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This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax (PTX). The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Figure 1) and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE V, Consensus algorithm from the Western Trauma Association.

Lindsley developed the “say all fast minute every day shuffled” (SAFMEDS) procedure in the late 1970s to enhance the typical use of flash cards (Graf & Auman, 2005). The acronym specifically guides the learner’s behavior when using flash cards. A review of SAFMEDS research indicates its successful use with children, college students, and older adults with and without disabilities. The literature also indicates that SAFMEDS procedures are not well documented and have multiple variations, limiting practitioners’ ability to know what procedures to use and when. The purpose of this study was to evaluate the effects of a basic SAFMEDS procedure and four supplementary SAFMEDS procedures on the rates of correct and incorrect responding to unfamiliar Russian words and Chinese characters in college students. The results of the study suggest that the basic SAFMEDS procedure produced some learning (i.e., increases in correct responding and decreases in incorrect responding), but all of the supplementary procedures led to greater increases in the number of correct responses per 1-min timing. Further research evaluating differences in performance across the supplementary procedures is warranted.

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.Prognostic/Epidemiologic, level III.

Previous discussions of synchronous modalities for online writing instruction have suggested the interpersonal benefits of this mode could minimize the isolation and transactional distance students can experience in online education. However, previous research on synchronous video courses (SVCs) has noted challenges for communication in this modality. This study examined these tensions between affordance and practice in SVCs, exploring how and why students participated and interacted in certain ways in these courses. A triangulated methodology of discourse analysis of class interactions and thematic analysis of interviews with students and instructors from the observed courses was used to present the prevalent discourse patterns within these courses and to contextualize these patterns within students’ and instructors’ experiences. Drawing on the findings of this study, this article presents recommendations for instructional practices faculty can use in SVCs to leverage the affordances and mitigate the challenges of teaching and learning in this modality.

Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p0.01), and prolonged immobilization (12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data.For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.Diagnostic tests or criteria, level II.

SAFMEDS is an assessment and instructional strategy pioneered in the late 1970s by Ogden Lindsley. SAFMEDS was developed as an extension and improvement of flashcards. The aims of this article are to provide an overview of the literature related to SAFMEDS and to identify further research needs. The results of this review suggest that a great deal of research is still needed to clarify the SAFMEDS procedures and the benefits of SAFMEDS over traditional instruction. These conclusions are in line with broader criticisms of fluency-based instruction.

For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury.This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings.Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease.For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.Diagnostic tests, level II.

Behavior analysts often work as part of an interdisciplinary team, and different team members may prescribe different interventions for a single client. One such intervention that is commonly encountered is a change in medication. Changes in medication regimens have the potential to alter behavior in a number of ways. As such, it is important for all team members to be aware of every intervention and to consider how different interventions may interact with each other. These facts make regular and clear communication among team members vital for treatment success. While working as part of an interdisciplinary team, behavior analysts must abide by their ethics code, which sometimes means advocating for their client with the rest of the team. This article will review some possible implications of medicinal interventions, potential ethical issues that can arise, and a case study from the authors' experience. Finally, the authors propose a decision-making tree that can aid in determining the best course of action when a team member proposes an intervention in addition to, or concurrent with, interventions proposed by the behavior analyst.

