Walter Mauritz

Serum S 100 B: A marker of brain damage in traumatic brain injury with and without multiple trauma

This prospective clinical study was conducted to determine whether S 100 B is a reliable serum marker for traumatic brain injury (TBI) with and without multiple trauma. Fifty-five trauma patients (Injury Severity Score [ISS] ≥24 and Glasgow Coma Score [GCS] ≤8) were classified by radiography, computer tomography, ultrasound, and neurology as TBI without multiple trauma (n = 23), TBI with multiple trauma (n = 23), or multiple trauma without TBI (n = 9). S 100 B was measured initially after trauma and daily for a maximum of 21 days. Both survivors and nonsurvivors had markedly increased S 100 B initially. All survivors returned to normal or moderately increased S 100 B levels within the first 48 h after trauma. In contrast, all nonsurvivors of isolated TBI had S 100 B values that either increased consistently or dropped and then increased again 48 h after the initial increase after trauma. There was no relationship between localization, extent, or severity of TBI and S 100 B. According to receiver operating characteristic curve analysis and calculation of the area under the curve (AUC), S 100 B is equally accurate for mortality prediction at 24, 48, and 72 h after trauma and is most accurate >84 h after trauma. Sensitivity/specificity for mortality prediction are more accurate in TBI without multiple trauma (AUC 0.802–0.971) than in TBI with multiple trauma (AUC 0.693–0.783). Thus, though S 100 B may be a reliable marker of brain damage in TBI without multiple trauma 24 h after trauma and thereafter, it appears to be less reliable in TBI with multiple trauma.

Severe Traumatic Brain Injury in Austria II: Epidemiology of hospital admissions

ZusammenfassungZIELE: Das Ziel der vorliegenden Arbeit ist es, anhand von Spitalsaufnahmen die Epidemiologie von Patienten mit schwerem Schädelhirntrauma (SHT) darzustellen. PATIENTEN UND METHODEN: Es standen Datensätze von 492 Patienten zur Verfügung, die von 5 österreichischen Zentren in die Studie inkludiert worden waren. Alters- und Geschlechtsverteilung, Ausbildung, Beruf, Unfallort und-mechanismus, Alkoholisierung, Art und Schweregrad des Traumas, Begleitverletzungen, sowie Dauer und Ergebnis der Intensivbehandlung wurden für jedes der beteiligten Zentren evaluiert. ERGEBNISSE: Die Stichprobe repräsentiert ungefähr 13% aller Fälle von schwerem SHT, welche während des Studienzeitraums in österreichischen Spitälern behandeltwurden. Das mittlere Alter betrug 48 ± 21 Jahre, und die Mehrzahl (72%) der Patienten war männlich. Die Unfälle ereigneten sich am häufigsten auf der Straße (50%), zu Hause (44%), in freier Natur (10%) und am Arbeitsplatz (7%). Verkehrsunfall (44%), Sturz (< 3 m; 30%), Fall (> 3 m; 11%) und Sportunfall (5%) waren die häufigsten Ursachen. Unter den Verkehrsunfällen waren Autolenker und -beifahrer am häufigsten (45%) betroffen, gefolgt von Fußgängern (20%), Motorradfahrern (19%) und Radfahrern (16%). Für die meisten der untersuchten Variablen fanden sich signifikante Unterschiede zwischen den Zentren. Das SHT war in 10% mit einer Rückenmarksverletzung und in 38% mit anderen schweren Verletzungen kombiniert. Die Intensivstations-Mortalität betrug 31,7%. Zwischen Unfallmechanismus und Verletzungsschwere oder Behandlungsergebnis fanden sich keine signifikanten Korrelationen. SCHLUSSFOLGERUNGEN: Die Epidemiologie des schweren SHT in Österreich ist nicht sehr verschieden von der in anderen Industrieländern. Die häufigste Ursache ist der Verkehrsunfall, was die Bedeutung der Verhütung dieser Unfälle aufzeigt. Die spezifischen Risken Älterer und die Verhütung von Unfällen im häuslichen Bereich verdienen besondere Beachtung.SummaryOBJECTIVES: The goal of this paper is to describe the hospital-based epidemiology of severe TBI in Austria. PATIENTS AND METHODS: Data sets from 492 patients included in the study by 5 Austrian hospitals were available. Age and gender distribution, education, occupation, location of trauma, mechanism of injury, alcohol use, type and severity of injury, associated injuries, length of intensive care unit stay, and intensive care unit outcome were evaluated for each of the 5 centers. RESULTS: The sample represents roughly 13% of all cases with severe TBI which were treated in Austrian hospitals during the study period. Mean age was 48 ± 21 years, and most patients were male (72%). The most important trauma locations were roads (50%), home (24%), outdoors (10%), and workplace (7%). Transportrelated trauma was the most important mechanism (44%) followed by falls < 3 m (30%), falls > 3 m (11%), and sports injuries (5%). Detailed analysis of transport-related trauma showed that car accidents (45%) were most common, followed by pedestrian (20%), motorbike (19%), and bicycle (16%) accidents. Significant differences between the centers were found for most of the variables analyzed. The severe traumatic brain injury was associated with spinal cord injury in 10%, and with severe multiple trauma in 38% of cases. Intensive care mortality was 31.7%. There were no significant correlations between mechanisms of injury and severity of trauma, nor between mechanisms and ICU outcome. CONCLUSIONS: Epidemiology of severe traumatic brain injuries in Austria is not much different from other industrialized countries. Traffic accidents are responsible for the majority of traumas, stressing the importance of road injury prevention. Attention should also be paid to the specific risks of older people and to prevent injuries at home.

