Safe management of paediatric penetrating head injury without a CT scanner: A strategy for humanitarian surgeons based on experience in southern Afghanistan.

INTRODUCTION: In many parts of the world, access to a CT scanner remains almost non-existent, and patients with a head injury are managed expectantly, often with poor results. Recent military medical experience in southern Afghanistan using a well-equipped surgical facility with a CT scanner has provided new insights into safe surgical practice in resource-poor environments. METHODS: All cases of children aged under 16 years with penetrating head injury who were treated in a trauma unit in southern Afghanistan by a single neurosurgeon between 2008 and 2010 were reviewed. Based on a previously published retrospective review, a clinical strategy aimed specifically at generalist surgeons is proposed for selecting children who can benefit from surgical intervention in environments with no access to CT scanners. RESULTS: Fourteen patients were reviewed, of whom three had a tangential wound, 10 had a penetrating wound with retained fragments and one had a perforating injury. Two operations for generalist surgeons are described in detail: limited wound excision; and simple decompression of the intra-cranial compartment without brain resection or dural repair. CONCLUSIONS: In resource-poor environments, clinically-based criteria may be used as a safe and appropriate strategy for selecting children who may benefit from relatively straightforward surgery after penetrating brain injury.

SGDI: system for genomic data integration.

This paper describes a framework for collecting, annotating, and archiving high-throughput assays from multiple experiments conducted on one or more series of samples. Specific applications include support for large-scale surveys of related transcriptional profiling studies, for investigations of the genetics of gene expression and for joint analysis of copy number variation and mRNA abundance. Our approach consists of data capture and modeling processes rooted in R/Bioconductor, sample annotation and sequence constituent ontology management based in R, secure data archiving in PostgreSQL, and browser-based workspace creation and management rooted in Zope. This effort has generated a completely transparent, extensible, and customizable interface to large archives of high-throughput assays. Sources and prototype interfaces are accessible at www.sgdi.org/software.

The ATLS course, a survey of 228 ATLS providers.

Advanced Trauma Life Support (ATLS) courses teach a system for the initial assessment and management of trauma patients that aims to optimise initial care and reduce mortality and morbidity, and have been adopted worldwide. This questionnaire survey characterised those who took up this particular educational resource in Scotland during a four year period after its introduction, and analysed how they felt it had affected their clinical competence. Irrespective of their previous level of training and experience, nearly all surgeons and anaesthetists who took this course felt that it had improved their clinical skills and other professional attributes. The significance of these results is discussed in the context of postgraduate surgical and anaesthetic training in Scotland.

Improving outcome after traumatic brain injury--progress and challenges.

This article describes the rapid advances in the head injury field which have taken place within the professional lifetime of many doctors in practice today. These have led to a better understanding of what happens in the injured brain and how these events might be manipulated to achieve better outcomes. Clinical tools we now take for granted, like the CT scanner and the Glasgow Coma Scale, were new developments 25 years ago. They provided a foundation on which clinicians and basic scientists could build what we now know: what to assess in the patient, how to respond to certain findings, what imaging to do, how to plan treatment rationally, how to minimise brain damage at different stages after injury, how to predict and measure outcome, what disabled survivors need, and how to organise the service to do the greatest good for the most people. Some of these topics raise as many questions as answers. The head injury field may be broad but it has essential unity. At one extreme, some patients have a life-threatening illness where the acts and omissions of the clinical team can powerfully influence not only survival but its quality. Later the drama of the acute phase gives way to the 'hidden disabilities' of the long-term deficits which so many survivors have. At the other end of the severity spectrum is the relatively vast number of people who suffer an apparently mild head injury, a few of whom deteriorate and need urgent treatment, and many of whom have unspectacular but, nevertheless, disabling problems. The article attempts to address this broad canvas. Clinicians, neuroscientists, policy makers, and service users must work together to address the major scientific, individual, and population challenges posed by head injury. Much has already been achieved, but much remains to be done, especially in translating 'what we know' into 'what we do'.

Causes and effects of systemic complications among severely head injured patients transferred to a neurosurgical unit.

Hypoxia and hypotension are potent causes of avoidable secondary brain damage after severe head injury. These systemic insults were studied in three cohorts of patients (600 in all) transferred in coma from general hospitals to a regional neurosurgical unit between 1979 and 1990. The incidence of hypoxia and hypotension on arrival at the neurosurgical unit fell from 30% in 1979-80 to 12% in 1989-90, even though the proportion of patients arriving within three hours of injury rose from 33% to 52%. Hypoxia was associated with airway obstruction, and hypotension with unsuspected or undertreated multiple injuries. Whatever the patient's age, CT scan findings, or depth of coma, hypoxia and hypotension has independent and additive adverse effects on outcome. The improvements between 1979 and 1990 are attributed to better airway care, especially the increased use of intubation and mechanical ventilation during transfer, and to greater appreciation of how relatively simple measures can reduce the potential hazards of ambulance transfer.

