Clinical and Biochemical Aspects of the Emergency Management of Traumatic Brain Injury

Populärvetenskaplig sammanfattning(Summary in Swedish)Hjärnskada som orsakas av olyckor är en vanlig orsak till både handikapp och död bland vuxna. För 30 år sedan var majoriteten av de som drabbades yngre eller väldigt gamla. Ålderssammansättningen av de som drabbas har skiftat under de senaste 20 åren och nu är det ungefär lika vanligt i alla åldrar. Dessutom är den vanligaste olycksorsaken inte längre fordonsolyckor utan fall i samma plan.För läkare som handlägger skallskadade patienter på akutmottagningar finns det flera olika riktlinjer. Dessa skiftar i olika länder och kan vara utfärdade av enskilda forskargrupper eller nationella organ. De är ofta baserade på forskning som är äldre än 15 år vilket kan medföra att de inte är helt aktuella.En riktlinje som ofta används i Skandinavien rekommenderar att man mäter nivån av S100B i blodet på vissa grupper av skallskadade patienter. Detta är en så kallad biomarkör som kan hjälpa till att utesluta att patienten som drabbats av skallskadan har hjärnblödning. Det finns ett antal sådana biomarkörer men S100B är den enda som används i klinisk praxis. Flera andra biomarkörer håller på att testas och nyligen har användning av två andra biomarkörer godkänts för kliniskt bruk i USA.Det finns två säkra sätt att utesluta allvarlig hjärnblödning efter skallskada: observation på sjukhus eller skiktröntgen av skallen. Fördelen med observation är att det inte innebär att patienten utsätts för strålning som kan vara skadlig och nackdelen är att man tar vårdresurser i anspråk. Skiktröntgen kan både utesluta och påvisa hjärnblödning med i det närmaste fullständig säkerhet men kräver att man utsätter patienten för strålning.Riktlinjerna för handläggning av skallskada har testats i flera vetenskapliga studier och det råder inga tvivel om att när de följs förbättrar de kvaliteten på handläggningen, dels genom att göra den mer konsekvent men också genom att minska antalet skiktröntgenundersökningar och därmed också kostnaderna. Dock efterföljs inte alltid riktlinjer och trots omfattande forskning på området har vi inget bra recept för att utveckla och införa en riktlinje så att den efterlevs av majoriteten av de som den riktar sig till.För att kunna mäta S100B måste man ta ett blodprov från en ven och detta sker vanligtvis i armvecket. Att mäta det i ett blodprov som tas från kapillära blodkärl (genom ett stick i fingret) eller i urin som insamlas genom att patienten kissar i en11provburk skulle ha uppenbara fördelar men det finns inte tillräckligt med kunskap om S100B i dessa kroppsvätskor för att det ska kunna rekommenderas.Denna avhandling baserar sig på fem olika delarbeten som utforskar olika aspekter av handläggning av patienter med skallskada och det övergripande syftet är att bidra med kunskap som ska kunna förbättra omhändertagande av skallskadade patienter på akutmottagningar.Delarbete 1 genomfördes med frågeformulär som delades ut till läkare på en akutmottagning efter att de handlagt en patient med skallskada. Syftet var att kartlägga läkarnas attityder till skiktröntgen av huvudet, att se hur väl de efterlevde riktlinjerna och hur införandet av nya riktlinjer påverkade användning av riktlinjer. Det visade sig att läkarna litade mer på sitt eget omdöme än riktlinjerna men att de ofta beställde skiktröntgen trots att de värderade risken för hjärnblödning som låg. Införandet av en ny riktlinje resulterade i en sänkning av användning från 60%-40%, trots en informationskampanj som bedrevs för att befrämja användandet av den nya riktlinjen.Delarbete 2 genomfördes som en journalgenomgång, Vi granskade journalerna för alla patienter som sökt med skallskada på en akutmottagning under ungefär 1 år. Det framgick att den vanligaste åldern var 56 år och att den vanligaste orsaken till huvudskada var fall i samma plan, precis som modern forskning på skallskada visar. En grupp som motsvarande ungefär hälften av patienterna, som alla hade fallit i samma plan och var under 59 år, befanns vara fria från hjärnblödning oavsett hur de mådde när de undersöktes på akutmottagningen. Konsekvensen av detta skulle kunna vara att man kan skriva hem betydligt fler patienter från akuten än man gör idag utan mer omfattande medicinsk undersökning och utan risk för allvarliga konsekvenser. Det fanns också indikationer på att risken för hjärnblödning om man behandlas med Trombyl 75mg var högre än om man behandlas med starkare blodförtunnande medel såsom Waran, något som traditionellt anses medföra högre risk för hjärnblödning i dessa sammanhang.Delarbete 3 gjordes på samma sätt som delarbete 2 med en journalgenomgång av alla patienter som sökt akutmottagningen för skallskada under 1 år för att testa den hypotes som framlades i delarbete 2 om att en stor grupp patienter med fall i samma plan som var under 59 år och inte tog blodförtunnande mediciner skulle kunna skickas hem utan mer omfattande medicinsk undersökning. Om dagens skandinaviska riktlinje för skallskada utökades med dessa villkor och skulle användningen av skiktröntgen minskas med 13%. Ändå skulle alla hjärnblödningar som krävde någon form av kirurgisk åtgärd upptäckas, det vill säga alla allvarliga hjärnblödningar.12Delarbete 4 och 5 genomfördes med syfte att utreda om S100B som mättes i kapillärt blod samt urin kunde användas för att utesluta hjärnblödning efter skallskada. Kapillära prover tagna på samma patient vid samma tillfälle hade mycket stor spridning och lämpade sig därför inte att använda till detta syfte. Analysmetoden för S100B i urin visade sig vara mycket pålitlig men S100B i urin hade sämre förmåga än det blodprov för S100B, som idag är standard, att utesluta hjärnblödning. Däremot visade det sig att en differens mellan standardblodprovet och urinprovet verkade ha bättre förmåga än dagens blodprov att påvisa hjärnblödning och att pH i urin förefaller påverka koncentrationen av S100B i urin.Avhandlingens slutsatser kan sammanfattas i följande punkter: Utvecklande och införande av riktlinjer måste ske på andra sätt än de traditionella om man ska få fler att efterleva dem. De riktlinjer som finns bör uppdateras med bakgrund i modernare forskning. Kapillärt S100B bör inte användas för att utesluta hjärnblödning men differensen mellan S100B mätt i blodprov från armen och i urin bör testas för att se om det kan ha bättre träffsäkerhet än något de enskilda proven har

