Neurointensive care of traumatic brain injury in the elderly—age-specific secondary insult levels and optimal physiological levels to target need to be defined

Background Elderly patients with traumatic brain injury increase. Current targets and secondary insult definitions during neurointensive care (NIC) are mostly based on younger patients. The aim was therefore to study the occurrence of predefined secondary insults and the impact on outcome in different ages with particular focus on elderly. Methods Patients admitted to Uppsala 2008–2014 were included. Patient characteristics, NIC management, monitoring data, and outcome were analyzed. The percentage of monitoring time for ICP, CPP, MAP, and SBP above-/below-predefined thresholds was calculated. Results Five hundred seventy patients were included, 151 elderly ≥ 65 years and 419 younger 16–64 years. Age ≥ 65 had significantly higher percentage of CPP > 100, MAP > 120, and SBP > 180 and age 16–64 had higher percentage of ICP ≥ 20, CPP ≤ 60, and MAP ≤ 80. Age ≥ 65 contributed independently to the different secondary insult patterens. When patients in all ages were analyzed, low percentage of CPP > 100 and SBP > 180, respectively, was significant predictors of favorable outcome and high percentage of ICP ≥ 20, CPP > 100, SBP ≤ 100, and SBP > 180, respectively, was predictors of death. Analysis of age interaction showed that patients ≥ 65 differed and had a higher odds for favorable outcome with large proportion of good monitoring time with SBP > 180. Conclusions Elderly ≥ 65 have different patterns of secondary insults/physiological variables, which is independently associated to age. The finding that SBP > 180 increased the odds of favorable outcome in the elderly but decreased the odds in younger patients may indicate that blood pressure should be treated differently depending on age.

Placental insufficiency induces a sexually dimorphic response in the expression of cardiac growth and metabolic signalling molecules upon exposure to a postnatal western diet in guinea pigs

There is a strong relationship between low birth weight (LBW) and an increased risk of developing cardiovascular disease (CVD). In postnatal life, LBW offspring are becoming more commonly exposed to the additional independent CVD risk factors, such as an obesogenic diet. However, how an already detrimentally programmed LBW myocardium responds to a secondary insult, such as an obesogenic diet (western diet; WD), during postnatal life is ill defined. Herein, we aimed to determine in a pre-clinical guinea pig model of CVD, both the independent and interactive effects of LBW and a postnatal WD on the molecular pathways that regulate cardiac growth and metabolism. Uterine artery ablation was used to induce placental insufficiency (PI) in pregnant guinea pigs to generate LBW offspring. Normal birth weight (NBW) and LBW offspring were weaned onto either a Control diet or WD. At ˜145 days after birth (young adulthood), male and female offspring were humanely killed, the heart weighed and left ventricle tissue collected. The mRNA expression of signalling molecules involved in a pathological hypertrophic and fibrotic response was increased in the myocardium of LBW male, but not female offspring, fed a WD as was the mRNA expression of transcription factors involved in fatty acid oxidation. The mRNA expression of glucose transporters was downregulated by LBW and WD in male, but not female hearts. This study has highlighted a sexually dimorphic cardiac pathological hypertrophic and fibrotic response to the secondary insult of postnatal WD consumption in LBW offspring.

Pre-hospital care: demography, current profile and future trends

Introduction. Traumatic brain injury (TBI) is a major public health problem throughout the world. It is one of the leading causes of mortality and disability as a consequence results in a great financial burden on societies. Damage to the brain following trauma does not occur only at the moment of injury but also develops over a period of hours to days with the further secondary insult of the brain. Methods. This was a prospective study done between April 2017 to March 2019. A total of 2134 patients were enrolled for this study with a collection of data in a formatted proforma. All the patients of trauma with clinical or radiological evidence of head injury coming to the trauma centre were included. Results. In our study patient, mortality was 6.79% in patients receiving pre-hospital care compared to 12.03% in patients not receiving adequate pre-hospital care. 29.42% were in the age group of 21–30 years. RTA (overall 64.45%) was the most common mode of injury in the age group 21–30 years with 81.36% cases. Mortality in first emergency care provider by ambulance paramedics was 5.69% and member of the public was 10.10%. Conclusion. It was observed that mortality was higher in patients not receiving adequate pre-hospital care. Early resuscitation facilities at the site of the accident have to be introduced and improved with the execution of rapid transportation to trauma care centres.

