Initial management and diagnostic strategy of severely head-injured patients

Limitation of secondary insults after severe head injury is a permanent con cern during the early phase of head trauma management. The objectives are t o maintain mean arterial pressure between 80 and 100 mmHg, to avoid hypoxae mia, and to maintain arterial PCO2 near to 35 mmHg. Volume loading can be n ecessary to improve arterial pressure, and is carried out with isotonic cri talloid (NaCl 9 parts per thousand) or colloids, with the exclusion of all hypotonic solutions (Ringer lactate or glucose). The use of catecholamines is reserved for patients with unstable haemodynamics despite an adequate vo lume loading. The rapid sequence induction is recommended for endotracheal intubation and is followed by continuous analgesia-sedation to keep patient -ventilator dysynchrony, but without compromising haemodynamic objectives. Mannitol is used in case of life-threatening intracranial hypertension. Con versely, specific treatment of intracranial hypertension, especially hypoca pnia, is not recommended. Initial diagnostic procedures include cerebral to modensitometry (TDM). However, TDM may be delayed in case of haemorrhage, w hich requires a rapid treatment. Intrahospital tranport for additional expl orations risks secondary insults, and thus requires close monitoring to det ect and treat in due time all adverse events. This monitoring includes inva sive arterial blood pressure assessment, use of continuous capnography and repeated arterial blood gas measurements. The usefulness of transcranial Do ppler for initial management of head-trauma patients needs further evaluati on. (C) 2000 Editions scientifiques et medicales Elsevier SAS.