A Review of Traumatic Axonal Injury

Traumatic brain injury is a major cause of mortality and neurological disability worldwide and varies according to its cause, pathogenesis, severity and clinical outcome. This review summarizes a significant aspect of diffuse brain injuries – traumatic axonal injury – important cause of severe disability and vegetative state. Traumatic axonal injury is a type of traumatic brain injury caused by blunt head trauma. It is defined both clinically (immediate and prolonged unconsciousness, characteristically in the absence of space-occupying lesions) and pathologically (widespread and diffuse damage of axons). Following traumatic brain injury, progressive axonal degeneration starts with disruption of axonal transport, axonal swelling, secondary axonal disconnection and Wallerian degeneration, respectively. However, traumatic axonal injury is difficult to define clinically, it should be considered in patients with Glasgow coma score < 8 for more than six hours after trauma and diffuse tensor imaging and sensitivity-weighted imaging MRI sequences are highly sensitive in its diagnosis. Glasgow coma score at the time of presentation, location and severity of axonal damage are prognostic factors for clinical outcome.

Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of In-Hospital Mortality

<b><i>Background:</i></b> Acute cholangitis (AC) is a common emergency with a significant mortality risk. The Tokyo Guidelines (TG) provide recommendations for diagnosis, severity stratification, and management of AC. However, validation of the TG remains poor. This study aims to validate TG07, TG13, and TG18 criteria and identify predictors of in-hospital mortality in patients with AC. <b><i>Methods:</i></b> This is a retrospective audit of patients with a discharge diagnosis of AC in the year 2016. Demographic, clinical, investigation, management and mortality data were documented. We performed a multinomial logistic regression analysis with stepwise variable selection to identify severity predictors for in-hospital mortality. <b><i>Results:</i></b> Two hundred sixty-two patients with a median age of 75.9 years (IQR 64.8–82.8) years were included for analysis. TG13/TG18 diagnostic criteria were more sensitive than TG07 diagnostic criteria (85.1 vs. 75.2%; <i>p</i> &#x3c; 0.006). The majority of the patients (<i>n</i> = 178; 67.9%) presented with abdominal pain, pyrexia (<i>n</i> = 156; 59.5%), and vomiting (<i>n</i> = 123; 46.9%). Blood cultures were positive in 95 (36.3%) patients, and 79 (83.2%) patients had monomicrobial growth. The 30-day, 90-day, and in-hospital mortality numbers were 3 (1.1%), 11 (4.2%), and 15 (5.7%), respectively. In multivariate analysis, type 2 diabetes mellitus (OR = 12.531; 95% CI 0.354–116.015; <i>p</i> = 0.026), systolic blood pressure &#x3c;100 mm Hg (OR = 10.108; 95% CI 1.094–93.395; <i>p</i> = 0.041), Glasgow coma score &#x3c;15 (OR = 38.16; 95% CI 1.804–807.191; <i>p</i> = 0.019), and malignancy (OR = 14.135; 95% CI 1.017–196.394; <i>p</i> = 0.049) predicted in-hospital mortality. <b><i>Conclusion:</i></b> TG13/18 diagnostic criteria are more sensitive than TG07 diagnostic criteria. Type 2 diabetes mellitus, systolic blood pressure &#x3c;100 mm Hg, Glasgow coma score &#x3c;15, and malignant etiology predict in-hospital mortality in patients with AC. These predictors could be considered in acute stratification and treatment of patients with AC.

Flumazenil therapy for a gabapentin-induced coma: a case report

Background Spasticity and neuropathic pain are common in patients after spinal cord injury and negatively affect patients’ quality of life. Gabapentin and baclofen are frequently used to treat these conditions. We present a flumazenil-reversed gabapentin-induced coma case, which, to our knowledge, is the second one described in scientific literature. Case presentation A 70-year-old Caucasian man was admitted to our neurorehabilitation ward following a fall with cervical trauma that resulted in immediate tetraplegia. During his stay, he suffered from lower limb pain, both neuropathic and due to severe spasticity. Gradual baclofen and gabapentin administration was prescribed, with reduction in both pain and spasticity. One morning, the patient was found unresponsive, with a Glasgow Coma Score of 3. Head computerized tomography, electrocardiogram, electroencephalogram, vital signs, blood tests, breathing, and blood oxygenation were normal. Renal and liver failure were ruled out. Intravenous 0.25 mg of flumazenil (Anexate) was administered, resulting in complete neurocognitive recovery with a Glasgow Coma Score of 15. Discussion and conclusions This case report highlights the importance of the individual response to certain pharmacological agents and suggests that further studies need to be conducted both on flumazenil and gabapentin pharmacodynamics to better understand their molecular–receptor activity, and on possible multiple flumazenil mechanisms of action, beyond its classical strict benzodiazepine antagonist action.

Analysis of Clinicoradiological Profile and Outcome of Traumatic Basal Ganglia Hematoma: A Perspective from Level 1 Trauma Center

Introduction: This study was conducted to analyze clinico-radiological profile of traumatic basal ganglia hematoma and identify its prognostic factors. Methods and Materials: A prospective study was conducted in the Department of neurosurgery, Trauma center of Banaras Hindu University from September 2016 to March 2020. All patients with traumatic basal ganglia hematoma based on admission CT scan were enrolled and their demographic, clinical, radiological details were maintained till the time of discharge and subsequent follow up. Follow up period was a maximum of two years. Results: Out of 41 patients of traumatic basal ganglia hematoma, 68% of cases were males in their third decade. Road traffic accident (76%) was the major etiology. 32% had severe head injury, 78% had hemiparesis at admission and 58% patients required ventilatory support. The mean volume of clot was 15.46 millilitres. Only 24% cases had isolated traumatic basal ganglia hematoma. Advance age, associated intraventricular hemorrhage, ventilator dependence, large hematoma (volume >20 millilitres) and poor Glasgow coma score at admission were significant prognostic factors (p<0.05). Conclusion: Traumatic basal ganglia hematoma is a rare entity. Advance age, large volume of hematoma, associated intraventricular hemorrhage, poor Glasgow coma score at admission and ventilator dependence are poor prognostic factors.

