Seizure Prophylaxis in Young Patients Following Traumatic Brain Injury.

Introduction: Phenytoin is one of the commonly used anti.seizure medications in nontraumatic seizures. However, its utility and safety in young patients with traumatic brain injury (TBI) for the prevention of early-onset seizures (EOS) are debatable. We sought to explore the use of phenytoin as a seizure prophylaxis following TBI. We hypothesized that administering phenytoin is not effective in preventing EOS after TBI. Methods: This was a retrospective observational study conducted on adult TBI patients. EOS was defined as a witnessed seizure within a week postinjury. Data were compared as phenytoin versus no-phenytoin use, EOS versus no-EOS, and among TBI severity groups. Results: During 1 year, 639 TBI patients were included with a mean age of 32 years; of them, 183 received phenytoin as seizure prophylaxis, and 453 received no prophylaxis medication. EOS was documented in 13 (2.0%) patients who received phenytoin, and none had EOS among the nonphenytoin group. The phenytoin group was more likely to have a higher Marshall Score (P = 0.001), lower Glasgow Coma Scale (GCS) (P = 0.001), EOS (P = 0.001), and higher mortality (P = 0.001). Phenytoin was administrated for 15.2%, 43.2%, and 64.5% of mild, moderate, and severe TBI patients, respectively. EOS and no-EOS groups were comparable for age, gender, mechanism of injury, GCS, Marshall Score, serum phenytoin levels, liver function levels, hospital stay, and mortality. Multivariable logistic regression analysis showed that low serum albumin (odds ratio [OR] 0.81; 95% confidence interval [CI] 0.676.0.962) and toxic phenytoin level (OR 43; 95% CI 2.420.780.7) were independent predictors of EOS. Conclusions: In this study, the prophylactic use of phenytoin in TBI was ineffective in preventing EOS. Large-scale matched studies and well-defined hospital protocols are needed for the proper utility of phenytoin post-TBI.

Empirical Pyridostigmine in a Patient with Difficult Weaning from Mechanical Ventilation after Traumatic Brain Injury.

We present a 30-year-old male who sustained a mild traumatic brain injury and then was intubated due to deterioration of consciousness. A head CT scan revealed mild brain oedema, a fractured nasal bone and mild left thoracic wall haematoma. Despite complete clinical and radiological normalisation within 36 hours, he failed to wean off the ventilator. The patient was found to have subtle bulbar manifestations including dysphonia, dysarthria, and dysphagia, with recurrent left lung collapse. He responded to an empirical pyridostigmine trial despite negative biochemical tests for myasthenia gravis (MG). The patient was weaned successfully from the ventilator, transferred to a long-term care facility, and then discharged home. Classic symptoms and signs of a disease may be absent, but the presence of dysarthria, dysphagia, transient vocal cord palsy, nasal speech, absent gag reflex and respiratory failure in difficult-to-wean patients, with no definitive diagnosis, may warrant an empirical trial of therapy for suspected MG and for the benefit of any doubt. LEARNING POINTS: "Hidden" cranial injuries may account for subtle bulbar symptoms in victims of traumatic brain injury and should be searched for.Myasthenia gravis has been reported in association with trauma, which comes first and is often difficult to ascertain.A trial of pyridostigmine may be reasonable in difficult-to-wean patients when all other causes have been excluded for the benefit of the doubt.

Massive traumatic subarachnoid hemorrhage mimicking aneurysmal subarachnoid hemorrhage.

Introduction: Massive traumatic subarachnoid hemorrhage (tSAH) is a rare but potentially life-threatening condition that can mimic the clinical presentation of aneurysmal subarachnoid hemorrhage (aSAH). The accurate differentiation between these two entities is crucial, as their management and prognoses significantly differ. Case presentation: We present a case of a 64-year-old male patient who presented to our emergency department after being involved in a motor vehicle collision. His radiological findings on a computed tomography (CT) scan were suggestive of aSAH based on its location, which showed massive SAH in bilateral sylvian fissures and the basal cisterns. There was no evidence of vasospasm. The patient later developed a stroke despite the use of Nimodipine. Conclusion: While traumatic subarachnoid hemorrhage mimicking aneurysmal subarachnoid hemorrhage is a recognized phenomenon, it is relatively uncommon. We present a case of massive tSAH complicated by a stroke with no evidence of aneurysm on cerebral angiogram, shedding light on the diagnostic challenges in differentiating tSAH from aSAH and emphasizing the importance of accurate diagnosis for appropriate management, in addition, we aim to remind the readers that trauma may be a cause for massive SAH and should prompt a medical SAH management plan.

