Crit Care Resusc
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Despite technological and medical advances for the treatment of SAH that have had a positive impact on outcomes over the last 20 years, but the all-cause mortality for this often-catastrophic condition remains high at 12 - 15%. Survival will ultimately depend on the severity of the haemorrhage, the subsequent loss of functional neurones and the extracranial reserve of the patient. ⋯ There is little or no evidence to justify the aggressive use of anti-vasospastic therapies as a preventative manner with exception of oral nimodipine in patients with low-grade aneurysmal subarachnoid haemorrhage. Concomitant use of induced hypertension/hypervolaemia/haemodilution cannot be recommended on current evidence, but if employed should be done on an individualised basis, considering the patients underlying neurological condition, cardiopulmonary reserve, adequacy of systemic and neurological monitoring and access to expert neuroradiological, neurosurgical and neurocritical care services.
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Intracerebral haemorrhage (ICH) is much less common than ischaemic stroke (15% versus 85% in most Western studies), but is associated with a significantly worse prognosis. ICH is much more common in Asian populations, probably reflecting higher rates of small vessel disease, hypertension and genetic factors. Overall, ICH mortality rates approach 50% and there has been little effective treatment to date, except for the overall benefit from stroke unit care. ⋯ Medical therapies to reduce brain edema and intracranial pressure, including glycerol and mannitol, are not of proven value. It is accepted that corticosteroids should not be used in ICH and may worsen outcomes. The management of acute hypertension is controversial and guidelines are based on little direct evidence.
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Therapeutic hypothermia is a potentially dangerous treatment with a very narrow therapeutic index. It is of proven benefit in certain conditions, including post ventricular fibrillation cardiac arrest and intermediate severity neonatal asphyxia. ⋯ While it is clear that hypothermia decreases intracranial pressure, a major phase III trial demonstrated no improvement in neurological outcomes with hypothermia, in an unselected group of patient with severe head injury. More focused phase III trials are underway but until the results are known this treatment should not be offered to patients outside the context of a clinical trial.
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Cervical spine injury occurs in 5-10% of patients with traumatic brain injury (TBI) and the consequences of missing significant cervical injuries in unconscious blunt trauma patients are potentially devastating. An adequate cervical spine clearance protocol for unconscious patients must avoid missed injuries, but must also avoid unnecessary cervical immobilisation and the associated morbidity. Existing protocols include various combinations of plain X-rays, helical CT, dynamic flexion-extension X-rays and MRI. ⋯ Nevertheless, recently at The Alfred Hospital, extremely high-risk TBI patients have had unstable cervical injuries detected solely by MRI. Current generation multi-slice CT with reconstructions may obviate the need for MRI even in these patients. The current Alfred Hospital cervical clearance protocol for unconscious patients, and the evolutionary steps in its development, will be discussed.
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Hypothermia for patients with severe traumatic brain injury (TBI) remains controversial despite a strong biological rationale and reasonable evidence from the literature. The "negative" Clifton study seems to have reduced enthusiasm for hypothermia, however the aim of this review is to analyse the evidence from all randomised controlled trials (RCT) and meta-analyses on this topic to determine whether there is adequate support for the view that hypothermia does improve outcome from TBI. The biological rationale for hypothermia is supported by animal and human mechanistic studies of TBI and human clinical studies of brain injury caused by out-of-hospital cardiac arrest. ⋯ Subsequent to these meta-analyses, a RCT was published which has confirmed that hypothermia is beneficial in a large group of TBI patients. When the published evidence is considered in total, even if hypothermia can't be justified in all TBI patients, if it is applied optimally in the most appropriate patients, hypothermia certainly improves outcome from TBI. If hypothermia is correctly applied (early, long and cool enough) in the optimal group of TBI patients (young with elevated ICP), there seems to be no doubt that hypothermia is effective in improving both survival and favourable neurological outcome from TBI.