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management of acute severe traumatic brain injury

Daniel Agustín Godoy, Santiago Lubillo, Alejandro A Rabinstein
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations...
April 2018: Neurosurgery Clinics of North America
Sonny Thiara, Donald E Griesdale, William R Henderson, Mypinder S Sekhon
BACKGROUND: Increased cerebral perfusion pressure (CPP)>70 mmHg has been associated with acute respiratory distress syndrome (ARDS) after traumatic brain injury (TBI). Since this reported association, significant changes in ventilation strategies and fluid management have been accepted as routine critical care. Recently, individualized perfusion targets using autoregulation monitoring suggest CPP titration>70 mmHg. Given these clinical advances, the association between ARDS and increased CPP requires further delineation...
February 19, 2018: Canadian Journal of Neurological Sciences. le Journal Canadien des Sciences Neurologiques
Tolu O Oyesanya, Barbara J Bowers, Heather R Royer, Lyn S Turkstra
BACKGROUND: Patients with moderate-to-severe traumatic brain injury (TBI) typically have significant immediate and chronic cognitive impairments. These cognitive impairments can negatively affect their inpatient stay after an acute TBI and affect their healthcare later in life when seeking care for other acute health conditions during the chronic phase of TBI. Nurses must be knowledgeable about modifying care to accommodate cognitive impairments of these patients throughout the continuum of care...
February 5, 2018: Journal of Clinical Nursing
Cristina Mei, Vicki Anderson, Mary-Clare Waugh, Louise Cahill, Angela T Morgan
OBJECTIVE: Evidence-based management guidelines for communication and swallowing disorders following pediatric traumatic brain injury (TBI) are scarcely available, potentially resulting in suboptimal outcomes. To improve clinical care of this population, a multidisciplinary guideline development committee was formed to develop evidence-based recommendation (EBR) and consensus-based recommendation (CBR) for the management of speech, language, and swallowing disorders during the first year of recovery...
January 30, 2018: Journal of Head Trauma Rehabilitation
Venencia Albert, Arulselvi Subramanian, Deepak Agrawal, Hara Prasad Pati, Siddhartha Datta Gupta, Asok Kumar Mukhopadhyay
STUDY DESIGN: Prospective observational cohort. OBJECTIVE: To investigate the difference in plasma levels of syndecan-1 (due to glycocalyx degradation) and soluble thrombomodulin (due to endothelial damage) in isolated severe traumatic brain injury (TBI) patients with/without early coagulopathy. A secondary objective was to compare the effects of the degree of TBI endotheliopathy on hospital mortality among patients with TBI-associated coagulopathy (TBI-AC). METHODS: Data was prospectively collected on isolated severe TBI (sTBI) patients with Glasgow Coma Scale (GCS) ≤8 less than 12 h after injury admitted to a level I trauma centre...
January 16, 2018: Medical Sciences: Open Access Journal
Jose D Alarcon, Andres M Rubiano, David O Okonkwo, Jairo Alarcón, Maria José Martinez-Zapata, Gerard Urrútia, Xavier Bonfill Cosp
BACKGROUND: Traumatic brain injury (TBI) is a major public health problem and a fundamental cause of morbidity and mortality worldwide. The burden of TBI disproportionately affects low- and middle-income countries. Intracranial hypertension is the most frequent cause of death and disability in brain-injured people. Special interventions in the intensive care unit are required to minimise factors contributing to secondary brain injury after trauma. Therapeutic positioning of the head (different degrees of head-of-bed elevation (HBE)) has been proposed as a low cost and simple way of preventing secondary brain injury in these people...
December 28, 2017: Cochrane Database of Systematic Reviews
G Lakshmi Prasad, N Anmol, Girish R Menon
BACKGROUND: The growing elderly population has contributed to an increasing incidence of traumatic brain injury (TBI) in this cohort worldwide. Here we describe our institutional experience in the management of TBI in elderly Indian patients. METHODS: This was a 3-year retrospective analysis of 73 consecutive patients age ≥65 years admitted to our university hospital with TBI. Exclusion criteria included a history of concussion injury, chronic subdural hematoma (SDH), discharge against medical advice, and declared dead within 6 hours after arrival...
