Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes.
OBJECTIVE
To determine the hemodynamic responses to blunt trauma with a closed-head injury and to investigate the effect that volume resuscitation has on intracranial pressure.


METHODS
Prospective study with retrospective analysis of patient data and hemodynamic responses.


METHODS
Surgical intensive care unit at an inner-city, Level I trauma center.


METHODS
Consecutive patients (n = 30) who sustained multiple system injury, including a closed-head injury that was severe enough to require intracranial pressure monitoring but not a craniotomy.


METHODS
All patients underwent invasive hemodynamic monitoring with percutaneous arterial and pulmonary arterial catheters. Serum lactate concentrations and hemodynamic and oxygen transport variables were measured every 4 hrs. Intracranial pressures and vital signs were recorded each hour. Attempts were made to achieve a state of nonflow-dependent oxygen consumption and a normal serum lactate concentration.


RESULTS
Despite being normotensive and neither tachycardiac nor oliguric, 80% of patients had evidence of inadequate tissue perfusion. 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, intracranial pressure did not increase. This observation was found in patients who showed clinically important intracranial pathology on computed tomography scan, as well as in all other patients. Intracranial pressure did not correlate with the amount of fluid or blood infused or with hemodynamic performance, but intracranial pressures did correlate with serum lactate concentrations.


CONCLUSIONS
Many patients with diffuse blunt trauma closed-head injuries, even when they are normotensive, have evidence of impaired peripheral perfusion. Volume infusion and vasodilating inotropic support improve oxygen transport without increasing intracranial pressure. The observed relationship between intracranial pressure and the serum lactate concentration requires further study.
Scalea
T M
TM
Department of Surgery, SUNY Health Science Center at Brooklyn 11203.
Maltz
S
S
Yelon
J
J
Trooskin
S Z
SZ
Duncan
A O
AO
Sclafani
S J
SJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006259:Craniocerebral Trauma / Q000628:therapy*; D005260:Female; D005440:Fluid Therapy; D015600:Glasgow Coma Scale; D006439:Hemodynamics; D006801:Humans; D007362:Intensive Care Units; D007427:Intracranial Pressure / Q000187:drug effects; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000628:therapy*; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods; D014193:Trauma Centers; D014505:Urban Population; D014665:Vasodilator Agents / Q000627:therapeutic use*
D014665:Vasodilator Agents