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Background There is limited data on transporting small children in hip spica casts used to treat pediatric femur fractures. Specific challenges include the fixed position of the body in the casted position and the increased size of the child due to cast thickness. Additionally, children less than 2 years old are recommended to be rear facing during transportation. This traveling position requires seats that are specifically designed to accommodate the small size of the child as well as accommodate the rear facing position. While seats able to accommodate casted children are available, it is unclear if they provide adequate protection in side impact collisions for rear facing spica casted infants. Therefore, the aim of this study was to evaluate traumatic injury metrics in a side impact collision model where a spica casted infant crash dummy was restrained in currently available car seats. Methods Two seats designed for spica casted children (R82 Quokka, Merritt Wallenberg) and two traditional car seats (Britax Emblem, Graco Sequel) able to accommodate a casted one-year-old crash test dummy were identified. Side impact collision testing was performed with the dummy positioned in the rear facing position and injury metrics recorded. Results Testing identified contact between the dummy's head and the door panel for a specialty spica car seat without protective side-wings for the head. All other seats contained side wings and prevented door-head contact. Conclusions Casted children should be transported in a seat able to accommodate the cast and safely restrain them. Our results demonstrate the importance of side wing protection in any seat used to transport these children as side bolsters may help decrease the potential for head contact with the door and lower the risk of severe head injury.

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Head Injury were the first clinical practice guidelines published by any surgical specialty. These guidelines have earned a reputation for rigor and have been widely adopted around the world. Implementation of these guidelines has been associated with a 50% reduction in mortality and reduced costs of patient care. Over their 25-yr history the traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards. Here, we discuss the history and accomplishments of BTF guidelines for TBI as well as their limitations. We also discuss planned changes to future TBI guidelines intended to increase their utility and positive impact in an evolving medical landscape. Perhaps the greatest limitation of TBI guidelines now is the lack of high-quality clinical research as well as novel diagnostics and treatments with which to generate substantially new recommendations.

BACKGROUND: The optimal tracheostomy time is considered a debatable issue for patients with severe Head injury in intensive care units [ICUs], which require mechanical ventilation [MV] for long period. THE AIM OF THE WORK: The current study aimed to investigate the effect of tracheostomy operation in early few days of admission on the length of mechanical ventilation [MV]. In addition, to determine outcomes and associated mortality rate.PATIENTS AND METHODS: a prospective randomized Comparative clinical study included 200 patients admitted to ICU units of Al-Azhar university hospitals and El Haram hospital who had the following criteria: severe head injury, Cerebral trauma on and Glasgow Coma Scale [GCS]score 8 or less on the fourth day viewed by brain CT scan done without given any sedation. Divided into 2 groups on the fourth day of admission each group includes 100 patients, one group submitted to early Tracheostomy [ET] [group A] and the other group submitted to extended endotracheal intubation[EEI] [group B].RESULTS: There was shorter in the main period of the mechanical ventilatory support for group A than group B with statistically significant relationship p value=0.02.Their no remarkable difference in the occurrence of Nosocomial pneumonia between group A and group B. p value of Nosocomial pneumonia = 0.62. CONCLUSION: In severe head injury, ET significantly decreases the mechanical ventilation time.

Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.

Background Road traffic accident (RTA) is the eighth leading cause of death worldwide. Motorcycle-associated head injury is the leading cause of road traffic associated morbidity and mortality in developing countries. Even though the incidence and mortality of head injury from motor cycle crash is on the increase in developing countries, especially in the African continent, most of the studies published in the literature on this subject matter took place in the developed Western countries. Materials and Methods This was a retrospective cross-sectional study of data from patients managed in our institution between December 2014 and November 2016. Results One hundred and eighty-four patients were analyzed. None of the patients used safety helmet for protection. The mean age was 27.6 ± 17.2 years with male female ratio of 6.7:1. Lone crash by cyclists and collisions accounted for 66.8% and 33.1% of the cases, respectively. Passengers and riders comprised 75% of the patients, while 25% were vulnerable pedestrians. The most frequently abused substance by the patients was tramadol (65.52%). Severe head injury and pupillary abnormality were found in 23.9% and 45.5% of the patients, respectively. Cranial CT scan showed abnormalities in 40.2% of the patients. Surgery was done in 28.3% of the patients with mortality rate of 20.7%. Conclusions The use of motorcycle as a mean of transportation has caused significant negative impact on the society. Young people, who constitute the workforce, are majorly affected, and this invariably leads to a serious economic burden on the concerned families and communities.

Background: Severe traumatic brain injury can be a serious condition. Objective: The purpose of the present study was to see the decompressive craniectomy (DC) of severe traumatic brain injury. Methodology: This clinical trial was conducted in the Department of Neurosurgery at Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2012 to December 2013 for a period of two (02) years. Patients with the age of 18 years and above, GCS of the patients 8 to 4, severe traumatic brain injury (TBI) with multiple hemorrhagic contusions and midline shift, on CT scan and severe TBI with gradual neurological deterioration were included for this study. Total 60 patients were included. Result: A total of 60 patients were included in this study. Almost two third 18 (60.0%) patients had favorable outcome (GOS 4 and 5) in group A and exactly two third 20(66.7%) patients had Unfavorable outcome (GOS 1,2 and 3) in group B (p

Background Head injury is a major health hazard throughout the world. Overall, the mortality/morbidity has not changed much in the last few decades. In developing nations, the situation is worse. Methods The study was conducted for a period of 1 year. The data collected include demographic profile, mode, circumstances and timing of the injury, neurological assessment using Glasgow Coma Scale (GCS) scoring, computed tomography (CT) scan findings, type of management, and outcome. Results Transport-related injuries and falls were the common cause of head injury, with more severe injuries seen in patients without wearing helmets and seat belts. The youth is at high risk of receiving head injuries. The summer season showed a maximum incidence of head injuries. The most common lesions on CT scan were linear fracture of the skull and brain contusion. Mortality rate was 26% and it correlated with the GCS at presentation. Conclusion Head injury mostly affects young people and males outnumber females. Road traffic accident is the major cause. People not abiding by the traffic rules, such as wearing helmets and seat belts, were at high risk of developing head injury and poor outcome.

Background Early tracheostomy is recommended in patients with severe traumatic brain injury (TBI); however, predicting the timing of tracheostomy in trauma patients without severe TBI can be challenging. Methods A one year retrospective analysis of all trauma patients who were admitted to intensive Care Unit for > 7 days was performed, using the ACS-TQIP database. Univariate and Multivariate regression analyses were performed to assess the appropriate weight of each factor in determining the eventual need for early tracheostomy. Results A total of 21,663 trauma patients who met inclusion and exclusion criteria were identified. Overall, tracheostomy was performed in 18.3% of patients. On multivariate regression analysis age >70, flail chest, major operative intervention, ventilator days >5 days and underlying COPD were independently associated with need of tracheostomy. Based on these data, we developed a scoring system to predict risk for requiring tracheostomy. Conclusion Age >70, presence of flail chest, need for major operative intervention, ventilator days >5 and underlying COPD are independent predictors of need for tracheostomy in trauma patients without severe TBI.

