Approaches in Critical Care - Hennepin County Medical Center

Dear Readers:
When I was seven, I was playing with friends at a playground when I fell off
a slide. The fall knocked me unconscious but, when I awoke, it didnʼt occur
to any of us that I should stop playing. I got up and promptly began climbing,
swinging, and sliding again. For the next several days, when I saw my sister,
I wasnʼt always able to recall exactly who she was. When we played our
games, I had trouble remembering the rules.
Today, when I see patients with brain injuries in the emergency department,
or see them passing by in the hallway on their way to appointments at
Hennepinʼs Mild-to-Moderate Traumatic Brain Injury (TBI) Program, I canʼt
help but think about my early experience and how lucky I was that the
effects of my minor injury didnʼt last. Few treatments for TBI were available
then and the topic wasnʼt one that held much interest for researchers.
The landscape has changed dramatically, prompting us to make TBI the
theme for this issue. From hyperbaric oxygen therapy (a treatment Gaylan
Rockswold, MD, medical director of Hennepinʼs TBI Center, discusses in the
Profiles in Critical Care section on page 11) to a new clinical trial on
protegesterone for TBIs (see page 18 for details), this issue provides
information on some of the best available treatments for TBIs.
The theme for our next issue will be sepsis. If you have an interesting case
study youʼd like to contribute, see the authorʼs guidelines on the
Approaches in Critical Care Web site at www.hcmc.org/approaches. Weʼd
love to hear from you.
Sincerely,
Michelle H. Biros, MD, MS
Approaches in Critical Care Editor-in-Chief
Department of Emergency Medicine
Hennepin County Medical Center
®
Every Life Matters

Contents Volume 4 | Approaches in Critical Care | July 2010
Approaches in Critical Care
Editor-in-Chief
Michelle Biros, MD, MS
Managing Editor
Linda Zespy
EMS Perspectives Editor
Robert Ball, EMT-P
Graphic Designer
Karen Olson
Public Relations Director
Tom Hayes
Patient Care Director,
Critical Care and
Emergency Services
Kendall Hicks, RN
Patient Care Director,
Behavioral and
Rehabilitative Services
Joanne Hall, RN
Printer
Sexton Printing
Photographers
Raoul Benavides
Karen Olson
Clinical Reviewers
Gaylan Rockswold, MD, PhD
Sarah Rockswold, MD
Carol Ann Smith, RN, CNRN
Events Calendar Editor
Susan Altmann
Case Reports
2 Aggressive management of severe TBI
Gaylan L. Rockswold, MD, PhD
5 Unsuspected brain injury after seemingly minor trauma
Sarah Rockswold, MD
7 Accidental pediatric head injury from a falling object
Andrew W. Kiragu, MD, FAAP
11 Critical Care Profile
Gaylan L. Rockswold, MD, PhD, medical director of Hennepin’s
Traumatic Brain Injury Center
14 RN Perspectives
The effectiveness of a peer-led campaign to change teenagers’
driving habits
16 Calendar of Events
18 News Notes
To submit an article
Contact managing editor Linda Zespy at approaches@hcmed.org. The editors reserve the right to
reject editorial or scientific materials for publication in Approaches in Critical Care. The views
expressed in this journal do not necessarily represent those of Hennepin County Medical Center, its
editors, or its staff members.
Copyright
Copyright 2010, Hennepin County Medical Center. Approaches in Critical Care is published twice per
year by Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.
Subscriptions
To subscribe, send an email to approaches@hcmed.org with your name and full mailing address.
Approaches in Critical Care | July 2010 | 1

Case Reports
Traumatic Brain Injury: Three Case Reports
Minnesota hospitals treat approximately
15,000 cases of non-fatal
traumatic brain injuries (TBIs) each
year, with approximately 11,000
treated in emergency departments
and 4,500 admitted for additional
care. These injuries are complex
and heterogenous and no specific
TBI treatment is available. Care is
further complicated by the fact that
the site of injury is the bodyʼs most
complex organ.
Aggressive management of TBIs
can lead to improved outcomes.
The following three Minnesota case
studies describe a range of TBIs,
from the mild to the severe, occurring
in both adult and pediatric patients.
her right pupil was 8 mm and non-reactive
and the left was 3 mm and non-reactive.
She demonstrated decorticate posturing to
painful stimuli.
Secondary survey, including an eFAST
examination, was unremarkable and it was
determined that she had an isolated TBI.
She underwent rapid sequence intubation
and 150 ccʼs of 5% hypertonic saline was
initiated. The total time in the emergency
department was 13 minutes. An emergent
head computed tomography (CT) scan was
performed (see Figure One), which
revealed an acute right subdural hematoma
measuring up to 9 mm in thickness with
considerable cerebral edema in the right
hemisphere. There was an 8 mm measured
midline shift. Basilar cisterns were
nearly completely effaced with right-sided
uncal herniation and subfalcine herniation.
The right lateral ventricle was moderately
compressed. A CT scan of her neck was
normal.
Aggressive management of
severe TBI
by Gaylan L. Rockswold, MD, PhD
Division of Neurosurgery
Hennepin County Medical Center
Case report
A 23 year-old woman was the unbelted,
rear-seat passenger in a motor vehicle
involved in a crash. A sports utility vehicle,
traveling at roughly 30-40 miles per hour,
had struck the side of the car where she
was sitting. At the scene, she was unresponsive
with a dilated, non-reactive right
pupil and had decorticate posturing
(stereotype flexor movements of the arms)
in the upper extremities.
Upon arrival to the Hennepin County
Medical Center stabilization room, her vital
signs were stable with the exception of a
low respiratory rate. On neurological exam,
Figure One. Emergent CT scan showing an acute right subdural
hematoma with cerebral edema in the right hemisphere.
The patient was taken immediately to the
operating room where a right decompressive
hemicraniectomy was performed with
evacuation of the subdural hematoma. An
external ventricular drain was placed on
the left. A Licox ® brain tissue oxygen tension
probe, a brain temperature probe, and
a microdialysis catheter were placed via
twist drills.
2 | Approaches in Critical Care | July 2010

Case Reports
The following morning, the patientʼs pupils were
equal and responsive to light. However, the attending
neurosurgeon remained very concerned about her
prognosis. It was decided that continued aggressive
therapy was indicated.
The patient was enrolled in a prospective, randomized
clinical trial to compare the effect of hyperbaric
to normobaric hyperoxia on cerebral metabolism,
intracranial pressure (ICP), and oxygen toxicity in
severe TBI. She was randomized to receive hyperbaric
oxygen therapy for three successive days.
The first hyperbaric treatment was delivered approximately
12 hours following admission.
The patientʼs ICP was relatively well controlled
throughout her course. By the fifth day of hospitalization,
she remained intubated but had purposeful
movements in all extremities and was following some
simple commands. On hospital day eight, she was
extubated but required reintubation and tracheostomy.
She also had a percutaneous endoscopic gastrostomy
placed. She remained quite alert with purposeful
movements. She followed commands in all
four extremities and her eyes were open. On hospital
day 19, her bone flap was replaced. Her course was
complicated by a postoperative epidural hematoma
under her bone flap, which required evacuation on
day 21. She was transferred to Hennepinʼs Miland E.
Knapp Rehabilitation Center on hospital day 25.
The patient spent 13 days at Knapp. At the time of
her first neuropsychological evaluation, she was
disoriented to time and had impaired short-term
memory, a flat affect, and balance deficits. However,
she rapidly improved. By the time of discharge she
had little difficulty with neuropsychological assessment.
She was last seen by the neurosurgical service
approximately two months after her discharge from
acute care. She was doing extremely well without
any complaints. Her plan was to enter dietitian school
in approximately three months at the Massachusetts
General Hospital in Boston.
Discussion
The following factors appear to have contributed to
this patientʼs excellent recovery from a severe TBI:
She was a healthy 23 year-old individual without
any co-morbidities.
She sustained an isolated, severe TBI without
injury to other body systems.
She underwent very rapid assessment in the
emergency department with immediate rapid
sequence intubation. Osmotic agents to reduce
ICP were initiated early in her course.
She went immediately to the operating room
where the acute subdural hematoma was evacuated.
Simultaneously, a large decompressive
craniectomy was performed, which resulted in
her ICP being controlled postoperatively.
Hyperbaric oxygen (HBO), as discussed below, is
a potential favorable factor.
Severe TBI is defined as patients who have a
Glasgow Coma Scale score of < 8 after resuscitation.
These patients typically do not open their eyes,
follow commands, or speak. Approximately half of
these patients will have multiple injuries involving
Approaches in Critical Care | July 2010 | 3

