Motocross-associated head and spine injuries in adult patients evaluated in an emergency department

Background

Motor vehicle–related injuries (including off-road) are the leading cause of traumatic brain injury (TBI) and acute traumatic spinal cord injury in the United States.

Current concepts: diffuse axonal injury-associated traumatic brain injury

OBJECTIVES: To review the probable physical, physiologic mechanisms that result in the medical and neuropsychologic complications of diffuse axonal injury (DAI)-associated traumatic brain injury (TBI). DATA SOURCES: Various materials were accessed: MEDLINE, textbooks, scientific presentations, and current ongoing research that has been recently reported. STUDY SELECTION: Included were scientific studies involving TBI, particularly direct injury to the axons and glia of the central nervous system (CNS) in both in vitro and in vivo models. These studies include pathologic findings in humans as well as the medical complications and behavioral outcomes of DAI. Studies that addressed animal models of DAI as well as cellular and/or tissue models of neuronal injury were emphasized. The review also covered work on the physical properties of materials involved in the transmission of energy associated with prolonged acceleration-deceleration injuries. DATA EXTRACTION: Studies were selected with regard to those that addressed the mechanism of TBI associated with DAI and direct injury to the axon within the CNS. The material was generally the emphasis of the article and was extracted by multiple observers. Studies that correlate the above findings with the clinical picture of DAI were included. DATA SYNTHESIS: Concepts were developed by the authors based on the current scientific findings and theories of DAI. The synthesis of these concepts involves expertise in physical science, basic science concepts of cellular injury to the CNS, acute medical indicators of DAI, neuropsychologic indicators of DAI, and rehabilitation outcomes from TBI. CONCLUSIONS: The term DAI is a misnomer. It is not a diffuse injury to the whole brain, rather it is predominant in discrete regions of the brain following high-speed, long-duration deceleration injuries. DAI is a consistent feature of TBI from transportation-related injuries as well as some sports injuries. The pathology of DAI in humans is characterized histologically by widespread damage to the axons of the brainstem, parasagittal white matter of the cerebral cortex, corpus callosum, and the gray-white matter junctions of the cerebral cortex. Computed tomography and magnetic resonance imaging scans taken initially after injury are often normal. The deformation of the brain due to plastic flow of the neural structures associated with DAI explains the micropathologic findings, radiologic findings, and medical and neuropsychologic complications from this type of injury mechanism. There is evidence that the types of cellular injury in TBI (DAI, anoxic, contusion, hemorrhagic, perfusion-reperfusion) should be differentiated, as all may involve different receptors and biochemical pathways that impact recovery. These differing mechanisms of cellular injury involving specific biochemical pathways and locations of injury may, in part, explain the lack of success in drug trials to ameliorate TBI.     

The effectiveness of memory remediation strategies after traumatic brain injury: Systematic review and meta-analysis

BackgroundTraumatic brain injury (TBI) is a steadily rising health concern associated with significant risk of emotional, behavioral and cognitive impairments. Cognitive memory impairment is one of the most concerning outcomes after TBI, affecting a wide range of everyday activities, social interactions and employment. Several comparative and comprehensive reviews on the effects of cognitive interventions in individuals with TBI have been conducted but usually with a qualitative rather than quantitative approach. Thus, evidence synthesis of the effects of TBI interventions on memory difficulties is limited.ObjectiveIn this meta-analysis, we examined the memory-remediating effects of internal and external interventions, injury severity and the interaction of both factors for patients with TBI.MethodsData were extracted from studies published between 1980 and 2020 that used objective memory measures (computerized or pencil-and-paper), and multiple meta-analyses were conducted to compare effectiveness across these interventions. Publication bias was assessed, as was quality of evidence using the Cochrane Risk of Bias tool for randomized controlled studies. Our final meta-analysis included 16 studies of 17 interventions classified into 3 categories: internal, external and mixed.ResultsMixed interventions demonstrated the highest average effect size for memory difficulties (Morris d = 0.79). An evaluation of injury severity yielded 2 categories: mild-moderate and moderate-severe. Analyses demonstrated a homogenous medium effect size of improvement across injury severity, with moderate-severe injury with the largest average effect size (Morris d = 0.65). Further evaluation of injury severity interaction with intervention type revealed a mediating effect for both factors, demonstrating the largest effect size for mixed interventions with moderate-severe injury (Morris d = 0.81).ConclusionThis study highlights the effectiveness of memory remediation interventions on memory impairment after TBI. A wide range of interventions are more effective because they address individual variability for severity and memory deficits. The study further supports and expands existing intervention standards and guidelines.     

