II. EMORRAGIA SUBARACNOIDEA
5. Conclusioni
Analizzando i dati, il timing diagnostico delle TC basali è differente in relazione all’età dei pazienti:
1) I pazienti sotto i 60 anni possono essere dimessi a domicilio dopo la prima TC fornendo loro le indicazioni (riportato in Appendice) con raccomandazioni di ri- presentarsi in PS in caso di variazioni cliniche;
2) Per i pazienti con età maggiore/uguale a 60 anni è indicata l’osservazione (OBI) e un controllo TC cranio a 40 ore dall’evento. Con dimostrazione radiologica di stabilità o miglioramento dell’ESA, in assenza di variazioni cliniche, i pazienti potranno essere dimessi.
Per quanto riguarda la dimostrazione di risoluzione dell’ESA, il tempo di follow-up può essere fissato per tutti a 30 giorni dal trauma.
78
Paziente con MTBI com-
plicato da ESA
Paziente < 60 anni
Paziente ≥ 60 anni
Dimissione a
domicilio
Eseguire TC di controllo non prima dei 30 giorni
OBI e TC con-
trollo a 40 ore
Stabilità o ridu-
zione dell’ESA?
Sì
NO
RICOVERO
80
APPENDICI
Copia del modulo informativo contenente le istruzioni per l’osservazione domiciliare in seguito a trauma cranico lieve (Studio Clinico; 5. Conclusioni).
AZIENDA OSPEDALIERA PISANA U.O. MEDICINA D’URGENZA E PRONTO SOCCORSO SPEDALI RIUNITI S.CHIARA Direttore: Dr. Massimo Santini
OSPEDALE DI RILIEVO NAZIONALE AD ALTA SPECIALIZZAZIONE
Presidio Ospedaliero di S. Chiara
CONSIGLI ALLA DIMISSIONE PER LE VITTIME
DI TRAUMA CRANICO LIEVE
Gentile Signora, Gentile Signore,
Lei ha subito un trauma cranico minore. Dalla valutazione eseguita non sono emersi ele- menti di preoccupazione, quindi può tranquillamente essere rinviato a domicilio dove ra- gionevolmente avrà un graduale ritorno alle condizioni di normalità.
COMPORTAMENTI CHE LA AIUTERANNO A STAR MEGLIO NELLE PROSSIME 48 ORE
Le consigliamo di:
• Stare a riposo evitando di rimanere solo
• Evitare di leggere e/o guardare la TV per molto tempo o comunque di fare attività stancanti
• Praticare attività rilassanti
• Evitare di bere alcolici
• Evitare gli sport da contatto (calcio, pallavolo, arti marziali, etc…) per almeno 1 settimana dal trauma
• Non assumere pillole per dormire, sedativi, tranquillanti, a meno che non siano stati prescritti da un Medico informato dell’accaduto
• È raccomandabile comunque, avvisare il Medico di Famiglia dell’evento trauma- tico
81 La invitiamo a contattare immediatamente il 118 e/o a ripresentarsi rapidamente in Pronto Soccorso qualora nei prossimi giorni Lei o i suoi conviventi notino almeno uno dei se- guenti sintomi:
• Tendenza ad addormentarsi più del normale, specie se uno vuole rimanere sveglio e non vi riesce, difficoltà ad essere risvegliato dal sonno (ad esempio difficoltà a mantenere aperti gli occhi)
• Confusione, difficoltà importante a mantenere la concentrazione e a seguire una discussione semplice
• Intenso mal di testa, continuo e tendente al peggioramento
• Episodi di vomito ripetuto
• Episodi convulsivi o perdita di conoscenza
• Debolezza o alterazione della sensibilità persistenti (ad esempio formicolii o pe- santezza) a un arto
• Comparsa di disturbi della vista
• Improvvisa comparsa di liquido chiaro dal naso o dalle orecchie o sangue dalle orecchie
SINTOMI CHE NON DEVONO DESTARE PREOCCUPAZIONE
Potrà invece provare alcuni sintomi che sono la normale conseguenza del trauma di cui è stato vittima e di cui non dovrà assolutamente preoccuparsi. Questi sintomi, che scompa- riranno in una o due settimane includono: lieve cefalea, sensazione generale di malessere, vertigine, irritabilità, lievi difficoltà di concentrazione e di memoria, stanchezza, ridu- zione dell’appetito e difficoltà nel sonno. Qualora questi sintomi durassero per più di 2 settimane La invitiamo a parlarne col suo Medico.