Acute acalculous cholecystitis after trauma: a prospective study.

OBJECTIVE The purpose of this study was to identify risk factors for the development of acute acalculous cholecystitis (AAC) and useful criteria to facilitate the decision to perform cholecystectomy. METHODS This was a prospective study of patients with an Injury Severity Score (ISS) > or = 12 requiring intensive care for > 4 days (n = 255), divided into three groups by ultrasound: AAC (n = 27), hydropic gallbladder (n = 37), and normal gallbladder (n = 191). Multivariate analysis was conducted for trauma scores and laboratory and intensive care unit (ICU) data and complemented by logistic regression analysis. RESULTS Three factors sufficiently define the risk for AAC: ISS, heart rate, and units of packed red blood cells required at ICU admission. All patients who underwent cholecystectomy (n = 21) had both highly pathologic ultrasound and major clinical symptoms, and all had histologically verified AAC. There was no significant difference in daily laboratory data between patients with and without AAC. CONCLUSION Patients with a high ISS who are tachycardic and have required several units of packed red blood cells at ICU admission should be monitored early by ultrasound. When ultrasound is highly pathologic together with major clinical symptoms, cholecystectomy should be performed. Daily laboratory data are of no additional value regarding the decision to perform cholecystectomy.

Severe Traumatic Brain Injury in Austria V: CT findings and surgical management

ZusammenfassungZIEL: Das Ziel dieser Arbeit ist es, CT-Befunde und chirurgisches Management von Patienten mit schwerem Schädel-Hirn-Trauma (SHT) in Österreich darzustellen. PATIENTEN UND METHODEN: Es standen Datensätze von 415 Patienten zur Verfügung, die von 5 österreichischen Zentren in die Studie inkludiert worden waren. Analysiert wurden Inzidenz, chirurgisches Management und Behandlungsergebnis unterschiedlicher intrakranieller Läsionen, sowie das Behandlungsergebnis von Patienten mit/ohne chirurgischer Intervention und mit/ohne Hirndruckmessung. Für die erste Analyse wurde die Patienten je nach dem CT-Befund insgesamt 16 Gruppen zugeordnet. Für die zweite Fragestellung wurden die Patienten in 4 Gruppen (mit/ohne Operation jeweils mit/ohne Hirndruckmessung) eingeteilt. RESULTS: Das mittlere Alter betrug 48,9 Jahre; das Verhältnis von Männern zu Frauen betrug 299:116. Die häufigstenisolierten Läsionen waren Kontusionen (CONT) und diffuses Ödem. Kombinierte Läsionen waren viel häufiger; die häufigsten Kombinationen waren CONT plus Subarachnoidalblutung (SAH) mit und ohne Subduralhämatom (SDH). 276 (66,5%) Patienten wurden operativ behandelt. Osteoplastistische Operationen (OPS; n = 221) wurden häufiger durchgeführt als osteoklastische (OCS; n = 91) und dekompressive Eingriffe (DEC; n = 15). Die Intensivstations(ICU)-Mortalität betrug 29,7% für operativ versorgte Patienten; bei konservativ behandelten Patienten lag diese etwas höher (33,1%). Die ICU-Mortalität von Patienten mit SDH war nach OCS niedriger (18,8%) als nach OPS (36,0%). Patienten die eine Hirndruckmessung erhielten, jedoch keine sonstige chirurgische Therapie benötigten, hatten die niedrigste 90-Tage Mortalität (17,5%). SCHLUSSFOLGERUNGEN: Hirndruckmessung scheint sowohl chirurgisch versorgten wie auch konservativ behandelten Patienten Vorteile zu bringen. Bei Patienten mit SDH, die operativ versorgt wurden, fand sich