In India because of increasing modern and high speed vehicles, there is high incidence of road traffic accident and there is high prevalence of head injury in western Uttar Pradesh which is semi urban part of India. Road conditions are in some parts good and in some parts very bed. Road maintenance departments are not up to the mark in all parts of state. It is estimated that nearly 1.5 to 2 million persons are injured and 1 million succumb to death every year in India. Road traffic injuries are the leading cause (60%) of TBIs followed by falls (20%-25%) and violence (10%). Alcohol involvement is known to be present among 15%-20% of TBIs at the time of injury. In severe head injury cases the ambulance services and pre hospital care is not up to the mark everywhere i.e. Golden hour management is not available in all cases and is responsible for high mortality. Although things are improving day by day but till date it is not of state of art level. In India, 1 out of 6 trauma victims die, while in the United States this figure is 1 out of 200.TBIs are a leading cause of morbidity, mortality, disability and socioeconomic losses in India and other developing countries. India and other developing countries face the major challenges of prevention, pre-hospital care and rehabilitation in their rapidly changing environments to reduce the burden of TBIs this is the aim to describe the hospital based clinical and demographic data This analyses the differences in severity and in short- and long-term outcome of TBIs with different causes that could help to make policies and recommendation to improve the care of head injury patients in developing areas of India. Keywords: Demographic and Clinical Profile, Head Injury.

Introduction: Severe head injury (SHI) is associated with a high mortality and morbidity rate and is one of the leading causes of death in intensive care units. The aim of this study was to identify predictors of hospital outcome and mortality in ICU admitted SHI patients and to estimate their impact. Methods: A retrospective analysis was carried on patients (n=321) with a severe head injury, defined as Glasgow Coma Scale (GCS) ? 8 who were admitted to the ICU neurosurgical department of National Trauma Center from 2017 to 2018. Both clinical and radiological predictors of hospitalized patients were identified. Results: Total mortality rate was 5.9%. 243 (75.7%) of the patients were male and 78 (24.3%) were female. 55 % of cases were due to traffic accidents. Patients Middle Ages group was 60%. Coexisting injuries, found in 25% of the patients aggravated the prognosis. Blood grouping pattern in SHI were B+, A+ and O+ 36.1, 28 and 24.3% respectively.45% of the patients had Tattoo which was aggravating factors. The outcome is highly correlated with GCS’ values. CT scan findings revealed that patients with subdural hygroma after few days of admission CT scan which was very important prognostic factors in SHI. Conclusions: SHI has high mortality and morbidity in today world as it has a high negative impact on young people, especially men with blood group B+. The age of the patient, presence of Tattoo, GCS at admission, the CT scanning at admission and CT scanning after a week of admission were significant predictors of outcome.

Background Post-traumatic cerebral venous sinus thrombosis (CVST) – incidence is rising during the last two decades, partly due to advanced imaging technologies and partly due to accidents caused by high-velocity vehicles. Case series During a period from January 2020 to September 2020, we had 264 cases of head injury patients. On average, we receive 30 head injury cases per month, among which 50% would be severe head injury cases. We documented ten CVST cases among them. Diagnosis and management In severe head injuries with suspicion, CT brain with contrast done immediately to diagnose CVST. After 48 h of admission, worsening of GCS, increased severity of headache despite adequate management, worsening of CT findings as an increase in edema, and hemorrhagic transformation are all indications for repeat CT brain with contrast. Management of CVST patients done with enoxaparin 40 mg twice a day/1.5 mg per kg in a day, for a duration of ten to fourteen days. Anticoagulants started only after 48 h of trauma. Conclusion Early diagnosis of CVST in severe head injury patients and treatment started early (after 48 h of trauma) will help to prevent morbidity and mortality.

Tracheostomy is a common airway procedure for life support in critically ill patients with head injuries. This procedure is safe but also associated with early and late complications. Tube fracture and dislodgement into the tracheobronchial tree leading to airway obstruction is a rare but life-threatening complication after prolonged tracheostomy tube placement. There are very few published reports of tracheostomy tube fracture and dislodgement into tracheobronchial tree in a neurologically injured patient. We report a case of a fractured tracheostomy tube which got impacted in the left main bronchus, in a 41-year-old male patient who had been on prolonged tracheostomy tube after craniotomy and evacuation of subdural hematoma. The distal part of the tracheostomy tube fractured and impacted in the left main bronchus. Fibreoptic bronchoscopy was performed through the oral cavity to extract it, and the anaesthetic management during the period is discussed.

Introduction: Hyperglycemia is a one of the common response to stress especially when it is related to the tissue injury like head injury. The purpose of this study was to detect the effect of admission hyperglycemia on the overall mortality and morbidity in the patients of severe head injury. Materials and Methods: Retrospective methods were used in this study and this study includes patients with severe TBI. The patients were divided into two groups: Hyperglycemia group and normal blood sugar level group. This was based on the serum glucose level. The Outcome measures of the study were mortality and Glasgow Outcome Scale which were recorded at 6 months. Results: A total of 160 patients (male = 112, female = 48) were included in this study who had severe TBI and also met the inclusion criteria. The mean (±SD) age of the patients taken for this study was 46.5 (±11.5) years. The mean GCS of the patients at the time of admission was 5.2 ± 1.5. The mean (±SD) serum glucose level within 24 hours of admission was 249 mg/dL with lowest being 110 mg/dL and highest of 390 mg/dL. Fifty-five (34%) patients had hyperglycemia (glucose level >200mg/dL) at admission and remaining 105 patients (66%) had normal serum magnesium levels. Hyperglycemia resulted in 55% of the total mortality (N = 30) compared to 38% (N=40) in patients who had normal blood glucose level after 24 hours of admission. The mortality rate is significantly higher in patients with hyperglycemia (?2 = 3.68; P = 0.04). The assessment of the patients with Glasgow outcome score was done at 6 months follow up. 80% (N=44) of the patients who had high blood sugar levels showed the poor Glasgow outcome compared to the patients with normal blood glucose where 66% (N=65) which was statistically significant (?2 =5.44; p= .019). Conclusion: Hyperglycemia at admission increases the rate of mortality and morbidity in head injury patients. Keywords: Hyperglycemia, Severe head injury, Glasgow outcome scale.

