A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol

Abstract

The imaging and clinical examination (ICE) algorithm used in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) randomized controlled trial is the only prospectively investigated clinical protocol for traumatic brain injury management without intracranial pressure (ICP) monitoring. As the default literature standard, it warrants careful evaluation. We present the ICE protocol in detail and analyze the demographics, outcome, treatment intensity, frequency of intervention usage, and related adverse events in the ICE-protocol cohort. The 167 ICE protocol patients were young (median 29 years) with a median Glasgow Coma Scale motor score of 4 but with anisocoria or abnormal pupillary reactivity in 40%. This protocol produced outcomes not significantly different from those randomized to the monitor-based protocol (favorable 6-month extended Glasgow Outcome Score in 39%; 41% mortality rate). Agents commonly employed to treat suspected intracranial hypertension included low-/moderate-dose hypertonic saline (72%) and mannitol (57%), mild hyperventilation (adjusted partial pressure of carbon dioxide 30-35 mm Hg in 73%), and pressors to maintain cerebral perfusion (62%). High-dose hyperosmotics or barbiturates were uncommonly used. Adverse event incidence was low and comparable to the BEST TRIP monitored group. Although this protocol should produce similar/acceptable results under circumstances comparable to those in the trial, influences such as longer pre-hospital times and non-specialist transport personnel, plus an intensive care unit model of aggressive physician-intensive care by small groups of neurotrauma-focused intensivists, which differs from most high-resource models, support caution in expecting the same results in dissimilar settings. Finally, this protocol's ICP-titration approach to suspected intracranial hypertension (vs. crisis management for monitored ICP) warrants further study.

Keywords: global health; intracranial hypertension; intracranial pressure monitoring; neurocritical care; severe traumatic brain injury.

FIG. 1.

Evaluation and management algorithm for severe traumatic brain injury patients randomized to the Imaging and Clinical Examination (non-monitored) arm of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure trial. Neurological evaluations are carried out frequently throughout the pathway and imaging studies are obtained on admission, at 48 h, and at 5–7 days post-injury at a minimum. The suspicion of intracranial hypertension and appraisal of its course is based on these evaluations. The individual steps involved in the basic care and treatment of intracranial hypertension are contained in Tables 1 and 2.

FIG. 2.

Algorithm for evaluation and management of neurological worsening occurring during the care of severe traumatic brain injury patients in either arm of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure trial. In that study, failure to document a change in therapy within 1 h of a neuroworsening event was a protocol violation.