December 16, 2017: World Neurosurgery
Grace E Martin, Christopher P Carroll, Zach J Plummer, D A Millar, Timothy A Pritts, Amy T Makley, Bellal A Joseph, Laura B Ngwenya, Michael D Goodman
BACKGROUND: Patients with mild-to-moderate traumatic brain injury (TBI) are often primarily managed by emergency medicine and trauma/acute care physicians. The Brain Injury Guidelines (BIG) were developed at an ACS-accredited level 1 trauma center to triage mild-to-moderate TBI patients and help identify patients who warrant neurosurgical consultation. The BIG have not been validated at a level III trauma center. We hypothesized that BIG criteria can be safely adapted to an ACS-accredited level III trauma center to guide transfers to a higher echelon of care...
December 14, 2017: Journal of Trauma and Acute Care Surgery
Jeffrey P Cheng, Jacob B Leary, Darik A O'Neil, Elizabeth A Meyer, Kristin E Free, Corina O Bondi, Anthony E Kline
Agitation and aggression are common sequelae of traumatic brain injury (TBI) and pose a challenge to physicians and other health providers during acute patient care and subsequent neurorehabilitation. Antipsychotic drugs (APDs) are routinely administered to manage TBI patients displaying such maladaptive behaviors despite several clinical and preclinical studies demonstrating that they hinder recovery. A potentially viable alternative to APDs may be the benzodiazepines, which have differing mechanisms of action...
February 26, 2018: Behavioural Brain Research
Laurent Carteron, Pierre Bouzat, Mauro Oddo
Cerebral microdialysis (CMD) allows bedside semicontinuous monitoring of patient brain extracellular fluid. Clinical indications of CMD monitoring are focused on the management of secondary cerebral and systemic insults in acute brain injury (ABI) patients [mainly, traumatic brain injury (TBI), subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)], specifically to tailor several routine interventions-such as optimization of cerebral perfusion pressure, blood transfusion, glycemic control and oxygen therapy-in the individual patient...
2017: Frontiers in Neurology
Jeremiah J Johnson, Andrea C Loeffert, Jennifer Stokes, Robert P Olympia, Harry Bramley, Steven D Hicks
Importance: Approximately one-third of children who experience a concussion develop prolonged concussion symptoms. To our knowledge, there are currently no objective or easily administered tests for predicting prolonged concussion symptoms. Several studies have identified alterations in epigenetic molecules known as microRNAs (miRNAs) following traumatic brain injury. No studies have examined whether miRNA expression can detect prolonged concussion symptoms. Objective: To evaluate the efficacy of salivary miRNAs for identifying children with concussion who are at risk for prolonged symptoms...
January 1, 2018: JAMA Pediatrics
Jeroen T van Dijck, Florence C Reith, Inge A van Erp, Thomas A van Essen, Andrew I Maas, Wilco C Peul, Godard C de Ruiter
INTRODUCTION: Patients presenting with an early Glasgow Coma Scale (GCS) Score of 3-5 after blunt or penetrating skull-brain assaults are categorized as having sustained a very severe traumatic brain injury (vs-TBI). This category is often overlooked in literature. Impact on patients and families lives however is huge and the question "whether to surgically treat or not" frequently poses a dilemma to treating physicians. Little is known about mortality and outcome, compared to what is known for the group of severe TBI patients (s-TBI) (GCS 3-8)...
April 2018: Journal of Neurosurgical Sciences
John K Yue, Jonathan W Rick, Hansen Deng, Michael J Feldman, Ethan A Winkler
Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP...
November 7, 2017: Journal of Neurosurgical Sciences
Brendan OʼConnell, Áine M Kelly, David Mockler, Matej Orešič, Karl Denvir, Garreth Farrell, Damir Janigro, Fiona Wilson
OBJECTIVES: To critically review current knowledge on the positive and negative predictive value of blood biomarkers for concussion; to illustrate the clinical and biological contexts that help evaluate the use of these markers in sport-related traumatic brain injuries (TBIs). METHODS: This systematic review was performed in accordance with PRISMA guidelines. We reviewed the measurement, clinical utility, endpoint, and biological significance of blood biomarkers in concussion...
