Intensivbehandlung des Schädel-Hirn-Traumas

Kernaussagen

Das schwere Schädel-Hirn-Trauma ist in der Altersklasse unter 45 Jahren die häufigste Ursache für Mortalität und dauerhafte Morbidität. Ziel der Therapie ist es, sekundäre Hirnschäden so gering wie möglich zu halten und dadurch das neurologische Outcome zu verbessern. Eine der Hauptursachen für die Entwicklung sekundärer Hirnschäden ist die Hirnschwellung, durch die der intrakraniale Druck steigt und die zerebrale Sauerstoffversorgung verschlechtert wird. Daher muss auf optimale Oxygenierung und Perfusion geachtet werden.

Patienten mit schwerem Schädel-Hirn-Trauma sollen vom Notarzt in ein Traumazentrum mit neurochirurgischer Abteilung gebracht werden. Je nach dem Ergebnis einer sofort durchgeführten CT muss eine operative (Trepanation) oder primär konservative (Liquordrainage, Hyperventilation, Mannitol) Therapie eingeleitet werden. Dabei sollte man zur Überwachung den intrakranialen Druck und ggf. den Gewebesauerstoffgehalt (ptiO2), die zerebrale Durchblutung (CBF) und Gewebemetaboliten (Mikrodialyse) messen.

Durch das optimale Zusammenspiel von Notarzt, Schockraumteam und Intensivmedizinern kann die Überlebenschance und das neurologische Outcome von Patienten mit schwerem SHT oft entscheidend gebessert werden.

