Critical care management of neurotrauma in children: new trends and perspectives

Abstract

Secondary brain lesions resulting from cerebral metabolic and hemodynamic reactions can be prevented by neurocritical care management. It must be initiated as soon as possible, ideally in a prehospital setting. Tracheal intubation, controlled ventilation and hemodynamic stabilization are the prerequisites. Beside intracranial and cerebral perfusion pressure, monitoring must evaluate the coupling between cerebral metabolic demand and blood flow. Jugular bulb oximetry is the most reliable approach to global cerebral coupling. Transcranial Doppler evaluates cerebral blood flow indirectly and noninvasively. Technological developments have led to local metabolic evaluation that does not yet have any clinical relevance. Therapeutic developments are more a new approach to the use of old drugs. Controlled hyperventilation, mannitol and, more recently, hypertonic saline solutions, used for restoring cerebral metabolic coupling, are the foundations of treatment. Thiopental, revisited as a vasoconstrictive agent, the "Lund" vasoconstrictive approach with anti-hypertensive drugs and cerebral vasoconstrictors, must be further evaluated in children, as must therapeutic hypothermia. Finally, what we probably need for the immediate future is a noninvasive and easily reproducible method of monitoring cerebral metabolic coupling that will allow precise therapeutic adaptation of multimodal therapy to the individual needs of the child.