Current recommendations for neurotrauma.

Abstract

Diagnostic and monitoring procedures for patients with head injury are aimed at early detection of mass lesions and secondary insults. Our therapeutic approach is based on our understanding of pathophysiologic mechanisms that cause secondary brain damage, and includes evacuation of mass lesions and prevention of secondary insults. Basic research has greatly increased our knowledge of these pathophysiologic mechanisms and has prompted the development of many neuroprotective agents, targeted to selected mechanisms. Unfortunately, it has proved difficult to demonstrate the benefit of such agents in the overall population of head-injured patients. Clinical research has emphasized the importance of ischemia in head injury and has demonstrated the deleterious effect of secondary insults on outcome. Medical management of patients with head injury has consequently focused on prevention of secondary insults, treatment of raised intracranial pressure, and maintenance of adequate cerebral perfusion pressure. The introduction of new monitoring techniques in head-injured patients offers the possibilities of more targeted therapy in individual patients, in contrast to the current practice of a staircase approach to treatment of raised intracranial pressure.In the US, an evidence-based approach has resulted in the wide acceptance of general principles, but at the same time highlighted the lack of hard evidence for the use of many therapeutic modalities. Practical guidelines, developed and published by the European Brain Injury Consortium, are based on expert opinion and consensus. Surveys have shown considerable variation in monitoring techniques and treatment. There is still considerable need for further improvements, both from a medical scientific perspective and from an organizational aspect. Particularly relevant are early resuscitation and stabilization at the scene of the accident, the organization of emergency services, admission policy to the intensive care unit, and improved policy for early identification of patients with operable intracranial hematoma. Further dissemination and general acceptance of already published guidelines may be expected to significantly improve care in head injury.