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Bench-to-bedside review: Hypothermia in traumatic brain injury.

Sinclair HL, Andrews PJ - Crit Care (2010)

Bottom Line: It causes the majority of the 50,000 deaths from road traffic accidents and leaves 10,000 patients severely handicapped: three quarters of these victims are young people.Brain swelling can be monitored by measuring intracranial pressure (ICP), and in most centres ICP is used to guide treatments and to monitor their success.There is an absence of evidence for the five commonly used treatments for raised ICP and all are potential 'double-edged swords' with significant disadvantages.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK. l.sinclair@ed.ac.uk

ABSTRACT
Traumatic brain injury remains a major cause of death and severe disability throughout the world. Traumatic brain injury leads to 1,000,000 hospital admissions per annum throughout the European Union. It causes the majority of the 50,000 deaths from road traffic accidents and leaves 10,000 patients severely handicapped: three quarters of these victims are young people. Therapeutic hypothermia has been shown to improve outcome after cardiac arrest, and consequently the European Resuscitation Council and American Heart Association guidelines recommend the use of hypothermia in these patients. Hypothermia is also thought to improve neurological outcome after neonatal birth asphyxia. Cardiac arrest and neonatal asphyxia patient populations present to health care services rapidly and without posing a diagnostic dilemma; therefore, therapeutic systemic hypothermia may be implemented relatively quickly. As a result, hypothermia in these two populations is similar to the laboratory models wherein systemic therapeutic hypothermia is commenced very soon after the injury and has shown so much promise. The need for resuscitation and computerised tomography imaging to confirm the diagnosis in patients with traumatic brain injury is a factor that delays intervention with temperature reduction strategies. Treatments in traumatic brain injury have traditionally focussed on restoring and maintaining adequate brain perfusion, surgically evacuating large haematomas where necessary, and preventing or promptly treating oedema. Brain swelling can be monitored by measuring intracranial pressure (ICP), and in most centres ICP is used to guide treatments and to monitor their success. There is an absence of evidence for the five commonly used treatments for raised ICP and all are potential 'double-edged swords' with significant disadvantages. The use of hypothermia in patients with traumatic brain injury may have beneficial effects in both ICP reduction and possible neuro-protection. This review will focus on the bench-to-bedside evidence that has supported the development of the Eurotherm3235Trial protocol.

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Stages of therapeutic management after traumatic brain injury. These 'stages' have been developed for use in the Eurotherm3235Trial using evidence synthesis from the Brain Trauma Foundation [73] and the European Brain Injury Consortium [81]. CSF, cerebrospinal fluid; PaCO2, arterial partial pressure of carbon dioxide; PaO2, arterial partial pressure of oxygen.
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Figure 2: Stages of therapeutic management after traumatic brain injury. These 'stages' have been developed for use in the Eurotherm3235Trial using evidence synthesis from the Brain Trauma Foundation [73] and the European Brain Injury Consortium [81]. CSF, cerebrospinal fluid; PaCO2, arterial partial pressure of carbon dioxide; PaO2, arterial partial pressure of oxygen.

Mentions: The Eurotherm3235Trial will enrol TBI patients who have an ICP of more than 20 mm Hg for at least 5 minutes after first-line treatments with no obvious reversible cause (for example, patient position, coughing, or inadequate sedation). Three stages of TBI management have been developed to support the trial and are based upon the best evidence available (Figure 2) [73,81]. The Brain Trauma Foundation's recommended treatment threshold for treatment of ICP is 20 mm Hg [73]. Although early cooling after injury is considered to be beneficial, this is offset by the failure to show benefit from hypothermia in the absence of raised ICP. Enrolment to the Eurotherm3235Trial will therefore be allowed for up to 72 hours following injury. This potential delay in cooling will be compensated for, to an extent, by inducing hypothermia with 20 to 30 mL/kg of refrigerated 0.9% saline given intravenously over the course of 30 minutes. No maximum duration of cooling is specified, and hypothermia will continue until ICP is no longer dependent on temperature reduction to remain below 20 mm Hg. Patients will then be slowly re-warmed at a rate of 0.25°C per hour (1°C/4 hours).


