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Journal of Neurology, Neurosurgery, and Psychiatry logoLink to Journal of Neurology, Neurosurgery, and Psychiatry
. 1998 Nov;65(5):729–733. doi: 10.1136/jnnp.65.5.729

Absence of evidence for the effectiveness of five interventions routinely used in the intensive care management of severe head injury: a systematic review

I Roberts 1, G Schierhout 1, P Alderson 1
PMCID: PMC2170326  PMID: 9810947

Abstract

OBJECTIVES—To assess the effectiveness of interventions routinely used in the intensive care management of severe head injury, specifically, the effectiveness of hyperventilation, mannitol, CSF drainage, barbiturates, and corticosteroids.
METHODS—Systematic review of all unconfounded randomised trials, published or unpublished, that were available by August 1996.
RESULTS—None of the interventions has been reliably shown to reduce death or disability after severe head injury. One trial of hyperventilation was identified of 77 participants. The relative risk for death was 0.73 (95% confidence interval (95% CI) 0.36-1.49), and for death or disability it was 1.14 (95% CI 0.82-1.58). One trial of mannitol was identified of 41 participants. The relative risk for death was 1.75 (95% CI 0.48-6.38), no data were available for disability. No randomised trials of CSF drainage were identified. Two randomised trials of barbiturate therapy were identified, including 126 participants. The pooled relative risk for death was 1.12 (95% CI 0.81-1.54). Disability data were available for one trial. The relative risk for death or disability was 0.96(95% CI 0.62-1.49). Thirteen randomised trials of corticosteroids were identified, comprising 2073 participants. The pooled relative risk for death was 0.95 (0.84 to 1.07) and for death or disability it was 1.01 (95% CI 0.91 to 1.11). On the basis of the currently available randomised evidence, for every intervention studied it is impossible to refute either a moderate increase or a moderate decrease in the risk of death or disability.
CONCLUSION—Existing trials have been too small to support or refute the existence of a real benefit from using hyperventilation, mannitol, CSF drainage, barbiturates, or corticosteroids. Further large scale randomised trials of these interventions are required.



