Critical care management of neurotrauma in children: new trends and perspectives

Secondary brain lesions resulting from cerebral metabolic and hemodynamic r eactions can be prevented by neurocritical care management. It must be init iated as soon as possible, ideally in a prehospital setting. Tracheal intub ation, controlled ventilation and hemodynamic stabilization are the prerequ isites. Beside intracranial and cerebral perfusion pressure, monitoring mus t evaluate the coupling between cerebral metabolic demand and blood flow. J ugular bulb oximetry is the most reliable approach to global cerebral coupl ing. Transcranial Doppler evaluates cerebral blood flow indirectly and noni nvasively. Technological developments have led to local metabolic evaluatio n that does not yet have any clinical relevance. Therapeutic developments a re more a new approach to the use of old drugs. Controlled hyperventilation , mannitol and, more recently, hypertonic saline solutions, used for restor ing cerebral metabolic coupling, are the foundations of treatment. Thiopent al, revisited as a vasoconstrictive agent, the "Lund" vasoconstrictive appr oach with anti-hypertensive drugs and cerebral vasoconstrictors, must be fu rther evaluated in children, as must therapeutic hypothermia. Finally, what we probably need for the immediate future is a noninvasive and easily repr oducible method of monitoring cerebral metabolic coupling that will allow p recise therapeutic adaptation of multimodal therapy to the individual needs of the child.