Amaç: Travmatik Beyin Hasarı (TBH), önemli bir sosyoekonomik ve halk sağlığı sorunudur. Amantadin sülfat nöroprotektif olarak kullanılan bir ilaçtır. Bu çalışmada, amantadin infüzyon tedavisinin, ciddi kafa travması olan hastalarda bilincin geri dönmesine pozitif etkisini araştırmayı amaçladık.Materyal ve Metot: TBH olan hastalar, amantadin infüzyonu kullanma durumarına göre iki gruba ayrıldı. Grup I (n=40): amantadin infüzyonu kullanan grup ve Grup II (n=40): amantadin infüzyonu kullanmayan grup. Hastaların yaşları, cinsiyetleri, Glasgow Koma Skalası (GKS), eğitim seviyeleri, yoğun bakım ünitesine geldiğinde entübe olup olmadıkları, bilincin geri dönüş zamanı, taburculuk zamanı ve BT veya MR sonuçları ve Coma Recovery Scale–Revised (CRS-R) skoru retrospektif olarak kaydedildi. Bulgular: Bilincin geri dönüş zamanı Grup I de istatistiksel olarak belirgin olarak daha kısaydı. Hastaların eğitim düzeyleri arasında istatistiksel olarak anlamlı bir fark saptanmadı. Grup I de hastaların yoğun bakıma kabulü sırasında GKS daha düşüktü. Fonksiyonel nesne kullanımı ve uzun dönemli dikkat Grup I de CRS-R’ye göre daha yüksekti.Sonuç: Bu çalışmaya göre, amantadin infüzyonu nörolojik iyileşmeyi ve nörokognitif fonksiyonları olumlu yönde etkilemektedir., Objective: Traumatic brain injury (TBI) is a significant socioeconomic and public health problem. Amantadine sulfate has been used as a neuroprotective drug. In this study, We aim that amantadine infusion treatment effects positively in patients with a severe head injury on conscious recovery. Materials and Methods: Patients with TBI were classified into two groups: Patients that used amantadine infusion group was Group I (n=40) and patients that not used amantadine infusion group was Group group II (n=40). Age, gender, Glasgow Coma Scale (GCS), education level, intubated or non-intubated when he/she come to Intensive Care Unit (ICU), the recovery time of conscious, discharge time, recovery of CT or MR scan and Coma Recovery Scale-Revised (CRS-R) were retrospectively recorded. Results: Time to recovery in consciousness was statistically significant shorter in group I. There were no statistically significant differences between the educational status of patients. The GCS of patients, when admitted to ICU, was lower in group I. Functional object use and long-term attention were have higher scores in group I when compared to CRS-R.Conclusion: Amantadine infusion affects positively neurological recovery and neurocognitive function for TBI in this study.

Background The management of severe traumatic brain injury is directed at avoidance of secondary brain injuries. The intensive care unit (ICU) provides the ideal environment to achieving improved survival and functional outcome. The study sets out to identify the factors that determine the access of patients with severe head injury presenting at our hospital, to the ICU and their impact on outcome. Materials and Methods his was a longitudinal study at the University College Hospital, Ibadan. Data of all consecutive severe head injury patients over a 9-month period, presenting to the accident and emergency department, was collected and analyzed using descriptive statistics and chi-squared test. The level of significance was p < 0.05. Result There were 36 males (80.0%) in our study, with road crashes (25; 79.5%) as the most common mechanism of injury. Most patients (33; 73.3%) were transferred to our center after initial care in another hospital. Though 31(68.9%) patients had access to the ICU, they were all delayed, with the most common reason for the delay being lack of ICU space. More patients who got admitted into ICU (14; 45.2%) were alive at 28 days into admission (p = 0.04). The females (6; 13.3%) significantly survived till 28 days on admission compared with males (p = 0.03), but there was no difference in the survival rates between children and adults. Conclusion Our study underscores the need for ICU admission in these patients to optimize outcome and identify the nonavailability of beds, as the most important cause of delayed access, as well as the need for increased manpower capacity and organized resource utilization.

Introduction For the prevention and better management of traumatic brain and spine injury patients, it is mandatory to understand the demographic and clinical profiles of cases of a particular region. This study was aimed at describing the epidemiology, pattern, and outcomes of head and spine injury patients at a tertiary care center in central India. Materials and Methods All the patients with head and spine injury admitted to the Department of Neurosurgery between September 1, 2018, and August 31, 2019 were included in the study. Data of all these patients were collected from the medical record section and analyzed for age, sex, mode of injury, severity of injury, management, and outcomes. Results During the study period, 932 patients with head injury and 241 patients with spine injury were admitted to our department. Around 65% of the patients in both head and spine injury categories fell in the age group of 26 to 55 years. Approximately 80% of all neurotrauma patients were male. The most common mode of injury was road traffic accident followed by fall from height. Mortality for severe head injury was 39% and that for ASIA A (American Spinal Injury Association grade A) cervical spine injury was 65%. Conclusion Even after aggressive treatment strategies, morbidity and mortality are very high, and the ultimate outcome depends mainly on the clinical status immediately after trauma. The data from this study can be helpful in strategy-making for the prevention and management of head and spine injury patients, especially in the central Indian population.

Background Consistent data on head injury is lacking especially in the low- and middle-income countries. Our study tries to characterize patients with head injury at the emergency department of one of the few tertiary public hospitals giving neurosurgical care in the country. Methods A retrospective cross-sectional study was performed from May 2015 to October 2015 in one of the neurosurgical teaching hospitals, Black Lion Specialized Hospital. All adult patients with head injury who visited the emergency department during the study period were included. Data on patients' sociodemographic, mechanism of trauma, clinical presentation, imaging findings, and presence of polytrauma were collected by a pretested questionnaire. The source of data was emergency department logbooks and patient charts. Results A total of 390 patients with head injury who visited the emergency department were included during the study period. There were 335 males (85.9%) and 55 females (14.1%) with the mean age (standard deviation) of 35.4 (15.6) years. Majority of patients came by taxi constituting 149 (38.2%) of all patients, whereas 147 patients (37.7%) used ambulance. Of 147 patients brought by ambulances, 133 (90.4%) were referred from other hospitals. The majority, 26 (45.6%), of patients who came directly to the emergency department used taxis. It is shown that the mode of arrival and origin of arrival are significantly related, P = 0.000. Mortality of severe head injury at the emergency department was 50.8%. Conclusions Prehospital care coverage was low and ambulances were used mainly for interhospital transfers. Mortality of severe head injury at the emergency department is high and significantly associated with preventable causes like vital sign derangement.