Intensive Care Physician-Led Clearance of the Cervical Spine: A Retrospective Review of the Utility of a Normal Cervical CT Scan for Safe Removal of Hard Collars by Critical Care Physicians.

Background: Cervical spine clearance in intubated patients due to blunt trauma remains contentious. Accumulating evidence suggests that a normal computed tomography (CT) cervical spine can be used to clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department. However, whether this strategy can safely be employed by critical care physicians with intubated patients admitted to the trauma intensive care unit (TICU) with cervical collars in situ, has not been definitively studied. Methods: A retrospective review of 730 intubated victims of trauma who presented to the Level 1 Trauma center of a tertiary hospital was conducted. The rates of missed cervical injuries in patients who had their cervical collars removed by intensive care physicians based on a normal CT scan of the cervical spine, were reviewed. Secondary outcomes included rates of collar-related complications. Results: Three hundred and fifty patients had their cervical collars removed by Trauma ICU doctors based on a high-quality, radiologist-interpreted normal CT cervical spine. Seventy percent of patients were sedated and/or comatose at the time of collar removal. Fifty-one percent of patients had concomitant traumatic brain injury. The average GCS at time of collar removal was 9. The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%). The rate of collar-related complications was 2%. Conclusion: Cervical collar removal by intensive care physicians on TICU following normal CT cervical spine, is safe, provided certain quality conditions related to the CT scan are met. Not removing the collar early may be associated with increased complications. An algorithm is suggested to assist critical care decision-making in this patient cohort.

Occult Perforation of the Esophagus during Removal of an Enteral Feeding Tube: A Case Report and Literature Review.

Background. The use of oral or nasal route for enteral feeding is a standard practice in intensive care patients with a safe profile in general. However, complications associated with the insertion of a nasogastric (NGT) or orogastric tube (OGT) are common in the medical literature compared to the removal of such tubes. Case presentation. We presented a 38-year-old male who was involved in a motor-vehicle collision and found with low Glasgow Coma Scale outside his vehicle. He had polytrauma and was intubated-and commenced on enteral feeding via an OGT. Esophageal bezoar developed within a few days around the feeding tube, resulting in significant force being required to remove it, which was complicated by esophageal perforation. The esophageal injury was treated conservatively with uneventful recovery. Discussion and conclusions. Although limited case reports of esophageal enteral feeding bezoar formation do exist in the literature, we believe that this is the first case report of esophageal perforation due to the forceful removal of a wedged OGT secondary to esophageal bezoar formation. Morbidity associated with OGT/NGT is not common and may require a high index of suspicion to be identified. This is especially true if resistance is appreciated while removing the NGT/OGT. Gastroenterology consultation is recommended as early as possible to detect and manage any complications, however, their role was very limited in such stable case. In addition, early computed tomography (CT) can be considered for timely recognition of esophageal perforation. Non-operative management may be considered in stable patients, especially if the leak is in the cervical portion of the esophagus. Finally, prevention is better than cure, so being diligent in confirming NGT/OGT position, both radiologically and by measuring the tube length at the nostril/mouth, is the key to avoid misplacement and complication. This case raises the awareness of physician for such preventable iatrogenic event.

A multidisciplinary approach to rescue a full-term pregnant and her fetus after blunt abdominal trauma: A case report and literature review.

Blunt abdominal trauma due to motor vehicle crash is one of the leading causes of mortality during pregnancy. Though the trauma team plays a critical role in the initial management, a multidisciplinary contribution is essential to ensure the safety of the mother and her fetus. This case report followed the multidisciplinary approach for the management of a 32-year-old female during the last week of pregnancy. She sustained blunt trauma causing maternal and fetal distress due to abruption of the placenta with a large intrauterine and retroplacental hemorrhage, retro-hepatic and retroperitoneal hemorrhage, pseudoaneurysm of uterine arteries leading to postpartum hemorrhage. Immediate intervention and management at a Level 1 trauma center led to survival of both the mother and infant.

