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Influence of systemic adverse events on outcome Av. J. Wybran 40, B-1070 Brussels, Belgium Tel. + 32.2.529.58.29; Fax + 32.2.527.00.62 In large series of patients with traumatic brain injury the incidence of pre-hospital hypotension/shock varies from 12.2 to 34.6 % [1±6]. Hypoxaemia is present in 14.3 to 45.6 % of these cases. Even in patients with moderate Assessment and stabilization of patients with head inju- injuries, the incidence of hypoxaemia is 14.8% [1±6].
ries begins at the scene of the injury by emergency med- Hypercarbia will occur in up to 6.1% [6]. The incidence ical personnel. It includes the following tasks: of hypocarbia in this setting has not been studied.
· maintenance of oxygenation and normal ventilation, Influence on outcome · initiation of haemodynamic resuscitation and fluid Adverse events, such as arterial hypotension, hypox- · assessment of the level of consciousness, aemia or hypercarbia eventually determine adjunctive · stabilization of the cervical and thoracolumbar spine, brain damage to the primary direct traumatic damage · identification and stabilization of extracranial inju- to neural tissues. This secondary brain damage adverse- ly influences the outcome of the majority of head trau- Other critical components of the initial management of Extracranial complications occur frequently in pa- such patients are to obtain information about the cir- tients with severe head injuries. Although the outcome cumstances of the injury as well as to provide transport of an individual patient may be adversely affected by a number of different complications, only a few have The present guidelines were drafted by the Working been identified as having an independent influence on Group for ªNeurosurgical Intensive Careº of the Euro- outcome including hypotension, pneumonia, coagulop- pean Society for Intensive Care Medicine. The docu- athy and septicaemia [5, 7±21]. If pre-hospital hypoxia ment is the general consensus on the minimal care and/or hypotension is present in such patients, the mor- which should be provided to patients with severe head tality rate is twice that of patients without these insults.
Conversely, normotensive/normoxic patients are twice as likely to make a good recovery [1, 4, 7, 9, 18, 21].
The risk of pneumonia increases with the presence of coma and with impairment of airway reflexes [22]. Intu- bation in patients with severe head injuries reduces the rate of aspiration and helps to prevent respiratory insuf- Primary care of the patient with traumatic brain injury is Adequate sedation and analgesia are essential in pa- aimed at preservation of a clear airway and adequate tients with head injuries, especially if ventilated. Seda- circulation at the scene and during the entire transport.
tives and analgesics should be carefully titrated as over- Initial administration of oxygen is mandatory in all dosing may cause profound hypotension, especially in patients with an isolated traumatic brain injury. Patients hemodynamically unstable patients. Short-acting drugs with a Glasgow Coma Scale [24] score of 8 or a motor should be preferred.
score of less than 5 should be intubated and ventilated as soon as safely possible. In patients with better motor scores and associated injuries, the risk of acute hypoxia, Muscle relaxants intubation and ventilation should also be considered.
Aspiration should be avoided and/or vigorously treated. When needed, short-acting muscle relaxants are advo- Artificial ventilation should be adjusted to achieve an cated.
arterial saturation of more than 95%. Aggressive hyper- ventilation should be avoided in the early phase of the injury when cerebral blood flow is typically at its lowest Vasopressors [25]. Aggressive hyperventilation can be considered only when signs of impending brain herniation are pre- Vasopressors should be considered if volume replace- sent. If end-tidal CO2 can be measured, it should be ment fails to assure an adequate systemic blood pres- kept between 30±35 mmHg (4±4.5 kPa) in normoten- sure within minutes. From a neurosurgical/neuro-anaes- thetical point of view no one vasopressor has been At least two large peripheral i.v. cannulas should be shown to be superior to others, subsequently no recom- in place and secured. The first step in establishing an ad- mendations concerning the type of vasopressors can be equate cerebral perfusion pressure is establishing nor- given.
mal blood pressure. Treatment of low blood pressure should be aimed at a systolic blood pressure of more than 120 mmHg (16 kPa) for adults. An increase in ªNeuroprotectiveº agents blood pressure is usually caused by inadequate sedation and analgesia. If this is not the case, treatment of raised So far no ªneuroprotectiveº agents (e.g. steroids, ni- blood pressure ( > 200 mmHg = 26.6 kPa) by vasodilat- modipine, barbiturates) have been used in large, ran- ing agents is usually not indicated and may cause fatal domized, placebo-controlled pre-clinical trials in pa- hypotension. It should be kept in mind that hypotension tients with severe head injuries, and they have shown is rarely caused by an isolated head injury [14] and that minor effects in patients in the clinical setting [45±48].
the most common cause for this event is an extracranial Although mannitol has been shown to be effective in re- ducing intracranial pressure [49±55], its general use is not advocated during pre-hospital care. In emergency situations (dilating of a formerly contracted pupil) how- Adequate volume resuscitation should be initiated. Iso- ever it can be administered (0.5±1 g/kg with an infusion tonic solutions (e.g. Ringer's solution, NaCl 0.9%) and time of 10±15 min).