Introduction: Blood glucose levels are important in the human body because to support health so that they can do work activities properly. The initial action in patients with blood glucose levels who experience a head injury determines the outcome in the hospital. Patients who cannot maintain their blood glucose levels within the first 24 hours of treatment can cause a bad outcome, in the end, even increasing the mortality rate due to blood glucose levels. Aims: This study aims to analyze the predictions of blood glucose levels on patient mortality at H. Adam Malik Hospital in Medan. Methods: In this study, the authors used observational analytic with a retrospective cohort study design. The population in this study were all patients with high blood glucose levels who suffered head injuries in the Emergency Room (IGD) of H. Adam Malik Hospital in Medan and used purposive sampling so that 40 patients selected for high blood glucose levels with a head injury. Results: Based on the tabulation result using chi-square test shows that mortality was more prone to occur in patients who had blood glucose levels> 145 mg/dl with p-value 0.00 and odds ratio of 0.18. Conclusion: So in conclusion, a severe head injury patients who have blood glucose levels > 145 mg/dl are prone to death but do not deny mortality in patients who have blood glucose levels

Aim Nutritional demand after traumatic brain injury is increased due to hypermetabolic response. The present study was undertaken to assess nutritional status with anthropometric indices, factors associated, and their prognostic role following severe head injury (SHI). Method A total of 114 patients in age group 20 to 60 years, admitted within 24 hours of SHI, with Glasgow Coma Scale of 4 to 8, and with no serious systemic disorder were enrolled for the study. Of these, 67 were prospectively assessed weekly till 21 days for changes in mid arm circumference (MAC), mid arm muscle circumference (MAMC), and triceps skin fold thickness (TSF). They were studied in relation to other factors and outcome was assessed at 3 months. Results The percentage fall at 3 weeks for MAC, MAMC, and TSF were 14, 10, and 37%, respectively. The percentage of fall in MAMC was the earliest, and was significantly greater in patients with surgical intervention, tracheostomy, prolonged fever, delayed enteral feeding, and greater caloric deficit. Admission MAMC < 90% of standard was significantly associated with unfavorable outcome (odds ratio 5.9 [95% confidence interval 1.3–27.8], p = 0.01). Unfavorable outcome was significantly more frequent in patients who had at least 15% fall in MAC (85.7 vs. 41.9%, p = 0.03), or 10% fall in MAMC (68.8 vs. 38.2%, p = 0.04) at 2 weeks, compared with others. Fall in TSF had no significant association with outcome at 3 months. In multivariate analysis, MAMC fall had significant independent association with unfavorable outcome. Conclusion Bedside anthropometry (especially MAMC) is efficient in identifying patients with nutrition depletion with significant influence on outcome at 3 months.

Injuries suffered while participating in extreme sports account for numerous emergency department visits. Isolated head injuries are a common presentation. Zorbing is an activity native to New Zealand. Like many emerging extreme sports there is little information regarding its safety. We conservatively managed a patient who suffered a skull fracture and epidural hematoma while zorbing. Publications (especially in the medical literature) are lacking regarding zorbing-related injuries. We hope that presenting this case will help elucidate the possibility of severe head injury despite the protective bubble offered by the sport.

Background Motorcycle-associated head injury is one of the leading causes of disability and deaths, with its main victims being the motorcyclists, passengers, and pedestrians in their young productive age group. This study determines the role of severity and some predictive factors on survival and mortality of motorcycle-associated head injury. Methods This is a cross-sectional study using data of patients managed for motorcycle-associated head injuries between December 2014 and November 2016. The patients’ biodata, clinical findings, and management outcomes were analyzed using Statistical Packages for the Social Sciences version 20. Results A total of 184 patients were analyzed, most of whom (81%) were aged ≤40 years and with a male dominance of 6.7:1. Pupillary abnormality was seen in 43.5% of the patients, and severe head injury occurred in 34.2% of the patients. Hemorrhagic contusion was the most common computed tomography (CT) finding (16.3%). Among 20.8% of the patients who died, 63.2% had severe head injury. Conclusions Motorcycle-associated head injury predominantly occurred among young men who used a motorcycle for commercial purposes. The survival rate was higher among patients who had brain CT scan performed, extra-axial clots, and operative treatment. However, high mortality was seen among patients who could not afford brain CT scan, and who had bilateral pupillary dilatation, CT findings of abnormalities that are not surgically amenable, and severe head injury.

To compare the profile, treatment and outcome of elderly patients with severe traumatic brain injuries (TBI) between southern Finland and Navarra (Spain). Data collected from, 2010 to 2015, in the Major Trauma Registry of Navarra (MTR-N) and the Helsinki Trauma Registry (HTR) were compared. Patients with New Injury Severity Score (NISS) ≥ 16 and age ≥ 65 with isolated severe TBI were considered. Patients who had been admitted to the hospital ≥ 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded. Outcome was defined by 30-day hospital mortality. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II). Other compared data included demographics, injury mechanism, pre-hospital and hospital treatment, and time intervals. A total of 305 (MTR-N) and 137 (HTR) patients were included in the outcome analysis. The standardized mortality ratio with 95% confidence interval was for MTR-N 1.4 (1.1–1.6) and for HTR 0.8 (0.6–1.1). Patients in Navarra were older (average 79.7 vs. 75.0) while in southern Finland the percentage of pre-hospital intubation in patients with GCS ≤ 8 (75.0% vs 50.0%) and ICU admission (72.2% vs 22.0%) were higher. The better adjusted outcome of elderly patients with severe TBI in southern Finland in comparison to Navarra could be due to higher rate of pre-hospital intubation and/or higher rate of ICU admissions in southern Finland. Increasing number of elderly patients with severe TBI necessitate uniformly accepted protocols in pre- and in-hospital management.

Background Most of the studies that examined the prognosis of acute subdural hematoma (ASDH) in severe head injury patients stated their overall prognosis as one group. The aim of the present study was to assess the prognosis of ASDH of > 10 mm in thickness in head injury patients with an extension or no motor response to pain after resuscitation. Material and methods This retrospective study reviewed the severe head injury patients admitted to our university hospitals from January 2014 to August 2017. The inclusion criteria were the patients with an extension or no motor response to pain after resuscitation with an ASDH > 10 mm in thickness and a midline shift > 5 mm in the initial head computed tomography (CT) scan. Two hundred six patients met the inclusion criteria of this study. Their mean age was 42.3 years. One hundred forty-two patients (68.9%) were males. Results The mean duration between trauma and admission was 41 min. Sixty-two patients (30%), including 38 anonymous patients, were surgically managed and the remainder were managed conservatively. All patients (100%) died in the intensive care unit within 1 month after trauma. Conclusion This study emphasized that both surgical and conservative management of ASDH had similar dismal results and that there was no additional benefit from surgical intervention in the studied group of head injury patients. Randomized controlled trials are needed to set a standard of care for the management of ASDH in this subgroup of the severe head injury patients.

