scholarly journals Initial management of traumatic brain injury in the rural setting

2013 ◽  
Vol 04 (01) ◽  
pp. 33-38 ◽  
Author(s):  
Stephen Honeybul ◽  
Paul Woods
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Medical Management ◽  
Healthcare Workers ◽  
Management Strategies ◽  
Rural Setting ◽  
Initial Management ◽  
Head Injured ◽  
Conscious Level ◽  
Injured Patients

ABSTRACTHealthcare workers in the rural setting face unique problems when dealing with head injured patients however the basic principle of medical management are the same in any situation. The key initial elements remain aggressive early resuscitation followed by a comprehensive assessment of conscious level and either early consultation or transfer to a neurosurgical facility. What has improved considerably over recent years is the understanding of the pathophysiology of traumatic brain injury and as such some of the medical management strategies have changed. A basic understanding of some of these concepts is useful in the clinical setting and serves to emphasis the importance of effective early medical management. Thereafter consideration must be given to which patients require radiological investigations and possible discussion with or transfer to a neurosurgical facility.

Cerebral circulation and metabolism after severe traumatic brain injury: the elusive role of ischemia

1991 ◽  
Vol 75 (5) ◽  
pp. 685-693 ◽  
Author(s):  
Gerrit J. Bouma ◽  
J. Paul Muizelaar ◽  
Sung C. Choi ◽  
Pauline G. Newlon ◽  
Harold F. Young
Keyword(s):  
Traumatic Brain Injury ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Brain Injury ◽  
Neurological Status ◽  
Content Type ◽  
Head Injured ◽  
Adult Head ◽  
Injured Patients

✓ Although experimental and pathological studies suggest an important role for ischemia in the majority of fatal cases of traumatic brain injury, ischemia has been a rare finding in most clinical studies of cerebral blood flow (CBF) in head-injured patients. The hypothesis of the present study was that cerebral ischemia occurs in the first few hours after injury, but that CBF measurements have not been performed early enough. Early measurements of CBF (by the 133Xe intravenous method) and arteriovenous oxygen difference (AVDO2) were obtained in 186 adult head-injured patients with a Glasgow Coma Scale score of 8 or less, and were correlated with neurological status and outcome. During the first 6 hours after injury, CBF was low (22.5 ± 5.2 ml/100 gm/min) but increased significantly during the first 24 hours. The AVDO2 followed the opposite course; the decline of AVDO2 was most profound in patients with low motor scores, suggesting relative hyperemia after 24 hours. A significant correlation between motor score and CBF was found in the first 8 hours after injury (Spearman coefficient = 0.69, p < 0.001), but as early as 12 hours postinjury this correlation was lost. A similar pattern was found for the relationship between CBF and outcome. Cerebral blood flow below the threshold for infarction (CBF ≤ 18 ml/100 gm/min) was found in one-third of the studies obtained within 6 hours, the incidence rapidly decreasing thereafter. A low CBF after 24 hours was not generally associated with a high AVDO2, and was probably a reflection of low oxidative metabolism rather than frank ischemia. In 24 patients, a CBF of 18 ml/100 gm/min or less was found at some point after injury; the mortality rate was significantly higher in this subgroup, and survivors did worse. In some cases, ischemia was successfully treated by reducing hyperventilation or inducing arterial hypertension. These results support the above hypothesis, and suggest that early ischemia after traumatic brain injury may be an important factor determining neurological outcome. Moreover, these data indicate that early hyperventilation or lowering of blood pressure to prevent brain edema may be harmful.

