New horizons (Baltimore, Md.)
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Optimal trauma care, including that for head and spinal cord injury, requires system organization and adoption throughout the United States and the world. Neurosurgeons play an essential role in system design and development in addition to treating neurotrauma patients. Areas of neurosurgical involvement include defining prehospital triage and treatment guidelines, emergency department evaluation and therapy, operative management, and active involvement in the critical care and acute hospital settings. Collaboration among all members of the trauma team is essential to ensure the best possible outcome for patients with traumatic injuries.
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Failure of high-dose corticosteroid therapy to ameliorate intracranial hypertension or improve long-term neurologic outcome in patients with traumatic brain injury has been shown in several prospective, randomized clinical trials. Additionally, the risk of complications, including elevations in serum glucose levels and gastrointestinal hemorrhage, although relatively low, make routine use of glucocorticoids further unwarranted in head-injured patients.
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An important feature of traumatic brain injury is that much of the ultimate damage appears to occur in a delayed or secondary fashion. Although the exact timing of these secondary sequelae has yet to be elucidated, recent experimental evidence suggests that an extended window of opportunity exists during which various forms of therapy appear to be efficacious. Moreover, new therapies have been developed which can be targeted at distinct pathophysiologic aspects of brain trauma. This article summarizes recent efforts to define secondary mechanisms of brain trauma and review the development of therapeutic strategies for reversing these deleterious events.
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Neurologic injury initiates a cascade of local and systemic metabolic responses. Patients become hypermetabolic, hypercatabolic, and hyperglycemic and develop decreased immune competency and altered gastrointestinal function. Provision of an adequate supply of nutrients is associated with improved outcome. ⋯ Evidence indicates that early small bowel feeding of patients with acute head injury results in a decreased incidence of infections and shorter ICU stay. The roles of specific nutrients in modulating injury responses are currently being evaluated. The optimal nutritional support for improving neurologic recovery following head injury remains to be established.
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The care of the acutely head-injured patient involves rapid evaluation and correction of hypoxia with appropriate airway management and treatment of associated problems. The primary focus is correction of underlying pathophysiology and prevention of secondary brain injury. ⋯ Airway management requires prompt intervention and definitive control, while protecting the cervical spine. Preparation for the possibility of failed intubation is important.