Chapter 6.

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NON-OPERATIVE TREATMENT

Note:
Standards of non-operative therapeutic procedures for brain injuries in the acute phase in Intensive Care Unit (ICU) are described.

Contents:
6.1.: Ventilation, sedation, and skeletal muscle relaxation
6.2.: Blood circulation
6.3.: Diuretics
6.4.: Glucocorticoids
6.5.: Barbiturates
6.6.: Antiepileptic drugs
6.7.: Psychostimulants
6.8.: Antioxidants
6.9.: Calcium channel blockers
6.10.: Hypothermia

STANDARD 6.1.: VENTILATION, SEDATION, AND SKELETAL MUSCLE RELAXATION Hvezdicka.GIF (147 bytes)

TBI casualties with a GCS between 3 and 8 should be intubated if this has not been done during pre-hospital care. Artificial pulmonary ventilation should be maintained at values of PaCO2 35 mmHg (4.5 kPa). Hyperventilation is not indicated. If necessary, skeletal muscle relaxants can be added on.

Recommended central nervous system depressants are midazolam, propofol, or chlorpromazine. For analgesia, morphine or fentanyl are used. All available skeletal muscle relaxants can be used. Efficient sedation is preferred to skeletal muscle relaxation concerning circulatory parameters.

Commentaries:
6.1.1. Management of non-surgical treatment of brain injury
6.1.2. Artificial ventilation of brain injury in the ICU
6.1.3. Sedatives for treatment of brain injury in the ICU
6.1.4. Skeletal muscle relaxants for treatment of brain injury in the ICU

STANDARD 6.2.: BLOOD CIRCULATION Hvezdicka.GIF (147 bytes)

Blood volume and pressure should be maintained by fluid resuscitation. Fluid balance shoud be kept slightly negative in the first few days of injury but the absolute difference between fluid intake and output should not be further increased.

STANDARD 6.3.: DIURETICS Hvezdicka.GIF (147 bytes)

After ruling out intracranial hemorrhage, mannitol can be given as a series of bolus intravenous doses of 0.25 g/kg every 4 or 6 hours during the acute phase of TBI. ICP and blood osmolality should be monitored.

Furosemide should be given in a short infusion or as single bolus dose of 1 mg/kg if a sudden fluid retention occurs in the acute phase of TBI.

STANDARD 6.4.: GLUCOCORTICOIDS Hvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)

There are no convincing data that prove the administration of glucocorticoids to patients with traumatic brain injuries is effective. At present, glucocorticoids are not indicated for the treatment of traumatic brain injuries.

STANDARD 6.5.: BARBITURATESHvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)

There are no convincing data that prove barbiturates efficient in improving the outcome of severe head injury.

STANDARD 6.6.: ANTIEPILEPTIC DRUGS Hvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)

There are no convincing data that advocate the administration of antiepileptic drugs to patients with traumatic brain injuries to prevent both the early and late posttraumatic seizures. It is recommended that early posttraumatic seizures should be treated with phenytoin.

STANDARD 6.7.: PSYCHOSTIMULANTS Hvezdicka.GIF (147 bytes)

There are no convincing data that prove psychostimulants efficient in improving outcome of severe head injury.

STANDARD 6.8.: ANTIOXIDANTS Hvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)

So far antioxidants have been discouraged for the treatment of patients with traumatic brain injuries since clinical studies have yet to prove their effectiveness.

STANDARD 6.9.: CALCIUM CHANNEL BLOCKERSHvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)

There are no convincing data that prove calcium channel blockers efficient in improving the outcome of severe head injury.

STANDARD 6.10.: HYPOTHERMIAHvezdicka.GIF (147 bytes)Hvezdicka.GIF (147 bytes)

Hypothermia is not recommended for. We maintain the body temperature below 37 degrees centigrade.

Coordinated by Karel ZITKO, M.D.

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Last updated: 1999-09-06