Experience with Althesin in the management of persistently raised ICP following severe head injury

Of 243 patients who underwent intracranial pressure (ICP) monitoring after severe head injury, 42 (17%) were found to have severe persistently raised ICP, in spite of hyperventilation, mannitol, and surgical decompression. Althesin was infused to reduce ICP in these patients. This agent was shown to be effective and safe in reducing ICP, and a significant improvement in cerebral perfusion pressure was demonstrated. In this respect, Althesin may be more effective than barbiturates. However, no improvement in patient outcome was demonstrated in this series.     

重型颅脑损伤持续颅内压及脑灌注压监护与预后关系

作者对５０例重型颅脑损伤患者（ＧＣＳ３－８分），及５０例伤情与诊断和手术方式基本相似的另一组患者进行颅内压（ＩＣＰ）与脑灌注压（ＣＣＰ）连续监测对比研究。结果表明，监护组除８例ＩＣＰ压力＜２．００ｋＰａ，ＣＰＰ＞９．３３ｋＰａ外，余４２例均有不同程度ＩＣＰ增高与ＣＰＰ降低。这些患者分别为创伤性颅内血肿、广泛性脑挫裂伤、继发性脑水肿或脑肿胀等，均采取积极的手术及综合治疗。死亡率为１４％。非监护组治疗方法与监护组相同，预后较差且并发症多，死亡率为２８％。作者认为，对重型颅脑损伤患者施行连续ＩＣＰ、ＣＰＰ监护，是降低并发症和死亡率，提高疗效的有力措施，具有重要的临床应用价值。     

Indomethacin: its role in the management of intractable intracranial pressure (ICP) after severe head injury

Intracranial hypertension that fails to respond to first linemedical and surgical treatment after head injury is associatedwith a 92% mortality overall.¹ The addition of barbiturateswill result in a good or moderate neurological outcome in 35%of patients,² but those with hyperaemia do significantly worse.However barbiturates may not be a logical choice for those patientswhose intracranial hypertension is secondary to hyperaemia,and may be associated with significant complications. In thesepatients cerebral vasoconstrictors such as indomethacin maybe more appropriate and possibly associated with fewer unwantedeffects. In one study six out of 10 patients who received indomethacinfor intracranial hypertension unresponsive to barbiturates survived.³However it is unclear how many were hyperaemic since jugularvenous saturation (Sj_O2) was not monitored. We report our experiencewith indomethacin in 10 severely head-injured patients. Our protocol aims to maintain a target cerebral perfusion pressure(CPP) and ICP through the application of sedation, diuretics,CSF drainage, mild hypothermia, muscle relaxation and controlof arterial carbon dioxide (Pa_CO2). If the ICP remains elevatedthen Sj_O2 is monitored. The combination of raised ICP and Sj_O2is taken to indicate hyperaemia (absolute or relative). In thesecircumstances the patient is hyperventilated to a Pa_CO2 of 28mmHg and if necessary an intravenous infusion of thiopentonecommenced. We used indomethacin infusions in 10 patients fulfillingthese criteria of hyperaemia. In seven patients the hyperaemiawas confirmed as absolute by demonstrating a raised middle cerebralartery velocity (MCAV) with transcranial Doppler. The mean ageof the patients was 21.2 yr (range 8–55). Indomethacinwas infused for a mean of 3.8 days (1–11) at a rate of3–11 mg h^–1. The effect of indomethacin on mean(SD) ICP, CPP and Sj_O2 is shown in Table 4. At 6-month follow up there were seven survivors (three goodrecovery, three moderate recovery, one severely disabled). Threepatients died with intractable ICP and septic shock. Two ofthese patients had associated renal failure. There were no episodesof gastrointestinal bleeding. Two of the three patients whodied did not have MCAV measured, and therefore indomethacinmay not have been strictly indicated. These results achievedin this subgroup of head injured patients is much better thanthat expected, and matches the outcome achieved in the overallICU head injury population. Indomethacin may have a role inthe management of raised ICP associated with hyperaemia aftersevere head injury. We recommend however that it should onlybe used with monitoring of both Sj_O2 and MCAV.     

Critical care management of severe head injury

Severe traumatic brain injury (TBI) is a significant cause of morbidity and mortality. The intensive care management of TBI requires a coordinated and comprehensive approach to treatment, including strategies to prevent secondary brain injury by avoidance of systemic physiological disturbances, such as hypotension, hypoxaemia, hypoglycaemia, hyperglycaemia and hyperthermia, and maintenance of adequate cerebral perfusion and oxygenation. There have been marked improvements in the management of patients with severe TBI over the last two decades, and treatment advances in the pre-hospital setting and emergency department have recently extended into the intensive care unit. The management of head injury has undergone extensive revision as evidence accumulates that established practices are not as effective or innocuous as previously believed. Management protocols have evolved with international consensus, providing guidelines that assist clinicians in delivering optimal care. Improved diagnostic and monitoring modalities are improving the understanding of the pathophysiology of head injury and allowing the delivery of individualised therapy.     

