ABSTRACT
Severe traumatic brain injuries are extremely heterogeneous. At least seven of the secondary derangements in the brain that have been identified as occurring after most traumatic brain injuries also occur after cardiac arrest. These secondary derangements include posttraumatic brain ischemia. In addition, traumatic brain injury causes insults not present after cardiac arrest, i.e., mechanical tissue injury (including axonal injury and hemorrhages), followed by inflammation, brain swelling, and brain herniation. Brain herniation, in the absence of a mass lesion, is due to a still-to-be-clarified mix of edema and increased cerebral blood flow and blood volume. Glutamate release immediately after traumatic brain injury is proven. Late excitotoxicity needs exploration. Inflammation is a trigger for repair mechanisms. In the 1950s and 1960s, traumatic brain injury with coma was treated empirically with prolonged moderate hypothermia and intracranial pressure monitoring and control. Moderate hypothermia (30 degrees to 32 degrees C), but not mild hypothermia, can help prevent increases in intracranial pressure. How to achieve optimized hypothermia and rewarming without delayed brain herniation remains a challenge for research. Deoxyribonucleic acid (DNA) damage and triggering of programmed cell death (apoptosis) by trauma deserve exploration. Rodent models of cortical contusion are being used effectively to clarify the molecular and cellular responses of brain tissue to trauma and to study axonal and dendritic injury. However, in order to optimize therapeutic manipulations of posttraumatic intracranial dynamics and solve the problem of brain herniation, it may be necessary to use traumatic brain injury models in large animals (e.g., the dog), with long-term intensive care. Stepwise measures to prevent lethal brain swelling after traumatic brain injury need experimental exploration, based on the multifactorial mechanisms of brain swelling. Novel treatments have so far influenced primarily healthy tissue; future explorations should benefit damaged tissue in the penumbra zones and in remote brain regions. The prehospital arena is unexplored territory for traumatic brain injury research.
Subject(s)
Brain Injuries/therapy , Resuscitation/methods , Animals , Brain Edema/etiology , Brain Injuries/complications , Brain Injuries/physiopathology , Brain Ischemia/etiology , Disease Models, Animal , Dogs , Humans , Hypothermia, Induced/methods , Mice , RatsABSTRACT
OBJECTIVE: To determine the short-term and long-term outcome of critically ill "oldest-old" (greater than or equal to 85 yrs) patients. DESIGN: Retrospective chart review and follow-up telephone interview. SETTING: ICUs at a tertiary care hospital. METHODS: The medical records of all patients greater than or equal to 85 yrs of age admitted to the ICUs during 1988 were reviewed. Demographic information, severity of illness, major interventions, mortality rate, and hospital charges were examined. A follow-up telephone interview was conducted to determine the quality of life and mortality rate after discharge. RESULTS: Of 34 patients greater than or equal to 85 yrs of age admitted to the ICU, 21 (62%) survived to discharge from the hospital, and 13 (62%) of these 21 patients were discharged to home. Mean +/- SD hospital charges were $34,738 +/- 34,366. Seventeen of the 21 patients were contacted for long-term follow-up, and ten of these patients were alive at a mean follow-up time of 18 +/- 10 months (range 1 to 32). Eight of the ten patients described their quality of life as fair or good. CONCLUSION: These findings suggest that age alone may be an inappropriate criterion for allocation of ICU resources.
Subject(s)
Aged, 80 and over , Critical Care , Critical Illness/therapy , Treatment Outcome , Aged , Critical Care/economics , Critical Care/statistics & numerical data , Critical Illness/economics , Critical Illness/mortality , Follow-Up Studies , Humans , Pennsylvania , Quality of Life , Retrospective Studies , Severity of Illness IndexABSTRACT
Analysis of 145 reports of adverse occurrences involving patients in a medical-surgical intensive care unite (ICU), during the yearts 1974 through 1978, disclosed 92 instances of human error and 53 cases of equipment malfunction. A peak occurrence of reported incidents was found between midnight and 1 AM. Harm occurred more frequently if the patient was unattended (72%) than attended (49%) during the incident. Mortality for patients with an incident report filed during their ICU admission (41%) was higher than for all ICU patients (21%). The importance of a well-structured incident-reporting program to minimize problems of human error and device malfunction is stressed.
