Worsening head bleeds in elderly blunt head trauma patients taking antithrombotics: Delayed CT head fails to change management

Background

Most elderly trauma patients suffer blunt head injury and many utilize antithrombotic (AT) medications. The utility of delayed CT-head (D-CTH) in neurologically intact elderly patients using AT who have an intracranial hemorrhage (ICH) on presentation is unknown. We hypothesized that D-CTH would not alter clinical management and aimed to evaluate the role of D-CTH in this population.

A systematic review of the safety and efficacy of non-operative management in patients with high grade liver injury

IntroductionThe liver is the most frequently damaged organ in blunt abdominal trauma. It is widely accepted that hemodynamically stable patients with low-grade liver trauma should be treated with non-operative management, however there is controversy surrounding its safety and efficacy in high-grade trauma. The purpose of this review is to investigate the role of non-operative management in patients with high-grade liver trauma.MethodsPubMed and reference lists of PubMed articles were searched to find studies that examined the efficacy of non-operative management in high-grade liver injury patients, and compare it to operative management. Non-operative management was considered successful if rescue surgery was avoided. Outcomes considered were success, mortality, and complication rates.ResultsThe electronic search revealed 2662 records, 8 of which met the inclusion criteria. All 8 studies contained results suggesting that non-operative management was safe and effective in hemodynamically stable patients with high-grade liver trauma. By combining the outcomes of the different studies, non-operative management had a high success rate of 92.4% (194/210) in high-grade liver trauma patients, which was near the overall 95.0% non-operative management success rate. Non-operative management also had mortality and complication rates of 4.6% (9/194) and 9.7% (7/72) in high-grade injury patients, respectively, compared to operative management's 17.6% (26/148) and 45.5% (5/11).ConclusionNon-operative management of liver trauma is safe and effective in hemodynamically stable patients with high-grade liver injury. It is associated with significantly lower mortality compared with operative management. More studies are required to evaluate complications of non-operative management in high-grade liver injury.     

Management of major trauma

Trauma is one of the leading cause of deaths in those <35 years old in the UK. It also has a significant morbidity burden with a subsequent economic impact. There is also a realisation that trauma is having an increasing impact in the elderly population. In the last two decades there have been changes in both the structure of trauma care across the UK, and also in clinical aspects from pre-hospital care to rehabilitation. This article will review the changes that have occurred, including the reasons, and give a broad overview of the immediate management of the critically ill trauma patient.     

A 4‐year follow‐up case of extrusive luxation in a patient with cerebral palsy

Cerebral palsy (CP) is a condition caused by brain damage before, during, or shortly after birth. Communication can be a challenge when treating patients with CP. Some patients can communicate verbally, while others use augmentative alternative communication tools or have individualized means of communication. Therefore, professional dental treatment in individuals with CP is challenging, especially if the patient is affected by dental trauma and requires emergency treatment. This report shows how individualized communication skills assessment allowed us to successfully manage a 9‐year‐old patient with CP, who suffered extrusive luxation of the permanent lower incisor. In the present case, the teeth were repositioned briefly after the trauma had occurred and then stabilized with a flexible splint according to international guidelines. The teeth remained vital and periodontal repair was observed during the 4‐year follow‐up.     

Surgery of the spleen

The spleen is a solid organ located beneath the left hemidiaphragm. Indications for surgical resection include trauma (blunt or penetrating), haematological diseases, abscesses, hydatid disease, oncological resection or immunosuppression. Surgical approaches include open, laparoscopic and, more recently, robotic; the complications of operative intervention will also be discussed. In patients with an absent spleen there is a significant increased risk of developing overwhelming post-splenectomy infection (OPSI). It is therefore essential to protect patients from infection due to encapsulated organisms through vaccination. This requires a combination of vaccinations, antibiotic prophylaxis and good education.     

Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury

BackgroundIncidence of delayed intracranial hemorrhage (DICH) in patients on warfarin has been controversial. No previous literature has reported the utility of international normalized ratio (INR) in predicting traumatic DICH.ObjectivesUtilizing INR to risk stratify head trauma patients who may be managed without repeat imaging.MethodsThis was a retrospective study at a Level II trauma center. All patients on warfarin with head injuries from March 2014 to December 31, 2017 were included. Each patient underwent an initial head computed tomography scan (HCT) and subsequent repeat HCT 12 h after. Patients presenting > 12 h after head injury received only one HCT. Two blinded neuroradiologists reviewed each case of DICH. Statistical analysis evaluated Glasgow Coma Scale (GCS), Injury Severity Score (ISS), heart rate, systolic blood pressure (SBP), age, and platelet count.ResultsThere were 395 patients who qualified for the protocol; 238 were female. Average age was 79 years. Seventy-seven percent of patients underwent repeat HCT. Five resulted in DICH (INR 2.6–3.0), three of which might have been present on initial HCT; incidence rate of 0.51–1.27%. One patient required neurosurgical intervention. Among 80 patients with INR < 2, no DICH was identified, resulting in high sensitivity, but with a wide confidence interval; sensitivity of 100% (95% confidence interval [CI] 47.8–100), specificity 21% (95% CI 16.6–28.9). Correlation of factors: ISS (p = 0.039), GCS (p = 0.978), HR (p = 0.601), SBP (p = 0.198), age (p = 0.014), and platelets (p = 0.281).ConclusionNo patient with INR < 2 suffered DICH, suggesting that warfarin users presenting with INR < 2 may be managed without repeat HCT. For INR > 2, patients age and injury severity can be used for shared decision-making to discharge home with standard head injury precautions and no repeat HCT.     

Relationship between physical growth and motor development in the WHO Child Growth Standards

Aim: To examine relationships among physical growth indicators and ages of achievement of six gross motor milestones in the WHO Child Growth Standards population. Methods: Gross motor development assessments were performed longitudinally on the 816 children included in the WHO Child Growth Standards. Six milestones (sitting without support, hands-and-knees crawling, standing with assistance, walking with assistance, standing alone, walking alone) were assessed monthly from 4 until 12 mo of age and bimonthly thereafter until children could walk alone or reached 24 mo. Failure time models were used 1) to examine associations between specified ages of motor milestone achievement and attained growth z scores and 2) to quantify these relationships as delays or accelerations in ages of milestone achievement. Results: Statistically significant associations were noted between ages of achievement of sitting without support and attained weight-for-age, weight-for-length and BMI-for-age z scores. An increase of one unit z score in these indicators was associated with 3 to 6 d acceleration in the respective achievement age. Statistically significant associations also were noted between various milestone achievement ages and growth when 3- or 6-mo and birth length-for-age z scores were entered jointly in the failure time models. In these analyses, one unit z-score increase in length-for-age was associated with 1 to 3 d delay in the respective achievement age.
Conclusion: Sporadic, significant associations were observed between gross motor development and some physical growth indicators, but these were quantitatively of limited practical significance. These results suggest that, in healthy populations, the attainment of these six gross motor milestones is largely independent of variations in physical growth.