Armonda, Rocco

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HUMAN BLAST TBI IS TOO HETEROGENEOUS FOR ONE ANIMAL MODEL

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Armonda, Rocco

  1. 1. Human Severe Blast TBI isToo Heterogenous for One Animal Model Col Rocco A. Armonda, MD National Capital Neurosurgery Consortium Walter Reed Military Medical Center, Bethesda
  2. 2. Disclaimer/Disclosure •  The views expressed in this presentation are those of the authors and do not reflect the official policy of the Department of the Army, Navy, Department of Defense, or U.S. Government.•  No Disclosures applicable to this presentation
  3. 3. Objective •  Delinate the Varied Patterns of Severe Human Blast Injury •  Discuss the Prognosis of Severe Blast Injury •  Identify Mean of Improving our Models for Predicting Injury/Outcome •  Introduce Bayseian Modeling as a Means to improve our understanding of Human Blast Injury
  4. 4. Gaining Wisdom..."  By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest. (Confucius)
  5. 5. ‘the road to Ruin...’"  There are three possible roads to ruin: women, gambling and technology. The most pleasant is with women, the quickest is with gambling, but the surest is with TECHNOLOGY! (Georges Pompidou)
  6. 6. Bayes Theorem •  Initial Beliefs+ Recent Objective Data= New/ Improved Belief •  English Clergyman Thomas Bayes (18th Century) •  “The Theory That Would Not Die, How Bayes’ Rule Cracked the Enigma Code, Hunted Down Russian Submarines and Emerged Triumphant from Two Centuries of Controversy” by Sharon McGrayne
  7. 7. Variables of Severe Human Blast Injury•  All Varies Depending on Characteristics of Explosion: Not one is alike!•  “Time, Distance, Shielding, Enclosures, Flying Fragments”•  Influence of Body Armour •  Protection/Amplification/Transmission of Energy Waves•  Effects of Terminal Ballistics on the Skull, Skull Base, Brain, and Cerebrovasculature•  Influence of Associated Pulmonary, Extremity, Abdominal Injuries
  8. 8. Demographic  Characteris0cs NEUROSURGERY Consults:Severe  Head  Injury                                        513:357 Age 27  +  7.7  years    (18-­‐73) Sex  (M:F) 350:7 Injury  Type  (CHI:PHI)  139:218 Mechanism: 207  Blast                            17  GSW 123  Other Branch  of  Service:214  USA                        8  USAF75  USMC                7  USN
  9. 9. Initial CT Scan: IED Explosion <15 Minutes from Injury Severe Cranial Base Injury
  10. 10. Immediate ICA Rupture Subsequent:" Occlusion/Stroke
  11. 11. DELAYED PROBLEMS
  12. 12. Serial TCDs: Pre/Post Angioplasty! ▲ ▲
  13. 13. MechanismsPrimary Brain Injury"BluntPenetrating (bullets and fragments)Combination- Blast (overpressure, direct strike, fragments, acceleration/ deceleration injury)Secondary Brain Injury"Hypotension (SBP<90), doubles mortalityHypoxia (PaO2<60)Intracranial Hypertension (ICH)Ischemia (blood flow)Herniation (tissue damage)
  14. 14. Not as SIMPLE!•  Blast Injuries Flying Fragments, Blunt force trauma, Fragmented Bone...
  15. 15. Pseudoaneurysm from Bone Fragments
  16. 16. Small Fragments Big Injury
  17. 17. IED Explosions
  18. 18. Immediate CT:What Lies Beneath?
  19. 19. Terminal Ballistics of Severe Blast Injury In Humans: Observations•  Edema is Diffuse•  Onset of Edema is Late•  Length of Increased ICP is PROLONGED!•  High Association with Delayed Cerebral-Vasospasm.•  Outcome is difficult to predict!!!!!!
  20. 20. Predicting Patient OUTCOME•  Poor Characteristics •  Associated Large Vessel Infarction: Defines Disability •  Penetration of Fragments/Injury Zone into Diencephalon: Defines Level of Independent Recovery •  Multiple Lobes Involvement/Bihemisphere/Combined Infra/Supra tentorial involvement: Survival/Long Term Independenence •  Severe Concomittant Pulmonary Dysfunction MAJOR MORTALITY!
  21. 21. •  Post-Injury #6 Day#6
  22. 22. Tests •  CT, EEG, TCDs, MRI... (institution dependent?) •  Labs, CXR? •  Bladder Pressure? •  ICP Waveform?
  23. 23. ICP and Abdominal Pressure •  Abdominal Compartment Syndrome •  Increased ICP •  Increased Bladder Pressure •  Decreased Urine Output
  24. 24. Severe Blast Injury with Under-Armour Injury
  25. 25. PBI Spherical BoltTransbasal Penetration
  26. 26. Serial TCD Changes
  27. 27. IA Nicardipine/Microangioplasty
  28. 28. Conclusions •  Each Patient/Injury is Different! •  Balancing the Brain vs Lungs for best overall outcomes •  The Model Must Adapt to New Information: BAYSEIAN THEORUM •  Prevention of Delayed Insults Occult Vascular Injury (Vasospasm, Dissection, TICA) Improves Outcomes. •  Predict Based on combined Model + Real-Time Data (continual update!).

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