Clinical Characteristics and Risk Factors for Early versus Late Pulmonary Embolism in Trauma Patients: A Retrospective, Observational Study.

Background: We sought to evaluate the clinical characteristics and risk factors for early versus late pulmonary embolism (PE) in trauma patients. Methods: This was a retrospective analysis of injured patients who presented with a confirmed PE between 2013 and 2019. Data were analysed and compared for patients with early PE (≤4 days) versus late PE (>4 days post-trauma). Results: The study included 82 consecutive trauma patients with confirmed diagnosis of PE. The mean age of patients was 42.3 ± 16.2 years. The majority were males (79.3%) and the median time from injury to PE was 10 days. Of the PE cases, 24 (29.3%) had early PE, while 58 (70.7%) had late PE. The early PE group had higher rates of surgical intervention within 24 hours of admission than the late PE group (p = 0.001). Also, the rate of sub-segmental thrombi was significantly higher in the early PE group (p = 0.01). The late PE group sustained more moderate-to-severe injuries ie, GCS ED <13 (p = 0.03) and the median time from injury to PE diagnosis was 15 days (p = 0.001). After adjusting for the potential covariates, surgery within 24 hours of admission [adjusted odds ratio 37.58 (95% confidence interval 3.393-416.20), p = 0.003] was found to be significant independent predictor of early PE in trauma patients. Conclusion: One-third of post-trauma PEs occurs early after trauma and the surgical intervention within the first 24 hours of admission is a major risk factor. A prospective study is needed to develop an objective risk assessment for the prevention and detection of early and late PE post-trauma.

Traumatic Pancreatic Injury Presentation, Management, and Outcome: An Observational Retrospective Study From a Level 1 Trauma Center.

BACKGROUND: We aimed to study the presentation, management, and outcomes of patients with a pancreatic traumatic injury. METHODS: We retrospectively analyzed data for all patients who were admitted with pancreatic injuries between 2011 and 2017 at the only level 1 trauma center in the country. RESULTS: There were 71 patients admitted with pancreatic trauma (0.6% of trauma admissions and 3.4% of abdominal injury admissions) with a mean age of 31 years. Sixty-two patients had pancreatic injury grade I-II and nine had injury grade III-IV. Thirty-eight percent had Glasgow Coma Scale (GCS) <9 and 73% had injury Severity Score (ISS) >16. The level of pancreatic enzymes was significantly proportional to the grade of injury. Over half of patients required laparotomy, of them 12 patients had an intervention on the pancreas. Eight patients developed complications related to pancreatic injuries ranging from pancreatitis to pancreatico-cutaneous fistula while 35% developed hemorrhagic shock. Mortality was 31% and regardless of the grade of injury, the mortality was associated with high ISS, low GCS, and presence of hemorrhagic shock. CONCLUSION: Pancreatic injuries following blunt trauma are rare, and the injured subjects are usually young men. However, most injuries are of low-grade severity. This study shows that regardless of the pancreatic injury grade on-admission shock, higher ISS and lower GCS are associated with worse in-hospital outcomes. Non-operative management (NOM) may suffice in patients with lower grade injuries, which may not be the case in patients with higher grade injuries unless carefully selected.

Relationship of Optic Nerve Sheath Diameter and Intracranial Hypertension in Patients with Traumatic Brain Injury.

BACKGROUND: to study the association between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in patients with moderate-to-severe brain injury. PATIENTS AND METHODS: A retrospective cohort study of traumatic brain injury (TBI) patients was conducted between 2010 and 2014. Data were analyzed and compared according to the ICP monitoring cutoff values. Outcomes included intracranial hypertension (ICH) and mortality. RESULTS: A total of 167 patients with a mean age of 33 ± 14 years, of them 96 had ICP monitored. ICP values correlated with ONSD measurement (r = 0.21, P = 0.04). Patients who developed ICH were more likely to have higher mean ONSD (P = 0.01) and subarachnoid hemorrhage (SAH) (P = 0.004). Receiver operating curve for ONSD showed a cutoff value of 5.6 mm to detect ICH with sensitivity 72.2% and specificity 50%. Age and ICP were independent predictors of inhospital mortality in multivariate model. Another model with same covariates showed ONSD and SAH to be independent predictors of ICH. Simple linear regression showed a significant association of ONSD with increased ICP (ß = 0.21, 95% confidence interval 0.25-5.08, P = 0.03). CONCLUSIONS: ONSD is a simple noninvasive measurement on initial CT in patients with TBI that could be a surrogate for ICP monitoring. However, further studies are warranted.

