Severe traumatic brain injury and hypotension is a frequent and lethal combination in mountain trauma patients – an analysis of the International Alpine Trauma Registry

Abstract Background: Hypotension is associated with worse outcome in patients with traumatic brain injury (TBI) and maintaining a systolic blood pressure (SBP) ≥110 mmHg is recommended. The aim of this study was to assess the incidence of TBI in patients suffering multi-trauma in remote and mountainous areas; to describe associated factors, treatment and outcome compared to non-hypotensive patients with TBI and patients without TBI; and to evaluate pre-hospital variables to predict admission hypotension.Methods: Data from the International Alpine Trauma Registry including mountain multi-trauma patients (ISS≥16) collected between 2010 and 2019 were analysed. Patients were divided into three groups: 1) TBI with hypotension, 2) TBI without hypotension and 3) no TBI. TBI was defined as Abbreviated Injury Scale (AIS) of the head/neck ≥3 and hypotension as SBP <110 mmHg on hospital arrival.Results: A total of 287 patients were included. Fifty (17%) had TBI and hypotension, 92 (32%) suffered TBI without hypotension and 145 (51%) patients did not have TBI. Patients in group 1 were more severely injured (mean ISS 43.1±17.4 vs 33.3±15.3 vs 26.2±18.1 for group 1 vs 2 vs 3, respectively, p<0.001). Mean SBP on hospital arrival was 83.1±12.9 vs 132.5±19.4 vs 119.4±25.8 mmHg (p<0.001) despite patients in group 1 received more fluids. Patients in group 1 had higher INR, lower haemoglobin and lower base excess (p<0.001). The rate of hypothermia on hospital arrival was different between the groups (p=0.029). Patients in group 1 had the highest mortality (24% vs 10% vs 1%, p<0.001).Conclusion: Multi-trauma in the mountains goes along with severe TBI in almost 50%. One third of patients with TBI is hypotensive on hospital arrival and this is associated with a worse outcome. No single variable or set of variables easily obtainable at scene was able to predict admission hypotension in TBI patients.

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Severe traumatic brain injury and hypotension is a frequent and lethal combination in multiple trauma patients in mountain areas – an analysis of the prospective international Alpine Trauma Registry

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-021-00879-1 ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

Simon Rauch ◽

◽

Matilde Marzolo ◽

Tomas Dal Cappello ◽

Mathias Ströhle ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Multiple Trauma ◽

Trauma Registry ◽

Trauma Patients ◽

Mountain Areas ◽

Hospital Arrival ◽

Severe Tbi ◽

Multiple Trauma Patients ◽

Group 1

Abstract Background Hypotension is associated with worse outcome in patients with traumatic brain injury (TBI) and maintaining a systolic blood pressure (SBP) ≥110 mmHg is recommended. The aim of this study was to assess the incidence of TBI in patients suffering multiple trauma in mountain areas; to describe associated factors, treatment and outcome compared to non-hypotensive patients with TBI and patients without TBI; and to evaluate pre-hospital variables to predict admission hypotension. Methods Data from the prospective International Alpine Trauma Registry including mountain multiple trauma patients (ISS ≥ 16) collected between 2010 and 2019 were analysed. Patients were divided into three groups: 1) TBI with hypotension, 2) TBI without hypotension and 3) no TBI. TBI was defined as Abbreviated Injury Scale (AIS) of the head/neck ≥3 and hypotension as SBP < 110 mmHg on hospital arrival. Results A total of 287 patients were included. Fifty (17%) had TBI and hypotension, 92 (32%) suffered TBI without hypotension and 145 (51%) patients did not have TBI. Patients in group 1 were more severely injured (mean ISS 43.1 ± 17.4 vs 33.3 ± 15.3 vs 26.2 ± 18.1 for group 1 vs 2 vs 3, respectively, p < 0.001). Mean SBP on hospital arrival was 83.1 ± 12.9 vs 132.5 ± 19.4 vs 119.4 ± 25.8 mmHg (p < 0.001) despite patients in group 1 received more fluids. Patients in group 1 had higher INR, lower haemoglobin and lower base excess (p < 0.001). More than one third of patients in group 1 and 2 were hypothermic (body temperature < 35 °C) on hospital arrival while the rate of admission hypothermia was low in patients without TBI (41% vs 35% vs 21%, for group 1 vs 2 vs 3, p = 0.029). The rate of hypothermia on hospital arrival was different between the groups (p = 0.029). Patients in group 1 had the highest mortality (24% vs 10% vs 1%, p < 0.001). Conclusion Multiple trauma in the mountains goes along with severe TBI in almost 50%. One third of patients with TBI is hypotensive on hospital arrival and this is associated with a worse outcome. No single variable or set of variables easily obtainable at scene was able to predict admission hypotension in TBI patients.