Literatur

• 1 Baethmann A, Wirth A, Schlesinger-Raab A,. The Study Group of the BMBF Research Consortium Neurotraumatology and Neuropsychological Rehabilitation . Prospective System Analysis of the Pre- and Early Hospital Care in Severe Head Injury in Bavaria at a Population-Bases Level.  Eur Surg Res. 2002;  34 42-46
• 2 Fisching R, Woischneck D. Present Status of Neurological Trauma in Germany.  World J Surg. 2001;  25 1221-1223
• 3 Rudehill A, Bellander B, Weitzberg E. et al . Outcome of Traumatic Brain Injuries in 1508 Patients: Impact of prehospital Care.  J Neurotrauma. 2002;  19 855-868
• 4 Jiang J, Gao G, Li W. et al . Early Indicators of Prognosis in 846 Cases of Severe Traumatic Brain Injury.  J Neurotrauma. 2002;  19 869-874
• 5 Adams H, Mitchell D E, Graham D I. et al . Diffuse brain damage of immediate impact type. Its relationship to „primary brain stem damage” in head injury.  Brain. 1977;  100 489-502
• 6 Ommaya A M, Gerneralli T A. Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries.  Brain. 1974;  97 633-654
• 7 Miller J, Sweet R, Narayan R. et al . Early insults to the injured brain.  JAMA. 1978;  240 439
• 8 Baethmann A, Kempski O, Unterberg A. et al . Origin and therapy of Secondary Brain Damage.  Münchner Med Wochenschr. 1982;  124 941-944
• 9 Baethmann A, Maier-Hauff K, Kempski O. et al . Mediators of Brain Edema and Secondary Brain Damage.  Crit Care Med. 1988;  16 972-978
• 10 Lynch D R, Dawson T M. Secondary Mechanisms in Neuronal Trauma.  Current Opinion in Neurology. 1994;  7 510-516
• 11 Marshall L F, Toole B M, Bowers S A. The National Trauma Coma Data Bank. Part 2: Patient who talk and deteriorate: Implications of treatment.  J Neurosurg. 1983;  59 285-288
• 12 Reilly P L, Graham D I, Adams J H. et al . Patients with head injury who talk and die.  Lancet. 1975;  2 375-377
• 13 Bouma G J, Muizelaar J P, Fatouros P. Pathogenesis of Traumatic Brain Swelling: Role of Cerebral Blood Volume.  Acta Neurochir. 1998;  71 [Suppl] 272-275
• 14 Marmarou A, Fatouros P, Barzò P. et al . Contribution of Edema and Cerebral Blood Volume to Traumatic Brain Swelling in Head-injured Patients.  J Neurosurg. 2000;  93 183-193
• 15 Narayan R K, Greenberg R P, Miller D J. et al . Improved Confidence of Outcome Prediction in Severe Head Injury.  J Neurosurg. 1981;  54 751-762
• 16 Klatzo I. Neuropathological Aspect of Brain Edema.  J Neuropathology and Experimental Neurology. 1967;  26 1-14
• 17 Marmarou A. Traumatic Brain Edema: An Overview.  Acta Neurochir. 1994;  60 (Suppl) 421-424
• 18 Sharma H S, Westman J, Nyberg F. et al . Pathophysiology of Brain Edema and Cell Changes Following Hypertermic Brain Injury.  Progress in Brain Research. 1998;  115 351-412
• 19 Mendelow A D, Teasdeal G M. Pathophysiology of Head Injuries.  Br J Surg. 1983;  70 641-650
• 20 von Oettinger G, Bergholt B, Gyldensted C. et al . Blood Flow and Ischemia within Traumatic Cerebral Contusions.  Neurosurgery. 2002;  50 781-788
• 21 Friedrich D H, Plesnila N, Eriskat J. et al . Cerebral Blood Flow and Secondary Growth of Brain Tissue Necrosis after Trauma.  Acta Neurochir. 2000;  76 (Suppl) 257-259
• 22 Jiang X B, Ohno K, Chian L. et al . Changes in Local Cerebral Blood Flow, Glucose Utilizataion, and Mitochondrial Function Following Traumatic Brain Injury in Rats.  Neurol Med Chir. 2000;  40 16-28
• 23 Kelly D F, Martin N A, Kordestani R. et al . Cerebral Blood Flow as a Predictor of Outcome following Traumatic Brain Injury.  J Neurosurg. 1997;  86 633-641
• 24 Vespa P, Prins M, Ronne-Engstrom E. et al . Increase in Extracellular Glutamate caused by Reduced Cerebral Perfusion Pressure and Seizures after Human Traumatic Brain Injury: a Microdialysis Study.  J Neurosurg. 1997;  21 971-982
• 25 Bullock R. Pathophysiological Alterations in the Central Nervous System due to Trauma.  Schweiz Med Wschr. 1993;  123 449-458
• 26 Kimelberg H K. Astrocytic Edema in CNS Trauma.  J Neurotrauma. 1992;  9 (Suppl 1) 71-81
• 27 Reinert M, Khaldi A, Zauner A. et al . High Level of Extracellular Potassium and its Correlates after Severe Head Injury: Relationship to High Intracranial Pressure.  J Neurosurg. 2000;  93 800-807
• 28 Schwab J M, Seid K, Schluesener H J. et al . Traumatic Brain Injury Induces Prolonged Accumulation of Cyclooxygenase-1 Expressing Microglia/Brain Macrophages in Rats.  J Neurotrauma. 2001;  18 881-890
• 29 Hartl R, Gerber L, Iacono L. et al . Direct transport within an organized state trauma system reducees mortality in patients with severe traumatic brain injury.  J Trauma. 2006;  60 1250-1256
• 30 Arbeitsgemeinschaft „Intensivmedizin und Neurotraumatologie” der Deutschen Gesellschaft für Neurochirurgie, „Arbeitskreis Neuroanästhesie” der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, „Sektion Rettungswesen” der Deutschen Interdiziplinären Vereinigung für Intensivmedizin . Leitlinie zur Primärversorgung von Patienten mit SHT.  Zbl Neurochir. 1997;  58 13
• 31 Moskopp D, Böker D K, Kurthen M. et al . Begleitende Wirbelsäulentraumata bei Schädel-Hirn-Verletzungen. 34 konsekutive Patienten aus 3 Jahren.  Unfallchirurg. 1990;  93 120-126
• 32 Brain Trauma Foundation, AANS Joint Section on Neurotrauma and Critical Care . Guidelines for the management of severe head injury: Critical pathway for the treatment of established intracranial hypertension.  J Neurotrauma. 2000;  17 537-538
• 33 Cooper D J, Myles P S, McDermott F T. et al . Prehospital Hypertonic Saline Resuscitation of Patients with Hypotension and Severe Traumatic Brain Injury: a Ranomized Control Trial.  JAMA. 2004;  17 1350-1357
