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in these patients and another study of patients with temporal lobe contusion by the same investigators In the end, it must be concluded that large boluses of mannitol are bene cial in closed head injury, especially if there is an acute subdural hematoma or contusions, and this may extend to patients who have pupillary abnormalities Hypertonic saline (3 percent) probably has a comparable effect to mannitol in the treatment of acutely raised ICP Hypocarbia, induced by hyperventilation, is effective in reducing ICP for only a limited period of time, since the pH of the spinal uid equilibrates over hours and allows cerebral blood volume to return to its previous level A single-step reduction in PCO2 typically lowers ICP for approximately 20 to 40 min Attempts to prolong the effect of hypocarbia and the alkalosis by the intravenous administration of ammonium buffers have met with mixed success It has even been suggested that hyperventilation may be harmful to some head-injured patients because of a reduction in cerebral blood ow, but the risk, if any, appears to be minimal For these reasons, hypocarbia is not often used in cases of head trauma The method of deep cooling has had its proponents over the years, but most attempts to demonstrate improved outcome have been unsuccessful (see Clifton et al) Lowering of the body temperature will, however, transiently reduce ICP If the ICP continues to rise and brain swelling progresses despite these measures, the outlook for survival is bleak Hypothermia and barbiturate anesthesia to reduce ICP have been used, but relatively few patients respond to such measures for long A randomized controlled trial of cooling patients with severe closed head injury (Glasgow Coma Scale scores of 3 to 7) to 33 C for 24 h appeared to hasten neurologic recovery and may have modestly improved outcome (Marion et al) Since on rewarming, however, there may be a rapid increase in ICP, the body temperature must be raised very gradually over a day or more It has been suggested by Shann, who has summarized the many trials of hypothermic treatment, that most were unlikely to show bene t because the degree and duration of cooling were inadequate Barbiturates, while they lower ICP, may lower the blood pressure as well; hence they may diminish cerebral perfusion However, Marshall and coworkers claimed a high rate of improvement and survival by using barbiturates even in cases where the ICP exceeded 40 mmHg The more de nitive randomized study by Eisenberg and associates showed no bene t from barbiturate-induced anesthesia in headinjured patients Several large controlled studies have established that the administration of high-dose steroids does not signi cantly affect the clinical outcome of severe head injuries Consequently, their use has been abandoned except for cases of marked edema surrounding a contusion or hematoma; even then, the bene t is uncertain (Gudeman et al; Dearden et al; Braakman et al; Saul et al) The use of wide decompression craniectomy in cases of intractable brain swelling is commented on below The management of posttraumatic systemic hypertension can be a dif cult problem Immediately after head injury, the sympathoadrenal response and elevation of blood pressure will recede spontaneously in a matter of a few hours or days Unless the blood pressure elevation is extreme (greater than 180/95 mmHg), it can be disregarded in the early stages In animal experiments, it has been found that severe hypertension leads to increased perfusion of the brain and an augmentation of the edema surrounding contusions and hemorrhages As mentioned earlier, edema is the main element in the genesis of brain swelling and of raised ICP in most head-injured patients (Marmarou et al) This re ects a failure of autoregulatory vascular mechanisms, with resulting transudative
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edema in damaged areas of the brain The control of high blood pressure must be balanced against the risk of reducing cerebral perfusion pressure and the observation that even a brief period of mild hypotension may provoke a cycle of cerebral vasodilation, increased cerebral blood volume, and elevated ICP in the form of plateau waves (Rosner and Becker) Observations such as these emphasize the need for immediate and vigorous management of hypotension in severely head-injured patients Since most therapies for elevated ICP dehydrate the patient or reduce cardiac lling pressures, thereby leading to hypotension, a middle course, of avoiding both severe hypertension and any degree of hypotension, seems the best compromise In lowering high levels of blood pressure, diuretics, beta-adrenergic blocking agents, or angiotensin converting enzyme inhibitors should be used, rather than agents that may dilate the cerebral vasculature (nitroglycerin and nitroprusside, hydralazine, and some of the calcium channel blockers) Hypotension should be corrected by vasopressor agents such as neosynephrine The precise level of blood pressure that requires treatment must be judged in the context of the ICP and the presence of plateau waves (the goal being to maintain normal cerebral perfusion) as well as the patient s previous blood pressure level; evidence of organ failure, such as cardiac or renal ischemia, must also be taken into account General Medical Measures If coma persists for more than 48 h, a nasogastric tube should be passed and uids and nutrition given by this route Agents that reduce gastric acid production or the equivalent, antacids by stomach tube to keep gastric acidity at a pH above 35 are of value in preventing gastric hemorrhage The prophylactic use of anticonvulsant drugs, as discussed earlier, under Posttraumatic Epilepsy, has recently been favored, but there is no evidence that delayed epileptic seizures are reduced (see Chand and Lowenstein) Only if there has been a seizure are anticonvulsants given Restlessness is controlled by diazepam or a similar sedative, but only if careful nursing fails to quiet the patient and provide sleep for a few hours at a time Haloperidol is usually avoided in the acute stage Fever is counteracted by antipyretics such as acetaminophen, and, if necessary, by a cooling blanket The use of morphine or bromocriptine to quiet episodes of vigorous extensor posturing and accompanying adrenergic activity has already been mentioned Surgical Measures The need for surgical intervention during the acute posttraumatic period is decided by two factors: the clinical status of the patient and CT scanning The presence of a subdural or epidural clot that is causing a shift of central brain structures calls for its immediate evacuation The approach to subdural hematomas has been discussed earlier in this chapter Should the elevated ICP not respond to this procedure or to the standard osmotic agents and other medical measures outlined above, or should the condition of the patient and vital signs then begin to deteriorate (pulse rising, temperature rising or falling below normal, state of consciousness worsening, hemiplegia more obvious, plantar re exes more clearly extensor), a renewed search must be undertaken for a late-occurring cerebral mass Usually in these clinical circumstances, CT scanning will disclose a new or enlarged epidural, subdural, or intracerebral hematoma, marked cerebral edema, and a lateral shift of central cerebral structures If death or severe disability is to be avoided, operation in these cases must be undertaken before the advanced signs of brainstem compression de-
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