Crit Care Resusc
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Cervical spine injury occurs in 5-10% of patients with traumatic brain injury (TBI) and the consequences of missing significant cervical injuries in unconscious blunt trauma patients are potentially devastating. An adequate cervical spine clearance protocol for unconscious patients must avoid missed injuries, but must also avoid unnecessary cervical immobilisation and the associated morbidity. Existing protocols include various combinations of plain X-rays, helical CT, dynamic flexion-extension X-rays and MRI. ⋯ Nevertheless, recently at The Alfred Hospital, extremely high-risk TBI patients have had unstable cervical injuries detected solely by MRI. Current generation multi-slice CT with reconstructions may obviate the need for MRI even in these patients. The current Alfred Hospital cervical clearance protocol for unconscious patients, and the evolutionary steps in its development, will be discussed.
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Intracerebral haemorrhage (ICH) is much less common than ischaemic stroke (15% versus 85% in most Western studies), but is associated with a significantly worse prognosis. ICH is much more common in Asian populations, probably reflecting higher rates of small vessel disease, hypertension and genetic factors. Overall, ICH mortality rates approach 50% and there has been little effective treatment to date, except for the overall benefit from stroke unit care. ⋯ Medical therapies to reduce brain edema and intracranial pressure, including glycerol and mannitol, are not of proven value. It is accepted that corticosteroids should not be used in ICH and may worsen outcomes. The management of acute hypertension is controversial and guidelines are based on little direct evidence.
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In 2004, two large randomised multi-centre Australian clinical trials provided new information concerning optimal resuscitation for patients with traumatic brain injury (TBI). One examined hypertonic saline (HTS) and the other, albumin versus saline.( )For the first time in a randomised trial, hypertonic saline was tested for pre-hospital resuscitation of hypotensive patients with traumatic brain injury, and for the first time a resuscitation fluid trial measured long term neurological function as the primary outcome. Despite many potential advantages which may have much greater relevance in the hospital setting, in the paramedic based VICn trauma system, HTS did not improve neurological outcome compared to conventional pre-hospital fluid protocols. ⋯ Intriguingly however, the SAFE study also reported that within a subgroup of 492 patients with TBI, 28 day survival was superior in patients receiving saline. This subgroup result was not considered definitive, but a post hoc examination of the TBI patients currently in progress by the SAFE investigators, is expected to provide further guidance for clinicians. In the meanwhile, and until more high quality data is available, many clinicians are likely to prefer crystalloid resuscitation for trauma patients, and especially for trauma patients with brain injury.