EFFECTS OF CASUALTY EVACUATION ON PATIENTS OF HEAD INJURY – A RETROSPECTIVE OBSERVATIONAL STUDY

Background: - A lot of patients of head injury are transferred to tertiary care centres for management by neurosurgeons. They are evacuated either by road or air. Many a time these patients arrive in a clinicoradilogical deteriorated state. Methods: - All patients of moderate and severe head injury that were transferred in from peripheral hospitals for management by Neurosurgeon between Jan 2017 to Dec 2017 were analyzed for their clinical status at the time of evacuation to their clinical status on arrival. Results:- 20 patients deteriorated, 19 required intervention, one was already intubated and his CT showed only increased edema, of the 19, 11 required surgery, 03 re-surgery, 5 required intubation and no surgery. Conclusion: - Neurosurgeons are not available at all hospitals thereby leading to the early evacuation of the patients. The frequent movements and travelling either by road or air can have fluctuations in the ICP and hypoxia/hypotension/hyper-hyothermia during travelling can aggravate secondary insult to brain. Although what effect these ICP fluctuations have on the brain is not confirmed but these are better avoided.

Biliary Disease: Calculous and Acalculous Cholecystitis

Cholelithiasis is extremely common in the United States, affecting approximately 10 to 15% of the population. The vast majority of patients remain asymptomatic. Elective cholecystectomy for symptomatic cholelithiasis is a well-established procedure with excellent outcomes. The diagnosis in critically ill patients may not be straightforward. Inflammation and infection of the gallbladder can lead to significant morbidity and mortality. Whether the gallbladder is the primary etiology of hemodynamic compromise (as in emphysematous or gangrenous cholecystitis) or is the victim of secondary insult (as in ischemia-related acalculous cholecystitis), the intensivist must consider cholecystitis in the differential of clinical deterioration. This review contains 6 figures, 5 tables, and 59 references. Key words: acalculous, biliary disease, cholangitis, cholecystitis, emphysematous cholecystitis

Biliary Disease: Calculous and Acalculous Cholecystitis

Cholelithiasis is extremely common in the United States, affecting approximately 10 to 15% of the population. The vast majority of patients remain asymptomatic. Elective cholecystectomy for symptomatic cholelithiasis is a well-established procedure with excellent outcomes. The diagnosis in critically ill patients may not be straightforward. Inflammation and infection of the gallbladder can lead to significant morbidity and mortality. Whether the gallbladder is the primary etiology of hemodynamic compromise (as in emphysematous or gangrenous cholecystitis) or is the victim of secondary insult (as in ischemia-related acalculous cholecystitis), the intensivist must consider cholecystitis in the differential of clinical deterioration. This review contains 6 figures, 5 tables, and 59 references. Key words: acalculous, biliary disease, cholangitis, cholecystitis, emphysematous cholecystitis

Changes in the gray and white matter of patients with ischemic-edematous insults after traumatic brain injury

