Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country – a prospective study

Background

An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving.Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury.

Methods

The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy. All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version. The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant.

Results

At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score. The average day of tracheostomy was 2.18 ± 1.0038 days. The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group.Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury

Conclusion

It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.     

Unintentional trazodone overdoses in children ≤6 years of age: data from poison center over a period of 16 years

Context: Trazodone is an atypical antidepressant with no established safety in children. Previous case reports showed no complications at doses 50–500?mg in children. Our study objective is to characterize the clinical effects, dose-related toxicity, and establish triage dose for acute trazodone ingestions in children ≤6 years of age.

Methods: Cases with acute trazodone ingestions in children ≤6 years of age between 2000 and 2015 were retrospectively reviewed. Data were analyzed for dose (mg/kg), clinical effects, management site, treatment, and outcome. Cases with coingestions, unknown outcome, or unknown dose were excluded.

Results: A total of 84 patients (mean age 26.7 months, 35 females, 49 males) were included. Of those, 52 (61.9%) had no clinical effects; 29 (34.5%) had minor effects (vomiting, dizziness, headache); and three (3.6%) had moderate effects (ataxia, slurred speech, priapism). No major effects or deaths were observed. Moderate effects were manifested at doses ≥6.9?mg/kg. Priapism occurred in a 2-year-old child at a dose of 6.9?mg/kg. Sixteen (19%) patients were managed at home and 68 (81%) patients were referred to a HCF. Among those referred to a HCF, three (4.4%) patients had moderate effects with ingested dose ≥6.9?mg/kg. However, 27 (39.7%) patients of those referred to a HCF had an ingested dose <6?mg/kg and none of them manifested symptoms beyond minor effects. All referred patients had uneventful recovery and no sequela.

Conclusions: Children should be referred for further evaluation in acute unintentional trazodone ingestions with doses ≥6?mg/kg.     

Familial risks of glomerulonephritis – a nationwide family study in Sweden

Objective: Familial risks of glomerulonephritis (acute, chronic and unspecified glomerulonephritis) have not been studied. This study aims to determine the familial risks of glomerulonephritis.

Methods: Individuals born from1932 onwards diagnosed with glomerulonephritis (acute [n?=?7011], chronic [n?=?10,242] and unspecified glomerulonephritis [n?=?5762]) were included. The familial risk (Standardized incidence ratio?=?SIR) was calculated for individuals whose parents/full-siblings were diagnosed with glomerulonephritis compared to those whose parents/full-siblings were not. The procedure was repeated for spouses. Familial concordant risk (same disease in proband and exposed relative) and discordant risk (different disease in proband and exposed relative) of glomerulonephritis were determined.

Results: Familial concordant risks (parents/full-sibling history) were: SIR?=?3.57 (95% confidence interval, 2.77–4.53) for acute glomerulonephritis, SIR?=?3.84 (3.37–4.36) for chronic glomerulonephritis and SIR?=?3.75 (2.85–4.83) for unspecified glomerulonephritis. High familial risks were observed if two or more relatives were affected; the SIR was 209.83 (150.51–284.87) in individuals with at least one affected parent as well as one full-sibling. The spouse risk was only moderately increased (SIR?=?1.53, 1.33–1.75).

Conclusions: Family history of glomerulonephritis is a strong predictor for glomerulonephritis, and is a potentially useful tool in clinical risk assessment. Our data emphasize the contribution of familial factors to the glomerulonephritis burden in the community.

• Key Messages

• The familial risks (full-sibling/parent history) of glomerulonephritis (acute, chronic and unspecified glomerulonephritis) have not been determined previously.

• The familial risks of glomerulonephritis were increased among individuals with family history of acute, chronic or unspecified glomerulonephritis.

• The familial risks of glomerulonephritis were slightly increased among spouses indicating a modest non-genetic contribution.

• Very high familial risks were observed in multiplex families, i.e. with one or more affected first-degree relatives.

     

Can latent heat safely warm blood? – in vitro testing of a portable prototype blood warmer

Background

Trauma/retrieval patients are often in shock and hypothermic. Treatment of such patients usually involves restoring their blood volume with transfusion of blood (stored at 2°C – 6°C) and/or crystalloids or colloids (stored at ambient temperature). Rapid infusion of these cold fluids can worsen or even induce hypothermia in these patients. Warming of intravenous fluids at accident sites has traditionally been difficult due to a lack of suitable portable fluid warmers that are not dependent on mains electrical or battery power. If latent heat, the heat released when a liquid solidifies (an inherently temperature limiting process) can warm intravenous fluids, portable devices without a reliance on electrical energy could be used to reduce the incidence of hypothermia in trauma patients.

