Therapeutic Momentum: Scenarios in Patients with Neurotrauma

Abstract

ment decisions can be clouded with the clinician’s personal biases or unrecognized acumen judgment errors. This translates to therapeutic momentum (TM). Therapeutic momentum was a term proposed by Rodrigo et al in 2012, they describe as: In situations when doctors do not stop or because of personal clinical decisions they do not interrupt therapeutic strategies without any benefit and contrary to evidence that supports maintaining treatment. In addition to the definition, we propose 2 classes of Therapeutic momentum: When the doctor has the deleterious effects of maintaining a therapy, and when the physician is unaware of the deleterious effects of maintaining a therapy. The concept of TM is strongly presented in the realm of traumatic brain injury (TBI). The examples of therapeutic momentum in BTI may include but are not limited to: fluid therapy (Hypertonic-Mannitol) without evidence of increased intracranial pressure, anticonvulsants keeping post-trauma antiepileptics for more than 7 days, gastroprotection (maintaining proton inhibitors without evidence of digestive tract bleeding), neuroimaging (performing control neuroimaging in unstable patients with no obvious clinical indication), and invasive intracranial pressure monitoring (maintaining intracranial pressure monitor when intracranial hypertension has resolved) We propose an algorithm for TM in circumstances where we consider strategies that are not effective in patients with TBI (Fig. 1). Truly the progression of TBI through the stages of care can lead to TM moments and each step deviation can lead the patient to a path of declined status. The moment of initial management includes optimization of perfusion pressure, airway control, avoid hypotension1), hypercarbia, correction of coagulopathy, control of temperature, and decision to proceed to surgery. Decompression after 48 hours if intracranial pressure (ICP) and cerebral perfusion pressure (CPP) can be controlled is the preferred pathway. Early decompression might be required from epidural hemorrhage, marked ICP not controlled with medical management, or obstructive hydrocephalus. Without trying medical management and going right to surgery might lead to unnecessary systemic Received: November 25, 2021 Accepted: December 30, 2021