Severe traumatic brain injury

Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms

Authors: Nigrovic LE, Lee LK, Hoyle J, Stanley RM, Gorelick MH, Miskin M, Atabaki SM, Dayan PS, Holmes JF, Kuppermann N; for the Traumatic Brain Injury (TBI) Working Group of the Pediatric Emergency Care Applied Research Network (PECARN).

OBJECTIVE: To determine the prevalence of clinically important traumatic brain injuries (TBIs) with severe injury mechanisms in children with minor blunt head trauma but with no other risk factors from the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules (defined as isolated severe injury mechanisms).

DESIGN: Secondary analysis of a large prospective observational cohort study.

SETTING: Twenty-five emergency departments participating in the PECARN. Patients  Children with minor blunt head trauma and Glasgow Coma Scale scores of at least 14. Intervention  Treating clinicians completed a structured data form that included injury mechanism (severity categories defined a priori).

MAIN OUTCOME MEASURES: Clinically important TBIs were defined as intracranial injuries resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights. We investigated the rate of clinically important TBIs in children with either severe injury mechanisms or isolated severe injury mechanisms.

RESULTS: Of the 42 412 patients enrolled in the overall study, 42 099 (99%) had injury mechanisms recorded, and their data were included for analysis. Of all study patients, 5869 (14%) had severe injury mechanisms, and 3302 (8%) had isolated severe injury mechanisms. Overall, 367 children had clinically important TBIs (0.9%; 95% CI, 0.8%-1.0%). Of the 1327 children younger than 2 years with isolated severe injury mechanisms, 4 (0.3%; 95% CI, 0.1%-0.8%) had clinically important TBIs, as did 12 of the 1975 children 2 years or older (0.6%; 95% CI, 0.3%-1.1%).

CONCLUSION: Children with isolated severe injury mechanisms are at low risk of clinically important TBI, and many do not require emergent neuroimaging.

Sedation for critically ill adults with severe traumatic brain injury: A systematic review of randomized controlled trials

Authors: Roberts DJ, Hall RI, Kramer AH, Robertson HL, Gallagher CN, Zygun DA.

OBJECTIVES: To summarize randomized controlled trials on the effects of sedative agents on neurologic outcome, mortality, intracranial pressure, cerebral perfusion pressure, and adverse drug events in critically ill adults with severe traumatic brain injury.

DATA SOURCES: PubMed, MEDLINE, EMBASE, the Cochrane Database, Google Scholar, two clinical trials registries, personal files, and reference lists of included articles.

STUDY SELECTION: Randomized controlled trials of propofol, ketamine, etomidate, and agents from the opioid, benzodiazepine, α-2 agonist, and antipsychotic drug classes for management of adult intensive care unit patients with severe traumatic brain injury.

DATA EXTRACTION: In duplicate and independently, two investigators extracted data and evaluated methodologic quality and results.

DATA SYNTHESIS: Among 1,892 citations, 13 randomized controlled trials enrolling 380 patients met inclusion criteria. Long-term sedation (≥24 hrs) was addressed in six studies, whereas a bolus dose, short infusion, or doubling of plasma drug concentration was investigated in remaining trials. Most trials did not describe baseline traumatic brain injury prognostic factors or important cointerventions. Eight trials possibly or definitely concealed allocation and six were blinded. Insufficient data exist regarding the effects of sedative agents on neurologic outcome or mortality. Although their effects are likely transient, bolus doses of opioids may increase intracranial pressure and decrease cerebral perfusion pressure. In one study, a long-term infusion of propofol vs. morphine was associated with a reduced requirement for intracranial pressure-lowering cointerventions and a lower intracranial pressure on the third day. Trials of propofol vs. midazolam and ketamine vs. sufentanil found no difference between agents in intracranial pressure and cerebral perfusion pressure.

CONCLUSIONS: This systematic review found no convincing evidence that one sedative agent is more efficacious than another for improvement of patient-centered outcomes, intracranial pressure, or cerebral perfusion pressure in critically ill adults with severe traumatic brain injury. High bolus doses of opioids, however, have potentially deleterious effects on intracranial pressure and cerebral perfusion pressure. Adequately powered, high-quality, randomized controlled trials are urgently warranted.

Long-term consequences: effects on normal development profile after concussion

Authors: Daneshvar DH, Riley DO, Nowinski CJ, McKee AC, Stern RA, Cantu RC.

Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. Effective diagnoses, treatments, and education plans are required to reduce the future burden and incidence of long-term effects of head injuries.

Elevated Intracranial Pressure, Low Cerebral Perfusion Pressure, and Impaired Brain Metabolism Correlate with Fatal Outcome after Severe Brain Injury

Authors: Hejčl A, Bolcha M, Procházka J, Hušková E, Sameš M.

BACKGROUND: New brain tissue monitoring techniques (tissue oxymetry, microdialysis) provide direct information about the state of brain oxygenation and brain metabolism in patients with severe traumatic brain injury (TBI). Despite this information being limited to a small region of the brain surrounding the probes, it could be associated with such global parameters as the clinical outcome.

OBJECTIVE: To study the predictive value of monitoring brain oxygenation and metabolism on clinical outcome in patients in the acute phase of severe TBI.

METHODS: An observational study of 20 patients with a severe TBI was undertaken, utilizing intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation, and brain metabolism monitoring. We correlated the clinical outcome of the patients with the following parameters: ICP, CPP, brain tissue oxymetry (PbtO (2)), glucose and glycerol levels, and the lactate/pyruvate (LP) ratio. Further, we analyzed the relationship between ICP, CPP, PbtO (2), and the metabolism parameters.

RESULTS: We found a correlation of the mean ICP values (8.73±1.18 in group A vs. 26.32±5.01 mmHg in group B, p <0.005), the mean CPP values (84.82±2.02 in group A vs. 66.62±4.64 mmHg, p<0.005), the LP ratio (37.36±3.44 vs. 199±87.97, p<0.05), and glycerol levels (62.07±12.14 vs. 215±46.52 μmol/l, p<0.05) with the clinical outcome. High ICP correlated with both a high LP ratio (Spearman R=0.61, p<0.05), and elevated glycerol concentrations (Spearman R=0.48, p<0.05). A low CPP correlated with a high LP ratio (Spearman R=-0.57, p<0.05), while a low PbtO (2) correlated with a high LP ratio (Spearman R=-0.49, p<0.05).

CONCLUSIONS: High ICP, low CPP, an elevated mean LP ratio, and high glycerol concentrations in the acute phase predict fatal outcome 6 months after TBI. Further, high ICP, low CPP, and low PbtO (2) correlate with impaired brain metabolism.

Brain Injury In Sports

Source: Brain Injury Resource Center

An estimated 300,000 sports related traumatic brain injuries, TBIs, of mild to moderate severity , most of which can be classified as concussions, (i.e., conditions of temporary altered mental status as a result of head trauma, occur in the United States each year.  The proportion of these concussions that are repeat injuries is unknown; however, there is an increased risk for subsequent TBI among persons who have had at least one previous TBI .  Repeated mild brain injuries occurring over an extended period (i.e., months or years can result in cumulative neurologic and cognitive deficits, but repeated mild brain injuries occurring within a short period (i.e., hours, days, weeks) can be catastrophic or fatal.  The latter phenomenon, termed "second impact syndrome" has been reported more frequently since it was first characterized in 1984.  This page describes two cases of second impact syndrome and presents recommendations developed by the American Academy of Neurology to prevent recurrent brain injuries in sports and their adverse consequences.

Traumatic Brain Injury in Children and Adolescents (Psychiatric Disorders at One Year)

Authors: Jeffrey E. Max, M.B.B.Ch., Donald A. Robin, Ph.D., Scott D. Lindgren, Ph.D., Wilbur L. Smith, Jr., M.D., Yutaka Sato, M.D., Philip J. Mattheis, M.D., Julie A. G. Stierwalt, M.A. and Carlos S. Castillo, M.D.

J Neuropsychiatry Clin Neurosci 10:290-297, August 1998 © 1998 American Psychiatric Press, Inc. 

Factors predictive of psychiatric outcome in the second 6 months following traumatic brain injury (TBI) in 43 children and adolescents were assessed prospectively. The outcome measure was the presence of a psychiatric disorder not present before the injury ("novel"). Out of six models tested, four were predictive of novel psychiatric disorder: preinjury family function, family psychiatric history, socioeconomic class/intellectual function, and behavior/adaptive function. Post hoc analyses suggested that preinjury family functioning measured by a structured interview was a significant predictive variable. Severity of injury, when reclassified as severe versus mild/moderate TBI, significantly predicted novel psychiatric disorders. These data suggest that some children, identifiable through clinical assessment, are at increased risk for psychiatric disorders following TBI.


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