Hypomagnesemia is postulated as one of the important determinants of outcome following traumatic brain injury (TBI) through its effect on secondary injuries to neurons. Aims and Objective: The aim of this study was to determine the relationship between serum magnesium level and neurological outcome in patients admitted with severe head injury. Materials and Methods: In this prospective study, patients admitted with severe TBI were recruited and dichotomized into low serum magnesium group and normal serum magnesium group based on the initial serum magnesium level. Data were collected regarding age, sex, and Glasgow Coma Scale at admission. Neurological outcome of the patients in these groups was assessed using Glasgow Outcome Scale at 6 months. Results: Seventy-two patients (male = 50, female = 22) with a mean (±standard deviation) age of 42.5 (±12.7) years were studied. Forty-two (58%) patients had low serum magnesium level (

Background: Early diagnosis and management of traumatic diaphragmatic hernia (TDH) can be challenging for the emergency department or the trauma surgeon, as these injuries are often clinically masked by other associated severe injuries. Methods: We retrospectively reviewed data of 50 patients diagnosed with an acute traumatic hernia from September 2014 to September 2017. Results: 50 patients were included in this study. Blunt trauma was the main cause in 40 patients (80%) patients. TDH occurred more on the left side; in 72% of patients. The diagnosis was preoperative in 20 patients (40%). In our study, 74% of cases were repaired through abdominal approach and 26% patients through thoracic approach. Complications of TDH occurred in 30 patients (60%) and were mainly pneumonia in 16 patients (32%), only 8 patients (16%) died (6 patients of them had delayed referral and 3 patients of them had severe head injury). Conclusions: TDH may be masked by associated injuries in multiple trauma patients and may lead to life-threatening intestinal and gastric strangulation. So, early diagnosis and treatment of TDH are important. Emergency physicians and trauma surgeon should maintain a high index of suspicion of TDH while dealing with patients assessed for abdominal or respiratory symptoms regardless the history of trauma was recent or delayed. Keywords: Injuries, Traumatic diaphragmatic hernia, Chest trauma

Background: Traumatic Brain injuries (TBI) are a real social problem with an upward trend worldwide. For these reason prognostic factors in head injury are of major importance to all surgeons who treat patients with severe head injury especially for countries like India for better targeting of limited health care resources and implementation of specific methods of treatment to patients and to determine the incidence of age, sex, distribution, etiological factors, clinical presentation, neurologically assessment and mode of head injuries with particular reference to severe head injury. Methods: This study was conducted in the Neurosurgery unit of Surgery department of Index Medical College, Hospital & Research Centre, Indore from Jan 2016 to Jun 2017. In this study 150 patients of severe head injury were included These patients were evaluated for the severity of the head injury (GCS), clinical presentation, X-rays, C T scan/MRI, early complication (Hypoxia and Hypotension) and Post traumatic seizures. Result: In all 150 patients with severe head injury were identified shows that road traffic accident is the main cause of head injury in majority of cases with male preponderance. Incidence of head injury due to fall from height was nearly equal in both sex. It was found that maximum number of head injury patients belonged to the age group of 21-40 years (78%) in male. Maximum number of head injury was caused due to road traffic accidents (72%). Conclusion: Males are more prone to head injury due to road traffic accident with maximum in two –wheeler accidents as most of the patients were not wearing helmets. CSF otorrhoea was more common than CSF rhinorrhoea. Extradural hematoma was more common in tempero-parietal region and Coup injuries were more common than contre coup injuries. Types of trauma and brain lesion, hypoxia and hypotension, hyperglycemia and early post traumatic seizures are the important prognostic factors.

The outcome after head injury is mostly determined by Glasgow Coma Scale ( GCS ) and the degree of brain damage which reveals. CT scan is also important to assess its severity. However relatively it is not in a less costly manner and sometimes patients mobilisation are needed. Brain damage due to traumatic head injury refers to homeostasis unbalance , and it is the important causes of releasing biochemical analyte from neuron via injured blood brain barrier to circulation. Neuron-specific enolase as a glycolytic enzyme in neuron cytoplasm might increase. Hopefully , measurement of NSE levels can provide information about the extent of the disease. The objective of the study is to test the correlation between the Neuron Specific Enolase ( NSE ) serum as a one of biochemical marker of brain injury and the GCS. For this purpose , a cross sectional , analytical observasional study was carried out at the Emergency Departement and Departement of Clinical Laboratory , Sardjito General Hospital , Yogyakarta , Indonesia. Fifty-one patients selected by an eligible criteria were included in the study , which consist of severe , moderate and mild head injury. Blood samples were collected and serum NSE was measured by immunoanalyzer using Electro Cheluminescence ImmunoAssay ( ECLIA ) . Chi square test was used to test the difference proportion of the group: NSE ≥ 21.7 ng/mL and NSE < 21.7 ng/mL according to measured variables , and Spearman correlation test was used to correlate serum NSE and GCS , and other variables. In the study fifty-one patients with head injury were included , 74.5% of patients were males and 68.6% is in the age of 15–45 years old. The patients were further divided into two groups on the basis of serum NSE ≥ 21.7 ng/mL and < 21.7 ng/mL ; the former group was dominated by severe head injury patients ( 54.1% ) . In addition , a proportion of non survivors ( 66.6% ) in group NSE ≥ 21.7 ng/mL was higher compared to those in NSE < 21.7 ng/mL group. Moreover , a large number of mild head injury ( 95.45% ) and survivors ( 83.33% ) had lower serum NSE ( < 21.7 ng/mL ) . In the study , was found a negative correlation between serum NSE and GCS ( r = -0.552 ; p = 0.00 ) . Also , serum NSE were inversely correlated with blood kalium and hemoglobin ( r = -0.162 ; p = 0.027 dan r = -0.376 ; p = 0.009 ), in contrast with leucocytes count ( r = 0.485 ; p = 0.001 ) . The conclusion so far there was a negative correlation between serum NSE and GCS. It is suggested that neuron-specific enolase can be very useful as a biochemical marker in assesssing the severity of head injury. Therefore , it is nessessary to carry out the prognostic study to know to what extent it can predicting the outcomes.

Background: Severe head injury (SHI) is a major cause of mortality and morbidity across the world. The current paradigm of management of SHI involves admission in Intensive Care Unit (ICU), mechanical ventilation (MV), and intracranial pressure (ICP) monitoring. Such resources are expensive and often unavailable in the developing world. Objective: MV or ICP monitoring was unavailable for our patients due to the scarcity of resources. Hence, other alternatives were considered to prevent secondary brain injury due to hypoxia. This study assessed the outcome after SHI when managed with an early tracheostomy (ET). Methods: This prospective observational study over 13 months included all medically managed SHI patients without MV or ICP monitoring. The Glasgow outcome scale (GOS) was assessed at discharge and compared with published historical data reported after treatment in an ICU environment. Results: Our study included 53 unoperated patients with SHI among 1862 patients with traumatic brain injury. Overall mortality was 24.5% (13/53) and compared favorably with reported mortality of 25%–40% reported from centers using intensive management. At discharge, the favorable outcome with a GOS of 4 or 5 was seen in 39.6% (21/53). Conclusion: With ET, the results of management of SHI in our patients were comparable to results reported after MV in an ICU environment. Hence, ET is a cost-effective alternative when resources are scarce. MV should be used if hypoxia persists after tracheostomy. Although MV effectively prevents hypoxia, it has complications. We conclude that although MV was unavailable for our patients, they did not have the complications associated with it.

