Articles: brain-injuries.
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Journal of neurosurgery · Feb 1983
Randomized Controlled Trial Clinical TrialFailure of prophylactically administered phenytoin to prevent early posttraumatic seizures.
A randomized double-blind placebo-controlled study was carried out to determine whether phenytoin administered soon after injury lessens the incidence of epilepsy in the 1st week after severe head trauma. In this study, 244 patients were randomized into either a phenytoin or placebo group. The patients in the phenytoin group were administered phenytoin intravenously or intramuscularly within 24 hours of hospital admission. ⋯ There was no significant difference in the interval from injury to first seizure between the treated and placebo groups (p = 0.41). The early administration of phenytoin did not lessen the occurrence of seizures in the 1st week after head injury. Since the effectiveness of seizure prophylaxis has not been established, the authors suggest that anticonvulsant drugs be administered only after an early seizure has occurred.
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Case Reports
Real-time ultrasonography: a useful tool in the evaluation of the craniectomized, brain-injured patient.
Real-time ultrasonography is being used increasingly to establish the diagnosis of and serially assess intraventricular hemorrhage and hydrocephalus in neonates. The procedure requires an open fontanel because scatter from the bone occurs from direct application of the transducer to the skull and bone density precludes satisfactory imaging. With an adult, under circumstances where a bone flap is left out after intracranial procedures and the patient's clinical status is such that the patient cannot be transferred for computed tomographic scanning, real-time ultrasonography allows a safe, noninvasive, bedside demonstration of ventricular size, degree of shift of midline structures, and intraparenchymal and intraventricular lesions.
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In summary, although the prognosis for the severely head-injured patient may be poor, there are a multitude of techniques available to the anesthetist for minimizing the occurrence of secondary head injury. Aggressive resuscitative efforts toward maintaining homeostasis must be directed at cardiovascular and neurological systems. Sound knowledge of physiologic principles and the clinical application of these principles are essential to the safe management of a patient who has sustained traumatic head injury.
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The effects of continuous and supplementary bolus dose administration of etomidate have been investigated in ten artificially ventilated patients in traumatic coma. Continuous infusion of etomidate (5-25 micrograms/kg/min) proved to be a practical and safe means of sedating these patients and appeared to control moderately elevated ICP. Additional bolus doses of etomidate (0.2 mg/kg) always reduced acutely elevated ICP (greater than 20 mmHg), which fell by a mean of 33%. ⋯ However, when the bolus of etomidate was not given, occasional dramatic and dangerous rises in ICP were seen, in spite of the infusion, during which CPP fell to critical levels. This very rarely occurred when the bolus had been given. Furthermore, serious episodes of hypotension in response to etomidate administration appeared to occur mainly in patients who were relatively hypo-volaemic.