Alejandro Sebastián Grandes Padilla

Background: Traumatic brain injury (TBI) remains a major cause of morbidity and mortality worldwide and represents a significant challenge in the management of critically ill patients. The choice of anesthetic agent during induction and sedation may influence key physiological parameters such as intracranial pressure, cerebral perfusion pressure, and hemodynamic stability. Propofol has traditionally been widely used in neuroanesthesia due to its ability to reduce cerebral metabolic demand. However, ketamine has historically been avoided in patients with TBI because of the belief that it could increase intracranial pressure. Recent evidence has challenged this assumption, suggesting that ketamine may be safe and could even offer hemodynamic advantages in these patients. Objective: To explore and synthesize the available evidence regarding the effects of ketamine compared with propofol on multimodal neuromonitoring parameters and clinical outcomes in patients with moderate and severe traumatic brain injury. Methods: A scoping review was conducted following the PRISMA-ScR guidelines. A systematic search was performed in electronic databases including PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar. The search strategy included terms related to traumatic brain injury, ketamine, propofol, intracranial pressure, and hemodynamic stability. After screening titles, abstracts, and full texts, twenty studies meeting the eligibility criteria were included. Data were extracted regarding study characteristics, multimodal neuromonitoring parameters, and clinical outcomes. Results: The included studies indicated that ketamine is not associated with clinically significant increases in intracranial pressure in adequately ventilated patients with TBI. Several studies reported greater hemodynamic stability and a lower incidence of post-induction hypotension with ketamine compared with propofol. Regarding multimodal neuromonitoring, most studies evaluated intracranial pressure and cerebral perfusion pressure. Clinical outcomes were heterogeneous across studies and did not consistently demonstrate significant differences between the two anesthetic agents. Conclusions: Current evidence suggests that ketamine can be safely used in patients with moderate and severe traumatic brain injury without increasing intracranial pressure, and its hemodynamic profile may represent an advantage over propofol in certain clinical scenarios. Nevertheless, further prospective studies and randomized controlled trials are needed to better define the impact of these anesthetic agents on long-term neurological and clinical outcomes.

Acute pain secondary to lower extremity trauma represents one of the most common reasons for emergency department visits and poses a clinical challenge due to its intensity, complex pathophysiology, and need for timely analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) have traditionally been used as first-line therapy because of their anti-inflammatory efficacy and favorable short-term safety profile; however, multimodal analgesia incorporating regional nerve blocks has recently gained prominence as a superior opioid-sparing strategy. A systematic review was conducted according to PRISMA 2020 guidelines, including studies published between 2015 and 2026 retrieved from PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library. From 500 identified records, 20 studies involving adult patients with acute lower extremity trauma and validated pain scale assessments were included. Findings indicate that NSAID monotherapy is effective in mild to moderate pain, achieving clinically meaningful reductions in pain intensity, but demonstrates limited efficacy in severe pain or unstable fractures. In contrast, regional nerve blocks—such as femoral, fascia iliaca, and PENG blocks—provided faster and greater pain reduction and significantly decreased opioid rescue requirements within the first 24 hours. The evidence supports an individualized and stepwise analgesic model based on trauma severity and pain intensity to optimize outcomes while minimizing opioid exposure.