Case Reports
chest, abdomen, pelvis, or long bones. Half will have
elevated ICP due to brain swelling or mass lesions.
Approximately half will require a major neurosurgical
procedure.
Although severe TBIs represent only about 10% of all
patients sustaining a TBI, they account for virtually all
of the 52,000 head injury deaths per year in the U.S.,
as well as the most severely disabled patients.
Despite decades of intensive care and many multicenter
therapeutic trials, currently there is no specific
treatment for severe TBI. Approximately 30% of
these patients die due to the injury and only approximately
40% achieve a favorable outcome or independent
life following their injury.
The appropriate early and subsequent management
of patients sustaining a severe TBI is critical to
achieving the best possible outcome. Maintaining an
adequate airway and ventilation is essential.
Although the brain represents only 2% of the body
weight, it consumes 20% of the oxygen delivered to
the body. There is no oxygen storage in the brain.
Following a severe TBI, there is relatively poor oxygen
delivery to the brain due to reduced cerebral
blood flow. Diffusion of oxygen from the blood capillaries
to brain cells is compromised due to edema,
microvascular collapse, and endothelial swelling. At
the very time in which the brain has increased metabolic
demands, its ability to achieve high-energy output
is reduced because of ischemia. Therefore, adequate
oxygen delivery is critical.
“At the very time in which the brain
has increased metabolic demands,
its ability to achieve high-energy output
is reduced because of ischemia.”
A second cornerstone of management of a patient
with uncal herniation and severe neurologic deficit is
the administration of osmotic agents. The administration
of intravenous mannitol has been the standard
osmotic agent for many years. Hennepin has pioneered
the use of hypertonic saline (HTS) as a substitute
for mannitol. HTS has several potential advantages
compared to mannitol. Mannitol creates a significant
diuresis of fluid and electrolytes and can
aggravate or produce hypotension, which significantly
increases mortality in severe TBI. Particularly in
prolonged administration of mannitol, intravascular
dehydration, hypotension, and prerenal azotemia followed
by renal failure can result. HTS does not have
this diuretic effect and, with relatively small volumes
of fluid, it maintains vascular volume. The measured
volume expansion efficacy of HTS is 10 times that of
lactated Ringer solution. HTS has a much higher
osmolarity per unit volume than mannitol (8008
mOsm/L for 23.4% HTS versus 1375 mOsm/L for
25% mannitol). Improved vascular volume improves
mean arterial pressure and cerebral perfusion pressure,
which results in better cerebral oxygen delivery.
A prospective, randomized clinical trial to compare
the effect of hyperbaric to normobaric hyperoxia on
cerebral metabolism, ICP, and oxygen toxicity in
severe TBI has recently been completed at Hennepin.
(See Bibliography.) Oxygen delivery depends on a
pressure gradient from the alveolar spaces to blood
and finally to the brain tissue itself. HBO increases
this vital oxygen delivery pressure gradient. Brain
tissue oxygen monitoring, both experimental and
clinical, has consistently recorded levels of 200-300
mmHg with HBO at 1.5 atmospheres absolute (ATA).
Such values typically represent a tenfold increase
over baseline brain tissue PO2 levels.
Mechanistically, it is not entirely clear why the very
high brain tissue oxygen levels are achieved.
However, one explanation is that HBO at 1.5 ATA
increases the amount of dissolved oxygen in the
plasma about tenfold. This level of oxygen in the
brain has been shown to improve mitochondrial function
and adenosine triphosphate production in experimental
animals. The clinical trial demonstrated that
the global consumption of oxygen was significantly
improved following HBO treatments and the effect
lasted for at least six hours. Since 90% of oxygen is
consumed by mitochondria in the brain, this is indirect
but very strong evidence that mitochondrial function
is improved. Improved oxidative metabolism has
been demonstrated to improve clinical outcome. In
addition, ICP is reduced following HBO treatment and
the therapeutic intensity level for intracranial hypertension
is correspondingly reduced.
Intracranial hypertension is the most significant
cause of deterioration and death following severe
TBI. In previous studies, HBO has been shown to
reduce mortality rates in severe TBI by about 50%
and improve favorable outcomes in patients with elevated
ICP and surgical mass lesions. At the present,
Hennepin has submitted an application to the
National Institute of Neurologic Disease and Stroke
for a prospective, multicenter clinical trial to evaluate
the efficacy of HBO in the treatment of severe TBI.
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Case Reports
Unsuspected brain injury after seemingly
minor trauma
by Sarah Rockswold, MD
Department of Phsical Medicine and Rehabilitation
Hennepin County Medical Center
Case report
A 52-year-old female was involved in a motor vehicle
collision on October 24 when a large delivery truck
broadsided her car. She had no loss of consciousness
at the scene and, at the receiving hospital, her
Glasgow Coma Scale score was 15. An emergent CT
scan of the head was negative for any acute intracranial
pathology. However, she had a small, left-sided
pneumothorax, a right hip abrasion, and a left-sided
coronoid fracture. She was admitted overnight for
these injuries. No diagnosis of TBI was made.
She was seen by her primary care physician (PCP) a
few days later. At that time, she complained of headaches,
nausea, emotional lability, and some subjective
memory difficulties. In addition, she was having
cervical and lumbar pain. These symptoms continued
for another three weeks. Her PCP ordered a second
CT scan, which was obtained 27 days after the first
scan; again, no acute intracranial pathology was
detected. (See Figure One.) She was then sent to a
neurologist for suspected neurologic abnormality and
radicular symptoms associated with her neck pain.
The neurologist ordered a magnetic resonance imaging
(MRI) scan of the brain, which was obtained on
December 1. (See Figure Two.) This scan showed a
small right subdural hematoma versus proteinaceous
subdural hygroma. The neurologist felt that these
injuries could be treated conservatively. An electroencephalography
(EEG) also was obtained and was
within normal limits.
The patient was told for the first time that she had
suffered a TBI. She was started on gabapentin for
sleep and also Lexapro for significant emotional lability.
These medications made her nauseous and she
developed diarrhea so the medications were
stopped. The patient continued to have significant
symptoms. She was unable to return to her work as
a first-grade teacher. Her physicians felt that she had
significant anxiety and this was what was preventing
her from making a full recovery.
The patient was referred to Hennepinʼs Mild-to-
Moderate TBI Program in February. When questioned
closely about the motor vehicle collision, it
was discovered that she was amnesic to the actual
event as well as for six hours following the injury. At
the time of the initial TBI clinic visit, she was having
daily frontal and occipital headaches, which were
associated with physical, emotional, or mental exertion.
She had a sensation of dizziness but denied any
true vertigo. She had disrupted sleep and was very
fatigued. She was also having significant mood lability
and anxiety. She was having flashbacks to the scene
of the accident that were intrusive throughout her day.
She felt one of the reasons she could not sleep was
because of her racing thoughts about the accident.
She had panic attacks when she was a passenger in
a car. She was having difficulty with concentration
and short-term memory and had slowed mental processing.
She also had some verbal fluency issues.
Past medical history was negative for any major illnesses,
previous TBI, psychiatric issues, or substance
abuse. Her physical examination was normal including
balance and coordination. She was started on a
low dose of tenazepam for sleep. Due to her medication
sensitivity, no other medications were started.
The patient was referred to Hennepinʼs interdisciplinary
TBI team. Neuropsychological testing revealed
cognitive deficits in visual reasoning, auditory memory,
auditory attention, and some perseveration in
problem solving. She was inefficient in visual scanning
and memory problem solving.
Speech pathology saw her on a weekly basis for direct
treatment of her cognitive deficits and to teach compensatory
techniques. In addition, they taught her
energy management skills. Clinical psychology diagnosed
her with post-traumatic stress disorder (PTSD)
and began to see her weekly. Vestibular testing was
normal with no evidence of central or peripheral
vestibular pathology. Neuro-ophthalmology detected
a profound convergence insufficiency that was likely
causing her dizziness. The patient was sent to occupational
therapy for vision rehabilitation. She also
was sent to physical therapy for her poor balance.
The patient was seen back in TBI clinic in April,
approximately two months after the initial Hennepin
clinic visit. At that time, she had dramatically
improved. Her dizziness and insomnia had resolved.
She stated that her fatigue and mood were improving.
However, her headaches had not improved so
she was started on a low dose of nortriptyline. She
was not yet ready to return to work and so she maintained
the various therapy disciplines.
By the time the patient was seen in TBI clinic in July,
she was able to return to work without restriction.
Overall, her symptoms had resolved except for rare,
mild exertional headaches. Her PTSD also had
resolved. Clinical psychology continued to follow her
Approaches in Critical Care | July 2010 | 5

