EARLY MANAGEMENT OF PATIENTS WITH HEAD-INJURY

The occurrence of severe head injury, isolated or in connection with polytrauma, is a challenge for all physicians working in emergency care at the scene af an accident or afterwards in hospital care. It is an advantage to have a basic knowledge of neurological assessment. The Glasgow Coma Scale is widely used in this context; we refer to mild, moderate, and severe injuries. It is very important to recognise concomitant injuries, which occur in about 40% of cases. As coexisting hypoxaemia and hypotension have an adverse effect on the time course of head injury by inducing secondary brain damage, it is essential in therapy to quickly restore the vital body functions. Unconscious patients are tracheally intubated and ventilated. Forced hyperventilation over a lengthy period seems to have an unfavourable effect on outcome. Anaesthetic drugs and adjuvant therapies are used that do not increase intracranial vessel diameter and consequently intracranial pressure (ICP). This applies to all i.v. anaesthetics, sedatives, and opioids, as long as no respiratory depression occurs. Ketamine has been useful for many years at the scene of an accident. An existing low blood pressure (BP) is raised while a significantly increased BP is moderately lowered. It is necessary to have adequate cerebral perfusion pressure (CPP), which is defined as mean BP minus ICP. In cases of polytrauma with heavy bleeding, e.g., from the liver or spleen, the blood loss must be stopped before the neurosurgeon begins. Excessive i.v. administration of Ringer's lactate should be avoided. Today, the routine use of osmodiuretics, e.g., mannitol, is not indicated. It has not yet been possible to show that using corticosteroids is definitely beneficial in human brain trauma; there may be a positive effect in connection with spinal trauma. New therapies are being investigated, such as increasing CPP, administering AMPA/NMDA-antagonists, 21-aminosteroids, or hypertonic-hyperoncotic solutions. However, they have not as yet been proven effective for general clinical use or clinical use et al.