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"AbstrakBrain relaxation and prevention from cerebral edema are essential in craniectomy. Osmotherapy with 20% mannitol are generally used to withdraw fluid from the brain parenchyma, however may cause hemodynamic fluctuation, due to increase diuresis. On the other hand 0.5 M hypertonic sodium lactate (HSL) appeared as an alternative of osmotherapy. This study aimed to observe the effect of hypertonic sodium lactate (HSL) on brain relaxation, blood glucose level and hemodynamic variables in craniectomy due to moderate brain injury.Methods: A randomized controlled study of 42 cases with moderate brain injury, aged 18 - 65 years, ASA 1 - 3, between September-November 2012, was carried out. The patients were divided into group M (n = 21) that received 2.5 mL/kg 20% mannitol and group HSL that received 2.5 mL/kg 0.5M HSL. Mean arterial pressures (MAP), central venous pressures (CVP) and urine output were measured after induction, and at 15, 30, 45, 60 min after infusion. Brain relaxation was assessed at a four-point scale after opening the duramater. Blood glucose levels were measured before induction and at 60 min after the infusion. Appropriate statistical tests were used for comparison. Unpaired t-test was used to compare hemodynamic and blood glucose level, and chi-square was used to compare brain relaxation.Results: MAP at 60 minute was significantly higher in HSL group than M group (81.66 ± 7.85 vs 74.33 ± 6.18 mmHg; p = 0.002). There was no difference in brain relaxation (p = 0.988). A significant increase in blood glucose level was observed in group HSL (17.95 ± 11.46 mg/dL; p = 0.001).Conclusion: Half-molar HSL was as effective as 20% mannitol in producing brain relaxation, with better hemodynamic stability and gave significant increase in blood glucose level."

"ABSTRAKLatar Belakang. Efek penurunan kadar hematokrit oleh manitol memberimanfaat lebih pada tata laksana cedera kepala. Kadar hematokrit 30-35%merupakan kadar hematokrit efektif untuk mendapatkan keluaran yang baik pascacedera kepala. Meski dosis awal rekomendasi pemberian manitol memilikirentang yang cukup besar antara dosis rendah dengan dosis tingginya, kedua dosisini memiliki efektivitas yang sama dalam menurunkan Tekanan Intrakranial(TIK). Diduga kedua dosis ini juga memiliki efek yang sama terhadap penurunankadar hematokrit.Metode. Penelitian ini merupakan uji eksperimental klinis dengan randomizedcontrolled trial tersamarkan. Subjek penelitian adalah pasien cedera kepalasedang (CKS) dan cedera kepala berat (CKB) dengan gejala dan tanda klinispeningkatan TIK yang terindikasi mendapat terapi manitol yang datang ke RumahSakit Cipto Mangunkusumo (RSCM) Jakarta dan bersedia mengikuti penelitian.Dilakukan wawancara, pemeriksaan fisik umum dan neurologis serta pemeriksaankadar hematokrit. Dilakukan analisis data menggunakan perangkat SPSS 17.0.Hasil. Diperoleh 30 subjek pasien cedera kepala sedang dan berat yang mendapatterapi manitol, masing-masing 15 orang untuk kelompok manitol dosis 0.5g /kgBB dan 1g/ kgBB. Terjadi penurunan kadar hematokrit sebesar 5% padakelompok dosis 0.5g/ kgBB dan sebesar 6% pada kelompok manitol dosis 1g/kgBB pasca 10 menit pemberian manitol. Kadar tersebut meningkat kembali kekadar normal 6 jam pasca pemberian. Didapatkan kecendrungan penurunan ratarataMean Arterial Blood Pressure (MABP) dan frekuensi nadi pasca 10 menitpemberian manitol, yang kemudian mengalami peningkatan nilai saat dilakukanpengukuran 6 pasca jam pemberian. Didapatkan kecendrungan peningkatan GCSdan perbaikan reaktivitas pupil pada kedua kelompok dosis manitol di dua waktupengukuran.Kesimpulan. Terdapat kecenderungan penurunan kadar hematokrit pasca 10menit pemberian manitol, yang meningkat kembali ke kadar normal 6 jam pascapemberian pada kedua dosis manitol yang diteliti. Pada penelitian ini jugadidapatkan kecendrungan perbaikan kondisi klinis pasien yang tidak berbeda padakedua dosis manitol pasca 10 menit dan 6 jam pemberian.