Bedside microdialysis for early detection of cerebral hypoxia in traumatic brain injury

2000 ◽  
Vol 9 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Asita S. Sarrafzadeh ◽  
Oliver W. Sakowitz ◽  
Tim A. Callsen ◽  
Wolfgang R. Lanksch ◽  
Andreas W. Unterberg
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Cerebral Metabolism ◽  
Cerebral Hypoxia ◽  
Extracellular Glutamate ◽  
Early Markers ◽  
Head Injured ◽  
Scale Scores ◽  
Minute Duration ◽  
Injured Patients

Object The authors evaluated the use of bedside cerebral online microdialysis for the detection of impending and present cerebral hypoxia in patients who had sustained traumatic brain injury. Methods Thirty-five severely head injured patients (with Glasgow Coma Scale scores ≤ 8) were studied. Patients underwent continuous brain tissue PO2 (PtiO2) monitoring. The PtiO2 catheter was placed into the unaffected frontal white matter within 32.2 hours postinjury (range 7–48 hours). The microdialysis catheter was placed close to the PtiO2 probe via a 2- or 3-way skull screw that was connected to a pump and perfused with Ringer's solution at 0.3 μl/minute. The microdialysis samples were collected hourly and analyzed at the bedside for glucose, lactate, lactate–pyruvate 5-minute ratio, and glutamate. Data were analyzed for identification of episodes of impending (PtiO2 10–15 mm, Hg > 5-minute duration) and present cerebral hypoxia (PtiO2 10 mm, Hg, > 5-minute duration). In 62% of the patients hypoxic episodes occurred and were most frequently associated with hyperventilation (p < 0.001). During impending hypox-ia, extracellular glutamate concentrations were increased (p = 0.006) whereas energy metabolites remained stable. During cerebral hypoxia, the extracellular glutamate (p < 0.001) and lactate (p = 0.001) concentrations were significantly higher than during normal oxygenation, whereas the lactate–pyruvate ratio was only slightly increased (p = 0.088, not significant). Conclusions The authors conclude that a PtiO2 below 10 mm Hg is critical to induce metabolic changes seen during hypoxia/ischemia. Early markers of cerebral hypoxia are increased levels of glutamate and lactate. Regional hypoxia is not always associated with anaerobic cerebral metabolism. In the future, this technology of bedside monitoring may allow optimization of the treatment of severely head injured patients.

Continuous measurement of jugular venous oxygen saturation in response to transient elevations of blood pressure in head-injured patients

1994 ◽  
Vol 80 (3) ◽  
pp. 461-468 ◽  
Author(s):  
John B. Fortune ◽  
Paul J. Feustel ◽  
Carl G. M. Weigle ◽  
A. John Popp
Keyword(s):  
Blood Pressure ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Oxygen Saturation ◽  
Perfusion Pressure ◽  
Endotracheal Suctioning ◽  
Jugular Venous Oxygen Saturation ◽  
Head Injured ◽  
Venous Oxygen Saturation ◽  
Injured Patients

✓ Following traumatic brain injury, continuous jugular venous oxygen saturation (SjvO2) measurements have been made and used to assess cerebral oxygenation. Transients of SjvO2 may reflect cerebral blood flow (CBF) changes if measurements are made over a short period of time during which cerebral metabolic rate for oxygen is assumed unchanged. In response to alterations in perfusion pressure, transients of SjvO2 may indicate the extent to which autoregulation has been preserved after injury. The effect of arterial pressure changes on SjvO2 was measured in 14 severely head-injured patients (Glasgow Coma Scale score < 8) within 36 hours of injury. Mean arterial blood pressure (MABP), arterial oxygen saturation, and intracranial pressure (ICP) data were also continuously recorded by a computer at the patients' bedside. The reliability of the SjvO2 oximetry measurements varied among patients, and an average 38% of SjvO2 measurements were off by more than 6% saturation, necessitating recalibration. During periods of satisfactory catheter performance, 120 instances were found in which MABP was elevated more than 8 torr (mean ± standard deviation: 32 ± 13 torr) due to endotracheal suctioning. In 94 of these measurements, there was an associated increase in the ICP of 5 torr or more, averaging 16.6 ± 10.2 torr. The SjvO2 was 0.62 ± 0.10 before the increase in MABP and rose to a peak of 0.77 ± 0.10 during the maximum MABP elevation, suggesting increased CBF during the transient hypertension. In 34 of 37 instances of persistent blood pressure elevations lasting for more than 10 minutes (mean 16.0 ± 8.0 minutes), the SjvO2 elevation persisted (average duration 15.0 ± 12.4 minutes), suggesting impaired or lost autoregulatory vasoconstriction. The presence or absence of hyperemia was unrelated to the extent of the autoregulation response. Results indicate that SjvO2 rises with increasing perfusion pressure during and after endotracheal suctioning, suggesting a feeble or absent autoregulatory response following traumatic brain injury.

