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Induced hypothermia in the management of head trauma: A literature review

07 December 2012
Volume 4 · Issue 12

Abstract

Mild hypothermia treatment (MHT) involves a controlled decrease of core temperature in order to mitigate the secondary damage to organs that follows post primary injury. In the case of traumatic brain injury (TBI) suggestions that the brain could be conserved by cooling go back as far as the 1940s. The idea was to reduce cerebral metabolism and hypoxic insult by using MHT. However, more recent research suggests that this is a ‘simplistic view’ of brain cooling when there is in fact a much more complex web of effects that need to be understood and accounted. There clearly needs to be a variety of multi-disciplinary team based simultaneous pre-hospital and then in-hospital treatments to ameliorate harm (Nonmaleficence ) and enhance brain healing processes (Beneficence). Examination will take place of the varied probable mechanisms of action and contemporary evidence for and against the use of MHT in TBI. Discussion will range across issues such as target range of MHT, time to achieve this range, duration of cooling, and finally re-warming rates on neurological outcomes following TBI. This in turn, should create a clearer evidence base, for the UK paramedic practitioner who is considering using MHT in the pre-hospital setting in the minutes following TBI and inform decisions around: methods and timing of cooling; shivering prevention using sedation; reliable on-going monitoring of core temperature and team building with hospital services.

The idea that the brain could be conserved in the field post-trauma from out-of-hospital cardiac arrest (OHCA) was suggested over half a century ago in 1948 (Safar et al, 2000). The notion put forward was to protect the brain from hypoxia in order that the patient could be transported to hospital for more advanced treatments (Lyon, 2012). Until the 1990s, researchers assumed that hypothermia created neurological protection to the brain by reducing cerebral metabolism. As a result of this, physicians mistakenly understood that the lower the body temperature the more the protective effects became apparent in terms of decreasing amounts of brain metabolism and oxygen consumption (Polderman, 2008). From this it may be the case that simplistic low level and out-of-date comprehension of the research based evidence in mild hyperthermia treatment (MHT) by paramedics may mislead treatments in the pre-hospital setting and increase morbidity and mortality in traumatic brain injury (TBI). This review attempts to inform this evidence-based debate and create a clear picture for the UK paramedic practitioner who is considering using mild-moderate hypothermia (between 32–34 ºC core temperature) in the field in the minutes after TBI has been inflicted in order to attempt to protect the brain against worsening of the brain trauma and increase the chances of the patient's survival.

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