Effect of Intravenous Corticosteroids on Death Within 14 Days in Adults With Clinically Significant Head Injury
The Lancet, 2004 · Large international randomized placebo-controlled trial, stopped early after the data monitoring committee identified excess mortality in the corticosteroid group.
Clinical question
Do high-dose corticosteroids improve survival after clinically significant traumatic brain injury?
What the trial found
High-dose corticosteroids increased mortality after traumatic brain injury and should not be used to treat acute TBI.
Current guideline position
Severe TBI guidelines recommend against corticosteroids for improving outcome or reducing intracranial pressure because of increased mortality.
Clinical interpretation
The CRASH result is a major harm signal and is the reason corticosteroids are contraindicated as a treatment for traumatic brain injury itself. Steroids may still be indicated for a separate coexisting condition, but not to improve TBI outcome.
Severe TBI neurocritical care: prevent hypoxemia/hypotension, treat intracranial hypertension, individualize ventilation/CPP, use evidence-based short antiseizure prophylaxis when chosen, and escalate surgery when indicated.
Monro-Kellie doctrine, ICP waveforms (P2>P1, Lundberg A-waves), CPP targets (60–70 mmHg), herniation syndromes, and the 4-tier BTF management protocol.