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


language: English

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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