General Principles of Head Injury Managenent

INTRODUCTION Traumatic brain injury continues to pose a serious health care challenge throughout the world. In the United states, trauma is the leading cause of death in individuals under 45 years of age and is a major cause of death and disability in order age groups as well. Brain injury result in more trauma deaths than do injuries to any other specific body region. Half of the 150,000 injury-related deaths that occur annually in the United States involve a seroius brain injury that is primarily responsible for the patient’s demise. Overall, approximately 500,000 head injuries per year in the United States are serious enough to require admission to a hospital. Despite intensive intervention, long-term disability or death occurs in the majority of severely head injured patients. Significant neuropsychological sequelae and physical disabilities also are common in patients sustaining milder injuries. Meaningful recovery of function after head injury is possible if patients are rapidly and effectively resuscitated, if surgical mass lesion are emergently evacuated, and if secondary insults are prevented or minimized. A key factor in recovery is the heightened vulnerability of the brain millieu following injury. After focal or diffuse insults, many neuronal, glial, and endothelial cell populations are functionally impaired. If conditions are favorable, these cells will recover with time. However, if such events as hypotension, hypoxia, or intracranial hypertension go unchecked, many vulnerable cells will succumb. Optimizing conditions for cellular recovery by maintainig adequate cerebral perfusion, normalizing intracranial pressure (ICP), and averting additional secondary insults is essential in the overall treatment strategy for the head-injured patient. Improvements in resuscitation, diagnosis, and surgical treatment may be reaching a plateau as means of further reducing morbidity and mortality. However, refinements in critical care to continue to offer new avenues for enhancing outcome. Monitoring cerebral blood flow and metabolism for detection and prevention of ischemia, as well as new neuroprotective pharmacological therapies hold the greatest promise for achieving further meaningful recovery after head injury. This chapter will provide an overview of the essential principles involved in optimizing outcome after traumatic brain injury, including aspects of prehospital and emergency room care, operative and perioperative strategies, and intensive care monitoring and intervention.