An appraisal of the impact of management guidelines in traumatic brain injury

To consider the evidence for the beneficial effects of the current management guidelines in traumatic brain injury, and to highlight the important issues.

Articles and published peer-review abstracts about the mechanisms and management of traumatic brain injury.

Guidelines for the management of traumatic brain injury focus on the recognition, detection and prevention of secondary brain insults. Defence of cerebral perfusion pressure with optimisation of cerebral blood flow and substrate delivery, form the vanguard of these guidelines. The impact of guidelines per se on outcome is difficult to determine due to rapid changes in practice and a dearth of controlled evidence predating these guidelines. Technological developments in multimodal monitoring may identify trends in changing practice. However, there are still significant limitations in the accuracy of assessment of the underlying neuropathological processes. The impact of management strategies using current or novel therapies on these neuropathological processes is difficult to assess in randomised controlled trials due to small sample sizes and heterogeneous practice. Preliminary studies using continuous multimodal monitoring in accordance with current management guidelines have identified that episodes of sustained jugular venous desaturation were significantly reduced, indicating that potentially harmful episodes of cerebral oligaemia were prevented. Although the impact of these strategies on outcome was favourable, limitations in these studies do not allow firm outcome based assessments. However, these studies suggest that by defending cerebral perfusion pressure, potentially ischaemic or hypoxic cerebral insults may be prevented and may result in a reassessment of the indications and clinical utility of neuromonitoring.

The impact of management guidelines in traumatic brain injury on patient outcome has been difficult to determine. However, there is a large body of uncontrolled evidence that suggests secondary global cerebral ischaemia-hypoxic insults are the major determinants in influencing outcome and that therapeutic interventions that maintain and defend cerebral perfusion pressures may improve outcome.