Methods

Rapid infusion of red cells into patients was timed to sample typical clinical flow rates. An approved dry heat blood warmer was compared with a prototype blood warmer using a supercooled liquid latent heat storage material, to warm red cells whilst monitoring inlet and outlet temperatures. To determine the effect of warming on red cell integrity compared to the normal storage lesion of blood, extracellular concentrations of potassium, lactate dehydrogenase and haemoglobin were measured in blood which had been warmed after storage at 2°C – 6°C for 1 to 42 days.

Results

A prototype latent heat fluid warmer consistently warmed red cells from approximately 4°C to approximately 35°C at typical clinical flow rates. Warming of stored blood with latent heat did not affect red cell integrity more than the approved dry heat blood warmer.

Conclusion

Using latent heat as an energy source can satisfactorily warm cold blood or other intravenous fluids to near body temperature, without any adverse affects.     

Key issues and challenges in developing a pedagogical intervention in the simulation skills center – An action research study

Simulation skills centers (SSC) are considered important learning arenas for preparing and qualifying nursing students. Limited clinical placements and claims of diminished learning opportunities raise concerns that newly educated nurses lack proficiency in many psychomotor skills. Accordingly, there is an increased focus on learning in the SSC. However, it has been questioned if the pedagogical underpinning of teaching and learning in the SSC is missing or unclear. At a bachelor nursing education in Norway, there was a desire to change practice and enhance learning in the SSC by systematic use of The Model of Practical Skill Performance (Bjørk and Kirkevold, 2000). A participatory action research design was chosen. A pedagogical intervention was developed and implemented in 2010 in a cohort of eighty-seven first year bachelor nursing students during their basic nursing skill course. The intervention is shortly described. This article reports key issues and challenges that emerged during development of the new intervention. Data to inform the study were collected via thorough meeting minutes and the project leader's logbook, and analyzed using fieldnotes analysis. Six key issues and challenges were identified. These are presented and discussed consecutively in light of their importance for development and implementation of the new intervention.     

Prediction of success in the first-year exam in the study of medicine – a prospective survey

OBJECTIVE: To identify predictors of students' success in the first-year exam in a new curriculum in the study of medicine in Vienna. DESIGN: We tested 11 topics (including socio-demographic variables, family background, school performance, economic situation, living conditions, social integration and health, learning capacity, study motivation and ability to cope with stress) for their relevance in terms of study success in a prospective study of an unselected student sample. Data were collected from questionnaires filled in by 674 first-year students (50.8% of the total number of 1327 new students) who enrolled in the academic year 2002/03. MAIN OUTCOME: Comparison of students who passed the first-year exam with students who failed identified four predictors: male sex, German mother tongue, performance in secondary school and learning capacity. CONCLUSIONS: The new curriculum exerted subliminal selectivity; the predictive powers of school marks and subjective learning capacity were confirmed; the influence of a student's sex should be investigated further; the influence of mother tongue requires modification of pre-study courses for foreign students.     

Short-term variability of blood pressure and heart rate in Guillain-Barré syndrome without respiratory failure.

The effect of Guillain-Barré syndrome (GBS) on the short-term variability of blood pressure and heart rate was evaluated in six patients presenting with a moderate form of the syndrome, i.e. unable to stand up unaided and without respiratory failure, at the height of the disease and during recovery. The patients were compared with six age-matched healthy volunteers. During the acute phase of the syndrome, GBS patients exhibited a significant heart rate elevation (+26 beats/min compared with healthy subjects), but the acceleratory response to atropine, or to 60 degrees head-up tilt, was maintained. Resting plasma noradrenaline levels were high in acute GBS, but the secretory response to tilt was preserved. Desensitization to noradrenaline was observed in acute GBS with a reduced pressor action of this alpha-adrenoceptor agonist. Blood pressure levels were normal and head-up tilt did not induce orthostatic hypotension in this moderate form of GBS. Power spectral analysis demonstrated marked alterations in cardiovascular variability. The overall heart period variability was markedly reduced with the reduction predominantly in the high-frequency (respiratory) range (-73%). The low-frequency component of heart period variability was also reduced (-54%). This cardiovascular profile of moderate GBS at the height of the disease could result from a demyelination of the reflex loop controlling respiratory oscillations in heart rate and from a desensitization of the arterial tree to an elevated plasma noradrenaline. Sympathetic nervous activation may contribute to the high resting heart rate in acute GBS.     

Return to work in the context of everyday life 7–11 years after spinal cord injury – a follow-up study

Abstract

Purpose: The aim of this follow-up study was to explore experiences of return to work in the context of everyday life among adults 7–11 years after spinal cord injury (SCI).

Methods: This study used in-depth interviews and observations in a qualitative design with eight persons who had previously been interviewed in 2008. A narrative approach was used during data gathering and analysis.