BACKGROUND: Older patients with traumatic brain injury (TBI) may be at high risk of death after hospitalization. The purpose of this study was to characterize long-term mortality of older TBI patients who survived to discharge. We hypothesized that predictors of postdischarge mortality differed from those of inpatient mortality. METHODS: A retrospective cohort study was performed on TBI patients older than 55 years admitted to our Level I trauma center between July 1, 2006, and December 31, 2011. Postdischarge deaths were identified by matching patient data with local vital records up to December 31, 2011, when data collection was terminated (censoring). Patients were categorized by age, comorbidities, history of preinjury anticoagulant/prescription antiplatelet agent therapy, injury severity indices, initial TBI type, prehospital living status, discharge location, and discharge condition. The effect of risk factors on postdischarge mortality was evaluated by Cox proportional hazards modeling. RESULTS: Of 353 patients, 322 (91.2%) survived to discharge. Postdischarge mortality was 19.8% (n = 63) for the study period. Of the postdischarge deaths, 54.0% died within 6 months of discharge, and 68.3% died within 1 year. Median days to death after discharge or censoring were 149 and 410, respectively. Factors associated with death after discharge included age, preinjury anticoagulant use, higher number of Charlson comorbidities, discharge to a long-term care facility, and severe disability. Factors related to injury severity (i.e., Injury Severity Score [ISS], initial Glasgow Coma Scale [GCS] score) and preinjury prescription antiplatelet agent use, previously found to predict inpatient death, did not predict postdischarge mortality. CONCLUSION: Older TBI patients who survive to discharge have a significant risk of death within 1 year. Predictors of postdischarge mortality and inpatient death differ. Death after discharge is largely a function of overall health status. Monitoring health status and continued aggressive management of comorbidities after discharge may be essential in determining long-term outcomes. LEVEL OF EVIDENCE: Epidemiologic/retrospective cohort analysis, level III. Language: en

Background Anticoagulants and prescription antiplatelet (ACAP) agents widely used by older adults have the potential to adversely affect traumatic brain injury (TBI) outcomes. We hypothesized that TBI patients on preinjury ACAP agents would have worse outcomes than non-ACAP patients. Methods This was a 5.5-year retrospective review of patients 55 years and older admitted to a Level I trauma center with blunt force TBI. Patients were categorized as ACAP (warfarin, clopidogrel, dipyridamole/aspirin, enoxaparin, subcutaneous heparin, or multiple agents) or non-ACAP. ACAP patients were further stratified by class of agent (anticoagulant or antiplatelet). Initial and subsequent head computerized tomographic results were examined for type and progression of TBI. Patient preadmission living status and discharge destination were identified. Primary outcome was in-hospital mortality. Secondary outcomes were progression of initial TBI, development of new intracranial hemorrhage (remote from initial), and the need for an increased level of care at discharge. Results A total of 353 patients met inclusion criteria: 273 non-ACAP (77%) and 80 ACAP (23%). Upon exclusion of three patients taking a combination of agents, 350 were available for advanced analyses. ACAP status was significantly related to in-hospital mortality. After adjustment for patient and injury characteristics, anticoagulant users were more likely than non-ACAP patients to show progression of initial hemorrhage and develop a new hemorrhagic focus. However, compared with non-ACAP users, antiplatelet users were more likely to die in the hospital. Among survivors to discharge, anticoagulant users were more likely to be discharged to a care facility, but this finding was not robust to adjustment. Conclusion Older TBI patients on preinjury ACAP agents experience a comparatively higher rate of inpatient mortality and other adverse outcomes caused by the effects of antiplatelet agents. Our findings should inform decision making regarding prognosis and caution against grouping anticoagulant and antiplatelet users together in considering outcomes. Level of evidence Therapeutic study, level IV.

Reliance on chest-abdomen-pelvis computed tomography (CAP) in the initial evaluation of blunt trauma is a major source of patient radiation exposure. Our trauma surgeon group (TSG) modified its practice to limit the use of CAP. We evaluated the effect of this practice change on patient radiation exposure and diagnostic accuracy.We compared data on blunt injury trauma activations evaluated by the five-member TSG for two 6-month intervals, before (T1) and after (T2) instituting the practice change. Patient demographic and injury data, complications, torso imaging and radiation dosage were collected. Following analysis of T1, the surgeon with the lowest CAP use was identified and found to have no errors or delays in diagnosis. The TSG agreed to adopt that surgeon's focus on findings of the physical examination and Focused Assessment Sonography for Trauma to reduce CAP use in the initial evaluation. T2 was analyzed to assess the effect of implementation of this guideline.There were 897 patients in T1 and 948 in T2. In the two intervals, patients did not differ by age, sex, mortality, or probability of survival. CAP use decreased by 38.5% with a significant drop in mean patient radiation exposure (p0.001). There were no missed injuries or delays in diagnosis in either interval.The use of CAP and its associated radiation burden in the initial evaluation of blunt trauma can be reduced without diagnostic errors by comparing use and identifying best practice. This process has implications for optimal trauma care.Diagnostic study, level IV; case management study, level IV.