PROBLEMI A LUNGO TERMINE (SINDROME POST-COMMO-
TIVA)
È possibile che alcuni di questi sintomi lievi, di cui non deve preoccuparsi, perdurino in maniera sfumata anche fino a 6 mesi dal trauma. La cosa è conosciuta come sindrome post-commotiva. Tale sindrome, che non ha particolari elementi di gravità, può essere trattata grazie all’aiuto del suo Medico di Famiglia e/o al supporto di un Neurologo. Con loro deciderà i passi da fare.
82
PAZIENTI IN TERAPIA CON ANTICOAGULANTI, CON PREGRESSO INTER-
VENTO NEUROCHIRURGICO O CHE PRESENTANO DISTURBI DELLA COA-
GULAZIONE
Gentile Signora, Gentile Signore,
Oltre alle indicazioni che Le abbiamo fornito sul modulo allegato per quanto riguarda il trauma cranico lieve di cui è stato vittima, Le ricordiamo che è un paziente a rischio di complicanze a lungo termine legate al trauma. Le terapie che sta eseguendo e/o le malattie di cui soffre, la predispongono a possibili sanguinamento anche a distanza di mesi dal trauma.
Abbiamo comunque fatto tutto il possibile per verificare tale evenienza e per prevenire che tali complicanze avvengano. Nonostante ciò Le ricordiamo di:
• Prestare attenzione agli elementi di preoccupazione sopra elencati non solo per le prossime 48 ore ma anche per i prossimi mesi
• Informare sempre adeguatamente il suo Medico dell’accaduto
• Attenersi scrupolosamente alle indicazioni terapeutiche da noi fornite
• Qualora si sentisse male, anche a distanza di molti mesi dal trauma, informi i sanitari che si prenderanno cura di Lei del trauma pregresso che ha subito
Rimaniamo a disposizione per qualsiasi chiarimento.
Cordiali saluti.
83
GLOSSARIO
AOD Anticoagulanti Orali Diretti MUO Medicina d’Urgenza Ospedaliera AOUP Azienda Ospedaliero-Universita-
ria Pisana
MTBI Mild Traumatic Brain Injury
ASA Acido AcetilSalicilico NC Nervi Cranici
ATLS Advanced Trauma Life Support NICE National Institute for Health and Care Excellence
BEE Barriera Emato-Encefalica NOC New Orleans Criteria
CBF Cerebral Blood Flow OBI Osservazione Breve Intensiva
CC Concussione Cerebrale PCS Post-Concussion Syndrome
CCB Channel Calcium Blockers PET Positron Emission Tomography
CCHR Canadian CT Head Rule PIC Pressione IntraCranica
CID Coagulazione Intravasale Disse- minata
PPC Pressione di Perfusione Cerebrale
CSF CereboSpinal Fluid PS Pronto Soccorso
DAI Diffuse Axonal Injury PTA Post-Traumatic Amnesia
DEA Dipartimento di Emergenza-Ac- cettazione
PTS Post-Traumatic Seizures
EBPM Eparina a Basso Peso Molecolare RM Risonanza Magnetica
EDH Epidural Hematoma ROS Reactive Oxygen Species
EO Esame Obiettivo ROT Riflessi Osteo-Tendinei
EON Esame Obiettivo Neurologico SDH Subdural Hematoma
ESA Emorragia SubAracnoidea SDO Schede Dimissione Ospedaliera
ESAa Emorragia SubAracnoidea aneuri- smatica
SPECT Single Photon Emission Computed To-
mography
ESAt Emorragia SubAracnoidea trau- matica
TAO Terapia Anticoagulante orale
ICH IntraCranial Hemorrhage TBI Traumatic Brain Injury
GCS Glasgow Coma Scale TC Tomografia Computerizzata
LOC Loss Of Consciousness TCD TransCranial Doppller
MAP Mean Arterial Pressure VKA Vitamin K Antaginist
84
85
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