CRITICAL CARE OF THE PATIENT WITH MULTIPL E TRAUMA

Multiple trauma often leads to systemic inflammatory reaction and mult iple organ dysfunction. Modulation of this response may be promising. Several pharmacologic approaches, such as antioxidants (e.g. superoxid edismutase), calcium channel blockers (e.g. diltiazem), cytokines (e.g . interferone gamma), and modulators of intracellular signal transduct ion pathways (e.g. pentoxiphylline) have been shown to improve outcome in experimental models and/or in clinical pilot studies. However, up to now no defintive evidence has been provided in prospective, randomi zed, and blinded ''intention to treat'' trials that these agents are a ble to reduce mortality and morbidity of the traumatized patient. Henc e, supportive care of failing organs, treatment of hypoxemia and maint enance of an appropriate systemic blood pressure remain the mainstay o f critical care therapy. Widely accepted therapeutic measures are (i) immediate treatment of hypoxia by administration of oxygen and ventila tory support, if needed, to maintain an oxygen tension of 60 mmHg or h igher (ii) maintenance of adequate oxygen content by transfusion of re d packed cells in order to restore a hematocrit of 23-30% (iii) treatm ent of hypovolemia by infusion of crystalloids, colloids and blood pro ducts (iv) normoventilation and restoration of a normal or elevated bl ood pressure in patients with severe head injury (v) immobilisation an d early administration of methylprednisolone in patients with spinal c ord injury (vi) analgesia by administration of opioids, non-steroidal antiinflammatory drugs, or ketamine (vii) sedation with benzodiazepine s, gamma-hydroxbutyrate or propofol (viii) early enteral nutrition (ix ); antibiotic therapy of infections (x) pessure controlled ventilation in patients with acute lung injury (xi) continuous veno-venous hemofi ltration in patients developing acute renal failure and (xii) early su rgical interventions to control bleeding and/or to evacuate intracereb ral hematomas.