Case Reports
for adjustment disorder with anxiety. She had been
discharged from all disciplines except for monthly
clinical psychology and speech pathology visits.
She currently is being maintained on temazepam
and nortriptyline.
Discussion
Mild TBI comprises 80% of the 1.7 million brain
injuries in the U.S. and costs an estimated $17 billion
annually. Patients with a mild TBI usually appear normal
on a gross neurologic exam and CT scan. For
this reason, many mild TBI patientsʼ needs are neglected.
However mild TBI symptoms may cause
havoc within the patientʼs social structure, as significant
occupational, social, and personal problems can
develop. If these patients are seen early by a trained
professional, many mild TBI complications can be
prevented and the duration of post-concussive symptoms
may be shortened.
Mild TBI can be defined by a loss of consciousness
< 30 minutes, a Glasgow coma scale score of
14-15, post-traumatic amnesia < 24 hours, and no
focal neurological deficit. It is important to realize that
a loss of consciousness does not have to occur for a
patient to suffer a TBI. Most symptoms from a mild
TBI, or concussion, resolve in 7-10 days. However,
some patients develop a significant post-concussive
syndrome that can persist for months.
Post concussive symptoms can be divided into three
categories – physical, cognitive, and emotional.
Common physical symptoms are headache, vertigo,
balance deficit, sleep impairment, fatigue, visual
changes, and photophobia. Cognitive changes affect
short-term memory, attention, verbal fluency, processing
speed and efficiency. These deficits are confirmed
on neuropsychological testing. Anxiety, irritability,
lability, and depression are emotional problems frequently
occurring after mild TBI.
Currently, the mechanism for these persistent symptoms
is unknown. Most traditional imaging techniques,
such as CT scans or MRIs, show no intracranial
pathology following mild TBI. As more sophisticated
imaging techniques, such as positron emission
tomography (PET), magnetic resonance spectroscopy,
diffuse tensor imaging, and functional MRI, are becoming
available, compelling results are beginning to
provide insight into symptom mechanism in mild TBI.
An interdisciplinary approach is a key to success with
patients who have symptoms lasting longer than a
month. All physical, cognitive, and emotional disturbances
must be identified and addressed for a good
recovery from TBI. Because each TBI is a unique
Figure One (left). This CT scan was obtained on 11/20, nearly one month
after the accident. It was noted that the subarachnoid spaces over the frontal
lobes looked somewhat prominent anteriorly but, at the time, this was
thought to represent a normal variant.
Figure Two (right). This MRI was obtained on 12/1. Small, bilateral, aging,
frontal subdural hematomas (vs. hygromas) were seen, with the left slightly
larger than the right.
event and no single treatment plan can handle an
injury so complex and multifaceted, a team of physicians,
neuropsychologists, therapists, and nurses is
needed to assess each patientʼs condition and develop
a comprehensive plan.
In addition, patient and family education is needed
about TBI symptoms and their timeframe. The patients
are forewarned about possible cognitive and behavioral
changes and what circumstances might worsen
them, such as a recurrent brain injury or alcohol use.
A cornerstone in the management of mild TBI patients
is physical and mental rest until post-concussive
symptoms are controlled, followed by a gradual return
to pre-injury activities. Mental and physical over-exertion
are common causes of lack of improvement in
post-concussive symptoms. Activities that require
concentration and attention, such as employment,
school, computer work, or even videogames, may
exacerbate symptoms and delay recovery. Therefore,
at times, patients are taken out of work or school.
This is also true for physical exertion, so patients,
including athletes, are banned from exercising until
they are symptom-free. Sometimes it is even necessary
for patients to stop performing daily activities,
such as yard work, grocery shopping, house cleaning,
or laundry. When symptom-free, patients must slowly
return to activities, as post-concussive symptoms may
recur if the return is done too quickly.
The treatment of mild TBI can be summarized by the
Four “Rs” – recognition, response, rehabilitation and
return. The mild TBI must be recognized and, if symptoms
persist for more than two weeks, the patient
should be referred to a comprehensive TBI clinic.
After the patient undergoes rehabilitation of all their
physical, cognitive and emotional symptoms, by using
an interdisciplinary approach with energy management,
they can be returned to their prior activities with
good success. ■
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Case Reports
Accidental pediatric head injury from a falling
object
by Andrew W. Kiragu, MD, FAAP
Pediatric Intensive Care Unit
Hennepin County Medical Center
Case report
A six month-old, previously healthy male presented
to Hennepin County Medical Center for management
of injuries sustained when a 27-inch television reportedly
fell on his head. The patient was at home with
his father who had placed him on the living room
floor next to an entertainment center. The father was
apparently moving the entertainment center when the
TV fell off and landed on the childʼs head. The father
immediately moved the TV and the baby was reported
to be responsive, crying, and moving his extremities
at that time.
The father called 911 and the baby was taken to a
local emergency department. By the time he got to
the local hospital, the baby had eye deviation to the
right with increasing somnolence and periods of
apnea. He was intubated and had an emergency
computed tomography (CT) scan of his head. The CT
showed frontal bone fractures, a subdural hematoma
and intraparenchymal hemorrhage in the frontal
lobes. (See Figure One.) Because of these findings,
the baby was flown by helicopter to HCMC. He was
immobilized on a backboard with a C-collar in place.
The patient had been paralyzed and sedated en
route, and therefore neurologic examination could not
be completed. An eFAST exam was negative. A significant
air leak was detected around the ETT, so it
was exchanged over a bougie to one with a larger
internal diameter. A repeat CT scan of his head was
performed, which showed a significant expansion of
the subdural hematoma, a newly appreciated epidural,
and the previously noted frontal bone fractures
and intraparenchymal hemorrhages. While in the
scanner, the patient became bradycardic and hypertensive.
He received a dose of mannitol and was
emergently taken to the operating room (OR).
In the OR, drainage of the subdural and epidural
hematomas and bifrontal craniectomies were performed,
and a ventriculostomy catheter was placed.
The patient developed severe disseminated intravascular
coagulopathy. He received transfusions of
blood, fresh frozen plasma, and recombinant Factor
VII in order to achieve adequate hemostasis. Near
the conclusion of the operation, he had a cardiac
arrest. Chest compressions were started and a round
of cardiac resuscitation drugs was given, with return
of spontaneous perfusion. He was subsequently
transferred to the pediatric intensive care unit (PICU)
for further management.
On arrival to the PICU, his vital signs were: temperature
of 35 degrees Celsius, blood pressure of 66/49,
pulse of 150, respirations breathing with the ventilator
at a rate of 24, and oxygen saturation 97% on
60% oxygen through the ventilator. He weighed 7 kg.
The baby was placed on dopamine and norepinephrine
drips for hemodynamic support, and was given
3% saline to help attenuate cerebral edema. The
patient had a complicated PICU course, including an
emergent return to the OR four days into his hospitalization
to evacuate a new large frontal lobe hematoma.
He was eventually weaned off inotropic and ventilatory
support as well as his sedation and analgesia.
A Child Maltreatment Physician Consult Team consultation
was obtained and Child Protective Services
(CPS) was called to investigate the circumstances
surrounding the childʼs injuries. There was concern
that the father had placed the child in harmʼs way.
While they found the father neglectful, the CPS
investigation concluded that he did not intentionally
drop the TV on his childʼs head. A skeletal survey
and ophthalmologic examination to look for retinal
hemorrhages were performed and were negative.
Figure One. This CT scan shows frontal bone fractures, a subdural
hematoma, and intraparenchymal hemorrhages in the frontal lobe.
About a month after admission, the patient underwent
a cranioplasty to replace his frontal bones and was
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Case Reports
The pediatric intensive care at Hennepin provides state-of-the-art, multidisciplinary care to infants, children, and adolescents.
treated by the occupational and speech therapy
teams and was set to continue to see them as
an outpatient.
At the time of his last clinic visit, the patient had no
obvious neurologic deficits and appeared to be an
active, playful toddler. However, he had notable
behavioral problems as a result of his TBI, including
mood swings and aggressive behavior, and a CT
scan showed notable encephalomalacia of his left
frontal lobe. (See Figure Two.)
Discussion
The management of severe traumatic brain injuries in
children is, in many respects, similar to that of adults.
The goals are similar, primarily the maintenance of
cerebral perfusion and the prevention of secondary
brain injury from hypoxia/ischemia, cerebral edema,
excitotoxicity and inflammation.
The basic approach to the child with a severe TBI
includes attention to the ABCs (airway, breathing,
and circulation) of trauma management. Airway protection
is essential, and requires endotracheal
intubation with an age- and weight- appropriate
Figure Two. This scan was done approximately two years after the patientʼs
initial injury and shows notable encephalomalacia of his left frontal lobe.
8 | Approaches in Critical Care | July 2010