Cervical dystonia (CD) is a condition that typically presents with cervical muscle spasm, producing head tilt and cervical rotation. CD is most often idiopathic, however, in a small number of patients, CD occurs within one day to one year after mild to severe trauma. This type of CD is further classified as posttraumatic CD. OnabotulinumtoxinA (Botox) injections are considered to be a controversial treatment for posttraumatic CD and have produced variable result. This report describes the case of a 32-year-old female presenting with a two year history of posttraumatic CD and associated head, neck, and shoulder pain after obtaining a severe head injury during a motorcycle accident. OnabotulinumtoxinA was used to successfully treat her posttraumatic CD muscle spasms and associated chronic pain. Three months after her first and second ONA treatments, the patient reported at least 50% improvement in her overall pain symptoms and a noticeable reduction in cervical paraspinal muscle spasms.

Durante o período de seis meses (janeiro a julho de 1991), 66 pacientes portadores de traumatismo craniencefálico (TCE) grave (graduados na Escala de Coma de Glasgow em igual ou menor que 9) foram analisados de forma prospectiva quanto aos procedimentos a que foram submetidos du¬rante o tratamento e as complicações resultantes destes procedimentos. Os procedimentos realizados mais frequentemente foram: a venóclise em 100%, a sondagem vesical em 96%, a entubação orotraqueal em 92%, o uso do respirador mecânico em 89%, a traqueostomia em 83% e a sondagem nasogástrica em 75% dos pacientes. As complicações que envolveram o aparelho respiratório foram as mais frequentes: na fase precoce, a obstrução do tubo orotraqueal ocorreu em 78,69% e a infecção pulmonar em 67,27%; na fase tardia, a estenose subglótica foi diagnosticada em 56,5% dos casos sobreviventes. Complicações, em geral, relacionadas com estes procedimentos, ocorreram em 72,73% dos pacientes internados nas enfermarias convencionais e em 27,27% dos internados na terapia intensiva (x2 = 11, p < 0,0008). A taxa de óbito desses pacientes nas enfermarias convencionais foi de 62,50%, enquanto que, na terapia intensiva, de 16,57% (x2 = 11, P < 0,0009). Sabemos que existem vários outros fatores que influenciam a evolução, mas a forte correlação entre os índices de complicações e óbitos, tanto nas enfermarias como na terapia intensiva, sugerem que a taxa de complicações também influenciou o resultado do tratamento do traumatizado craniencefálico grave.

Nos últimos 5 anos o trauma passou a ser a segunda causa de mortalidade no Distrito Federal, sendo no momento, a primeira entre o 5° e o 39° ano de vida. Na Unidade de Neurocirurgia e Politraumatizados do Hospital de Base, que centraliza o atendimento das vítimas do trauma, foram atendidos 13.521 pacientes com politraumatismos. Destes, 5.436 apresentaram traumatismo crânio-encefálico, sendo 2.391 (44%) decorrentes de acidentes de trânsito, 2.174 (40%) de quedas e 761 (16%) de agressão. Calculamos que para cada 100 mil habitantes do Distrito Federal, durante um ano tenham ocorrido 341 traumatismos crânio-encefálicos. Do total de traumatizados crânio-encefálicos, 808 foram internados e 211 foram operados pela neurocirurgia devido a fraturas com afundamentos cranianos, contusões cerebrais, coleções subdurais crônicas, hematomas subdarais e extradurais agudos, dos quais 118 foram ao óbito nas enfermarias. Durante o ano de 1991, ocorreram 797 óbitos por traumatismo crânio-encefálico sendo 481 (60.35%) causados por acidente de trânsito. Estes índices, quando comparados proporcionalmente com outras comunidades, se mostram elevados, justificando medidas rígidas de profilaxia principalmente relacionadas com os acidentes de trânsito.

Background: Post traumatic hydrocephalus (PTH) is a commonest treatable complication of severe traumatic brain injury that’s leads to failure of improvement and worsening of the outcome. Incidence of posttraumatic hydrocephalus is 0.7%-29% reported in different literature. We have observed the development of PTH frequently seen in patients with severe head injury and after decompressive craniectomy (DC). Pathophysiology includes inflammatory changes and adhesion of arachnoid granulation, cerebral ischemia and alteration in cerebrospinal fluid (CSF) dynamics. We studied 35 cases of PTH diagnosed and treated at our institute from May 2008 to May 2017. Material and methods: This is hospital based retrospective and prospective study conducted in tertiary center on the basis of neuro-radiological examination of the patient. Clinical biodata and radiological profile of the patients was studied at initial presentation with trauma, and when the patient worsened with symptoms of raised intracranial pressure (ICP) in state of established PTH. These cases were treated by medium pressure ventriculoperitoneal shunt (V.P shunt) and outcome was evaluated. Results: Incidence of PTH in our study is (2.3%). Out of 35 cases 24 (68.57%) were male and 11(31.4%) were female. Road traffic accident (RTA) was the most common mode of injury (82.85%), acute subdural hematoma (SDH) was the most common finding on C.T scan in 15 cases (42.8 %). Decompressive craniectomy was performed in 77% at time of initial trauma. PTH had favourable outcome with V.P. shunting in 91.42%. Conclusion: Patients with traumatic brain injury present with many complications but PTH is most frequent sequeale that can present in form of various neurological symptoms after trauma and decompressive craniectomy. C.T. scan brain is the investigation of choice for diagnosis of PTH. Outcome was favourable after V.P. shunt in PTH.

Objective The main objective of the study is to obtain knowledge about the organisation of care for severe head trauma as well as the initial management of these patients in Neurosurgical Departments in Spain. Material and method A 22-item questionnaire was designed and sent to 59 Neurosurgical Departments. The aim of the questionnaire was to collect data regarding the general profile of the patients with a severe head injury, the general characteristics of the hospitals, the initial care of these patients, the monitoring techniques used, and the measures used to control Intracranial pressure (ICP). Results Of the 59 Neurosurgical Departments identified, 29 (49.2%) completed the questionnaire. There was a wide variability in the number of patients treated per year between the different departments. The leadership of care often fell (58.6%) on the intensive care specialist. Many (69%) of the departments did not have a neurosurgeon specially dedicated to the management and monitoring of these patients. The initial care in the Emergency department usually fell (51.7%) on the general medicine practitioner. The availability of computed tomography (CT) was universal. The use of telemedicine was highly variable. ICP monitoring was performed on more than 75% of patients in most (89.7%) of departments, but there was limited use of other monitoring techniques. Most Departments followed the recommendations of the Brain Trauma Foundation (BTF) guidelines for the control of ICP. Conclusions The organisation of care and the initial management of severe head trauma in Spain is very similar to its neighbouring countries. However, there are shortcomings, such as low participation by a neurosurgeon in the initial management of these patients, insufficient use of telemedicine, and the low implementation of certain brain monitoring techniques (SjO 2 , PtiO 2 , and Doppler).

