Ashok Munivenkatappa

Traumatic brain injury: Does gender influence outcomes?

Background: Traumatic brain injury (TBI) is a major public health problem. Both genders are affected, but little is known about female TBI. The present study exclusively explores epidemiological, clinical, imaging, and death aspects of female TBI, and how it differs from males. Methods: It is a retrospective study. Data were documented from a tertiary institute during January 2010 to March 2010. All variables were documented on standard proforma. The data were analyzed using R statistics software. Age group was categorized into pediatric (<18 years), middle (19–60 years) and elderly (>61 years). Significance was tested using Chi-square test at the significance level ofP< 0.05. Results: Data of 1627 TBI patients were recorded. Of the total, female TBIs contributed nearly 20%. Compared to males, female patients reported higher percentages in manifesting symptoms (84.3% vs. 82.6%), injuries due to fall (32.1% vs. 24.4%), and surgical interventions (11.6% vs. 10.4%). Female patients were significantly higher in mild head injury group (76.8% vs. 69.5%, P - 0.016) and mortality (3.4% vs. 1.6%, P - 0.048). Number of patients and deaths was more among females than males in pediatric and elderly age group. Severities of injuries were more among female patients than male patients in middle and elder age groups. Conclusion: The study results observe that female TBI group differ significantly in the severity of injury and mortality.

Clinical predictors of abnormal head computed tomography scan in patients who are conscious after head injury

Background: Indication of a head computed tomography (CT) scan in a patient who remains conscious after head injury is controversial. We aimed to determine the clinical features that are most likely to be associated with abnormal CT scan in patients with a history of head injury, and who are conscious at the time of presentation to casualty. Materials and Methods: This is a prospective observation study of patients presented to casualty with history of head injury, and who were conscious, i.e., Glasgow Coma Scale (GCS) 15 at the time of evaluation. All patients underwent head CT scan. The CT scan was reported as abnormal if it showed any pathology ascribed to trauma. The following variables were used: age, gender, mode of injury (road traffic accident, fall, assault, and others), duration since injury, and history of transient loss of consciousness, headache, vomiting, ear/nose bleeding, and seizures. Logistic regression analysis was used to identify the clinical features that predicted an abnormal CT scan. Results: During the observation period, a total of 1629 patients with head injury were evaluated, out of which 453 were in GCS 15. Abnormal CT scan was present in 195 (43%) patients. Among all the variables, the following were found significantly associated with abnormal CT scan: duration since injury (>12 h) P < 0.001; vomiting odds, ratio (OR) 1.89 (1.23, 2.80), P < 0.001; and presence of any symptom, OR 2.36 (1.52, 3.71), P < 0.001. Conclusion: A patient with GCS 15 presenting after 12 hours of injury with vomiting or combination of symptoms has a significant risk of abnormal head CT scan.

Pattern of reporting and practices for the management of traumatic brain injury: An overview of published literature from India

Background: Published literature regarding the demographics and mechanism of injury for traumatic brain injury (TBI) in India has not been analyzed in an organized sample. Objectives: The objective of this systematic review was to organize the published literature from India related to TBI and analyze it in a very specific sample to identify the specific patterns of injury and associated mortality. Materials and Methods: A search strategy with specific inclusion criteria was performed in PubMed, Cochrane, Web of Science, and the World Health Organisation (WHO) Global Health Library. The process included an additional search within the indexed literature and the website-based population survey reports. Results: Our review identified 72 studies from 300 potentially relevant articles based on the broad criteria that defined the demographics of the patients suffering from TBI and the details of trauma sustained, including the mechanism of injury as well as its diagnosis, management, and outcome. Changes in demographic patterns, the patterns of the body regions involved, the associated injuries, the clinical presentation, the follow-up status of patients suffering from TBI, who may or may not have shown clinical improvement, the overall outcome, as well as the mortality and disability status reported in the literature were analyzed. A high incidence of TBI in the productive population is of serious concern. Extremes of ages are more vulnerable to severe injury and a poor outcome. Conclusion: Quantitative analysis of injuries and outcomes of TBI victims shows a bigger health impact in the economically active population and in patients in the extremes of age groups.

Distribution of Laboratory Parameters in Trauma Population

Background: Biochemical laboratory investigations help plan optimum management and communication in short- as well as long-term outcome to trauma victims. Objective: To assess the status of real-time values of biochemical laboratory investigations of different trauma patients and their association with overall mortality. Materials and Methods: Data based on prospective, observational registry of “Towards Improved Trauma Care Outcomes” (TITCO) from four Indian city hospitals. Hemoglobin, hematocrit, random blood sugar, blood urea nitrogen (BUN), and serum creatinine of patients on admission were recorded. Logistic regression was applied with all biochemical investigation as independent variable and overall mortality as dependent variable. Results: Among 17047 trauma patients, 3456 with available laboratory result details were considered for this study. Overall mortality was 20% (range 14%–21%). For the higher laboratory results, value mortality was 21%–70%, with highest death (70%) for higher hemoglobin patients, followed by hematocrit (44%) and then creatinine (43%). Odds of high hemoglobin compared to normal were 15.20; odds of higher and lower of normal creatinine were 3.80 and 1.65 and for BUN were 2.17 and 1.92, respectively. Gender-wise significant difference was in overall female mortality (29%)% compared males (18%). Similar differences were replicated with results of each laboratory tests. Conclusion: The study ascertained the composite additional explanatory values of laboratory parameters in predicting outcome among injured patients in our population from Indian settings.

