Traumatic brain injury.
OBJECTIVE
Management of the patient with traumatic brain injury is a rapidly advancing field, characterized in recent years by an improved understanding of intracranial pathophysiology and ways in which outcomes can be improved. Many traditional therapies, such as fluid restriction and hyperventilation, have been called into question and are no longer recommended. Other proposed therapies, such as deliberate hypothermia, remain controversial. This detailed review of the recent literature helps the reader come to an understanding of current scientific and evidence-based practices in this area, with emphasis on those therapies most likely to be of use to the practicing intensivist.


RESULTS
High-quality care of the traumatic brain injury patient demands the integrated activities of a number of different medical and nursing specialties. The best outcomes today are achieved by those systems that are able to focus as a team on the collective goal of minimizing secondary brain injury, and the respiratory therapist adjusting the patient's mechanical ventilation may be just as important to this effort as the attending neurosurgeon. Although the search for new diagnostic, prognostic, and therapeutic modalities continues (many of the more promising of which are reviewed in this article), it is clear that there exists no "silver bullet" therapy that will help all patients. Instead, it is the systematic integration and application of many small advances that will ultimately lead to better outcomes.


CONCLUSIONS
Some issues in traumatic brain injury have now been resolved, and specific recommendations can be made. Fluid therapy directed toward a euvolemic state is now universally recommended, for example, as is the role of intracranial pressure monitoring. Other areas, such as the use of hypertonic saline, remain controversial. In both cases the authors have made an effort to cite the most recent literature, so that readers can draw their own conclusions from the original source material.
Dutton
Richard P
RP
University of Marlyand School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical System Baltimore, Maryland 21201, USA. rdutton@umaryland.edu
McCunn
Maureen
M
D001930:Brain Injuries / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D003422:Critical Care / Q000379:methods*; D019299:Decompression, Surgical / Q000379:methods; D004234:Diuretics, Osmotic / Q000627:therapeutic use; D006801:Humans; D007362:Intensive Care Units; D019586:Intracranial Hypertension / Q000209:etiology / Q000628:therapy; D008353:Mannitol / Q000627:therapeutic use; D011379:Prognosis; D012121:Respiration, Artificial / Q000379:methods
D004234:Diuretics, Osmotic; D008353:Mannitol