HBO
IN PROPHYLAXIS OF SHARP PERIOD OF HARD CRANIOCEREBRAL TRAUMA.
Practical recommendations.
Craniocerebral trauma is a usual accident becoming
especially from developing of transport. Its hardness depends on many factors,
such as: localization of violation; type of morphological transfigurations and
becoming pathophysiological changes; presence of crashes of cranium;
intercerebral hemorrhages, etc. Craniocerebral trauma is dangerous for its
complications, such as: psychical violations; meningitis and
meningoencephalitis; purulence of wound; pneumonia. Thus prediction of result
of treating is usually impossible even in simple cases. Prophylaxis of
complications of sharp period of craniocerebral trauma is a vital problem of
reanimatology; neurosurgery, neurology and psychiatry.
Indications for HBO in prophylaxis of complications of
craniocerebral trauma in sharp period.
In sharp period of craniocerebral trauma a
disintegration of functions of cerebrum is developed; that results in
transgressions of neirodynamics, cranial and systematic circulation, external
respiration, metabolism (of cranial tissue, in particular). Hypoxia of whole
body is developing; cerebral hypoxia, in particular, causes transgressions,
caused by primary violation. One of the hardest violations is cerebral
inflation, caused by complex pathophysical
changes - it improves further hypoxia of cerebral
tissue. Thus hypoxia is one of the principal pathogenic mechanisms founding
the cerebral transgressions; sequentially HBO as method of improving of the
concentration of oxygen in plasma; speed and penetration path of oxygental
diffusion in tissue, is an advantageous one.
Investigations of scientists of Sklifosovsky Institute
had adopted the positive influence of HBO on cerebral inflation of traumatic
essence. In particular, it was shown for animals with experimental trauma of
cerebrum, that oxygen under pressure causes lessening of cerebral inflation
(perivascular and pericellular inflation; crubrosity of white materia; amount
of ishemiac neurons; foci of ganglious-cellar locations; changes of vascular
system). Besides, the strengthening of reparation of cerebral tissue had been
observed; existence of two-level neurons; hypertrophy and hyper plaza of glia
nuclei; improvment of the amount of perineiral and liberated glia; hyperplaza
of nuclei of endothelia. Other words, an improvement of metabolism of system
vessel - neirocyt - glia takes place, resulting in reduction of
pathogystologic displays of cerebral trauma and becoming inflation.
Concentration of water in cerebral tissue is lessening
after HBO.
Besides experimental data we suppose information on
influence of hyperbaric oxygen on external respiration and central
hemodynamics to be the approval of helpfulness of HBO.
The most impressive are the results of treating the
secondary cordial violations. Before the procedure a wave-type respiration
with hyperventilational syndrome: VPM = 148,8+-0,5%; ChD = 165+-1,5%; DO =
127+-0,83% of standard). This is a compensation of hypoxia. After procedure
the rhythm of respiration was changing to normal; VPM reduced; consume of
oxygen also was normalizing. Thus HBO diminished hyperventilational syndrome -
that permitted to lessen the
tension of respiratoric system; reduce the consumption of energy and
normalize the venose output from cerebrum.
Some of sicks had pathalogies of respiratoric rhythm -
wave respiration with expiratoric delays; inlet breathes; Chainy-Stocks
respiration; hyperventilation was caused by tachypnea. After HBO inlet
breathes with expiratoric delays disappeared; expiratoric delays was changed
by wave respiration.
Investigation of influence of HBO on central
hemodynamics (by means of tetra polar reography) represented lessening of
hyperdynamic syndrome (MOC - 10,2+-0,05 l/min. and SI - 5,60+-0,05 l/min.*m2)
caused both by lessening of stroke volume and reducing of pulse index.
Reduction of myocard hyperfunction, as a response to hypoxia, can be
classified as a positive reaction. The fact is that prolonged hyperfunction of
myocard can damage compensational system and cause the syndrome of low
cardio-outlet, strengthening the hypoxia and encouraging cerebrovascular
deficiency.
Correction of indexes of external respiration and
central hemodynamics permits the sicks with hard craniocerebral trauma to
survive in sharp period of formation of complications.
Thus our experimental data together with data of
Influence of HBO on principal vital systems permit us to recommend HBO as the
prophylaxis of complications (psychical and purulent-trophic) of hard
craniocerebral trauma.
Indications and contraindications.
For prophylaxis of psychical transgressions; meningitis
and meningoencephalitis ; purulence of wound and pneumonia HBO is indicated
for craniocerebral traumata:
1. Contusion of cerebrum with subarachnoidal hemorrhage
with cranial crush or without it. If operation is needed to reduce perifocal
inflation HBO would begin after operation; if not - as soon as possible.
2. State after diminishment of cerebral suppressions by
hematomes (epi-, subdural, inter cerebral, multiple). Other words, HBO is
recommended as soon as possible, but only after operation on reduction of
hematoma or focus of cerebral contusion. HBO with prolonging compression of
cerebrum is contraindicated because first the reason of dislocation would be
ejected.
As chambers "Oka-MT" and "BL-3"
aren't equipped with reanimation facilities, the continuation of spontaneous
respiration and stable hemodynamics are compulsory.
Unconsciousness and existence of tracheosome can't be
contraindications for HBO.
Persuing of HBO-procedures with symptomatical
convulsions (focal and generalized) of sharp period caused by intercranial
hematoma is experimentally approved. After its deleting the convulsions
disappeared and HBO could be held. But in such case special care would be
taken and EEG is desirable to exclude convulsions.
