The pathophysiology of brain injury: understanding innovative drug therapies

Acute care management of severe traumatic brain injuries

Preservation or restoration of optimal neurologic function following traumatic brain injury (TBI) requires timely and aggressive therapeutic interventions. Effective diagnostic tools, together with an armamentarium of treatment modalities, have augmented the treatment strategies utilized today. In addition, the Guidelinesfor the Management of Severe Head Injury have established a standardized approach for the TBI patient. This article will provide current information regarding the resuscitation priorities, appropriate interventions, and pharmacological agents used in the treatment required by the complex nature of TBI. Also, a review of the occurrences associated with TBI will be discussed.

Pathophysiology of traumatic brain injury

Approximately 7 million people in the United States each year experience traumatic brain injury, the leading cause of death from injury in this country. The initial traumatic event, often described as the primary injury, and the pathophysiologic sequelae, the secondary injury, are the themes of this article. Primary injuries to the extracranial and intracranial structures will be discussed, as well as the secondary injuries that occur minutes to days after the initial insult. It is critical that the bedside nurse clinician understand these concepts to anticipate potential complications and plan appropriate interventions with the multidisciplinary team. The goal of these interventions is to prevent the devastating effects of secondary injury.

[Management of severely head-injured patients during the first 24 hours. Which specific therapeutics?]

Intracranial and systemic mechanisms of the secondary brain lesion are the targets of specific therapy for the head-injured patient. Recommendations for good clinical practice have recently defined the role of the main therapeutic measures. There is no indication for corticosteroids in head injury. Mannitol is the first-choice therapy for increased intracranial pressure, and barbiturates are still considered as a rescue therapy in case of refractory intracranial hypertension. The place of hypothermia remains to be defined. Although controversial, optimized hyperventilation, induced systemic hypertension and vasoconstrictive therapy are optimally used under multimodal monitoring. New therapeutic perspectives, aimed at controlling biochemical disorders at a cellular level, are under investigation, but are still inconclusive at the present time.