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Journal of Neurosurgical Sciences 2000 March;44(1):1-10


lingua: Inglese

Guidelines for the treatment of adults with severe head trauma (Part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring

Pro­cac­cio F. 1, Stoc­chet­ti N. 2, Cit­e­rio G. 3, Berar­di­no M. 4, Beret­ta L. 5, Del­la ­Corte F. 6, ­d’Avella D. 7, Bram­bil­la G. L. 8, Del­fi­ni R. 9, Ser­va­dei F. 10, Tomei G. 11

1 Depart­ment of Anaesthe­sio­lo­gy ­and Inten­sive ­Care, Ospe­dale Mag­giore, Vero­na;
2 Depart­ment of Anaesthe­sio­lo­gy ­and Inten­sive ­Care, Ospe­dale Pol­i­clin­i­co ­IRCCS, Mila­no;
3 Depart­ment of Anaesthe­sio­lo­gy ­and Inten­sive ­Care, Nuo­vo Ospe­dale ­San Gerar­do, Mon­za;
4 Depart­ment of Anaesthe­sio­lo­gy ­and Inten­sive ­Care, Azien­da Osped­a­lie­ra ­CTO-­CRF - M. Ade­laide, Tori­no;
5 Neu­ro­sur­gi­cal Anaesthe­sia ­and Inten­sive ­Care Depart­ment, Ospe­dale S. Raf­faele ­IRCCS, Mila­no;
6 Anaesthe­sia ­and Inten­sive ­Care Insti­tute, Cath­o­lic Uni­ver­sity - ­Roma;
7 Neu­ro­sur­gery Depart­ment, Uni­ver­sity of Mes­si­na;
8 Neu­ro­sur­gery Depart­ment, IRCCS Pol­i­clin­i­co S. Mat­teo, ­Pavia;
9 Neu­ro­log­i­cal Sci­enc­es Depart­ment, Chair of Neu­ro­trau­ma­tol­o­gy, Uni­ver­sity La Sapien­za, ­Roma;
10 Neu­ro­sur­gery Depart­ment, Ospe­dale Bufa­li­ni, Ces­e­na;
11 Neu­ro­sur­gery Depart­ment, Ospe­dale Pol­i­clin­i­co ­IRCCS, Mila­no


If prag­mat­ic rec­om­men­da­tions ­for treat­ment of severe­ly ­head-­injured ­patients ­could real­ly be ­applied, ­they ­would prob­ably ­have a con­sid­er­able ­impact in ­terms of reduc­tion in mor­tal­ity ­and dis­abil­ity. ­Since 1995 a ­Group of Ital­ian Neu­ro­in­ten­si­vists ­and Neu­ro­sur­geons belong­ing to ­the Ital­ian Soci­eties of Neu­ro­sur­gery (­SINch) ­and Anes­the­sio­lo­gy & Inten­sive ­Care (SIAAR­TI) ­has pro­duced ­this ­first ­part of rec­om­men­da­tions ­that ­are com­plet­ed by Med­i­cal treat­ment (­Part II) ­and Sur­gi­cal treat­ment cri­te­ria (­Part ­III). ­These rec­om­men­da­tions ­reflect a mul­ti­dis­ci­pli­nary con­sent ­but ­are ­based on sci­en­tif­ic evi­dence, ­when avail­able, ­and ­take ori­gin main­ly ­from ­expert opin­ions ­and ­the cur­rent clin­i­cal ­and organ­iza­tion­al sit­u­a­tion. ­For ­this ­aspect ­they dif­fer ­from oth­er Amer­i­can ­and Euro­pe­an guide­lines, ­which ­are strict­ly ­based on cri­te­ria of prov­en effi­ca­cy. ­These rec­om­men­da­tions ­aim at pro­vid­ing a prac­ti­cal ref­er­ence ­for ­all ­those deal­ing ­with ­severe ­head inju­ries ­from ­first-­aid to inten­sive ­care ­units, set­ting ­out ­the min­i­mal ­goals of man­age­ment to be ­reached through­out ­the coun­try. ­For ­these rea­sons ­they ­need con­tin­u­al crit­i­cal ­review ­and updat­ing. ­Main clin­i­cal ­aims ­are: 1) to pre­vent sec­on­dary cere­bral dam­age by con­tin­u­ous ­and metic­u­lous main­te­nance of system­ic homeo­sta­sis 2) to stan­dard­ize meth­ods of neu­ro­log­i­cal eval­u­a­tion ­and CT ­scan clas­sifi­ca­tion ­and sched­ul­ing; 3) to ­give sim­ple indi­ca­tions ­for system­ic ­and cere­bral mon­i­tor­ing 4) to prag­mat­i­cal­ly dis­cuss ­the organ­iza­tion­al sce­nar­ios ­and spec­i­fy ­the min­i­mal ­safe clin­i­cal ­approach ­when ­patients ­are treat­ed in ­non-spe­cial­ized set­tings. Brief­ly, ­smooth tra­cheal intu­ba­tion ­and ven­ti­la­tion in ­all coma­tose ­patients, admin­is­tra­tion of rap­id­ly metab­o­lized sed­a­tive ­and anal­ge­sic ­drugs to per­mit fre­quent neu­ro­log­i­cal eval­u­a­tion, res­to­ra­tion of vole­mia ­and sys­tol­ic ­blood pres­sure ­above 110 ­mmHg, oxy­gen sat­u­ra­tion > 95% ­and nor­mo­cap­nia, ­are ­all rec­om­mend­ed ­from ­the ­very ear­ly treat­ment ­and trans­port. Homo­ge­ne­ity of lan­guage, reli­able ­and cor­rect­ly test­ed Glas­gow ­Coma ­Score ­and pupil­lary reflex­es, ­and a sim­ple CT ­scan clas­sifi­ca­tion ­are rec­om­mend­ed to ­improve com­mu­ni­ca­tions ­and clin­i­cal deci­sions in ­the mul­ti­dis­ci­pli­nary set­ting of man­age­ment. In coma­tose ­patients, cere­bral per­fu­sion pres­sure, intra­cra­ni­al pres­sure ­and oxy­gen jug­u­lar sat­u­ra­tion ­must be mon­i­tored accord­ing to spe­cif­ic cri­te­ria, ­which ­are ­described. Ther­a­py ­with hyper­ven­ti­la­tion ­and man­ni­tol ­should be ­used ­only in ­case of clin­i­cal dete­ri­ora­tion ­and ­uncal her­ni­a­tion. ­This ther­a­py ­could be use­ful to ­gain ­time to ­reach neu­ro­sur­gery. ­The ­aim of ­these rec­om­men­da­tions is to ­achieve saf­er man­age­ment of severe­ly ­brain ­injured ­patients, imme­di­ate diag­no­sis of clin­i­cal dete­ri­ora­tion ­and suc­cess­ful iden­tifi­ca­tion ­and treat­ment of sur­gi­cal ­lesions. ­The ­impact of ­these guide­lines ­requires fur­ther ver­ifi­ca­tion.

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