2026-07-05 | Gastrointestinal Dysfunction in Critically Ill Patients With Traumatic Brain Injury: Clinical Implications and Putative Mechanisms: a Narrative Review.
Moderate to severe traumatic brain injury (TBI) requiring intensive care is associated with high morbidity, mortality and long-term disability. In addition to neurologic sequelae, TBI causes a systemic disease with associated injury to other organ systems, including the gastrointestinal (GI) tract. Here, we review the evidence that GI tract dysfunction occurs after TBI and discuss the clinical implications of GI tract dysfunction on the clinical care of TBI patients, including inadequate nutritional support, elevated risk of pneumonia, and a hyperactive inflammatory response. We highlight recent findings that highlight putative mechanisms through which GI tract pathology may arise after TBI, including vagal nerve and enteric nervous system dysfunction, gut microbiome dysbiosis, sympathetic hyperactivity and iatrogenic injury. Finally, we highlight future approaches to target the GI tract that could improve outcomes in this critically ill patient population. In summary, we review the evidence supporting a role for GI tract dysfunction in the pathophysiology of critically ill TBI patients and highlight potential mechanisms through which GI tract dysfunction may worsen outcomes in this population.
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2026-06-22 | Timing of fracture fixation for femur and pelvis fractures in patients with severe traumatic brain injury - an analysis of the TraumaRegister DGU®.
Fracture fixation timing and strategy in polytrauma patients with traumatic brain injury (TBI) remain controversial. This study investigates treatment patterns and outcomes for femoral and/or pelvic fractures stratified by TBI severity. Patients in the TraumaRegister DGU® (2016-2022) with pelvic and/or femoral fractures (AIS ≥3) and TBI (head AIS ≥3) were included. Strategies were non-operative management (NOM), early total care (ETC), and damage-control orthopedics (DCO). Outcomes included treatment allocation, fixation timing, and in-hospital mortality. 985 patients were included (mean age 52.5, SD 26.3 years; ISS 27.8, SD 8.1). Allocation was NOM in 320 (32.5%), ETC in 336 (34.1%), and DCO in 329 (33.4%) patients. Head AIS was 3 in 48.5%, 4 in 31.1%, and 5 in 20.3%. NOM patients were older, had the highest ISS and estimated mortality, and showed the largest proportion of critical TBI (AIS 5: NOM 30.9%, ETC 14.3%, DCO 16.1%). Femoral ETC was mainly performed within the first day (median 0, IQR 0-1 days), whereas pelvic ETC was delayed with increasing TBI severity (median 3, IQR 0-5 days for head AIS 3; 5, IQR 0-7 days for AIS 4). Observed mortality was 37.2% after NOM, 9.2% after ETC, and 10.3% after DCO. ETC in patients with moderate TBI (AIS 3) was associated with reduced observed mortality relative to NOM and matching DCO. Increasing TBI severity shifted practice patterns to DCO/NOM. These findings suggest that critical head injuries may prolong time to definitive fixation being associated with higher morbidity and mortality.
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2026-06-09 | Impact of IV metoclopramide + diphenhydramine on post-concussion symptoms. A secondary analysis of data from an ED-based randomized study.
In a randomized, placebo-controlled study, intravenous metoclopramide 20 mg + diphenhydramine 25 mg (M+D) improved post-concussion symptoms 1 h later among patients seeking care in an emergency department (ED) following head trauma. We performed a secondary hypothesis-generating analysis of those data to determine whether M+D is effective against cognitive and affective symptoms in addition to somatic symptoms, and whether post-treatment symptomatology is associated with 1-week and 1-month outcomes. We enrolled patients in two urban EDs in the Bronx, NY. Enrollment commenced in August 2017 and concluded in March 2020. Patients were included in the initial randomized controlled trial if they experienced head trauma and reported a new onset headache of at least moderate or severe intensity. We assessed post-concussion symptoms at 1 h, 1 week, and 1 month after treatment using the Post-Concussion Symptom Scale (PCSS), a 22-item instrument on which each symptom is graded as zero (none) through 6 (severe). We determined the impact of treatment, time, and their interaction on PCSS score. We repeated this analysis among the somatic, cognitive, and affective domains of the PCSS scale. Finally, we determined if post-treatment PCSS scores in the ED were associated with any severe symptom 1 week and 1 month later. Eighty-one participants received M+D; of those, 30 (37.0%) were female. Their mean age was 43.3 (standard deviation 16.1) years. All 81 provided 1-h data; 72 (89.9%) provided 1-week data; and 61 (75.3%) provided 1-month data. Seventy-nine received placebo; of those, 23 (29.1%) were female. Their mean age was 45.7 (SD 17.3) years. All 79 provided 1-h data; 67 (84.8%) provided 1-week data; and 54 (68.4%) 1-month data. At 1 h, the overall mean PCSS score was 20.8 (SD 20.2); at 1 week it was 17.4 (SD 23.0); and at 1 month it was 19.5 (SD 27.7). Participants who received M+D reported lower post-concussion symptom scores on the PCSS at 1 h (9.2 units lower, 95% confidence interval [CI]: 2.0, 16.4) but not at 1 week (7.2, 95% CI: -0.4, 14.9) or 1 month (2.4, 95% CI: -5.9, 10.8). In the main mixed-effects model, there was a significant effect of treatment (p = 0.008), indicating overall lower PCSS scores in the M+D group across follow-up, although not for time (p = 0.289) or treatment-by-time interaction (p = 0.175). The treatment effect remained significant in the affective (p = 0.002) and cognitive (0.010) domains. PCSS scores prior to ED discharge were associated with severe symptoms at 1 week (adjusted odds ratio [OR] 1.02, 95% CI: 1.01, 1.04), but not 1 month (adjusted OR 1.02, 95% CI: 1.00, 1.04). In this exploratory secondary analysis, M+D improved post-concussive symptoms 1 h after treatment, including affective and cognitive post-concussion symptoms. PCSS scores after treatment are associated with 1-week but not 1-month outcomes.
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