Concussive Symptoms in Emergency Department Patients Diagnosed with Minor Head Injury

Background: Evidence-based protocols exist for Emergency Department (ED) patients diagnosed with minor head injury. These protocols focus on the need for acute intervention or in-hospital management. The frequency and nature of concussive symptoms experienced by patients discharged from the ED are not well understood. Objectives: To examine the prevalence and nature of concussive symptoms, up to 1 month post-presentation, among ED patients diagnosed with minor head injury. Methods: Eligible and consenting patients presenting to Kingston EDs with minor head injury (n = 94) were recruited for study. The Rivermead Post-Concussion Symptoms Questionnaire was administered at baseline and at 1 month post-injury to assess concussive symptoms. This analysis focused upon acute and ongoing symptoms. Results: Proportions of patients reporting concussive symptoms were 68/94 (72%) at baseline and 59/94 (63%) at follow-up. Seventeen percent of patients (18/102) were investigated with computed tomography scanning during their ED encounter. The prevalence of somatic symptoms declined between baseline and follow-up, whereas some cognitive and emotional symptoms persisted. Conclusion: The majority of patients who present to the ED with minor head injuries suffer from concussive symptoms that do not resolve quickly. This information should be incorporated into discharge planning for these patients.     

脑外伤动物模型认知障碍评价方法研究进展

认知障碍是脑外伤常见的后遗症之一。脑外伤动物模型目前广泛应用于基础和药物研究中,也出现了多种评价该模型的认知障碍评价的方法。本文综述近年来不同研究者对脑外伤动物模型认知障碍的行为学评价方法。     

脑外伤患者认知障碍的特点及康复疗效分析

目的:检测不同部位脑外伤患者恢复期的认知功能障碍特点及康复治疗后的效果。方法:脑外伤恢复期患者125例,均按颅脑损伤常规治疗,并配合高压氧及康复疗法等治疗。于治疗前后通过认知评定成套测验量表(LOT-CA)对患者进行认知障碍程度评分。结果:125例患者中左侧半球损伤患者在定向和思维障碍上明显重于右侧。双侧大脑半球或弥漫性脑损伤患者认知障碍更为广泛,LOTCA测验的各个项目分普遍低于正常值。经康复治疗70d后,84例获完整资料,LOTCA总分较治疗前均有明显提高,其中左侧或双侧损伤患者提高幅度较右侧明显。结论:不同部位脑外伤患者表现出不同的认知障碍特点。传统的综合康复治疗对于脑外伤后认知障碍具有很好的疗效。     

功能训练结合都可喜对重型颅脑损伤患者认知障碍的康复效果

目的 :探讨功能训练结合都可喜对重型颅脑损伤恢复期患者认知功能障碍的治疗作用及其机制。方法 :将 48例重型颅脑损伤恢复期患者分为常规组和都可喜组 ,治疗前后检测SPECT并评估认知功能。分析脑局部血流量及认知功能的变化。结果 :都可喜组与常规组治疗后SPECT检查显示病灶数均有明显减少 ,但两者比较差异无显著性。都可喜组治疗后认知功能评分较常规组高 ,虽然总体评分差异无显著性 ,但都可喜组定向力及记忆力改善明显优于常规组 (P <0 0 5 )。结论 :功能训练结合都可喜治疗可改善重型颅脑损伤患者的认知功能。     

高压氧对颅脑损伤大鼠认知功能的影响

目的：观察高压氧对颅脑损伤大鼠认知功能的影响。方法：30只SD大鼠采用Feeney自由落体撞击法造模，随机分为脑外伤组（A组）、脑外伤加高压氧治疗组（B组）和假手术对照组（C组）各10只，于造模24d后同时在水迷宫内进行定位航行和空间搜索实验。结果：在相同时间点寻找水下平台的潜伏期，B组大鼠均少于A组；在空间搜索实验中，跨越水下平台位置的次数B组明显高于A组（均P〈0．01）。结论：高压氧能够改善颅脑损伤大鼠学习记忆功能障碍，对神经功能具有保护作用。     