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ABSTRACTBackground: The decreasing effect of hematocrit due to mannitol givesadditional benefit in management of traumatic brain injury (TBI). Hematocritlevel of 30 - 35% is the effective level to obtain good outcome after TBI. Eventhough initial recommended dosage of mannitol has a relatively wide rangebetween low and high dosage, both dosages have similar effectivity in reducingintracranial pressure (ICP). It is assumed that both dosages also have similareffect on decreasing hematocrit level.Methods: This was a clinical experimental study with double-blind randomizedcontrolled trial. The study subjects were patients with moderate and severe TBIwith signs and symptoms of increased ICP who have indications to be givenmannitol and were hospitalized in Cipto Mangunkusumo Hospital, Jakarta andagree to participate in the study. All subjects were interviewed, underwent generaland neurological physical examination, as well as level of hematocrit. Dataanalysis were done by using SPSS 17.0.Results: There were 30 patients with moderate and severe TBI who receivedmannitol. They were divided into two groups, each consists of 15 patients. Thefirst group received mannitol 0.5g/kgBW and the second group received 1g/kgBW. Hematocrit level was decreased by 5% in the first group, and 6% in thesecond group after 10 minutes administration of mannitol. The hematocrit levelwas observed to increase to its normal value after 6 hours administration ofmannitol. There was a tendency of decreasing Mean Arterial Blood Pressure(MABP) and heart rate after 10 minutes administration of mannitol, which thenwould increased after 6 hours after administration. In addition, there were alsotendencies of increasing GCS and better pupillary reactivity in both groups onboth measurement.Conclusions: The hematocrit level was found to decrease after 10 minutesadministration of mannitol, and increase back to its normal value after 6 hoursadministration on both dosages. This study also found that moderate and severeTBI patients receiving mannitol tend to show clinical improvement which weresimilar on both dosages both after 10 minutes and 6 hours of adminstration."

"ABSTRAKTujuan : Mengetahui hubungan kadar protein S100 pada pasien cedera otak ringan dan sedang yang diukur secara bertahap pada saat pasien tiba di rumah sakit, beberapa jam pasca trauma, dan sekian hari perawatan di rumah sakit, sehingga dapat digunakan sebagai petanda kerusakan otak.Latar belakang : Cedera otak menjadi masalah kesehatan masyarakat di seluruh dunia karena dapat menyebabkan kecacatan dan kematian. Diagnosis cedera otak ditegakkan berdasarkan pemeriksaan klinis neurologi, dan CT scan atau MRI untuk melihat kerusakan anatomi. Pemeriksaan kadar protein S100 pada pasien cedera otak ringan dan sedang dengan menggunakan bahan serum diperlukan untuk mendeteksi dan dapat untuk mengevaluasi adanya kerusakan otak pasca traumatik.Metode : Subyek penelitian adalah orang sehat dan pasien cedera otak ringan dan sedang berdasarkan nilai SKG, pemeriksaan klinis neurologi, dan CT scan, yang diambil darahnya untuk pemeriksaan kadar protein S100 pada saat tiba di rumah sakit, 6 jam pasca trauma, 24 jam pasca trauma, dan hari terakhir perawatan. Pemeriksaan kadar protein S100 dalam serum menggunakan Elecsys S100 dengan prinsip ECLIA.Hasil : Terdapat perbedaan bermakna (p = 0,001) pada semua kadar protein S100 yang diukur saat tiba di rumah sakit, 6 jam pasca trauma, 24 jam pasca trauma, dan hari terakhir perawatan, baik pada pasien cedera ringan maupun sedang. Puncak kadar protein S100 tercapai pada 6 jam pasca trauma pada pasien cedera otak ringan dan sedang. Kadar protein S100 pada pasien cedera otak sedang saat tiba di rumah sakit lebih tinggi secara bermakna dibandingkan pasien cedera otak ringan (median 0,259 μg/L rentang 0,207 – 0,680 μg/L vs median 0,150 μg/L rentang 0,051 – 0,289 μg/L, p = 0,001) dan kadar protein S100 pasien cedera otak ringan saat tiba di rumah sakit lebih tinggi secara bermakna dibandingkan kadar protein S100 orang sehat (median 0,150 μg/L rentang 0,051 – 0,289 μg/L vs rerata 0,065 ± 0,017μg/L, p = 0,001).Kesimpulan : Pada pasien cedera otak ringan dan sedang saat tiba di rumah sakit sudah terdapat peningkatan kadar protein S100 secara bermakna dibandingkan dengan orang sehat. Protein S100 dapat digunakan sebagai petanda untuk deteksi dan evaluasi kerusakan otak pasca traumatik.