Real-time Monitoring for the Next Core-Collapse Supernova in JUNO

Core-collapse supernova (CCSN) is one of the most energetic astrophysical events in the Universe. The early and prompt detection of neutrinos before (pre-SN) and during the SN burst is a unique opportunity to realize the multi-messenger observation of the CCSN events. In this work, we describe the monitoring concept and present the sensitivity of the system to the pre-SN and SN neutrinos at the Jiangmen Underground Neutrino Observatory (JUNO), which is a 20 kton liquid scintillator detector under construction in South China. The real-time monitoring system is designed with both the prompt monitors on the electronic board and online monitors at the data acquisition stage, in order to ensure both the alert speed and alert coverage of progenitor stars. By assuming a false alert rate of 1 per year, this monitoring system can be sensitive to the pre-SN neutrinos up to the distance of about 1.6 (0.9) kpc and SN neutrinos up to about 370 (360) kpc for a progenitor mass of 30$M_{\odot}$ for the case of normal (inverted) mass ordering. The pointing ability of the CCSN is evaluated by using the accumulated event anisotropy of the inverse beta decay interactions from pre-SN or SN neutrinos, which, along with the early alert, can play important roles for the followup multi-messenger observations of the next Galactic or nearby extragalactic CCSN.Comment: 24 pages, 9 figure

