Ebook Traumatic brain injury: Part 2
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Ebook Traumatic brain injury: Part 2
CHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University Uiis Ebook Traumatic brain injury: Part 2spital of Bared, SwitzerlandInjury resulting from traumatic insults to the brain is typically divided into primary and secondary injury. Primary injury occurs al the moment OÍ the trauma and currently cannot be inlluenced in the clinical selling. In contrast, secondary brain injury occurs at some ti Ebook Traumatic brain injury: Part 2me after the primary' impact as a complication of primary' injury and is potentially preventable and treatable. Secondary insults are classilied as eiEbook Traumatic brain injury: Part 2
ther intracranial or extracranial (Table 7.1) and have a major impact on outcome, rhe goal ol neuromonitoring and neurological intensive care treatmenCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University Uiis Ebook Traumatic brain injury: Part 2toringClinical neuromonitoringClinical deterioration is often the first sign OÍ a secondary insult suc h as a rise in intracranial pressure (ICP) or developing intracerebral hematoma. This underlines the importance ol repealed standardized neurological assessments lo deled such a clinical deteriorat Ebook Traumatic brain injury: Part 2ion as early as possible, standardized scoring systems facilitate quantitative reporting of the neurological status and arc indispensable if the neuroEbook Traumatic brain injury: Part 2
logical status needs to be compared to earlier assessments. The most widely' used score is the Glasgow Coma Scale (GCS).Of the three components of theCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University Uiis Ebook Traumatic brain injury: Part 2OUR score) 11]. It addresses some of the shortcomings of the GCS by including brainstem reflexes and respiration, allowing detection of subtle neurological changes and, thus, further classification of deeply' comatose patients. A comparison between the GCS and the FOUR score is shown in Table 7.2. w Ebook Traumatic brain injury: Part 2hile such scores arcTraumatic Brain Injury, FirsJ Edition. Edited l»v Pieter E. Vos and Ramon Diaz-Arrastia. o 2015 .John Wiley & Sons. l.td. PublisheEbook Traumatic brain injury: Part 2
d 2015 by John Wiley fr Sons. I.td.115116 Traumatic Brain InjuryTable 7.1 Secondary brain insults following TBI.Intracranial insultsSystemic insultsInCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University Uiis Ebook Traumatic brain injury: Part 2ia Hypoglycemia-hyperglycemia Hyponatremia Hypo-osrnolarity-liyperosnriolarity Hyperthermia Anemia Sepsisrapidly administered and have a high inlerraler reliability, they cannot replace frequent in-depth neurological examinations.Intracranial pressure and cerebral perfusion pressure monitoringIn con Ebook Traumatic brain injury: Part 2trast to most other organs the brain is protected by a stiff skull. A rise in ICP may therefore impede cerebral blood flow (CBF) and may cause ischemiEbook Traumatic brain injury: Part 2
a. I ’leva led KJ’ is an important secondary insult and a predictor ol poor outcome alter Till. Possible causes ol raised KJ’ are intracranial mass leCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University Uiis Ebook Traumatic brain injury: Part 2perfusion pressure (CPP), delined as the dil Terence between mean arterial pressure (MAP) and KJ’ (CI’I’sMAI’ - KJ’). (J’P represents the pressure gradient across the cerebral vascular bed and is used as a therapeutic target for patients with TBI in most intensive care units (ICUs).The gold standard Ebook Traumatic brain injury: Part 2 lor assessing KJ’ is an intraventricular drain inserted into one of I he lateral vent Tides and connec ted Io an external pressure transduc er [21. TEbook Traumatic brain injury: Part 2
he foramen of Monro or for clinical purposes the external auditory meatus is the reference point lor zeroing the transducer. As patients are maintaineCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University Uiis Ebook Traumatic brain injury: Part 2monitoring pressure, intraventricular catheters allow withdrawal of CSF to treat raised ICP. The main drawback of intraventricular catheters is the risk of inlet lion that inc Teases over lime and may reach 20%. In many units CSF samples are analyzed on a daily basis to detect infection, although da Ebook Traumatic brain injury: Part 2ily sampling itself may increase risk of infection. Moreover, the insertion of ventricular catheters may be difficult in patients with severe brain swEbook Traumatic brain injury: Part 2
elling. As an alternative, inlraparenchymal probes are used. The infection rate of these probes is very low. An example of such a device is shown in FCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University Uiis Ebook Traumatic brain injury: Part 2 117Table 7.2 CCS and FOUR score [I]: A comparison.FOUR scoreGCSEye response4Eyelids open/opened, tracking, or blink to command4Spontaneous eye opening3Eyelids open but not tracking——2Eyelids closed but open to loud voice3Fye opening to speech1Eyelids closed but open to pain2Fye opening to pain0Eyel Ebook Traumatic brain injury: Part 2ids remain closed with pain1No rear iron to painMotor response 4Thumbs-up, fist, or peace6Obeying commands3sign localization Io pain5localization to pEbook Traumatic brain injury: Part 2
ain2flexion response to pain4Normal flexion to pain——3Abnormal flexion Io pain1Extension response to pain2Extension to pain0No response Io pain or1NcrCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University UiisCHAPTER 7ICU care: surgical and medical management—neurological monitoring and treatmentLuzius A. SteinerDepartment of Anesthesiolqfy. University UiisGọi ngay
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