ein signifikant besseres Ergebnis. Bei Patienten mit SDH war das Ergebnis nach osteoklastischer Operation signifikant besser als nach osteoplastischer Operation.SummaryOBJECTIVES: The aim of this paper is to describe CT findings and surgical management of patients with severe traumatic brain injury (TBI) in Austria. PATIENTS AND METHODS: Data sets from 415 patients treated by 5 Austrian hospitals were available. The analysis focused on incidence, surgical management, and outcome of different types of intracranial lesions, and outcome of surgical interventions with and without monitoring of intracranial pressure (ICP). For the first analysis we assigned the patients to 16 groups based on the type of lesion as evaluated by CT scan. For the second analysis we created 4 groups based on surgical treatment (yes/no) and ICP monitoring (yes/no). RESULTS: The mean age was 48.9 years with a male to female ratio of 299:116. The most frequent single lesions were contusions (CONT) and diffuse brain edema. Combined lesions were far more common than single lesions; the most frequently observed combinations included CONT and subarachnoid hemorrhage (SAH) with or without subdural hematoma (SDH). Surgery was done in 276 (66.5%) patients. Osteoplastic surgery (OPS; n = 221) was the most common method followed by osteoclastic surgery (OCS; n = 91) and decompressive craniectomy (DEC; n = 15). ICU mortality was 29.7% for all patients who had any kind of surgery, which was lower than that of patients who were treated non-operatively (33.1%). The ICU mortality of patients with SDH was lower with OCS (18.8%) than with OPS (36.0%). Patients who received ICP monitoring but did not require surgery had the lowest 90 day mortality (17.5%). CONCLUSIONS: ICP monitoring seems to be beneficial in both operatively and non-operatively treated patients with severe TBI. Patients with SDH who were operated on had significantly better outcomes. In patients with SDH, their outcome after osteoclastic surgery was significantly better than after osteoplastic procedures.

Severity and outcome of traumatic brain injuries (TBI) with different causes of injury

Introduction: Most epidemiological studies and reports have reached a consensus on the leading causes of traumatic brain injury (TBI). Despite the fact that the area of TBI is relatively well studied, reports on differences in severity and outcome of TBI with different causes are lacking. Goal: This paper analyses the differences in severity and in short- and long-term outcome of TBIs with different causes. Method: This study analysed data on 1109 patients with severe TBI by dividing them into three injury-cause groups: ‘traffic-related’, ‘falls’ and ‘other causes’. Severity and outcome was evaluated using chosen direct and indirect indicators. Results: The most severe trauma occurred in the traffic-related group followed by falls and injuries with other causes. On the other hand, patients with traffic-related TBI had the best outcome. Age improves the outcome in the traffic-related group significantly. However, in the multivariate analysis after adjusting for age (and other important predictors including level of care) the odds for favourable long-term outcome stayed significantly higher in the traffic-related group. Conclusions: It is concluded that the causes of TBI should be considered by both clinicians and public health professionals as a lead in prognosis of outcome and policy planning.

