Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Did someone say accident?
- Brendon J Smith (31 August 2002)
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Psychiatric Aspects of head injury
- Mamoun Mobayed (3 September 2002)
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Neurostimulants: a piece in the brain injury rehabilitation puzzle
- Tarek A Gaber (4 September 2002)
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Brain injury rehabilitation -Who benefits the most ?
- Ajoy Nair (7 September 2002)
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treating head injury
- Vincenzo Bonicalzi, Sergio Canavero (10 September 2002)
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A&E departments take major role in treating head injuries
- Marc D Wittenberg, Mr John Sloan, Consultant in Emergency Medicine (12 September 2002)
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Hypothermia in head injuries
- Richard G Fiddian-Green (13 September 2002)
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Treating head injuries
- Peter S Baxter, Judith A Short and Charles G Stack (25 September 2002)
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Intracranial compartment syndrome
- Richard G Fiddian-Green (3 October 2002)
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Psychiatric aspects: an energy deficit?
- Richard G Fiddian-Green (3 October 2002)
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Practical difficulties in managing head injuries
- jonathan l hart (8 October 2002)
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Brendon J Smith, Staff Specialist - Emergency Medicine Bankstown Hospital, Sydney, Australia
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I refer to your June 2001 editorial (BMJ 2001;322:1320-1321 (2 June)BMJ bans "accidents") inviting readers to "...keep us on our toes by alerting us to instances when "accidents" slip through". The guide to managing head injuries warrant some comments, not least of which is that all are managed in an emergency department, and only a small fraction are referred to neurosurgeons. It is perhaps the emergency department, rather than the surgeons, who should be taking the leading role in their management. What is also less than ideal is that guidelines are given as to when a skull x-ray or CT should be ordered. There is little evidence to support this, and best practice would suggest that there is no role for a skull x -ray in head trauma. The Canadian Head CT Rule developed by Ian Stiell (Lancet 2001;357:1391–6) is a useful start in clarifying indications for CT, and the NEXUS group have a study in progress. It is frustrating to have UK staff working in emergency medicine in the antipodes who base their practice on guidelines designed to reduce the cost of care rather than the incidence of missed injuries which are inevitable if such an approach is followed. It is important to acknowledge the lack of evidence in an area where there can be a false sense of security in relying on opinion based guidelines. |
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Mamoun Mobayed, Associate Specialist Psychiatrist Muckamore Abbey Hospital, Antrim, BT41 4ST
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Editor, Wasserberg’s editorial on Treating head injuries (1) provides a constructively critical view on managing this very common major health problem particularly in young adults, but to complete the picture there is an urgent need to increase the awareness of the psychiatric sequelae of both major and minor head injuries. Effects of head injury on mental functions have usually been studied in patients with severe trauma, where there are several neurological and psychological sequelae including; cognitive impairment, personality change, psychoses, affective disorders and suicide. (2) Studies of the consequences of minor head injury are much rarer, in spite the fact that these patients frequently complain of psychiatric difficulties. (3) A wide range of symptoms which are usually reported following minor trauma include; headache, dizziness, hypersensitivity to noises, fatigue, impaired concentration, memory difficulty, irritability, anxiety and depression. (2) The psychiatric presentation often comes to light within a few weeks to months following the accident. The trauma may first present as relatively subtle affective or behavioural changes. The patient, while providing the history, may fail to associate the complaints with the traumatic event. In our own study of post minor head injury depression the prevalence of DSM-III depression among the victims of minor head injury was found to be 15.7 per cent, 2 to 12 months after the trauma, and all these patients were undetected and untreated. (4) The prolactin responses to buspirone and fenfluramine challenges were significantly blunted in these patients, and this suggests the biological nature of depression in the form of 5-HT dysfunction following trauma. The 5-HT dysfunction returned to normal with clinical recovery following treatment with amitriptyline antidepressant, although post head injury depression was found to be relatively resistant to standard antidepressant therapy. (5) Mamoun Mobayed, Associate Specialist Psychiatrist, Muckamore Abbey Hospital, Antrim BT41 4SH Mobayed@hotmail.com References: 1- Wasserberg J. Treating head injuries. BMJ 2002;454:455-7362(31 August.) 