Tag Archives: trauma

What Is the Incidence of Subclinical and Clinical Seizures in Pediatric TBI?

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. The primary medical management of TBI relies on minimization of secondary injury. Posttraumatic seizures are relatively common and can cause secondary injury or worsen other sources of secondary injury. O’Neill et al sought to determine the incidence of seizures in children with TBI using a protocol for early continuous electroencephalography monitoring.

This study affirmed that posttraumatic seizures are relatively common in pediatric patients with TBI.

Read the full Concise Critical Appraisal by logging in to the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Effect of RBC Transfusion on Cerebral Autoregulation in Severe TBI Patients

What is the impact of red blood cell (RBC) transfusion on cerebral autoregulation in patients with severe traumatic brain injury (TBI)? Seeking to find out, Sekhon et al conducted a retrospective, single-center, cohort study to evaluate the relationship between RBC transfusion and cerebral autoregulation as measured by pressure reactivity index (PRx).

They found that RBC transfusion in severe TBI patients results in worsening PRx, indicating impaired cerebral autoregulation.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Autologous BMMNC Therapy and Pediatric Traumatic Brain Injury

Traumatic brain injury (TBI) is a major cause of death and disability in children. Most of the therapies available in TBI management focus on management of intracranial pressure in a tiered fashion. Liao et al used a novel technique in TBI management, infusing autologous bone marrow-derived mononuclear cells (BMMNCs). Using data obtained from a phase 1 trial published in 2011, the  authors compared the therapeutic intensity needed to prevent intracranial hypertension in 10 pediatric patients who received infusions of BMMNCs between 2006 and 2008 versus 19 control patients who were admitted with TBI between 2000 to 2008. The authors employed the Pediatric Intensity Level of Therapy (PILOT) scoring system, a validated tool used to identify therapeutic intensity.

They found that PILOT scores were significantly lower in the treatment group compared to the control group, starting at 24 hours posttreatment and lasting through the first week. Liao and colleagues should be applauded for pursuing this unconventional and novel approach to TBI management.  However, more work needs to be done—perhaps in a multicenter trial—before this therapy is applied.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Vasospasm in Pediatric Traumatic Brain Injury

Pediatric traumatic brain injury (TBI) is a major cause of death and disability. While the damage caused by the primary injury may not be alterable by treatment, the effects of the secondary injury—subsequent metabolic, humoral and cellular derangements—can be modified. By ensuring good hemodynamics, gas exchange and intracranial pressure control, physicians can improve outcomes. However, the appearance of vasospasm and subsequent ischemia has been demonstrated in up to 45% of adults with TBI (depending on the criteria used to define vasospasm) and has been associated with worse outcomes. In a recent study, O’Brien et al sought to evaluate the prevalence, time to onset and duration of vasospasm in children with moderate to severe TBI. For their single center, prospective, observational study, the authors enrolled 69 children with TBI (35 subjects had moderate TBI and 34 had severe TBI).

They found that vasospasm occurs in a sizeable number of children with moderate and severe TBI. However, while the authors recommend “aggressive screening” for posttraumatic vasospasm in these patients, appropriate therapies have not been described in any studies. Clearly, future studies should be done to measure long-term outcomes and responses to specific therapies.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Incidence of Subdural Hemorrhage in Infants with Congenital Heart Disease

Subdural hemorrhage (SDH) in infants is commonly associated with nonaccidental trauma and “shaken baby syndrome,” and some reports suggest that SDH may appear in susceptible infants who have suffered apnea or significant hypoxia. Although generally asymptomatic, SDH related to birth trauma has also been reported to be common. Kelly and colleagues sought to determine the true incidence of SDH in infancy by looking at pre- and postoperative infants who have undergone a repair of congenital heart disease (CHD). In addition, the authors sought an association between the development of SDH and the presence of hypoxia.

The authors found that asymptomatic SDH was common in infants with CHD at a rate similar to those without CHD. These SDHs were typically small and resolved within three months of birth. The authors were unable to demonstrate any association between hypoxia and SDH in this cohort. However, the ability to generalize these results is limited due to the nature of the selected patient population.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Red Blood Cell Transfusion and Associated Outcomes

Many studies have detailed increasing risks of morbidity and mortality associated with anemia in critically ill patients.  Despite these findings, transfusion of red blood cells (RBCs) to optimize oxygen delivery has been shown to carry its own inherent risks, ranging from the development of acute lung injury to immunomodulation to problems with the storage lesion and oxygen delivery. A study by Hassan et al adds to the mounting evidence regarding the deleterious effects of RBC transfusion by retrospectively looking at the impact of transfusion on pediatric trauma patients. The authors compared the outcomes of 81 children with trauma who were transfused with RBCs to 282 who did not receive any blood products.

