Secondary insults in severe head injury--do multiply injured patients do worse?
OBJECTIVE
To study the occurrence of secondary insults and the influence of extracranial injuries on cerebral oxygenation and outcome in patients with closed severe head injury (Glasgow Coma Scale score < or =8).


METHODS
Two-year prospective, clinical study.


METHODS
Two intensive care units in a level III trauma center.


METHODS
We studied 119 patients. Eighty patients had severe head injury and were divided into two categories: "isolated" severe head injury patients (n = 36, Injury Severity Score <30), and severe head injury patients with associated extracranial injuries (n = 44, Injury Severity Score >29). Thirty-nine patients with extracranial injuries and no head injury served as the control group.


METHODS
After patients were admitted to the intensive care unit, we began continuous multimodal cerebral monitoring of intracranial pressure, mean arterial blood pressure, cerebral perfusion pressure, end-tidal Co2, brain tissue Po2 (Licox), jugular bulb oxyhemoglobin saturation in severe head injury patients, and mean arterial blood pressure in the control group. Targets of management included intracranial pressure <20 mm Hg, cerebral perfusion pressure >60 mm Hg, Paco2 > 30 mm Hg, control of cerebral oxygenation, and delayed surgery for non-life-threatening extracranial lesions.


RESULTS
Data were analyzed for critical thresholds. The occurrence of secondary insults (intracranial pressure >20 mm Hg, mean arterial blood pressure <70 mm Hg, cerebral perfusion pressure <60 mm Hg, end-tidal Co2 <30 torr, brain tissue Po2 <10 torr, jugular bulb oxyhemoglobin saturation <50%) was comparable in patients with isolated severe head injury and those with severe head injury with associated extracranial lesions (Abbreviated Injury Scale score < or =5). The duration of intracranial hypertension and arterial hypotension significantly correlated with an unfavorable outcome, independent of the Injury Severity Score. In patients with severe head injury, 1-yr outcome was 29% dead or vegetative, 17% severely disabled, and 54% moderate or good outcome. This was similar to patients with severe head injury and extracranial injuries (31% dead or vegetative, 14% severely disabled, and 56% moderate or good outcome) and was independent of the Injury Severity Score. Patients with no head injury had less secondary insults (mean arterial blood pressure <70 mm Hg, p <.01) and a better outcome compared with both severe head injury groups (p <.044).


CONCLUSIONS
In patients with severe head injury who have targeted management including intracranial pressure- and cerebral perfusion pressure-guided therapy and delayed surgery for extracranial lesions, the occurrence of secondary insults in the intensive care unit and long-term neurological outcome were comparable and independent of the presence of extracranial lesions (Abbreviated Injury Severity level < or =5). A severe head injury is still a major contributor predicting an unfavorable outcome in multiply injured patients.
Sarrafzadeh
A S
AS
Department of Neurosurgery, Charité Campus Virchow Medical Center, Humboldt-University Berlin, Austenburger Platz 1, 13353 Berlin, Germany. asita.sarrafzadeh@charite.de
Peltonen
E E
EE
Kaisers
U
U
Küchler
I
I
Lanksch
W R
WR
Unterberg
A W
AW
D000328:Adult; D000368:Aged; D001794:Blood Pressure; D002560:Cerebrovascular Circulation; D016009:Chi-Square Distribution; D005260:Female; D015600:Glasgow Coma Scale; D016489:Head Injuries, Closed / Q000150:complications* / Q000401:mortality / Q000628:therapy; D006801:Humans; D002534:Hypoxia, Brain / Q000209:etiology*; D015601:Injury Severity Score; D007362:Intensive Care Units; D019586:Intracranial Hypertension / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D016896:Treatment Outcome