2- Lishman WA. Head Injurt. In: Organic Psychiatry. Oxford:Blackwell; 1988. 3- Schoenhuber R, Gentilini M. Anxiety and depression after mild head injury: a case control study. Journal of Neurology, Neurosurgery and Psychiatry 1988;722:725-51. 4- Mobayed M, Dinan T. Buspirone/prolactin response in post head injury depression. Journal of Affective Disorders 1990;237:241-19 5- Dinan T, Mobayed M. Treatment resistance of depression after head injury: a preliminary study of amitriptyline response. Acta Psychiatrica Scandinavica 1992;292:295-85(4). |
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Tarek A Gaber, Consultant in Neurological Rehabilitation Leigh Infirmary, Greater Manchester. UK. WN7 1HS
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I share Wasserberg (1) frustration with the failure of the neuroprotective drugs to show any benefit despite the initial high hopes that were based on the effect it showed in the lab and on animal models. A more promising pharmacological intervention seldom used in the UK, is the neurostimulant group of drugs, which proved useful in managing some of the long term cognitive impairments secondary to traumatic brain injury. Speed of information processing could be improved with Methylphenidate (2) and short term memory problems showed some improvement with Donepezil (3). Most of the evidence comes from small trials or single subject design studies, but that didn’t stop neurostimulants use becoming a standard practice in the United States for selected patients with such cognitive Problems (2). Researchers in neurological rehabilitation have always found it difficult to organise large randomized trials or analyse results of smaller trials for different reasons such as the difficulty randomizing patients because of their heterogeneity and use of different outcome measures. The main difficulty however comes from the fact that rehabilitation outcome depends on complex interactions between medical, therapeutic and psychosocial factors. It is hard to see these research methodological difficulties resolving in the near future. I feel if we continue to wait for clear non- equivocal proof for the effectiveness of a particular intervention in the rehabilitation of brain injury victims, our patients might miss out on a chance to make a real difference to their quality of life. References 1- Wasserberg J. Treating head injury. BMJ 2002; 325:454-455 2- Whyte J, Vaccaro M, Grieb-Neff P, Hart T. Psychstimulants use in the rehabilitation of individuals with traumatic brain injury. J Head Trauma Rehabil 2002;4:284-99 3- Masanic CA, Bayley MT, VanReekum R, Simard M. Open label study of Donepezil in traumatic brain injury. Arch Phys Med Rehabil 2001; 82(7): 896-901 |
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Ajoy Nair, Specialist Registrar Rehabilitation Medicine DSC, Royal National Orthopaedic Hospital, Brockley Hill,Stanmore
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Wasserberg's editorial on head injury mentions that analysis of the efficacy of rehabilitation has been hampered by methodological difficulties and the lack of randomised trials. Whilst this is largely true, there have been a few randomised controlled trials with sufficient patient numbers which have not only shown that patients benefit from rehabilitation but have been able to shed some light on the group of patients who are likely to benefit the most. Wade et al (1)have shown in a randomised control trial involving 1156 cases that patients with moderate to severe head injury benefitted most from early rehabilitation interventions.Powell et al(2) in another randomised controlled trial involving 110 cases showed that community multidisciplinary rehabilitation after severe brain injury can yield benefits even years after the injury. Shiel et al(3) in a much smaller controlled trial showed that patients with moderate to severe head injury (Glasgow coma scale <12) recieving intensive inpatient made more rapid progress and were discharged