Ariana Alejandra Chacón-Aponte, Érika Andrea Durán-Vargas, Jaime Adolfo Arévalo-Carrillo, Iván David Lozada-Martínez, Maria Paz Bolaño-Romero, Luis Rafael Moscote-Salazar, Pedro Grille, Tariq Janjua
Acute Crit Care. 2022;37(1):35-44. Published online February 11, 2022
The brain-lung interaction can seriously affect patients with traumatic brain injury, triggering a vicious cycle that worsens patient prognosis. Although the mechanisms of the interaction are not fully elucidated, several hypotheses, notably the “blast injury” theory or “double hit” model, have been proposed and constitute the basis of its development and progression. The brain and lungs strongly interact via complex pathways from the brain to the lungs but also from the lungs to the brain. The main pulmonary disorders that occur after brain injuries are neurogenic pulmonary edema, acute respiratory distress syndrome, and ventilator-associated pneumonia, and the principal brain disorders after lung injuries include brain hypoxia and intracranial hypertension. All of these conditions are key considerations for management therapies after traumatic brain injury and need exceptional case-by-case monitoring to avoid neurological or pulmonary complications. This review aims to describe the history, pathophysiology, risk factors, characteristics, and complications of brain-lung and lung-brain interactions and the impact of different old and recent modalities of treatment in the context of traumatic brain injury.
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Background Decreases in heart rate variability have been shown to be associated with poor outcomes in severe acute brain injury. However, it is unknown whether the changes in heart rate variability precede neurological deterioration in such patients. We explored the changes in heart rate variability measured by electrocardiography in patients who had neurological deterioration following severe acute brain injury, and examined the relationship between heart rate variability and electroencephalography parameters.
Methods Retrospective analysis of 25 patients who manifested neurological deterioration after severe acute brain injury and underwent simultaneous electroencephalography plus electrocardiography monitoring.
Results Eighteen electroencephalography channels and one simultaneously recorded electrocardiography channel were segmented into epochs of 120-second duration and processed to compute 10 heart rate variability parameters and three quantitative electroencephalography parameters. Raw electroencephalography of the epochs was also assessed by standardized visual interpretation and categorized based on their background abnormalities and ictalinterictal continuum patterns. The heart rate variability and electroencephalography parameters showed consistent changes in the 2-day period before neurological deterioration commenced. Remarkably, the suppression ratio and background abnormality of the electroencephalography parameters had significant reverse correlations with all heart rate variability parameters.
Conclusions We observed a significantly progressive decline in heart rate variability from the day before the neurological deterioration events in patients with severe acute brain injury were first observed.
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Background We evaluated clinical and nutritional outcomes according to multidisciplinary team involvement in nutrition support in a regional trauma intensive care unit (TICU).
Methods We retrospectively compared the outcomes for 339 patients admitted to the TICU for >5 days depending on nutrition support team (NST) involvement (n=176) and non-NST involvement (n=163).
Results The mean age and injury severity score (ISS) were 57.3±16.7 years and 18.6±9.7, respectively. Fifty-three patients (15.6%) had shock on admission and 182 (53.7%) underwent surgery during TICU admission. Some patients were admitted to neurosurgery (46%), general surgery (35.4%), and other (18.6%) departments. There were significant differences in the ISS, Acute Physiology and Chronic Health Evaluation (APACHE) II score, shock on TICU admission, and initial laboratory results. After propensity score matching, the total delivered/required caloric ratio and total delivered/required protein ratio were significantly higher in the NST group than in the non-NST group (calorie: 80.4% vs. 66.7%, P=0.007; protein: 93.1% vs. 68.3%, P<0.001). The NST group had an adequate protein supply more frequently than the non-NST group (protein: 48.0% vs. 25.8%, P=0.002). There was no significant difference in survival, even after adjustment for risk factors using Cox proportional hazard analysis.
Conclusions The results of our study suggest that multidisciplinary team involvement in nutrition support in TICU patients may improve nutritional, but not clinical, outcomes.
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Background This study aimed to develop a model for predicting trauma outcomes by adding arterial lactate levels measured upon emergency room (ER) arrival to existing trauma injury severity scoring systems.
Methods We examined blunt trauma cases that were admitted to our hospital during 2010– 2014. Eligibility criteria were cases with an Injury Severity Score of ≥9, complete Trauma and Injury Severity Score (TRISS) variable data, and lactate levels that were assessed upon ER arrival. Survivor and non-survivor groups were compared and lactate-based prediction models were generated using logistic regression. We compared the predictive performances of traditional prediction models (Revised Trauma Score [RTS] and TRISS) and lactate-based models using the area under the curve (AUC) of receiver operating characteristic curves.
Results We included 829 patients, and the in-hospital mortality rate among these patients was 21.6%. The model that used lactate levels and age provided a significantly better AUC value than the RTS model. The model with lactate added to the TRISS variables provided the highest Youden J statistic, with 86.0% sensitivity and 70.8% specificity at a cutoff value of 0.15, as well as the highest predictive value, with a significantly higher AUC than the TRISS.
Conclusions These findings indicate that lactate testing upon ER arrival may help supplement or replace traditional physiological parameters to predict mortality outcomes among Korean trauma patients. Adding lactate levels also appears to improve the predictive abilities of existing trauma outcome prediction models.
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Background We hypothesized that the recent change of sepsis definition by sepsis-3 would facilitate the measurement of timing of sepsis for trauma patients presenting with initial systemic inflammatory response syndrome. Moreover, we investigated factors associated with sepsis according to the sepsis-3 definition.
