The outcome with aggressive treatment in severe head injuries

Abstract

In 100 consecutive patients with severe head injuries, uncontrolled intracranial hypertension, which was defined as occurring when intracranial pressure (ICP) exceeded 40 mm Hg for 15 min or more, occurred in 25 patients. This was despite high-dose dexamethasone, hyperventilation, mannitol, normothermia, appropriate surgical evacuation and CSF drainage when possible. Persistently elevated ICP occurred in 19 patients with diffuse brain injury, and in 6 patients uncontrolled intracranial hypertension followed evacuation of a surgical mass. All of these patients received i.v. barbiturates to control the ICP. At the time of initial barbiturate administration, 11 of the 25 had bilaterally unreactive pupuls and 12 were decerebrate. The initial pentobarbital loading dose (3-5 mg/kg) effectively reduced the ICP in 76% of the patients. Prolonged pentobarbital treatment with blood barbiturate levels from 2.5-3.5 mg% was associated with normalization of the ICP (ICP < 15 mm Hg) in 13 patients. In those patients responding to barbiturates, the daily mannitol requirement was reduced from 4.5 to 0.5 mg/kg per day (P < 0.01). In 6 nonresponders to barbiturates, mannitol requirements increased to 5.9 gm/kg per day; 5 of these died and 1 remains vegetative. Of the 19 barbiturate, responders 10 have returned to a productive life, 2 remain moderately disabled, 2 are severely disabled, 1 is vegetative and 4 are dead. The high rate of good quality survival in this series of severely brain-injured patients indicates that barbiturates are useful in the treatment of uncontrolled intracranial hypertension and that a broader investigation of the clinical application of barbiturates is indicated.