Results: Return to work was experienced as something constantly needing to be negotiated in the context of everyday life. Several years after SCI expectations for work and perceptions of possibilities for meaningful work had changed. Five main themes were identified through the analysis, (1) negotiating the possibilities of working, (2) hope for future work tempered with concern, (3) education as a possible path to employment, (4) paths toward return to work in light of unmet support, and (5) unpaid occupations grounded in interest and competence.

Conclusions: Persons who have no higher education or lack viable employment to return to after SCI seem to be vulnerable in return to work. Early and timely interventions tailored to the person’s interests and competencies, in which the rehabilitation team has a distinct coordinating role, are thus critical in return to work.

• Implications for Rehabilitation

• Tensions between hope and expectations for work and unmet needs of support can lead to barriers in return to work, particularly for those who have no higher education or lack employment to return to after spinal cord injury.

• Rehabilitation after spinal cord injury can benefit from focus on how the balance of work fits into routines in the context of everyday life.

• Early and timely interventions integrating the person’s interests and competencies in return to work after spinal cord injury in combination with having a health care provider who has a distinct coordinating role are critical.

     

Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study

Rationale, aims and objectives Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well‐defined, general Norwegian population without known CVD at baseline. Methods We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20–74, who participated in the Nord‐Trøndelag Health Study (HUNT 2, 1995–1997) and were followed‐up on cause‐specific mortality for 10 years (510 297 person‐years in total). Results Among women, cholesterol had an inverse association with all‐cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89–0.99 per 1.0 mmol L^?1 increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88–1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92–1.24) was not linear but seemed to follow a ‘U‐shaped’ curve, with the highest mortality <5.0 and ≥7.0 mmol L^?1. Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98–1.15) and in total (HR: 0.98; 95% CI: 0.93–1.03) followed a ‘U‐shaped’ pattern. Conclusion Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the ‘dangers’ of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial.     

Survival among children and adults treated with granulocyte transfusions: Twenty years’ experience at a Brazilian blood center

BackgroundIt remains controversial whether granulocyte transfusions as a supportive treatment improve survival in patients with febrile neutropenia or granulocyte dysfunctions. We describe survival rates subsequent to granulocyte transfusions in pediatric and adults patients treated at a major blood center in Brazil.Material and methodsWe retrospectively reviewed the clinical charts of pediatric and adult patients treated with granulocyte transfusions at our institution from January 2000 to October 2019. We assessed demographic characteristics, clinical features, indications for transfusion, units transfused, dose of granulocytes administered and survival rates 30 and 100 days after the initial transfusion.ResultsWe identified 64 pediatric and 67 adult patients treated with 262 granulocyte transfusions. An optimal dose (> 0.6 × 10⁹ granulocytes per kilogram per transfused unit) was available for transfusion in 80.4 % of pediatric patients but in only 19.6 % of adults (p = 0.017). Thirty days after their first granulocyte transfusion, 38 (59.4 %) pediatric and 61 (91 %) adult patients had died. Patients receiving the optimal dose of granulocytes had better survival outcomes, but even among this sub-group, adults were more likely to die than were children either at 30 days (OR = 8.67, 95 %CI 2.69–34.9) or 100 days (OR = 6.27, 95 %CI 1.86–25.9) after their initial granulocyte transfusion.ConclusionSurvival rates following granulocyte transfusion varied by the dose transfused and were higher in children than in adults.     

Thoracoscopic management of primary spontaneous pneumothorax – a comparative study

A retrospective study was performed to assess the advantages and disadvantages of a video-assisted thoracoscopic approach (VTS) to the surgical management of primary spontaneous pneumothorax compared with the standard posterolateral thoracotomy (PLT) or posterior muscle sparing (PMS) approaches. It was possible to make comparisons between 12 VTS, nine PLT and six PMS patients who underwent unilateral apical bullectomy/stapling with apical pleurectomy/abrasion for primary spontaneous pneumothorax. The groups were evenly matched with regards age, sex and incidence of pneumothorax. The operative time for VTS was significantly greater than for PLT (P = 0.014) but not for PMS (P = 0.297) procedures. VTS procedures resulted in significant decreases in the overall period of pleural drainage compared with PLT (P = 0.031) and PMS (P < 0.001) procedures. Patients having a VTS procedure had a median hospital stay of 3 days, significantly shorter than that associated with the other approaches (PLT, P < 0.001; PMS, P < 0.001). The daily in-hospital analgesic requirements were similar for all groups. Using VTS an identical operation can be performed with smaller incisions and shorter hospital stay. Long-term recurrence rates and length of time off work will eventually determine whether VTS is a more economic approach to pleurectomy.