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ABSTRACTObjective: To identify the relation of protein S100 level in mild and moderate brain injury patient, which is measured repeatedly at admission, few hours post trauma, and few days of hospitalization, thus it can be used as brain injury biomarker.Background: Brain injury becomes worldwide public health issue since it may cause disability and mortality. The diagnosis of brain injury is made based on clinical neurology examination, and CT scan or MRI, to observe anatomical impairment. Serum S100 protein examination in mild and moderate brain injury patients is needed to detect and evaluate the presence of post traumatic brain injury.Method: This research subject is healthy people and patients with mild and moderate brain injury, based on their GCS grade, clinical neurologic examination, and CT scan. On these patients, the blood for S100 protein examination is taken at admission, 6 hours post trauma, 24 hours post trauma, and last day of hospitalization. Examination of a serum S100 protein is conducted using Elecsys S100 with ECLIA method.Result: There is significant difference (p = 0,001) in mild or moderate brain injury patients in all serum S100 protein which is measured at admission, 6 hours post trauma, 24 hours post trauma, and the last day of hospitalization. The peak level of serum S100 protein reached at 6 hours post trauma. Serum S100 protein in moderate brain injury patients at admission is significantly higher than the mild ones (median 0, 259 μg/L range 0,207 – 0,680 μg/L vs median 0,150 μg/L range 0,051 – 0,289 μg/L, p = 0,001), and serum S100 protein in mild brain injury patients is also significantly higher than healthy people (median 0,150 μg/L range 0,051 – 0,289 μg/L vs mean 0,065 ± 0,017μg/L, p = 0,001).Conclusion: In mild and moderate brain injury patients, serum S100 protein is already significantly increased at admission, compared to healthy people. Serum S100 protein can be used as brain injury biomarker to detect and evaluate the presence of post traumatic brain injury."

"Tatalaksana nutrisi pada pasien cedera kepala sedang dan berat mencakup pemberian makronutrien mikronutrien nutrien spesifik pengelolaan cairan dan elektrolit serta pemantauan dan evaluasi Dukungan nutrisi yang adekuat perlu diberikan pada pasien cedera kepala agar meningkatkan perbaikan kondisi optimal pasien Sebagian besar pasien cedera kepala memiliki status gizi yang baik sebelum terjadinya trauma Pemenuhan nutrisi yang optimal dapat turut menunjang perbaikan inflamasi metabolisme dan menjaga tidak terjadi penurunan status gizi Pasien pada serial kasus ini seluruh pasien laki laki mempunyai rentang usia 19 sampai 49 tahun Adanya penyakit penyerta mempengaruhi luaran akhir pasien cedera kepala Terapi nutrisi diberikan sesuai dengan kebutuhan setiap pasien Kebutuhan energi total dihitung berdasarkan perkiraan kebutuhan energi basal menggunakan persamaan Harris Benedict dikalikan faktor stres 1 4 1 6 dan pemberiannya disesuaikan dengan kondisi klinis pasien Kebutuhan protein 1 5 2 g kg BB hari dan lemak 20 30 Pemantauan mencakup tanda klinis toleransi asupan makanan kapasitas fungsional keseimbangan cairan parameter laboratorium dan antropometri Pemberian nutrisi pada pasien cedera kepala berat dengan sakit kritis bersifat individual dan mencakup semua aspek Tatalaksana nutrisi yang baik dan dilanjutkan dengan edukasi pada pasien dan keluarga diharapkan dapat meningkatkan kualitas hidup pasien cedera kepala dengan meminimalkan komplikasi yang dapat terjadi

