HBO
IN COMPLEX TREATING OF CRANIOCEREBRAL TRAUMA WITH CRUSHING OF CEREBRAL
HEMISPHERES.
Practical recommendations.
Treating of craniocerebral trauma has achieved clinic
successes, but still remains because the amount of these traumata improves,
especially hard ones with sequence invalidity and lethality.
Focus of injurity of cerebral hemispheres is a sequence
not only of trauma, but also of neirodistrophic changes. It is shown
experimentally, that secondary violation of cerebral circulation, activity of
ferments and development of hypoxia improve the size of focus. Development of
ishemiac, hypoxic and neirodistrophic changes encourages local and general
cerebral inflation.
There are several degrees of damaging of cerebrum
(dependent on anatomical destruction, G.Goryachkina, 1966): 1) hard violations
with outlet of cerebral detrite and hemorrhage in around focus; 2) destruction
of cerebral tissue without damaging of its surface with bloody imbibition and
saving of shape of cerebrum; 3) concussion foci with remaining if cerebral
surface and tissue unchanged.
A system of treating of cerebral traumata has been
worked out in Leningrad's Research Institute after Polenov; according to which
surgeonal treating is needed in case of first degree of trauma; second degree
- only sometimes in case of complications. Use of that system permitted to
lessen lethality by 25 - 27%. Indication for urgent operation is combination
of foci of crashing with cranial hematomes (70 - 75% of patients).
In absence of hematoma the indication for operation is
irresponsible to medicines hypertension-dislocation syndrome. It would be
stressed, that in case of deposition of focus in vitally important cerebral
segment or existence of several foci their complete rejection is impossible;
even complete rejection can't promise satisfactory treating.
Thus, secondary violation of cerebral circulation,
activity of ferments and hypoxia must be taken into account when treating.
Hypoxia (hypoxic, circulator, hemic) can result in violation of cerebral
tissue metabolism.
Clinical displays of hypoxia with strong cerebral
damage depend on deepness and size of damaged zone, level of violation of
cord, existence of subdural hematoma; they can be: violation of consciousness
(deafening, sopor or coma) or different cordial and cerebral focal symptoms.
Hypoxia can also be determined after additional
physiological and biochemical investigations of cerebrum. The
oxidation-reduction processes are being violated as well as carbohydrate
exchange; as the result - reduction of tissue respiration; improvement of
glycolisis; arriving of intermediate products of metabolism in blood, cerebral
tissue and cordial liquid, changing pH to acid's and decaying of
phosphorus-containing compounds.
Cerebral tissue, especially its damaged sector, is in
state of ishemia. The normalization of cerebral activity depends on degree and
period of hypoxia. In "transitional" zones of foci in 4 - 5 days
oxygental tension and local circulation are lessening with inflation and
necrosis as the result.
All the treating activity would try to interrupt that
processes in order to lessen hypoxia; forbid necrotization of tissue and
inflation of cerebrum.
Methods of treating cerebral hypoxia after
craniocerebral trauma are:
1) respiratory reanimation;
2) investigation and deleting in time of squeezing of
cerebrum;
3) treating of cardiovascular transgressions;
4) neurovegetative blockade;
5) treating of inflation of cerebrum;
6) HBO.
Indications and contraindications for HBO.
Appearing of hypoxia in pathology if craniocerebral
trauma is an indication for HBO-therapy as a specific method of treating.
The principles of application of HBO in treating the
diseases of central nervous system are represented in practical
recommendations of All-Union Center of HBO (1978), according to which treating
of hypoxia caused by craniocerebral trauma is observed. The results of complex
clinics-physiological and clinics-biochemical investigation (necrologies
investigation; electrocardiogram; EEG; impedance pneumogram; determination of
pO2 and pCO2; lactate, piruvirate, sugar; acid-alkaline balance in cerebral
blood and liquid; intercranial pressure before and after procedure) of 70
sicks (38 had verified foci) when HBO was used permitted us to complete
indications and contraindications for HBO.
HBO is an important form of therapy of hypoxia after
craniocerebral traumata, if used in time and adequately the needs of body in
additional hyperbaric oxygen.
The main indication for HBO is the development of local
and general cerebral inflation, that displays a specific clinic picture.
Degree and form of hypoxia are determined after additional laboratory
investigations.
When foci combine with intercranial hematoma, cranial
crushing or inflation and dislocation with violation of cord, HBO would be
used only after operational diminishing those. Otherwise HBO would be started
as soon as possible to prevent improvement of cerebral inflation.
In localization of focus of decay in vital segment or
if many foci are present, HBO is desirable independently of operation.
The character of principle violation of cord would be
taken into account when HBO is applied. The efficiency is the largest in case
of mesencephal or diencephal violations; especially secondary ones. Absolute
contraindications are absent; the conditional ones are:
1) violations of conductivity of respiratory system;
2) epileptic syndrome;
3) pneumonia.
Selection of regime of HBO.
The results of complex clinics-physiological and
clinics-biochemical investigation permit to recommend the following optimal
regimes. In case of mesencephal or diencephal violations the first procedure
would be persued at 1,4 - 1,5AT and 25 - 30 min. exposition. If no negative
reactions are observed, the next would be 1,8AT and 40 - 50 min. exposition.
For sicks with secondary violations of cerebral cord
only tender regime is permitted: 1,1 - 1,2AT with 20 - 25 min. exposition; if
no negative reactions are observed, the next would be 1,5AT and 40 min.
exposition. We use HBO once a day with breaks sometimes for 1 - 2 days,
because the body's response can change suddenly. The procedures are prolonging
till stable bettering of state of sick; usually that no more than 10
procedures.
