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Journal of Neurosurgical Sciences 2000 March;44(1):11-8


lingua: Inglese

Guidelines for the treatment of adults with severe head trauma (Part II). Criteria for medical treatment

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


­Since 1995 a ­Group of Ital­ian Neu­ro­in­ten­si­vists ­and Neu­ro­sur­geons belong­ing to ­the Ital­ian Soci­eties of Neu­ro­sur­gery (­SINch) ­and Anes­the­sia & Inten­sive ­Care (SIAAR­TI) ­has pro­duced ­some rec­om­men­da­tions ­for treat­ment of ­adults ­with ­severe ­head trau­ma. ­They ­have ­been pub­lished in 3 ­parts: ­Part I (­Initial assess­ment, Eval­u­a­tion ­and ­pre-hos­pi­tal treat­ment, Cri­te­ria ­for hos­pi­tal admis­sion, System­ic ­and cere­bral mon­i­tor­ing), ­Part II (Med­i­cal treat­ment) ­and ­Part ­III (Sur­gi­cal treat­ment cri­te­ria). ­These rec­om­men­da­tions ­reflect a mul­ti­dis­ci­pli­nary con­sent ­and ­are most­ly ­based on ­expert opin­ion. ­The ­main ­aim is to pro­vide 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. ­These rec­om­men­da­tions ­need a con­tin­u­ous crit­i­cal ­review ­and updat­ing. Med­i­cal treat­ment is ­aimed at pre­vent­ing or min­i­miz­ing sec­on­dary ­brain dam­age fol­low­ing ­acute ­brain inju­ry, pro­vid­ed ­that sur­gi­cal mass­es ­have ­been prompt­ly iden­ti­fied ­and ­removed. In ­order to ­assure cere­bral per­fu­sion, system­ic hemo­dy­nam­ics ­and res­pir­a­to­ry exchang­es ­should be nor­mal. Vole­mia is cru­cial, ­and ­mean arte­ri­al pres­sure ­should ­remain ­above 90 ­mmHg. ­Good gen­er­al inten­sive ­care, includ­ing gas­trop­ro­tec­tion, ­water-elec­tro­lyte bal­ance, infec­tion con­trol, nutri­tion ­and phys­io­ther­a­py, is ­assumed as ­the ­basis ­for ­brain-orient­ed ther­a­py. Intra­cra­ni­al hyper­ten­sion ­requires an ­approach ­based on var­i­ous ­steps. ­First, fac­tors ­that ­can direct­ly ­rise intra­cra­ni­al pres­sure (­ICP) ­such as ­venous out­flow obstruc­tion, ­fever, ­pain ­etc. ­should be ­checked ­and cor­rect­ed. Sec­ond, Man­ni­tol, ­CSF with­draw­al, seda­tion ­and mod­er­ate hyper­ven­ti­la­tion ­should be ­applied. ­This ­can be ­done by tar­get­ing spe­cif­ic prob­lems ­with spe­cif­ic treat­ment (­which is pos­sible ­when ­the ­cause of ­ICP ­rise is ­known) or in a ­step-­wise ­approach, by ­using ­less aggres­sive inter­ven­tions ­before ­than ­more aggres­sive ­ones, ­with a high­er ­risk of com­pli­ca­tions. ­Third, ­extreme treat­ment, ­such as bar­bit­u­rates, ­should be ­reserved to cas­es ­with refrac­to­ry intra­cra­ni­al hyper­ten­sion. ­The ­main ­goal of ­ICP treat­ment is ­not sim­ply ­ICP reduc­tion, ­but ­the main­te­nance of ade­quate cere­bral per­fu­sion pres­sure.

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