[Polytrauma and concomitant traumatic brain injury : The role of the trauma surgeon]. / Polytrauma und begleitendes Schädel-Hirn-Trauma : Die Rolle des Unfallchirurgen.

BACKGROUND: Concomitant traumatic brain injury (TBI) increases mortality and reduces quality of life of polytrauma patients. These facts demand effective treatment strategies while the growing specialization of medicine is questioning the role of the trauma surgeon in the management of these patients. OBJECTIVES: Which factors influence outcome of polytrauma with concomitant TBI? Who should be responsible for the management of these patients and what is the limit of management? MATERIALS AND METHODS: A literature search using Medline via PubMed was performed with Medical Subject Headings and text word search. RESULTS: The crucial factors for outcome are absence of hypotension, adherence to pre- and in-hospital standards like fast transportation to appropriate centers, priority-based diagnostic and therapeutic strategies and strict adherence to principles of damage control surgery. Patients with polytrauma and TBI are treated by different specialties around the world based on the trauma system, geographic circumstances and resources. Investigations of operative and conservative management by different medical specialties showed comparable outcomes. CONCLUSIONS: In an age of standardization and a high degree of specialization in the field of medicine, the trauma surgeon still seems to be able to ensure an optimal treatment of polytrauma and concomitant TBI by focusing on priority-based diagnostic and therapeutic strategies and adhering to principles of damage control surgery.

Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center.

BACKGROUND: Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children. HYPOTHESIS: We hypothese that due to adequate treatment of EDH in children and adolescence excellent clinical and functional outcome can be reached. PURPOSE: To evaluate retrospectively our treatment process of EDH and to elucidate the relationship between trauma mechanism, injury pattern, radiological presentation, subsequent therapy and functional outcome. PATIENTS AND METHODS: Hundred and twenty infants and children with traumatic brain injuries (TBI) were treated between 1992 and 2009 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow Outcome Scale (GOS) scores at hospital discharge and at follow-up visits were used. EDH was classified according to the Rotterdam score. RESULTS: Finally, 41 cases were diagnosed with an EDH and therefore included in our study. Twenty-one cases were treated surgically; however of these in 11 patients delayed surgery was necessary. Twenty patients were treated conservatively. Two patients (5%) died within 24hours, 39 patients (95%) survived. One of the operatively treated patients (2%) presented in a vegetative state, another one had severe disability, and however, 32 patients (78%) showed good recovery at latest follow-up. DISCUSSION: Age, severity of TBI, and neurological status were the main factors influencing outcome after TBI due to acute EDH. We found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases - however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached.

Preliminary findings on biomarker levels from extracerebral sources in patients undergoing trauma surgery: Potential implications for TBI outcome studies.

BACKGROUND: Despite several experimental studies on the role of S100B and NSE in fractures, no studies on the influence of surgery on the biomarker serum levels have been performed yet. METHODS: The serum levels of S100B and NSE were analysed in patients with fractures that were located in the spine (group 1, n = 35) or in the lower extremity (group 2, n = 32) pre- and post-operatively. RESULTS: The mean S100B serum level showed a significant increase (p = 0.04) post-surgery in the patients of group 1. In patients undergoing acute surgery (< 24 hours) the mean S100B serum level was 0.23 ± 0.22 µg L(-1) pre-operatively and 1.24 ± 1.38 µg L(-1) post-operatively. Likewise, the mean S100B serum level significantly increased in group 2 after surgery (p < 0.0001). In this group patients undergoing acute surgery showed a mean S100B serum level of 0.23 ± 0.14 µg L(-1) and 1.11 ± 0.73 µg L(-1) pre- and post-operatively. CONCLUSION: This study demonstrates significant alterations of the biomarker S100B serum levels in patients undergoing surgery. Higher S100B serum levels were found within 24 hours and might be related to the acute fracture. The NSE serum levels were unchanged and this biomarker may offer the probability to serve as a future outcome predictor in studies with patients with traumatic brain injury and additional extracerebral injuries.

Timing and duration of intracranial hypertension versus outcomes after severe traumatic brain injury.