home earlier than a similar group of patients receiving lesser therapy input. There is less robust evidence suggesting that early referral to an inpatient rehabilitation setting can reduce total length of hospital stay and improve functional and cognitive outcomes(4). Guidelines due from NICE in 2003 should help by ensuring that appropriate patients are referred early to specialist inpatient rehabilitation settings. References 1)Wade DT, Crawford S, Wenden FJ, et al. Does routine follow up after head injury help? A randomised controlled trial.J Neurol Neurosurg Psychiatry 1997;62:478-84 2)Powell J,Heslin J,et al .Community based rehabilitation after severe traumatic brain injury:a randomised controlled trial.J Neurol Neurosurg Psychiatry 2002;72(2):193-202 3)Shiel A, J.P.S.Burn,et al.The effects of increased rehabilitation therapy after brain injury:results of a prospective controlled trial. Clinical Rehabilitation 2001;15(5):501-14 4)Cope D.N. The effectiveness of traumatic brain injury rehabilitation. Brain Injury 1995; 9(7): 649-70 |
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Vincenzo Bonicalzi Dept. of Neurosciences, Ospedale Molinette, Via Cherasco 15, 10126 Torino Italy, Sergio Canavero
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In the last decades the mortality and morbidity from head injury appears to have been reduced, presumably by organized trauma care systems and adequate critical care (1). In his editorial on treating head injuries Wasserberg (2) stated that there is now evidence of an overall improvement in head injury outcome from treatment in a specialist unit that uses protocol driven treatment (PDT). Yet, this statement is not based on a randomized controlled trial (RCT) but on a retrospective survey (3) actually showing that in the whole referral population the tendency to increased favourable outcome after institution of PDT did not reach significance and the overall mortality did not significantly change. Only patients with severe head injury showed an increase in favourable outcome, without difference in mortality. So, Wasserberg's statement seems unsubstantiated. On the other hand, all PDT are based on successive introduction of hyperventilation, cerebrospinal fluid (CSF) drainage, infusion of mannitol, hypothermia, barbiturates and (rarely) decompressive craniotomy (all ICP lowering treatments). However Roberts et al. (ref. 11 in 1) and Dickinson et al. (ref. 5 in 1) concluded on the basis of RCTs that it was impossible to refute either a moderate increase or a moderate decrease in the risk of death or disability from the use of hyperventilation, CSF drainage, mannitol, barbiturates or corticosteroids. Wasserberg quotes a Cochrane review concluding that there is no evidence that hypothermia is beneficial in head injury, forgetting that a recent RCT was halted by the patient safety and monitoring board because the treatment was not effective and actually worsened the prognosis in patients older than 45 years of age (4). As hypothermia did reduce raised ICP, but outcome did not improve, it has been noted that "surrogate markers of efficacy (such as ICP) are not reliable substitutes for actual clinical outcomes in determining the value of therapy" (1). PDT and guidelines might be valuable tools in the treatment of head injury, but according to Roberts et al. (ref. 11 in 1) "guidelines for the management of severe head injury assembled by the US Brain Trauma Foundation did take randomized trials into account, but the methods used would not satisfy the criteria .for scientific overviews". Step by step, "neurocritical" research has been able to improve the control of raised ICP, but the conclusion that this improves mortality and morbidity after head injury is not only scientifically unproven but may prove false. References 1. Raj K. Narayan RK. Hypothermia for traumatic brain injury. A good idea proved ineffective. N Engl J Med 2001;344: 602-3 2. Wasserber J. Treating head injuries.BMJ 2002; 325:454-5 3. Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrik PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med 2002; 28:547-53 4. Clifton GL, Miller ER, Choi SC, Levin HS, McCauley S, Smith KR Jr, Muizelaar JP, Franklin C. Wagner FC Jr., Marion DW, Luerssen TG, Chesnut RM, Schwartz M. Lack of Effect of Induction of Hypothermia after Acute Brain Injury. N Engl J Med 2001;344:556-63 Competing interest: none |
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Marc D Wittenberg, 4th Year Medical Student Accident & Emergency Department, The General Infirmary at Leeds, Leeds LS1 3EX, Mr John Sloan, Consultant in Emergency Medicine
