RESUSCITATION OF MULTIPLE TRAUMA AND HEAD-INJURY - ROLE OF CRYSTALLOID FLUIDS AND INOTROPES

Objectives: To determine the hemodynamic responses to blunt trauma wit h a closed-head injury and to investigate the effect that volume resus citation has on intracranial pressure. Design: Prospective study with retrospective analysis of patient data and hemodynamic responses. Sett ing: Surgical intensive care unit at an inner-city, Level I trauma cen ter.Patients: Consecutive patients (n = 30) who sustained multiple sys tem injury, including a closed-head injury that was severe enough to r equire intracranial pressure monitoring but not a craniotomy. Interven tions: All patients underwent invasive hemodynamic monitoring with per cutaneous arterial and pulmonary arterial catheters. Serum lactate con centrations and hemodynamic and oxygen transport variables were measur ed every 4 hrs. Intracranial pressures and vital signs were recorded e ach hour. Attempts were made to achieve a state of nonflow-dependent o xygen consumption and a normal serum lactate concentration. Measuremen ts and Main Results: Despite being normotensive and neither tachycardi ac nor oliguric, 80% of patients had evidence of inadequate tissue per fusion. Only 50% of the remaining patients had an adequate response to volume. The other 50% received vasodilating inotropic agents. Despite volume loading and the administration of inotropic agents, intracrani al pressure did not increase. This observation was found in patients w ho showed clinically important intracranial pathology on computed tomo graphy scan, as well as in all other patients. Intracranial pressure d id not correlate with the amount of fluid or blood infused or with hem odynamic performance, but intracranial pressures did correlate with se rum lactate concentrations. Conclusions: Many patients with diffuse bl unt trauma closed-head injuries, even when they are normotensive, have evidence of impaired peripheral perfusion. Volume infusion and vasodi lating inotropic support improve oxygen transport without increasing i ntracranial pressure. The observed relationship between intracranial p ressure and the serum lactate concentration requires further study.