An Unusual Cause of Concordance in the Setting of Left Bundle Branch Block

A 73-year-old female with a past medical history of atrial fibrillation, mechanical mitral valve replacement on warfarin, hypertension and hypothyroidism presented to the emergency department with a fall. She fell and hit her head upon standing up from a seated position. She reported a constant posteriorly located headache along with episodes of nausea and vomiting. She denied chest pain, shortness of breath, syncope and fever. The initial examination showed blood pressure of 107/64mmHg, respiratory rate of 13/Min, pulse of 76/Min, oxygen saturation of 96% and Glascow Coma Scale (GCS) of 13, verbal response 4, motor response 6 and eye response 3. Pupils were round and reactive to light. No focal weakness or sensory loss were noted. The patient’s mental status and GCS progressively worsened for which she eventually was intubated. The patient had a mild leukocytosis of 14.11×109 (4.0-10.0). Her sodium, calcium, magnesium, phosphorus and potassium were normal. International Normalized Ratio (INR) was 2.9. The troponin upon presentation was 0.69ng/ml and trended down throughout the hospitalization. Her EKG showed normal sinus rhythm with a left bundle branch block with ST segment elevation in leads V3 - V5 and concordant ST elevation >1mm in V5. Sgarbossa criteria for acute myocardial infarction in the presence of LBBB was 5 points. Computed tomography (CT) scan of the head without contrast showed large bilateral cerebellar hemorrhages with mild inferior herniation of the cerebellar tonsils. Echocardiogram showed ejection fraction of 55-60% with no wall motion abnormalities. Immediate supportive treatment, including fluids and reversal of anticoagulation with prothrombin complex concentrate and vitamin K were administered. The patient underwent a successful suboccipital decompressive craniotomy.

Observational Study of Demographic Factors among Patients Posted for Major Neurosurgical Procedures in an Elective Setting at a Tertiary Care Centre

BACKGROUND Major neurosurgical procedures are to be well planned prior to surgery. For Preventing the mortality a morbidity, preparedness preoperatively is essential for smooth conduct of the prolonged neurosurgical procedures. Both anaesthesia and surgery may carry inadvertent risks to patients. Study of the demographic factors like age, sex, associated disease (in the form of ASA-PS stratification) and type of surgery are useful in this direction. METHODS It is a small group cross sectional study. Major neurosurgical elective procedures are very limited even in tertiary medical centres. Demographic factors are elicited preoperatively in the patients. Since these patients were posted electively for major neurosurgeries, their mentation is usually stable, with good Glascow coma scale scores. RESULTS 36 % of patients were males and 64 % patients were females, 56 % paients belonged to ASA PS I with no systemic illness. Majority of patients belonged to the age group 41-50 years. CONCLUSIONS The mean height of the patients was 164.2 cm with a standard deviation of 7. Mean weight of the patients was 63.2 Kg + 7.1. KEYWORDS CP Angle – Cerebello Pontine Angle, CVP – Central Venous Pressure, NIBP- Non Invasive Blood Pressure, BIS – Bispectral Index, ECG – Electrocardiogram, TBI – Traumatic Brain Injury

Treatment of a self-inflicted intracranial nail gun injury

A 30-year-old man walked into the emergency department after a suicide attempt by firing a nail from a pneumatic nail gun directed at his left temple. He was haemodynamically stable and neurologically intact, able to recall all events and moving all extremities with a Glascow Coma Scale of 15. CT of the brain showed a 6.3 cm nail in the right frontal region without major intracerebral vessel disruption. He was taken to the operating room for left temporal wound washout, debridement of gross contamination and closure with titanium cranial fixation plate. The foreign body was not accessible on initial surgical intervention and was left in place to define anatomy and plan for subsequent removal. Thin slice CT images were used to create 3D reconstructions to facilitate stereotactic navigation and foreign body removal via right craniotomy the following day. The patient tolerated the procedures well and recovered with full neurological function.

Selective Serotonin Reuptake Inhibitor Therapy Reduces Time to Emergence and Arousal from TBI-induced Prolonged Coma: A Pilot Study

Objective: Traumatic Brain Injury (TBI) continues to be a significant cause of death and disability in the United States and is commonly due to sudden, forceful impacts to the head. This may lead to disruption of neurological and neurochemical functioning of the brain, resulting in coma (Glascow Coma Scale score (GCS) ≤ 8). The objective of this study is to evaluate the potential effect of Selective Serotonin Re-uptake Inhibitors(SSRI), sertraline, on improvement in the level of consciousness and motor function in patients with prolonged, refractory coma after severe TBI. It has been theorized that the administration of SSRIs may shorten the time to emergence from comain trauma victims presenting with low GCS scores. Methods: The data from 14 trauma patients with severe TBI and Refractorycoma (RC) as defined by a GCS score <8 (coma) for >6 days admitted to the surgical intensive care unit (SICU) at a busy urban level 1 trauma center was retrospectively collected and screened. The patients were started on sertraline between 7 to 21 days after sustaining TBI-induced coma, principally based on attending judgment and preference, and were compared to a control group of similar TBI-induced prolonged coma patients admitted to the ICU during the study period who did not receive SSRI therapy. Results: In the study, 100% of the SSRI group became aroused to a GCS >8 and 66.7% (6/9) emerged to a minimally conscious state or regained consciousness based on a GCS scores >9 or 9T over a period of 11.9 days after initiation of therapy whereas 60% of control patients (3/5) emerged from coma. Conclusion: SSRI therapy using Sertraline may be associated with shorter time to emergence and improved reactiveness in patients with prolonged refractory coma states post-TBI.