Ultra-early evaluation of regional cerebral blood flow in severely head-injured patients using xenon-enhanced computerized tomography

1992 ◽  
Vol 77 (3) ◽  
pp. 360-368 ◽  
Author(s):  
Gerrit J. Bouma ◽  
J. Paul Muizelaar ◽  
Warren A. Stringer ◽  
Sung C. Choi ◽  
Panos Fatouros ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Brain Injury ◽  
Cerebral Ischemia ◽  
Computerized Tomography ◽  
Regional Ischemia ◽  
Head Injured ◽  
Intracranial Hematomas ◽  
Injured Patients

✓ The role of cerebral ischemia in the pathophysiology of traumatic brain injury is unclear. Cerebral blood flow (CBF) measurements with 133Xe have thus far revealed ischemia in a substantial number of patients only when performed between 4 and 12 hours postinjury. But these studies cannot be performed sooner after injury, they cannot be done in patients with intracranial hematomas still in place, and they cannot detect focal ischemia. Therefore, the authors performed CBF measurements in 35 comatose head-injured patients using stable xenon-enhanced computerized tomography (CT), simultaneously with the initial CT scan (at a mean (± standard error of the mean) interval of 3.1 ± 2.1 hours after injury). Seven patients with diffuse cerebral swelling had significantly lower flows in all brain regions measured as compared to patients without swelling or with focal contusions; in four of the seven, cerebral ischemia (CBF ≤ 18 ml/100 gm · min−1) was present. Acute intracranial hematomas were associated with decreased CBF and regional ischemia in the ipsilateral hemisphere, but did not disproportionately impair brain-stem blood flow. Overall, global or regional ischemia was found in 11 patients (31.4%). There was no correlation between the presence of hypoxia or hypertension before resuscitation and the occurrence of ischemia, neither could ischemia be attributed to low pCO2. Ischemia was significantly associated with early mortality (p < 0.02), whereas normal or high CBF values were not predictive of favorable short-term outcome. These data support the hypothesis that ischemia is an important secondary injury mechanism after traumatic brain injury, and that trauma may share pathophysiological mechanisms with stroke in a large number of cases; this may have important implications for the use of hyperventilation and antihypertensive drugs in the acute management of severely head-injured patients, and may lead to testing of drugs that are effective or have shown promise in the treatment of ischemic stroke.

scholarly journals Acoustofluidic separation enables early diagnosis of traumatic brain injury based on circulating exosomes

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Zeyu Wang ◽  
Haichen Wang ◽  
Ryan Becker ◽  
Joseph Rufo ◽  
Shujie Yang ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Flow Cytometry ◽  
Brain Injury ◽  
Early Diagnosis ◽  
Tissue Injury ◽  
Management Strategies ◽  
Acoustic Properties ◽  
Early Management ◽  
Biomarker Analysis ◽  
Downstream Analysis