Background : Head injury patients commonly present to our health facilities with the resultant morbidity, mortality and economic losses being enormous. This study aimed to document the causes, characteristics, current practices in diagnosis, management and the outcomes of head injury. Methods : A prospective descriptive study conducted at Nakuru level five hospital from January to November 2015. Descriptive patient data, clinical presentation, investigations, treatments offered and outcomes were captured using a questionnaire. Results : A total of 445 patients were recruited with a male preponderance at 88.7%. The mean age was 30.5 years. The commonest cause of injury was assault at 25 .6%. Sixty-five percent (65.4%) of the patients had a mild head injury, 22.5% and 12.1% had moderate and severe head injury respectively.Fifty-four patients (12.1%) died and the rest had varying degrees of recovery. A lower GCS, transfer into hospital, convulsions, otorrhoea, rhinorrhea, loss of consciousness, presence of other injuries and admission to the ICU were associated with poor outcomes. Conclusion : The commonest causes of head injury are; violence /assault, pedestrians, motor cycle crashes, motor vehicle accidents and falls in reducing order amongst others. There’s need for training to care givers on head injury at the Nakuru level five hospital. Key words: Head trauma, Brain injury, Hematoma.

This article describes how the liver is one of the most commonly injured organs in the abdomen, especially in road traffic accidents. Patients do present with polytrauma and those who are hemodynamically unstable have a high morbidity and mortality, even in advanced hospital settings. Following is the case report of a 17-yr. old boy, who was involved in a road traffic accident with polytrauma, presented to a tertiary care hospital in a remote island, with Grade IV-V liver injury and developed ARDS in post-operative period. The patient was managed successfully and discharged.

Tjokorda Gde Agung Senapathi,Made Wiryana,I Gusti Ngurah Mahaalit Aribawa,Christopher Ryalino Department of Anesthesiology and Intensive Care, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia Background: Accuracy of consciousness level assessment is very important. It may determine and influence further clinical decisions, thus influences patients’ outcomes. The widest method in determining the level of awareness is the Glasgow Coma Scale (GCS). Despite its common use, GCS scores obtained by one clinician may differ from others depending on their interpretations and past experience. One of the tools used to assess the level of consciousness objectively is bispectral index (BIS). The aim of this study was to identify the correlation between BIS and GCS score in patients with traumatic brain injury. Patients and Methods: A total of 78 patients who were admitted to emergency room for traumatic brain injury were included in this study. One observer evaluated the GCS of all patients to minimize subjectivity. Another investigator then obtained the BIS values for each patient. Spearman’s rank correlation coefficient was used to determine whether GCS correlated with BIS value. Results: In 78 patients, the BIS was found to be significantly correlated with GCS (r=0.744, p

Introduction. Nosocomial pneumonia (NP) is one of the most dangerous infectious complications of severe traumatic brain injury (TBI). According to some researchers, NP formed 0.5–1 % of hospitalized patients and in patients of ICU – NP develops with a frequency from 15 to 65 %. The aim of our study was to determine the clinical and demographic characteristics of patients with NP, developed on the background of severe TBI. Materials and Methods. 166 patients had been examined, including 58 patients with isolated severe head injury (group 1) and 108 patients with traumatic brain injury, which were complicated by the development of NP (group 2). Results. Out of the first group patients 50 (86.2 %) were men, 8 (13.8 %) were women. The average age of patients in this group was 49.2 ± 15.2 years. Out of the first group patients 89 (82.4 %) were men, 19 (17.6 %) were women. The average age of patients in this group was 48.2 ± 16.7 years. The average length of in-patient treatment was 14.1 ± 6.2 days in patients of the 1st group versus 38.7 ± 17.6 days in patients of the 2nd group. In the 1st group 41 (70.7 %) were non-smokers, 10 (17.2 %) smokers 10 cigarettes per day, 10 to 20 cigarettes per day – 3 (5.2 %), more than 20 cigarettes per day – 4 (6.9 %). In the 2nd group 40 (37.0 %) were non-smokers, 33 (30.6 %) smokers 10 cigarettes per day, 10 to 20 cigarettes per day – 16 persons (14.8 %), more than 20 cigarettes per day – 19 (17.6 %). Conclusions. In demographic structure of the NP, developed on the background by TBI, young men were dominated. The mean duration of hospital treatment of patients with NP increased 2.7 times compared with the patients with TBI uncomplicated by NP. Most patients of both the 1st and the 2nd groups were overweight (more than 50 % of patients). There is a significant percentage of the unemployed. A larger percentage of people who consume alcohol in the 2nd group of patients could be indicative of their poor social adaptation and difficult social conditions. Significantly greater number of smokers among the patients of the 2nd group confirms the importance of smoking as a risk factor of the NP development on the background of TBI. nosocomial infections; traumatic brain injury; TBI

Intracranial pressure (ICP) is an important metric in the management of severe head injury. We show alternatives to today’s standard of highly invasive measurement devices using near-infrared spectroscopy and diffuse correlation spectroscopy to create a real-time ICP monitor. The algorithms were developed and tested in an animal model. First results of a clinical validation will be presented.

Epidural and subdural hematomas are common sequelae of severe head injury and usually require urgent surgical evacuation. The general principles that apply to the management of raised intracranial pressure following head injury should also be used in these patients. In this chapter we highlight the characteristics that are considered “typical” for the presentation of patients with acute epidural and subdural hematomas and discuss some aspects of management that are specific to these conditions.

Summary Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER‐TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed‐effects multinomial regression to quantify the effects on pre‐hospital or in‐hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre‐hospital and 483 (13%) in‐hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre‐hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1–4.3) for pre‐hospital intubation, and 2.7 (95%CI 1.9–3.5) for in‐hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre‐hospital intubation (OR 2.9, 95%CI 1.3–6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3–0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between‐centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.

Background: Craniocervical CT scan is an essential part of the routine evaluation of patient with moderate and severe head injury to rule out associated cervical spine injury. Computed tomography motion artifacts can affect clinical decision making. The aim of this report is to emphasize that motion artifact still exists despite advance in technology and this can pose clinical challenge. Case Description: A 20-year-old man presented to our facility with severe head injury GCS 8. Craniocervical CT scan reported 75% C3 on C4 anterior subluxation and urgent spinal stabilization surgery was recommended. A static lateral cervical spine X-ray showed normal bony alignment. He was successfully managed and dynamic studies after recovery were normal. Conclusion: Cervical spine CT motion artifact can lead to unneeded surgery but routine clinical evaluation and cervical spine static and dynamic X-rays may be sufficient to resolve the puzzle.

