Comparative Analysis of Cervical Spine Management in a Subset of Severe Traumatic Brain Injury Cases Using Computer Simulation

BACKGROUND: No randomized control trial to date has studied the use of cervical spine management strategies in cases of severe traumatic brain injury (TBI) at risk for cervical spine instability solely due to damaged ligaments. A computer algorithm is used to decide between four cervical spine management strategies. A model assumption is that the emergency room evaluation shows no spinal deficit and a computerized tomogram of the cervical spine excludes the possibility of fracture of cervical vertebrae. The study's goal is to determine cervical spine management strategies that maximize brain injury functional survival while minimizing quadriplegia. METHODS/FINDINGS: The severity of TBI is categorized as unstable, high risk and stable based on intracranial hypertension, hypoxemia, hypotension, early ventilator associated pneumonia, admission Glasgow Coma Scale (GCS) and age. Complications resulting from cervical spine management are simulated using three decision trees. Each case starts with an amount of primary and secondary brain injury and ends as a functional survivor, severely brain injured, quadriplegic or dead. Cervical spine instability is studied with one-way and two-way sensitivity analyses providing rankings of cervical spine management strategies for probabilities of management complications based on QALYs. Early collar removal received more QALYs than the alternative strategies in most arrangements of these comparisons. A limitation of the model is the absence of testing against an independent data set. CONCLUSIONS: When clinical logic and components of cervical spine management are systematically altered, changes that improve health outcomes are identified. In the absence of controlled clinical studies, the results of this comparative computer assessment show that early collar removal is preferred over a wide range of realistic inputs for this subset of traumatic brain injury. Future research is needed on identifying factors in projecting awakening from coma and the role of delirium in these cases

Penetrating Abdominal Trauma

While immediate laparotomy is still indicated for patients who present with hemodynamic instability, signs of shock, evisceration, impalement, or peritonitis, further investigation and/or serial clinical examinations can be undertaken in the stable patient without evidence of peritonitis. Head injury, high spinal cord injury, depressed mental status due to intoxication, sedation, or anesthesia all mandate further diagnostic investigation or laparotomy to exclude intraperitoneal injury. In abdominal gunshot wounds (GSWs), the entrance and exit wounds, if present, should be identified with radiopaque markers and chest and abdominal X-rays taken in order to identify the location of the ballistic. If the patient remains hemodynamically normal and without signs of peritonitis, the clinician should strongly consider computed tomography (CT) with intravenous contrast. In hemodynamically stable, asymptomatic patients with a stab wound (SW) to the anterior abdominal wall, defined as the area between the costal margin, the anterior axillary lines, and the inguinal ligaments, local wound exploration can be performed. The role of diagnostic laparoscopy for the detection of peritoneal violation remains unclear. CT scan with IV contrast is indicated in patients presenting with penetrating trauma to the flank or back in order to evaluate for retroperitoneal injury. Solid organ injuries in the hemodynamically stable patient may be managed nonoperatively with serial clinical examinations