Tag Archives: TBI

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Operative Management Of TBI By Non-Neurosurgeons?

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In the US, Level I and II trauma centers are required to have around the clock neurosurgical coverage. This becomes problematic, especially in more rural areas, because they are a scarce resource. This problem is not limited to the States, and other countries have learned how to deal with it in their own ways.

A recent paper from Austria and the Slovak Republic looked at how this issue is dealt with at some centers in central Europe, and the impact of having neurosurgical procedures performed by trauma surgeons. The researchers looked at various databases maintained by 10 tertiary care hospitals in a retrospective fashion. Patients were included if they had a GCS of 8 or less and they survived to ICU admission. Some centers had neurosurgeons available, while others had only trauma surgeons. Procedures were performed by the appropriate type of surgeon in each center.

A total of 743 patients were evaluated, and about 68% underwent a neurosurgical procedure while 6% had an ICP monitor inserted. About a quarter of these patients had other significant associated injuries and were excluded, since the authors were interested in measuring effects in TBI patients. This left 311 patients, of whom 61% were treated by neurosurgeons and the remainder by trauma surgeons.

Here are some of the interesting findings:

  • Prehospital airway was provided more frequently in the neurosurgical treatment group, which should potentially improve outcome
  • ED management time and time to OR was shorter in the neurosurgical treatment group, which should also potentially improve outcome
  • However, there was no difference in ICU survival, hospital survival, or long-term outcome!

Bottom line: This is an interesting but poorly constructed study. Don’t believe the results! Other researchers’ leftover databases were used, and some databases were excluded because “quality of care was not comparable” to other centers. This is the worst kind of selection bias! If you believe the results, then you would also have to believe that airway control and prompt operative management don’t really matter much. The paucity of neurosurgeons who are interested in trauma care is pervasive. However, we still need to look for solutions to this problem and they remain a very valuable member of the trauma team.

Reference: Outcome of patients with severe brain trauma who were treated either by neurosurgeons or by trauma surgeons. J Trauma 72(5):1263-1270, 2012.

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Resident Work Hour Restrictions And Neurotrauma Complications

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In the US, resident work hour restrictions went into effect in 2003, limiting the total number of hours worked per week and the number of consecutive hours without a break. The idea was that fatigue caused errors, which translates into patient complications or worse. Has this panned out? A number of previous publications have found no change; only a few have shown some benefit.

Researchers at Massachusetts General Hospital decided to apply the acid test to this theory. They selected a group of patients who were critically ill and challenging to care for, taken care of by a group of residents who had long work hours and were involved in long operative cases. The AHRQ National Inpatient Sampling Database was studied, comparing the outcomes of neurotrauma patients before and after work hours were initiated and in teaching and non-teaching centers.

A huge number of records were analyzed (40,000 before work hours restrictions, 67,000 after). The findings were intriguing:

  • The overall complication rate was the same before and after restrictions (1.2%)
  • The complication rate was 25% higher in teaching hospitals after restrictions took effect. It appears that this also correlated with higher hospital charges after restrictions.
  • Logistic regression was used to figure out whether this difference was from duty hours or just from the involvement of residents in care. Only duty hours were significant in this analysis.
  • If injury severity was included in the analysis, there were no differences in complications at all
  • There were no differences in mortality rates between any of the groups

Bottom line: Yes, fatigue is bad (see my previous posts below). But here is another (correlation) study that doesn’t bear out the original reasons to restrict resident work hours. In actuality, complications and charges increased after the restrictions went into effect. It is possible that the checks and balances in the system were effective in protecting patients from adverse outcomes. Could the changes in this study be due to staffing changes to meet the restrictions, which results in chronic understaffing which undercuts those checks and balances? Studies of this type can’t tell us that. And unfortunately, restrictions in the US are not going to go away, they’ll probably get worse.

Related posts:

Reference: Higher Complications and No Improvement in Mortality in the ACGME Resident Duty-Hour Restriction Era: An Analysis of More Than 107?000 Neurosurgical Trauma Patients in the Nationwide Inpatient Sample Database. Neurosurgery 70(6):1369-1382, 2012.

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Intracranial Hypertension In Pediatric Head Trauma

This 44 minute video is a good introduction to pediatric head trauma and intracranial hypertension. It covers physiology, diagnosis, as well as management using medications, position, decompression and hypothermia.

Presented at Multidisciplinary Trauma Conference at Regions Hospital on May 3, 2012 by Debbie Song MD, a pediatric neurosurgeon.

(Source: https://player.vimeo.com/)
General

When To Give Mannitol

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Patients with severe head injury need all the help they can get. Mannitol is one tool that is time-tested and cheap. But how do you decide who gets it and when?

Mannitol is a powerful osmotic diuretic that pulls extracellular water from everywhere, including the brain. By reducing the size of the brain overall, it drops pressure inside the skull (ICP) somewhat.

Mannitol can be used anytime during the acute phase of trauma care for three indications in patients with head trauma:

  • Focal neurologic deficit. This is due to transtorial herniation, and may manifest clinically as unilateral pupil dilation or hemiparesis. It may also be seen on CT scan.
  • Progressive neurologic deterioration. This is typical of rising ICP and can be diagnosed when your previously talking patient becomes lethargic.
  • Clinical evidence of high ICP. This is the Cushing response (hypertension with bradycardia). Do not treat this hypertension with other meds, it is a brain protective mechanism!

The literature does not have any good studies that show effectiveness or survival benefit. However, most trauma professionals have seen the dramatic improvement in neurologic status that can occur after early administration.

Bottom line: Mannitol is cheap and it works! Consider it early if any of the three indications above are seen. And don’t forget to put a urinary catheter in immediately because the diuresis that it causes is impressive. And no studies thus far have been able to prove that hypertonic saline is any better or worse than mannitol.

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New Technology: Help Brain Injured Patients To Talk

It is can be extremely difficult to communicate with some brain injured patients. Many have global damage that precludes the processing necessary to formulate thoughts. However, some may be able to think but can’t effectively make themselves understood. Patients with the “locked in” syndrome are a perfect example.

A company called NeuroVigil has developed technology and data analysis techniques for extracting a wealth of information from a single-channel EEG. The iBrain system uses two sensors that do not require being stuck to the head with adhesive. A simple elastic band can hold them in place. 

Last year, the company fitted the device on Stephen Hawking to begin testing and training the system to assist with his communication efforts. Currently, Hawking uses an IR sensor that detects twitches in his cheek. These are painstakingly translated into letters and then words that are spoken by a computer. The iBrain system is being trained to recognize words via his EEG patterns and should speed up his communication with the outside world.

If this technology pans out, it may be used to communicate with moderate to severely injured TBI patients who have expressive language problems. It could also be used to test for and communicate with patients who are “locked in.”

The video was recorded at TEDMED 2009. Much of the key information is presented beginning at 10:10 into the video.

I have no financial interest in NeuroVigil

(Source: https://www.youtube.com/)