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Editor, Wasserberg (1) correctly identifies that head injuries are a major cause of morbidity and mortality in the UK. However, it has been estimated that of the one million patients attending A&E departments, only 1% are actually transferred to neurosurgical units. (2) Therefore, a large majority of care for these patients is actually undertaken by non- specialists in emergency departments. The RCSE report (3) recommends that the role of A&E departments is to determine which patients should either go home, be admitted for less than 48 hours within the department, or be transferred for specialist care. This necessarily requires comprehensive training for all A&E staff involved in their care and it is hoped that the forthcoming NICE guidelines will reflect this. In Leeds, a recent audit was carried out of patients with an isolated head injury admitted to the A&E department at Leeds General Infirmary from 1990-2001. It showed, suprisingly, that overall survival has decreased over the period from around 92% to 81% (as yet unpublished data). The epidemiology of these injuries has shown a trend towards more severe injury, but this does not appear to be sufficient reason for this decrease in survival. Although the need for research into new therapeutic agents is paramount, it is also clear that there is an urgent need for multi-centre analysis to ascertain current trends in outcome. References (1) Wasserberg J. Treating head injury. BMJ. 2002;325:454-455. (2) Currie D. The management of head injuries. A practical guide for the emergency room. 2nd Ed. 2000; OUP: Oxford. (3) The Royal College of Surgeons of England. Report of the working party on the management of head injuries. In: London: RCS, 1999. |
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Richard G Fiddian-Green, None None
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Although a Cochrane review showed that hypothermia had no beneficial effect this only means that hypothermia as applied in those studies included in the review had no beneficial effect (1). Ultraprofound hypothermia maintains hippocampus neuronal viability in rats (2). More relevant to man is the report that hypothermia preserves memory and learning abilities in pigs (3). To exert a beneficial effect it may, therefore, be necesssary to achieve ultraprofound hypothermia which would cause cardiac arrest and require either cardiopulmonary bypass or the pacement of a Jarvik 2000 shunt to maintain perfusion. It may, alternatively, be necessary to perfuse the brain with an oxygenated asanguinous solution such as Celsior or perfluorocarbon emulsion. 1. Wasserberg J. Treating head injuries. BMJ 2002; 325: 454-455. 2. Ikonomovic M, Kelly KM, Hentosz TM, Shih SR, Armstrong DM, Taylor MJ. Ultraprofound cerebral hypothermia and blood substitution with an acellular synthetic solution maintains neuronal viability in rat hippocampus. Cryo Letters. 2001 Jan-Feb;22(1):19-26. 3. Alam HB, Bowyer MW, Koustova E, Gushchin V, Anderson D, Stanton K, Kreishman P, Cryer PM, Hancock T, Rhee P. Learning and memory is preserved after induced asanguineous hyperkalemic hypothermic arrest in a swine model of traumatic exsanguination. Surgery. 2002 Aug;132(2):278-88. |
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Peter S Baxter, Consultant Paediatric Neurologist Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, Judith A Short and Charles G Stack
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Editor, The editorial by Wasserberg (1) highlights the lack of evidence on the effectiveness of currently used protocols in the management of significant head injury. The current large-scale study of corticosteroid treatment will be a welcome exception. The management of raised intracranial pressure is another important issue that deserves proper trials. A systematic review in adults and children found that there is no Class I data that can clarify the role of ICP monitoring in acute coma, either traumatic or non-traumatic (2). In 1998, we conducted a retrospective audit of the management of paediatric head injury in the North of England. We audited 54 children with head trauma and Glasgow Coma Scores of 8 or less, who were admitted to eight paediatric intensive care units for ventilatory management in 1994. At that time three of the units routinely monitored intracranial pressure, three rarely did so and two did selectively. In the 19 monitored children, there was a significant increase in the use of interventions to lower intracranial pressure or increase cerebral perfusion pressure and in the duration of ventilation (median 7 days vs. 2 days, p<0.001). There was no marked difference in outcome (19 monitored: four died, six good outcome; 35 not