中重型颅脑损伤患者的康复治疗

目的 :研究中重型颅脑损伤患者综合康复治疗效果及影响因素。方法 :6 4例中重型颅脑损伤患者采用综合康复措施进行治疗 ,并运用Glasgow昏迷量表 (GCS)、简易精神状态检查量表 (MMSE)、平衡功能量表、运动功能 (Fugl Meyer)量表及日常生活活动能力 (ADL)进行疗效评定。结果 :6 4例患者平均治疗 12 0d ,其认知功能、平衡功能、运动功能及ADL均有明显改善。ADL的恢复主要受损伤程度和治疗时间的影响 (P <0 .0 5 ) ,认知功能的恢复与GCS和病程有关 (P <0 .0 5 )。结论 :中重型颅脑损伤患者ADL及认知能力恢复受颅脑损伤程度影响 ,综合康复治疗可降低颅脑损伤的残疾率 ,提高ADL。     

不同年龄段脑外伤患者认知功能评定

对６３例脑外伤患者的认知功能采用美国Ｈａｌｓｔｅａｄ－Ｒｅｉｔａｉｎ神经心理测验进行评定。结果：脑外伤患者普遍存在认知障碍,尤其是触摸操作总时间,记位,敲击及连线测验成绩最差,异常率分别为６１．８％,６３．８％,５３．９％,５４．８％。且不同年龄段脑外伤患者认知障碍也略有不同。中青年组认知障碍表现在触摸操作总时间,记形,语声,范畴分测验成绩较差,而老年前期表现在精细运动和记忆功能较差。     

Multiple Episodes of Mild Traumatic Brain Injury Result in Impaired Cognitive Performance in Mice

OBJECTIVES: Results from recent studies on animal models of concussion suggest that multiple, rather than single, episodes of mild traumatic brain injury result in impaired cognitive performance in mice. The objective of the present study was to administer multiple impacts to the heads of mice while directly measuring the force of the impacts to determine how these parameters are related to transient loss of consciousness, cognitive deficits, and potential neuropathologic effects. METHODS: even-week-old male C57BL/6 mice were randomly assigned to experimental conditions involving three impacts (weight-drop method) to the head to induce mild traumatic brain injury or to sham control procedures. Some impacted (n = 10) and sham control (n = 10) mice were evaluated behaviorally and tested for spatial learning using the Morris water maze (MWM), whereas other impacted (n = 10) and sham control (n = 5) mice were used for histopathologic analysis. RESULTS: The mean ( +/- SD) force of impact was 19 ( +/- 3.5) N. Impacted mice took longer to regain consciousness compared with sham control mice (p < 0.0005). Behavioral test results showed that the groups did not differ on activity or sensorimotor tests or during cued trials in the MWM. Impacted mice exhibited impaired spatial learning performance during place trials in the MWM (p < 0.05). Silver staining revealed a contra-coup type of injury involving ventral brain structures in contact with or in close proximity to the skull. CONCLUSIONS: This multiple-impact model, delivered within a specifiable force range, results in transient, reversible loss of consciousness, a contra-coup brain injury, and cognitive impairment.     

Prolonged Emergency Department Length of Stay is Not Associated with Worse Outcomes in Traumatic Brain Injury

Background

Data suggest that prolonged Emergency Department length of stay (EDLOS) has a detrimental effect on outcomes in some critically ill patients. However, the relationship between EDLOS and outcomes in traumatic brain injury (TBI) has not been examined.

Objective

Our objective was to determine the effect of EDLOS on neurologic outcomes in TBI patients.

Methods

We performed a retrospective analysis of a prospectively identified cohort of patients with moderate (Glasgow Coma Scale [GCS] score 9–13) and severe (GCS ≤ 8) TBI who presented to a Level 1 trauma center (2006–2010). Inclusion criteria were transfer to the intensive care unit (ICU) or operating room (OR) from the ED. Primary outcome was Glasgow Outcome Scale (GOS) score, a measure of neurologic function, at discharge. We used a proportional odds model to control for significant predictors of GOS in univariate analysis.

