Consensus-Based Management Protocol (CREVICE Protocol) for the Treatment of Severe Traumatic Brain Injury Based on Imaging and Clinical Examination for Use When Intracranial Pressure Monitoring Is Not Employed

Abstract

Globally, intracranial pressure (ICP) monitoring use in severe traumatic brain injury (sTBI) is inconsistent and susceptible to resource limitations and clinical philosophies. For situations without monitoring, there is no published comprehensive management algorithm specific to identifying and treating suspected intracranial hypertension (SICH) outside of the one ad hoc Imaging and Clinical Examination (ICE) protocol in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial. As part of an ongoing National Institutes of Health (NIH)-supported project, a consensus conference involving 43 experienced Latin American Intensivists and Neurosurgeons who routinely care for sTBI patients without ICP monitoring, refined, revised, and augmented the original BEST:TRIP algorithm. Based on BEST:TRIP trial data and pre-meeting polling, 11 issues were targeted for development. We used Delphi-based methodology to codify individual statements and the final algorithm, using a group agreement threshold of 80%. The resulting CREVICE (Consensus REVised ICE) algorithm defines SICH and addresses both general management and specific treatment. SICH treatment modalities are organized into tiers to guide treatment escalation and tapering. Treatment schedules were developed to facilitate targeted management of disease severity. A decision-support model, based on the group's combined practices, is provided to guide this process. This algorithm provides the first comprehensive management algorithm for treating sTBI patients when ICP monitoring is not available. It is intended to provide a framework to guide clinical care and direct future research toward sTBI management. Because of the dearth of relevant literature, it is explicitly consensus based, and is provided solely as a resource (a "consensus-based curbside consult") to assist in treating sTBI in general intensive care units in resource-limited environments.

Keywords: ICP monitoring, intracranial hypertension; global health; neurocritical care; sTBI.

FIG. 1.

Graphic representation of the Consensus REVised Imaging and Clinical Examination (CREVICE) protocol for the treatment of suspected intracranial hypertension (SICH). The flow chart represents individual steps involved in the decision to treat for SICH, the choice of therapeutic agents, and the evaluation of the need for treatment escalation. The definition of “neuroworsening” is presented in a box at the upper right. The indications for initiating treatment for SICH are in the box at the lower left. The recommended therapeutic agents and their ranking into treatment tiers are contained in the box at the lower right. See text and supplementary section for further details.

FIG. 2.

Graphic representation of the Consensus REVised Imaging and Clinical Examination (CREVICE) protocol for the weaning of treatment of suspected intracranial hypertension (SICH). The flow chart represents individual steps in the evaluation of a patient regarding the decision to initiate the tapering of ongoing SICH treatment. The modification of the Marshall computer tomography (CT) classification for use with evacuated mass lesions is presented in the box at the upper right. The SICH Treatment Decision Support Matrix presented at the lower right represents the concatenation of the decisions of four subgroups of the Consensus Working Group regarding their tendencies to consider weaning ongoing intracranial pressure (ICP) treatment in stable-to-improving patients based on their most recent Marshall CT scan classification and clinical examination status (patient's Glasgow Coma Scale [GCS] motor score and pupillary examination). Evaluations are performed during the first 24 h, then at ∼48 and 72 h, and then at >72 h. The recommendations as to whether to begin tapering therapy are interpreted using a traffic light analogy:

1. Green: it is recommended to begin to taper therapy.

2. Red: it is recommended not to taper therapy.

3. Yellow: this represents an intermediate status, wherein tapering therapy may be considered, but caution is recommended. The treating physician may choose to begin decreasing therapy, not to do so at that time, or to get more information to help in the decision. The decision to begin tapering treatment in patients in the “yellow” category should be accompanied by close observation as to the success of that decision.