colloids are advocated. Although controversial [28], hy- pertonic saline has recently been used in the acute re- suscitative phase after head injury both experimentally Transport and clinically [29±38]. Hypertonic saline [39±43] is a therapy which is not generally accepted for resuscitation Although controversial [56, 57], the patient's head in this patient group. If given, hypertonic saline (250 cc should be elevated at a 15±30° angle. About 5% of of NaCl 7.25 %) should be administered first, followed head injury victims sustain cervical spine injury by rapid infusion of colloids. Hypotonic crystalloids [58±63]. A rigid collar should be applied in order to (e.g. Glc 5%, Ringer lactate) may worsen cerebral secure the cervical spine as soon as possible and this should be kept in position until radiographic images verify, beyond any doubt, the absence of any cervical spine lesion down to the second thoracic vertebra. The spine should always lie in a neutral position on a rigid · medical history (if possible) · neurological state: GCS scale (broken down into vi- Unstable fractures should be immobilized. Rolled sual, verbal and motor), pupil reactivity, focal neuro- sheets, sandbags, or commercially available devices should secure the position of the head. Endotracheal · extracranial injuries tubes should be secured by tapes, but the tape should · trauma score (any score which is standardized at not be passed around the neck in order to avoid com- · repeated documentation of pulse, blood pressure; After his/her clothes have been removed, the patient should be carefully checked for further injuries. Of par- · medication administered (type, dose, timing) ticular importance are thoracic, abdominal, pelvic and · interventions (type, timing) limb injuries which carry a high risk for hypotension · free space for comments and/or hypoxaemia. The patient's temperature should · name and telephone number of the transporting phy- A complete system of transport with the patient ªpackedº together with monitoring and therapeutic de- Precautionary radio communication of the patient's clinical status to the receiving hospital medical staff is strongly advocated and deserves standard local guide- The patient should be positioned on a stretcher that will allow various radiological imaging (X-ray, computer to- Feed-back and quality assessment mography) in hospital so that he can remain on the one After handover of the patient, members of the hospital from the scene of the injury until admission to the medical staff should compile a form containing any ob- servation (especially problems) related to the handover of the patient. This form (standardized at least at a re- gional level) should be given to the transporting team in order to assure the quality of patient transport. Re- gional conferences on a regular base should be held be- Besides the driver (transport and communication) at tween emergency teams and the receiving hospitals to least two people should be devoted to the patient's assure and to improve the quality of pre-hospital care.
care. One of the team members should be a physician.
Members of the team should be very familiar with the The members of the Working Group on Neurosurgical Intensive equipment and have personally checked it before use. Care of the European Society for Intensive Care Medicine: They should have received a specific training in: Piek J (Germany) Chairman; Aerdts S (The Netherlands), An- sec-Letonja D (Slovenia), Asgeirsson B (Sweden), Bahar M (Tur- key), Bellinzona G (Italy), BerrØ J (Belgium), Beuret P (France), Bochicchio M (Italy), Bruzzone P (Italy), Candiani G (Italy), De · ventilation by mask and portable mechanical ventila- Deyne C (Belgium), Dive A (Belgium), Dobb G (Australia), Esen F (Turkey), Ferdinande P (Belgium), Floros J (Greece), Futo J (Hungary), Gemma M (Italy), Grande P (Sweden), Hem- mer M (Luxemburg), Karlis P (Greece), Korfali G (Turkey), Mo- · neurological examination of unconscious patients.
retti M (Italy), Rebelo A (Portugal), Ruetsch Y (Switzerland), Sonkajahru E (Finland), Spec-Marn A (Slovenia), Specht M (Ger- many), Telles de Freitas P (Portugal), Wöbker G (Germany) Neurological assessment and documentationA complete and comprehensive chart should be com- piled by the transporting team. A protocol should be used which is standardized at the regional level, at least.
The chart should contain additional copies to provide the referring hospitals with the information. Documen- tation should include information (minimum) on: · patient's name, gender, address, birth date 11. Jennett B, Carlin J (1978) Preventable 14. Miller JD, Sweet RC, Narayan R, Beck- er DP (1978) Early insults to the injured 15. Miller JD, Becker DP (1982) Secondary 16. Newfiled P, Pitts L, Kaktis J (1980) The come of severely head-injured patients.
29. Berger S, Schürer L, Hartl R, Deisbock 30. Hartl R, Schürer L, Goetz C, Berger S, fect of hypertonic fluid resuscitation on 31. Berger S, Schürer L, Hartl R (1995) Re- tal: a three-year study of deaths follow- 21. Wald SL, Shackford SR, Fenick J (1993) 22. Chevret S, Hemmer M, Carlet J, Langer sults after head injury: clinical perpec- präklinischen Notfallversorgung für die ticenter clinical trial of 396 cases. Res Ringer ´ s solution on intracranial pres- ullary injuries. Analysis of 121 cases.
63. Vollmer DG, Torner JC, Jane JA (1991) coma: why do older patients fare worse.
mitters and free fatty acids in rat brain.
65. Clifton GL, Allen S, Barrodale P, Pleng- orrhagic shock: patterns of regional cir- 43. Valesco IT, Potieri Y, Rocha-e-Silva M, for patients with severe head injuries: a reduction of intracranial pressure in in-

Source: http://icu.gr/guidelines/915.pdf