The CT classification of diffuse head injury permits the early identification of patients at high risk from intracranial hypertension and allows the neurosurgeon the option of early intervention. With the CT classification it is feasible to identify the patients who would appear to be at low risk based on a clinical examination, but who are known from the CT scan diagnosis to be at high risk. The CT classification was based on the status of the mesencephalic cisterns and the degree of midline shift. Diffuse head injury was divided into four subgroups(I, II, III, IV). We analyzed 276 patients with diffuse head injury from January 1995 to september 1996 for identification of likelihood of early raised intracranial pressure in emergency room and decision about early management in patients with diffuse injury. There was close relationship between these diffuse injury type of CT scan and the prognosis. Patients suffering with no pathology(diffuse injury I) and without compression of mesencephalic cistern and midline shift (diffuse injury II) had the lowest mortality rate(1.3%,4.1%), while the mortality rate in patients suffering diffuse injury with a obliteration of mesencephalic cistern(diffuse injury IIIB) and midline shift(diffuse injury IV) was greater than 50%(84.2%,50.0%). The CT diagnosis was a highly significant independent predictor of mortality in diffuse injury I and IIIB but there was an interdependence between the degree of consciousness level and pupil change and the finding on CT scan in diffuse injury II, IIIA and IV.
Classification* ; Consciousness ; Craniocerebral Trauma* ; Diagnosis ; Early Intervention (Education) ; Emergency Service, Hospital ; Head* ; Humans ; Intracranial Hypertension ; Intracranial Pressure ; Mortality ; Prognosis* ; Pupil ; Tomography, X-Ray Computed

We evaluated the ability of a simple scoring system for prediction of outcome soon after subarachnoid hemorrhage(SAH). The scoring system was calculated on the basis of the distribution of blood seen on the CT scan and patients' neurological grade on admission. Two points each were scored for interhemispheric, intraventricular, basal and intracerebral hemorrhage. We excluded hemorrhage in the Sylvian cistern from the calculation of the scoring system. Patients in neurological grade 1-3 scored -1, grade 4 scored 0, grades 5 & 6 scored +5. The CT score and grade score were summated to give the overall score. Patients were placed in 3 risk groups, low risk group in score of -1, medium risk group in score of 0-2, and high risk group in score above 3. The scoring system was applied prospectively to 134 patients who were admitted to our hospital from January 1995 to December 1996. The overall mortality rate was 32.1% within 3 months after onset of SAH. There was a close relationship between the patients' scores and their outcomes. Over 90% of low risk patients experienced a full and good recovery from the SAH compared to 30% of high risk patients. Less than 5% of low risk patients were died, whereas 56% of high risk group died. Thus a low risk patient has a better outcome than a high risk patient(p<0.001). The classification into risk groups has predictive value independent of angiographic finding, hypertension and vasospasm.
Cerebral Hemorrhage ; Classification ; Hemorrhage ; Humans ; Hypertension ; Mortality ; Prospective Studies ; Tomography, X-Ray Computed

To evaluate the risk factors affecting mortality in blunt abdominal injury we prospectively analysed 149 abdominal traumatic patients, who were performed laparotomy in 84 cases and conservative management in 65 cases, from January 1st. 1995 to September 30th. 1996. The liver was most frequently injured intraabdominal organ(46.3%), followed by spleen(32.9%), kidney(23.5%), small intestine(16.1%) and mesentery(13.4%). Mortality rate was 19.5%. The cause of death was hemorrhagic shock and its complications in 11 cases, craniocerebral injuries in 7 cases, pulmonary complications in 6 cases, and septic shock in 5 cases. The presence of hypotension(less than 90mmHg), head trauma(above 3 in severity code of abbreviated injury scale(AIS)) and chest trauma(hemothorax and/or pneumothorax) was associated with a high mortality rate(88.9%), but the mortality rate for the patients neither hypotension nor head and chest trauma was very low(1.8%). The mortality in the blunt abdominal injuries was highly influenced by hypotension, head injury and multiple intraabdominal injuries(p<0.05). Of the above influencing risk factors, the associated head injury was the most powerful determinant in the prognosis in the patients of blunt abdominal injuries.
Abdominal Injuries ; Cause of Death ; Craniocerebral Trauma ; Head ; Humans ; Hypotension ; Laparotomy ; Liver ; Mortality* ; Prognosis ; Prospective Studies ; Risk Factors ; Shock, Hemorrhagic ; Shock, Septic ; Thorax