Prehospital endotracheal intubation in patients with severe traumatic brain injury: Guidelines versus reality

The international Brain Trauma Foundation guidelines recommend prehospital endotracheal intubation in all patients with traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS) ≤ 8. Close adherence to these guidelines is associated with improved outcome, but not all severely injured TBI patients receive adequate prehospital airway support. Here we hypothesized that guideline adherence varies when skills are involved that rely on training and expertise, such as endotracheal intubation.We retrospectively studied the medical records of CT-confirmed TBI patients with a GCS ≤ 8 who were referred to a level 1 trauma centre in Amsterdam (n = 127). Records were analyzed for demographic parameters, prehospital treatment modalities, involvement of an emergency medical service (EMS) and respiratory and metabolic parameters upon arrival at the hospital.Patients were mostly male, aged 45 ± 21 years with a median injury severity score (ISS) of 26. Of all patients for whom guidelines recommend endotracheal intubation, only 56% were intubated. In 21 out of 106 severe cases an EMS was not called for, suggesting low guideline adherence. Especially those TBI patients treated by paramedics tended to develop higher levels of stress markers like glucose and lactate.We observed a low degree of adherence to intubation guidelines in a Dutch urban area. Main reasons for low adherence were the unavailability of specialized care, scoop and run strategies and absence of a specialist physician in cases where intubation was recommended. The discrepancy between guidelines and reality warrants changing practice to improve guideline compliance and optimize outcome in TBI patients.     

Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial

BackgroundReturning to work is often a primary rehabilitation goal after traumatic brain injury (TBI). However, the evidence base for treatment options regarding return to work (RTW) and stable work maintenance remains scarce.ObjectiveThis study aimed to examine the effect of a combined cognitive and vocational intervention on work-related outcomes after mild-to-moderate TBI.MethodsIn this study, we compared 6 months of a combined compensatory cognitive training and supported employment (CCT-SE) intervention with 6 months of treatment as usual (TAU) in a randomised controlled trial to examine the effect on time to RTW, work percentage, hours worked per week and work stability. Eligible patients were those with mild-to-moderate TBI who were employed ≥ 50% at the time of injury, 18 to 60 years old and sick-listed ≥ 50% at 8 to 12 weeks after injury due to post-concussion symptoms, assessed by the Rivermead Post Concussion Symptoms Questionnaire. Both treatments were provided at the outpatient TBI department at Oslo University Hospital, and follow-ups were conducted at 3, 6 and 12 months after inclusion.ResultsWe included 116 individuals, 60 randomised to CCT-SE and 56 to TAU. The groups did not differ in characteristics at the 12-month follow-up. Overall, a high proportion had returned to work at 12 months (CCT-SE, 90%; TAU, 84%, P = 0.40), and all except 3 were stably employed after the RTW. However, a significantly higher proportion of participants in the CCT-SE than TAU group had returned to stable employment at 3 months (81% vs. 60%, P = 0.02).ConclusionThese results suggest that the CCT-SE intervention might help patients with mild-to-moderate TBI who are still sick-listed 8 to 12 weeks after injury in an earlier return to stable employment. However, the results should be replicated and a cost-benefit analysis performed before concluding.     

Interest of workplace support for returning to work after a traumatic brain injury: A retrospective study

ObjectiveTo analyse usefulness of the SPASE programme, a coordinated facility programme to assist traumatic brain injury (TBI) persons in returning to work and retaining their job in the ordinary work environment.DesignA retrospective study including 100 subjects aged over 18 who had suffered traumatic brain injury (GOS 1 or 2). The criterion for return to work (RTW) success was the ability to return to the job he/she had before the accident or to a new professional activity.ResultsFactors associated with RTW success were at short-term (2–3 years): the presence of significant workplace support OR = 15.1 [3.7–61.7], the presence of physical disabilities OR = 0.32 [0.12–0.87] or serious traumatic brain injury OR = 0.22 [0.07–0.66]. At medium-term (over 3 years) these factors were: significant workplace support OR = 3.9 [1.3–11.3] and presence of mental illness OR = 0.15 [0.03–0.7].ConclusionThis study suggests that a case coordination vocational programme may facilitate the return and maintain to work of TBI persons. It reveals that the workplace support is a key factor for job retention in the medium-term.     

