Guidelines for Corticosteroid Use in Trauma Cases

Corticosteroids are not recommended for use in major trauma cases due to lack of mortality benefit and potential risks of complications. 1

General Recommendations for Trauma Patients

The Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) explicitly recommend against the use of corticosteroids in major trauma (conditional recommendation, low quality of evidence) 1
Analysis of 19 clinical trials (n=12,269) showed no mortality benefit with corticosteroid use in trauma patients (RR=1.00,95% CI 0.89-1.13) 1
No significant dose effect was found when comparing low-dose versus high-dose corticosteroid treatment in trauma (test for interaction p=0.73) 1

Meta-analysis data showed similar mortality rates between corticosteroid and placebo groups in trauma patients (26.9% vs 23.4%) 1
Stratified analysis showed no mortality benefit with:
- Low-dose corticosteroids (RR=1.03,95% CI 0.86-1.22) 1
- High-dose corticosteroids (RR=0.98,95% CI 0.81-1.18) 1
While corticosteroids did not significantly increase risks of gastroduodenal bleeding (RR=1.22,95% CI 0.90-1.65) or superinfection (RR=0.93,95% CI 0.80-1.08), the potential for harm remains a concern 1

For post-traumatic spinal cord injury, corticosteroids are not recommended to improve neurological prognosis (Grade 1 recommendation with strong agreement) 1
Previous trials with methylprednisolone in spinal cord injury showed:
- Modest motor improvement in some subgroups but higher infection rates 1
- A propensity score analysis of a large Canadian cohort found no beneficial effect on one-year motor function but more infectious pulmonary and urinary complications 1

Some trauma patients may develop CIRCI, characterized by uncontrolled inflammation, vasopressor dependency, and poor outcomes 1
Two trials examining hydrocortisone in trauma-associated CIRCI showed mixed results:
- In multiple trauma patients with CIRCI (n=113), hydrocortisone prevented hospital-acquired pneumonia and increased mechanical ventilation-free days 1
- In head trauma patients with CIRCI (n=267), no significant reduction in hospital-acquired pneumonia was observed 1
Despite these findings in specific CIRCI subgroups, the overall evidence does not support routine corticosteroid use in trauma 2

Corticosteroids suppress the immune system and increase infection risk with any pathogen 3
They can reduce resistance to new infections, exacerbate existing infections, increase risk of disseminated infections, and mask signs of infection 3
High-dose corticosteroids have shown detrimental effects in traumatic brain injury (increased mortality) 1
Pre-trauma steroid use has been associated with potential complications including impaired wound healing and compromised immune responses 4

If a trauma patient is already on chronic corticosteroid therapy, stress-dose steroids may be indicated to prevent adrenal insufficiency 3
For patients with long bone fractures, early surgical stabilization (within 24 hours) is recommended to reduce ARDS and fat embolism risk rather than corticosteroid administration 1
Infection surveillance is particularly important if corticosteroids must be used, as they can blunt the febrile response 1

Administering high-dose corticosteroids in trauma based on older protocols that are no longer supported by evidence 2
Failing to recognize that while corticosteroids may have specific indications in critical care (e.g., septic shock, ARDS), they are not indicated for general trauma management 2
Abrupt discontinuation of corticosteroids in patients who were on them chronically prior to trauma, which can lead to adrenal crisis 3