Case Reports
Sign Glasgow Coma Scale Modification for Children Score
Eye opening Spontaneous Spontaneous 4
To command To sound 3
To pain To pain 2
None None 1
Verbal response Oriented Age-appropriate verbalization, orients to sound, fixes
and follows, social smile 5
Confused Cries but consolable 4
Disoriented
Irritable, uncooperative, aware of environment
Inappropriate words Irritable, persistent cries, inconsistently consolable 3
Incomprehensible
Inconsolable crying, unaware of environment or parents,
sounds restless, agitated 2
None None 1
Motor response Obeys commands Obeys commands, spontaneous movement 6
Localizes pain Localizes pain 5
Withdraws Withdraws 4
Abnormal flexion Abnormal flexion to pain 3
to pain
Abnormal extension Abnormal extension 2
None None 1
Best possible 15
score
Figure Three. The Glasgow Coma Scale with Pediatric Modification.
Source: Nichols DG, Ackerman AD, Carcillo JA, Dalton HJ, Kisoon NT(Eds): Rogers Textbook of Pediatric Intensive Care, 4th edition. Philadelphia, Lippincott
Williams & Wilkins, 2008.
endotracheal tube. Intubation is accomplished with
rapid sequence intubation with premedication with
lidocaine and atropine (for children under 12 months)
and cervical spine precautions. Provision of oxygen
to maintain an arterial PCO 2 of >100mmHg is important
as is the avoidance of hyperventilation resulting
in a PO 2 < 35mmHg except when hyperventilation is
used emergently (and briefly) to halt cerebral herniation.
Adequate fluid resuscitation with isotonic fluids
and blood products as needed is important to maintain
cerebral perfusion. When there is evidence of
ICH or herniation, hyperosmolar solutions such as
hypertonic saline and mannitol may be employed as
a bolus. Many patients who have required hyperosmolar
therapy will require maintenance drips of
hypertonic saline (HTS) to attenuate cerebral edema.
The level of injury in children, just as in adults, is
assessed using the Glasgow Coma Scale, which is
modified for children. (See Figure Three.) Additional
evaluation likely will include a CT scan of the head
and this is done in a protocolized manner so as to
minimize the radiation exposure to the child.
Depending on the CT scan and clinical exam findings,
the patient may require a craniotomy and/or
craniectomy and also will need additional invasive
monitoring in the form of a ventriculostomy catheter
and/or intraparenchymal pressure monitor. Pressure
monitors help in determining cerebral perfusion pressure,
which is key in the goal-directed therapy of
severe TBI. There are age-dependent cerebral perfusion
pressure goals in children. Additional neurologic
monitoring modalities that are used in children
include the Licox ® monitor for brain tissue oxygenation,
which aids in the evaluation and treatment of
intracranial hemorrhage and in the prevention of secondary
brain injury.
In addition, key to the management of children with
severe TBI is the maintenance of metabolic
equipoise. Avoidance and treatment of hyperglycemia
is important. In general, maintenance of glucose levels
< 150mg/dL is acceptable; adequate nutritional
support is essential as is the provision of adequate
Approaches in Critical Care | July 2010 | 9

