Journal of Trauma & Treatment

Traumatic brain INJURY is a significant problem in American health care which taps a tremendous number of resources. Neurosurgeons are an integral part of head injury care along with the trauma surgeon, particularly in those cases involving multi system trauma. The intensely trained neurosurgical practitioner dedicated to the care of a broad range of neurologically based conditions, including trauma, is in short supply. Furthermore, like their general surgical colleagues, they are being taxed not only by the glut of head injuries but also by the attendant social, financial and perceived legal disincentives associated with their care. That is why, together, we must find a way to share and reduce the burden of head injury care for both practitioner types and keep both engaged in this vitally needed service to society.

It is toward that end that this admittedly provocative and “tongue-in-cheek” essay is offered. Its purpose is not to single out neurosurgeons for castigation, but rather, the intent is to stimulate spirited, yet collegial, honest and productive debate of fundamental issues. It is crucial that these issues be resolved expeditiously in order to move forward and provide much needed access to quality care that is rendered by well trained, committed practitioners who draw pride and satisfaction from their work.

Blunt abdominal aortic injury is an extremely rare and fatal condition. Hemothorax with bleeding from an extrathoracic organ is also an extremely rare condition. Studies have reported abdominal aortic aneurysm and renal trauma but not hemothorax following blunt abdominal aortic injury.

Critical Illness Related Corticosteroid Insufficiency is an intense inflammatory condition associated with steroid tissue resistance. Although traditionally felt to be uncommon, it is being increasingly recognized in severely stressed patients with prolonged intensive care unit stays. Over the last decade the spectrum of CIRCI in trauma has been better defined. Trauma patients with CNS (brain and or spinal cord) injury, burns or blunt multisystem injury are at particular risk. The diagnosis is best established using a random cortisol level combined with an Adrenocorticotrophic Hormone (ACTH) stimulation test. A low cortisol level and or a low response to the ACTH stimulation test in the setting of refractory shock makes the diagnosis. Stress dose hydrocortisone therapy is essential and improves outcome. CIRCI should be suspected in any elderly trauma victim with a prolonged ICU stay that exhibits shock. Drugs known to inhibit cortisol synthesis (like etomidate) are probably best avoided in this trauma subset. CIRCI in trauma has a bimodal distribution. The first peak occurs early (within 48 hours) after injury and is associated with shock and the attendant inflammatory response. The second peak occurs a week or more into the hospital course. This peak is usually associated with sepsis. Inflammatory cytokines (particularly IL-6) are elevated during both peaks but their exact role in establishing the diagnosis remains unclear. Physicians continue to search for the Eucorticoid state that achieves a balance between the inflammation initiated by the injury and the anti-inflammatory response anchored by endogenous steroid production. The administration of exogenous steroids to achieve this balance is an approach that seems to hold promise.

Background: The cardinal symptoms of posttraumatic stress disorder, which is exhibited as intrusions, avoidance strategies and hypervigilance, are rarely highlighted by psycho traumatized patients when they seek care. Furthermore, the clinical features of posttraumatic stress disorder (PTSD) change over time and vary between patients; thus, a classical description of PTSD that can apply to all patients is more of the exception than the rule.
Clinical findings: Many comorbidities affect both the clinical presentation and the development of PTSD. The demand for care is generally expressed via addictive and somatic comorbidities in psycho traumatized subjects: physical bodily injuries are more socially acceptable than psychological injuries. Indeed, the multifaceted nature of PTSD can often mislead clinicians because they tend to focus on the somatic complaints. Psychological comorbidities can also be present, such as depressive and anxiety disorders, dissociative disorders, psychoactive substance use and suicidal behavior.
Literature findings: PTSD is favored by a polygenic vulnerability, and a preponderance of susceptibility to neuromodulation implicates various endophenotypes, which explain the different clinical dimensions that are encountered. But no neurobiological study has revealed a biological marker which would apparently and inevitably destine a subject to structure a PTSD in reaction to a stress. In contrast, the psychopathological study discovers afterwards that a particular subject has necessarily built a traumatic repetition syndrome according to the concordance of significant data relating to their history.
Conclusion: Although the only FDA-approved drugs for the treatment of PTSD are sertraline and paroxetine, numerous studies have evaluated the use of Serotonin-norepinephrine reuptake inhibitors and atypical antipsychotics. The psychotherapy will thus require active commitment of the subject who far from clearing themselves of the traumatic scene will produce meaning by breaking away from a purely passive position taken at the heart of the tragedy. If the trauma is in essence nonsense, the psychotherapeutic reconstruction will promote this search for a meaning enabling the subject to continue to produce rather than again returning to real death.