kétamine dans le trauma cranien : oui ou oui ?
TRANSCRIPT
KétamineetTraumacrânien
OUIouOUI???
MPDABANServiced’anesthésieHIAPERCY,Clamart
AUCUNCONFLIT
Quefaire?• AVPhautecinétiquemoto• Homme28ans– Casquedéformé
• CGS3Anisocorie
– 85/45mmHgFC125bpm– Amputationtraumatiquejambedroite
LePremiergeste «sedonnerletempsdefairelereste»
• Polytraumatismegrave+++– Stophémorragie– 10mindeplatine
JEmergTraumaShock2011;4:395–402.EmergMedJ.2006October;23(10):745–746.
Intubation
IOTpréhospitalieramélioresurvie/pronosticdesTCgraves
Préhospitalier
PourquoiIOT?LimiterdesACSOS
Lancet380p1088–1098,2012.
IOTmais…
PAS<90mmHgenPréHospUNEFOIS=
MORTALITEFOIS2
«Hypoxiaandhypotension,the“lethalduo”intraumaticbraininjury»
DSC
PPC (mmHg
50 70
Autorégulation cérébrale et traumatisme crânien
Rôledel’hypotension
Pourfairelepointoncherche
• Hypnotiquepour• ISR• PasbaissePA• PasdehaussePIC-PasdebaissedelaPPC• Neuroprotecteur
?
KétamineetISR
• Trèsliposoluble
• DÉLAID’ACTION:15-60secondes(IV).• DURÉED’ACTION:5-10minutes(IV)
• 1/2vieélimination2-3heures
• «Anesthésiedissociative»• MaintienVS• Maintiencarrefour
Kétamineethémodynamique
Agent EffetsHD
Thiopental FChausseDCstableTAbaisse
Propofol FCstableDCbaisseTAbaisse
Etomidate FCstableDCstableTAstable
Ketamine FChausseDChausseTAhausse
« Ketamine represents a very rational choice for rapid sequence induction in haemodynamically compromised
patients »
KetamineetHTICCacommencemal…
KetamineetHTICetalors…
« For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on
imaging and clinical examination »
LE DEBIT PAS LA PRESSION…
KetamineetHTICetalors…
Ann Emerg Med. 2014
« Two of 8 studies reported small reductions in intracranial pressure
within 10 minutes of ketamine administration, and 2 studies
reported an increase. None of the studies reported significant
differences in cerebral perfusion pressure, neurologic outcomes, ICU
length of stay, or mortality »
« According to the available literature, the use of ketamine
in critically ill patients does not appear to adversely affect
patient outcomes »
KetamineetHTICetalors…
KetamineetHTICetalors…
prospectifrandomisemidazolam/ketvsmidazolam/sufSEDATION=CONTINUE
KetamineetHTICetalors…
Lancet 2009; 374: 293–300
KétamineetHTICmêmelesenfants…
Boluschezenfantsédaté1-1,5mg/kg
BaissePIC30%postinjection
Kétamineetneuroprotection
Moded’actiondeshypnotiques
RGABA
Moded’actiondelakétamine
NMDA
RNMDA
MIONG,SFAR2015
Neuroprotectionetkétamine
Anesth Analg 2005;101:524 –34
Atropine?NON
Mauvaistrip?
«Themechanismofthisisunclearbutcouldresultfrombetterpaincontrol,neuronalprotectionbyketamine,andantagonismofthe
NMDAreceptor»JTrauma.2008;64:S195–S199.
EnouvertureQuoipourentretenir???
« Patient arrival within 60 min of injury time was associated with increased odds of survival to hospital discharge without requiring ongoing rehabilitation (OR 1.78, 95%CI 1.14–2.79, p = 0.01) »
« Prehospital hypotension and hypothermia is associated with mortality, and prehospital hypoxemia with impaired consciousness »
Conclusion
KETAMINE