Improved Hemodynamic Status of Head Injured Patients in the Emergency Unit (ER): Literature Review

Background: Head injury is a serious problem that can lead to death and even death. Handling of head injuries starts from protecting the brain with blood flow to the brain so that hypoxia or brain ischemia does not occur. Hemodynamics is the result of measuring systolic and diastolic blood pressure, pulse rate, and respiratory rate. Objectives: This literature review aims to find out what interventions can be done when there is an increase in hemodynamic status in head injury patients Methods: This database search was conducted by searching on google scholars with the keywords head injury, hemodynamics. The inclusion criteria of this literature review are articles that were researched within the last 5 years with the year published 2015-2020, full text, using the Indonesian language, the article that used is the article. Results: Interventions that can be done when there is an increase in hemodynamic status in head injury patients are giving oxygen and increasing 30o, giving oxygen through a simple mask and head position 30o, giving head-up position 30o compared to 15o position, giving nasal prong oxygenation therapy and murotal therapy Al-Qur'an for 30 minutes 3 times/day. Conclusion: All interventions resulting from this literature review were in the form of giving oxygen and increasing the head 30o, giving oxygen through a simple mask and head position 30o, giving the head position 30o compared to 15o position, giving nasal branch oxygenation therapy, and murotal Al-Qur'an therapy for 30 minutes 3 times/day.

Post-traumatic peripheral vestibular disorders (excluding positional vertigo) in workers following head injury

Benign paroxysmal positional vertigo has typically been reported to be the most common cause of post-traumatic dizziness. There is however paucity in the literature about other peripheral vestibular disorders post-head injury. This article provides an overview of other causes of non-positional dizziness post-head trauma from our large institutional experience. The UHN WSIB Neurotology database (n = 4291) between 1998 and 2018 was retrospectively studied for those head-injured workers presenting with non-positional peripheral vestibular disorders. All subjects had a detailed neurotological history and examination and vestibular testing including video nystagmography, video head impulse testing (or a magnetic scleral search coil study), vestibular-evoked myogenic potentials, and audiometry. Imaging studies included routine brain and high-resolution temporal bone CT scans and/or brain MRI. Based on a database of 4291 head-injured workers with dizziness, 244 were diagnosed with non-positional peripheral vertigo. Recurrent vestibulopathy (RV) was the most common cause of non-positional post-traumatic vertigo. The incidence of Meniere’s disease in the post-traumatic setting did not appear greater than found in the general population. The clinical spectrum pertaining to recurrent vestibulopathy, Meniere’s disease, delayed endolymphatic hydrops, drop attacks, superior semicircular canal dehiscence syndrome, and uncompensated peripheral vestibular loss are discussed.

Post-traumatic Peripheral Vestibular Disorders (Excluding Positional Vertigo): Institutional Experience from University Health Network’s Workplace Safety and Insurance Board Head-Injury Program

Purpose: Benign paroxysmal positional vertigo has typically been reported to be the most common cause of post-traumatic dizziness. There is however paucity in the literature about other peripheral vestibular disorders post-head injury. This article provides an overview of other causes of non-positional dizziness post-head trauma from our large institutional experience.Methods: The UHN WSIB Neurotology database (n=4,291) between 1998 and 2018 was retrospectively studied for those head-injured workers presenting with non-positional peripheral vestibular disorders. All subjects had a detailed neurotological history and examination and vestibular testing including video nystagmography, video head impulse testing (or a magnetic scleral search coil study), vestibular-evoked myogenic potentials, and audiometry. Imaging studies included routine brain and high-resolution temporal bone CT scans and/or brain MRI.Results: Based on a database of 4,291 head-injured workers with dizziness, 244 were diagnosed with non-positional peripheral vertigo. Recurrent vestibulopathy (RV) was the most common cause of non-positional post-traumatic vertigo. The incidence of Meniere’s disease in the post-traumatic setting did not appear greater than found in the general population. Conclusion: The clinical spectrum pertaining to recurrent vestibulopathy, Meniere’s disease, delayed endolymphatic hydrops, drop attacks, superior semicircular canal dehiscence syndrome, and uncompensated peripheral vestibular loss are discussed.

Spectrum of remote site extradural hematomas following decompressive craniectomy: Does fracture always co-exist?

Background: Remote-site extradural hematomas (EDHs) after decompressive-surgeries for traumatic brain injury (TBI) are rarely encountered. Typically, they form contralateral to the injured side, with an overlying fracture. We present a subset which developed EDH immediately after decompressive-hemi-craniectomy for TBI, most without an evidence of fracture, and not limited to contralateral location. Methods: Nine such patients were retrospectively identified. Plausible mechanisms, management issues and outcomes have been discussed. Results: All nine patients were victims of severe-TBI. Six did not have any skull-fractures. Eight showed hemispheric-injuries while one had bifrontal-contusions. In hemispheric-injuries, midline-shift was at least 8 mm except one with midline-shift of 6 mm. The EDH was straddling the midline in 2 (bifrontal-1, bi-occipital-1), and juxtaposed to the previous craniectomy in 1, apart from a contralateral-bleed in 6; all, except one, needed evacuation. In most patients, venous-source of bleed was identified. All had improved from their preoperative Glasgow coma scale (GCS) at follow-up. Conclusion: A fracture need not always co-exist in EDH following decompressive craniectomy. However, an extra-caution is suggested in its presence. Given the need for surgical-evacuation in most patients and an inability to assess immediate postoperative-GCS in severely head-injured, a routine postoperative-computed tomography is recommended to avoid overlooking such potentially treatable condition.