Bench-to-bedside review: Hypothermia in traumatic brain injury.

Sinclair HL, Andrews PJ - Crit Care (2010)

Stages of therapeutic management after traumatic brain injury. These 'stages' have been developed for use in the Eurotherm3235Trial using evidence synthesis from the Brain Trauma Foundation [73] and the European Brain Injury Consortium [81]. CSF, cerebrospinal fluid; PaCO2, arterial partial pressure of carbon dioxide; PaO2, arterial partial pressure of oxygen.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2875496&req=5

Figure 2: Stages of therapeutic management after traumatic brain injury. These 'stages' have been developed for use in the Eurotherm3235Trial using evidence synthesis from the Brain Trauma Foundation [73] and the European Brain Injury Consortium [81]. CSF, cerebrospinal fluid; PaCO2, arterial partial pressure of carbon dioxide; PaO2, arterial partial pressure of oxygen.
Mentions: The Eurotherm3235Trial will enrol TBI patients who have an ICP of more than 20 mm Hg for at least 5 minutes after first-line treatments with no obvious reversible cause (for example, patient position, coughing, or inadequate sedation). Three stages of TBI management have been developed to support the trial and are based upon the best evidence available (Figure 2) [73,81]. The Brain Trauma Foundation's recommended treatment threshold for treatment of ICP is 20 mm Hg [73]. Although early cooling after injury is considered to be beneficial, this is offset by the failure to show benefit from hypothermia in the absence of raised ICP. Enrolment to the Eurotherm3235Trial will therefore be allowed for up to 72 hours following injury. This potential delay in cooling will be compensated for, to an extent, by inducing hypothermia with 20 to 30 mL/kg of refrigerated 0.9% saline given intravenously over the course of 30 minutes. No maximum duration of cooling is specified, and hypothermia will continue until ICP is no longer dependent on temperature reduction to remain below 20 mm Hg. Patients will then be slowly re-warmed at a rate of 0.25°C per hour (1°C/4 hours).

Bottom Line: It causes the majority of the 50,000 deaths from road traffic accidents and leaves 10,000 patients severely handicapped: three quarters of these victims are young people.Brain swelling can be monitored by measuring intracranial pressure (ICP), and in most centres ICP is used to guide treatments and to monitor their success.There is an absence of evidence for the five commonly used treatments for raised ICP and all are potential 'double-edged swords' with significant disadvantages.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK. l.sinclair@ed.ac.uk

ABSTRACT
Traumatic brain injury remains a major cause of death and severe disability throughout the world. Traumatic brain injury leads to 1,000,000 hospital admissions per annum throughout the European Union. It causes the majority of the 50,000 deaths from road traffic accidents and leaves 10,000 patients severely handicapped: three quarters of these victims are young people. Therapeutic hypothermia has been shown to improve outcome after cardiac arrest, and consequently the European Resuscitation Council and American Heart Association guidelines recommend the use of hypothermia in these patients. Hypothermia is also thought to improve neurological outcome after neonatal birth asphyxia. Cardiac arrest and neonatal asphyxia patient populations present to health care services rapidly and without posing a diagnostic dilemma; therefore, therapeutic systemic hypothermia may be implemented relatively quickly. As a result, hypothermia in these two populations is similar to the laboratory models wherein systemic therapeutic hypothermia is commenced very soon after the injury and has shown so much promise. The need for resuscitation and computerised tomography imaging to confirm the diagnosis in patients with traumatic brain injury is a factor that delays intervention with temperature reduction strategies. Treatments in traumatic brain injury have traditionally focussed on restoring and maintaining adequate brain perfusion, surgically evacuating large haematomas where necessary, and preventing or promptly treating oedema. Brain swelling can be monitored by measuring intracranial pressure (ICP), and in most centres ICP is used to guide treatments and to monitor their success. There is an absence of evidence for the five commonly used treatments for raised ICP and all are potential 'double-edged swords' with significant disadvantages. The use of hypothermia in patients with traumatic brain injury may have beneficial effects in both ICP reduction and possible neuro-protection. This review will focus on the bench-to-bedside evidence that has supported the development of the Eurotherm3235Trial protocol.

Show MeSH
Related in: MedlinePlus