One Small Probably Biased GCS Predictive Rate Study Mis-Used As
Profiling Threshold for ICP-Pre-Emptive Craniotomy:
Catch 22...but not in the military!?
If shot or roadside-bombed in the head in Iraq and surviving
medevac to Baghdad--
"50 to 60 percent will be functional and doing things,'' said
Maj.
Richard Gullick"
The US military routinely does craniotomies for head wounds,
pre-emptively relieving intra-cranial pressure, their 60% success
rate debunking civilian GCS-score predictive as profiling threshold
for doing craniotomies for gunshot head wounds.
http://www.emedicine.com/med/topic2888.htm
"The following are significant reasons for
surgery: .......prevent
further swelling and ischemia"
Civilian doctors KNOW BETTER than to GCS-profile as
threshold for pressure pre-emptive craniotomy!!! Smell
that greedy insurance company rat behind a GCS-profiling
threshold for intra-cranial pressure pre-emptive surgery
stateside? Ice pack and nasal oxygen tube are shown
to be arranging deck chairs on the Titanic if you see the
eyes swell as indicator that the brain is crushing itself
inside the general GCS-profiling lock-down on mostly
young black males, or if you simply believe a 60% success
rate reported in Baghdad. I believe I watched GPC-profiling
kill a man last night.
Could ambulances just take gunshot head wound victims
to George Washington Hospital Center instead of Howard?
That's the rumor on the street right now, true or not.
Pentagon boycotted GWHC on 911, inexplicably, which
seems to run counter to all of this, or was that BECAUSE
GWHC has a great burn trauma unit so we could take
that as a further recommendation that GWHC is an
oasis of sanity(inferring Pentagon didn't want any 911
survivors) inside the DC Beltway?
http://www.emedicine.com/med/topic2888.htm
"The following are significant reasons for
surgery: .......prevent
further swelling and ischemia...Often a craniotomy or craniectomy
with removal of accessible bone fragments and foreign bodies is
performed. Gentle debridement of devitalized brain is performed
using a combination of suction and irrigation...In gun shot wounds,
the bullet is not removed unless it
is easily accessible"
In contrast, civilian stats for gunshot wounds to the head are
horrible, because many hospitals screen for a high Glasgow score
plateauing for an extended period without heading off the
inevitable swelling by craniotomies. If swelling is not relieved
by craniotomies, Catch 22, swelling will cause unconsciousness,
which translates directly into a Glasgow score lower than that
predictive of success by insurance company standards. Results
reported from the US military hospital in Baghdad call hiding
behind Glasgow scores as cowardly as the lobotomized moron
who crept up behind Skip and shot him in the side of his head.
Apparently head shot victims who lapse into unconsciousness or
shock will not score high enough GCS for the extended window of
time to receive a craniotomy, so swelling will ALWAYS kill them at
most civilian hospitals. If shot at midnight, gcs score at nine in
the morning when the neuro-surgeon shows up will be lowered
below threshold for surgery by unconsciousness. More drunken
neuro-surgeons were summoned to work by rotary telephones
than currently by portable cell phones. Throw a cell phone at
a neuro-surgeon and he doesn't feel a thing.
Specifically, my friend Skip had a high Glasgow on arrival at
Howard Hospital, talking coherently and answering questions,
but once at the hospital, the staff started doing Glasgow testing
to screen him out of an immediate craniotomy. His insurance
company was relieved of the expense of surgery. Why work to
pay for insurance that is worse than medicaid?
Skip's Glasgow score fell off, predictably, until he no longer had
the GCS to qualify statistically as being a good prospect to fluff up
per surgery corporate stats. Catch 22.
Twelve hours later he was still breathing regularly but edema had
swelled his eyeballs, indicating that his brain had swelled enough to
stop his heart, thanks to GCS profiling in lieu of pressure relief
(craniotomy indicated by head wound and if you like, high initial
GCS).
Ambulance personnel had assumed that Skip would survive
because initial GCS was that high until and when they dropped
him off. But in twelve hours his GCS was zero, due to swelling
of the brain. His brain had crushed itself against the unforgiving
walls of his skull.
Baghdad is the capital of Iraq. DC is the capital of the US. If
only Skip could have been medevacced from the capital of the
US to the capital of Iraq, he would have had a six out of ten
chance of survival.
If Skip had been a young black male in uniform, his doctors
would not have cowered behind Glasgow scoring. Young black
males not in uniform are instead systematically gcs-profiled
to death. About twelve hours without pressure relief and a
young black male brain bruised by hydraulic shock will reliably
crush itself to death by swelling.
