Guidelines for head injury: their use and limitations

Within medicine in general, and particularly in the field of head injury, a revolution is currently occurring wherein the traditional expert opinion-based approach to therapy is quickly changing towards a standardized approach, based on scientific analysis of available evidence. The guideline movement may be considered a child of this revolution. Correct understanding, interpretation and application of guidelines requires an understanding of the reasons for formulating the guidelines and of the methodology on which they are based. From this perspective the North American guidelines and the EBIC guidelines, as main international exponents towards guidelines in head injury, are discussed. Specific attention is focussed on the interpretation of the practice recommendations from the North American guidelines at the level of a standard. The evidence underlying these standards is critically discussed and the conclusions put in to further perspective. The EBIC guidelines were formulated from a desire to obtain a 'common core approach' to basic therapy in centers participating in clinical trials. The recommendations are more pragmatic, based on an understanding of the pathophysiology, and address various issues not analyzed in the North American guidelines. The recommendations of both initiatives however are very similar, illustrating the consensus that already exists to general approach of management in head injury. Guidelines should be considered a very important topic in clinical practice, but on the other hand recommendations should not always be accepted uncritically. The lack of evidence underlying many aspects of management in head injury, as illustrated by the North American approach, should form an incentive for further scientific studies, especially towards targeted therapy. Clinical experience and an understanding of the pathophysiology are the basic ingredients for developing alternative and more targeted approaches which can then be subjected to scientific analysis. Guidelines should be considered a tool which we need to learn how to use; they form part of a process which, following implementation and dissemination should lead to standardized registration, an important element in facilitating improved quality control and assurance.