Glasgow Coma Scale Motor Score and Pupillary Reaction To Predict Six-Month Mortality in Patients with Traumatic Brain Injury: Comparison of Field and Admission Assessment

The Glasgow Coma Scale (GCS) and pupillary reactivity are well-known prognostic factors in traumatic brain injury (TBI). The aim of this study was to compare the GCS motor score and pupillary reactivity assessed in the field and at hospital admission and assess their prognostic value for 6-month mortality in patients with moderate or severe TBI. We studied 445 patients with moderate or severe TBI from Austria enrolled to hospital in 2009-2012. The area under the curve (AUC) and Nagelkerkes R(2) were used to evaluate the predictive ability of GCS motor score and pupillary reactivity assessed in the field and at admission. Uni- and multi-variable analyses-adjusting for age, other clinical, and computed tomography findings-were performed using combinations of field and admission GCS motor score and pupillary reactivity. Motor scores generally deteriorated from the field to admission, whereas pupillary reactivity was similar. GCS motor score assessed in field (AUC=0.754; R(2)=0.273) and pupillary assessment at admission (AUC=0.662; R(2)=0.214) performed best as predictors of 6-month mortality in the univariate analysis. This combination also showed best performance in the adjusted analyses (AUC=0.876; R(2)=0.508), but the performance of both predictors assessed at admission was not much worse (AUC=0.857; R(2)=0.460). Field GCS motor score and pupillary reactivity at hospital admission, compared to other combinations of these parameters, possess the best prognostic value to predict 6-month mortality in patients with moderate-to-severe TBI. Given that differences in prognostic performance are only small, both the field and admission values of GCS motor score and pupillary reaction may be reasonable to use in multi-variable prediction models to predict 6-month outcome.

Epidemiology of traumatic brain injury in Austria

SummaryBackgroundTraumatic brain injury (TBI) is an important cause of preventable deaths. The goal of this study was to provide data on epidemiology of TBI in Austria.MethodsData on all hospital discharges, outpatients, and extra- as well as in-hospital deaths due to TBI were collected from various sources for the years 2009–2011. Population data (number of male/female people per age-group, population of Austrian cities, towns, and villages) for 2009–2011 were collected from the national statistical office. Incidence, case fatality rate(s) (CFR), and mortality rate(s) (MR) were calculated for the whole population and for age groups.ResultsIncidence (303/100,000/year), CFR (3.6 %), and MR (11/100,000/year) of TBI in Austria are comparable with those from other European countries. We found a high rate of geriatric TBI. The ratio between male and female cases was 1.4:1 for all cases, and was 2.2:1 for fatal cases. The most common mechanism was falls; traffic accidents accounted for only 7 % of the cases. Males died more frequently from traffic accidents and suicides, and females died more frequently from falls. CFRs and MRs increased with increasing age. CFRs were higher in patients from less populated areas, and MRs were lower in cases who lived closer to hospitals that admitted TBI.ConclusionsThe high rate of geriatric TBI warrants better prevention of falls in this age group.ZusammenfassungZiel der StudieSchädelhirntraumen (SHT) sind eine relevante Ursache von potentiell verhinderbaren Todesfällen. Das Ziel der Studie war, Daten zur Epidemiologie des SHT in Österreich zu erheben.MethodikAngaben zu SHT-bedingten Spitalaufnahmen und Ambulanzbesuchen sowie zu präklinischen und innerklinischen Todesfällen für die Jahre 2009–2011 wurden von verschiedenen Institutionen zur Verfügung gestellt. Angaben zur Bevölkerung (Geschlechtsverteilung, Altersgruppen, Einwohnerzahlen der österreichischen Gemeinden) der Jahre 2009–2011wurden von der Webseite der „Statistik Austria“ heruntergeladen. Inzidenz, Letalität, und Mortalität wurden für die gesamte Population sowie für Altersgruppen errechnet.ErgebnisseInzidenz (303/100.000/Jahr), Letalität (3,6 %), und Mortalität (11/100.000/Jahr) des SHT in Österreich entsprechen den Werten, die für andere europäische Länder erhoben wurden. Auffällig war die hohe Anzahl von geriatrischen SHT-Fällen. Das Verhältnis zwischen männlichen und weiblichen Fällen betrug 1,4:1 insgesamt, und betrug 2,2:1 in Fällen mit letalem Ausgang. Der häufigste Unfallmechanismus war Fall/Sturz; Verkehrsunfälle machten nur 7 % der Fälle aus. Männer verstarben häufiger durch Verkehrsunfälle und Selbstmorde, Frauen verstarben häufiger durch Fall/Sturz. Letalität und Mortalität nahmen mit zunehmendem Alter zu. Die Letalität war höher bei Patienten aus Regionen mit geringer Bevölkerungsdichte. In Regionen mit einem Krankenhaus, das SHT-Fälle versorgt, war die Mortalität niedriger als in Regionen ohne solches.SchlussfolgerungenDie hohe Rate an SHT-Fällen durch Fall/Sturz bei geriatrischen Patienten legt nahe, dass hier Präventionsmaßnahmen dringend erforderlich sind.

