J Trauma
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This study aimed to identify early radiologic signs that are predictive of hemorrhage progression and clinical deterioration in patients with traumatic cerebral contusion. We hypothesized that contrast extravasation (CE) and blood-brain barrier disruption might be associated with hemorrhage progression, brain edema, and clinical deterioration in these patients. ⋯ Early parenchymal CE is associated with hemorrhage progression, cerebral edema, clinical deterioration, and need for subsequent surgery. These patients should be monitored closely, and early surgery may be needed if deterioration occurs. Further elucidation of the pathophysiology is needed to formulate effective treatment for these high-risk patients.
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Comparative Study
Safety of performing a delayed anastomosis during damage control laparotomy in patients with destructive colon injuries.
Recent studies report the safety and feasibility of performing delayed anastomosis (DA) in patients undergoing damage control laparotomy (DCL) for destructive colon injuries (DCIs). Despite accumulating experience in both civilian and military trauma, questions regarding how to best identify high-risk patients and minimize the number of anastomosis-associated complications remain. Our current practice is to perform a definitive closure of the colon during DCL, unless there is persistent acidosis, bowel wall edema, or evidence of intra-abdominal abscess. In this study, we evaluated the safety of this approach by comparing outcomes of patients with DCI who underwent definitive closure of the colon during DCL versus patients managed with colostomy with or without DCL. ⋯ Performing a DA in DCI during DCL is a reliable and feasible approach as long as severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections are not present.
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Comparative Study
Talk and die revisited: bifrontal contusions and late deterioration.
Severe bifrontal contusions in an awake traumatic brain injury (TBI) patient is a challenging clinical picture, as they are prone to late deterioration. We evaluated our series of patients with severe bifrontal contusions, characterizing their clinical course and suggestions for management. ⋯ Awake patients with bifrontal contusions represent a unique cohort of TBI patients who are prone to rapid deterioration late in their clinical course. They have extensive frontal edema and mass effect, yet we were unable to find a correlation between edema volumes and incidence of deterioration. Based on this series and our experience in other TBI patients, we no longer utilize prophylactic infusions of hypertonic saline in the setting of TBI. We recommend managing these patients with intensive care unit admission and early intracranial pressure monitoring. If they do deteriorate despite these measures, rapid bifrontal decompression can lead to good functional outcomes.
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Patients with closed head injury and expanding epidural (EDH) or subdural (SDH) hematoma require urgent craniotomy for decompression and control of hemorrhage. In remote areas where neurosurgeons are not available, trauma surgeons may occasionally need to intervene to avert progressive neurologic injury and death. In 1990, a young man with rapidly deteriorating neurologic signs underwent emergency burr hole decompression of a combined EDH/SDH at our hospital, with complete recovery. ⋯ One patient with a GCS score of 3 on arrival died. Seven survivors (mean follow-up, 3.9 years; range, 1-6.5 years), including the index case, function independently, although one survivor has moderate cognitive and motor impairment. We conclude that early craniotomy for expanding epidural and subdural hematomas by properly trained surgeons may save lives and reduce morbidity in properly selected cases when timely access to a neurosurgeon is not possible.
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Comparative Study
Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk?
Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero. ⋯ The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.