Methods Trauma patients in a single level I trauma center were retrospectively reviewed from January 2014 to December 2016. Exclusion criteria were younger than 18 years, Injury Severity Score (ISS) <15, length of stay <8 days, transferred from other hospitals, uncertain trauma history, and incomplete medical records. A binary logistic regression test was used to identify the risk factors for sepsis-3.
Results A total of 3,869 patients were considered and, after a process of exclusion, 422 patients were reviewed. Fifty patients (11.85%) were diagnosed with sepsis. The sepsis group presented with higher mortality (14 [28.0%] vs. 17 [4.6%], P<0.001) and longer intensive care unit stay (23 days [range, 11 to 35 days] vs. 3 days [range, 1 to 9 days], P<0.001). Multivariate analysis demonstrated that, in men, high lactate level and red blood cell transfusion within 24 hours were risk factors for sepsis. The median timing of sepsis-3 was at 8 hospital days and 4 postoperative days. The most common focus was the respiratory system.
Conclusions Sepsis defined by sepsis-3 remains a critical issue in severe trauma patients. Male patients with higher ISS, lactate level, and red blood cell transfusion should be cared for with caution. Reassessment of sepsis should be considered at day 8 of hospital stay or day 4 postoperatively.
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Background Initial evaluation of injury severity in trauma patients is an important and challenging task. We aimed to assess whether easily measurable biochemical parameters (hemoglobin, pH, and prothrombin time/international normalized ratio [PT/INR]) can predict in-hospital mortality in patients with severe trauma. Methods: This retrospective study involved review of the medical records of 315 patients with severe trauma and an injury severity score >15 who were managed at Gyeongsang National University Hospital between January 2005 and December 2015. We extracted the following data: in-hospital mortality, injury severity score, and initial hemoglobin level, pH, and PT/INR. The predictive values of these variables were compared using receiver operation characteristic curves. Results: Of the 315 patients, 72 (22.9%) died. The in-hospital mortality rates of patients with hemoglobin levels <8.4 g/dl and ≥8.4 g/dl were 49.8% and 9.9%, respectively (P < 0.001). At a cutoff hemoglobin level of 8.4 g/dl, the sensitivity and specificity values for mortality were 81.9% and 86.4%, respectively. At a pH cutoff of 7.25, the sensitivity and specificity values for mortality were 66.7% and 77.8%, respectively; 66.7% of patients with a pH <7.25 died versus 22.2% with a pH ≥7.25 (P < 0.001). The in-hospital mortality rates for patients with PT/INR values ≥1.4 and <1.4 were 37.5% and 16%, respectively (P < 0.001; sensitivity, 37.5%; specificity, 84%). Conclusions: Using the suggested cutoff values, hemoglobin level, pH, and PT/INR can simply and easily be used to predict in-hospital mortality in patients with severe trauma.
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Background Burn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve vital organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage problems related to thermal injury, including lightning and electrical injuries.
Methods A selected review is provided of key management concepts as well as of recent reports published by the American Burn Association.
Results The burn-injured patient is easily and frequently over resuscitated, with ensuing complications that include delayed wound healing and respiratory compromise. A feedback protocol designed to limit the occurrence of excessive resuscitation has been proposed, but no new “gold standard” for resuscitation has replaced the venerated Parkland formula. While new medical therapies have been proposed for patients sustaining inhalation injury, a paradigm-shifting standard of medical therapy has not emerged. Renal failure as a specific contributor to adverse outcome in burns has been reinforced by recent data. Of special problems addressed in burn centers, electrical injuries pose multisystem physiologic challenges and do not fit typical scoring systems.
Conclusion Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury has been generally adopted, but new standards for description of burn-related infections have been presented. The value of the burn center in care of the problems of electrical exposure, both manmade and natural, is demonstrated in recent reports.
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Managing acute respiratory distress syndrome (ARDS) after severe blunt traumatic lung injury can be challenging. In cases where patients are refractory to conventional therapy, extracorporeal membrane oxygenation (ECMO) should be considered. In addition, the heparin-coated circuit can reduce hemorrhagic complications in patients with multiple traumas. Although prolonged ECMO may be necessary, excellent outcomes are frequently associated. In this study, we report long-term support with venovenous-ECMO applied in a child with severe blunt trauma in Korea. This 10-year-old and 30-kg male with severe blunt thoracic trauma after a car accident developed severe ARDS a few days later, and ECMO was administered for 33 days. Because of pulmonary hemorrhage during ECMO support, heparin was stopped for 3 days and then restarted. He was weaned from ECMO successfully and has been able to run without difficulty for the 2 years since discharge.
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The fact that therapeutic hypothermia (TH) has lowered intracranial pressure and protected brain in severe traumatic brain injury (TBI) is well known throughout past sources and experimental data. In this paper, the result of TH in TBI needs to be confirmed. The result of North American Brain Injury Study; Hypothermia (NAVIS-H) 1 and 2, Eurotherm3235, Japan trauma society study was reviewed throughout randomized controlled study which performed recently. The prognosis was not confirmed throughout TH in NAVIS-H1; however, there was statistical significance among the group of 45 years or less and below 35 degree in celcius which checked when he or she visited initially. Hence, NAVIS-H2 study was preceded. In patient who had surgically removed hematoma, the effects of TH were proved compared to diffuse brain damage in NAVIS-H2 study. This was found in the result of Japan neurotrauma data bank. Eurotherm study has been doing, which leads to collect many data later on. The TBI of TH makes them better prognosis in patients who had surgically removed hematoma and lowered initial body temperature. Later on, it is considered further study is necessary.
Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.