PURPOSE: Evaluating chest pain is one of the greatest challenges facing emergency physicians. Accurate diagnosis and triage of patients with acute cardiac ischemia (ACI) containing acute myocardial infarction (AMI) and unstable angina at the emergency department should increase survival for such patients. METHODS: In 333 patients with chest pain, we evaluated the diagnostic performance of creatine kinase-MB (CK-MB), electrocardiograms (ECG), Cardiac STATus(TH), the Goldman chest-pain protocol, and a combination of Cardiac STATus(TH) and the Goldman chest-pain protocol. Diagnostic performance was assessed using estimates of test sensitivity, specificity, and diagnostic odds ratio. RESULTS: Diagnostic technologies for AMI, such as CK-MB, ECG, Cardiac STATus(TH), and the Goldman chest-pain protocol have good sensitivity (80-90%), but they have poor sensitivity for ACI (60-70%). To increase the diagnostic accuracy for ACI we combined the Cardiac STATus(TH) and the Goldman chest-pain protocol. The combination had excellent sensitivity (97%) for AMI at 4 hours after onset of chest pain. However the combination did not have the desired very high sensitivity to diagnose ACI (78.5%). With serial Cardiac STATus(TH), ECG, and echocardiography measurements in the chest-pain observation unit, we improved the ACI detection rate. CONCLUSION: The combination of Cardiac STATus(TH) and the Goldman chest-pain protocol had excellent diagnostic performance for AMI and good performance for ACI.
Angina, Unstable ; Chest Pain ; Creatine ; Diagnosis ; Echocardiography ; Electrocardiography ; Emergencies* ; Emergency Service, Hospital ; Humans ; Ischemia* ; Myocardial Infarction ; Myocardial Ischemia ; Odds Ratio ; Sensitivity and Specificity ; Triage

PURPOSE: Most minor head injury (MHI) patients can be discharged without complication but a small percentage of these patients have intracranial lesions which can be observed by computed tomography (CT), and in these cases, neurosurgical intervention may be necessary. Selective use of the CT-scan in cases of MHI is important in reducing the risks associated with unnecessary radiation exposure. We conducted a retrospective study with the goal of creating a set of clinical criteria for deciding when to utilize the CT scan for MHI cases. METHODS: This retrospective study was conducted using 1,735 patients with MHI (GCS=15, > or =6 years old) from January 2009 to December 2010. Based on literature review results, we selected risk factors associated with the presence of intracranial lesions observable by cranial CT-scan, which may have resulted from MHI. The detection of intracranial lesions by CT scan was regarded as the primary clinical outcome. RESULTS: Of the total cases, 87(5.0%) had intracranial lesions as observed by CT scan. All patients with abnormal CT scans had at least one of the following risk factors: headache, loss of consciousness (LOC)/posttraumatic amnesia (PTA), vomiting, focal neurological deficit, coagulopathy, alcohol intoxication, skull fracture, age greater than 65 years, dangerous mechanism of injury, or facial fracture. A decision model for application of CT scanning in MHI cases was derived which consisted of 5 risk factors: headache, LOC/PTA, skull fracture, and age greater than 65 years. The decision model was 100% sensitive (95% CI, 95.8~100%) and 42.4% specific (95% CI, 40.0~44.8%) for predicting intracranial lesions, and would require only 59.8% of patients to undergo CT. CONCLUSION: The decision model developed for CT scanning in MHI cases was highly sensitive. Patients who meet the criteria of the model require evaluation by CT scan.
Amnesia ; Craniocerebral Trauma ; Headache ; Humans ; Retrospective Studies ; Risk Factors ; Skull Fractures ; Unconsciousness ; Vomiting

