Neurosurgical intervention in patients with mild traumatic brain injury and its effect on neurological outcomes.

OBJECTIVE: The object of this study was to determine the mortality and neurological outcome of patients with mild traumatic brain injury (mTBI) who require neurosurgical intervention (NSI), identify clinical predictors of a poor outcome, and investigate the effect of failed nonoperative management and delayed NSI on outcome. METHODS: A cross-sectional study of 10 years was performed, capturing all adults with mTBI and NSI. Primary outcome variables were mortality and Glasgow Outcome Scale (GOS) score. Patients were divided into an immediate intervention group, which received an NSI after the initial cranial CT scan, and a delayed intervention group, which had failed nonoperative management and received an NSI after 2 or more cranial CT scans. RESULTS: The mortality rate in mTBI patients requiring NSI was 13%, and the mean GOS score was 3.6 ± 1.2. An age > 60 years was independently predictive of a worse outcome, and epidural hematoma was independently predictive of a good outcome. Logistic regression analysis using independent variables was calculated to create a model for predicting poor neurological outcomes in patients with mTBI undergoing NSI and had 74.1% accuracy. Patients in the delayed intervention group had worse mortality (25% vs 9%) and worse mean GOS scores (2.9 ± 1.3 vs 3.7 ± 1.2) than those in the immediate intervention group. CONCLUSIONS: Data in this study demonstrate that patients with mTBI requiring NSI have higher mortality rates and worse neurological outcomes and should therefore be classified separately from mTBI patients not requiring NSI. Additionally, mTBI patients requiring NSI after the failure of nonoperative management have worse outcomes than those receiving immediate intervention and should be considered separately.

Lidocaine-Induced Cardiac Arrest in the Emergency Department: Effectiveness of Lipid Therapy.

BACKGROUND: Local anesthetics are commonly used in the emergency department (ED). Overdoses can lead to disastrous complications including cardiac toxicity and arrest. Recognition of local anesthetic systemic toxicity (LAST) is important; however, prevention is even more critical. Knowledge of proper lidocaine dosage can prevent LAST. LAST may be effectively treated with lipid emulsion therapy. Although the mechanism is not well understood, its use may have a profound impact on morbidity and mortality. CASE REPORT: Fifty milliliters of 2% lidocaine was infiltrated for local anesthesia in a 35-year-old woman during the incision and drainage of a labial abscess. Following the procedure, the patient complained of vomiting, with rapid progression to an altered mental state and seizure requiring endotracheal intubation for airway protection. Suspecting lidocaine toxicity, intralipids were ordered. While waiting for the intralipids, the patient decompensated and suffered pulseless electrical activity (PEA) cardiac arrest. A 100-mL bolus of 20% intralipids was administered 3 minutes into the resuscitation, after which return of spontaneous circulation occurred. The intralipid bolus was then followed by a continuous infusion of 0.25 mL/kg/minute, for an infusion dose of 930 mL. Despite a complicated hospital course, the patient was discharged home neurologically intact. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We believe this patient's cardiovascular collapse was secondary to an iatrogenic overdose of lidocaine. This is one of the first cases to support the efficacy of intravenous lipids in the treatment of LAST in humans in the ED.