Secondary insults in severe head injury—Do multiply injured patients do worse?

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Abstract
To study the occurrence of secondary insults and the influence of extracranial injuries on cerebral oxygenation and outcome in patients with closed severe head injury (Glasgow Coma Scale score ≤8). Two-year prospective, clinical study. Two intensive care units in a level III trauma center. We studied 119 patients. Eighty patients had severe head injury and were divided into two categories: “isolated” severe head injury patients (n = 36, Injury Severity Score 29). Thirty-nine patients with extracranial injuries and no head injury served as the control group. After patients were admitted to the intensive care unit, we began continuous multimodal cerebral monitoring of intracranial pressure, mean arterial blood pressure, cerebral perfusion pressure, end-tidal Co2 , brain tissue Po2 (Licox), jugular bulb oxyhemoglobin saturation in severe head injury patients, and mean arterial blood pressure in the control group. Targets of management included intracranial pressure 60 mm Hg, Paco2 > 30 mm Hg, control of cerebral oxygenation, and delayed surgery for non-life-threatening extracranial lesions. Data were analyzed for critical thresholds. The occurrence of secondary insults (intracranial pressure >20 mm Hg, mean arterial blood pressure 2 In patients with severe head injury who have targeted management including intracranial pressure- and cerebral perfusion pressure-guided therapy and delayed surgery for extracranial lesions, the occurrence of secondary insults in the intensive care unit and long-term neurological outcome were comparable and independent of the presence of extracranial lesions (Abbreviated Injury Severity level ≤5). A severe head injury is still a major contributor predicting an unfavorable outcome in multiply injured patients.