E lEvatEd intracranial pressure (ICP) > 20 mm Hg is associated with poor outcome after traumatic brain injury (TBI). 2,13 Especially in the early posttraumatic period, elevated ICP is associated with a high risk of secondary ischemic brain damage. Interventions that lower the ICP should be started as soon as possible to optimize cerebral perfusion pressure and save brain tissue.3 Early diagnosis of elevated ICP is therefore essential in preventing this secondary damage. Elevated ICP and disorders noted on emergency CT scanning of the brain have a poor correlation.12 Invasive ICP measurement with an intraparenchymal probe is considered to be the gold standard.For safe insertion of the probe, optimal blood coagulation, sterile conditions, and a neurosurgeon are required.6 These are not readily available at the trauma scene. Therefore, a noninvasive, simple bedside method can be beneficial in early detection of increased ICP, especially in the prehospital and emergency care setting.Transcranial Doppler (TCD) pulsatility index and transocular ultrasonography have been suggested for rapid assessment of elevated ICP. The TCD pulsatility index detects decreases in cerebral perfusion pressure due to an increased ICP. 8 However, TCD is difficult to perform, even when the user is experienced. obJect Ultrasonographic measurement of the optic nerve sheath diameter (ONSD) is known to be an accurate monitor of elevated intracranial pressure (ICP). However, it is yet unknown whether fluctuations in ICP result in direct changes in ONSD. Therefore, the authors researched whether ONSD and ICP simultaneously change during tracheal manipulation in patients in the intensive care unit (ICU) who have suffered a traumatic brain injury (TBI). materials The authors included 18 ICP-monitored patients who had sustained TBI and were admitted to the ICU. They examined the optic nerve sheath by performing ultrasound before, during, and after tracheal manipulation, which is known to increase ICP. The correlation between ONSD and ICP measurements was determined, and the diagnostic performance of ONSD measurement was tested using receiver operating characteristic curve analysis. results In all patients ICP increased above 20 mm Hg during manipulation of the trachea, and this increase was directly associated with a dilation of the ONSD of > 5.0 mm. After tracheal manipulation stopped, ICP as well as ONSD decreased immediately to baseline levels. The correlation between ICP and ONSD was high (R 2 = 0.80); at a cutoff of ≥ 5.0 mm ONSD, a sensitivity of 94%, a specificity of 98%, and an area under the curve of 0.99 (95% CI 0.97-1.00) for detecting elevated ICP were determined. coNclusioNs In patients who have sustained a TBI, ultrasonography of the ONSD is an accurate, simple, and rapid measurement for detecting elevated ICP as well as immediate changes in ICP. Therefore, it might be a useful tool to monitor ICP, especially in conditions in which invasive ICP monitoring is not available, such as at trauma scenes.

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Background Circulatory arrest after trauma is a life-threatening situation that mandates urgent action. The aims of this systematic review and meta-analysis on prehospital traumatic cardiac arrest (TCA) were to provide an updated pooled mortality rate for prehospital TCA, to investigate the impact of the time of patient inclusion and the type of prehospital trauma system on TCA mortality rates and neurological outcome, and to investigate which pre- and intra-arrest factors are prognostic for prehospital TCA mortality. Methods This review was conducted in accordance with the PRISMA and CHARMS guidelines. Databases were searched for primary studies published about prehospital TCA patients (1995–2020). Studies were divided into various EMS-system categories. Data were analyzed using MedCalc, Review Manager, Microsoft Excel, and Shinyapps Meta Power Calculator software. Results Thirty-six studies involving 51.722 patients were included. Overall mortality for TCA was 96.2% and a favorable neurological outcome was seen in 43.5% of the survivors. Mortality rates were 97.2% in studies including prehospital deaths and 92.3% in studies excluding prehospital deaths. Favorable neurological outcome rates were 35.8% in studies including prehospital deaths and 49.5% in studies excluding prehospital deaths. Mortality rates were 97.6% if no physician was available at the prehospital scene and 93.9% if a physician was available. Favorable neurological outcome rates were 57.0% if no physician was available at the prehospital scene and 38.0% if a physician was available. Only non-shockable rhythm was associated with a higher mortality (RR 1.12, p = 0.06). Conclusion Approximately 1 in 20 patients with prehospital TCA will survive; about 40% of survivors have favorable neurological outcome.

We included 22 male and 23 female volunteers. In total 360 ONSD measurements were performed in these 45 volunteers. Application of a collar resulted in a significant increase in ONSD in both the left (β=0.06, 95% confidence interval: 0.05-0.07, P<0.001) and the right eye (β=0.01, 95% confidence interval: 0.00-0.02, P=0.027) CONCLUSION: Application of a rigid cervical collar significantly increases the ONSD in healthy volunteers with intact cerebral autoregulation. This suggests that ICP may increase after application of a collar. In healthy volunteers, this seems to be of minor importance. On the basis of our findings the effect of a collar on ONSD and ICP in patients with mild and moderate TBI needs to be determined.

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