AbstractTraumatic brain injury (TBI) is a global cause of morbidity and mortality. Initial management and risk stratification of patients with TBI is made difficult by the relative insensitivity of screening radiographic studies as well as by the absence of a widely available, noninvasive diagnostic biomarker. In particular, a blood-based biomarker assay could provide a quick and minimally invasive process to stratify risk and guide early management strategies in patients with mild TBI (mTBI). Analysis of circulating exosomes allows the potential for rapid and specific identification of tissue injury. By applying acoustofluidic exosome separation—which uses a combination of microfluidics and acoustics to separate bioparticles based on differences in size and acoustic properties—we successfully isolated exosomes from plasma samples obtained from mice after TBI. Acoustofluidic isolation eliminated interference from other blood components, making it possible to detect exosomal biomarkers for TBI via flow cytometry. Flow cytometry analysis indicated that exosomal biomarkers for TBI increase in the first 24 h following head trauma, indicating the potential of using circulating exosomes for the rapid diagnosis of TBI. Elevated levels of TBI biomarkers were only detected in the samples separated via acoustofluidics; no changes were observed in the analysis of the raw plasma sample. This finding demonstrated the necessity of sample purification prior to exosomal biomarker analysis. Since acoustofluidic exosome separation can easily be integrated with downstream analysis methods, it shows great potential for improving early diagnosis and treatment decisions associated with TBI.

scholarly journals The Expanding Role of Quantitative Pupillometry in the Evaluation and Management of Traumatic Brain Injury

2021 ◽  
Vol 12 ◽  
Author(s):  
Jason H. Boulter ◽  
Margaret M. Shields ◽  
Melissa R. Meister ◽  
Gregory Murtha ◽  
Brian P. Curry ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Brain Injuries ◽  
Ease Of Use ◽  
Brain Injured ◽  
The World ◽  
Injured Patients ◽  
Austere Environments ◽  
Active Investigation

Traumatic brain injury is a rapidly increasing source of morbidity and mortality across the world. As such, the evaluation and management of traumatic brain injuries ranging from mild to severe are under active investigation. Over the last two decades, quantitative pupillometry has been increasingly found to be useful in both the immediate evaluation and ongoing management of traumatic brain injured patients. Given these findings and the portability and ease of use of modern pupillometers, further adoption and deployment of quantitative pupillometers into the preclinical and hospital settings of both resource rich and medically austere environments.

scholarly journals Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

BMJ Open ◽  
2017 ◽  
Vol 7 (10) ◽  
pp. e016355 ◽  
Author(s):  
Fiona Elizabeth Lecky ◽  
Wanda Russell ◽  
Graham McClelland ◽  
Elspeth Pennington ◽  
Gordon Fuller ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Injury Severity ◽  
Controlled Trial ◽  
Randomised Trial ◽  
Cluster Randomised Trial ◽  
Measurable Effect ◽  
Cluster Randomised ◽  
Head Injured ◽  
Secondary Transfer

ObjectiveReconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)—bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI —directly into SNCs—producing a measurable effect.SettingTwo English Ambulance Services.Participants74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults—injured nearest to an NSAH—with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC.InterventionsIntervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC.OutcomesTrial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes.Results56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7–14.0)% vs intervention=9.4(2.3–14.0)%).ConclusionBypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely.Trial registration numberISRCTN68087745.

Multimodality Monitoring

2018 ◽  
pp. 155-164
Author(s):  
Maranatha Ayodele ◽  
Kristine O’Phelan
Keyword(s):  
Traumatic Brain Injury ◽  
Critical Care ◽  
Brain Injury ◽  
Early Recognition ◽  
Secondary Injury ◽  
Multimodality Monitoring ◽  
Injured Brain ◽  
Brain Injured ◽  
Physiologic Parameters ◽  
Injured Patients

Advancements in the critical care of patients with various forms of acute brain injury (traumatic brain injury, subarachnoid hemorrhage, stroke, etc.) in its current evolution recognizes that in addition to the initial insult, there is a secondary cascade of physiological events in the injured brain that contribute significantly to morbidity and mortality. Multimodality monitoring (MMM) in neurocritical care aims to recognize this secondary cascade in a timely manner. With early recognition, critical care of brain-injured patients may then be tailored to preventing and alleviating this secondary injury. MMM includes a variety of invasive and noninvasive techniques aimed at monitoring brain physiologic parameters such as intracranial pressure, perfusion, oxygenation, blood flow, metabolism, and electrical activity. This chapter provides an overview of these techniques and offers a practical guide to their integration and use in the intensive care setting.

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