Maturation process and international accreditation of trauma system in a rapidly developing country.

BACKGROUND: As trauma systems mature, they are expected to improve patient care, reduce in-hospital complications and optimize outcomes. Qatar has a single trauma center, at the Hamad General Hospital, which serves as the hub for the trauma system that was verified as a level 1 trauma system by the Accreditation Canada International Distinction program in 2014. We hypothesized that this international accreditation was a major step, in the maturation process of the Qatar trauma system, that has positively impacted patient care, reduced complications and improved outcomes of trauma patients in such a rapidly developing country. METHODS: A retrospective analysis of data was conducted for all trauma patients who were admitted between 2010 and 2018. Data were obtained from the level 1 trauma center registry at Hamad Medical Corporation. Patients were divided into Group 1- pre-accreditation (admitted from January 2010 to October 2014) and Group 2- post-accreditation (admitted from November 2014 to December 2018). Patients' characteristics and in-hospital outcomes were analyzed and compared. Data included patients' demographics; injury types, mechanism and injury severity scores, interventions, hospital stay, complications and mortality (pre-hospital and in-hospital). Time series analysis for mortality was performed using expert modeler. RESULTS: Data from a total of 15,864 patients was collected and analyzed. Group 2 patients had more severe injuries in comparison to Group 1 (p<0.05). However, Group 2, had a lower complication rate (ventilator associated pneumonia (VAP)) and a shorter mean hospital length of stay (p<0.05). The overall mortality was 8%. In Group 2; the pre-hospital mortality was higher (52% vs. 41%, p = 0.001), while in-hospital mortality was lower (48% vs. 59%) compared to Group 1 (p = 0.001). CONCLUSIONS: The international recognition and accreditation of the trauma center in 2014 was the key factor in the maturation of the trauma system that improved the in-hospital outcomes. Accreditation also brought other benefits including a reduction in VAP and hospital length of stay. However, further studies are required to explore the maturation process of all individual components of the trauma system including the prehospital setting.

Clinical Characteristics, Management Practices, and In-hospital Outcomes among Trauma Patients with Venous Thromboembolism.

BACKGROUND: We aimed to assess the clinical characteristics, management practices, and inhospital outcomes of venous thromboembolism (VTE) among trauma patients. METHODS: A retrospective analysis of all trauma patients with documented venous thromboembolic events in a level 1 trauma center was conducted. Patients were categorized into two groups based on the primary initial presentation postinjury (deep-vein thrombosis [DVT] or pulmonary embolism [PE]). RESULTS: Across the study period, a total of 662 patients were confirmed to have DVT and 258 patients were diagnosed with acute PE. Among them, 84 patients were identified to have trauma-associated VTE; 56 (8.5%) had DVT and 28 (10.9%) had PE. Two patients who initially presented with DVT developed PE on follow-up. There were 38 females and 46 males with a mean age of 46 ± 18 years. Abnormal coagulation profile was reported as 7 protein C deficiencies, 5 protein S deficiencies, 6 homocystinemia, 4 antithrombin III deficiency, 4 lupus anticoagulant, and 2 Factor V Leiden. Age, sex, obesity, D-dimer level, and treatment (except for heparin) were comparable between the two groups; whereas protein S deficiency, prior history of PE, bedridden status, congestive heart failure, and history of recent surgery, were more evident in the PE group. The incidence of postthrombotic syndrome was significantly higher in the DVT group. Overall mortality rate was 8.3% (DVT; 8.9% vs. PE; 7.1%, respectively = 0.78). CONCLUSION: Coagulation profile plays an important role in posttraumatic thromboembolic disease. A thorough assessment for features of thromboembolic disorders is warranted in polytrauma patients to avoid missing this potentially life-threatening diagnosis. Larger studies are needed for better understanding and management of VTE in trauma.

