolute number or percentage of 100 cells observed in 10 fields of view of the microscope intact pathologically altered neurons and glial cells. Results. Under the recovery and regeneration (day 21) due to the neuroprotective therapy after traumatic brain injury modeling moderate severity in both hemispheres an increase of normal neurons was observed, it was expressed in the absence of significant differences in this indicator when compared with the control. The same trend was observed on the 14th day after the injury, but occurs only in the damaged hemisphere. On day 21 compared to control a decline of the total number of neurons changed, the values of this index approaches the value 1 day after the injury. Morphometric analysis showed a reduction in the bulk density of the nucleus is 7, and 21 days of experimental traumatic brain injury in the group without treatment. In Cerebrolysin group on day 14 and 21, the bulk density of the nucleus closer to the control parameters. The same trend was observed in relation to the bulk density of ribosomes and neurofibrillary. In case of injury of moderate severity in the group without a neuroprotectant during the entire study period there is a diffuse lesion of the brain studied departments mostly damaged hemisphere, which appeared resistant dystrophic and destructive changes of the neurons without significant signs of pronounced reparative regeneration in the regenerative posttraumatic period. Conclusion. When using a neuroprotectant cerebrolysin marked increase in intact neurons, which was celebrated not only in the injured, but also in the contralateral hemisphere on the day 21st of the experiment. In this case an increase amount of glial cells was also seen.

Neurocritical care in the treatment of stroke

In this review, we briefly introduce recent developments and updates in neurocritical care in the treatment of stroke, including both ischemic and hemorrhagic stroke. Time to recanalization remains the major rate limiting step in the treatment of acute ischemic stroke as only a minority of patients arrive within a timeframe appropriate for treatment. Whether caring for a patient following ischemic or hemorrhagic stroke, the principle focus of neurocritical care for acute brain catastrophes is the identification and prevention of secondary brain injury. While much advancement is still needed for optimum care of patients suffering from ischemic or hemorrhagic stroke, the field continues to evolve in ways that promote improved patient outcomes.

Factors hindering critical care nurses' compliance with evidence based guidelines for prevention of secondary brain injury

Background: Evidence-based clinical guidelines provide nurses with a method to use critically appraised. But, there are several barriers to their implementation which can be grouped as barriers related to individual nurse characteristics, organizational characteristics, and the nature of research information. The aim of the study: was to identify hindering factors for critical care nurses' compliance with evidence based guidelines for prevention of secondary brain injury. Materials & Method: Two tools were developed to collect data. “Evidence based guidelines for prevention of secondary brain injury observational checklist tool” and “Factors hindering nurses' compliance with Evidenced based guidelines for prevention of secondary brain injury questionnaire tool” to determine factors hinder nurses' compliance with evidenced based guidelines for prevention of secondary brain injury. Results: The study revealed that the overall average compliance with seizure control recommendations was the highest (91.9%) followed by maintaining adequate nutrition and preventing DVT recommendations which were more than two thirds among secondary brain injury prevention recommendations. Moreover, the organizational barriers were the most reported barriers by the majority of the CCNs (84%). Conclusion: In conclusion, the barriers to studied nurses' compliance are ranked and categorized as organizational barriers, followed by nature of research information barriers, then personal barriers.

Jugular venous oximetry

AbstractThe measurement of saturation of venous blood as it drains out of brain by sampling it from the jugular bulb provides us with an estimate of cerebral oxygenation, cerebral blood flow and cerebral metabolic requirement. Arterio-jugular venous difference of the oxygen content (AVDO2) and jugular venous oxygen saturation (SjVO2) values per se helps clinicians in identifying the impairment of cerebral oxygenation due to various factors thereby prompting implementation of corrective measures and the prevention of secondary injury to the brain due to ischaemia. SjVO2 values are also used for prognostication of patients after traumatic brain injury and in other clinical situations. Sampling and measuring SjVO2 intermittently or continuously using fibreoptic oximetry requires the tip of the catheter to be placed in the jugular bulb, which is a relatively simple bedside procedure. In the review below we have discussed the relevant anatomy, physiology, techniques, clinical applications and pitfalls of performing jugular venous oximetry as a tool for measurement of cerebral oxygenation.

The Evaluation and Management of Adult Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) is the most disabling and deadly form of stroke. Although mortality remains high, new data suggest that outcomes can be improved with standardized medical care. In this review, the authors outline the most up-to-date knowledge, including the results of the latest phase III clinical trials on the specialized care needed to treat patients with ICH. They provide an overview on how to achieve rapid diagnosis and the initial steps of intervention to reduce hematoma volume or prevent expansion by modifying potentially treatable conditions, such as underlying vascular etiologies, blood pressure control, and coagulopathies. Grading scales can help identify patients at risk for hematoma expansion and functional disabilities and guide clinical decision making. Other medical management topics important to recovery and prevention of secondary brain injury include seizure prevention and treatment, glycemic control, temperature control, and deep venous thrombosis prophylaxis and treatment. Treatment options in surgery are also possible in select patients; there are emerging studies regarding minimally invasive surgery for the management of ICH. These aggressive therapies are essential to lower the morbidity and mortality of patients presenting with ICH.