Case Reports
sedation and analgesia. At times, muscle relaxants
may be needed as well as the induction of a barbiturate
coma to control intracranial pressures. Seizure
prophylaxis, typically with phenytoin or fosphenytoin,
also is important. Therapeutic hypothermia for the
management of severe TBI in children is under
investigation although a recent trial revealed
increased mortality in the hypothermia group.
Similar to other forms of physical child abuse, abusive
head trauma sometimes can be difficult to diagnose.
Key to the diagnosis is a thorough history and
physical examination, which must be considered in
relation to the injuries sustained. If the injuries are
not consistent with the history, abuse should be suspected.
The history should include questions regarding
the circumstances of the injury, timelines, details
about the mechanism of injury, and the response of
the caregivers to the injury. The clinician also should
look for behaviors that suggest abuse, including but
not limited to colic, constant crying, and problems
with toileting. The physical examination is aimed at
looking for evidence of physical injury including bruises,
long bone and other fractures. Retinal hemorrhages
often are seen in small children who have
been forcefully shaken.
“If the injuries are not consistent
with the history, abuse should
be suspected.”
Diagnostic imaging includes non-contrast CT scans
of the head looking for skull fractures, intracranial
bleeding and cerebral edema. Magnetic resonance
imaging scans are better than CT scans in delineating
diffuse axonal injury and other intraparenchymal
lesions. Skeletal surveys, particularly for children
under the age of two, are important in evaluation for
fractures due to abuse. When abuse is high in the
differential diagnosis, a skeletal scan should be
strongly considered in order to search for other,
older injuries.
Suggested Readings/Bibliographies for Case Reports
Brain Trauma Foundation: Guidelines for the management of traumatic
brain injury, Third Edition. J Neurotrauma 24(1):S1-S106,
2007.
Chiesa A and Duhaime AC. Abusive Head Trauma. Pediatr Clin N
Am. 56(2): 317-31, 2009.
Dekruijk J, Twijnstra A, Leffers. Diagnostic criteria and differential
diagnosis of mild traumatic brain injury. Brain Injury 15(2):99-106,
2001.
Kissic J, Johnston K. Return to play after concussion: Principles
and practice. Clin J Sport Med 15(6):426-431, 2005.
Kushner D. Mild traumatic brain injury. Arch Intern Med 158:1617-
1624, 1998.
Mazzola C and Adelson PD. Critical Care Management of Head
Trauma in Children. Critical Care Medicine. 30(11): S393-401,
2002.
McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement
on concussion in sport: The Third International Conference on
Concussion in Sport held in Zurich, November 2008. Br J Sports
Med 43 (Suppl1):i76-i84, 2009.
Rockswold GL, Ford SE, Anderson DC, Bergman TA, Sherman
RE. The results of a prospective, randomized trial for treatment of
severely brain-injured patients with hyperbaric oxygen. J
Neurosurg 76:929-934, 1992.
Rockswold GL, Solid CA, Paredes-Andrade E, Rockswold SB,
Jancik JT, Quickel RR. Hypertonic saline and its effect on intracranial
pressure, cerebral perfusion pressure, and brain tissue oxygen.
Neurosurg 65(6):1035-41; Discussion 1041-2, 2009.
Rockswold SB, Rockswold GL, Zaun DA, Zhang X, Cerra CE,
Bergman TA, Liu J. A prospective, randomized clinical trial to compare
the effect of hyperbaric to normobaric hyperoxia on cerebral
metabolism, intracranial pressure, and oxygen toxicity in severe
traumatic brain injury. J Neurosurg: Online October 2009; In print
May 2010.
Rockswold SB, Rockswold GL, Vargo JM, Erickson CA, Sutton RL,
Bergman TA, Biros MH. Effects of hyperbaric oxygen therapy on
cerebral metabolism and intracranial pressure in severely braininjured
patients. J Neurosurg 94(3):403-411,2001.
Vlasselaers D et al. Intensive insulin therapy for patients in paediatric
intensive care: a prospective, randomised controlled study.
Lancet. 373:547-56, 2009.
See www.hcmc.org/approaches for an expanded list of
suggested readings.
Given the difficulty in making the diagnosis of child
abuse and the medical and legal implications of the
diagnosis, a multidisciplinary team approach to
patients with suspected child abuse is essential. The
multidisciplinary team should include pediatricians
with expertise in child maltreatment. Proper training
of health care providers who care for these children
is also important. ■
10 | Approaches in Critical Care | July 2010

Critical Care Profile
Q and A withQ and A with
Gaylan L. Rockswold, MD, PhD
Gaylan L. Rockswold, MD, PhD
In his roles as the medical director of the
Traumatic Brain Injury Center and the chief
of neurosurgery at Hennepin County
Medical Center, Gaylan Rockswold, MD,
has won numerous awards, conducted cutting-edge
clinical research, and treated
thousands of patients with traumatic brain
injuries. Rockswold answered questions for
this article about the history and future of
TBI care.
How did you become interested in TBI?
When I was a resident, I was asked to
come to Hennepin to take over neurosurgery.
This being a trauma hospital, we
saw a lot of TBI patients. Also, even back
then, we knew that hyperbaric oxygen
(HBO) could be helpful to TBI patients, and
Hennepin was a major HBO facility. So it
was a natural evolution based on the state
of affairs here at Hennepin. But I was also
struck by the fact that the major victims of
TBI tend to be young males injured in the
prime of their lives. Someone who is 22 and
brain-injured is almost always going to live
another 20 years but theyʼre disabled. There
was no specific treatment for these patients.
If you look at the statistics, the number of
people who suffer from a TBI has been
estimated at 1.7 million (which includes
mild and moderate TBIs, too) with 52,000
deaths per year. Itʼs been called a silent
epidemic because, in terms of research
and funds, itʼs an under-represented group.
Other conditions that cause major disabilities—heart
disease, stroke, cancer—occur
in older age groups.
How has TBI care changed in the
course of your career?
When I first came to Hennepin in the mid-
1960s as an intern and neurosurgery resident,
there was no intracranial monitoring
of the patient. The diagnostic tools we had
basically consisted of an exam or an
angiogram, where you punctured the
carotid artery, injected dye and took pictures.
Now we have MRI and CT scans,
and a lot of takeoffs on those tests, like CT
angiograms and venograms. In the last 7-8
years, weʼve been able to monitor oxygen
delivery to the brain using a small probe.
The treatment of TBI really changed in the
late 1970s and early 1980s, when neurosurgeon
Don Becker, MD, who was then at
Virginia Commonwealth University, took a
very systematic approach to TBI, with early
intubation of the patient, the removal of
mass lesions and blood clots, etc. He ushered
in a very systematic, protocol-driven
approach to the management of these
patients and a step-wise approach to monitoring
and treating intracranial pressure
(ICP), where we increased the intensity of
treatment as the level of pressure rose.
That approach really improved mortality
and outcomes.
Having said that, we still donʼt have a silver
bullet treatment, despite many multi-centered
clinical trials.
What promising treatments are on
the horizon?
Hyperbaric oxygen (HBO) treatment is an
area of great interest to me. The brain is 2%
of body weight and consumes 20% of the
oxygen the body takes in. At the time of a
severe TBI, the demand for oxygen is high.
HBO treatment increases the delivery of
oxygen to the brain dramatically.
Also, HBO increases oxygen tension in the
brain tenfold, from 25 mmHg of mercury to
250 mmHg. The ability of HBO to dissolve
oxygen in plasma appears to make oxygen
more able to get to the cells. Following
HBO treatment, total oxygen consumption
is increased by one third, and that lasts at
least six hours after treatment. Previous
studies utilizing HBO have shown the mortality
rate in patients with a severe TBI and
increased ICP is cut by a relative 50%.
Those are the preliminary data, which are
very strong. But we need to improve the
data with a larger group of patients, a
Approaches in Critical Care | July 2010 | 11