Death in hospital after head injury without transfer to a neurosurgical unit: who, when, and why?

Most studies of hospital deaths after head injury have been in patients transferred to neurosurgical units (NSU), but over 90 per cent of hospitalized head-injured patients are not transferred and some of these die. To assess the effectiveness of triage of seriously head-injured patients in Glasgow, we studied 270 patients who died after head injury in any of the six Glasgow general hospitals during 1979-1988 and who were not transferred to the regional NSU. The proportion of fatal cases of head injury who had not been to the NSU fell from 69 per cent in 1971-1975 to 45 per cent in 1979-1988. Most of the untransferred patients were elderly, and most died from irremediable injuries or complications. Although 31 (11 per cent) had a significant intracranial haematoma, only seven of these might have been salvaged by neurosurgical intervention. Seven other patients died from potentially preventable extracranial injuries or complications. These findings suggest that a relatively satisfactory level of triage of seriously head-injured patients has been achieved, by promoting effective communication between neurosurgeons and other specialists, and by a continuous programme of audit and education.

Brain death and organ donation in a neurosurgical unit: audit of recent practice.

OBJECTIVE: To assess the potential for increasing the yield of donors by comparing the current pattern of brain death and organ donation in a neurosurgical unit with that reported in 1981 and with a recent national audit. DESIGN: Retrospective review of all deaths for 1986, 1987, and 1988 and prospective data for 1989. SETTING: A regional neurosurgical unit serving 2.7 million population. RESULTS: Of 553 deaths, 35% (191) patients died while on a ventilator and 17% (92) after discontinuation of ventilation. Medical contraindications to donation were found in 23% (32) of 141 patients tested for brain death, in 38% (19) of 50 patients who died while being ventilated who were not tested, and in 12% (11) of 92 patients no longer being ventilated. Consent for donation was sought in 88% (96) of 109 medically suitable brain dead patients and granted in 70% (67) of these. Half those with permission for multiorgan donation had only the kidneys removed. CONCLUSIONS: More organs may be lost owing to transplant team logistics than by failure to seek consent from relatives of brain dead patients. The estimated size of the pool of potential donors depends on what types of patients might be considered. Ensuring that all who die while being ventilated are tested for brain death and considering the potential for donation before withdrawing ventilation could yield more donors. Ventilating more patients who are hopelessly brain damaged to secure more donors raises ethical and economic issues.

Audit of transfer of unconscious head-injured patients to a neurosurgical unit.

Features of patients transferred to a regional neurosurgical unit in coma after recent head injury were compared with a similar audit seven years previously. There were fewer avoidable adverse factors in the recent series, but some patients received inadequate care of the airway, while in some others major extracranial injuries were overlooked or poorly managed. Only 42% of the comatose patients had had an endotracheal tube inserted; half those in whom neither a tube nor an oral airway had been inserted were transported supine. Systemic hypoxia or hypotension [corrected] were associated with a poor outcome. Even when computed tomography scanners become available in more hospitals, many patients who are unconscious after head injury will still need to be transferred to a neurosurgical unit. Detailed guidelines should be agreed locally to minimise the hazards of transfer of unconscious patients between hospitals. A rota of experienced doctors and nurses at the sending hospital should be responsible for deciding how each individual patient should be managed during transfer, according to the guidelines. Continuing audit of such cases is needed to indicate whether revision of local practice is needed.

Diagnosis and management of delayed traumatic intracerebral haematomas.

In a retrospective study of 888 consecutive patients with traumatic intracranial haematomas, we identified 23 (2.6%) who had developed a delayed intracerebral haematoma after admission to hospital. The initial CT scan within 48 h of injury had been abnormal in all 23 cases; a haematoma had been evacuated in eight (35%) and intracranial pressure (ICP) had been monitored in 14 (61%). A delayed intracerebral haematoma had been diagnosed by repeat CT scan between 4 h and 10 days later, and nine of these had been evacuated on clinical grounds. Patients with persistently elevated ICP were rescanned more quickly than those who deteriorated clinically or failed to improve. Seven patients (30%) died, and the main cause of death was severe primary brain damage. Overall outcome was better in this series than in other reported series of delayed haematomas. We conclude that delayed haematomas occur only when the initial CT scan has been abnormal, and that clinically important ones are uncommon. ICP monitoring offers earlier diagnosis, but it remains to be established that this affects outcome.

Intracranial rupture of a pressure monitoring transducer: technical note.

A solid state catheter tip transducer was used to measure intracranial pressure. During calibration, air escaped into the subdural space. Ways of recognizing and preventing this complication are discussed.

Postoperative extradural hematoma associated with induced hypertension.

We describe a patient who developed a delayed postoperative hematoma while receiving hypertensive therapy for delayed cerebral ischemia after aneurysm operation. The association between delayed extradural hematoma and induced hypertension has not been described previously.