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Nutrition therapy in patients with moderate and severe traumatic brain injury includes the provision of macronutrient micronutrient specific nutrition fluid and electrolyte management with monitoring and evaluation Adequate nutrition support should be given in traumatic brain injury to optmalyze outcome patient Three from four this case series have a normoweight before trauma Nutritional support can improve metabolism decrease inflammation and manage nutritional status Patients in this case series all male have an age range from 19 to 49 kg years Their comorbid condition influence outcome of traumatic brain injury patient Nutritional support is given according to each patient rsquo s requirement which is calculated with basal energy requirement using Harris Benedict equation with stress factor 1 4 1 6 and the administration starts with individual condition which gradually increased to reach the total energy expenditure Protein requirement 1 5 2 g kg day and lipid requirement is calculated 20 30 total energy requirement Patient rsquo s monitoring include clinical signs food intake tolerance functional capacity fluid balance laboratory and anthropometric parameter were taken With the management of good nutrition expected quality of life of patients with moderate and severe traumatic brain injury various comorbidities would be better "

"Latar belakang. Laktat awalnya dianggap sebagai produk berbahaya dari metabolisme anaerobik, namun bukti terbaru menunjukkan laktat dapat melindungi neuron dan memperbaiki luaran. Dalam studi ini, kami mencari korelasi antara kadar laktat darah dan luaran pascaoperasi pasien dengan cedera otak traumatika (traumatic brain injury, TBI). Metode. Studi kohort prospektif ini mengambil sampel dari pasien dengan TBI terisolasi yang menjalani operasi di Departemen Bedah Saraf RSUPN dr. Cipto Mangunkusumo dari April 2020 hingga Juni 2021. TBI dikategorikan menjadi ringan (GCS 13-15), sedang (GCS 9-12), dan berat (GCS 3-8). Kadar laktat darah diambil dari vena perifer sebelum dan pada hari ke-3 pascaoperasi. Luaran klinis dievaluasi berdasarkan perubahan (D) GCS pada hari ke-7 pascaoperasi dengan preoperasi, lalu dibagi menjadi 3 kelompok: membaik, tidak berubah, dan memburuk. Hasil. Dari 72 subjek dalam penelitian ini, ditemukan terdapat korelasi yang signifikan (p = 0,019, r = 0,275) antara kadar laktat preoperatif dengan D GCS, dimana semakin tinggi kadar laktat preoperatif maka D GCS akan semakin positif. Berdasarkan analisis dengan kurva receiver operating characteristics (ROC) dan Chi-square, ditemukan bahwa subjek dengan kadar laktat >=2,35 mmol/L memiliki kemungkinan 1,64 kali lebih besar untuk mengalami peningkatan GCS pascaoperasi. Kesimpulan. Laktat dapat dijadikan suatu faktor prognostik luaran baik pascaoperasi pasien TBI.

