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