The National Traumatic Coma Data Bank: Part 1: Design, purpose, goals, and results

ABSTRACTS

24 m o n t h s old: 1) u n k e m p t appearance; 2) a b n o r m a l bruises, all burns, or any human bites; 3) combination of unkempt appearance and abnormal bruises, burns, or bites; or 4) combination of unkempt appearance and abnormal parenting patterns. Mark J Rubin, MD

AORTIC RUPTURE; TRAUMA, AORTIC RUPTURE

Traumatic rupture of the thoracic a o r ta

shift on CT scan. Of 15 patients with a shift of 5 to 15 mm, eight recovered. In contrast, of eight patidnts with a shift of more than 15 ram, all deteriorated and required surgery; seven died. The authors suggest that advanced age, marked midline shift, and presence of subdural hematoma are poor prognostic signs. Because patients who are awake and talkmg may have marked shift and inevitably deteriorate, overreliance on clinical examination should be avoided. Prognostic information provided by CT scan should be noted, and patients with marked shifts and operable lesions should receive prompt surgical intervention. Richard C Dart, MD

Schiessler A, Hepp W, Krautzberger W, et al VASA 11:194-199 1982

The authors review traumatic rupture of the thoracic aorta based on a retrospective analysis of five cases. The cases were all typical deceleration injuries, and all patients had sustained major multiple system injury. The authors found that the most sensitive indicator of the need for aortography was an immediate chest radiograph. Time was critical in determining ultimate prognosis. Reasonable suspicion of mediastinal widening warrants immediate aortogram. If angiography confirms the diagnosis, operation must be performed without delay. [Editor's note: As reported by Gundry et al at the 1982 meeting of the American Association for the Surgery of Trauma, % widened mediastinum is in the eye of the beholder and not in his yardstick." Nevertheless, this subjective impression remains the best criterion we have.] Douglas Lindsey, MD

COMA; COMPUTERIZED TOMOGRAPHY; HEAD INJURY

The National T r a u m a t i c C o m a Data Bank, Part 2: Patients who t a l k and deteriorate: Implications for t r e a t m e n t Marshall LF, Toole BM, Bowers SA J Neuresurg 59:285-288 Aug 1983

The authors reviewed the records of the first 325 patients entered into the pilot phase of the National Traumatic Coma Data Bank. Of these, 34 were found to be severely head-injured patients who talked prior to deteriorating to a Glasgow Coma Scale (GCS) score of 8 or less. The authors compared the 16 patients who talked, deteriorated, and recovered with 18 patients who died or were left vegetative. No differences in the two groups were found in distance from injury site to hospital, time from injury to deterioration or operation, or initial GCS score. However, several significant differences between the two groups were identified, including age, degree of midline shift on CT scan, and presence of subdural hematoma. Patients who recovered were younger (mean age 32 vs 50) and less likely to have marked 122/295

PHENYTOIN, AND SEIZURES; SEIZURES, PHENYTOIN

Failure of prophylactically a d m i n i s t e r e d phenytoin to prevent early post-tr auma ti c seizures Young B, Rapp RP, Norton JA, et al J Neurosurg 58:231-235 Feb 1983

The authors addressed the question of whether prophylactic anticonvulsive drug therapy reduces the incidence of early post-trauma seizures. The authors report the results of a double-blind, randomized, placebo-controlled study involving 244 patients during a three-year period. "Early seizures" were defined as "one or more seizures occurring within one week of head injury without any other obvious causes." Dilantin was administered to 136 patients at a loading dose of 1i mg/kg intravenously, followed by 13 rag/ kg intramuscularly in divided doses u n t i l an oral form could be given. One hundred eight patients received a. placebo. Medications were initiated within 24 hours of admission. Therapeutic dilantin levels (10 to 20 ~g/mL)were maintained for at least one week. All patients were followed for one week for seizure activity. Patients with a prior history of severe head injury,, seizure disorder, or one month prior anticonvulsive drug usage were excluded from the study. Analysis of results revealed no statistical difference between the two groups with regard to type of injury,, sex, age, family history of seizures, initial ICP measurements, initial GCS scores, number of deaths, or surgical intervention. Five dilantin patients (3.7%) and four placebo patients (3.7%) had early seizures (P = .75). Dilantin patients had a mean of 2.8 seizures, as compared to 5.0 seizures in the placebo group (P = .06). The results were not statistically significant. There was also no difference in time of onset of the first seizure in either group. The authors conclude that prophylactic dilantin is not efficacious in preventing early seizures. Nevertheless, because seizure control is important to allow accurate neurological evaluation and to prevent complications such as aspiration, the authors recommend prompt dilantin administration if early seizures do occur.

Annals of EmergencyMedicine

M Andrew Levitt, DO 13:4 April t984