Practice Uncertainties Page

How effective are some common treatments for traumatic brain injury?

BMJ 2008; 337 doi: (Published 14 August 2008) Cite this as: BMJ 2008;337:a865
  1. Katharine Ker, research fellow,
  2. Pablo Perel, clinical lecturer,
  3. Karen Blackhall, trials search coordinator, Cochrane Injuries Group,
  4. Ian Roberts, professor of epidemiology and public health
  1. 1Nutrition and Public Health Intervention Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
  1. Correspondence to: K Ker Katharine.Ker{at}

    Surveys show that mannitol, hyperventilation, cerebrospinal fluid drainage, and barbiturates are commonly used in the United Kingdom, Europe, and the United States to treat traumatic brain injury.1 2 3 Yet the effects of such treatments are uncertain.

    Traumatic brain injury is a major cause of death and disability worldwide. Every year at least 10 million people sustain a traumatic brain injury serious enough to result in death or admission to hospital.4 Bearing in mind that almost half of all patients with traumatic brain injury experience long term disability5 6 and that most injury occurs in young adults, the medical, social, and financial burden is clear.

    What is the evidence of the uncertainty?

    The Cochrane Injuries Group maintains a specialised register of randomised controlled trials of interventions for traumatic brain injury and has searched extensively for trials evaluating the effects of mannitol, hyperventilation, cerebrospinal fluid drainage, and barbiturates. The group has also prepared, and regularly updates, systematic reviews to assess the effects of barbiturates,7 hyperventilation,8 and mannitol.9

    In 1998 the Cochrane Injuries Group highlighted the absence of reliable evidence for the effectiveness of these four treatments10 when searches identified only three small trials of barbiturates,11 12 …

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