Rapidly fatal pneumococcal meningitis following non-penetrating traumatic brain injury.

A previously healthy young man presented to hospital with severe traumatic brain injury following a motor vehicle collision. Within 24 hours of admission, and despite antibiotic coverage, he developed a fever. On the second day, the source of infection was discovered to be purulent pneumococcal meningitis. At 48 hours post-accident, he developed brain-stem death without evidence of raised intracranial pressure or trans-tentorial herniation. Initial CT scans of the head were essentially normal, but early repeat scans revealed evidence of pneumocephalus and possible frontal bone fracture. Current recommendations do not make room for targeted antibiotic prophylaxis in traumatic brain injury patients with traumatic skull fracture. We argue that our case demonstrates the need for aggressive targeted antibiotic prophylaxis in the presence of certain features such as frontal or sphenoid bone fracture and pneumocephalus.

Surgical management of a patient with traumatic tension pneumorachis: A rare case report.

INTRODUCTION: Pneumorachis is a rare underdiagnosed phenomenon in which air enters the spinal canal mostly following injury to the respiratory system. PRESENTATION OF CASE: We presented a rare case of pneumorachis associated with neurological deficits following traumatic compressed air insufflation to the rectum. A 44-year-old, male, construction laborer presented to the accident and emergency department with a history of insufflation by compressed air through his rectum, as a prank by his workmates. Imaging studies revealed pneumoperitoneum and the exploratory laparotomy showed perforation of the sigmoid colon as well as a serosal tear of the transverse colon. Resection of the sigmoid by GI staplers was done. The patient remained unwell even after surgical management and massive transfusion and eventually succumbed to his injuries on the second day in the hospital. CONCLUSION: Our case suggests that pneumorachis should be considered one of the various causes for sublesional post-traumatic neurological deficits and mortality.

Trauma intensive care unit (TICU) at Hamad General Hospital.