Using the National Trauma Data Bank (NTDB) and machine learning to predict trauma patient mortality at admission

A 400-estimator gradient boosting classifier was trained to predict survival probabilities of trauma patients. The National Trauma Data Bank (NTDB) provided 799233 complete patient records (778303 survivors and 20930 deaths) each containing 32 features, a number further reduced to only 8 features via the permutation importance method. Importantly, the 8 features can all be readily determined at admission: systolic blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, gender, age and Glasgow coma score. Since death was rare, a rebalanced training set was used to train the model. The model is able to predict a survival probability for any trauma patient and accurately distinguish between a deceased and survived patient in 92.4% of all cases. Partial dependence curves (Psurvival vs. feature value) obtained from the trained model revealed the global importance of Glasgow coma score, age, and systolic blood pressure while pulse rate, respiratory rate, temperature, oxygen saturation, and gender had more subtle single variable influences. Shapley values, which measure the relative contribution of each of the 8 features to individual patient risk, were computed for several patients and were able to quantify patient-specific warning signs. Using the NTDB to sample across numerous patient traumas and hospital protocols, the trained model and Shapley values rapidly provides quantitative insight into which combination of variables in an 8-dimensional space contributed most to each trauma patient’s predicted global risk of death upon emergency room admission.

Progression of vital signs during ambulance transport categorised by a paediatric triage model: a population-based historical cohort study

ObjectivesTo examine the severity and progression of acute illness or injury in children using vital signs obtained during ambulance transport and categorised according to a paediatric triage model.DesignA population-based historical cohort study using data from prehospital patient medical records linked to a national civil registration database.SettingEmergency medical services providing ground-level transport in a mixed urban–rural region with three hospitals in Denmark.Participants25 039 events with patients aged <18 years attended by emergency medical services dispatched after a 1-1-2 emergency call during the years 2006–2018.Primary and secondary outcome measuresDistribution of the first observed vital signs according to a paediatric triage model: heart rate, Glasgow Coma Score, respiratory rate, oxygen saturation and oxygen treatment, and proportion of patients progressing to a triage score with a lower level of urgency during ambulance transport.ResultsThe proportion of patients with the first observed vital signs outside the normal age-specific range was as follows: 33.6% for heart rate, 15.3% for Glasgow Coma Score, 17.4% for respiratory rate and 37.4% for oxygen saturation regardless of oxygen treatment. The proportion of patients progressing to a triage score with a lower level of urgency during transport varied with age: 146/354 (41.2%) for age 0–2 months, 440/986 (44.6%) for age 3–11 months, 1278/3212 (39.8%) for age 1–2 years, 967/2814 (34.4%) for age 3–7 years and 4029/13 864 (29.1%) for age 8–17 years (p<0.001). One-day mortality was 3.05 deaths per 1000 patient-days (95% CI 2.43 to 3.83).ConclusionsOne third of the patients’ condition progressed to a triage score with a lower level of urgency during ambulance transport. Vital sign documentation in paediatric patients was incomplete, and educational initiatives should be taken to increase documentation of vital signs, especially in patients aged ≤2 years.

The Effect of Low-Dose Atorvastatin on Inflammatory Factors in Patients with Traumatic Brain Injury: A Randomized Clinical Trial

Background: Traumatic brain injury (TBI) is the leading cause of morbidity and mortality. Each year near 1.5 million Americans experience a TBI. Of which about 235,000 are hospitalized. Also, TBI claims 50 000 American lives each year. TBI causes mechanical damage to the blood-brain barrier and white blood cells (WBCs) entry to the brain. Objectives: The current study aimed to evaluate the efficacy of low-dose Atorvastatin on inflammatory factors in patients with traumatic brain injury (TBI). Methods: This double-blind, randomized clinical trial study was conducted in the ICU ward of Golestan Hospital in the city of Ahvaz (Iran) from April 2019-May 2020. Sixty patients with moderate to severe TBI were studied. Patients were randomly assigned into two groups of Atorvastatin and control. The main outcomes included the amount of CRP and ESR as well as white blood cells in the first 14 days of hospitalization. Glasgow Coma Score, the length of ICU stay, and the duration of mechanical ventilation were secondary outcomes. Results: The amount of CRP in the Atorvastatin group on the 14th day of hospitalization was significantly lower than those in the control group (31.99 ± 8.38 vs 59.65 ± 10.43) (P < 0.0001). On the same day, the Atorvastatin group had lower levels of ESR than the control group (14.28 ± 4.18 vs 25.57 ± 5.18) (P < 0.0001). The Atorvastatin group had significantly lower levels of white blood cells than the control group (5247.53 ± 751.93 vs 7143.94 ± 907.64, P < 0.0001). Glasgow Coma Score at the time of discharge from the ICU in the Atorvastatin group was more than control (14.06 ± 1.45 and 11.85 ± 0.75, respectively) (P < 0.05). A significant difference was found concerning the ICU stay between the two groups (P = 0.03). Conclusions: This study demonstrated that Atorvastatin could reduce the rate of inflammatory factors in TBI patients. The inflammatory condition of TBI patients heavily determines their prognosis. Inflammation leads to several reactions as well as interactions between different cells and chemical mediators. The Atorvastatin could reduce the rate of inflammatory factors and improved GCS in TBI patients.