Who gets shot in the head in the US? Young black males not
in uniform.
Who pays for craniotomies? Insurance companies.
Who paid for false GCS craniotomy success rate predictive
profiles, contradicting Baghdad US military hospital results,
while profiting the insurance companies? Insurance
companies.
Which young black males routinely receive pre-emptive
pressure relief by craniotomy for head wounds? Only
those in uniform in Iraq.
Did Saddam Hussein anthrax the Reichstag? Did Saddam
release 380 tons of Bush-Pinochet HMX? Where is that
wmd? Where is Osama? Weapons of mass deception include
deployment of gcs profiling against young black males shot
in the head in DC instead of Baghdad. Stop lying about gcs
and wmd and anthrax and 911.
http://www.emedicine.com/med/topic2888.htm
"50% of all trauma deaths are secondary to TBI, and gunshot wounds to
the head caused 35% of these. The current increase in firearm-related
violence and subsequent
increase in penetrating head injury remains of
concern to neurosurgeons
in particular and to the community as a whole.
The definition of a penetrating head trauma is a wound in which a
projectile breaches the cranium but does not exit it"
"A biochemical cascade begins when a mechanical
force disrupts the
normal cell integrity, producing the release of
numerous enzymes,
phospholipids, excitatory neurotransmitters
(glutamate), Ca, and free
oxygen radicals that propagate further cell
damage"
"(1) laceration and crushing, (2) cavitation, and
(3) shock waves"
[shock wave from shot to side of head extended to causing eyeball
edema, but Skip was conscious and conversing coherently until
after emt's dropped him off at Howard ER]
"The following are significant reasons for
surgery: .......prevent
further swelling and ischemia"
Intraoperative details:
- Often a craniotomy or craniectomy with removal of accessible bone
fragments and foreign bodies is performed.
- Gentle debridement of devitalized brain is performed using a
combination of suction and irrigation.
- In gun shot wounds, the bullet is not removed unless it
is easily accessible because the risk of brain injury from the
retrieval of the bullet exceeds the benefit of its removal.
- In cases of stab wounds, the knife or penetrating
object should not be removed until the dura is opened in the operating
room and the procedure can be performed under direct vision.
- In all cases, the surgeon should be prepared to manage
potential vascular injuries that may be encountered. The importance of
a watertight dural closure cannot be overemphasized in order to prevent
centripetal infection and CSF fistula.
- If a dural defect is present, pericranium or
temporalis fascia may be needed for the dural repair. The use of
artificial synthetic or biological dural substitutes should be avoided.
- Patients with penetrating head injury often require
cranioplasty secondary to craniectomy and/or damage by the missile.
Cranioplasty should be delayed for approximately 1 year, when the
patient is medically stable and risk of infectious complications is low.
Postoperative details: The same principles
discussed under Medical
therapy
apply to the postoperative care of patients with penetrating head
trauma. An ICP monitor or a ventricular drain usually is placed
intraoperatively in patients with a GCS of 8 or less. This is placed to
monitor and maintain an adequate cerebral perfusion pressure
[Glasgow CS in range of 6-15 during transport to hospital, no cpr,
conscious, intelligible speech, response to questions, understood
he had been shot, regular breathing for twelve hours, emt's
expected good recovery, they told detective and family]
no patients with a GCS of 6-8 and bihemispheric or multilobar
dominant hemisphere injuries had a satisfactory outcome.
In a review of 190
patients, Levy et al (1994) found that only 2 patients with a GCS of
3-5 achieved a moderately disabled outcome. Further analysis showed
that these patients had reactive pupils at admission and did not have
bihemispheric/multilobar dominant hemispheric injuries. They concluded
that surgical intervention is not beneficial in most patients with a
GCS of 3-5 but may be beneficial for the rare patient with reactive
pupils but without ominous findings on CT scan. Despite these studies,
some controversy remains regarding surgery performed on patients with a
GCS of less than 9... Patients
with a GCS greater than 9 have much lower mortality rates.
Approximately one half of these patients make good recoveries, and 90%
have satisfactory
outcomes
[ambulance emt's assumed good recovery,
Glasgow that]
http://www.nda.ox.ac.uk/wfsa/html/u06/u06_009.htm
"significant extradural and subdural haematomas require urgent
evacuation. In units far from a neurosurgical centre, the general or
orthopaedic surgeons must perform the necessary
procedure"
"rigid cervical collars also may impede venous return and ventilation
patterns should be tailored individually" [a white plastic disk was
left in place around his neck, probably applied in the ambulance.
