Aktuelle Aspekte der intensivmedizinischen Versorgung bei Schädel-Hirn-Trauma – Teil 1

Das Schädel-Hirn-Trauma ist ein komplexes Krankheitsbild mit hoher Mortalität. Ziel ist es primär, die Homöostase des Gehirns anhand physiologischer Zielwerte aufrechtzuerhalten. Daneben gilt es, die weitere Therapie an der zerebralen Durchblutung und dem intrakraniellen Druck auszurichten. Teil 1 adressiert die primäre Therapiestrategie, das hämodynamische Management und das multimodale Monitoring, Teil 2 sekundäre Behandlungsstrategien, Langzeitergebnis, Neuroprognostik und Chronifizierung [1].

Abstract

This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the “cross-talk” of the organs, which has a significant influence on further intensive medical care.

Kernaussagen

• Für ein ausreichendes Sauerstoffangebot an das Zerebrum müssen adäquate Werte von Herzzeitvolumen, Mitteldruck, Sauerstoffsättigung und Sauerstoffträgern vorliegen (MAD > 80 mmHg, SpO₂ > 90%, Hb > 7 g/dl).

• Wichtige Basismaßnahmen zur Hirndruckvermeidung sind eine Neutralposition des Kopfes, ein 30° erhöhter Oberkörper, eine Normothermie und Normoglykämie.

• Husten, Pressen, Schmerzen und Agitation, die einen ICP-Anstieg bedingen, sollen mittels ausreichender Sedierung bzw. Analgesie vermieden werden.

• Zur kurzfristigen Hirndrucksenkung können NaCl 3% oder Mannitol zum Einsatz kommen.

• Durch eine Hirndrucksonde lässt sich der intrakranielle Druck kontinuierlich messen, die Hämodynamik bzw. der zerebrale Perfusionsdruck anpassen und eine Dynamik des Hirndrucks frühzeitig detektieren.

• Die transokuläre Sonografie der N.-opticus-Scheide kann als Surrogat des intrakraniellen Drucks genutzt werden.

• Ein multimodales Monitoring des Gehirns in spezialisierten neurochirurgischen Zentren könnte zukünftig die Patientenversorgung weiter verbessern.

Schlüsselwörter

Schädelhirntrauma - Behandlungsstrategien - Hämodynamik - multimodales Monitoring - erhöhter Hirndruck

Keywords

traumatic brain injury - primary treatment strategy - haemodynamic management - multimodal monitoring - increased intracranial pressure

Publication History

Article published online:
29 July 2024

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