Late Campylobacter jejuni mastitis after augmentation mammoplasty

Breast implant-associated infections (BIAI) occur in approximately 2% of patients after augmentation mammoplasty. In some cases, BIAI can be treated conservatively, whereas others need implant removal. Knowledge of uncommon potential pathogens in BIAI is important to ensure optimal treatment of BIAI. In the present case report, we describe a case of bilateral late Campylobacter jejuni mastitis in a 34-year-old woman without previous symptoms of gastroenteritis. While Staphylococci are common causative pathogens in BIAI, there are numerous potential pathogens. This case highlights the importance of careful consideration of antibiotic treatment and switch to broad-spectrum antibiotic regimen in BIAI not responding to initial treatment

Cervical myoma causing colonic obstruction in the first trimester of pregnancy – a case report

A 39-year-old nulliparous woman with a previously known cervical myoma was admitted to the obstetrics department during the first trimester with complaints of severe abdominal pain, lack of bowel movements and the suspicion of a clinical bowel obstruction. Because no literature on this exact condition could be found, clinical decisions were based on reports and practice in similar situations. Ultrasound revealed the progression of a cervical myoma (previously 9 cm across), now 12 × 12 × 11 cm in size and a distended large bowel. Sigmoidoscopy excluded intraluminal obstruction. The patient was treated with oral laxatives and enema without success and her condition deteriorated. The myomatous cervix was examined vaginally (bimanual manoeuvre) with the patient under anaesthesia; however, attempts to dislodge the obstruction proved unsuccessful. After surgical consultation the patient was planned for an emergency laparoscopic sigmoidostomy. The post-operative course was uneventful and the patient discharged. She delivered a healthy child with caesarean section in gestation week 36. Bowel continuity was later laparoscopically restored in conjunction with a hysterectomy. This case illustrates the importance of active multidisciplinary management in a case of severe colonic obstruction caused by pregnancy-related obstruction in the small pelvis. In this case, colonic perforation and abortion of the fetus were both avoided

Diagnostic performance of biomarker S100B and guideline adherence in routine care of mild head trauma

Abstract Background The Scandinavian Neurotrauma Committee (SNC) has recommended the use of serum S100B as a biomarker for mild low-risk Traumatic brain injuries (TBI). This study aimed to assess the adherence to the SNC guidelines in clinical practice and the diagnostic performance of S100B in patients with TBI. The aims of this study were to examine adherence to the SNC guideline and the diagnostic accuracy of serum protein S100B. Methods Data of consecutive patients of 18 years and above who presented to the emergency department (ED) at Helsingborg Hospital with isolated head injuries, were retrieved from hospital records. Patients with multitrauma, follow-up visits, and visits managed by a nurse without physician involvement were excluded. Results A total of 1671 patients were included of which 93 (5.6%) had intracranial hemorrhage. CT scans were performed in 62% of patients. S100B was measured in 26% of patients and 30% of all measurements targeted the low-risk mild head injuries indicated by the guideline. S100B's recommended cut-off value (≥ 0.10 µg/L) had a 100% sensitivity, 47% specificity, 10.1% positive predictive value, and 100% negative predictive value—if applied to the target SNC category (SNC 4). If applied to all patients tested, the sensitivity was 93% for traumatic intracranial hemorrhage (TICH). Current ED practices were adherent to the SNC guideline in 55% of patients. Non-adherent practices occurred in 64% of patients with low-risk mild head injuries (SNC4) including overtesting or undertesting of S100B and CT scans. Conclusion Adherence to guidelines was low and associated with a higher admission rate than non-adherence practice but no significant increase in missed TICH or death associated with non-adherence to guideline was found. In routine care, we found that the sensitivity and NPV of serum protein S100B was excellent and safely ruled out TICH when measured in the patient category recommended by the guideline. However, measuring serum protein S100B in patients not recommended by the guideline rendered unacceptably low sensitivity with possible missed TICHs as a consequence. To further delineate the magnitude and impact of non-adherence, more studies are needed

Application of NICE or SNC guidelines may reduce the need for computerized tomographies in patients with mild traumatic brain injury : A retrospective chart review and theoretical application of five guidelines

