From the Guidelines
Corticosteroids are not recommended for use in traumatic brain injury (TBI) due to lack of proven benefit and potential harm. The primary reasons for this contraindication include increased risk of infections, impaired wound healing, hyperglycemia, gastrointestinal bleeding, and potential neurotoxicity. According to the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017 guidelines, we suggest against the use of corticosteroids in major trauma, including TBI, as stated in the guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients 1.
The management of TBI focuses on controlling intracranial pressure, maintaining adequate cerebral perfusion, preventing secondary injury, and providing supportive care, which may include interventions such as proper positioning, osmotic therapy (e.g., mannitol or hypertonic saline), sedation, and in severe cases, surgical decompression. The use of corticosteroids in TBI does not improve outcomes and may actually increase mortality rates, as suggested by the lack of benefit and potential harm associated with their use 1.
Key points to consider in the management of TBI include:
- Controlling intracranial pressure to prevent further brain injury
- Maintaining adequate cerebral perfusion to ensure sufficient blood flow to the brain
- Preventing secondary injury through measures such as proper positioning and sedation
- Providing supportive care, including osmotic therapy and surgical decompression as needed
- Avoiding the use of corticosteroids due to the potential risks and lack of proven benefit.
In summary, the contraindication of corticosteroids in TBI is based on the understanding that the potential risks outweigh any theoretical benefits in reducing brain swelling or inflammation, and the most recent and highest quality evidence supports avoiding the use of corticosteroids in major trauma, including TBI 1.
From the Research
Reasons for Not Indicating Corticosteroids in Traumatic Brain Injury (TBI)
- Corticosteroids do not confer significant benefit in the TBI population, as consistently shown in five key randomized control trials (RCTs) 2.
- The use of corticosteroids in TBI has been associated with significantly higher mortality within two weeks, as seen in the large, multi-centre CRASH study 3.
- Clinical trials have yielded no convincing evidence of clinical benefit, despite laboratory studies providing a conceptual framework for the potential efficacy of corticosteroids in TBI 2, 4.
- The potential risks of treating head-injured patients with corticosteroids include:
- Metabolic derangements (particularly hyperglycaemia)
- Adrenal insufficiency
- Critical illness myopathy
- Harmful effects on neural tissue 3
- A Brain Trauma Foundation standard concluded that steroids fail to improve outcome and lower intracranial pressure in severe TBI 4.
- A systematic review of 19 trials with 2295 randomized participants found that the effect of corticosteroids on the risk of death was not significant, and neither moderate benefits nor moderate harmful effects of steroids could be excluded 5.