PATIENTS admitted to accident and emergency departments with serious injuries are treated routinely with untested therapies that may kill them, one of Britain’s leading public health experts said yesterday.
Hardly any treatments used in emergency trauma care have been subjected to proper clinical trials, according to Ian Roberts, Professor of Public Health at the London School of Hygiene and Tropical Medicine.
Professor Roberts led the first important study in the specialty, which has shown that drugs commonly used for 30 years to treat head injuries actually increase the chances of death and disability. An “evidential black hole” means that doctors have no way of knowing whether other therapies are similarly dangerous.
Though injury is among the biggest causes of death, it receives a fraction of the research funding given to other killers, such as cancer and heart disease. This is because pharmaceutical companies have no interest in evaluating the effectiveness of widely used but untested drugs, and because injury disproportionately affects the poor, Professor Roberts said.
“It is a worrying fact that injury is a major cause of death worldwide, but most of the treatments used in its management are untested,” he told the festival conference in Norwich. In the UK, injuries account for 6.6 per cent of the burden of disease, but less than 1 per cent of research spending. This compares with 27 per cent for cancer, 16 per cent for neurology, 12 per cent for infectious disease and 9 per cent for cardiovascular disease.
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The biggest random controlled trial of a trauma treatment — the Crash study into corticosteroids for head injury — was stopped early in 2004 after finding that the drugs raised the risk of death by 3 per cent. The Lancet, the medical journal, estimated that at least 10,000 patients had died from the untested drugs. “I very much hope these treatments do more good than harm, but we don’t know and I think we should,” Professor Roberts said.
Soldiers also suffer from the lack of research, he said, and the Ministry of Defence should devote more funding to trials for treating trauma.
“You would have thought the MoD has a duty of care towards soldiers,” he said. “Not at all. I think they should show a little interest in evaluating treatment of trauma.”
THE THERAPIES: TRIED AND TESTED?
Corticosteroids
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These anti-inflammatory drugs were used for 30 years in cases of head injury. The Crash (corticosteroid randomisation after significant head injury) study found that the drugs raised death rates from 18 per cent to 21 per cent. No longer used for this purpose in British hospitals
Barbiturates
Sedatives that slow the brain action, reducing the production of fluid that can raise pressure within the skull after injury. Cochrane review of clinical trials showed no evidence that they lower the death rate
Drainage of cerebrospinal fluid
A surgical incision is made and cerebrospinal fluid is removed to ease pressure on the brain. No evidence is available because no randomised controlled trials have been conducted
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Mannitol
Sugar solution used to ease brain swelling by osmosis. No solid evidence that it is effective
Hypothermia
Cooling the patient is often used as a way of treating head injury. Cochrane review found no evidence that this improved outcomes, and it can raise the risk of pneumonia
Hyperventilation
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A respirator is used to raise a patient’s breathing rate artificially. This is supposed to lower blood flow to the brain, easing swelling. Only one randomised controlled trial has been conducted, involving only 77 patients. There is no firm evidence of its benefits