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Background. Lactate was initially thought to be a harmful product of anaerobic metabolism, but recent evidence suggests it can protect neurons and improve outcomes. Therefore, we sought a correlation between blood lactate levels and the postoperative outcome of patients with traumatic brain injury (TBI). Method. This prospective cohort study took samples from patients with isolated TBI who underwent surgery at the Department of Neurosurgery, Cipto Mangunkusumo National Hospital from April 2020 to June 2021. Blood lactate levels were taken from peripheral veins before surgery and on the 3rd postoperative day. The clinical outcome was evaluated based on the change (D) of GCS from before surgery and on the 7th postoperative day, then categorized into 3 groups: improved, unchanged, and worsen. Results. From 72 subjects in this study, significant correlation (p = 0.019, r = 0.275) was found between preoperative lactate levels and D GCS, where the higher preoperative lactate levels, the more positive D GCS would be. Based on the analysis using ROC curve and Chi-square, subjects with lactate levels >=2.35 mmol/L were 1.64 times more likely to experience an increase in postoperative GCS. Conclusion. Lactate can be used as a favorable prognostic factor in TBI patients."

"Latar Belakang: Cedera kepala dikaitkan dengan aktivasi kaskade koagulasi dapat menyebabkan koagulopati. Hal ini berhubungan dengan hasil akhir atau keluaran yang tidak baik pada pasien. Deteksi dini dan evaluasi berkala faktor hemostasis dibutuhkan pada pengelolaan pasien cedera kepala sedang dan berat dalam memperbaiki hasil keluaran perawatan pasien cedera kepala.Tujuan: Diketahuinya angka kejadian prevalensi koagulopati pada pasien cedera kepala sedang berat dan hubungan gangguan hemostasis tersebut dengan hasil keluarannya.Metode Penelitian: Penelitian ini merupakan studi ?nested case control?. Studi ini bersarang pada penelitian awal yang berupa studi komparasi potong lintang. Data hemostasis diperiksa pada hari pertama(<24 jam dari kejadian) saat di Instalasi Gawat Darurat(IGD) RSCM. Pasien cedera kepala sedang dan berat ini nantinya akan diikuti sampai akhir perawatan inap dan dinilai hasil keluaran perawatannya. Koagulopati adalah gangguan status koagulasi, dapat berupa hiperkoagulasi atau hipokoagulasiHasil: Terdapat 76 sampel, 38 sampel memiliki keluaran baik dan 38 sampel memiliki keluaran buruk. Pria(81,6%) lebih banyak dari wanita. Sebagian besar subjek berusia 18-50 tahun(81,6%). Koagulopati terjadi pada 34,2% pasien. Koagulopati merupakan faktor prediksi keluaran buruk pada cedera kepala (OR 4,429; 95%IK 1,569 ? 12,502; p=0,004). Hasil analisis multivariat menunjukkan urutan prioritas kemaknaan faktor yang mempengaruhi keluaran subjek cedera kepala yang terkuat berturut-turut di penelitian ini adalah usia (50,271), derajat cedera kepala (46,522), dan koagulopati (5,409). Terdapat hubungan bermakna antara beratnya derajat cedera kepala dengan terjadinya koagulopati p= 0,009.Kesimpulan: Prevalensi koagulopati pada cedera kepala sedang berat cukup tinggi. Pasien dengan koagulopati memiliki keluaran yang lebih buruk

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Background: Brain injury is associated with activation of the coagulation cascade, contributing to coagulopathy. This condition is correlated with unfavorable outcome. Early detection and evaluation of hemostatic factors are needed in treatment of moderate-severe traumatic brain injury (TBI) to improve patient outcome.

Objectives: To determined the number of prevelence coagulopathy in moderate severe TBI and the relationship of the hemostatic disorder with outcome.

Materials and Method: We did the nested case control study. Hemostatic parameters were recorded from emergency departement (ED) not exceeding 24 hours from onset of accident. Moderate-severe TBI patients were followed until the patients discharged and we assessed the outcome. Coagulopathy was defined as hypocoagulopathy or hypercoagulopathy.