OBJECTIVEGray matter (GM) and white matter (WM) are vulnerable to ischemic-edematous insults after traumatic brain injury (TBI). The extent of secondary insult after brain injury is quantifiable using quantitative CT analysis. One conventional quantitative CT measure, the gray-white matter ratio (GWR), and a more recently proposed densitometric analysis are used to assess the extent of these insults. However, the prognostic capacity of the GWR in patients with TBI has not yet been validated. This study aims to test the prognostic value of the GWR and evaluate the alternative parameters derived from the densitometric analysis acquired during the acute phase of TBI. In addition, the prognostic ability of the conventional TBI prognostic models (i.e., IMPACT [International Mission for Prognosis and Analysis of Clinical Trials in TBI] and CRASH [Corticosteroid Randomisation After Significant Head Injury] models) were compared to that of the quantitative CT measures.METHODSThree hundred patients with TBI of varying ages (92 pediatric, 94 adult, and 114 geriatric patients) and admitted between 2008 and 2013 were included in this retrospective cohort study. The normality of the density of the deep GM and whole WM was evaluated as the proportion of CT pixels with Hounsfield unit values of 31–35 for GM and 26–30 for WM on CT images of the entire supratentorial brain. The outcome was evaluated using the Glasgow Outcome Scale (GOS) at discharge (GOS score ≤ 3, n = 100).RESULTSLower proportions of normal densities in the deep GM and whole WM indicated worse outcomes. The proportion of normal WM exhibited a significant prognostic capacity (area under the curve [AUC] = 0.844). The association between the outcome and the normality of the WM density was significant in adult (AUC = 0.792), pediatric (AUC = 0.814), and geriatric (AUC = 0.885) patients. In pediatric patients, the normality of the overall density and the density of the GM were indicative of the outcome (AUC = 0.751). The average GWR was not associated with the outcome (AUC = 0.511). IMPACT and CRASH models showed adequate and reliable performance in the pediatric and geriatric groups but not in the adult group. The highest overall predictive performance was achieved by the densitometry-augmented IMPACT model (AUC = 0.881).CONCLUSIONSBoth deep GM and WM are susceptible to ischemic-edematous insults during the early phase of TBI. The extent of the secondary injury was better evaluated by analyzing the normality of the deep GM and WM rather than by calculating the GWR.

Fever in the Neurointensive Care Unit

Fever occurs commonly in patients admitted to the neurocritical care unit. An increase in the body temperature is known to have deleterious effects on patients with acute nervous system injury and in most cases is associated with an increase in mortality and morbidity of these patients. There are multiple causes of fever in these patients. Due to the potentially devastating effects of fever in patients with cerebral diseases, it warrants treatment in every case. In all patients with acute cerebral damage, treatment of fever and maintenance of euthermia is important to obtain a better functional recovery and to limit any further secondary insult to the brain. This review highlights the etiology and pathophysiology of fever in neurocritical care unit patients, the effects on various organ systems and associated systemic complications, and the evaluation and different therapeutic options available for the management of fever in this patient subset.

Critical Care Management of Acute Spinal Cord Injury—Part II: Intensive Care to Rehabilitation

Spinal cord injury is devastating to those affected due to the loss of motor and sensory function, and, in some cases, cardiovascular collapse, ventilatory failure, and bowel and bladder dysfunction. Primary trauma to the spinal cord is exacerbated by secondary insult from the inflammatory response to injury. Specialized intensive care of patients with acute spinal cord injury involves the management of multiple systems and incorporates evidence-based practices to reduce secondary injury to the spinal cord. Patients greatly benefit from early multidisciplinary rehabilitation for neurologic and functional recovery. Treatment of acute spinal cord injury may soon incorporate novel molecular agents currently undergoing clinical investigation to assist in neuroprotection and neuroregeneration.

Early Management of Acute Spinal Cord Injury—Part I: Initial Injury to Surgery

Acute spinal cord injury is a devastating event associated with substantial morbidity worldwide. The pathophysiology of spinal cord injury involves the initial mechanical trauma and the subsequent inflammatory response, which may worsen the severity of neurologic dysfunction. Interventions have been studied to reduce the extent of primary injury to the spinal cord through preventive measures and to mitigate secondary insult through early specialized care. Management, therefore, is multifold, interdisciplinary, and begins immediately at the time of injury. It includes the trauma triage, acute management of the circulatory and respiratory systems, and definitive treatment, mainly with surgical decompression and stabilization.