The management of acute severe head injury

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Relationship of acute CBF and ICP findings to neuropsychological outcome in severe head injury

Neuropsychological outcome within 1 year after severe head injury was examined in 42 conscious survivors and correlated with acute measurements of cerebral blood flow (CBF) and intracranial pressure (ICP). During acute coma, CBF was elevated in 23 patients, indicating hyperemia, and was reduced in the remaining 19 cases. Intracranial hypertension (ICP 20 mm Hg or greater) was present acutely in 15 patients and absent in 27. Occurrences of hyperemia and intracranial hypertension were significantly related. During chronic recovery, neuropsychological dysfunction was found in all cases. However, patients with hyperemia revealed greater impairment of overall intellectual and memory functions than did those with reduced flow, while patients with intracranial hypertension showed greater memory deficit than did those without ICP elevations. The results suggest that early pathophysiological events can influence subsequent neuropsychological outcome, and that chronic recovery is not homogeneous in young severely head-injured adults.     

EBIC-Guidelines for management of severe head injury in adults

Summary Guidelines for the management of severe head injury in adults as evolved by the European Brain Injury Consortium are presented and discussed. The importance of preventing and treating secondary insults is emphasized and the principles on which treatment is based are reviewed. Guidelines presented are of a pragmatic nature, based on consensus and expert opinion, covering the treatment from accident site to intensive care unit. Specific aspects pertaining to the conduct of clinical trials in head injury are highlighted. The adopted approach is further discussed in relation to other approaches to the development of guidelines, such as evidence based analysis.     

Haemodynamic defect in patients with severe head injury

Haemodynamic studies were made in 34 patients with severe head injury. The changes of cardiac output were noteworthy and correlated well with the clinical course and the prognosis of the patients. Marked systemic hypotension at the moment of brain death was mainly caused by the decrease of cardiac output. At this moment, peripheral resistance fell only to normal limits from the raised level. In the patients who survived, the cardiac output increased in proportion to the respiratory insufficiency, that is, the increased A-aDO₂ and Q?s/Q?t. The increase of oxygen consumption was also accompanied by an increased cardiac output, but in the patients with the severest head injury who died, the cardiac output remained low. It failed to respond to increased A-aDO₂ and Q?s/Q?t, and oxygen consumption remained low.     

Infectious complications in patients with severe head injury

Mortality and morbidity from head trauma have been substantially reduced by improved prehospital care and aggressive diagnostic and therapeutic management. However, a substantial number of patients will require prolonged periods of hospitalization, intensive care, and ventilator support during their recovery, placing them at risk for infectious complications. Eighty-two such patients were reviewed during a 30-month period at a Level I trauma center. Forty-one patients (50%) developed at least one infectious complication. The most common source was respiratory, occurring in 34 patients relatively early (average, 3.2 days) in their hospital course. The severity of head injury and presence of coexisting thoracic trauma correlated statistically; administration of prophylactic antibiotics and corticosteroids did not in the development of infectious problems. Only three patients died as a result of sepsis, indicating that early recognition and prompt treatment may control the severity of infectious complications.     

Outcome after severe head injury. Relationship to mass lesions, diffuse injury, and ICP course in pediatric and adult patients

A consecutive series of 330 severely head-injured patients was studied prospectively. All of the patients were treated with the same protocols by the same physicians and staff in the same intensive care unit. All of the patients had intracranial pressure (ICP) monitoring. Of the 330 patients, 100 were in the pediatric age group (0 to 19 years of age) and 230 were in the adult group (20 to 80 years of age). Statistical analyses were performed with regard to outcome, Glasgow Coma Scale (GCS) score, ICP course, and incidence of surgical lesions. The average emergency room GCS score as well as the 24-hour GCS score for each group was the same. The percentage of patients having ICP that was normal, increased but reducible, and increased but not reducible in each group was the same. The pediatric patients had a significantly higher percentage of good outcomes (43%) than the adult patients (28%) (p less than 0.01). They also had a significantly lower mortality rate (24%) than the adult patients (45%) (p less than 0.01). At 1 year following injury, 55% of pediatric patients had a good outcome compared to 21% of adults (p less than 0.001); this trend was evident at 3 months, with the same p value. Pediatric patients with normal ICP had a higher percentage of good outcomes (70%) than the adult patients with normal ICP (48%) (p less than 0.05). There was no significant difference in outcome in pediatric and adult patients with mass lesions or with increased ICP, regardless of whether or not the pressure was reducible. There was a much higher incidence of surgical mass lesions in adult patients (46%) than in pediatric patients (24%) (p less than 0.001).     

