Miniexamen neurológico en el traumatismo craneoencefálico grave / Neurologic mini-examination in severe cranio-encephalic trauma

No disponible

Manejo del traumatismo craneoencefálico grave en un hospital comarcal / Management of severe head injury at a district hospital

El traumatismo craneoencefálico grave representa una de las causas más frecuentes de mortalidad e invalidez en la población joven de nuestra sociedad. Requiere de un tratamiento médico, y a veces quirúrgico, inmediato. El tratamiento debe iniciarse mediante una reanimación adecuada del paciente, según el protocolo del soporte vital avanzado al trauma, preferentemente, en el lugar del accidente. Debe ir seguido de la aplicación de las medidas necesarias para evitar las lesiones cerebrales secundarias y de la realización de un diagnóstico anatómico preciso. Debemos identificar a los pacientes que presentan hipertensión endocraneal o que puedan precisar un tratamiento neuroquirúrgico inmediato. La cartera de servicio de los hospitales comarcales no suele contar con los servicios de neurocirugía, por lo que será imprescindible realizar un transporte sanitario hacia centros neuroquirúrgicos con las máximas medidas de seguridad. No sólo deberemos trasladar a los pacientes con patología neuroquirúrgica, sino también a aquellos pacientes, que aún no requiriendo cirugía de forma clara podrían beneficiarse de neuromonitorización, tales como la monitorización de la presión intracraneal o neurofisiología (AU)

Immediate application of positive-end expiratory pressure is more effective than delayed positive-end expiratory pressure to reduce extravascular lung water.

OBJECTIVE: To determine by the measurement of extravascular lung water (EVLW) whether the timing of positive-end expiratory pressure (PEEP) application influences the intensity of lung injury. DESIGN: Animal experimental study. SETTING: Animal experimental laboratory. SUBJECTS: Mixed-breed pigs (n = 18), aged 4 to 5 mos, weighing 25 to 30 kg. INTERVENTIONS: The animals were anesthetized and tracheotomized, after which a permeability pulmonary edema was instigated by infusing oleic acid (0.1/kg) into the central vein. All animals were then randomly divided into three groups. In group 1 (n = 5), 10 cm H2O of PEEP was applied immediately after the oleic acid infusion and maintained throughout the 6 hrs of the experiment. Group 2 (n = 7) received the same level of PEEP 120 mins after the insult for 4 hrs. Group 3 (n = 6), the control group, was ventilated without PEEP for the six hrs of the experiment. MEASUREMENTS AND MAIN RESULTS: At the end of the experiment, EVLW was calculated by gravimetric method. EVLW in group 1 (11.46+/-2.00 mL/kg) was significantly less than in group 2 (19.12+/-2.62 mL/kg) and group 3 (25.81+/-1.57 mL/kg), (p<.0001). Oxygenation also showed important differences by the end of the experiment when the Pao2/Fio2 ratio was significantly better in group 1 (467+/-73) than in group 2 (180+/-82) and group 3 (39+/-9), (p<.0001). CONCLUSIONS: The application of 10 cm H2O of PEEP reduces EVLW in a time-dependent manner and maximum protective effect is achieved if it is applied immediately after lung injury production.