Characterizing surf zone injuries from the five most populated beaches on the Atlantic-fronting Delaware coast

Introduction

Beaches are a popular destination for recreation activities. Surf zone injuries (SZI) can occur resulting from a variety of in-water activities. Little is known regarding the sustained injury types, or demographics of injured persons and activities leading to injuries.

Stove-related injuries treated in EDs in the United States, 1990-2010

BackgroundHousehold stoves are a common source of injury in the United States.PurposeTo investigate the epidemiology of stove-related injuries.MethodsThe National Electronic Injury Surveillance System database was used to analyze cases of nonfatal stove-related injuries treated in US hospital emergency departments (EDs) from 1990 through 2010.ResultsAn estimated 910 696 (95% CI, 789 279-1 032 113) individuals were treated for stove-related injuries during the 21-year study period, yielding an average of 43 366 injured persons annually or 5 injuries every hour. The number (m = ? 252.85; P = .033) and rate (m = ? 0.026; P < .001) of injured individuals significantly decreased during the study. Injuries were highest in 1991 (50 656 cases; 2.0 per 10 000) and lowest in 2005 (38 669 cases; 1.31 per 10 000), although there was an increase in 2010 (48 990 cases; 1.58 per 10 000). Patients ≤ 19 years experienced 41.3% of stove-related injuries. The primary mechanism of injury was contact with stove parts (37.5%). The body region most commonly injured was the hand (44.6%), and a thermal burn was the most common diagnosis (51.8%). The majority (94.4%) of patients were treated and released from the ED. Patients > 60 years of age were 3.85 (95% CI, 2.97-4.98) times more likely to be admitted to the hospital than younger patients.ConclusionsThis is the first comprehensive study of stove-related injuries in the United States using a nationally representative sample. Strategies to prevent stove-related injuries should address the multiple mechanisms of injury.     

Stair-related injuries treated in United States emergency departments

Objective

To investigate the characteristics of stair-related injuries among individuals of all ages and estimate national injury frequencies and rates using a representative sample of patients treated in United States emergency departments.

Executive functions and attention 7 years after severe childhood traumatic brain injury: Results of the Traumatisme Grave de l’Enfant (TGE) cohort

ObjectivesSevere childhood traumatic brain injury (TBI) leads to long-standing executive function and attention deficits, with negative consequences for participation, academic outcome and independence. This study aimed to assess executive function and attention 7 years after severe childhood TBI in comparison with a matched control group and to investigate associated factors.MethodsChildren (< 15 years) with severe accidental TBI consecutively admitted in a single trauma center over 3 years were included in the Traumatisme Grave de l’Enfant (TGE) prospective longitudinal study. Of the 81 children initially included, 65 survived. At 7 years post-TBI, executive functions and attention were assessed in 27 participants (42 % of the 65 survivors) by using a combination of computerized tasks from the Test of Attentional Performance (TAP) and the Behavioral Rating of Executive Functions (BRIEF) questionnaire. Patients were compared to a group of 27 typically developing controls who were matched for sex, age and parental education level.ResultsAmong the 27 participants, mean (SD) age at injury was 7.7 (4.6) years, and mean length of coma 5.6 (4.6) days. Regarding the TAP, the number of errors was significantly higher (P = 0.003) and reaction time marginally slower (P = 0.08) in the TBI than control group. The BRIEF questionnaire completed by parents indicated significantly more executive difficulties in the TBI than control group (Behavior Regulation Index, P = 0.005; Metacognitive index, P = 0.02; Global Executive Composite, P = 0.012). Correlations between BRIEF and TAP scores did not reach statistical significance. BRIEF total score was correlated moderately with length of coma (r = 0.40, P = 0.037), and TAP scores were correlated with the Full-Scale Intellectual Quotient (total number of errors: r = -0.48; P = 0.01; mean reaction time: r = −0.51; P = 0.009).ConclusionsExecutive and attention deficits were evident 7 years after severe childhood TBI. Computerized tasks and questionnaires provide complementary and non-redundant information. Systematic long-term follow-up should be provided until the transition to adulthood, to assess ongoing development and to implement timely tailored interventions.     

Golf-related injuries treated in United States emergency departments

Objective

This study investigates unintentional non-fatal golf-related injuries in the US using a nationally representative database.