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Human Lung Cell Pyroptosis Following Traumatic Brain Injury

Cells ◽

10.3390/cells8010069 ◽

2019 ◽

Vol 8 (1) ◽

pp. 69 ◽

Cited By ~ 4

Author(s):

Nadine Kerr ◽

Juan de Rivero Vaccari ◽

Oliver Umland ◽

M. Bullock ◽

Gregory Conner ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Endothelial Cell ◽

Brain Injury ◽

Lung Injury ◽

Critical Role ◽

Gunshot Wounds ◽

Extracellular Vesicle ◽

Inflammasome Activation ◽

Trauma Patients ◽

Severe Tbi

Approximately 30% of traumatic brain injured patients suffer from acute lung injury or acute respiratory distress syndrome. Our previous work revealed that extracellular vesicle (EV)-mediated inflammasome signaling plays a crucial role in the pathophysiology of traumatic brain injury (TBI)-induced lung injury. Here, serum-derived EVs from severe TBI patients were analyzed for particle size, concentration, origin, and levels of the inflammasome component, an apoptosis-associated speck-like protein containing a caspase-recruiting domain (ASC). Serum ASC levels were analyzed from EV obtained from patients that presented lung injury after TBI and compared them to EV obtained from patients that did not show any signs of lung injury. EVs were co-cultured with lung human microvascular endothelial cells (HMVEC-L) to evaluate inflammasome activation and endothelial cell pyroptosis. TBI patients had a significant increase in the number of serum-derived EVs and levels of ASC. Severe TBI patients with lung injury had a significantly higher level of ASC in serum and serum-derived EVs compared to individuals without lung injury. Only EVs isolated from head trauma patients with gunshot wounds were of neural origin. Delivery of serum-derived EVs to HMVEC-L activated the inflammasome and resulted in endothelial cell pyroptosis. Thus, serum-derived EVs and inflammasome proteins play a critical role in the pathogenesis of TBI-induced lung injury, supporting activation of an EV-mediated neural-respiratory inflammasome axis in TBI-induced lung injury.

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Comparison of strategies for monitoring and treating patients at the early phase of severe traumatic brain injury: the multicentre randomised controlled OXY-TC trial study protocol

BMJ Open ◽

10.1136/bmjopen-2020-040550 ◽

2020 ◽

Vol 10 (8) ◽

pp. e040550

Author(s):

Jean-Francois Payen ◽

Marion Richard ◽

Gilles Francony ◽

Gérard Audibert ◽

Emmanuel L Barbier ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Life Assessment ◽

Secondary Outcome ◽

Trauma Patients ◽

Brain Tissue Oxygenation ◽

Severe Tbi ◽

Randomised Controlled ◽

The Impact

IntroductionIntracranial hypertension is considered as an independent risk factor of mortality and neurological disabilities after severe traumatic brain injury (TBI). However, clinical studies have demonstrated that episodes of brain ischaemia/hypoxia are common despite normalisation of intracranial pressure (ICP). This study assesses the impact on neurological outcome of guiding therapeutic strategies based on the monitoring of both brain tissue oxygenation pressure (PbtO2) and ICP during the first 5 days following severe TBI.Methods and analysisMulticentre, open-labelled, randomised controlled superiority trial with two parallel groups in 300 patients with severe TBI. Intracerebral monitoring must be in place within the first 16 hours post-trauma. Patients are randomly assigned to the ICP group or to the ICP + PbtO2 group. The ICP group is managed according to the international guidelines to maintain ICP≤20 mm Hg. The ICP + PbtO2 group is managed to maintain PbtO2 ≥20 mm Hg in addition to the conventional optimisation of ICP. The primary outcome measure is the neurological status at 6 months as assessed using the extended Glasgow Outcome Scale. Secondary outcome measures include quality-of-life assessment, mortality rate, therapeutic intensity and incidence of critical events during the first 5 days. Analysis will be performed according to the intention-to-treat principle and full statistical analysis plan developed prior to database freeze.Ethics and disseminationThis study has been approved by the Institutional Review Board of Sud-Est V (14-CHUG-48) and from the National Agency for Medicines and Health Products Safety (Agence Nationale de Sécurité du Médicament et des produits de santé) (141 435B-31). Results will be presented at scientific meetings and published in peer-reviewed publications.The study was registered with ClinTrials NCT02754063 on 28 April 2016 (pre-results).