The Eastern Association for the Surgery of Trauma Practice Management Guidelines identify indications (EI) for early intubation. However, EI have not been clinically validated. Many intubations are performed for other discretionary indications (DI). We evaluated early intubation to assess the incidence and outcomes of those performed for both EI and DI.One thousand consecutive intubations performed in the first 2 hours after arrival at our Level I trauma center were reviewed. Indications, outcomes, and trauma surgeon (TS) intubation rates were evaluated.During a 56-month period, 1,000 (9.9%) of 10,137 trauma patients were intubated within 2 hours of arrival. DI were present in 444 (44.4%) and EI in 556 (55.6%). DI were combativeness or altered mental status in 375 (84.5%), airway or respiratory problems in 21 (4.7%), and preoperative management in 48 (10.8%). Injury Severity Score was 14.6 in DI patients and 22.7 in EI patients (p0.001). Predicted versus observed survival was 96.6% versus 95.9% in DI patients and 75.2% versus 75.0% in EI patients (p0.001). Head Abbreviated Injury Scale score ofor=3 occurred in 32.7% with DI and 52.0% with EI (p0.001). Seven (0.7%) surgical airways were performed; two for DI (0.2%). Eleven (1.1%) patients aspirated during intubation and five (0.5%) suffered oral trauma. There were no other significant complications of intubation for either DI or EI and complication rates were similar in the two groups. Delayed intubation (early intubation after leaving the trauma bay) was required in 67 (6.7%) patients and 59 (88.1%) were for combativeness, neurologic deterioration, or respiratory distress or airway problems. Intubation rates varied among TS from 7.6% to 15.3% (p0.001) and rates for DI ranged from 3.3% to 7.4% (p0.001). There was a statistically insignificant trend among TS with higher intubation rates to perform fewer delayed intubations.Early intubation for EI as well as DI was safe and effective. One third of the DI patients had significant head injury. Surgical airways were rarely needed and delayed intubations were uncommon. The intubation rates for EI and DI varied significantly among TSs. The Eastern Association for the Surgery of Trauma Guidelines may not identify all patients who would benefit from early intubation after injury.

Resuscitation with blood products improves survival in patients with traumatic hemorrhage. However, the risk of venous thromboembolic (VTE) complications associated with fresh frozen plasma (FFP) resuscitation is unknown. We hypothesized that a higher ratio of FFP to packed red blood cells (PRBCs) given during acute resuscitation increases the risk of VTE independent of severity of injury and shock.The records of patients admitted from April 2007 to December 2011 who had surveillance lower extremity duplex ultrasounds were retrospectively reviewed. Patients who received at least 1 U of PRBCs within 24 hours of admission were included. Patients who died without VTE were excluded. The relationship between FFP and VTE was evaluated using logistic regression.A total of 381 patients met inclusion criteria, of whom 77 (20.2%) developed VTE. In patients who required less than 4 U of PRBCs, increasing units of FFP were associated with an increasing risk for VTE, with each unit of FFP having an adjusted odds ratio of 1.27 (95% confidence interval, 1.04-1.54, p = 0.015). Conversely, in patients who required four or greater units of PRBCs, FFP in equal or greater ratios than PRBCs was not associated with VTE.Each unit of FFP increased VTE risk by 25% in patients who required less than 4 U of PRBCs. In patients who required 4 U or greater PRBCs, FFP administration conferred no increased risk of VTE. This suggests that FFP should be used cautiously when early hemodynamic stability can be achieved with less than 4 U of PRBCs.Care management study, level III.