Background: Traumatic brain injuries continue to be a significant cause of mortality and morbidity worldwide. Most traumatic brain injuries are classified as mild, with a low but not negligible risk of intracranial hemorrhage. To help physicians decide which patients might benefit from a computerized tomography (CT) of the head to rule out intracranial hemorrhage, several clinical decision rules have been developed and proven effective in reducing the amount of negative CTs, but they have not been compared against one another in the same cohort as to which one demonstrates the best performance. Methods: This study involved a retrospective review of the medical records of patients seeking care between January 1 and December 31, 2017 at Helsingborg Hospital, Sweden after head trauma. The Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), the National Emergency X-Radiography Utilization Study II (NEXUS II), the National Institute of Health and Care Excellence (NICE) guideline and the Scandinavian Neurotrauma Committee (SNC) guideline were analyzed. A theoretical model for each guideline was constructed and applied to the cohort to yield a theoretical CT-rate for each guideline. Performance parameters were calculated and compared. Results: One thousand three hundred fifty-three patients were included; 825 (61%) CTs were performed, and 70 (5.2%) cases of intracranial hemorrhage were found. The CCHR and the NOC were applicable to a minority of the patients, while the NEXUS II, the NICE, and the SNC guidelines were applicable to the entire cohort. A theoretical application of the NICE and the SNC guidelines would have reduced the number of CT scans by 17 and 9% (P = < 0.0001), respectively, without missing patients with intracranial hemorrhages requiring neurosurgical intervention. Conclusion: A broad application of either NICE or the SNC guidelines could potentially reduce the number of CT scans in patients suffering from mTBI in a Scandinavian setting, while the other guidelines seemed to increase the CT frequency. The sensitivity for intracranial hemorrhage was lower than in previous studies for all guidelines, but no fatality or need for neurosurgical intervention was missed by any guideline when they were applicable

Delayed intracranial hemorrhage after head trauma seems rare and rarely needs intervention—even in antiplatelet or anticoagulation therapy

Abstract Background Traumatic brain injury causes morbidity, mortality, and at least 2,500,000 yearly emergency department visits in the USA. Computerized tomography of the head is the gold standard to detect traumatic intracranial hemorrhage. Some are not diagnosed at the first scan, and they are denoted “delayed intracranial hemorrhages. ” To detect these delayed hemorrhages, current guidelines for head trauma recommend observation and/or rescanning for patients on anticoagulation therapy but not for patients on antiplatelet therapy. The aim of this study was to investigate the prevalence and need for interventions of delayed intracranial hemorrhage after head trauma. Methods The study was a retrospective review of medical records of adult patients with isolated head trauma presenting at Helsingborg General Hospital between January 1, 2020, and December 31, 2020. Univariate statistical analyses were performed. Results In total, 1627 patients were included and four (0.25%, 95% confidence interval 0.06–0.60%) patients had delayed intracranial hemorrhage. One of these patients was diagnosed within 24 h and three within 2–30 days. The patient was diagnosed within 24 h, and one of the patients diagnosed within 2–30 days was on antiplatelet therapy. None of these four patients was prescribed anticoagulation therapy, and no intensive care, no neurosurgical operations, or deaths were recorded. Conclusion Traumatic delayed intracranial hemorrhage is rare and consequences mild and antiplatelet and anticoagulation therapy might confer similar risk. Because serious complications appear rare, observing, and/or rescanning all patients with either of these medications can be debated. Risk stratification of these patients might have the potential to identify the patients at risk while safely reducing observation times and rescanning

Management of Traumatic Brain Injury in the Emergency Department : Guideline Adherence and Patient Safety

