Articles: trauma.
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Therapeutic hypothermia is a potentially dangerous treatment with a very narrow therapeutic index. It is of proven benefit in certain conditions, including post ventricular fibrillation cardiac arrest and intermediate severity neonatal asphyxia. ⋯ While it is clear that hypothermia decreases intracranial pressure, a major phase III trial demonstrated no improvement in neurological outcomes with hypothermia, in an unselected group of patient with severe head injury. More focused phase III trials are underway but until the results are known this treatment should not be offered to patients outside the context of a clinical trial.
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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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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.
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Anesthesia and analgesia · Aug 2005
Review Meta AnalysisRevising a dogma: ketamine for patients with neurological injury?
We evaluated reports of randomized clinical trials in the perioperative and intensive care setting concerning ketamine's effects on the brain in patients with, or at risk for, neurological injury. We also reviewed other studies in humans on the drug's effects on the brain, and reports that examined ketamine in experimental brain injury. In the clinical setting, level II evidence indicates that ketamine does not increase intracranial pressure when used under conditions of controlled ventilation, coadministration of a gamma-aminobutyric acid (GABA) receptor agonist, and without nitrous oxide. Ketamine may thus safely be used in neurologically impaired patients. Compared with other anesthetics or sedatives, level II and III evidence indicates that hemodynamic stimulation induced by ketamine may improve cerebral perfusion; this could make the drug a preferred choice in sedative regimes after brain injury. In the laboratory, ketamine has neuroprotective, and S(+)-ketamine additional neuroregenerative effects, even when administered after onset of a cerebral insult. However, improved outcomes were only reported in studies with brief recovery observation intervals. In developing animals, and in certain brain areas of adult rats without cerebral injury, neurotoxic effects were noted after large-dose ketamine. These were prevented by coadministration of GABA receptor agonists. ⋯ Ketamine can be used safely in neurologically impaired patients under conditions of controlled ventilation, coadministration of a {gamma}-aminobutyric acid receptor agonist, and avoidance of nitrous oxide. Its beneficial circulatory effects and preclinical data demonstrating neuroprotection merit further animal and patient investigation.
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Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi · Aug 2005
Review[Advances of functional electrical stimulation in treatment of peripheral nerve injuries].
To review the advances of functional electrical stimulation (FES) in treatment of peripheral nerve injuries. ⋯ FES is an effective treatment for peripheral nerve injuries.