Neurosurgical and Intensive Care Management of Traumatic Brain Injury.

Optimal management of patients with traumatic brain injury (TBI) remains a challenge, despite significant improvements in pathophysiologic understanding and treatment strategies in recent decades. Because primary brain injury sustained at the time of trauma is irreversible, the TBI management mainly aims for early detection and treatment of secondary brain injury such as space-occupying intracerebral hematomas and brain edema. Prevention of secondary brain injury requires a high standard of care and understanding of both medical and surgical treatment modalities. This review focuses on practical recommendations for neurosurgical and intensive care management in patients with severe TBI.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Common Data Elements and Federal Interagency Traumatic Brain Injury Research Informatics System for TBI Research

Despite increased attention to traumatic brain injury (TBI), there remains no specific treatment and available interventions focus rather on the prevention of secondary injury. One of the reasons posited for the lack of a successful therapy is the amalgamation of various types of injuries under the same severity category in clinical trials. Informatics approaches have been suggested as a means to develop an improved classification system for TBI. As a result of federal interagency efforts, common data elements (CDEs) for TBI have now been developed. Further, the Federal Interagency Traumatic Brain Injury Research Informatics System (FITBIR) has been created and is now available for TBI researchers to both add and retrieve data. This chapter will discuss the goals, development, and evolution of the CDEs and FITBIR and discuss how these tools can be used to support TBI research. A specific exemplar using the CDEs and lessons learned from working with the CDEs and FITBIR are included to aid future researchers.

Higher haemoglobin levels and dedicated trauma admission are associated with survival after severe traumatic brain injury

Background: Prevention of secondary brain injury is a key component of acute management of patients with severe traumatic brain injury (TBI). Haemoglobin concentration may have an impact on optimization of cerebral oxygenation. Patients with TBI may best be served by an organized trauma service. The objective is to determine if haemoglobin concentration or dedicated trauma admission has an impact on outcomes after severe TBI.Methods: This study retrospectively analysed consecutive patients with severe TBI admitted to a level-I trauma centre over 3 years. Patients <16 years-old and with length of stay (LOS) <24 hours were excluded. Data were collected on demographics; injury severity; LOS; admission service; survival to discharge; and haemoglobin levels from hospital days 1–7. Data were also collected on number of transfusions of packed red blood cells. The sample was stratified based on admission service and survival to discharge.Results: Of 147 patients (age = 54.1 ± 3.7 years), overall mortality rate was 15.4% (n = 23). Overall, non-survivors had lower daily and 7-day mean haemoglobin levels (10.7 ± 0.9 vs. 12.9 ± 0.4 g dL−1, p < 0.001). Non-surgical admissions had lower haemoglobin levels and a higher mortality rate (28.9% vs. 12.2%, p < 0.001) compared to dedicated trauma admissions.Conclusions: Among patients with severe TBI, higher haemoglobin levels and maintenance as a dedicated trauma admission are associated with higher survival to discharge.

Neurocritical care monitoring

Neurocritical care in children is aimed at the prevention and treatment of secondary brain injury. Advanced neuromonitoring tools have gained popularity over the last decade owing to its ability to gather and integrate information related to physiological and biochemical variables of brain metabolism, perfusion, and oxygenation status. Intracranial pressine monitoring complemented with direct brain oxygen (Pbt02) measurement and cerebral microdialysis might help to target therapy to patient-specific pathophysiology. Non-invasive modalities like Near infrared spectroscopy (NIRS). Transcranial doppler and advanced EEG monitoring have also evolved in parallel with the advancement of modem neurocritical care. The multimodal approach offers promise as it is shown to improve quality of care and neurological outcome in brain-injured children.

Emergency and critical care management of acute ischaemic stroke.

Ischaemic stroke is a devastating condition that is the leading cause of disability in the USA. Over the last 2 decades, the focus of management has shifted from secondary stroke prevention to acute treatment. Coordinated care starts in the field with the emergency medical service providers and continues in the ambulance and the emergency department through to the intensive care unit. After diagnosis and stabilization, a major goal is reperfusion therapy with intravenous fibrinolytics. Neuroimaging research is focused on improving patient selection, expanding treatment windows, and increasing the safety of therapeutic intervention. The role of adjunctive intra-arterial and mechanical thrombectomy remains undefined, and methods to improve reperfusion using sonolysis and new-generation fibrinolytics are currently investigational. Treatment in the intensive care unit targets prevention of secondary brain injury through optimization of blood pressure, cerebral perfusion, glucose, and temperature management, ventilation, and oxygenation. The most feared complications include malignant cerebral edema and symptomatic hemorrhagic transformation. Decompressive craniectomy is life saving, but questions regarding patient selection and timing remain. Hyperosmolar agents are currently used to mitigate cerebral edema, but newer agents to prevent the formation of cerebral edema at the molecular level are being studied. We outline a practical approach to current emergency and intensive care management based on consensus guidelines and the best available evidence.