High dose glucocorticoids in the management of severe head injury

Eighty-eight patients with a Glasgow coma score of 8 or less 6 hours after nonpenetrating head trauma were given either high dose methylprednisolone sodium succinate (30 mg/kg q6h X2, then 250 mg q6h X6, then tapering over 8 days), low dose methylprednisolone (1.5 mg/kg q6h X2, then 25 mg q6h X6, then tapering over 8 days), or placebo. Standard care including the removal of traumatic hematomas, assisted ventilation, and intracranial pressure monitoring and control was carried out. Follow-up assessments were performed on all surviving patients at 6 months and were graded according to the Glascow outcome scale. No statistically significant difference in outcome was seen between the low dose group and the placebo group. The high dose group experienced a mortality of 39% as compared to a 52% mortality in the low dose and placebo groups (P less than 0.05). Mortality differences were most marked in patients less than 40 years old, with the high dose group experiencing a mortality of 6% as compared to a 43% mortality for the low dose and placebo groups (P less than 0.05). For patients under 50 years old, the incidence of recovery of speech was 62% compared to 36% in the low dose and placebo groups (P less than 0.5). The increased survival in those treated with high dose corticoids, however, was associated with an increase in the poorer outcome categories.     

Prehospital intubation in patients with severe head injury

BACKGROUND: Prehospital intubation and airway control is routinely performed by paramedics in critically injured patients. Despite the advantages provided by this procedure, numerous potential risks exist when this is performed in the field. We reviewed the outcome of patients with severe head injury, to determine whether prehospital intubation is associated with an improved outcome. METHODS: A retrospective review of registry data of patients admitted to an urban trauma center with severe head injury (field Glasgow Coma Scale score of < or =8 and head Abbreviated Injury Scale score of > or =3) was performed. Patients were stratified by methods of airway control performed by prehospital personnel: not intubated, intubated, or unsuccessful intubation. Mortality was determined for each group. To control for significant variables between these populations, matching and multivariate analysis were performed. RESULTS: Patients requiring prehospital intubation or in whom intubation was attempted had an increased mortality (81% and 77%, respectively) when compared with nonintubated patients (43%). The mortality for patients who had prehospital intubation performed did not demonstrate an improved survival using matching. In fact, intubated patients had a significantly higher relative risk (RR) of mortality when compared with nonintubation (RR = 1.74,p < 0.001) and unsuccessful intubation patients (RR = 1.53, p = 0.008) CONCLUSION: For patients with severe head injury, prehospital intubation did not demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results.     

Haemodynamic changes in patients with severe head injury

Summary Haemodynamic studies were carried out in 12 patients who had sustained severe head injury. Radial artery pressure (AP), pulmonary artery pressure (PAP), central venous pressure (CVP), and pulmonary wedge pressure (PAWP) were directly measured. Heart rate was monitored from the ECG, and cardiac output (CO) was measured intermittently by the thermodilution technique. Arterial and mixed venous blood samples were withdrawn simultaneously for measurement of PH, PCO₂, PO₂, and oxygen saturation. Additional cardiovascular data were calculated from standard formulae. The haemodynamic pattern in these head-injured patients was characterized by high cardiac index, low systemic vascular resistance, moderately high systemic pressure and heart rate, high pulmonary artery pressure and wedge pressure, and normal stroke index. These findings may be the result of autonomic or adrenergic stimulation by the injured brain.     

Analysis of hyperamylasemia in patients with severe head injury

To evaluate the influence of severe head injury (SHI) on amylase activity, we studied the amylase profile of 60 patients with SHIs and Glasgow Coma Scores less than 10. Fourteen additional multiple trauma patients without head injuries were studied as a control group. We excluded patients with pancreatic injury and abdominal trauma. Total serum amylase (TA), pancreatic isoamylase (PA), and nonpancreatic isoamylase (NPA) levels were measured on Days 0, 2, 4, 7, and 14 postinjury. Values greater than 2 SD above the normal mean were considered elevated. All SHI patients were comatose; 14 died. In the SHI group, TA increased in 23 patients, PA increased in 40, and NPA increased in 14. The source of hyperamylasemia was PA in 14, NPA in one, and mixed in 8 patients. While PA increases occurred throughout the study, NPA elevations occurred early. These increases did not correlate with shock (BP less than 80 mm Hg; 17 patients), facial trauma (24 patients), or associated injury (29 patients). On Day 7 postinjury, the mean TA (215 du%) and the mean PA (203.8 du%) were significantly elevated in the SHI patients compared to controls (122.1 du%, P less than 0.05, Wilcoxon's rank sum test). These data indicate that serum amylase is not a reliable index of pancreatic injury in patients with SHI. Severe head injury and multiple trauma activate pathways that increase amylase levels in the blood, suggesting a central nervous system regulation of serum amylase levels.     

Prognosis of patients with severe head injury.

The relationship between clinical features of brain dysfunction in the first week after severe head injury and outcome 6 months later has been analyzed for 1000 patients. Depth of coma, pupil reaction, eye movements, and motor response pattern, and patient age prove to be the most reliable predictors. The degree of brain dysfunction changes markedly soon after injury, and more reliable predictions of outcome result when assessment is based on the best level of functioning recorded in each early epoch. Predictions based on very early assessment are, therefore, often unduly pessimistic. Individual predictions of outcome, based on a large data bank, provide a powerful tool for assessing the relative efficacy of alternative treatments.