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miR-142-3p Expression Is Predictive for Severe Traumatic Brain Injury (TBI) in Trauma Patients

International Journal of Molecular Sciences ◽

10.3390/ijms21155381 ◽

2020 ◽

Vol 21 (15) ◽

pp. 5381

Author(s):

Cora Rebecca Schindler ◽

Mathias Woschek ◽

Jan Tilmann Vollrath ◽

Kerstin Kontradowitz ◽

Thomas Lustenberger ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Predictive Biomarkers ◽

Severe Trauma ◽

Trauma Patients ◽

Predictive Values ◽

Risk Of Mortality ◽

Affected Tissue ◽

Severe Tbi ◽

Injured Patients

Background: Predictive biomarkers in biofluids are the most commonly used diagnostic method, but established markers in trauma diagnostics lack accuracy. This study investigates promising microRNAs (miRNA) released from affected tissue after severe trauma that have predictive values for the effects of the injury. Methods: A retrospective analysis of prospectively collected data and blood samples of n = 33 trauma patients (ISS ≥ 16) is provided. Levels of miR-9-5p, -124-3p, -142-3p, -219a-5p, -338-3p and -423-3p in severely injured patients (PT) without traumatic brain injury (TBI) or with severe TBI (PT + TBI) and patients with isolated TBI (isTBI) were measured within 6 h after trauma. Results: The highest miR-423-3p expression was detected in patients with severe isTBI, followed by patients with PT + TBI, and lowest levels were found in PT patients without TBI (2−∆∆Ct, p = 0.009). A positive correlation between miR-423-3p level and increasing AIShead (p = 0.001) and risk of mortality (RISC II, p = 0.062) in trauma patients (n = 33) was found. ROC analysis of miR-423-3p levels revealed them as statistically significant to predict the severity of brain injury in trauma patients (p = 0.006). miR-124-3p was only found in patients with severe TBI, miR-338-3p was shown in all trauma groups. miR-9-5p, miR-142-3p and miR-219a-5p could not be detected in any of the four groups. Conclusion: miR-423-3p expression is significantly elevated after isolated traumatic brain injury and predictable for severe TBI in the first hours after trauma. miR-423-3p could represent a promising new biomarker to identify severe isolated TBI.

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Limit Crystalloid Resuscitation after Traumatic Brain Injury

The American Surgeon ◽

10.1177/000313481708301234 ◽

2017 ◽

Vol 83 (12) ◽

pp. 1447-1452 ◽

Cited By ~ 2

Author(s):

Ara Ko ◽

Megan Y. Harada ◽

Galinos Barmparas ◽

Eric J. T. Smith ◽

Kurtis Birch ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Scale Score ◽

Injury Severity ◽

Multivariable Analysis ◽

High Volume ◽

Trauma Patients ◽

Abbreviated Injury Scale ◽

Gender And Age ◽

Multivariable Regression

Patients with traumatic brain injury (TBI) are often resuscitated with crystalloids in the emergency department (ED) to maintain cerebral perfusion. The purpose of this study was to evaluate whether crystalloid resuscitation volume impacts mortality in TBI patients. This was a retrospective study of trauma patients with head abbreviated injury scale score ≥2, who received crystalloids during ED resuscitation between 2004 and 2013. Clinical characteristics and volume of crystalloids received in the ED were collected. Patients who received <2 L of crystalloids were categorized as low volume (LOW), whereas those who received ≥2 L were considered high volume (HIGH). Mortality and outcomes were compared. Multivariable regression analysis was used to determine the odds of mortality while controlling for confounders. Over 10 years, 875 patients met inclusion criteria. Overall mortality was 12.5 per cent. Seven hundred and forty-two (85%) were in the LOW cohort and 133 (15%) in the HIGH cohort. Gender and age were similar between the groups. The HIGH cohort had lower admission systolic blood pressure (128 vs 138 mm Hg, P = 0.001), lower Glasgow coma scale score (10 vs 12, P < 0.001), higher head abbreviated injury scale (3.8 vs 3.3, P < 0.001), and higher injury severity score (25 vs 18, P < 0.001). The LOW group had a lower unadjusted mortality (10 vs 26%, P < 0.001). Multivariable analysis adjusting for confounders demonstrated that those resuscitated with ≥2 L of crystalloids had increased odds of mortality (adjusted odds ratio 2.25, P = 0.005). Higher volume crystalloid resuscitation after TBI is associated with increased mortality, thus limited resuscitation for TBI patients may be indicated.

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Is Routine Continuous EEG for Traumatic Brain Injury Beneficial?