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Selected References

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  1. Alderson P., Roberts I. Corticosteroids in acute traumatic brain injury: systematic review of randomised controlled trials. BMJ. 1997 Jun 28;314(7098):1855–1859. doi: 10.1136/bmj.314.7098.1855. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Alexander E., Jr Global Spine and Head Injury Prevention Project (SHIP) Surg Neurol. 1992 Dec;38(6):478–479. doi: 10.1016/0090-3019(92)90124-6. [DOI] [PubMed] [Google Scholar]
  3. Calne D. B., Pallis C. A. Vibratory sense: a critical review. Brain. 1966 Dec;89(4):723–746. doi: 10.1093/brain/89.4.723. [DOI] [PubMed] [Google Scholar]
  4. Chole R. A., Cook G. B. The Rinne test for conductive deafness. A critical reappraisal. Arch Otolaryngol Head Neck Surg. 1988 Apr;114(4):399–403. doi: 10.1001/archotol.1988.01860160043018. [DOI] [PubMed] [Google Scholar]
  5. Doppenberg E. M., Bullock R. Clinical neuro-protection trials in severe traumatic brain injury: lessons from previous studies. J Neurotrauma. 1997 Feb;14(2):71–80. doi: 10.1089/neu.1997.14.71. [DOI] [PubMed] [Google Scholar]
  6. Eisenberg H. M., Frankowski R. F., Contant C. F., Marshall L. F., Walker M. D. High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg. 1988 Jul;69(1):15–23. doi: 10.3171/jns.1988.69.1.0015. [DOI] [PubMed] [Google Scholar]
  7. Fanconi S., Klöti J., Meuli M., Zaugg H., Zachmann M. Dexamethasone therapy and endogenous cortisol production in severe pediatric head injury. Intensive Care Med. 1988;14(2):163–166. doi: 10.1007/BF00257471. [DOI] [PubMed] [Google Scholar]
  8. Feldmann H. Die Geschichte der Stimmgabel. Teil l: Die Erfindung der Stimmgabel, ihr Weg in der Musik und den Naturwissenschaften. Bilder aus der Geschichte der Hals-Nasen-Ohren-Heilkunde, dargestellt an Instrumenten aus der Sammlung im Deutschen Medizinhistorischen Museum in Ingolstadt. Laryngorhinootologie. 1997 Feb;76(2):116–122. doi: 10.1055/s-2007-997398. [DOI] [PubMed] [Google Scholar]
  9. Gentleman D. Preventing secondary brain damage after head injury: a multidisciplinary challenge. Injury. 1990 Sep;21(5):305–308. doi: 10.1016/0020-1383(90)90047-x. [DOI] [PubMed] [Google Scholar]
  10. Ghajar J., Hariri R. J., Narayan R. K., Iacono L. A., Firlik K., Patterson R. H. Survey of critical care management of comatose, head-injured patients in the United States. Crit Care Med. 1995 Mar;23(3):560–567. doi: 10.1097/00003246-199503000-00023. [DOI] [PubMed] [Google Scholar]
  11. Haughton P. M., Pearce J. M. Observations on the Rinne test. Lancet. 1982 Apr 10;1(8276):829–830. doi: 10.1016/s0140-6736(82)91875-x. [DOI] [PubMed] [Google Scholar]
  12. Huizing E. H. The early descriptions of the so-called tuning-fork tests of Weber, Rinne, Schwabach, and Bing. II. The "Rhine Test" and its first description by Polansky. ORL J Otorhinolaryngol Relat Spec. 1975;37(2):88–91. doi: 10.1159/000275210. [DOI] [PubMed] [Google Scholar]
  13. Huizing E. H. The early descriptions of the so-called tuning-fork tests of Weber, Rinne, Schwabach, and Bing. III. The development of the Schwabach and Bing tests. ORL J Otorhinolaryngol Relat Spec. 1975;37(2):92–96. doi: 10.1159/000275211. [DOI] [PubMed] [Google Scholar]
  14. Kaufmann A. M., Cardoso E. R. Aggravation of vasogenic cerebral edema by multiple-dose mannitol. J Neurosurg. 1992 Oct;77(4):584–589. doi: 10.3171/jns.1992.77.4.0584. [DOI] [PubMed] [Google Scholar]
  15. Liniger C., Albeanu A., Bloise D., Assal J. P. The tuning fork revisited. Diabet Med. 1990 Dec;7(10):859–864. doi: 10.1111/j.1464-5491.1990.tb01319.x. [DOI] [PubMed] [Google Scholar]
  16. Matta B., Menon D. Severe head injury in the United Kingdom and Ireland: a survey of practice and implications for management. Crit Care Med. 1996 Oct;24(10):1743–1748. doi: 10.1097/00003246-199610000-00023. [DOI] [PubMed] [Google Scholar]
  17. Muizelaar J. P., Marmarou A., Ward J. D., Kontos H. A., Choi S. C., Becker D. P., Gruemer H., Young H. F. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg. 1991 Nov;75(5):731–739. doi: 10.3171/jns.1991.75.5.0731. [DOI] [PubMed] [Google Scholar]
  18. Ng M., Jackler R. K. Early history of tuning-fork tests. Am J Otol. 1993 Jan;14(1):100–105. [PubMed] [Google Scholar]
  19. Oxman A. D., Cook D. J., Guyatt G. H. Users' guides to the medical literature. VI. How to use an overview. Evidence-Based Medicine Working Group. JAMA. 1994 Nov 2;272(17):1367–1371. doi: 10.1001/jama.272.17.1367. [DOI] [PubMed] [Google Scholar]
  20. Peto R., Collins R., Gray R. Large-scale randomized evidence: large, simple trials and overviews of trials. J Clin Epidemiol. 1995 Jan;48(1):23–40. doi: 10.1016/0895-4356(94)00150-o. [DOI] [PubMed] [Google Scholar]
  21. Raichle M. E., Plum F. Hyperventilation and cerebral blood flow. Stroke. 1972 Sep-Oct;3(5):566–575. doi: 10.1161/01.str.3.5.566. [DOI] [PubMed] [Google Scholar]
  22. Saul T. G., Ducker T. B. Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg. 1982 Apr;56(4):498–503. doi: 10.3171/jns.1982.56.4.0498. [DOI] [PubMed] [Google Scholar]
  23. Sayre M. R., Daily S. W., Stern S. A., Storer D. L., van Loveren H. R., Hurst J. M. Out-of-hospital administration of mannitol to head-injured patients does not change systolic blood pressure. Acad Emerg Med. 1996 Sep;3(9):840–848. doi: 10.1111/j.1553-2712.1996.tb03528.x. [DOI] [PubMed] [Google Scholar]
  24. Ward J. D., Becker D. P., Miller J. D., Choi S. C., Marmarou A., Wood C., Newlon P. G., Keenan R. Failure of prophylactic barbiturate coma in the treatment of severe head injury. J Neurosurg. 1985 Mar;62(3):383–388. doi: 10.3171/jns.1985.62.3.0383. [DOI] [PubMed] [Google Scholar]
  25. Yano M., Kobayashi S., Aruga T., Yamamoto Y., Ohtsuka T., Nishimura N. [Barbiturate overloading in 85 cases of severe head injury (author's transl)]. Neurol Med Chir (Tokyo) 1981 Feb;21(2):163–170. doi: 10.2176/nmc.21.163. [DOI] [PubMed] [Google Scholar]

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