Trauma is a leading cause of mortality and morbidity worldwide, and thus represents a great global health challenge. The World Health Organization (WHO) estimated that 9% of deaths in the world are the result of trauma.1 In addition, approximately 100 million people are temporarily or permanently disabled every year.2 The situation is no different in Qatar, and injury related morbidity and mortality is increasing in the entire region, with road traffic collisions (RTCs) being the most common mechanism.1 It is well recognized now that trauma care provided in high-volume, dedicated, level-one trauma centers, improves outcome. Studies have also looked at what are the components of a trauma system that contribute to their effectiveness2. However, in general, it usually implies a high-volume of cases, dedicated full-time trauma qualified professionals, a solid pre-hospital system, a multidisciplinary team, and excellent rehabilitation services. Similarly, critically injured trauma patients managed in a dedicated trauma intensive care unit (TICU), has been shown to improve outcomes, especially for polytrauma patients with traumatic brain injury (TBI).3 In fact, the American College of Surgeons (ACS) Committee on Trauma requires verified trauma centers to have a designated ICU, and that a trauma surgeon be its director.4 Furthermore, studies have shown that for TBI, it is not necessary for this ICU to be a neurocritical care unit, but rather it should be a unit that is dedicated to trauma, that has standardized protocols for TBI management.5,6 In fact, the outcomes are better in the latter, with lower mortality in multiple-injured patients with TBI, when admitted to a TICU (versus a medical-surgical ICU or neurocritical care unit).3 These benefits were shown to increase, with increased injury severity. The proposed reason for this is thought to be due to the associated injuries being managed better.7 The aim of this editorial is to describe the TICU at Hamad General Hospital (HGH), at Hamad Medical Corporation (HMC), including a comparison of its data and outcomes with other similar trauma centers in the world. The Qatar Trauma Registry, as well as previous publications from our Trauma Center,1,8 were used to obtain HGH TICU and worldwide Level-1 Trauma Center standards, respectively. With respect to HGH, the TICU is part of an integrated trauma program, the only level-1 trauma centre in Qatar. It provides the highest standard of care for critically-ill trauma patients admitted at HGH, striving to achieve the best outcomes, excellence in evidence-based patient care, up to date technology, and a high level of academics in research and teaching. This integrated program includes an excellent pre-hospital unit, emergency and trauma resuscitation unit, TICU, trauma step-down unit (TSDU), inpatient ward, and rehabilitation unit. The new TICU is a closed 19-bed unit, that was inaugurated in 2016, is managed 24/7 by highly qualified and experienced intensivists (9 senior consultants and consultants), along with 24 well-trained and experienced associate consultants or specialists, and fellows and residents in training, as well as expert nursing staff (1:1 nurse to patient ratio) and allied health professionals (respiratory therapists, pharmacists, dieticians, physiotherapists, occupational therapists, social workers, case managers, and psychologists). It is supported by all medical and surgical subspecialty services. It is equipped with the latest state-of-the-art technology and equipment, including 'intelligent ventilators", neuro-monitoring devices, ultrasound, point-of-care testing such as arterial blood gas and rotational thromboelastrometry (ROTEM), and video airway devices. The TICU is a teaching unit, linked to the HMC Medical Education department, with presence of fellows, and residents (see below for details). Medical students (Clerkship level) from Weill-Cornell Medicine Qatar also complete a one-week rotation in the TICU, as part of their exposure to critical care. The first batch of clerks from Qatar University College of Medicine are expected to start rotating in the TICU soon. The Trauma Critical Care Fellowship Program (TCCFP) is an ACGME (Accreditation Council for Graduate Medical Education) fellowship that was established over seven years ago. To date, over 40 physicians from both within, and out of, the trauma department have completed the program. Up to seven fellows, including international candidates, are trained each year. A number of physicians have succeeded in gaining the European Diploma of Intensive Care Medicine (EDIC). The program continues to attract many applicants from various specialties including surgery, anesthesia, and emergency medicine. An increasing number of international physicians from Europe and South America have expressed interest in applying for our fellowship. The first international fellows are likely to join us from early 2020. Residents (from general surgery, ER, ENT, plastics, orthopedics, and neurosurgery) rotate (one to three months' rotations) in the TICU, and are actively part of the clinical team. There were 568 admissions to the TICU in 2018. The patients admitted were either mainly polytrauma patients with varying degrees and combinations of head, chest, abdominal, pelvic, spine, and orthopedic injuries, or isolated-TBI. Of these patients, 378 were severely injured with an injury severity score (ISS)9 greater than 16. According to previously published data from our Trauma Centre,1,8 our mortality rates (overall approximately 6-7%, as well as when looked at in terms of early and late deaths) compare favorably with other trauma centers around the world, when looking at similarly sized retrospective studies. The TICU continues to be an active member of the Critical Care Network of HMC.10 This network involves all of the ICU's in all the HMC facilities. The main processes that the TICU is presently involved in as part of this network are: patient flow, clinical practice guidelines, evaluation and procurement of technologies, HMC sepsis program, and in general, taking part in any process that pertains to critical care at HMC. A number of quality improvement projects are being undertaken in the TICU. Examples of such projects include: - Decreasing rates of infection in TICU- Score-guided sedation orders to decrease sedation use, ventilator days and length of stay- Reducing blood taking and associated costs- Sepsis alert response and bundle compliance- Medical and surgical management of rib fracturesA multidisciplinary team of physicians, nurses, and allied health professionals participate in these projects, and meet once a month to review all projects. Similarly, many research projects are taking place in the TICU, in coordination with the Trauma Research program, and often in collaboration with other departments (local and international). Examples of some of the research projects include: - The "POLAR" study (RCT on Hypothermia in TBI)11- B-blockers in TBI (RCT-ongoing)- Tranexamic acid (TXA) for bleeding in trauma (RCT-ongoing) The team is also involved in conducting systematic reviews in relation to the role of transcranial doppler in TBI,12 sepsis in TBI patients (ongoing), self-extubation in TBI patients,13 safety and efficacy of phenytoin in TBI (ongoing), and optic nerve diameter for predicting outcome in TBI (submitted). The TICU at HGH is a high-volume, high acuity unit that manages all the severely injured trauma patients in Qatar. It is well staffed with highly trained and qualified personnel, and utilizes the latest in technology and state-of-the-art equipment. It performs very well, when compared to other similar units in the world, and achieves a comparable, or even lower mortality rate. With continued great support from the hospital, corporation administration, and Ministry of Public Health, the future goals of the TICU will be to maintain and improve upon the high standards of clinical care it provides, as well as perform a high quality and quantity of research, quality improvement initiatives, and educational work, in order for it to be amongst the best trauma critical care units in the world.