Touching upon literature's data on application of
pressure of 2AT - we think on the basis of our own experience this is too
large figure for that pathology. Besides, we suggest immediate changing of
regime of HBO in any moment in sick investigates negative reaction on it.
Persuing of HBO-therapy.
a) preparation to the procedure.
In case the motoral excitation the use of seduxen 20%
sodium oxybutirat in 5% glucose is used; in case diencephal syndrome - litic
compounds. But the most useful is special mechanical fixation of sick in
chamber, forbidding him to move and take off diagnostic hardware. The urinary
bladder would be empty; respiratory conductivity - good (especially for sicks
with peripheral violations of respiration. Sometimes the patient would be
deposited laterally. Anesthesiologist is desirable at the beginning of course.
Chamber would contain only oxygen without purifies -
this can be achieved after prolonged ventilation of chamber with oxygen at low
pressure. This is especially important for neiro-therapy: "chemical"
effect would appear before the barometric one.
b) methods of physiologic control.
First HBO procedures would be supported with permanent
physiologic control for immediate managing the response and processes in body.
Firstly the beginner figures are registrated for later on comparison of data
under improved pressure and after the procedure. The figures for registration
are: EEG; electrocardiogram; impedance pneumogram; determination of pO2 and
pCO2; lactate, piruvirate, sugar; acid-alkaline balance in cerebral blood and
liquid; intercranial pressure before and after procedure.
For registration of EEG needle electrodes are put under
cranial skin yet during operation - this is possible to do for three days
after operation; later they would be changed with ordinary ones. Methodology
and practical application of IPG are described in literature (Batkin, 1973;
Zhukovsky and Frinerman, 1976; Geddes, 1962).
The advantages of IPG are that it informs on
respiration and hemodynamics by one channel and registrate it together with
EEG and electrocardiogram.
c) physiologic response for HBO of sicks with
craniocerebral traumata.
The very first, stabile and obvious response - is
enforcing of respiration, hyperventilation, that is registrated directly or at
IPG. It is important, that the frequency of respiration wouldn't change; only
the respiratory volume would improve. If the frequency of respiration is also
improving, the compression would be immediately lessened.
It would be also noted that hypoxia reduces the
capability of tissue to utilize oxygen. Thus enormous proposal of it can load
tissue respiration too much; HBO would only compensate hypoxia and never cause
tension - this is controlled by pulse; respiration; arterial pressure.
The most general display of bioelectrical activity is
improvement of synchronization: first appears synchronization of cerebral
biopotentials in amplitude; some new signals, unobservable before,
appear. Then comes synchronization of period of waves and low shift of
their spectrum.
These effects probably can be the displays of tensions
in compensatory cerebral systems.
If EEG-graphic turns to more flat and trivial one,
improvement of arterial pressure and pulse; transgressions of respiration -
the procedure would be interrupted.
d) biochemical figures.
Besides the figures of complex physiological control
biochemical control, in particular on the concentration of intermediate
metabolic products in venial blood and liquid from spinal cord. Thus, lowering
of concentration of lactic and piruvate acids displays satisfactory results
with achieving normal figures in 4 - 5 procedures. On contrary, their
improvement displays irreversable changes in cerebral tissue. The glycolitic
index describes the process of glycolisis.
Acid-alkaline index doesn't change significantly after
HBO; buffer line can move slightly to the right with small improvement of pH
and lessening of pCO2.
The principle criteria on continuation of HBO after
probe ones for patients with craniocerebral traumata would be the dynamics of
neurology and its comparison with the figures of complex physiological control
and biochemical control. Efficiency of HBO at different degrees of violation
of cerebral cord.
The best results of HBO are after secondary violations
of mesencephalic form; if inflation and dislocation are absent, the results
can be displayed already after the first procedure in recreation of
consciousness, lessening of psychomotor excitation, improvement of speaking
abilities. EEG displays arriving and strengthening of elements of general
rhythm. Intercranial pressure lessens; visual lessening of cerebral inflation;
appears its pulsation.
After diencephalic form HBO would be applied as soon as
possible, before the pneumonia develops, probably in combination with
neirovegetative blockade. If pneumonia appears before HBO, the results of its
use produce negative reaction of clinic, physiologic and biochemical indexes
and sequent refuse from HBO.
The most difficult for treating by HBO is violation of
bulbar segment of cerebral cord. The sicks are usually in comatose state with
primary transgression if cord, or secondary one, supported by inflation and
dislocation. HBO is commonly ineffective or has slight temporary result.
If HBO is used immediately after trauma, before the
development of traumatic foci with inflation and dislocation, they can prevent
the arrival of necrosis of tissue; if that is done too late or in presence of
many deep traumata the efficiency of HBO sharply lessens.
Conclusion.
HBO has an exact use in therapy of craniocerebral
traumata: reducing of hypoxia, both general and regionally-cerebral one. From
this point of view HBO can't be replaced with anything other. It also can't be
alternative to other forms of therapy, it only completes them.
All the recommendations represented here can't be
fulfilled in ordinary hospital for the reason of shortage of hardware; thus
general orientations are: pulse and respiration wouldn't improve too much and
become too complicated during the procedure. Arterial tension would steady
normalize, not contrary. Adequate regime of HBO would be based on all these
dynamic requirements.
With the use of all of these requirements HBO wouldn't
damage, anyhow, the state of sick.