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Background: Patients with traumatic intracranial hemorrhagic injuries (IHIs) are at high risk for venous thromboembolism (VTE). The safety of early anticoagulation for IHI has not been established.Hypothesis: Enoxaparin can be safely administered to most patients with IHI for VTE prophylaxis.

To determine the efficacy of early jejunal hyperalimentation as nutritional support in the head-injured patient, 32 head-injured patients with Glasgow Coma Scale scores less than 10 were studied for the first 7 days after injury. The experimental (E) group had nasojejunal feeding tubes placed fluoroscopically. Within 36 hours of injury, they received nutritional support equal to their measured resting energy expenditure. The control (C) group was fed gastrically when bowel sounds returned. There were no significant differences (P > 0.05) in age, Glasgow Coma Scale score, type of neurological injury, or associated injuries between the two groups. The mean resting energy expenditure, serum albumin, glucose, lymphocyte count, body weight, and total nitrogen loss were nearly identical for both groups. With the jejunal feedings, daily caloric (E = 2102 kcal versus C = 1100 kcal) and nitrogen intake (E = 11.1 g versus C = 5.6 g) and daily nitrogen balance (E = -4.3 g versus C = -11,8 g) improved. The incidence of bacterial infections (E = 3 versus C = 14) and days of intensive care unit hospitalization (E = 6 versus C = 10) were significantly reduced (P < .05). Headinjured patients will tolerate early jejunal hyperalimentation despite the presence of a clinically silent abdomen, and the cost and complications of total parenteral nutrition are avoided. The increased caloric and nitrogen intake and improved nitrogen retention markedly reduced infections and days of stay in the intensive care unit. (Neurosurgery 25:729-735, 1989)

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To determine the efficacy of early jejunal hyperalimentation as nutritional support in the head-injured patient, 32 head-injured patients with Glasgow Coma Scale scores less than 10 were studied for the first 7 days after injury. The experimental (E) group had nasojejunal feeding tubes placed fluoroscopically. Within 36 hours of injury, they received nutritional support equal to their measured resting energy expenditure. The control (C) group was fed gastrically when bowel sounds returned. There were no significant differences (P greater than 0.05) in age, Glasgow Coma Scale score, type of neurological injury, or associated injuries between the two groups. The mean resting energy expenditure, serum albumin, glucose, lymphocyte count, body weight, and total nitrogen loss were nearly identical for both groups. With the jejunal feedings, daily caloric (E = 2102 kcal versus C = 1100 kcal) and nitrogen intake (E = 11.1 g versus C = 5.6 g) and daily nitrogen balance (E = -4.3 g versus C = -11.8 g) improved. The incidence of bacterial infections (E = 3 versus C = 14) and days of intensive care unit hospitalization (E = 6 versus C = 10) were significantly reduced (P less than .05). Head-injured patients will tolerate early jejunal hyperalimentation despite the presence of a clinically silent abdomen, and the cost and complications of total parenteral nutrition are avoided. The increased caloric and nitrogen intake and improved nitrogen retention markedly reduced infections and days of stay in the intensive care unit.

Forty-five acute head trauma patients were randomized into a neurotrauma nutritional study to compare the efficacy of two forms of standard nutritional supplementation; namely total parenteral nutrition (TPN) versus enteral nutrition (NG). Forty patients were male, 5 were female, with a median age of 28 years. The mean admitting Glasgow coma scale score was 5.8. Patients were given high calorie and nitrogen feedings for the 14 days of the study period in an attempt to achieve positive calorie and nitrogen balance. TPN patients had significantly higher mean daily nitrogen intakes (P less than 0.01) and mean daily nitrogen losses (P less than 0.001) than the NG fed patients; however, no significant differences were discovered with respect to maintenance of serum albumin levels, weight loss, the incidence of infection, nitrogen balance, and final outcome. The exaggerated nitrogen excretion experienced by patients fed large nitrogen loads illustrates a problem in achieving nitrogen equilibrium in acute head injured patients.

Previous retrospective studies of cranial gunshot wounds have failed to determine whether aggressive field resuscitation, triage to a neurosurgical center, and early surgical intervention can improve the assumed poor outcome of these severely injured patients. Therefore, we studied 100 consecutive patients prospectively to establish a systematic approach to treatment. If the patient retained two or more neurological signs after aggressive field resuscitation/intubation, a computed tomographic scan was performed. Rapid surgical debridement was done unless the patient deteriorated to clinical brain death. The Glasgow Coma Scale (GCS) score after resuscitation was 3 to 5 in 58 patients, 6 to 8 in 8 patients, 9 to 12 in 12 patients, and 13 to 15 in 22 patients. Seventy-six computed tomographic scans and 43 craniotomies were performed. The Glasgow Outcome Scale scores showed that 60 patients died, 2 were vegetative, 6 were severely disabled, 20 were moderately disabled, and 13 had good outcomes. There were 10 postoperative deaths. No patient with a GCS score of 3 to 5 had a satisfactory outcome; however, outcome progressively improved as the GCS score increased. We conclude that all cranial gunshot patients should initially receive aggressive resuscitation. Patients with stable vital signs should be examined by computed tomographic scan. If the patient's GCS score after resuscitation is 3 to 5 and no operable hematomas are present, then no further therapy should be offered. All patients with a GCS score greater than 5 should receive aggressive surgical therapy.

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