The American Surgeon ◽

10.1177/000313481708301232 ◽

2017 ◽

Vol 83 (12) ◽

pp. 1433-1437 ◽

Cited By ~ 2

Author(s):

Lia Aquino ◽

Christopher Y. Kang ◽

Megan Y. Harada ◽

Ara Ko ◽

Amy Do-nguyen ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Injury Severity ◽

Trauma Patients ◽

Injury Score ◽

Increased Risk ◽

Continuous Eeg ◽

Severe Tbi ◽

Level I ◽

Abbreviated Injury Score

Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and sub-clinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of “routine” cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.

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Management and Challenges of Severe Traumatic Brain Injury

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0040-1716493 ◽

2020 ◽

Author(s):

Shayan Rakhit ◽

Mina F. Nordness ◽

Sarah R. Lombardo ◽

Madison Cook ◽

Laney Smith ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Great Promise ◽

Secondary Brain Injury ◽

Trauma Patients ◽

Barbiturate Coma ◽

High Quality Research ◽

Paroxysmal Sympathetic Hyperactivity ◽

Vte Prophylaxis ◽

Severe Tbi

AbstractTraumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro–Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.

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Should Uncooperative Trauma Patients with Suspected Head Injury be Intubated?

The American Surgeon ◽

10.1177/000313481307900333 ◽

2013 ◽

Vol 79 (3) ◽

pp. 313-320 ◽

Cited By ~ 1

Author(s):

Arturo Garcia ◽

Louise Y. Yeung ◽

Emily J. Miraflor ◽

Gregory P. Victorino

Keyword(s):

Brain Injury ◽

Head Injury ◽

Ct Scan ◽

Warning Sign ◽

Trauma Patients ◽

Abbreviated Injury Scale ◽

Early Warning Sign ◽

Severe Tbi ◽

Hospital Stays ◽

Head Computed Tomography

In trauma patients with a suspicion for traumatic brain injury (TBI), a head computed tomography (CT) scan is imperative. However, uncooperative patients often cannot undergo imaging without sedation and may need to be intubated. Our hypothesis was that among mildly injured trauma patients, in whom there is a suspicion of a head injury, uncooperative patients have higher rates of TBI and intubation should be considered to obtain a CT scan. We found that uncooperative patients intubated for diagnostic purposes were more likely to have moderate to severe TBI than nonintubated patients (21.4 vs 8.4%, P < 0.0001) and uncooperative behavior leading to intubation was an independent predictor of TBI (odds ratio, 2.5; 95% confidence interval, 1.5 to 4.5). Of patients with brain injury, intubated patients more often had a head Abbreviated Injury Scale score of 4 (20.8 vs 7.9%, P = 0.04). Uncooperative intubated patients had longer hospital stays (3.6 vs 2.6 days, P = 0.003) and higher mortality (0.9 vs 0.2%, P = 0.02) than nonintubated patients. Uncooperative behavior may be an early warning sign of TBI and the trauma surgeon should consider intubating uncooperative trauma patients if there is suspicion for brain injury based on the mechanism of their trauma.

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Challenges and Opportunities for Neuroimaging in Young Patients with Traumatic Brain Injury: a Coordinated Effort towards Advancing Discovery from the ENIGMA Pediatric Moderate/Severe TBI Group

10.31234/osf.io/y2txh ◽

2019 ◽

Cited By ~ 4

Author(s):

Emily L. Dennis ◽

Karen Caeyenberghs ◽

Robert F. Asarnow ◽

Talin Babikian ◽

Brenda Bartnik-Olson ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Meta Analysis ◽

Young Patients ◽

Future Research ◽

Childhood And Adolescence ◽

Developmental Issues ◽

Challenges And Opportunities ◽

Severe Tbi ◽

Advance Research

Traumatic brain injury (TBI) is a major cause of death and disability in children in both developed and developing nations. Children and adolescents suffer from TBI at a higher rate than the general population; however, research in this population lags behind research in adults. This may be due, in part, to the smaller number of investigators engaged in research with this population and may also be related to changes in safety laws and clinical practice that have altered length of hospital stays, treatment, and access to this population. Specific developmental issues also warrant attention in studies of children, and the ever-changing context of childhood and adolescence may require larger sample sizes than are commonly available to adequately address remaining questions related to TBI. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric Moderate-Severe TBI (msTBI) group aims to advance research in this area through global collaborative meta-analysis. In this paper we discuss important challenges in pediatric TBI research and opportunities that we believe the ENIGMA Pediatric msTBI group can provide to address them. We conclude with recommendations for future research in this field of study.

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