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Prevención/minimización de la injuria secundaria en el TCE

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      Abstract

      La injuria secundaria es la principal causa prevenible de los desenlaces neurológicos adversos, en pacientes con TCE severo. A la luz del conocimiento actual, se sabe que una adecuada prevención de estos factores injuriantes, puede evitar estos malos desenlaces. Se describen los mecanismos causales de la injuria secundaria, que hacen que el tejido de la penumbra eventualmente empeore su perfusión, desarrolle isquemia y muerte. Es trascendental que todo el personal que intervenga en el manejo de estos pacientes conozca estos conceptos, además de comprender que la simple ejecución de intervenciones sencillas, puede salvar miles de vidas sin implicar costos inmanejables. Es responsabilidad de todos divulgar estos conceptos.

      Translated abstract

      Secondary injury is the most important preventable determinant of poor outcome in patients with severe traumatic brain injury (TBI). It is essential to understand that the adequate management of the insults responsible for it, can produce a dramatic improvement in outcome. The mechanisms responsible for secondary injury which lead to penumbral tissue to develop further ischemia and death, are described. It is of foremost importance to educate all personnel involved in caring for these patients to understand that the execution of simple medical interventions can save thousand of lives without incurring in unbearable costs. It is the responsibility of everyone involved to ensure the maximum diffusion of these concepts.

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      Most cited references 47

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      The Monro-Kellie hypothesis: applications in CSF volume depletion.

       B Mokri (2001)
      More than two centuries ago, Alexander Monro applied some of the principles of physics to the intracranial contents and for the first time hypothesized that the blood circulating in the cranium was of constant volume at all times. This hypothesis was supported by experiments by Kellie. In its original form, the hypothesis had shortcomings that prompted modification by others. What finally came to be known as the Monro-Kellie doctrine, or hypothesis, is that the sum of volumes of brain, CSF, and intracranial blood is constant. An increase in one should cause a decrease in one or both of the remaining two. This hypothesis has substantial theoretical implications in increased intracranial pressure and in decreased CSF volume. Many of the MRI abnormalities seen in intracranial hypotension or CSF volume depletion can be explained by the Monro-Kellie hypothesis. These abnormalities include meningeal enhancement, subdural fluid collections, engorgement of cerebral venous sinuses, prominence of the spinal epidural venous plexus, and enlargement of the pituitary gland.
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        Regional ischemia after head injury.

         J Coles (2004)
        To examine the evidence of regional cerebral ischemia after traumatic brain injury. This review describes the mechanisms responsible for secondary brain injury and the similarities between traumatic and ischemic neuronal cell death. Cerebral ischemia is defined, and the difficulties of quantifying the burden of cerebral ischemia in the context of clinical head injury are presented. Recent clinical data obtained from monitoring brain tissue oxygenation, tissue metabolites using microdialysis, and cerebral blood flow, blood volume, oxygen metabolism, and oxygen extraction fraction using oxygen-15 positron emission tomography are discussed. These data highlight that significant episodes of regional ischemia occur within the acute phase after injury and are associated with poor outcome. Although various monitoring tools are capable of detecting significant episodes of regional ischemia, each of the currently available techniques is limited in its clinical application. There is increasing evidence to suggest that a small but significant volume of brain tissue is at risk of ischemic injury after trauma. Future studies should examine the pathophysiology underlying such ischemia and how monitoring techniques can be used to direct appropriate therapy and influence outcome.
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          Measuring the Burden of Secondary Insults in Head-Injured Patients During Intensive Care

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            Author and article information

            Affiliations
            [1 ] Universidad Javeriana Colombia
            Contributors
            Role: ND
            Journal
            rca
            Revista Colombiana de Anestesiología
            Rev. colomb. anestesiol.
            SCARE-Sociedad Colombiana de Anestesiología y Reanimación (Bogotá )
            0120-3347
            December 2005
            : 33
            : 4
            : 259-268
            S0120-33472005000400006

            http://creativecommons.org/licenses/by/4.0/

            Product
            Product Information: SciELO Colombia
            Categories
            ANESTHESIOLOGY

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