Results: From 76 subjects, 38 subjects were favorable outcome and 38 subjects had unfavorable outcome. Men were higher than women (81,6%), mostly subjects were in range 18-50 years(81,6%). Coagulopathy occured in 36% of all patients. Coagulopathy was the predictor of unfavorable outcome for TBI (OR 4,429; 95%CI 1,569 ? 12,502; p=0,004). From the multivariate analysis, the priority level for TBI outcome, in order of strongest to weakest correlation, were age (50,271), severity of traumatic brain injury(46,522) and coagulopathy(5,409). There was significant correlation between severity of traumatic brain injury and coagulopathy (p= 0,009).

Conclusions: Our study confirmed a quite high prevalence of coagulopathy in patients with moderate-severe TBI. Patients with coagulopathy had poorer outcome compared to non-coagulopathy"

"Cedera kepala merupakan penyebab utama kematian dan kecacatan pada populasi dunia berusia di bawah 45 tahun. Cedera kepala sedang (CKS) dan berat (CKB) biasanya memerlukan perawatan intensif dan pendekatan medis-bedah. Pasien dengan cedera kepala mengalami peningkatan laju metabolisme sehingga memerlukan tatalaksana medik gizi yang sesuai. Pemenuhan kebutuhan energi yang tidak adekuat dapat menyebabkan peningkatan angka morbiditas, risiko infeksi, dan komplikasi lainnya. Pemberian nutrisi enteral dini dalam kurun 24-48 jam setelah masuk Intensive Care Unit (ICU) dapat memperbaiki luaran klinis pasca cedera. Serial kasus ini bertujuan untuk melaporkan peran tatalaksana medik gizi pada status gizi, lama pemakaian ventilator, tingkat kesadaran dan kapasitas fungsional pada pasien kritis dengan CKS dan CKB. Empat pasien laki-laki dengan rentang usia 25-46 tahun diobservasi selama perawatan di ICU RS Cipto Mangunkusumo, dua pasien dengan diagnosis CKS dan sisanya dengan diagnosis CKB. Status gizi berdasarkan indeks massa tubuh, dua pasien memiliki berat badan (BB) normal, satu pasien BB lebih dan satu pasien obesitas II. Tingkat kesadaran berdasarkan skor Glascow Coma Scale (GCS) pasien pada saat masuk ICU adalah 6-11. Selama perawatan keempat pasien mendapat nutrisi enteral dini dan pemberian nutrisi ditingkatkan bertahap. Pada seluruh pasien, kebutuhan energi dapat dipenuhi sesuai target 25-30 kkal/kg BB. Kebutuhan makronutrien dapat dipenuhi sesuai target, yaitu protein 1,2-2 g/kg BB, lemak 20-30%, dan karbohidrat minimal 100 g/hari. Pada dua pasien dengan CKB, diberikan nutrien spesifik berupa glutamin sebesar 0,2 g/kgBB/hari dan mikronutrien berupa vitamin C, vitamin B kompleks, asam folat, dan seng. Hingga akhir pemantauan status gizi pada dua pasien CKS dapat dipertahankan, sedangkan dua pasien dengan CKB mengalami penurunan berat badan. Dua pasien CKS hanya menggunakan ventilator selama 4-5 hari, sedangkan dua pasien dengan CKB menggunakan ventilator lebih lama yaitu 12 dan 31 hari dengan disertai komorbiditas pneumotoraks dan ventilator-associated pneumonia. Tingkat kesadaran seluruh pasien mengalami perbaikan. Skor GCS pasien pada akhir perawatan di ICU adalah 7-15. Kapasitas fungsional berdasarkan Indeks Barthel juga mengalami perbaikan pada tiga pasien, yaitu dari ketergantungan total menjadi ketergantungan sedang atau berat. Dapat disimpulkan bahwa tatalaksana medik gizi dapat berperan dalam mempertahankan status gizi, menurunkan lamanya pemakaian ventilator, memperbaiki tingkat kesadaran dan kapasitas fungsional pada pasien sakit kritis dengan CKB dan CKS. Tingkat keparahan cedera kepala dan komorbiditas dapat memengaruhi luaran klinis dan harus dipertimbangkan dalam memberi tatalaksana medik gizi.

