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Which treatments are safe and effective to reduce intracranial pressure following severe traumatic brain injury?
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Perkins, Gavin D., Horner, Daniel and Naisbitt, Michael J. (2022) Which treatments are safe and effective to reduce intracranial pressure following severe traumatic brain injury? BMJ, 378 . e061960. doi:10.1136/bmj-2020-061960
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Official URL: https://doi.org/10.1136/bmj-2020-061960
Abstract
More than 50 million people suffer a traumatic brain injury (TBI) each year. Forceful impact to the head can impair mental status and lead to neurobehavioral deficits. Most traumatic brain injuries are mild. Severe TBI (defined by a Glasgow Coma Score 8 at presentation) accounts for approximately 20% of all TBI cases and has a reported incidence of 70 per 100,000 worldwide.
Severe TBI encompasses multiple pathologies, which often combine to cause more harm than the initial primary head injury. Injuries may be focal or diffuse and over time can coalesce through local response to injury, or systemic exacerbation. These physiological changes can increase the volume of the intracranial contents, leading to rising intracranial pressure (ICP) and furthersecondary injury to brain tissue. The normal range for ICP is 7 to 15mmHg in the horizontal position, with fluctuation depending on age, posture and clinical condition. In the context of TBI, a continued and sustained rise in ICP well above this threshold can result in progressive cerebral ischaemia, herniation syndromes or death. In a retrospective single centre cohort of 459 patients with severe TBI, an elevated ICP >22mmHg for >37 minutes was associated with worsening functional outcomes. The clinical consequences of such neurological injury are devastating for patients; in a recent well conducted international cohort study including 2113 patients with severe TBI, 21.3% of had died and 43.1% had survived with an unfavourable neurological outcome atsixmonths. 3 The latter metric describes a Glasgow Outcome Score Extended (GOSE) of <5, implying a permanent need for help with activities of daily living or absence of awareness of self/environment.
Early resuscitation and emergency care of severe TBI involves a number of routine critical care interventions alongside regular consideration of emergency neurosurgery, to reduce cerebral oxygen demand, optimise perfusion to the brain and limit further secondary injury. These interventions are often bundled together as ‘tier zero’ measures in expert consensus guidelines (figure 1). If ICP increases despite the optimisation of physiology and provision of such therapies, then several additional medical treatment options are commonly used to reduce ICP (tier one and two interventions in figure 1). It is uncertain which of these treatments are safe, when they should be deployed and whether they can improve survival or prevent disability.
Additional rescue therapies (tier 3 interventions in figure 1) for those with refractory intracranial hypertension are used in <10% patients with severe TBI. There are major limitations in the evidence for these treatments and as such they are not covered in this article.
| Item Type: | Journal Article | |||||||||
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| Subjects: | R Medicine > RC Internal medicine R Medicine > RD Surgery |
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| Divisions: | Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School | |||||||||
| SWORD Depositor: | Library Publications Router | |||||||||
| Library of Congress Subject Headings (LCSH): | Brain damage, Brain -- Wounds and injuries -- Treatment, Intracranial pressure | |||||||||
| Journal or Publication Title: | BMJ | |||||||||
| Publisher: | BMJ Publishing Group Ltd. | |||||||||
| ISSN: | 0959-535X | |||||||||
| Official Date: | 3 August 2022 | |||||||||
| Dates: |
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| Volume: | 378 | |||||||||
| Article Number: | e061960 | |||||||||
| DOI: | 10.1136/bmj-2020-061960 | |||||||||
| Status: | Peer Reviewed | |||||||||
| Publication Status: | Published | |||||||||
| Access rights to Published version: | Restricted or Subscription Access | |||||||||
| Copyright Holders: | Copyright © 2022 BMJ Publishing Group Ltd | |||||||||
| RIOXX Funder/Project Grant: |
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