Functional Outcomes in Moderate-to-Severe Traumatic Brain Injury Survivors.

INTRODUCTION: We aimed to analyze the functional outcomes based on the admission characteristics in individuals with moderate-to-severe traumatic brain injury (TBI) over a 5-year period. METHODS: A retrospective cohort study was conducted to assess the cognitive, physical, and functional outcomes based on traditional and novel metrics used in potential outcome prediction. RESULTS: A total of 201 participants were enrolled with a mean age of 31.9 ± 11.9 years. Glasgow Coma Score (GCS) at emergency department did not correlate with the functional independence measure (FIM) score or Ranchos Los Amigos (RLA) scores at discharge. The absolute functional gain was significantly higher in individuals who sustained TBI with RLA 4-5 (34.7 ± 18.8 vs. 26.5 ± 15.9, P = 0.006). Participants with RLA 4-5 on admission to rehabilitation showed good correlation with the absolute FIM gain. On multivariate regression analysis, only age (odds ratio 0.96; 95% confidence interval: 0.93-0.98; P = 0.005) was found to be the independent predictor of good functional outcome. CONCLUSIONS: Initial GCS is not a predictor of functional outcome in individuals who sustained TBI. Consideration of age and development of novel functional measures might be promising to predict the outcomes in individuals with moderate-to-severe TBI.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis.

BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis / 世界急诊医学杂志（英文）

BACKGROUND:We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS:Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS:Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5％, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION:In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Delirium in the Intensive Care Unit.

Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU) patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings.

The influence of duration of fluid abstinence on hypotension during propofol induction.

BACKGROUND: Prolonged preoperative fasting might be expected to exacerbate hypotension during the induction of general anesthesia. We aimed to establish whether the duration of preoperative abstinence from fluids independently contributed to arterial blood pressure changes and dosage requirements during propofol induction. METHODS: We prospectively recruited 130 ASA I or II nonhypertensive patients, ages 18 to 65 years scheduled for surgery under general anesthesia. Standard physiological and electroencephalographic bispectral index (BIS) monitoring was applied to each patient. Intravenous propofol infusion was commenced at 40 mg · kg(-1) · h(-1) and reduced to 8 mg · kg(-1) · h(-1) when the BIS decreased to 50. Frequent cardiovascular data were collected for 15 minutes. The primary endpoint was maximal percentage decrease from baseline mean arterial blood pressure (max%ΔMAP). The secondary endpoint was the propofol dose at which BIS decreased to 50 (PDBIS50). Univariate linear regression and then multivariate linear regression was used to analyze the associations between potential predictors, including fasting time, and these 2 endpoints. RESULTS: Mean fluid abstinence time was 694 minutes (range: 115 to 1263 minutes). Unstandardized regression coefficients (95% confidence intervals [CIs]) for fluid abstinence (minutes) versus max%ΔMAP (%) and PDBIS50 (mg) were, respectively, 0.003% (-0.002% to + 0.009%) and 0.021 mg (-0.017 mg to + 0.059 mg). On adjusting for other, significant predictors in a multivariate model and applying type II sum of squares tests, the corresponding values were -0.0001% (-0.004% to + 0.004%, P = 0.94) and -0.006 mg (-0.039 mg to + 0.026 mg, P = 0.70). The effect of a 1-hour increase in fluid abstinence on max%ΔMAP was therefore -0.01% (-0.26% to + 0.24%) and on PDBIS50, -0.38 mg (-2.34 mg to + 1.58 mg). CONCLUSION: When propofol is infused rapidly for induction of anesthesia in healthy adults younger than 65 years, the duration of preoperative fluid abstinence does not appear to affect MAP or propofol dose requirements.