The Triage of Older Adults with Physiologic Markers of Serious Injury Using a State-Wide Prehospital Plan

Introduction:In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.Hypothesis/Problem:The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.Methods:This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.Results:The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure &lt;90 mmHg (22.5% versus 23.5%); respiratory rate &lt;10 or &gt;29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score &lt;13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.Conclusions:State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.

THE EFFECT OF NATURE SOUNDS MUSIC THERAPY ON THE GLASGOW COMA SCALE ON STROKE PATIENTS

Latar Belakang: Definisi stroke adalah disfungsi neurologis akut yang disebabkan oleh gangguan aliran darah yang timbul secara tiba-tiba, sehingga suplai darah ke otak terganggu. Di Indonesia 1 dari 7 orang meninggal karena stroke. Insiden stroke adalah 12,1 per 1.000 orang Indonesia. Terapi musik alami adalah salah satu jenis terapi non-farmakologis yang dapat meningkatkan nilai GCS. Tujuan penelitian ini untuk menganalisa efek terapi musik suara alam pada skala koma glascow pada pasien stroke. Metode: Sebuah studi pre eksperimen kuantitatif tanpa kelompok kontrol. Sampel penelitian adalah 35 pasien stroke non hemoragik. Sampel akan mendapatkan terapi musik suara alam selama 3 hari dengan durasi 20 menit dengan volume 50% atau 60dB. Data akan dianalisis menggunakan uji wilcoxon. Hasil: Hasil tes wilcoxon adalah p = 0,000. Artinya, terapi musik suara alam memberi efek pada glascow coma scale pasien stroke. Kesimpulan: Terapi musik suara alam dapat meningkatkan GCS pada pasien stroke.

Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection

Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.

STROKE ISKEMIK EMBOLI DENGAN TRANSFORMASI HEMORAGIK

Seorang laki-laki, 84 tahun, dibawa ke UGD RSUD dr. M. Haulussy Ambon dengan keluhan lemah badan kiri yang dialami sejak 4 jam sebelum masuk RS. Keluhan ini dirasakan saat pasien sementara beraktivitas (makan). Sebelumnya pasien mengeluh nyeri kepala dan muntah sebanyak 2 kali. Pemeriksaan neurologi ditemukan GCS (Glascow Coma Scale) 14 (somnolen), hemiparese sinistra, parese N. VII, XII sinistra tipe sentral. Pasien didiagnosis stroke iskemik emboli dan atrium fibrilasi berdasarkan klinis dan gambaran CT Scan kepala. Perawatan hari ke-10 temperatur meningkat, hari ke-19 terjadi penurunan kesadaran, dilakukan CT Scan kepala kontrol hasilnya terjadi transformasi hemoragik, kondisi memberat dan pada akhirnya pasien meninggal.Kata kunci: atrium fibrilasi, stroke emboli, transformasi hemoragik

Diagnosis, monitoring and prognosis of secondary brain damage in icu patients with traumatic brain injuries

Traumatic brain injury (TBI) is the brain injury that occurs whenever a physical force that impacts the head leads to neuropathology. The types of primary TBI are penentrating TBI or non-penetrating TBI and it can lead to intracerebral contusions, hemorrhages or extra-axial hematomas. Patients with TBI can also have skull fractures or concussions. The injury severity can be classified in many ways but the most established and common used is the Glascow Coma Scale (GCS). However, with the GCS, each of the severity criteria has limitations and might mot be an accurate predictor of TBI severity and outcome when used alone. For this reason it is often used in conjunction with other parameters (Abbreviated Injury Scale - AIS). Secondary Brain Damage is the injury that occurs to the TBI patient not at the time of the accident, but during the following minutes, hours or days. There are many mechanisms that lead to development of cerebral edema, blood-brain barrier disruption, vasospasm, increase in volume of bleeding, contusions and intracranial hypertension. These mechanisms can act either in cellular level or systemic level. The cellular mechanisms that lead to secondary brain damage include necrosis or apoptosis, mitochondrial dysfunction, excitotoxicicty, formation of free radicals, changes in cerebral glucose metabolism and inflammation. The mechanisms at systemic level include hypoxia-cerebral oxygenation, hypo or hypertension, hypo or hyper-capnia, anemia, hyponatremia and hyper or hypoglycemia. The first tool to diagnose severe TBI and secondary brain injury is neurological assessment. Neuroimaging is one of the most important ways for diagnosis. Computed Tomography (CT scan), Magnetic Resonance Imaging (MRI), cerebral angiography, transcranial Doppler, CT perfusion, Xenon CT, MRI diffusion, MRI perfusion, MRI spectrometry and Positron Emission Tomography (PET) are possible ways of imaging that not only help in the diagnosis but give important information that help in choosing the correct management. Moreover, neuromonitoring, helps in the correct management of the patient.