They found that transfusion of packed RBCs is associated with higher risk of adverse outcomes independent of injury severity. Due to its retrospective nature, this study does not provide any new evidence proving that transfusion of RBCs can be harmful to critically ill patients, but it adds to the evidence of the effects in pediatric trauma patients.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Latest News from the SCCM eCommunity

The Society of Critical Care Medicine’s eCommunities offer critical care professionals the opportunity to connect, share and collaborate. Communities are open to SCCM members and nonmembers to facilitate knowledge sharing and improve care.

Log into the various SCCM eCommunities at www.sccm.org/eCommunity to be part of the discussion.

Latest SCCM eCommunity Posts

Fear and Anxiety is Healthy; Helping Patients and Families to Understand the Fears of Returning to Work after Traumatic Brain Injury
Twice I had to be told I had a rip in the seat of my pants.  All I could see as my vision came into focus was a floating man’s head six feet above my face. Before that, I was hearing shouting “Are you Ok? Are you OK?” coming from not one but multiple directions. When he helped me sit up, I immediately began squeezing my head with increasing pressure because it was spinning in frenzy. I squeezed my head harder and with more intensity without success. My head felt like it was an old tin spinning top just after the plastic handle had been pumped hundreds of times and released.  These are the realities of my personal experience of the initial accident which later would be diagnosed as a concussive traumatic brain injury.  I am a critical care practitioner and pharmacy faculty member, yet I attempted to convince myself I was fine until I walked to my car and the man followed closely behind reminding me multiple times that my pants were ripped and that I should take it easy.

Family Centered Care in the PICU
Family Centered Care (FCC) is an inherent part of all pediatric practice. However, until quite recently, families were not considered an integral part of the health care team when patients were cared for in the pediatric intensive care unit (PICU). In fact, restricted visiting hours, removal of family members for codes and invasive procedures, and efforts to maintain a “minimal stim environment” often led to a complete abdication of the family members’ roles as caregivers while the child was in the PICU.

Can You See Retinal Hemorrhages with Increased Intracranial Pressure?

Child abuse is a significant problem in the United States with approximately four children dying of abuse every day, most of whom are younger than 4 years. Additionally, 1300 children are presumed to die each year following abusive head trauma. Rapid identification of non-accidental head trauma helps child-protection workers and the police protect children and apprehend and prosecute abusers.

For many years, the presence of retinal hemorrhages in an infant with a neurologic injury was thought to be diagnostic for shaken baby syndrome (SBS), and frequently these hemorrhages were the only physical finding suggestive of abuse. However, the literature supporting this assumption was lacking, and many have suggested that cardiopulmonary resuscitation and increased intracranial pressure could also cause retinal hemorrhages. In 1997, Odom et al helped dispel the notion that cardiopulmonary resuscitation could cause the types of retinal bleeding seen with SBS. The recent article by Binenbaum et al, which appeared in the August issue of Pediatrics, continues this process of validation by examining the presence of retinal hemorrhages in children with non-traumatic causes of increased intracranial pressure (ICP).

In this work, the authors recruited subjects between the ages of 1 and 17 years who were undergoing lumbar punctures. Children with a history of head trauma, indwelling ventricular catheters, lumbar drains, or brain tumors were excluded. Opening pressure (OP) measurements were obtained. OP was defined as the highest pressure sustained for 10 seconds. All subjects also underwent a dilated funduscopic examination performed by a pediatric ophthalmologist no later than 96 hours after the lumbar puncture; 93% were completed within 48 hours.

Of the 100 subjects who met inclusion criteria, 32 had an OP between 20 and 28 cm H2O, and 68 had an OP >28 cm H2O. The most common diagnosis was idiopathic intracranial hypertension, but other diagnoses included infectious disease, rheumatologic or demyelinating disease, and venous thrombosis. Optic disc swelling was noted in 74 children. Sixteen subjects had splinter optic disc hemorrhages or superficial intraretinal hemorrhages, as well as moderate to severe optic disc swelling. Retinal hemorrhages were not seen in other areas (e.g., retinal periphery), not even in one case of papilledema causing severe vision loss.