Objectives To identify the number of CT scans repeated in acute trauma patients receiving imaging before being referred to a trauma center, to define indications, and to assess radiation doses and costs of repeated CT. Methods This retrospective study included all adult trauma patients transferred from other hospitals to a Level-I trauma center during 2014. Indications for repeated CT scans were categorized into: inadequate CT image data transfer, poor image quality, repetition of head CT after head injury together with completion to whole-body CT (WBCT), and follow-up of injury known from previous CT. Radiation doses from repeated CT were determined; costs were calculated using a nation-wide fee schedule. Results Within one year, 85/298 (28.5%) trauma patients were transferred from another hospital because of severe head injury (n = 45,53%) and major body trauma (n = 23;27%) not manageable in the referring hospital, repatriation from a foreign country (n = 14;16.5%), and no ICU-capacity (n = 3;3.5%). Of these 85 patients, 74 (87%) had repeated CT in our center because of inadequate CT data transfer (n = 29;39%), repetition of head CT with completion to WBCT (n = 24;32.5%), and follow-up of known injury (n = 21;28.5%). None occurred because of poor image quality. Cumulative dose length product (DLP) and annual costs of potential preventable, repeated CT (inadequate data transfer) was 631mSv (81′304mGy*cm) and 35′233€, respectively. Conclusion A considerable number of transferred trauma patients undergo potentially preventable, repeated CT, adding radiation dose to patients and costs to the health care system.

Cranioplasty is the surgical repair of cranial defect or deficiency of the skull with a aim for functional and cosmetic improvement. Inorganic and organic materials have both been used for cranioplasty with the ideal cranioplasty material is yet to be made or discovered with present focus of research on molecular biology. This article does a brief review of the history of materials used and discusses the results of the use of bone cement cranioplasty (BCC) in this centre. A total of 61 cases were included in the study with the majority being males (44 cases). Road traffic accident was the most common initial cause of injury (45 cases), followed by fall (10 cases) and physical assault in the rest. On admission and based on the GCS based head injury classification the majority were in the severe head injury type (GCS

Background: Non-contrast head computer tomography (CT) is widely used to evaluate eligibility of patients after acute traumatic brain injury (TBI) for clinical trials. The NINDS Common Data Elements (CDEs) TBI were developed to standardize collection of CT variables. The objectives of this study were to train research assistants (RAs) to rate CDEs and then to evaluate their performance. The aim was to assess inter-rater reliability (IRR) of CDEs between trained RAs and a neurologist and to evaluate applicability of CDEs in acute and sub-acute TBI to test the feasibility of using CDE CT ratings in future trials and ultimately in clinical practice. The second aim was to confirm that the ratings of CDEs reflect pathophysiological events after TBI.Methods and results: First, a manual was developed for application of the CDEs, which was used to rate brain CTs (n = 100). An excellent agreement was found in combined kappas between RAs on admission and on 24-hour follow-up CTs (Iota = 0.803 and 0.787, respectively). Good IRR (kappa > 0.61) was shown for six CDEs on admissions and for seven CDEs on follow-up CTs. Low IRR (kappa

Context: In traumatic brain injury patients, coagulation disorder causes secondary brain injury, thereby increasing mortality and morbidity. Aims: The aim of this study is to identify the factors responsible for coagulopathy in traumatic brain injury. Settings and Design: This prospective longitudinal study from June 2012 included 100 patients with moderate and severe head injury presenting to National Institute of Neurological and Allied Sciences, Kathmandu, over 1-year period. Subjects and Methods: Patients were evaluated for the development of coagulopathy, defined as collectively three abnormal hemostatic parameters, and associated risk factors for coagulopathy. They were then analyzed for correlation with coagulopathy. Statistical Analysis Used: SPSS version 16 was used for the analysis of data. For identification of contributing factors, a stepwise logistic regression analysis was performed, including the factors with P < 0.05 from the analysis. Results: Among the 100 patients, coagulopathy was present in 63% of cohort. Forty-three patients had severe head injury, and 76.7% (n = 33) of them had coagulopathy compared to 52.7% (n = 30) in 57 patients with moderate head injury (P = 0.013). Statistically significant correlation with coagulopathy was present with polytrauma, severity of head injury, blood transfusion, surgical intervention, and Marshall's classification of CT of the head; however, stepwise logistic regression analysis showed that blood transfusion, surgical intervention, polytrauma, and severity of head injury were significant independent variables responsible for the development of coagulopathy. Conclusions: Traumatic brain injury is complicated with coagulopathy in up to 63% of patients. Blood transfusion, surgical intervention, polytrauma, and severity of head injury are significant independent variables responsible for coagulopathy.

Generally, according to international literature, cerebral ischemia is a secondary posttraumatic lesion produced by direct compression in the context of a cerebral herniation syndrome or indirect by vasospasm produced by posttraumatic subarachnoid, subdural or intraventricular hemorrhages. We present the case of a patient with an acute MCA ischemia with severe head injury due to a fall with subsequent intracranial acute intracerebral and subdural hematoma which evolved with acute left uncal, parahipocampal and subfalcinecerebral herniation (coma, GCS 6, left mydriasis, right severe hemiparesis). Surgical emergency aspiration of the hematomas was performed. Postoperative treatment of cerebral ischemia and residual hematomas was properly done. We consider important and underdiagnosed the association of cerebral ischemia and secondary posttraumatic brain injuries. Abbreviations: MCA-middle cerebral artery, GCS-Glasgow Coma Scale, ICA-internal carotid artery, PCA-posterior cerebral artery, ACA-anterior cerebral artery. Conclusion: We present a case of a patient with an acute MCA ischemia with secondary head injury due to a fall with subsequent intracranial acute intracerebral and subdural hematomas. Surgical emergency aspiration of the hematomas was performed. The treatment was performed for both lesions (cerebral ischemia and posttraumatic hematomas) with vitamins B, neurotrophycs, pain killers, antibiotics. Unfortunately, due to aggravation of the Mendelson syndrome, the patient died 7 days later.

This is case report of a young adult male who had developed Parkinsonism symptoms shortly after severe head injury due to accidental fall. This 45-year-old man was diagnosed as multiple hemorrhagic contusions, sub arachnoid hemorrhage and linear skull fracture. After 4 weeks of fall, he developed Parkinsonian symptoms which were relieved by anti-parkinson’s disease medication. After doing thorough journal review only few reports were found regarding short term onset of Parkinson’s disease after severe head injury, though most of the literatures evident of the similar symptoms after more than years after the head trauma.