Critical Care Profile
randomized trial, and an independent psychological/
clinical outcome evaluation at six and 12 months out.
Weʼre also participating in a multicenter trial evaluating
progesterone in TBI treatment, which shows promise.
When it comes to TBI care, what does Minnesota
do well? What could we do better?
Given the enormity of the problem and the large
numbers of people at young ages that are seriously
disabled, we need more financial support for prevention.
Also, I think we need more regionalization of
care, particularly for the severe TBI patient. Patients
need to have state-of-the-art, aggressive care, which
makes a difference in outcomes.
What is the TBI Center at Hennepin?
Basically, weʼre dedicated to the concept of a comprehensive,
multidisciplinary center of excellence for
TBI patient care, education, and research. That covers
a very wide spectrum of care, from emergency
medical services and emergency department care to
acute intensive unit care and the multidisciplinary follow-up
care at Knapp Rehabilitation Center. It also
includes the Mild-to-Moderate TBI Program, research,
and a major prevention program thatʼs been around
for decades.
What is the Mild-to-Moderate TBI Program?
Many people donʼt understand that a mild TBI may
have occurred even when there is no clear history of
a loss of consciousness. But these patients can have
severe problems cognitively and emotionally. Some
of our patients have said, “I thought I was going crazy.”
Theyʼd get CT scans that wouldnʼt show anything so
theyʼd try harder at work to concentrate and perform,
but the harder they would try the worse it would get.
The Mild-to-Moderate TBI Program includes a clinic
where a highly trained and experienced physician
assesses them, gives them a plan, and serves as an
advocate for the patient with their school, job, or family.
The program is directed by my daughter, Sarah
Rockswold, a physical medicine and rehabilitation
physician, along with an interdisciplinary team of
healthcare professionals in nursing, speech language
pathology, occupational therapy, neuropsychology,
clinical psychology, therapeutic recreation, audiology,
physical therapy and social work.
Functional MRIs show that people with mild TBIs
tend to recruit larger areas of brain to do the same
tasks. Thatʼs why patients may fatigue so quickly,
and why pushing harder makes it worse. What weʼve
Sarah Rockswold, MD conducts follow-up evaluation with a patient
from the Mild-to-Moderate TBI Program.
learned is that a big part of recovery from a mild TBI
is mental, emotional, and physical rest.
With mild TBIs, the earlier the treatment, the better.
At Hennepin, if someone has a TBI severe enough to
put them in the hospital or if theyʼve had a loss of
consciousness, they are referred automatically to our
clinic. Also, if someone still has symptoms a few
weeks after trauma to the head, itʼs time to be
assessed. Patients like these, especially the young
athlete, are much more vulnerable to a second injury.
To have someone understand and diagnose the
problem, and provide a plan for them, really aids the
rapidity of their recovery.
How did you and your daughter end up in the
same field?
Sarah has heard TBI talk since she was young and I
think she got intrigued with HBO. Our previous NIHfunded
clinical trial in HBO generated a lot of data,
which we had difficulty analyzing properly. Sarah took
a year off from her education in the late 1990s and
analyzed this data, and subsequently it was published
in the Journal of Neurosurgery in 2001. This was a
critical piece of work, which led to further NIH funding
and our most recent clinical trial. Following this year
of working with the HBO data, she entered a physical
medicine and rehabilitation residency at the University
of Minnesota and joined the faculty at Hennepin in
2004 when she started the Mild-to-Moderate TBI
Program. She ended up specializing in this niche of
mild TBI and has become very expert in it. Itʼs great
as a father to be working together with your daughter.
How is treating pediatric TBI different?
Weʼve had a pediatric TBI program here even prior to
the overall TBI center—it has always been a special
interest. What we know is, older teens have a lot of
similarities with adults but as the age drops, the differences
are bigger. With children, blood volumes are
relatively small so they donʼt tolerate blood loss very
well. For very small children, skulls are thin and the
12 | Approaches in Critical Care | July 2010

Critical Care Profile
brain is more fragile so monitoring them requires
special techniques.
As children get older, over the age of five or six, their
brains have better potential for recovery. Kids have
special needs post-injury in terms of their education
and fitting into their peer groups and often parents
want guidance with this. At Hennepin, children have
their own pediatric intensive care unit with pediatric
subspecialty experts and their own outpatient program
until they are in their early teens.
In the future, what will TBI care in Minnesota
look like?
We are going to find a treatment thatʼs specific to
traumatic brain jury. Iʼm confident of that. Right now,
HBO is the only way to deliver the supranormal amounts
of oxygen needed but maybe there will be simplerways
to get there like oxygen-carrying medications.
I think someday thereʼll be specific protocols that
may include a combination of treatments and there
could be a varying combination of treatments
depending upon the type, severity, and specific
pathology of the TBI. Thatʼs a ways off, at least a
couple of decades, but thatʼs the kind of thought that
keeps you going. ■
The Traumatic Brain Injury Center at
Hennepin County Medical Center
A comprehensive multidisciplinary center
of excellence for patient care, education and
research to serve people who have sustained
a traumatic brain injury.
More than 2,000 patients served each year
with patients from throughout the upper Midwest.
#1 hospital in Minnesota for inpatient TBI
admissions. (Source: Minnesota Hospital
Association data)
Severe Traumatic Brain Injury
In-house specialty physician expertise
available 24/7, including neurosurgery, trauma
surgery, and critical care services.
Lower lengths-of-stay and mortality ratios
than national benchmarks. (Source: University
Hospital Consortium)
Pediatric Brain Injury
Twenty-one year-old program, with more than
2,000 patients served since the programʼs inception.
Multidisciplinary, pediatric team of experts,
including a dedicated program coordinator to
coordinate return to school.
Child maltreatment team specializing in
pediatric abusive head trauma.
Mild-to-Moderate Traumatic Brain Injury
Dedicated physical medicine and
rehabilitation physicians specializing in TBI.
Comprehensive, multidisciplinary outpatient
therapy team.
More than 1,300 adult and pediatric clinic
visits per year.
Rehabilitation
On-site, brain-injury-accredited acute
rehabilitation by the Miland E. Knapp
Rehabilitation Center. Accreditation by the
Commission on Accreditation of Rehabilitation
Facilities for its adult and adolescent inpatient
program with a specialty accreditation for brain
injury rehabilitation.
Nearly 70% of admissions are patients with
brain injuries due to trauma or stroke.
For more information, please call Carol Ann Smith,
RN, CNRN, program coordinator, at (612) 873-3284.
Hennepin County Medical Center took its TBI message to the streets
as part of its nationally recognized TBI public information campaign.
The rolling tub is used to educate onlookers about the danger of falling
in the shower.
Approaches in Critical Care | July 2010 | 13

RN Perspectives
RN Perspectives: The effectiveness of a peer-led
campaign to change teenagers’ driving habits
by Julie Philbrook, RN, MA
Trauma Services
Hennepin County Medical Center
“This
campaign
is one that
would be
easy to
replicate
in other
communities
and resources
are available
to help.”
In Minnesota, motor vehicle crashes (MVC)
are the leading cause of death among
teenagers. In 2008, 29 Minnesota teens
between 15 and 19 years of age died in
traffic crashes and over four thousand
were injured. Of those killed, 43% were not
wearing their seat belt, even though seat
belts increase the likelihood of surviving a
crash by nearly 50%. Unfortunately, not
only are teens more likely to be involved in
a car crash, they also are more likely to
eschew seat belt use.
As a former critical care nurse, I always
was troubled by how frequently I cared for
young people with preventable injuries. As
the current injury prevention coordinator at
Hennepin County Medical Center, I have
witnessed significant positive impact when
critical care providers and other hospital
staff members get involved in prevention
efforts. Teens and young adults look to
front-line care providers as authorities on
the issue of injury prevention.
The alarming statistics on survival, and the
conviction that we could make a difference
with teen drivers, led Hennepin to launch a
seat belt safety program called the Drive
Smart Challenge in 2007. This campaign is
one that would be easy to replicate in other
communities and resources are available
to help clinicians interested in launching a
similar program.
The Drive Smart Challenge was funded by
the Minnesota Department of Public Safety
and AAA Minneapolis and based heavily on
a preexisting initiative administered by the
Department of Public Health of Hennepin
County. The elements of the preexisting
program that created the foundation for the
Drive Smart Challenge included:
Hennepin County manual of
interventions. A Hennepin County
manual provided a list of potential
interventions to foster behavior change
among the target population. Interventions
included video or public address
system announcements, posters, seat
belt pledge cards, guest speakers,
mock crashes staged in or near school
buildings, and unannounced seat belt
checks in the schoolsʼ parking lots,
among other choices.
14 | Approaches in Critical Care | July 2010