Results

Two hundred and twenty-four patients were included in the analysis, 77 (34%) of which were transferred to the OR. Median EDLOS was 3.3 h and 81.2% of patients had a GOS score ≤3 (e.g., severe disability, vegetative, or deceased). In multivariable analyses, EDLOS was not associated with GOS score in either ICU bound (p = 0.57) or OR bound (p = 0.11) patients. Younger age, pupil reactivity, and absence of intubation were independent predictors of good outcomes in the ICU group. In OR patients, predictors of higher GOS score included presence of an epidural hemorrhage, absence of midline shift, and pupil reactivity.

Conclusions

Our study demonstrates that EDLOS was not associated with poor outcomes in patients with moderate to severe TBI who required intensive care or early operative intervention in an academic Level 1 trauma center.     

Alcohol and Tobacco Use in the Elder Emergency Department Patient: Assessment of Rates and Medical Care Utilization

OBJECTIVES: To determine rates of alcohol and tobacco use among independent elder emergency department (ED) patients and assess the extent of health care use of this population. METHODS: A convenience sample of independent elders (age > or =65 years) in an urban academic ED was enrolled. Patients were excluded if they were medically unstable or had a change in mental status. The Fagerstrom Test for Nicotine Dependence, and the Alcohol Use Disorders Identification Test (AUDIT) scales were used to measure tobacco and alcohol use. Subjects completed questionnaires about their health and use of the health care system. Data were analyzed by using t-tests to compare independent variables. RESULTS: A total of 565 subjects completed the study. Of these, 296 (52.4%) were male and 269 (47.6%) were female; mean age was 77.1 years. Fifty-four (9.5%) were smokers, and 22 (3.9%) were nicotine-dependent by the Fagerstrom test (Fagerstrom+). Alcohol use was reported at least once monthly by 176 (31.2%) and twice monthly by 76 (13.5%) patients; 12 (2.1%) were alcohol-dependent by the AUDIT scale (AUDIT+). Two (0.35%) were both Fagerstrom+ and AUDIT+. Fagerstrom+ subjects visited a physician less often than Fagerstrom- subjects (3.9 vs. 4.6 annual visits, p < 0.0009). AUDIT+ subjects visited a primary care physician less (3.3 vs. 4.2 annual visits, p < 0.007) or "any" physician less (3.9 vs. 4.6 annual visits, p < 0.01) than AUDIT- subjects. AUDIT+ and Fagerstrom+ subjects did not differ from AUDIT- and Fagerstrom- subjects in number of annual ED visits, self-reported general health, physical symptoms (except nervousness, p < 0.004), comorbid illnesses, hospital admissions, and injuries requiring treatment. CONCLUSIONS: Elder ED patients have low rates of nicotine and alcohol dependence. Nicotine- or alcohol-dependent elders use outpatient providers less often than nondependent elders but use EDs at the same rate and report similar health patterns.     

重复经颅磁刺激治疗脑外伤患者认知障碍的Meta分析

目的 系统评价重复经颅磁刺激(rTMS)对脑外伤(TBI)患者认知障碍的疗效。方法 从PubMed、Embase、Web of Science、Cochrane Library、中国知网、万方、维普、中国生物医学期刊引文数据库检索自建库至2021年6月全文发表的关于rTMS治疗脑外伤患者认知障碍的随机对照试验。由2名研究者独立进行文献筛选、数据提取、质量评价,采用RevMan 5.4软件进行Meta分析。结果 共纳入10个随机对照试验,368例患者。亚组分析表明,rTMS能改善患者的单一认知功能(SMD = 1.00, 95%CI 0.04~1.96, P = 0.04),但对改善总体认知功能无明显效果(SMD = 0.47, 95%CI -0.05~0.98, P = 0.08)。rTMS耐受性良好,虽出现头晕、轻微头痛等不良反应,但与对照组相比无显著性差异(RR = 1.67, 95%CI 0.98~2.86, P = 0.06)。结论 rTMS对脑外伤患者认知障碍的治疗效果尚不明确,但耐受性良好。     