Barbiturates Use and Its Effects in Patients with Severe Traumatic Brain Injury in Five European Countries

The guidelines for management of traumatic brain injury (TBI) recommend that high-dose barbiturate therapy may be considered to lower intracranial pressure (ICP) that is refractory to other therapeutic options. Lower doses of barbiturates may be used for sedation of patients with TBI, although there is no mention of this in the published guidelines. The goal of this study was to analyze the use of barbiturates in patients with severe TBI in the European centers where the International Neurotrauma Research Organization introduced guideline-based TBI management and to analyze the effects of barbiturates on ICP, use of vasopressors, and short- and long-term outcome of these patients. Data on 1172 patients with severe TBI were collected in 13 centers located in five European countries. Patients were categorized into three groups based on doses of barbiturates administered during treatment. Univariate and multivariate statistical methods were used to analyze the effects of barbiturates on the outcome of patients. Fewer than 20% of all patients with severe TBI were given barbiturates overall, and only 6% was given high doses. High-dose barbiturate treatment caused a decrease in ICP in 69% of patients but also caused hemodynamic instability leading to longer periods of mean arterial pressure <70 mm Hg despite increased use of high doses of vasopressors. The adjusted analysis showed no significant effect on outcome on any stage after injury.Thiopental and methohexital were equally effective. Low doses of thiopental and methohexital were used for sedation of patients without side effects. Phenobarbital was probably used for prophylaxis of post-traumatic seizures.

Maßnahmen durch Ersthelfer am Unfallort Eine prospektive, epidemiologische Studie im Raum Wien