I assume that the hole in the disk was not of an area of contact
with neck suitable for more than transport time to hospital, think,
a half inch or less, not suitable for twelve hours!]
"The presence of a significant haematoma needs evacuation"
"In the patient undergoing immediate or early (<12 hours) operation"
[transport to hospital half hour or less from gunshot wound,
time at hospital twelve hours until death, no operation, no
icp relief]
"intravenous fluid therapy should be titrated against urine output.
Where there is difficulty about deciding how much fluid replacement
is required and particularly in the presence of thoracic injuries,
central venous pressure should be monitored"
http://www.vin.com/VINDBPub/SearchPB/Proceedings/PR05000/PR00166.htm
[veterinary]
"cerebral blood flow (CBF).
The CBF decreases when the ICP increases
without concomitant
augmentation of the arterial blood pressure; the CBF
may also decrease
when the cranial venous outflow is impaired because of
edema,
hemorrhage, or cervical trauma. ICP starts to increase once the
cerebrospinal fluid (CSF) and blood redistribution buffering
capabilities
are exhausted respectively by reabsorption or displacement
of CSF and
brain vasoconstriction. Intracranial perfusion regulation is
usually
maintained by means of vascular constriction/dilation in a
normal brain.
In an injured brain, this ability may be lost. PaCO2, pH,
and PaO2 influence
the autoregulation response of the cerebro-vasculature. Increased PaCO2
and hypoxemia, frequent findings in traumatized patient, will
cause
vasodilatation and increase ICP. Ischaemia triggers the Cushing reflex,
ultimate guarantee in CBF maintenance, by increasing the systemic
arterial pressure. ICP will finally increase too. Brain edema is the
source
of the increased ICP.
The traumatic disruption of the blood brain barrier
explains its
vasogenic extracellular component. Liberation of vasoactive
substances
and the osmotic effect of interstitial byproduct from dead cells
will
also increase its development. The cytotoxic intracellular component
of
brain edema results from abnormal cell metabolism caused by
ischaemia.
The all-molecular chain reaction drives to more vasogenic and
cytotoxic
edema and higher and higher intracranial pressure"
"The head is elevated no more
than 30°; this facilitates venous and CSF
outflow from the skull" [single pillow, BUT elevation
neutralized by not
removing the emt transport disk from neck!]
"When the brain stem is
severely damaged, the respiratory pattern
becomes irregular" [regular and normal paced after twelve hours,
patient talking during ambulance ride]
"One aim is to treat edema.
While vasogenic edema is
responsive to
therapy, cytotoxic edema, once initiated, is not. The
treatment is thus
directed at preventing the creation of ischaemia and
decreasing its
degree and duration...the vasogenic edema
already present and
minimizing the cytotoxic edema to come"
http://www.motherspeak.org/intervs/rachela.html
"Ryan's injuries include burns and multiple
injuries to his neck, face, and
arms, torn cheek muscles, severed artery in this wrist, metal and
shrapnel
lodged in his skull and brain, and unknown injuries to his eyes. Ryan
has
undergone surgeries including a craniotomy to release pressure from
swelling on his brain"
http://thomas.loc.gov/cgi-bin/query/R?r108:FLD001:S54467
The Lasting Wounds of War
(By Karl Vick)
BAGHDAD.--The soldiers were lifted into the helicopters under
a moonless sky, their bandaged heads grossly swollen by trauma...The
blue screen at the knees announced the level of postoperative pressure
on the brain...The neurosurgeons at the 31st Combat Support Hospital
measure the
damage in the number of skulls they remove to get to the injured brain
inside, a procedure known as a craniotomy
Carroll, an eye surgeon from Waynesville, Mo., sat at his desk
during a rare slow night last Wednesday and called up a digital photo
on his laptop computer. The image was of a brain opened for surgery
earlier that day, the skull neatly lifted away, most of the organ
healthy and pink. But a thumb-sized section behind the ear was gray.
``See all that dark stuff? That's dead brain,'' he said.
``That ain't gonna regenerate. And that's not uncommon. That's really
not uncommon. We do craniotomies on average, lately, of one a day.''
``We can save you,'' the surgeon said. ``You might not be what
you were.''
Accurate statistics are not yet available on recovery from
this new round of battlefield brain injuries, an obstacle that
frustrates combat surgeons. But judging by medical literature and
surgeons' experience with their own patients, ``three of four months
from now 50 to 60 percent will be functional and doing things,'' said
Maj. Richard Gullick.
``Functional,'' he said, means ``up and around, but with pretty
significant disabilities,'' including paralysis.
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