RN Perspectives
A peer leadership model. Student leaders
recruited from student government or Students
Against Driving Drunk chapters shaped their
schoolsʼ campaigns by choosing up to eight
interventions from the Hennepin County manual.
Pre- and post-campaign seat belt checks. To
measure the effect of the campaign, student
leaders conducted unannounced seat belt
checks at the entrance of student parking lots at
the beginning and end of the month-long campaign.
Hennepin County Medical Center program leaders
added several new elements to the Drive Smart
Challenge:
A focus on crash prevention. The Drive Smart
Challenge crafted educational content around the
top three factors in motor vehicle crashes in
Minnesota: the dangers of excessive speed,
distracted driving, and failure to yield right-of-way.
A modified results measurement process. The
modified seat belt check included data on driversʼ
use of seat belts as well as the use of belts by
any teenage passengers who were sitting in the
front seat. Data were collected on both car
occupants and schools were assigned an overall
score based on the two measures.
A locally produced documentary called
“Room to Live.” Schools were required to show
this documentary, which demonstrated what
happens when the occupant of a car doesnʼt
wear a seat belt and is ejected.
Increased parental involvement. Program
leaders communicated with parents to recommend
that they sign a safe driving contract obligating
all driving family members to use safe practices
while driving. Program leaders suggested that
families use the safe driving contracts available
from many auto insurance companies. These
contracts typically are customizable, allowing
family members to list specific driving expectations
and the consequences to breaking the rules.
Participation of local law enforcement.
Program leaders partnered with law enforcement
personnel to produce a mock crash event, provide
speakers for assemblies, and generate visible
enforcement efforts in the area around the school.
Financial incentives. Each school was awarded
$125 for completing the campaign and the
schools with the most improved seat belt use
rate and the best overall seat belt use rate
received an additional $125.
In Spring 2008, eleven schools with a total of 21,000
students agreed to participate in the program. The
majority of the schools began the challenge with a
driver seat belt use rate below the statewide driver
seat belt use rate of 88%. Upon completion of the
program, all but one school documented an increase
in driver seat belt use. The most improved school
saw a 15% increase. However, most schoolsʼ overall
scores were compromised by the seat belt use rates
of front-seat passengers.
Approximately six months later, in the fall of 2008,
four schools agreed to recheck seat belt use.
Unfortunately, three schools reported a driver use
rate that had dropped below the rate calculated
before the Drive Smart Challenge had begun, which
schools attributed in large part to the fact that the
senior class that had led and participated in the campaign
had graduated and new freshmen students
with lower seat belt use rates had arrived. Once
again, unbuckled front-seat passengers lowered the
schoolsʼ overall scores.
Reaching teens with safe driving messages continues
to be a challenge and each year brings a fresh
crop of students who have received driversʼ licenses
and could benefit from education.
While the month-long Drive Smart Challenge has
shown great improvement in teen seat belt use, the
post-campaign drops in seat belt use reveal a need
for consistent but strategic message repetition.
Repeat the messages too often and teens may tune
the messages out; repeat the messages too infrequently
and teens might revert back to unsafe habits.
Drive Smart Challenge leaders currently are assessing
how often to repeat messages and continue to
update and hone campaign strategies.
This program can be easily replicated in any high
school or college environment. You can download the
manual and supporting materials from www.hcmc.org/
approaches. For more information, contact Julie
Philbrook, Hennepinʼs trauma prevention specialist,
at julie.philbrook@hcmed.org or (612) 873-8500. ■
Bibliography/Suggested Readings
Berg, H-Y. Reducing crashes and injuries among young drivers:
what kind of prevention should we be focusing on? Injury
Prevention. Jun 2006. i15-19.
Minnesota Department of Public Safety Office of Traffic Safety
2008 Crash Facts,http://www.dps.state.mn.us/OTS/crashdata/
crash_facts.asp (Retrieved 3/8/2010.)
Senserrick TM. Reducing young driver road trauma: guidance and
optimism for the future. Injury Prevention. Jun 2006. i56-60.
Simons-Morton B, Ouimet MC. Parent involvement in novice teen
driving: a review of the literature. Injury Prevention. Jun 2006. i30-37.
Winston FK, Senserrick TM. Competent independent driving as an
archetypal task of adolescence. Injury Prevention, Jun 2006. i1-3.
Approaches in Critical Care | July 2010 | 15

Calendar of Events
To register for a course, visit
www.hcmc.org and click on
“Professional Education and
Training.” For questions or
additional information, contact
Susan Altmann in Medical
Education at Hennepin County
Medical Center at (612) 873-5681
or susan.altmann@hcmed.org
unless another contact person
is provided. Classes are at
Hennepin County Medical
Center unless otherwise indicated.
Many courses fill quickly; please
register early to avoid being
wait-listed.
July
July 6______________________________________
Advanced Cardiac Life Support
July 9______________________________________
Cardiopulmonary Resuscitation, for MDs
July 13-14__________________________________
Advanced Trauma Life Support
July 15_____________________________________
Basic Life Support, for Hennepin staff only
July 20-21__________________________________
Advanced Pediatric Life Support
July 24_____________________________________
Infant and Child Cardiopulmonary Resuscitation
July 27_____________________________________
Advanced Cardiac Life Support Renewal, for
Hennepin staff only
August
August 4___________________________________
Infant and Child Cardiopulmonary Resuscitation
August 6___________________________________
Cardiopulmonary Resuscitation, for MDs
August 10-11________________________________
Advanced Cardiac Life Support
August 11___________________________________
Advanced Cardiac Life Support Renewal
August 12__________________________________
Basic Life Support, for Hennepin staff only
August 17-18________________________________
Advanced Cardiac Life Support, for Hennepin staff
only
August 24__________________________________
Advanced Cardiac Life Support, for Hennepin staff
only
September
September 7________________________________
Advanced Cardiac Life Support, for Hennepin staff
only
16 | Approaches in Critical Care | July 2010

Calendar of Events
September continued
September 8________________________________
Emergency Medical Technician basic course
September 8-9_______________________________
Pediatric Advanced Life Support
September 9________________________________
Pediatric Advanced Life Support Renewal
September 10_______________________________
Cardiopulmonary Resuscitation, for MDs
September 13_______________________________
Emergency Medical Technician basic course
September 14_______________________________
Basic Life Support, for Hennepin staff only
September 15_______________________________
Emergency Medical Technician basic course
September 15-16_____________________________
Trauma Nursing Core Course
September 20_______________________________
Emergency Medical Technician basic course
September 21-22_____________________________
Advanced Cardiac Life Support, for Hennepin
staff only
September 22_______________________________
Emergency Medical Technician basic course
September 25_______________________________
Infant and Child Cardiopulmonary Resuscitation
September 27_______________________________
Emergency Medical Technician basic course
September 29_______________________________
Emergency Medical Technician basic course
October 6___________________________________
Advanced Cardiac Life Support Renewal, for
Hennepin providers only
Emergency Medical Technician basic course
October 8___________________________________
Cardiopulmonary Resuscitation, for MDs
October 11__________________________________
Advanced Cardiac Life Support
Emergency Medical Technician basic course
October 12__________________________________
Advanced Cardiac Life Support
Advanced Cardiac Life Support Renewal
October 13__________________________________
Basic Life Support, for Hennepin providers only
Emergency Medical Technician basic course
October 18__________________________________
Pedicatric Advanced Life Support
Emergency Medical Technician basic course
October 19__________________________________
Pedicatric Advanced Life Support
Pedicatric Advanced Life Support Renewal
Emergency Medical Technician basic course
October 20__________________________________
Cardiopulmonary Resuscitation, for MDs
Emergency Medical Technician basic course
October 25__________________________________
Emergency Medical Technician basic course
October 27__________________________________
Emergency Medical Technician basic course
October 27-29_______________________________
Advanced Cardiac Life Support, in Willmar
Hennepin Connect magnet v2 3/31/08 10:16 AM Page 5
October
October 4___________________________________
Emergency Medical Technician basic course
October 5___________________________________
Advanced Cardiac Life Support, for experienced
providers
Rapid access to Hennepin physicians
for referrals and consults
Services available 24/7
1-800-424-4262
612-873-4262
Approaches in Critical Care | July 2010 | 17

