Barbiturate therapy in uncontrolled intracranial hypertension

From July 1978 to September 1981, 27 patients from a group of 210 patients with severe head injuries developed uncontrolled intracranial hypertension despite intensive medical and surgical management. These 27 patients were considered appropriate candidates for barbiturate therapy. Abnormal posturing or flaccidity was present in 70% of the patients, and 41% had bilaterally fixed pupils. Twenty-five of 27 patients had mass lesions requiring operation. Of the 15 patients who responded to barbiturate therapy with normalization of intracranial pressure for 24 hours, 5 died (33% mortality). Nine of the 12 patients who did not respond to the barbiturate therapy died (75% mortality). The total mortality in this group of 27 patients was 52%. Of the survivors, 69% had a recovery classified as good recovery/moderate disability, and 31% were in a severe disability/vegetative state. The morbidity and mortality in these patients is high, but comparisons with previous studies show that this is a selected group of severe head injuries with a high percentage of poor prognostic indicators. Our experience suggests that barbiturates can be effective in lowering intracranial pressure in patients with otherwise unresponsive intracranial hypertension and, by doing so, may decrease the mortality in a group of patients considered untreatable by the usual therapeutic modalities.