Background: Traumatic brain injury is a common reason not only for emergency visits worldwide but also for significant morbidity and mortality. Several clinical guidelines exist but adherence is generally low. Aim: To study attitudes toward computed tomography of the head among emergency department Change to physicians throughout the article who manage patients with trauma to the head and doctors' adherence to guidelines. Methods: Quantitative questionnaire study with questionnaires collected over 3 months before introduction of new guidelines. After introduction, intermission of 8 months passed when information and education were given. Thereafter, questionnaires were collected for another 3 months. Results: A total of 694 patients were registered at the emergency department. A total of 161 questionnaires were analyzed; 50.9% did not use guidelines, 39% before intermission, and 60.5% after. When Canadian CT Head Rule was applied, 30.4% of patients with no loss of consciousness were referred to computed tomography, violating guideline recommendation. Conclusion: Guidelines are designed to improve performance but are not always applied correctly or as frequently as intended. Information and education did not increase guideline adherence. To improve guideline adherence, more innovative measures than formal guidelines must be undertaken. To find out what these measures are, we suggest qualitative studies to elucidate interventions that will have bigger impact on performance

Ways to improve guideline adherence in the emergency department: an interview study on the management of traumatic brain injuries

PurposeThe aim was to explore factors affecting guideline adherence among doctors in the emergency department and to explore the general perception about local guidelines for traumatic brain injuries.MethodsThirty semi-structured interviews were conducted with doctors with experience working in the emergency department regarding different aspects of guideline use, with emphasis on the management of traumatic brain injuries. Twenty-eight interviews were included for analysis. The interviews were recorded, transcribed, and analysed iteratively. Emergent codes were identified and organised into themes and subthemes.ResultsEight themes were identified. Barriers were centred on low availability of local guidelines and guideline document design. Facilitating factors included a concise document, appropriate visual aids, high accessibility, and encouragement by management and senior peers. The local guidelines on traumatic brain injuries were regarded as distinct, but it was occasionally difficult to determine when they were applicable. Mandatory admission of patients on anticoagulants was sometimes perceived as excessive. Biomarker S100b was believed to sometimes lead to delayed care.ConclusionThe participants believed that guideline adherence would increase by facilitating guideline availability, by providing concise, easy-to-understand, and well-illustrated guidelines available in printed form, as well as establishing a culture that promotes guideline use. The local guidelines for traumatic brain injuries were appreciated, but could be improved

Prospective comparison of capillary and venous brain biomarker S100B : Capillary samples have large inter-sample variation and poor correlation with venous samples

Background: Guidelines for the emergency management of mild traumatic brain injury have been used for over a decade and are considered safe. However, they recommend computerized tomography for at least half of these patients. The Scandinavian Neurotrauma Committee guideline uses serum S100B protein level to rule out intracranial hemorrhage. Analysis of capillary serum S100B protein level has not yet been employed for this purpose. The primary aim of this study was to investigate the correlation and agreement of capillary and venous serum S100B protein level over a spectrum of concentrations typical for mild traumatic brain injury. Methods: Eighteen patients with traumatic intracranial hemorrhage and 39 volunteers without trauma to the head within the past 7 days were recruited. Blood was sampled from patients with intracranial hemorrhage daily up to four consecutive days and healthy volunteers were sampled once during the study. One venous and two capillary samples were drawn at each sampling event. Samples were analyzed using the Cobas e411 S100 electrochemiluminescence assay. Results: Median serum S100B protein level of capillary sampling 1 was 0.12 (IQR 0.075-0.21) μg/l and median serum S100B protein level of capillary sampling 2 was 0.13 (IQR 0.08-0.22) μg/l. Median serum S100B protein level of all venous samples was 0.05 (IQR 0.03-0.07) μg/l. Correlation plots of capillary and venous samples showed poor correlation and Bland-Altman plots showed a large dispersion of samples and wide limits of agreement. Conclusion: The results of this study indicate that correlation and agreement between capillary and venous samples are low, and because of this, we cannot recommend studies on capillary serum S100B protein level to rule out intracranial hemorrhage in mild traumatic brain injury. Given the limitations of the current sampling and analysis methods of capillary protein S100B protein level, we conclude that evaluating its predictive ability to rule out intracranial hemorrhage should be withheld until more reliable methods can be incorporated into the study design