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Traumatic brain injury (TBI) is a leading cause of death and disability in the global population under 45 years old. Moderate and severe TBI usually require intensive care and a medical-surgical approach. Patients with TBI experience an increase in metabolic rate and therefore require appropriate medical nutrition therapy. Inadequate energy intake can cause an increase in morbidity, risk of infection, and other complications. Early enteral nutrition within 24-48 hours after ICU admission has been shown to improve clinical outcome.

This case series aims to report the role of medical nutrition therapy on nutritional status and clinical outcomes of critically ill patients with moderate and severe TBI. Four male patients aged 25-46 years were observed during their stay at the ICU of Cipto Mangunkusumo Hospital. Based on body mass index, two patients were normoweight, one patient was overweight and one patient was class II obese. The Glascow Coma Scale (GCS) scores of the patients on ICU admission were ranged 6-11.

Two of the four patients were classified as moderate TBI and the other two patients were as classified as severe TBI. On monitoring four patients received early enteral nutrition and the nutrition was gradually increased to reach the target of 25-30 kcal/kg body weight (BW). Enteral formula were targeted to achieve protein intake of 1.2-2 g/kgBW, fat intake of 20-30% of energy intake, and carbohydrate intake of at least 100 g/day. Two patients with severe TBI were given specific nutrients in the form of glutamine as much as 0.2 g/kgBW/day and micronutrients in the form of vitamin C, vitamin B complex, folic acid, and zinc. Two patients with moderate TBI received mechanical ventilation for 4 and 5 days, while two patients with severe TBI received mechanical ventilation for 12 and 31 days. In two patients with severe TBI, prolonged use of mechanical ventilation may be associated with the comorbidities of pneumothorax and ventilator-associated pneumonia.

At the end of monitoring, the levels of consciousness were improved in all patients. The patients GCS score at the end of treatment in the ICU were ranged 7-15. Functional capacity based on the Barthel Index also improved in three patients, from total dependence to moderate or severe dependence. Weight loss was experienced in two patients with severe TBI, possibly due to severe and prolonged catabolism in severe TBI. Patients with severe TBI may have higher energy requirements to maintain their nutritional status.

It can be concluded that medical nutrition therapy may play a role in improving the level of consciousness and functional capacity in critically ill patients with moderate and severe traumatic brain injury."

"This book is a concise guide designed for neurologists, primary care, and sports physicians and other medical providers, psychologists and neuropsychologists, and athletic trainers who may evaluate and care for patients with TBI. The book features summaries of the most pertinent areas of diagnosis and therapy, which can be readily accessed by the busy clinician/professional. "

"In order to reduce the number of deaths from severe head injuries, systematic management is essential. This book is a practical, comprehensive guide to the treatment of patients (both adults and children) with such injuries, from the time of initial contact through to the rehabilitation center. Sections are devoted to prehospital treatment, admission and diagnostics, acute management, and neurointensive care and rehabilitation. Evidence-based recommendations are presented for each diagnostic and therapeutic measure, and tips, tricks, and pitfalls are highlighted. Throughout, the emphasis is on the provision of sound clinical advice that will maximize the likelihood of an optimal outcome. Helpful flowcharts designed for use in daily routine are also provided. The authors are all members of the Scandinavian Neurotrauma Committee and have extensive practical experience in the areas they write about."

"A comprehensive introduction to evaluating and treating patients with traumatic brain injuries, this second edition of a bestseller features new information regarding the epidemiology and pathophysiology of brain injury as well as structural and functional imaging in the assessment of traumatic brain injury, including functional MRI, PET scanning, and magnetic resonance spectroscopy. With expanded discussions of brain-injury malingering and family dynamics, this revised and updated text gives an overview of state-of-the-art techniques and discusses new pharmacological treatments, acquired psychopathy, and test instruments for assessing behavior."