Page 15 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

their medical needs and the local possibilities to provide care. Deciding to initiate 1 or withhold surgical and/or non-surgical treatment during the acute treatment decisions-making process is often very difficult for treating physicians.
Figure 1. Computed tomography (CT) scans of patients with traumatic intracranial abnormalities. A and B: Subdural hematoma. C: Contusion and parenchymal hematoma. D: Epidural hematoma.
The acute treatment decision-making process
Several evidence-based guidelines, treatment protocols, and consensus-based recommendations are made to support physicians in this decision-making process. 20,22- 26 Despite their existence, adherence to TBI guidelines is generally poor. This is caused by the low evidence level on which recommendations are based 27,28, delay between literature search and publication, the fact that recommendations are not restated in subsequent guideline versions, and downgrading of a recommendations’ evidence level. 29 In addition, there are several areas of uncertainty that are not included in available guidelines because essential evidence is not available. 23,24
The extent of the problem of evidence availability is also reported in two recent reviews. The first review of 191 completed randomized controlled trials for acute TBI management found very little translatable evidence because of multiple methodological shortcomings. 30 The second investigated systematic reviews on the acute management of moderate to s-TBI patients and concluded a lack of currency, completeness and quality. 31
General introduction
13