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

Copyright © 2000 EDIZIONI MINERVA MEDICA

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


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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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