Analyse de l’efficacité du programme « Décathlon de prévention des blessures » en athlétisme : étude pilote de faisabilité

Introduction

The practice of athletics deals to injury risk of musculoskeletal system. Epidemiology is beginning to be known, especially among elite athletes. Preventing these injuries becomes an important issue for practitioners. A prevention program has been created, entitled “Decathlon of injury prevention”, however its effectiveness is not yet analyzed. The objective of this study was to analyze the feasibility of implementation of this program within athletics clubs, and to study the feasibility of analyzing of its effectiveness. The secondary objective was to evaluate its effectiveness in reducing the incidence of injuries.

Blast Lung Injury

Current trends in global terrorism mandate that emergency medical services, emergency medicine andother acute care clinicians have a basic understanding of the physics of explosions, the types of injuries that can result from an explosion, andcurrent management for patients injured by explosions. High-order explosive detonations result in near instantaneous transformation of the explosive material into a highly pressurized gas, releasing energy at supersonic speeds. This results in the formation of a blast wave that travels out from the epicenter of the blast. Primary blast injuries are characterized by anatomical andphysiological changes from the force generated by the blast wave impacting the body's surface, andaffect primarily gas-containing structures (lungs, gastrointestinal tract, ears). “Blast lung” is a clinical diagnosis andis characterized as respiratory difficulty andhypoxia without obvious external injury to the chest. It may be complicated by pneumothoraces andair emboli andmay be associated with multiple other injuries. Patients may present with a variety of symptoms, including dyspnea, chest pain, cough, andhemoptysis. Physical examination may reveal tachypnea, hypoxia, cyanosis, anddecreased breath sounds. Chest radiography, computerized tomography, andarterial blood gases may assist with diagnosis andmanagement; however, they should not delay diagnosis andemergency interventions in the patient exposed to a blast. High flow oxygen, airway management, tube thoracostomy in the setting of pneumothoraces, mechanical ventilation (when required) with permissive hypercapnia, andjudicious fluid administration are essential components in the management of blast lung injury.     

Rationale,methodology, and implementation of a nationwide multicenter randomized controlled trial of long-term mild hypothermia for severe traumatic brain injury (the LTH-1 trial)

BackgroundTraumatic brain injury (TBI) is a major public health problem recently, however, no intervention showing convincing efficacy. Therapeutic hypothermia with a relatively long duration (more than 48 h), as a promising treatment measure, might improve the patient outcome following severe TBI.Methods/designThe LTH-1 trial is a prospective, nationwide multicenter, randomized, controlled clinical trial to examine the efficacy and safety of long-term mild hypothermia in adult patients after severe traumatic brain injury. A total of 300 consecutive patients will be recruited from 15 large neurosurgical centers in China. The eligible patient will be randomized to receive either long-term mild hypothermia (34–35 °C) for 5 days, or normothermia (36–37 °C). Additionally, a standardized management protocol will be used in all patients. The primary end point is the neurological outcome 6 months post-injury on the Glasgow Outcome Scale. The secondary outcomes include GOS score at one month post-injury, mortality during six months after injury, length of ICU and hospital stay, intracranial pressure control and Glasgow Coma Scale score during the hospital stay and frequency of complications during the six-month follow-up period.DiscussionLong-term hypothermia is recommended by most recent studies and its efficacy urgently needs to be established in randomized controlled settings. The LTH-1 trial, together with other ongoing studies, will present more evidence for optimal use of hypothermia in severe TBI patients.     

Blood–brain barrier integrity in a rat model of emergency preservation and resuscitation

Emergency Preservation and Resuscitation (EPR) represents a novel approach to treat exsanguination cardiac arrest (CA) victims, using an aortic flush to induce hypothermia during circulatory arrest, followed by delayed resuscitation with cardiopulmonary bypass (CPB). The status of the blood–brain barrier (BBB) integrity after prolonged hypothermic CA is unclear. The objective of this study was to assess BBB permeability in two EPR models in rats, associated with poor outcome. Rats subjected to traumatic brain injury (TBI) and naïve rats served as positive and negative controls, respectively.HypothesisThe BBB will be disrupted after TBI, but intact after prolonged hypothermic CA.MethodsFour groups were studied: (1) EPR-IC (ice cold)-75 min CA at 15 °C; (2) EPR-RT (room temperature)-20 min CA at 28 °C; (3) TBI; (4) sham. Rats in EPR groups were subjected to rapid hemorrhage, followed by CA. Rats in the TBI group had a controlled cortical impact to the left hemisphere. Naïves were subjected to the same anesthesia and surgery. 1 h after insult, rats were injected with Evans Blue (EB), a marker of BBB permeability for albumin. Rats were sacrificed after 5 h and EB absorbance was quantified in brain samples.ResultsTBI produced an approximately 10-fold increase in EB absorbance in the left (injured) hemisphere vs. left hemisphere for all other groups (p = 0.001). In contrast, EB absorbance in either EPR group did not differ from sham.ConclusionBBB integrity to albumin is not disrupted early after resuscitation from prolonged CA treated with EPR. Neuroprotective adjuncts to hypothermia in this setting should focus on agents that penetrate the BBB. These findings also have implications for deep hypothermic circulatory arrest.     