PURPOSE: Most minor head injury (MHI) patients can be discharged without complication but a small percentage of these patients have intracranial lesions which can be observed by computed tomography (CT), and in these cases, neurosurgical intervention may be necessary. Selective use of the CT-scan in cases of MHI is important in reducing the risks associated with unnecessary radiation exposure. We conducted a retrospective study with the goal of creating a set of clinical criteria for deciding when to utilize the CT scan for MHI cases. METHODS: This retrospective study was conducted using 1,735 patients with MHI (GCS=15, > or =6 years old) from January 2009 to December 2010. Based on literature review results, we selected risk factors associated with the presence of intracranial lesions observable by cranial CT-scan, which may have resulted from MHI. The detection of intracranial lesions by CT scan was regarded as the primary clinical outcome. RESULTS: Of the total cases, 87(5.0%) had intracranial lesions as observed by CT scan. All patients with abnormal CT scans had at least one of the following risk factors: headache, loss of consciousness (LOC)/posttraumatic amnesia (PTA), vomiting, focal neurological deficit, coagulopathy, alcohol intoxication, skull fracture, age greater than 65 years, dangerous mechanism of injury, or facial fracture. A decision model for application of CT scanning in MHI cases was derived which consisted of 5 risk factors: headache, LOC/PTA, skull fracture, and age greater than 65 years. The decision model was 100% sensitive (95% CI, 95.8~100%) and 42.4% specific (95% CI, 40.0~44.8%) for predicting intracranial lesions, and would require only 59.8% of patients to undergo CT. CONCLUSION: The decision model developed for CT scanning in MHI cases was highly sensitive. Patients who meet the criteria of the model require evaluation by CT scan.
Amnesia ; Craniocerebral Trauma ; Headache ; Humans ; Retrospective Studies ; Risk Factors ; Skull Fractures ; Unconsciousness ; Vomiting

Despite aggressive management, severe emotional and physical disability or death occurs in the majority of patients with severe head injury. Significant recovery of function of impaired neuronal cells is possible if patients are rapidly and effectively resuscitated after focal or diffuse brain insults. However, if secondary insults such as hypotension, hypoxia, or intracranial hypertension occur, many vulnerable cells may be irreversibly damaged by a cerebral ischemia. The most important points in the management of traumatic brain insults are the maintenance of an adequate cerebral perfusion pressure rather than the control of intracranial hypertension as a means of averting cerebral ischemia, and recognition that aggressive hyperventilation to control increased cerebral pressure may aggravate cerebral ischemia. So it is recommended that cerebral perfusion pressure be maintained at or above 70mmHg and that use of prophylactic hyperventilation (PaCO2 < 35mmHg) should be avoided within the 1st 24 hours after brain injury.
Anoxia ; Brain ; Brain Injuries ; Brain Ischemia ; Craniocerebral Trauma* ; Emergencies* ; Emergency Service, Hospital* ; Head* ; Humans ; Hyperventilation ; Hypotension ; Intracranial Hypertension ; Neurons ; Perfusion ; Recovery of Function

To evaluate the effects of hypoxia to the outcome of patients with head injury, we analyzed 223 patients prospectively. We divided patients into two groups; without hypoxia and with hypoxia. Hypoxia was defined as PaO2<60mmHg at room air. And clinical parameters such as patient's age, causes of injury, time interval from injury until arrival at the emergency medical center, Glasgow Coma Scale(GCS) on admission, types of brain lesion, and presence of hypotension were compared. Hypoxia was seen in 37 patients with head injury(16.6%). Hypoxia was noted in 32 patients among 162 traffic accidents(19.8%), in 28 patients among 150 cases with mass lesions(18.6%), and in 18 patients among 56 cases with obliterated basal cisterns in CT scan(32.1%). Hypoxia was more commonly seen in patients with severe head injury(GCS< or =8)(26.3%) compared to patients with mild to moderate head injury(GCS>9)(8.9%). Hypoxic insult to the already-injured brain was closely associated with increased mortality and morbidity. Of the 37 patients with hypoxic insult, 23(62.2%) showed poor outcome (vegetative state & dead); only 48 patients(25.8%) without hypoxia showed poor outcome(p<0.001). Among hypoxic group, the incidence of poor outcome was especially high in patients injured in vehicular accidents(55.6%), in low consciousness level(GCS<8) on admission(80.7%), and in intracranial mass lesions(67.9%). Care for the patient with head injuries should start at the scene of injury. 100% oxygen should be administered via a suitable airway during transportation to the hospital, and early positive-pressure ventilation may be necessary.
Anoxia* ; Brain ; Coma ; Consciousness ; Craniocerebral Trauma* ; Emergencies ; Head* ; Humans ; Hypotension ; Incidence ; Mortality ; Oxygen ; Positive-Pressure Respiration ; Prospective Studies ; Transportation