Background Traumatic brain injury (TBI) is considered an independent risk factor of venous thromboembolism (VTE). However, the role of TBI severity in VTE risk has not been determined. We hypothesized that increased severity of brain injury in patients with isolated TBI (iTBI) is associated with an increased incidence of VTE. Methods The records of patients admitted from June 2006 to December 2011 were reviewed for injury data, VTE risk factors, results of lower extremity surveillance ultrasound, and severity of TBI. Patients were identified by DRG International Classification of Diseases-9th Rev. codes for TBI, and only those with a nonhead Abbreviated Injury Scale (AIS) score of 1 or lower, indicating minimal associated injury, were included. The association of iTBI and VTE was determined using a case-control design. Among iTBI patients, those diagnosed with VTE (cases) were matched for age, sex, and admission year to those without VTE (controls). Data were analyzed using conditional logistic regression. Results There were 345 iTBI patients: 41 cases (12%) and 304 controls (88%). A total of 151 controls could not be matched to an appropriate case and were excluded. Of the remaining 153 controls, 1 to 16 controls were matched to each of the 41 VTE cases. Compared with the controls, the cases had a higher mean head-AIS score (4.4 vs. 3.9, p = 0.001) and overall Injury Severity Score (20.4 vs. 16.8, p = 0.001). Following adjustment for all factors found to be associated with VTE (ventilator days, central line placement, operative time > 2 hours, chemoprophylaxis, history of VTE, and history of cancer), the cases were significantly more likely to have a greater head injury severity (head-AIS score ≥ 5; odds ratio, 5.25; 95% confidence interval, 1.59-17.30; p = 0.006). Conclusion The incidence of VTE in iTBI patients was significantly associated with the severity of TBI. VTE surveillance protocols may be warranted in these high-risk patients, as early detection of VTE could guide subsequent therapy. Level of evidence Epidemiologic/prognostic study, level III.

Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero.We retrospectively reviewed adult blunt trauma patients admitted to our Level I trauma center from January 2006 to August 2009 who were receiving preinjury ACAP therapy. We reviewed medications, mechanism of injury, head CT results, and outcomes. Demographic data, injury severity scores, international normalized ratio, and neurologic examinations were recorded. We determined the incidence of delayed ICH on CT2 for patients with a negative CT1.Five hundred patients qualified for the protocol. Of these, 424 patients (85%) had a negative CT1. Among these patients, mean age was 75 years; 210 (50%) were male. Fall from standing was the most common mechanism of injury found in 357 patients (84%). Warfarin alone was taken in 68%, clopidogrel alone in 24%, and other agents in 2%. Six percent of patients were taking two agents. Mean international normalized ratio for patients on warfarin was 2.5. Among patients with a negative CT1, CT2 was obtained in 362 patients (85%) and was negative in 358 patients (99%). Four patients (1%) with a negative CT1 had a positive (n = 3) or equivocal (n = 1) CT2. All the changes on CT2 were minor and had either resolved or stabilized on third head CT. Of the four patients with positive or equivocal CT2, none had a change in neurologic examination; however, two had symptoms that could be attributed to head injury. Three were discharged home and one died of cardiac disease unrelated to head trauma.The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.

Background: Patients with severe traumatic brain injury (TBI) require aggressive management to prevent secondary brain injury. "Preemptive" craniectomy (CE)―craniectomy performed as a primary procedure in conjunction with craniotomy―has been used as prophylaxis for secondary injury, but the indications and outcomes of craniectomy used for this purpose are not well defined. Methods: To evaluate the role of CE in the management of TBI, we retrospectively reviewed 62 consecutive patients who underwent CE in a 78-month period at our level I trauma center. A cohort of patients who underwent craniotomy only (CO) during this period was compared with the CE group for TBI patterns, indications for operation, and outcomes. Multivariable logistic regression and matched propensity score analysis were used to test the association between CE and survival. The rate of CE was determined by individual neurosurgeons. Results: Of 197 patients with brain injuries who underwent craniotomy, 62 (31.5%) had CE and 135 (68.5%) had CO. Mean age for CE versus CO was 41 years versus 51 years (p < 0.01). Mean admission Glasgow Coma Score was lower in CE versus CO (7.6 vs. 11.8, p < 0.001); Injury Severity Score was higher (30.2 vs. 26.3, p < 0.01). The indication for operation for CE compared with CO was subdural hematoma in 41 (66.1%) versus 87 (64.4%, p = 0.82), epidural hematoma in 2 (3.2%) versus 26 (19.3%,p p < 0.01), and cerebral contusion or hematoma in 15 (24.2%) versus 8 (5.9%, p < 0.001). Postoperative intracranial pressure was monitored in 48 (77.4%) CE and 44 (32.6%) CO patients (p < 0.001). Intracranial pressure