• 34 Bullock M R, Chesnut R, Ghajar J. et al . Surgical management of acute subdural hematomas.  Neurosurgery. 2006;  58 (Suppl 2) 16-24
• 35 Cooper P, Grossman R, Gildenberg P. et al .Posttraumatic intracranial mass lesions. Head Injura. Baltimore, London; Lippincott, Williams & Willkins 1982: 185
• 36 Marshall L F, Gautille T, Klauber M. et al . The outcome of severe closed head injury.  J Neurosurg. 1991;  75 28
• 37 Knapp J, Gielchinsky I, Deardourff S. Operative techniques for management of lesions involving the dural venous sinuses.  Surg Neurol. 1977;  7 339
• 38 Maas A, Dearden M, Teasdale G. et al . EBIC-guidelines for management of severe head injury in adults. European Brain Injury Consortium.  Acta Neurochir. 1997;  139 286
• 39 Caricato A, Conti D, Della Corte F. et al . Effect of PEEP and the Intracranial System of Patients with Head Injury and Subarachnoidal Hemorrage: the Role of Respiratory System Compliance.  J Trauma. 2005;  58 571-576
• 40 Huynh T, Messer M, Sing R F. et al . Positive end-expiratory Pressure alters Intracranial and Cerebral Perfusion Pressure in Severe Traumatic Brain Injury?.  J Trauma. 2005;  53 488-492
• 41 Pfenninger E G, Reith A, Breiting D. et al . Early Changes of Intracranial Pressure, Perfusion Pressure, and Blood Flow after Acute Head Injury. Part 1: an Experimental Study of the underlying Pathophysiology.  J Neurosurg. 1989;  70 774-779
• 42 Clark R S, Kochanek P M, Marion D W. et al . Mild posttraumatic hypothermia reduces mortality after severe controlled cortical impact injury in rats.  J Cereb Blood Flow and Metab. 1996;  16 253-261
• 43 Dietrich W D, Alonso O, Busto R. et al . Post-traumatic brain hypothermia reduces histopathological damage following concussive brain injury in the rat.  Acta Neuropathol. 1994;  87 250-258
• 44 Palmer A M, Marion D W, Motscheller M L. et al . Therapeutic hypothermia is cytoprotective without attenuating the traumatic brain injury-induced elevation in interstitial concentrations of aspertate and glutamate.  J Neurotrauma. 1993;  10 363-372
• 45 Faupel R, Reulen H, Muller D. et al . Double-blind study on the effect of steroids on severe closed head injury. In: Pappius HM, Feindel W (eds) Dynamics of brain edema. Heidelberg, Berlin, New York; Springer 1976: 337
• 46 Alzaga A G, Cerdan M, Varon J. Therapeutic Hypothermia.  Resuscitation. 2006;  70 369-380
• 47 Andrews P J. Head Injury: Complications and Management.  Curr Opin Anaesthesiol. 1998;  11 (5) 473-477
• 48 Lescot T, Abdennour L, Degos V. et al . Management of Severe Traumatic Brain Injury.  Presse Med. 2007;  20
• 49 Ramani R. Hypothermia for Brain Protection and Resuscitation.  Curr Opin Anaesthesiol. 2006;  19 487-491
• 50 Allison S P. Nutritional support - who needs it and who does it?.  Clin Nutr. 1992;  11 165-166
• 51 Heyland D K, Dhaliwai R, Day A. et al . Validation of the Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critical Ill Adult Patients: Results of a Prospective Observational Study.  Crit Care Med. 2004;  32 2260-2266
• 52 Bochiccio G V, Bochiccio K, Nehmann S. et al . Tolerance and Efficacy of Enteral Nutrition in Traumatic Brian-injured Patients included into Barbiturate Coma.  JPEN J Parenteral Enteral Nutr. 2006;  30 503-506
• 53 Heller A R, Rossler S, Litz R J. et al . Omega-3-fatty acids improve the diagnosis-related clinical outcome.  Crit Care Med. 2006;  34 972-979
• 54 Balestreri M, Czosnyka M, Hutchinson P. et al . Impact of Intracranial Pressure and Cerebral Perfusion Pressure on Severe Disability and Mortality after Head Injury.  Neuocrit Care. 2006;  4 8-13
• 55 Vajkoczy P, Roth H, Horn P. et al . Continuous monitoring of regional cerebral blood flow: experimental and clinical validation of a novel thermal diffusion microprobe.  J Neurosurg. 2000;  93 265
• 56 The SAFE Study Investigators . A Comparison of Albumine and Saline for Fluid Resuscitation in the Intensive Care Unit.  N Engl J Med. 2004;  350 2247-2256
• 57 Doyle J, Davis D, Hoyt D. et al . The use of hypertonic saline in the treatment of traumatic brain injury.  J Neurosurg. 2001;  50 367
• 58 Braakman R, Schouten H, van Blaauw D. et al . Megadose steroids in severe head injury. Results of a prospective double-blind clinical trial.  J Neurosurg. 1983;  58 326
• 59 Dearden N, Gibson J, McDowall D. et al . Effect of high dose dexamethason on outcome from severe head injury.  J Neurosurg. 1986;  64 81
• 60 Gobiet W, Bock W, Liesgang J. et al . Treatment of acute cerebral edema with high dose of dexamethasone. In: Beks J et al. (eds) Intracranial pressure III. Berlin, Heidelberg, New York; Springer 1976: 351
• 61 Gaab M, Trost H, Alcantara A. et al . „Ultrahigh” dexamethason in acute brain injury. Results from a prospective randomized double-blind multicenter trial (GUDHIS).  Zbl Neurochir. 1994;  55 135
• 62 Grumme T, Baethmann A, Kolodziejczyk D. et al . Treatment of patient with severe haed injury by triamcinolone: a prospective controlled, multicenter clinical trial of 396 cases.  Res Exp Med (Berl). 1995;  195 217
• 63 Roberts I, Yates D, Sandercock P. et al . Effect of intravenous corticosteroids on death within 14 days in 10 008 adults with clinically signifcant head injury (MRC CRASH trial): randomized placebo- controlled trial.  Lancet. 2004;  364 1321-1328
• 64 Zweckberger K, Eroes C, Zimmermann R. et al . Effect of Early and Delayed Decompressive Craniotomy on Secondary Brain Damage after Controlled Cortical Impact in Mice.  J Neurotrauma. 2006;  7 1083-1093