PubMed · 14931591
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F BERKAY. 1951. [Post-traumatic epilepsy].. https://pubmed.ncbi.nlm.nih.gov/14931591/
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Craniocerebral trauma (CCT) is the most frequent cause of morbidity-mortality as a result of an accident. The probable origins and etiologies are multifactorial and include free radical formation and oxidative stress, the suppression of nonspecific resistance, lymphocytopenia (disorder in the adhesion and activation of cells), opportunistic infections, regional macro and microcirculatory alterations, disruptive sleep-wake cycles and toxicity caused by therapeutic agents. These pathogenic factors contribute to the unfavorable development of clinical symptoms as the disease progresses. Melatonin (N-acetyl-5-methoxytryptamine) is an indoleamine endogenously produced in the pineal gland and in other organs and it is protective agent against damage following CCT. Some of the actions of melatonin that support its pharmacological use after CCT include its role as a scavenger of both oxygen and nitrogen-based reactants, stimulation of the activities of a variety of antioxidative enzymes (e.g. superoxide dismutase, glutathione peroxidase, glutathione reductase and catalase), inhibition of pro-inflammatory cytokines and activation-adhesion molecules which consequently reduces lymphocytopenia and infections by opportunistic organisms. The chronobiotic capacity of melatonin may also reset the natural circadian rhythm of sleep and wakefulness. Melatonin reduces the toxicity of the drugs used in the treatment of CCT and increases their efficacy. Finally, melatonin crosses the blood-brain barrier and reduces contusion volume and stabilizes cellular membranes preventing vasospasm and apoptosis of endothelial cells that occurs as a result of CCT.
OBJECTIVE: To describe the impact of implementing clinical practice guidelines (CPG) for head injury in a trauma referral system in Songkla province, Thailand. METHODS: The CPG was developed by a local multidisciplinary team and implemented using multi-faceted methods. The outcome of patients with head injury from three community hospitals and a university hospital (Songklanagarind Hospital) was reported in terms of "talk and deteriorate" patients and a "poor" outcome for patients with severe head injury. Changes to clinical practice were observed where the guidelines were implemented. RESULTS: 1000 patients with head injury were enrolled from 1st August 2005 to 15th January 2006. The incidence of "talk and deteriorate" patients was 10.5% and a poor outcome was noted in 35.5% of patients with severe head injury, similar to the results of a previous study in Songklanagarind Hospital (p>0.05). Following implementation of the guidelines, 19.8% of patients underwent CT scanning with similar outcomes for alert patients with and without basal skull fracture (p>0.05). The clinician-nurse relationship also improved and there was closer collaboration between hospitals. Short observation in community hospitals for repeat neurological examination may be an appropriate strategy for management of some patients with minor head injury. CONCLUSIONS: Local ownership, an appropriate implementation strategy and working as a multidisciplinary team are key factors for success in implementing the CPG. Basal skull fracture may not be an absolute criterion for CT imaging of the head. Further initiatives will be developed in response to the incidence of "talk and deteriorate" patients.
The practice of neurosurgery in a war zone provides enormous challenges and risks for the individual surgeon working in such an austere and hostile environment, but also provides a unique opportunity to treat a high volume of severe penetrating and blast injuries to the head, neck and the spine. The purpose of this article is to present the author's personal experiences and perspective as a military neurosurgeon working in the US Airforce Hospital in Balad (the 332nd Expeditionary Medical Group) Iraq in for 3 months in 2004. Strategies for managing the mass casualties, and the severe penetrating craniofacial trauma are presented and the reasons for the low mortality of troops injured in Iraq are discussed.