Dynamic variations in platelet counts may reflect the severity and prognosis of stingray injuries in the early phase

There is often a delay in offering quality and prompt treatment after a stingray sting. We present 3 cases of stings and discuss the Poisoning Severity Score (PSS) and a simple tool to assess the severity of such injuries. A 34-year-old man, who worked as an aquarium keeper, presented a wound on the left fifth digit caused by a stingray. Acute myocardial injury and rhabdomyolysis were detected. After 6 weeks, the wound had almost healed. A 27-year-old man who experienced a stingray injury on the left second digit recovered without sequelae after 5 weeks. A 45-year-old man with a history of diabetes, who was accidentally stung in the right palm by a stingray, experienced rhabdomyolysis and returned to work after 2 months. We performed debridement, administered the tetanus toxoid and antibiotics, and immersed the wounded hand in warm water (about 43 °C) for all three cases. Meanwhile, patients with rhabdomyolysis were administered intravenous hydration. Upon presentation at the emergency department, we recorded the severity of the injury by using PSS. We found that relatively high PSSs were associated with lower platelet counts that happen due to various adverse events. We suggest that dynamic changes in platelet counts may be associated with the severity of the injury. Furthermore, lower platelet counts in the normal or abnormal range may indicate poor prognoses.     

Blunt traumatic diaphragmatic injury: A diagnostic enigma with potential surgical pitfalls

Background

Blunt traumatic diaphragmatic injury (BTDI) is an uncommon injury and one which is difficult to diagnose. The objective of this study was to identify features associated with this injury.

Coagulopathy as a predictor of mortality after penetrating traumatic brain injury

Study hypothesis

Traumatic brain injury (TBI) is a leading cause of mortality with penetrating TBI (p-TBI) patients having worse outcomes. These patients are more likely to be coagulopathic than blunt TBI (b-TBI) patients, thus we hypothesize that coagulopathy would be an early predictor of mortality.

Role of clinical suspicion in pediatric blunt trauma patients with severe mechanisms of injury

Objectives

In adult patients with blunt trauma, severe mechanism of injury leads to routine pan-computed tomography (CT). Due to concerns about the risk of radiation, we sought to determine whether clinical suspicion could identify children requiring radiographic imaging.

Care transitions in the first 6 months following traumatic brain injury: Lessons from the CENTER-TBI study

BackgroundNo large international studies have investigated care transitions during or after acute hospitalisations for traumatic brain injury (TBI).ObjectivesTo characterise various TBI-care pathways and the number of associated transitions during the first 6 months after TBI and to assess the impact of these on functional TBI outcome controlled for demographic and injury-related factors.MethodsThis was a cohort study of patients with TBI admitted to various trauma centres enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Number of transitions and specific care pathways were identified. Multiple logistic regression analyses were used to assess the impact of number of transitions and care pathways on functional outcome at 6 months post-injury as assessed by the Glasgow Outcome Scale-Extended (GOSE).ResultsIn total, 3133 patients survived the acute TBI-care pathway and had at least one documented in-hospital transition at 6-month follow-up. The median number of transitions was 3 (interquartile range 2–3). The number of transitions did not predict functional outcome at 6 months (odds ratio 1.08, 95% confidence interval 1.09–1.18; P = 0.063). A total of 378 different care pathways were identified; 8 were identical for at least 100 patients and characterized as “common pathways”. Five of these common care pathways predicted better functional outcomes at 6 months, and the remaining 3 pathways were unrelated to outcome. In both models, increased age, violence as the cause of injury, pre-injury presence of systemic disease, both intracranial and overall injury severity, and regions of Southern/Eastern Europe were associated with unfavourable functional outcomes at 6 months.ConclusionsA high number of different and complex care pathways was found for patients with TBI, particularly those with severe injuries. This high number and variety of care pathway possibilities indicates a need for standardisation and development of “common data elements for TBI care pathways” for future studies.Study registrationClinicalTrials.gov NCT02210221.