October 12, 2017: Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine
Tatyana Mollayeva, Chen Xiong, Sara Hanafy, Vincy Chan, Zheng Jing Hu, Mitchell Sutton, Michael Escobar, Angela Colantonio
INTRODUCTION: Reports on the association between comorbidity and functional status and risk of death in patients with traumatic brain injury (TBI) have been inconsistent; it is currently unknown which additional clinical entities (comorbidities) have an adverse influence on the evolution of outcomes across the lifespan of men and women with TBI. The current protocol outlines a strategy for a systematic review of the current evidence examining the impact of comorbidity on functional status and early-term and late-term mortality, taking into account known risk factors of these adverse outcomes (ie, demographic (age and sex) and injury-related characteristics)...
October 13, 2017: BMJ Open
Tim Martindale, Phillip McGlone, Robert Chambers, Jon Fennell
The effects of a high carbon dioxide on cerebral perfusion and intracranial pressure are well known. We report the case of a man who presented after with a severe traumatic brain injury including intracranial and extradural haemorrhage. Neuroprotective ventilation was impossible without supramaximal tidal volumes due to a combination of chest trauma and severe bronchospasm. A pump driven Novalung iLA active® system was inserted to achieve both ARDSnet ventilation and a lowering of intracranial pressure. To our knowledge, this is the first time this system has been used to this effect...
February 2017: Journal of the Intensive Care Society
Shigeo Godo, Shigemi Irino, Atsuhiro Nakagawa, Yu Kawazoe, Motoo Fujita, Daisuke Kudo, Ryosuke Nomura, Hiroaki Shimokawa, Shigeki Kushimoto
Paroxysmal sympathetic hyperactivity (PSH) is a distinct syndrome of episodic sympathetic hyperactivities following severe acquired brain injury, characterized by paroxysmal transient fever, tachycardia, hypertension, tachypnea, excessive diaphoresis and specific posturing. PSH remains to be an under-recognized condition with a diagnostic pitfall especially in the intensive care unit (ICU) settings due to the high prevalence of concomitant diseases that mimic PSH. A consensus set of diagnostic criteria named PSH-Assessment Measure (PSH-AM) has been developed recently, which is consisted of two components: a diagnosis likelihood tool derived from clinical characteristics of PSH, and a clinical feature scale assigned to the severity of each sympathetic hyperactivity...
September 2017: Tohoku Journal of Experimental Medicine
Martin Smith
Raised intracranial pressure (ICP) is associated with worse outcomes after acute brain injury, and clinical guidelines advocate early treatment of intracranial hypertension. ICP-lowering therapies are usually administered in a stepwise manner, starting with safer first-line interventions, while reserving higher-risk options for patients with intractable intracranial hypertension. Decompressive craniectomy is a surgical procedure in which part of the skull is removed and the underlying dura opened to reduce brain swelling-related raised ICP; it can be performed as a primary or secondary procedure...
December 2017: Anesthesia and Analgesia
M Irem Baharoglu, Anneke Brand, Maria M Koopman, Marinus Vermeulen, Yvo B W E M Roos
Neurological injuries can be divided into those with traumatic and nontraumatic causes. The largest groups are traumatic brain injury (TBI) and nontraumatic stroke. TBI patients may present with intracranial hemorrhages (contusions, or subdural or epidural hematomas). Strokes are ischemic or hemorrhagic. In all these disorders, thrombosis and hemostasis play a major role. Treatment aims to either cease bleeding and/or restore perfusion. We reviewed hemostatic and thrombolytic therapies in patients with neurological injuries by MEDLINE and EMBASE search using various key words for neurological disorders and hemostatic therapies restricted to English language and human adults...
October 2017: Transfusion Medicine Reviews
Daniel Agustín Godoy, Pablo David Guerrero Suarez, Luis Rafael Moscote-Salazar, Mario Di Napoli
Intracranial hypertension (IH) is one of the final pathways of acute brain injury. In severe traumatic brain injury (sTBI), it independently predicts poor outcomes. Its control represents a key aspect of the management. Lack of response to conventional therapies signals a state of ''refractory IH'', with an associated mortality rate of 80-100%. In such cases, hypothermia, barbiturates at high doses (BBT), decompressive craniectomy (DC), and extreme hyperventilation are utilized. However, none of them has proven efficacy...
July 2017: Bulletin of Emergency and Trauma
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