monitored: nine died, 18 good outcome), but the numbers were far too small to detect any benefit or disadvantage below an approximately 20% level. At the time of the audit, decompression was rarely considered and treatment of raised intracranial pressure relied on medical interventions. Surgical decompression is generally considered much earlier for compartment syndromes in the calf or abdomen and, although neurosurgical decompression seems logical, it is worrying that it is coming into use without any formal study of its effectiveness. As the management of raised intracranial pressure does have significant resource implications, we suggest that formal studies of the efficacy of medical and surgical interventions are urgently needed. References: 1. Wasserberg J. Treating head injuries. BMJ 2002;325:454-455 (31 August) 2. Forsyth R, Baxter P, Elliott T. Routine intracranial pressure monitoring in acute coma. Cochrane Injuries Group, Cochrane Database of Systematic Reviews Issue 3 2001. |
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Richard G Fiddian-Green, None None
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Baxter et al's comments add weight to my concerns that rational management of head injuries is seriously limited by the absence of the monitoring of any objective measurements of the adequacy of systemic and cerebral mitochondrial oxidative phosphorylation (1). 1. Fiddian-Green RG. Intracranial compartment syndrome bmj.com/cgi/eletters/325/7364/598/a#25555, 16 Sep 2002 |
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Richard G Fiddian-Green, None None
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Are not the psychiatric aspects of head injuries, addressed in the rapid responses to this article by Mobayed, the product of cerebral energy deficits be they focal, regional and/or systemic? Might not the medications being prescribed to achieve what is considered to be a desirable therapeutic response be acting as chemical coshes compounding the problem? Should not the adequacy of mitochondrial oxidative phosphorylation first be assessed objectively and, if found to be inadequate, reversed with measures designed to restore the adequcy of oxygen and/or glucose delivery to all cerebral tissues? I have serious doubts about the safety of all psychotropic drugs especially when administered in circumstances in which there might already be a cerebral enrgey deficit. 1. RAPID RESPONSES Delirium: a cerebral energy deficit? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7365/644#25750, 23 Sep 2002 2. RAPID RESPONSES Intracranial compartment syndrome Richard G Fiddian-Green bmj.com/cgi/eletters/325/7364/598/a#25555, 16 Sep 2002 3. RAPID RESPONSES Concerns about prescribing antidepressants Richard G Fiddian-Green bmj.com/cgi/eletters/325/7366/701#25874, 28 Sep 2002 |
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jonathan l hart, sho general surgery st mary's hospital, london
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EDITOR- I read with interest Wasserberg’s editorial “Treating Head Injuries” . Whilst the note of optimism which he sounds has some justification, I feel it is appropriate to highlight considerable problems in the management of head injuries at a local level. The provision of facilities to assess and refer serious head injuries within four hours are not consistent. Reliance on hospital taxis to transfer CT scans to a neurosurgical centre for review is not uncommon, as I discovered to my frustration as a casualty officer. Furthermore, finding a suitable referral hospital for a multiply injured patient is not straightforward. Many neurosurgical centres remain “splendidly isolated” without provision of a general surgical or orthopaedic service. Less serious head injuries requiring a period of observation are usually admitted under general surgery or orthopaedic teams according to local policy. Care of these patients usually devolves on the most junior member of the team with potentially serious consequences if problems should arise. Similarly, patients discharged from a neurosurgical unit back to their local referring hospitals are placed under the care of the admitting general surgical or orthopaedic consultant. It is entirely inappropriate that dependent patients with considerable rehabilitation needs be looked after on a surgical ward. The provision of dedicated multidisciplinary head injury rehabilitation teams with appropriate physician input (neurological or other) is ideal but not the norm. If the treatment and outcome of the head injured patient is to improve further, a serious appraisal of these practical issues is required. |
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