News Notes
News Notes
Within 24 hours after injury, eligible
patients for the study were randomized into
three groups: One group received normobaric
treatment (increased levels of oxygen
delivered at the patientʼs bedside through
the ventilator); another group received
hyperbaric treatment in Hennepinʼs hyperbaric
oxygen chamber; and a control group
received standard oxygen therapy. The
patients who received higher levels of oxygen
via the hyperbaric oxygen chamber
were found to have a marked increase in
positive brain metabolism compared to the
normobaric and control group.
This research provides important preliminary
data for a National Institutes of Health
(NIH) supported multicenter trial. NIH trials
directly assess the ability to improve clinical
outcomes, which is the final step needed
to change standard clinical processes.
Currently standard clinical practice does
not include hyperbaric oxygen for traumatic
brain injury.
__________________________________
Study on traumatic brain injury
patients shows potential benefit of
hyperbaric oxygen therapy
A five-year study conducted at Hennepin
County Medical Center shows a significant
benefit to using hyperbaric oxygen therapy
to improve brain metabolism and recovery
after a traumatic brain injury (TBI). Results
were published online in October 2009 and
in print in the May 2010 Journal of
Neurosurgery.
“Thereʼs a direct correlation between clinical
outcome and the degree to which the
brainʼs metabolism is restored,” explains
one of the studyʼs authors, neurosurgeon
Gaylan Rockswold, MD. “In previous
research we learned that the brainʼs energy
production is improved and maintained
with hyperbaric oxygen treatment but this
study confirms that hyperbaric oxygen
treatment has a major impact in terms of
increased energy production.”
New clinical trial available for patients
with moderate to severe TBIs
A new clinical trial called ProTECT, which
will test protegesterone as a treatment for
patients with moderate to severe brain
injuries, is now available at three Twin
Cities hospitals through the Neurological
Emergency Treatment Trials (NETT).
Hennepin County Medical Center, Regions
Hospital, and North Memorial Medical
Center are participating in the trial. Patients
must arrive within four hours of trauma and
will be randomized to receive either progesterone
or a placebo. Outcomes will be
assessed throughout hospitalization and at
six months after injury.
Study coordinators anticipate enrolling
1,140 patients over the next five years. The
study will be conducted at 17 academic
centers and involve over 60 hospitals
nationwide.
18 | Approaches in Critical Care | July 2010

News Notes
their own brains” and learn about the effects of TBIs.
The Brain Bar is one of many tools Hennepinʼs TBI
Center uses to try to prevent TBIs in the community.
“With the recent release of new data from the CDC
stating that 1.7 million traumatic brain injuries occur
each year in the U.S., and the increasing number of
sports concussions each year, it is an important part
of our mission to focus on prevention,” said Carol
Ann Smith, RN, CNRN, program coordinator for the
TBI Center.
National Football League focuses
on concussion
Last fall, a National-Football-
League-commissioned study
found that former professional
football players experience
memory-related diseases at 19
times the normal rate for males
ages 30 through 49.
The Brain Bar goes to several community events
each year. In addition, the TBI Center works with the
Minnesota Thunder and Minnesota Timberwolves to
host TBI prevention “camps” for children each year.
Other events focus on sports and recreational safety,
helmet use, ladder safety, and senior fall prevention.
An online version of the Brain Bar is available for
children and adults at www.savethisbrain.org.
The findings led to congressional hearings about how
NFL teams make decisions about when players
return to the game after concussion. Shortly after the
hearings, the physician leaders of the NFLʼs mild
traumatic brain injury committee resigned.
“Itʼs important to recognize that many players donʼt
get a TBI but when they do, even if itʼs mild, it can
significantly affect their lives and make them more
vulnerable to more severe brain damage if they are
returned to play while they are still symptomatic,”
says Sarah Rockswold, MD, medical director of
Hennepinʼs Mild-to-Moderate TBI program. “Our hope
is that the attention to this issue leads to changes not
just at the professional level but at the college, high
school and youth league level.”
__________________________________________
Brain Injury Awareness Month attracts
learners of all ages
Several Minnesota organizations spent March—Brain
Injury Awareness Month—hosting events to help educate
the public about the many effects of traumatic
brain injury. Hennepin County Medical Centerʼs Brain
Bar was used during a variety of events. The Brain
Bar is a computerized kiosk that lets users “build
Approaches in Critical Care | July 2010 | 19

News Notes
Easy Street, one
of Hennepinʼs
physical therapy
facilities, which
is located within
the Knapp
Rehabilitation
Center, aids
TBI patients
by simulating
many of their
daily activities.
New comparative data released on TBI
patient rehabilitation
Hennepinʼs Miland E. Knapp Rehabilitation Center
achieved impressive outcomes again in 2009,
according to recently released outcomes data on
rehabilitation patient programs across the U.S.
The database, maintained by Uniform Data System
for Medical Rehabilitation © , allows comparisons of
length-of-stay efficiency and discharges-to-home for
TBI rehabilitation patients, among other measures.
Results for 2009 show:
Knappʼs TBI patients make more progress
than TBI patients nationally. The measure,
called the length-of-stay efficiency rate, takes into
account patientsʼ functional abilities at admission
and discharge, and divides by the number of
inpatient days (so centers donʼt accrue a higher
score because of longer lengths-of-stay).
Knappʼs 2009 length-of-stay efficiency rate was
2.63 while the national rate was 2.27. “When you
dig into the data, what it shows is that patients
typically come into Knapp with the same functional
ability as patients nationally, but when they
leave, they leave at a higher rate of functioning—
without staying longer,” says Mary Jo Peck, RN,
program manager for Knapp Rehabilitation Center.
More Knapp TBI patients are able to return
home than TBI patients nationally. Nationally,
72% of TBI patients are discharged to home,
while 78% of Hennepinʼs TBI patients are able to
return to home.
Knapp has special expertise in brain injuries, with 2/3
of Knapp patients having brain injuries, as compared
to 5.5% of patients in rehabilitation program nationally.
Brain injury patients are served by an interdisciplinary
team, which includes physicians, nurses, speech
pathologists, occupational and physical therapists,
clinical psychologists, neuropsychologists and therapeutic
recreation specialists. Knapp is accredited by
the Commission on Accreditation of Rehabilitation
Facilities (CARF) for Adult and Adolescent Inpatient
Program with a specialty accreditation for Brain
Injury Rehabilitation.
20 | Approaches in Critical Care | July 2010

For more information
To download additional resources for
critical care physicians, please visit
the Approaches in Critical Care Web
site at www.hcmc.org/approaches.
There, youʼll find:
An electronic version of
Approaches in Critical Care that
you can email to colleagues
Manual and supporting materials
for launching a Drive Smart
Challenge campaign to prevent
traumatic brain injuries in your
community.
Hennepin protocols for the
emergency care and intensive
care of adult and pediatric TBIs.
Downloadable brochures with
guidelines for determining when
students/athletes can return to
sports/school after TBIs.
Information on scheduling a
Hennepin TBI Center team
member to speak at educational
events for medical providers.
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Trauma Center and public teaching hospital
repeatedly recognized as one of Americaʼs
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As one of the largest and oldest hospitals in
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