颅脑损伤患者CRP含量的动态变化及临床意义

目的：研究颅脑损伤患者血清C-反应蛋白（CRP）含量的动态变化及临床意义。方法：97例颅脑损伤患者按照GCS计分法分为重型组（29例）、中型组（31例）、轻型组（37例）三组,35例健康体检者为对照组。用免疫比浊法测定颅脑损伤患者伤后6h、1d、3d、14d血清中CRP水平。结果：颅脑外伤患者血清CRP水平与正常对照组比较有显著性差异（P〈0.01）,且CRP水平与患者的病情呈正相关,重型组CRP水平显著性高于中型和轻型组（P〈0.01）;各组患者入院6hCRP水平有不同程度的升高,在1d内达到峰值,以后逐渐下降,14d后轻型和中型组降至正常水平,重型组病情重的患者其CRP值升高幅度大且持续时间更长。结论：监测颅脑外伤患者血清CRP水平并进行动态观察对判断病情的严重程度及预后有重要的临床价值。目的：研究颅脑损伤患者血清C-反应蛋白（CRP）含量的动态变化及临床意义。方法：97例颅脑损伤患者按照GCS计分法分为重型组（29例）、中型组（31例）、轻型组（37例）三组,35例健康体检者为对照组。用免疫比浊法测定颅脑损伤患者伤后6h、1d、3d、14d血清中CRP水平。结果：颅脑外伤患者血清CRP水平与正常对照组比较有显著性差异（P〈0.01）,且CRP水平与患者的病情呈正相关,重型组CRP水平显著性高于中型和轻型组（P〈0.01）;各组患者入院6hCRP水平有不同程度的升高,在1d内达到峰值,以后逐渐下降,14d后轻型和中型组降至正常水平,重型组病情重的患者其CRP值升高幅度大且持续时间更长。结论：监测颅脑外伤患者血清CRP水平并进行动态观察对判断病情的严重程度及预后有重要的临床价值。     

头针治疗脑外伤后认知障碍的临床效果

目的观察头针治疗脑外伤后认知障碍的临床疗效。方法 42例脑外伤后认知障碍患者随机分为治疗组(n=23)和对照组(n=19)。对照组予认知功能训练及盐酸多奈哌齐治疗,治疗组在此基础上予头针治疗,共3个月。分别于治疗前、治疗1个月后、治疗3个月后应用蒙特利尔认知功能评定(Mo CA)及事件相关电位P300进行评估。结果治疗3个月后,两组患者P300和MoCA评分均较治疗前显著改善(P0.001),治疗组均显著优于对照组(P0.001)。结论头针对改善脑外伤后认知障碍有一定疗效。     

脑外伤康复患者WHO-DAS 2.0评定研究

目的探讨脑外伤患者活动和参与功能状况。方法使用世界卫生组织残疾评定方案2.0(WHO-DAS 2.0)国际中文版(检查者评定版)对34 例住院康复的脑外伤患者进行评定。结果脑外伤康复患者理解与交流维度平均为轻度障碍(2.10±1.33),四处走动维度中度障碍(3.20±1.56),生活自理维度中度障碍(3.06±1.41),与人相处维度轻中度障碍(2.43±1.33),生活活动维度中重度障碍(3.86±1.33),社会参与维度中重度障碍(3.51±1.19)。结论脑外伤患者的活动与参与障碍主要表现在生活活动、社会参与、四处走动等方面。     

早期应用高渗盐水对急性颅脑损伤后应激性高血糖的影响

目的:探讨早期应用高渗盐水对急性颅脑损伤后应激性高血糖的影响。方法:急性重型颅脑损伤患者146例,随机分为甘露醇组和高渗盐水组各73例,分别给予甘露醇或高渗盐水治疗,测定2组入院后24、48、72、96 h的血糖值、HOMA-IR值及NCU住院时间。结果:与甘露醇组相比,高渗盐水组入院后72、96 h的血糖值、HOMA-IR值明显降低(P0.05),NCU住院时间明显缩短(P0.05)。结论:早期应用高渗盐水治疗急性颅脑损伤患者可降低应激性高血糖、缩短NCU住院时间。     

Effect of Physician-Staffed Emergency Medical Services (P-EMS) on the Outcome of Patients with Severe Traumatic Brain Injury: A Review of the Literature

Introduction: Traumatic injury is the fourth leading cause of death in western countries and the leading cause of death in younger age. However, it is still unclear which groups of patients benefit most from advanced prehospital trauma care. A minimal amount is known about the effect of prehospital physician-based care on patients with specifically traumatic brain injury (TBI). The aim of this review is to assess the effect of physician-staffed Emergency Medical Services (EMS) on the outcome of patients with severe TBI.

