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ON PREHOSPITAL TREATMENT OF SEVERE TRAUMATIC BRAIN INJURY

The following points are made by D.J Cooper et al (J. Am. Med. Assoc. 2004 291:1350):

1) Severe traumatic brain injury (TBI) is common in patients with major trauma and typically involves young adult men.(1) Despite current management strategies, patients with severe TBI have a high mortality rate (31%-49%) and a large number of survivors have persistent severe neurological disability.(1-4) There are 80,000 to 90,000 cases of survivors with long-term disability after head injury annually in the United States.(5) The mean lifetime cost of each TBI survivor with severe disability from TBI exceeds US $2 million.

2) After initial head trauma, secondary brain injury may occur due to hypoxia, hypotension, or elevated intracranial pressure (ICP) and is associated with a worse neurological outcome.(3) Patients with hypotension after severe TBI have twice the mortality rate of normotensive patients.(5) Therefore, aggressive resuscitation with intravenous fluids is recommended in current guidelines for the management of patients with severe TBI. Treatment of increased ICP in patients with TBI is also likely to improve outcomes.(3)

3) Previous studies in unselected patients with trauma found that intravenous hypertonic saline (HTS) increased blood pressure and decreased ICP compared with isotonic resuscitation fluids. Hypertonic saline is also used for resuscitation in combination with hypertonic colloids (usually dextran 70) to increase duration of effect. However, the combinations are more expensive and in a randomized comparative 4-group trial, highest survival rates were achieved with HTS alone (HTS alone, 60%; HTS with dextran 70, 56%; Ringer's lactate solution alone, 49%). A meta-analysis of patients with TBI from 8 randomized trials of HTS-dextran resuscitation reported increased survival from 27% to 38%.

4) The authors report a study to determine whether prehospital resuscitation with intravenous hypertonic solution (HTS) improves long-term neurological outcome in patients with severe traumatic brain injury (TBI) compared with resuscitation with conventional fluids. The study was a double-blind, randomized controlled trial of 229 patients with TBI who were comatose (Glasgow Coma Scale score, less than 9) and hypotensive (systolic blood pressure less than 100 mm Hg). The patients were enrolled between December 14, 1998, and April 9, 2002, in Melbourne, Australia.

5) Conclusions: The authors report that in this study patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.

References (abridged):

1. Fearnside MR, Cook RJ, McDougall P, McNeil RJ. The Westmead Head Injury Project outcome in severe head injury: a comparative analysis of pre-hospital, clinical and CT variables. Br J Neurosurg. 1993;7:267-279

2. Khan F, Baguley IJ, Cameron ID. Rehabilitation after traumatic brain injury. Med J Aust. 2003;178:290-295

3. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216-222

4. Hunt J, Hill D, Besser M, West R, Roncal S. Outcome of patients with neurotrauma: the effect of a regionalized trauma system. Aust N Z J Surg. 1995;65:83-86

5. US National Institutes of Health. Rehabilitation of persons with traumatic brain injury: NIH Consensus Statement 1998. Available at: http://consensus.nih.gov/cons/109/109_intro.htm Accessibility verified February 20, 2004

J. Am. Med. Assoc. http://www.jama.com

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