The authors claim that these findings are consistent with anecdotal experiences of other pediatric ophthalmologists who routinely perform funduscopic exams on children with increased ICP. However, they also claim that the hemorrhages seen in this study are fundamentally different from the severe hemorrhagic retinopathy typically described with SBS, which are often multilayered and deeper, &#34dot-and-blot&#34 intraretinal hemorrhages. The authors also comment on the relative infrequency of disc swelling (<9% of cases) seen with head trauma compared to the study subjects.

This study&#39s strengths lie in the number of subjects enrolled and in the fact that pediatric ophthalmologists performed the funduscopic exams. The authors acknowledged the weaknesses, which are not insignificant. First, the ICPs in these subjects were presumably chronic in nature as opposed to the circumstances seen with an acute head injury. The pattern of hemorrhage seen in acute injuries is primarily preretinal and vitreous and is, again, different from the patterns seen with SBS (or Terson syndrome). Secondly, the subjects in this study were older than those seen with SBS, but, as the authors comment, because of their open sutures and fontanelles, infants are less likely to have papilledema and associated retinal hemorrhage.

Critical care physicians, child abuse specialists, and other medical professionals are often asked to testify in court about the nature of injuries, particularly in cases of non-accidental head trauma, and must be able to support their conclusions with good medical evidence. While there is not an exhaustive supply of literature supporting the notion that significant retinal hemorrhages are diagnostic of SBS, this work provides more affirming evidence.

This Concise Critical Appraisal is authored by SCCM member Daniel E. Sloniewsky, MD. Each installment highlights journal articles most relevant to the critical care practitionerDaniel Sloniewsky is an associate professor in the Department of Pediatrics at the Stony Brook Long Island Children&#39s Hospital in Stony Brook, NY, where he is board certified in pediatrics and pediatric critical care. He completed his fellowship training at Children&#39s Memorial Hospital and Northwestern University in Chicago. His major interests are in acute pediatric pulmonary disease, transfusion medicine and ethics. He is also actively involved in resident education, Pediatric Advanced Life Support and Pediatric Fundamental Critical Care Support instruction.

Webcast Highlights Third Edition of SSC Guidelines

Severe sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, killing one in four (and often more), and increasing in incidence. Similar to polytrauma, acute myocardial infarction, or stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome.

During the Society of Critical Care Medicine’s (SCCM) webcast, What’s New in the Third Edition of the SSC Guidelines?, R. Phillip Dellinger, MD, MCCM, and Christa A. Schorr, RN, MSN, FCCM, will discuss the additions to the latest update of the Surviving Sepsis Campaign guidelines and the rationale for the changes. The webcast will be held Wednesday, May 29, from 1:00 p.m. to 2:00 p.m. Central Time.

Register online today. Registration is complimentary for all participants. If you have any questions, please contact SCCM Customer Service at +1 847 827-6888. This event is part of SCCM’s newest webcast series, which outlines strategies for successful implementation of the SSC recommendations. Previous webcasts, now available free of charge, are available for download at www.survivingsepsis.org.

Programs are supported by the Gordon and Betty Moore Foundation:

SCCM Congratulates Members on Research Awards

The Patient Centered Outcomes Research Institute (PCORI) has approved 51 new awards, totaling $88.6 million over three years, to fund patient-centered comparative clinical effectiveness research projects under the first four areas of its National Priorities for Research and Research Agenda.  The Society of Critical Care Medicine congratulates the following members for their award-winning projects related to critical care:

  • Christopher Ethan Cox, MD, MPH – Improving Psychological Distress Among Critical Illness Survivors and Their Informal Caregivers
  • J. Randall Curtis, MD, MPH – Health System Intervention to Improve Communication About End-of-Life Care for Vulnerable Patients
  • Elliott R. Haut, MD – Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology
  • Rebecca Aslakson, MD – Utilizing Advance Care Planning Videos to Empower Perioperative Cancer Patients and Families
  • Erik Paul Hess, MD, MS – Shared Decision Making in the Emergency Department: The Chest Pain Choice Trial; and Shared Decision Making in Parents of Children with Head Trauma: Head CT Choice
  • Debra Kay Moser, DNSc, RN – Reducing Health Disparities in Appalachians with Multiple Cardiovascular Disease Risk Factors
  • Rachel Berger, MD, MPH – Using the Electronic Medical Record to Improve Outcomes and Decrease Disparities in Screening for Child Physical Abuse

We congratulate these members for their dedication to evolving research and to the field of critical care medicine.