Epidemiological characteristics affecting outcome in traumatic brain injury

Background: Traumatic brain injury (TBI) is affected by multiple injury factors. Geography and vehicle prone to the accident may have an important role on the outcome. Aims: This study aims to study the details of place and mechanism of injury and their effect on discharge outcome. Settings and Design: Prospective study. Methods: This is a prospective study where 337 patients diagnosed with TBI were selected from an emergency department, after obtaining their consent. The details of place and cause of injury data was recorded on standard proforma using FileMaker Pro Advanced 13 software. Statistical Analysis: The data were analyzed using Stats Direct version 3.0.150. Results: The study reports that age, gender, and severity of the injury as per Glasgow coma scale was significant with the outcome at discharge. Higher number of patients was from rural setup (72.6%). Roadside accidents account for about 56% of injuries. About 77% of injuries were due to accidents. Two-wheeler was cause for accidents in 54% of injuries. Mechanism of injury like motor vehicle accident, fall, blunt, and the penetrating injury was significant with discharge outcome. Conclusion: The study addresses that majority of TBI patients are from rural areas and injuries are due to accidents. Mechanism of injury has significance with discharge outcome.

On-admission blood pressure and pulse rate in trauma patients and their correlation with mortality: Cushing's phenomenon revisited

Background: Injury-induced alteration in initial physiological responses such as hypertension and heart rate (HR) has a significant effect on mortality. Research on such associations from our country-India is limited. The present study investigates the injury-induced early blood pressure (BP) and HR changes and their association with mortality. Materials and Methods: The data were selected from Towards Improved Trauma Care Outcomes collected from October 1, 2013, to July 24, 2014. Patients above 18 years of age with documented systolic BP (SBP) and HR were selected. BP was categorized into hypotension (SBP <90 mmHg), hypertension (SBP >140 mmHg), and normal (SBP 90–140 mmHg). HR was categorized into bradycardia (HR <60 beats/min [bpm]), tachycardia (HR >100 bpm), and normal (HR 60–100 bpm). These categories were compared with mortality. Results: A total of 10,200 patients were considered for the study. Mortality rate was 24%. Mortality among females was more than males. Patients with normal BP and HR had 20% of mortality. Mortality in patients with abnormal BP and HR findings was 36%. Mortality was higher among hypotension-bradycardia patients (80%) followed by hypertension-bradycardia patients (58%) and tachycardia hypotension patients (48%). Elderly patients were at higher risk of deaths with an overall mortality of 35% compared to 23% of adults. Conclusion: The study reports that initial combination of hypotension-bradycardia had higher mortality rate. Specific precautions in prehospital care should be given to trauma patients with these findings. Further prospective study in detail should be considered for exploring this abnormality.

Time of admission and outcome in traumatic brain injury patients

Introduction: In spite of heterogeneous manifestation of traumatic brain injury (TBI), it is affected by multiple factors at the time of admission. This pilot study aims to detect the effect of admission time, day, and month with outcome at discharge, among patients with TBI. Materials and Methods: It is a prospective study conducted in the Department of Neurosurgery at Narayana Medical Health Hospital, Nellore. The head injury patient data were documented on a standard proforma. FileMaker Pro Advanced 13 was used for electronic data entry interface. The analysis was done using Stats Direct version 3.0.150. The variables in categories and continuous were evaluated with descriptive and frequencies, respectively. Results: In the study, 337 head injury patients were reported with 7.12% (n = 24) mortality. The hospital discharge outcome was significant with age, gender, severity of injury, and seasons. More number of patients were admitted during 9 pm to 7 am, but was not significant. During all the seasons of a year, there was significance with admittance of head injury patients in working days of a week and patients undergoing intracranial surgery. Conclusion: The pilot study reports that the outcome at discharge of a head injury patient has significance with admission at week, day, and season.

Predicting outcome in traumatic brain injury: Sharing experience of pilot traumatic brain injury registry.

Background: A reliable prediction of outcome for the victims of traumatic brain injury (TBI) on admission is possible from concurrent data analysis from any systematic real-time registry. Objective: To determine the clinical relevance of the findings from our TBI registry to develop prognostic futuristic models with readily available traditional and novel predictors. Materials and Methods: Prospectively collected data using predesigned pro forma were analyzed from the first phase of a trauma registry from a South Indian Trauma Centre, compatible with computerized management system at electronic data entry and web data entry interface on demographics, clinical, management, and discharge status. Statistical Analysis: On univariate analysis, the variables with P < 0.15 were chosen for binary logistic model. On regression model, variables were selected with test of coefficient 0.001 and with Nagelkerke R 2 with alpha error of 5%. Results: From 337 cases, predominantly males from rural areas in their productive age, road traffic injuries accounted for two-thirds cases, one-fourths occurred during postmonsoon while two-wheeler was the most common prerequisite. Fifty percent of patients had moderate to severe brain injury; the most common finding was unconsciousness followed by vomiting, ear bleed, seizures, and traumatic amnesia. Fifteen percent required intracranial surgery. Patients with severe Glasgow coma scale score were 4.5 times likely to have the fatal outcome (P = 0.003). Other important clinical variables accountable for fatal outcomes were oral bleeds and cervical spine injury while imperative socio-demographic risk correlates were age and seasons. Conclusion: TBI registry helped us finding predictors of clinical relevance for the outcomes in victims of TBI in search of prognostic futuristic models in TBI victims.