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Minerva Anestesiologica 1999 June;65(6):353-6

Copyright © 2000 EDIZIONI MINERVA MEDICA

language: Italian

Head injury and politrauma: from the street to the operating room

Stocchetti N., Longhi L., Magnoni S., Rossi S., Rotelli S.

Ospedale Maggiore Policlinico IRCCS - Milano, Terapia Intensiva Neuroscienze, Servizio di Anestesia e Rianimazione

Brain inju­ry ­occurs ­with a ­range of sever­ity: ­even ­less ­severe cas­es ­should be care­ful­ly ­observed ­since ­they may dete­ri­orate. By def­i­ni­tion ­severe ­head inju­ry has a Glasgow Coma Scale ­score of 8 or ­less; coma­tose ­patients are ­defined as cas­es who do not ­obey com­mands, do not ­open ­their ­eyes and do not ­speak. Very ­often (50% of ­case in our ­series) ­brain inju­ry is asso­ciat­ed ­with rel­e­vant extra­cra­ni­al inju­ries ­that may add to the sever­ity of cas­es and may wors­en out­come. The con­cep­tu­al frame­work for treat­ing ­head inju­ry is ­based on the evi­dence ­that ­after the ­impact, the ­initial dam­age may be exac­er­bat­ed by ­insults ­capable of fur­ther dis­turb­ing cere­bral metab­olism, lead­ing to a ­final dam­age ­defined as sec­on­dary dam­age. Secondary dam­age rep­re­sents the ­final end of ­many path­ways ­that can be stud­ied at the bio­chem­i­cal lev­el and are cen­tered in a cal­cium ­influx ­into the neu­ro­nal ­cell. Most prob­ably ­there is a genet­ic sus­cep­ti­bil­ity to sec­on­dary dam­age lead­ing to a ­range of cel­lu­lar dis-func­tions for any giv­en lev­el of ­insult. The man­age­ment of trau­mat­ic ­brain inju­ry is ­aimed at inter­rupt­ing the ­chain of ­events lead­ing to sec­on­dary ­brain dam­age and ­from ­this per­spec­tive the ­fact ­that dam­age may devel­op ­over ­time can be ­seen as a win­dow of oppor­tu­nity for time­ly treat­ment. The mile­stone of treat­ment is the remov­al of sur­gi­cal mass­es. This sur­gi­cal treat­ment can be per­formed ­only in a ­brain ­that is prop­er­ly per­fused and ­once coag­u­la­tion is pre­served. Therefore the organ­iza­tion of treat­ment ­from res­cue to neu­ro-trau­mat­o­log­i­cal cen­ters ­should pro­vide appro­pri­ate res­to­ra­tion of the vol­ume and a nor­mal oxy­gen deliv­ery to the ­brain and to the over­all organ­ism.