Avances en el tratamiento de los traumatismos craneoencefálicos graves

Abstract

The theoretical basis for treatment of severe head injury derives from the concept of secondary damage to the brain. This paper provides an overview of the current therapeutic approaches used in treating severe head injury and in particular those patients who develop high intracranial pressure. Special emphasis is given to the new paradigm of so-called evidence-based medicine and its influence on the present and future management of severe head injuries. A review of the recommendations suggested by the Guidelines for the Treatment of Severe Head Injury, recently published by the Brain Trauma Foundation are presented. Specific types of drugs covered in this review include sedatives, analgesics, paralytic agents, barbiturates, steroids and hyperosmolar solutions. The controversies surrounding certain treatments such as the increase of cerebral perfusion pressure with vasoactive drugs, hyperventilation, indomethacine or dihydroergotamine are outlined. We also review the historical background and the controversies over the use of steroids in these patients. The recentiy developed drugs capable of blocking the damaging neurochemical cascades identified in severe head injury are discussed. Finally, the rationale for using 21-aminosteroids (Lazaroids), calcium-antagonists, potential membrane-protectors and the different types of glutamate receptors is also presented.