Articles: outcome.
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In 2004, two large randomised multi-centre Australian clinical trials provided new information concerning optimal resuscitation for patients with traumatic brain injury (TBI). One examined hypertonic saline (HTS) and the other, albumin versus saline.( )For the first time in a randomised trial, hypertonic saline was tested for pre-hospital resuscitation of hypotensive patients with traumatic brain injury, and for the first time a resuscitation fluid trial measured long term neurological function as the primary outcome. Despite many potential advantages which may have much greater relevance in the hospital setting, in the paramedic based VICn trauma system, HTS did not improve neurological outcome compared to conventional pre-hospital fluid protocols. ⋯ Intriguingly however, the SAFE study also reported that within a subgroup of 492 patients with TBI, 28 day survival was superior in patients receiving saline. This subgroup result was not considered definitive, but a post hoc examination of the TBI patients currently in progress by the SAFE investigators, is expected to provide further guidance for clinicians. In the meanwhile, and until more high quality data is available, many clinicians are likely to prefer crystalloid resuscitation for trauma patients, and especially for trauma patients with brain injury.
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Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. ⋯ Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.
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In traumatic brain injury, cerebral hypoperfusion is associated with adverse outcome, particularly in the early phases of management. This has resulted in the increased use of drugs such as adrenaline, noradrenaline, dopamine and phenylephrine to augment or maintain systemic blood pressures at near normal levels. This is now part of standard practice and is endorsed by the Brain Trauma Foundation guidelines. ⋯ A paradigm shift from a "set and forget" philosophy to one of "titration against time" to achieve appropriate therapeutic targets is now required. In this context the rational use of vasoactive agents to optimise cerebral perfusion pressure may be employed. On the basis of limited animal and human evidence, noradrenaline appears to be the most appropriate catecholamine for traumatic brain injury, although definitive, targeted trials are required.
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The impetus for cerebral hemodynamic monitoring in neurotrauma first arose from the original "talk and die" studies which described the group of head injured patients "who talk and then subsequently died". At necropsy, hypoxic or ischaemic brain damage was observed in a variable proportion of patients raising the possibility that systemic or cerebral hypoxia post trauma may have contributed to the poor neurological outcome. Improved understanding of the pathophysiology of neurotrauma influenced clinical practice in two ways: a) there was a plethora of monitoring modalities developed for evaluating cerebral hemodynamics and oxygenation and b) squeezing oxygenated blood through a swollen brain became the cornerstone of therapy in patients with head injury. ⋯ Although initial monitoring was largely confined to global indices of brain oxygenation, refinement in technology has made the measurement of oxygen tensions further down in the oxygen cascade at the level of the tissue possible and applicable by the bedside. Metabolic monitoring of the brain is now possible with the use of a variety of biochemical indices and with the availability of microdialysis. The purpose of this review is to examine the various modes of monitoring cerebral oxygenation, critically review the literature concerning their use in day to day intensive care practice, outline their limitations and define possible indications for their use.
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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.