Methods: Literature searches have been performed in the bibliographic databases of PubMed, EMBASE and The Cochrane Library. Data concerning (physician-staffed) prehospital care for patients with severe TBI were only included if the control group was based on non-physician-staffed EMS. Primarily the mortality rate and secondarily the neurological outcome were examined. Additionally, data concerning hypotension, hypoxia, length of stay (hospital and intensive care unit) and the number of required early neurosurgical interventions were taken into account.

Results: The overall mortality was decreased in three of the fourteen included studies after the implementation of a physician in the prehospital setting. One study found also a decrease in mortality only for patients with a Glasgow Coma Scale of 6–8. Strikingly, two other studies reported higher mortality, one for all the included patients and one for patients with GCS 10–12 only. Neurological outcome was improved in five studies after prehospital deployment of a physician. One study reported that more patients had a poor neurological outcome in the P-EMS group. Results of the remaining outcome measures differed widely.

Conclusion: The included literature did not show a clear beneficial effect of P-EMS in the prehospital management of patients with severe TBI. The available evidence showed contradictory results, suggesting more research should be performed in this field with focus on decreasing heterogeneity in the compared groups.     

严重脑外伤急性期后运动功能障碍的康复疗效分析

21例严重脑外伤患者经过正规系统康复治疗后,ADL能力有明显提高,其中能独立步行的比例由原来的33％提高到62％,下肢Brunnstrom分级Ⅳ～Ⅵ级比例由57％提高到86％。结果提示:治疗前Brunnstrom分级愈高改善的幅度愈小,而且上肢运动功能及手的精细动作的恢复也相对较差。     

急性颅脑损伤患者血清白介素-8的变化及临床意义

目的:探讨急性颅脑损伤(TBI)后血清中自介素-8(IL-8)的含量变化及其意义.方法:采用ELISA法检测48例TBI患者不同时间血清IL-8含量,按GCS评分分组并与对照组比较,进行统计学分析.结果:TBI患者组IL-8在发病后24 h、3天、5天的血清水平显著高于对照组(P<0.05),发病后血清IL-8水平与入院时Gcs评分呈负相关.结论:IL-8参与了TBI后的病理生理过程,其测定对于评估脑损伤的严重程度和预后有重要的临床意义.     

早期康复训练对创伤性颅脑损伤患者血清基质金属蛋白酶蛋白表达的影响

目的探讨早期康复训练对创伤性颅脑损伤患者血清中基质金属蛋白酶(MMP)的作用。方法创伤性颅脑损伤患者分为两组,对照组(n=45)应用常规治疗,观察组(n=45)在常规治疗的基础上加用早期康复训练。观察两组疗效及治疗4 周后患者血清MMP-2 和MMP-9 水平。结果观察组的显效率明显优于对照组(P<0.01)。观察组治疗后血清MMP-2 和MMP-9 水平下降多于对照组(P<0.05)。结论早期康复训练能有效下调血清中MMP的表达,促进神经细胞功能的恢复。     

Writers' Award Winner: Experiences of Family Members Acting as Primary Caregivers for Patients with Traumatic Brain Injury

Research on caregiving experiences of families of patients with traumatic brain injuries has been limited to studies emphasizing negative aspects of care. During this study, families caring for patients with traumatic brain injury (TBI) shared their experiences, allowing us to collect basic data about factors related to their psychosocial adjustment. Fifteen primary caregivers were interviewed using semistructured interviews, and content analysis was performed on obtained data. One thousand eighteen recording units were grouped into seven categories: (1) spending time with the patient with TBI and understanding invisible disabilities, (2) evaluating medical professionals' handling of the case, (3) devoting oneself to caring for the patient with TBI despite feeling psychological distress, (4) accepting the disability and constructing a care system, (5) seeking out and participating in specialized treatment (rehabilitation) for TBIs, (6) hoping for better understanding and creation of an appropriate response system for TBIs, and (7) making efforts to influence people around the caregiver and those in similar circumstances to promote deeper understanding of TBIs.