BACKGROUND: The goal of this paper was to investigate the association between patterns of intracranial hypertension (IH) and outcomes, to describe the treatment of patients with different patterns of IH, and to examine whether IH is an independent predictor of mortality and unfavourable outcome, respectively. METHODS: A retrospective analysis of data collected prospectively in 9 central European centers is presented. 204 patients with severe TBI who had intracranial pressure (ICP) monitoring were coded as having either early (within first 2 days), late (after first 2 days), or no IH. IH was defined as >60 min of ICP >20 mmHg/day. The total number of hours/day of IH was recorded. Treatment was followed closely for the first 10 days using the therapy intensity level (TIL) score. Associations between types of IH and demographic factors, trauma severity, or treatment factors as well as outcomes were analysed. RESULTS: Patients in the early IH group were the most severely injured. They had the highest TIL levels, had the highest mortality (48%) and the highest rate of unfavourable outcome (65%) followed by the late IH group (20% and 57%) and the no IH group (23% and 36%). Duration of IH correlated significantly with hospital mortality. IH was an independent predictor of mortality and unfavourable outcome after adjusting for age, Glasgow Coma Scale score, and Abbreviated Injury Score "head". CONCLUSION: Intracranial hypertension with early onset is independently associated with significantly worse outcome in patients with severe TBI. The total duration of IH shows a significant correlation to mortality.

Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury.

OBJECTIVE: To analyse the association between the Glasgow Coma Scale (GCS) score at intensive care unit (ICU) discharge and the 1-year outcome of patients with severe traumatic brain injury (TBI). DESIGN: Retrospective analysis of prospectively collected observational data. PATIENTS: Between 01/2001 and 12/2005, 13 European centres enrolled 1,172 patients with severe TBI. Data on accident, treatment and outcomes were collected. According to the GCS score at ICU discharge, survivors were classified into four groups: GCS scores 3-6, 7-9, 10-12 and 13-15. Using the Glasgow Outcome Scale (GOS), 1-year outcomes were classified as "favourable" (scores 5, 4) or "unfavourable" (scores <4). Factors that may have contributed to outcomes were compared between groups and for favourable versus unfavourable outcomes within each group. MAIN RESULTS: Of the 538 patients analysed, 308 (57 %) had GCS scores 13-15, 101 (19 %) had scores 10-12, 46 (9 %) had scores 7-9 and 83 (15 %) had scores 3-6 at ICU discharge. Factors significantly associated with these GCS scores included age, severity of trauma, neurological status (GCS, pupils) at admission and patency of the basal cisterns on the first computed tomography (CT) scan. Favourable outcome was achieved in 74 % of all patients; the rates were significantly different between GCS groups (93, 83, 37 and 10 %, respectively). Within each of the GCS groups, significant differences regarding age and trauma severity were found between patients with favourable versus unfavourable outcomes; neurological status at admission and CT findings were not relevant. CONCLUSION: The GCS score at ICU discharge is a good predictor of 1-year outcome. Patients with a GCS score <10 at ICU discharge have a poor chance of favourable outcome.

One-year outcome and course of recovery after severe traumatic brain injury.

GOAL: To describe the outcome of patients with severe traumatic brain injury (TBI) 3, 6 and 12 months after trauma. METHODS: Between January 2001 and December 2005, 13 European centres enrolled 1,172 patients with severe TBI defined as Glasgow Coma Scale (GCS) score < 9. Demographic data, trauma severity, results of computed tomography (CT) scans, data on status, treatment and outcome were recorded. The five-level Glasgow Outcome Scale (GOS) score was used to classify patients as having a "favourable" (GOS scores 5 and 4) or an "unfavourable outcome" (GOS scores 3, 2 and 1). RESULTS AND CONCLUSIONS: Of the 1,172 patients, 37% died in the intensive care unit (ICU) and 8.5% died after ICU discharge. At 12 months after trauma, almost half of the outcomes (46.6%) were classified as "favourable" (33% "good recovery", 13.6% "moderate disability") and 7.9% were classified as "unfavourable" (6.1% "severe disability", 1.8% "vegetative status"). As in previous studies, long-term outcomes were influenced by age, severity of trauma, first GCS score, pupillary status and CT findings (e.g. subdural haematoma and closed basal cistern on the first CT scan). Patients with "good recovery" had a high likelihood to remain in that category (91%). Patients with "moderate disability" had a 50% chance to improve to "good recovery". Patients with "severe disability" had a 40% chance to improve and had a 4% chance of death. Patients with "vegetative status" were more likely to die (42%) than to improve (31%). Changes were more likely to occur during the first than during the second half-year after trauma.

First experience with fiberoptically directed wire-guided endobronchial blockade in severe pulmonary bleeding in an emergency setting.

We report the first use of a new wire-guided endobronchial blocker in a critical respiratory situation caused by localized pulmonary bleeding. During emergency management, it became increasingly difficult to ventilate a multiple-trauma patient with a conventional single-lumen tube because of massive bleeding through the bronchus of the left lower lobe. Using the Arndt endobronchial blocker set (William Cook Europe A/S; Bjaeverskor, Denmark), we were able to prevent the spread of hemorrhaging and achieved effective ventilation and marked improvement in gas exchange. This new device allows the effective blockade of an isolated lobe under direct bronchoscopy to buy time for further intervention.