PURPOSE: Mild traumatic brain injury (mTBI) is defined as head injury resulting from blunt trauma with one or more of the following conditions: 1) any period of transient confusion, disorientation, or impaired consciousness; 2) any period of dysfunction of memory (amnesia) around the time of injury; 3) observed signs of other neurological or neuropsychological dysfunction; 4) any period of loss of consciousness lasting 30 minutes or less. As a result of its subtle computed tomography (CT) findings, patients with mTBI were almost ordered discharged in the emergency setting. However, postconcussion syndrome (PCS) could develop in approximately 10 to 20% of these patients. This study was conducted in order to investigate the prognostic factors of PCS, and the role of magnetic resonance imaging (MRI) for diagnosis of PCS in mTBI patients. METHODS: This retrospective study was conducted in 397 patients who were admitted with mTBI (GCS=15, age> or =6 years old) for analysis of the prognostic factors of PCS, and 187 patients who underwent both CT scan and MRI for comparison of the sensitivity of CT to that of MRI from January 2009 to December 2010. PCS was defined as a disorder with somatic, cognitive, or affective symptoms. RESULTS: Of the mTBI patients, 44.2% had PCS. The independent prognostic factors were loss of consciousness (LOC)/posttraumatic amnesia (PTA), headache, and intracranial hemorrhage on CT scans. Strong suggestive CT findings of PCS were lesions located in intra-axial and white matter, subdural hematoma, and intraprenchymal contusion of the frontal or temporal lobe. A decision model for prediction of PCS in mTBI consisted of three risk factors: LOC/PTA, headache, facial fracture, and intracranial hemorrhage on CT scans. The sensitivity of MRI was superior to that of CT in detection of PCS (72.4.4% vs 60.9%, p=0.021). CONCLUSION: The possibility of developing PCS was high in mTBI patients with LOC/PTA, headache, and abnormal CT findings. These patients may require MRI evaluation.
Amnesia ; Brain Injuries ; Contusions ; Craniocerebral Trauma ; Emergencies ; Headache ; Hematoma, Subdural ; Humans ; Intracranial Hemorrhages ; Magnetic Resonance Imaging ; Memory ; Retrospective Studies ; Temporal Lobe ; Unconsciousness

BACKGROUND: The mortality of patients with rebleeding of an aneurysmal rupture is very high despite scheduling of an early operation. The period of greatest risk of rebleeding is during the time in which the patient is undergoing transport, assessment, diagnostic testing, and management in the emergency room or ward. If rebleeing can be prevented, it is clear that the overall clinical outcome for patients with an aneurysmal rupture will be dramatically improved. MATERIALS AND EMTHODS: To determine the risk factors for rebleeding in patients with an aneurysmal rupture between admission in emergency room and operation, we retrospectively reviewed the cases of 194 patients with an aneurysmal rupture that had been confirmed by CT scanning and cerebral angiography between January 1, 1998 and December 31, 2000. RESULT: Thirty-eight(19.6%) of the 194 patients had rebleeding. The incidence of rebleeding significantly increased in patients with stroke symptoms and signs on first-time aneurysmal ruptures(loss of consciousness, decreased mentality, coma, or motor deficits), in those with poor neurological conditions on admission, in those with a poor Hunt-Hess grade on admission(IV or V), and in those with a intracerebral hematoma indicated on the CT scanning compared to those without these factors. Multivariate analysis revealed that the following three factors were independently associated with rebleeding: the symptoms and signs on first-time aneurysmal ruptures, the Hunt-Hess grade on admission, and the value of prothrombin time on admission. CONCLUSION: A considerably high risk of rebleeding was observed in those patients who had stroke symptoms and signs, who were in a poor Hunt-Hess grade(grade IV or V), and who had extremely delayed values of the prothrombin time.
Aneurysm* ; Cerebral Angiography ; Coma ; Consciousness ; Diagnostic Tests, Routine ; Emergency Service, Hospital ; Hematoma ; Humans ; Incidence ; Mortality ; Multivariate Analysis ; Prothrombin Time ; Retrospective Studies ; Risk Factors* ; Rupture ; Stroke ; Tomography, X-Ray Computed