Neurobehavioral Changes: An under looked aspect of Head Injury

Background: Different types of behavioral changes are seen in head injury patients, and these changes are directly or indirectly related to daily activities. Major alterations of personality after head injury are generally seen in the patients with severe head injury. However, disturbing post-concussional symptoms like headache, dizziness and memory problems generally persists for few months even in the less severely injured ones. Materials and methods: Objective: To analyze the neurobehavioral changes in adult head injured patients. Study design: Prospective analytical study. Sampling technique: Non - probability consecutive sampling. Site of study: National Institute of Neurological and Allied Sciences, Bansbari, Nepal. Inclusion Criteria: All head injured patients above the age of 16 years. Exclusion Criteria: Extended Glasgow Outcome Scale of less than 3 at 6 months follow up. Data Collection and Analysis: All patients above the age of 16 years with head injury who got admitted were enrolled in the study. Parameters like age, gender, mode of injury, GCS at presentation were recorded. Extended Glasgow Outcome Scale along with Neurobehavioral rating was evaluated at 6 months. Then neurobehavioral rating scale was obtained by direct interview. Data analysis was done using SPSS v.20. Results: Total number patients were 76 among which 71% were below 40 years of age and majorities (87%) were males. Neurobehavioral categories like abnormal intentional behavior, lowered emotional state, heightened emotional state, arousal state and language had significant association with GCS at presentation and EGOS at 6 months. Similarly, age had significant association with language, where there was absent to mild language difficulty in patients below 40 years of age. Likewise, language difficulty, lower emotional state and abnormal intentional behavior were significantly associated with gender, as it was mild to severe in 30% of the female population who had sustained head injury. Conclusion: Several neurobehavioral characters seem to be present in the various categories of the head injured patients in different ratios. Language problems seems to be less in the younger patients below the age of 40 years; although, few neurobehavioral parameters seems to affects the females more common compared to male counterparts. Also, family disruption and its extent of severity was significantly related to the severity of head injury.

Ambulance deceleration causes increased intra cranial pressure in supine position: a prospective observational prove of principle study

Background Ambulance drivers in the Netherlands are trained to drive as fluent as possible when transporting a head injured patient to the hospital. Acceleration and deceleration have the potential to create pressure changes in the head that may worsen outcome. Although the idea of fluid shift during braking causing intra cranial pressure (ICP) to rise is widely accepted, it lacks any scientific evidence. In this study we evaluated the effects of driving and deceleration during ambulance transportation on the intra cranial pressure in supine position and 30° upright position. Methods Participants were placed on the ambulance gurney in supine position. During driving and braking the optical nerve sheath diameter (ONSD) was measured with ultrasound. Because cerebro spinal fluid percolates in the optical nerve sheath when ICP rises, the diameter of this sheath will distend if ICP rises during braking of the ambulance. The same measurements were taken with the headrest in 30° upright position. Results Mean ONSD in 20 subjects in supine position increased from 4.80 (IQR 4.80–5.00) mm during normal transportation to 6.00 (IQR 5.75–6.40) mm (p < 0.001) during braking. ONSD’s increased in all subjects in supine position. After raising the headrest of the gurney 30° mean ONSD increased from 4.80 (IQR 4.67–5.02) mm during normal transportation to 4.90 (IQR 4.80–5.02) mm (p = 0.022) during braking. In 15 subjects (75%) there was no change in ONSD at all. Conclusions ONSD and thereby ICP increases during deceleration of a transporting vehicle in participants in supine position. Raising the headrest of the gurney to 30 degrees reduces the effect of breaking on ICP.

Helicopter emergency medical service dispatch in older trauma: time to reconsider the trigger?

Background Helicopter Emergency Medical Services (HEMS) respond to serious trauma and medical emergencies. Geographical disparity and the regionalisation of trauma systems can complicate accurate HEMS dispatch. We sought to evaluate HEMS dispatch sensitivity in older trauma patients by analysing critical care interventions and conveyance in a well-established trauma system. Methods All trauma patients aged ≥65 years that were attended by the Air Ambulance Kent Surrey Sussex over a 6-year period from 1 July 2013 to 30 June 2019 were included. Patient characteristics, critical care interventions and hospital disposition were stratified by dispatch type (immediate, interrogate and crew request). Results 1321 trauma patients aged ≥65 were included. Median age was 75 years [IQR 69–89]. HEMS dispatch was by immediate (32.0%), interrogation (43.5%) and at the request of ambulance clinicians (24.5%). Older age was associated with a longer dispatch interval and was significantly longer in the crew request category (37 min [34–39]) compared to immediate dispatch (6 min [5–6] (p = .001). Dispatch by crew request was common in patients with falls < 2 m, whereas pedestrian road traffic collisions and falls > 2 m more often resulted in immediate dispatch (p = .001). Immediate dispatch to isolated head injured patients often resulted in pre-hospital emergency anaesthesia (PHEA) (39%). However, over a third of head injured patients attended after dispatch by crew request received PHEA (36%) and a large proportion were triaged to major trauma centres (69%). Conclusions Many patients who do not fulfil the criteria for immediate HEMS dispatch need advanced clinical interventions and subsequent tertiary level care at a major trauma centre. Further studies should evaluate if HEMS activation criteria, nuanced by age-dependant triggers for mechanism and physiological parameters, optimise dispatch sensitivity and HEMS utilisation.