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PRACTICE: Katharine Ker, Pablo Perel, Karen Blackhall, and Ian Roberts How effective are some common treatments for traumatic brain injury? BMJ 2008; 337: a865 [Full text]

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Common treatments for Traumatic Brain Injury

Dee Kotak   (10 October 2008)

Common treatments for Traumatic Brain Injury 10 October 2008
Dee Kotak, Consultant in Intensive Care 1Department of Anaesthesia, King’s College Hospital, London SE5 9RS Send response to journal: Re: Common treatments for Traumatic Brain Injury	Ker et al. highlight the uncertainty caused by the continuing lack of adequately powered randomised controlled trials in the use of mannitol, hyperventilation, cerebrospinal fluid drainage and barbiturates in the treatment of traumatic brain injury (TBI).1 This is understandable from a purely evidence based perspective. However, there are sound pathophysiological reasons for the use of these treatments and individual patient management is based on clinical and neuro monitoring information which provide evidence of physiological efficacy. Furthermore, it is debateable whether limited resources should be focused on the large trials needed to remove uncertainty from these four treatments rather than on trials of emerging therapies that may be of greater benefit. Internationally this seems to be the view of those involved in the research and management of TBI. There are presently two ongoing trials in decompressive craniectomy, the RESCUEicp: Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intra-Cranial Pressure (600 patients) and the DECRA Trial: Early Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury (165 patients). The European Society of Intensive Care Medicine study of therapeutic hypothermia after traumatic brain injury (EuroTherm) is scheduled to start in January next year and aims to recruit 1,800 patients which will be the largest hypothermia trial in TBI. Normobaric hyperoxia holds promise and awaits further studies to evaluate the potential of this simple low cost intervention. Although most clinicians agree on the general principles of management of TBI, there have been differences between individual clinicians and institutions based on historical tradition, local practice, and a lack of clear evidence of benefit of any one therapeutic approach. There are now well established international guidelines which are being increasingly followed and this may improve outcome, facilitate trial recruitment and enable better comparison of studies.2 Following these guidelines and implementing protocolised management are more likely to lead to improved outcome of severe TBI rather than any small increment in the evidence base of the common treatments mentioned, particularly in low and middle income countries.3 Ker at al. make the case for a new approach to raise the profile of trauma and generate the necessary financial resources to address many of the unanswered questions, this is welcomed but they also give the unintentional impression that there is little activity in this area and that there has been little progress. Two recent landmark trials, albeit not favouring the treatments studied, illustrate the move to robust appropriately designed studies compared to the small old studies to which Ker et al. refer. The CRASH study(Corticosteroid Randomization After Significant Head Injury, (10,008 patients)) was stopped after interim analysis showed worse outcome in the corticosteroid group.4 A recent trial of magnesium for neuroprotection after TBI (499 patients) demonstrated detriment in the magnesium arms.5 There have been several developments and initiatives in trauma and TBI. In the United States the National Trauma Data Bank is the largest aggregation of trauma data ever assembled (in 2007 it contained more than 2.7 million records) and the Neurological Emergencies Trials (NETT) network has been created to conduct large simple trials to reduce the burden of very acute injuries and illnesses affecting the brain, spinal cord, and peripheral nervous system.6,7 In Europe the Brain Monitoring with Information Technology (Brain IT) group is an international collaborative network of neurointensive care centres.8 In the UK there is the Neuro-Critical Care Network (NCCnet) and the Trauma Audit and Research network (TARN).9,10 NCCnet is a key stakeholder in the Risk Adjustment in Neurocritical care (RAIN) project based at the Intensive Care National Audit and Research Centre (ICNARC) which seeks to evaluate and refine existing models of risk adjustment in TBI. References 1) Ker K, Perel P, Blackhall K, Roberts I. How effective are some common treatments for traumatic brain injury? BMJ 2008; 337:754-6. 2) Brain trauma Foundation. Guidelines for the management of Severe Traumatic Brain Injury, 3rd edition. New York: Brain Trauma Foundation, 2007. 3) De Silva MJ, Roberts I, Perel P, Edwards P, Kenward MG, Fernandes J, Shakur H, Patel V;on behalf of the CRASH Trial Collaborators.Patient outcome after traumatic brain injury in high-, middle- and low-income countries: analysis of data on 8927 patients in 46 countries. Int J Epidemiol. 2008 Sep 9. [Epub ahead of print]. 4) Roberts I, Yates D, Sandercock P, Farrell B, et al. Effects of intravenous corticosteroids on death within 14 days in 10,008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo controlled trial. Lancet 2004; 364:1321-8. 5) Temkin NR, Anderson GD, Winn HR, Ellenbogen RG, Britz GW, Schuster J, Lucas T, Newell DW, Mansfield PN, Machamer JE, Barber J, Dikmen SS. Magnesium sulfate for neuroprotection after traumatic brain injury: a randomised controlled trial. Lancet Neurol. 2007 Jan; 6(1):29-38. 6) www.ntdbdatacentre.com. 7) www.nett.umich.edu/nett/welcome. 8) www.brainit.org. 9) www.nccnet.org.uk. 10) www.tarn.ac.uk. Competing interests: None declared