HBO doesn't cause recidives of intercranial
hemorrhages, doesn't improve outlet of otorhinolaryngologic liquid,
pneumocephalin or infection of subarachonoidal space, i.e. for these
complications HBO isn't contraindicated.
The contraindications for application of HBO are:
epilepsy; caverns in lung; hypertension.
If application of HBO was delayed for more than 1 - 2
days, it would be persued nevertheless in complex therapy for it is useful
against meningitis, meningoencephalitis, pneumonia and traumatic psychoses.
Practice of application of HBO in sharp period of
craniocerebral trauma.
For prophylaxis of sharp period of craniocerebral
trauma HBO would be applied immediately after determination of reason for
cranial suppression - 1 - 2 days
after trauma.
Roentgenoscopy of lung is compulsory before the first
procedure to avoid existence of caverns. Solution of ephedrine or nathtyzine
are desirable to avoid otorhinolaryngological pain.
To realize electrocardicgraphical control in process of
procedure the electrodes are connected. If the patient is excited sedatives
are used (seduxen, relanium). If the patient managed anyhow to release from
electrodes and electrocardiographic control becomes impossible, the
continuation of procedure is discussed individually - if hemodynamics is
unchanged, age isn't large, doctor can continue the procedure with compulsory
permanent visual control.
Tracheostoma isn't a contraindication if spontaneous
respiration is reserved; tracheobronches would be cleaned before and after the
procedure.
If patient is unconscious, lateral deposition is
demanded to avoid tongue retraction. If respiration is worthening (dyspnea,
cyanosis, apnea) the procedure would be interrupted. All oil would be removed
from the skin as well as metal accessories and synthetics.
If the sick isn't operated, his hair would be covered
with special cotton hat; cotton dress is also needed.
HBO is most applicable to begin 1 - 2 days after
trauma; if the time is left, therapy is also used but the healing effect will
depend on many conditions including the development of thaumal complications.
Regime for prophylaxis is: 1,6 - 2AT; compression and
decompression for 15 - 20 min.; isopression time - 40 min.; 8 - 10 procedures,
1 per day. If the state is hard (cerebral inflation, danger of meningitis), in
first three day 2 procedures with no less than 6-hour break are predicted.
The results of application of HBO in sharp period of
craniocerebral trauma.
Such kind of sicks usually satisfactorily spend the
time during the procedure. Lessening of disorder of consciousness is observed
sometimes; less distinct are secondary cordial symptoms. If disorder of
speaking abilities takes place, it also lessens in chamber. All these
bettering are temporary; nevertheless they assist the regress of pathology in
neurological and psychological status.
Analysis of 145 sicks after HBO-therapy (main group)
and 145 sicks without it (control group)represents 3-times lessening of
traumatic psychoses for main group. In character of traumata; volume and time
of operations; age; sex and complex therapy the groups were taken
similar.
The degree of psychical transgressions for patients
after coma was various: from temporary dismnestic phenomena to traumatic
feablemindness to be treated in clinic.
Analysis of psychopathic symptomation and its changes
present absence of difference of pathology, if this is caused by hard traumata
of forehead segment. The violations of psychics are stable for them. The
application of HBO wasn't of use because of unreversable degradation of
corresponding structures.
In control group other psychopathalogies (usually
independent of the localization the violation) could be observed: amnesiac
syndrome together with amnesia; pseudoreminescences; confabulations;
desorientation in time, place and self-desorientations. Emotional
transgressions - dysphories; depression; hypomaniacal state or apathy,
nevrosious transgressions of astenic or hysteric type; sometimes combinations
of these could be observed. Other words, the control group represented
diffusional cerebral violation, "psychoses with cerebral inflation".
Sequentially HBO can successfully prevent or lessen, at least, cerebral
inflation and psychical violations caused by them; if psychical violation
dealt with structural transgression of forehead segment, HBO was useless.
Meningitis and meningoencephalitis are dangerous
purulence complications. They often cause lethality even after not hard
trauma. Infection penetrates in tunic and subarachnoidal space from wound,
from nose, from ear. The most probable arrival of meningitis after damaging
forehead and basal segment; it also improved latest years for the improvement
of hard traumata and improvement of resistance of microbes to antibiotics.
HBO in complex therapy reduces the probability of
meningitis and meningo encephalitis 2 times comparatively the traditional
therapy (antibiotics; sulphanilamides; liquids and electrolytes; vitamins;
cardiac medicines; etc.).
In early including of HBO for patients with crushed
cranium (without primary violation of cord) the meningitis could be avoided.
The pressure for this was no less than 1,8AT. Later inclusion or lower
pressure couldn't prevent from meningitis.
Purulence of operational wound for the main group was
10 times less. The pressure for this also wasn't to be less than 1,8AT.
Pneumonia was observed for 16,5% of the main group and
21,3% of control one. For prophylaxis of pneumonia 1,8AT is desirable; for its
therapy - 1,4-1,6AT.
The troubles on toxic violation after HBO were in vain.
Bedsores appeared for the main group 4 times rarer.
Thus HBO is an effective prophylaxis of traumatic
psychoses; meningitis and meningoencephalitis; purulence of operational wound;
pneumonia and bedsores.
HBO normalizes external respiration and hemodynamics;
that improves the resistance to hypoxia, infection, intoxication, etc. and
results in reduction of complications.
HBO can be recommended for prophylaxis of complications
of craniocerebral traumata of sharp period.
Professor
Yu. Isakov,
Doctor
M. Romasenko,
Doctor
E. Churkin,
Doctor
V. Shelkovsky.