SummaryThe object of this prospective, epidemiological study was to determine whether bystanders provided necessary first aid measures in the prehospital trauma setting, whether they performed these measures correctly, and whether the level of first aid training affected the quality of first aid measures performed. Data were collected by means of a questionnaire, which was filled out between March and July 2000 for all cases attended to by the Vienna Ambulance Service. A total of 2812 cases were documented. The most frequent causes of trauma were falls from heights less than 1 meter (50%) and traffic accidents (17%). The most frequent injuries were injuries to the extremities (59%) and head and traumatic brain injuries (42%). Most patients were “moderately” or “severely” injured (69% and 29%,. respectively), but life-threatening injuries were rare (2%). Bystanders were present in 57% of the cases. The most frequently required first aid measures were “application of a dressing” and “positioning” of the patient, “Control of haemorrhage”, “ensuring accident site safety” and “extrication” of the patient were less frequently required. “Clearing of the airway”, “precautions against hypothermia” and cardio-pulmonary resuscitation were very rarely required. Bystanders were most frequently policemen, relatives or friends of the patient, and strangers. The vast majority of bystanders had no training in first aid or had only attended the first aid course required to attain a driving licence. We found a clear relationship between the level of first aid training and the quality of first aid measures provided. It would be advisable to offer an increased amount of refresher courses in first aid to improve bystander trauma care.ZusammenfassungZiel dieser prospektiven, epidemiologischen Studie war es, zu erheben, ob Erste-Hilfe-Maßnahmen am Unfallort notwendig waren und ob sie von Ersthelfern geleistet und korrekt durchgeführt wurden. Weiters sollten Angaben zu den Ersthelfern erhoben und festgestellt werden, ob der Ausbildungsstand die Qualität der Erste-Hilfe-Maßnahmen beeinflusst. Die Erhebung erfolgte mittels eines Fragebogens, der zwischen März und Juli 2000 bei allen Einsätzen der Wiener Rettung ausgefüllt wurde. Insgesamt wurden 2812 Einsätze erfasst. Die häufigsten Unfallursachen waren Sturz aus <1 m Höhe (50%) und Verkehrsunfälle (17%). Die häufigsten Verletzungen waren Extremitätenverletzungen (59%) und Schädel- und Schädel-Hirn-Traumen (42%). Die meislen Patienten waren „mäßig schwer” (69%) oder „schwer” (29%) verletzt, aber lebensbedrohliche Verletzungen waren selten (2%). Ersthelfer waren in 57% der Unfälle anwesend. Die am häufigsten indizierten Erste-Hilfe-Maßnahmen waren „Anlegen eines Verbands” und „Lagerung”. Seltener waren „Stillung einer Bluttung”, „Absicherung der Unfallstelle” und „Bergung” indiziert „Freimachen der Atemwege”, „Schutz gegen Unterkühlung” und „Atemspende und Herzmassage” waren sehr selten indiziert. Die häufigsten Ersthelfer waren Polizisten. Verwandte oder Freunde des Verunfallten, und Unbetelligte. Die überwiegende Mehrzahl aller Ersthelfer hatte keine Erste-Hilfe-Ausbildung oder nur den für den Erwerb des Führerscheins notwendigen Kurs. Es bestand ein deutlicher Zusammenhang zwischen Ausbildungsstand und Qualität der Erste-Hilfe-Maßnahmen. Es wäre sinnvoll, vermehrt Wiederholungskurse anzubieten, um bestehende Defizite zu beheben.

Traumatic brain injuries caused by traffic accidents in five European countries: outcome and public health consequences

BACKGROUND Road traffic accidents (RTAs) have been identified by public health organizations as being of major global concern. Traumatic brain injuries (TBIs) are among the most severe injuries and are in a large part caused by RTA. The objective of this article is to analyse the severity and outcome of TBI caused by RTA in different types of road users in five European countries. METHODS The demographic, severity and outcome measures of 683 individuals with RTA-related TBI from Austria, Slovakia, Bosnia, Croatia and Macedonia were analysed. Five types of road users (car drivers, car passengers, motorcyclists, bicyclists and pedestrians) were compared using univariate and multivariate statistical methods. Short-term outcome [intensive care unit (ICU) survival] and last available long-term outcome of patients were analysed. RESULTS In our data set, 44% of TBI were traffic related. The median age of patients was 32.5 years, being the lowest (25 years) in car passengers. The most severe and extensive injuries were reported in pedestrians. Pedestrians had the lowest rate of ICU survival (60%) and favourable long-term outcome (46%). Drivers had the highest ICU survival (73%) and car passengers had the best long-term outcome (59% favourable). No differences in the outcome were found between countries with different economy levels. CONCLUSION TBI are significantly associated with RTA and thus, tackling them together could be more effective. The population at highest risk of RTA-related TBI are young males (in our sample median age: 32.5 years). Pedestrians have the most severe TBI with the worst outcome. Both groups should be a priority for public health action.