Acute management of traumatic brain injury
In a three-part review of acute management for traumatic brain injury, researchers recently recommended what they considered to be best practices within non-pharmacological interventions, pharmacological interventions, and interventions used to promote arousal from coma. Their findings were as follows.
Non-pharmacological interventions used to reduce secondary injury:
After the primary injury, acute care of traumatic brain injury focuses on the prevention of secondary injury, such as inflammation, hypoxia, ischemia, or edema. Non-pharmacological interventions used to prevent the intracranial pressure and reduce secondary damage include: adjusting head posture, body rotation, hyperventilation, hypothermia, hyperbaric oxygen, cerebrospinal fluid drainage, and decompressive craniectomy.
Of these seven interventions, only decompressive craniectomy, cerebrospinal fluid drainage, hypothermia, and hyperbaric oxygen provided strong evidence to be recommended as an appropriate treatment in the acute care of traumatic brain injury
Pharmacological interventions used to reduce secondary injury and improve neural recovery:
There are three types of pharmacological agents that are used to decrease intracranial pressure after brain injury. These are: 1) diuretics to draw fluid from the cranial cavity, 2) analgesics to reduce metabolic demands from injured neurons and reduce brain activity, and 3) sedatives that act in the same way as analgesics.
Of the 11 pharmacological interventions commonly used-propofol, barbiturates, opioids, midazolam, mannitol, hypertonic saline, corticosteroids, progesterone, bradykinin antagonists, dimethyl sulphoxide, and cannabinoids-all but corticosteroids (which were contraindicated) and cannabinoids (which were ineffective) showed strong evidence of providing some benefit in the acute care of traumatic brain injury.
Interventions used to promote arousal from coma:
Both pharmacological and non-pharmacological interventions were reviewed in this study. Pharmacological interventions included amantadine, bromocriptine, and levodopa. Non-pharmacological interventions included sensory stimulation, music therapy, and medial nerve electrical stimulation.
All interventions showed a trend towards promoting arousal from coma. However, only amantadine showed strong evidence of substantial benefit, and this was only reported from a single case. Further research is needed in all therapies, since there is currently a lack of thorough research.
Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury part I: An evidence-based review of non-pharmacological interventions. Brain Injury. (May 2010).
Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury part II: An evidence-based review of pharmacological interventions. Brain Injury. (May 2010).
Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury part III: An evidence-based review of interventions used to promote arousal from coma. Brain Injury. (May 2010).