The Roles of Protocols and Protocolization in Improving Outcome From Severe Traumatic Brain Injury

Area of Science:

• Neuroscience
• Clinical Medicine
• Trauma Surgery

Background:

• Severe traumatic brain injury (sTBI) management often lacks standardized protocols, particularly in resource-limited settings without intracranial pressure (ICP) monitoring.
• Previous studies suggested a benefit from an ad hoc Imaging and Clinical Examination (ICE) protocol for sTBI.
• The influence of protocolization versus the specific protocol in improving outcomes remained unclear.

Purpose of the Study:

• To investigate whether adopting the Consensus REVised Imaging and Clinical Examination (CREVICE) protocol improved outcomes in sTBI patients.
• To determine if improvements were directly due to the CREVICE protocol or indirectly through the process of protocolization.
• To evaluate the CREVICE protocol in centers managing sTBI without ICP monitoring.

Main Methods:

• A Phase-II sequential parallel-cohort study was conducted.
• Patients with sTBI (older than 13 years) presenting within 24 hours of injury were included.
• The study compared the adoption of the CREVICE protocol from either no protocol or a previous protocol (ICE) in South American centers without ICP monitoring.

Main Results:

• Adopting CREVICE from no protocol significantly improved 6-month extended Glasgow Outcome Score (GOSE), reduced mortality, and enhanced orientation.
• Adopting CREVICE from the ICE protocol also showed significant benefits in GOSE, mortality, and orientation.
• Patients previously managed with ICE and then adopting CREVICE demonstrated superior GOSE compared to those adopting CREVICE from no protocol.

Conclusions:

• The CREVICE protocol is a viable and effective strategy for managing adult sTBI without ICP monitoring.
• Protocolization, as exemplified by the CREVICE protocol, offers significant benefits for sTBI management regardless of resource availability.
• Centers managing sTBI without ICP monitoring are strongly encouraged to adopt or adapt the CREVICE protocol.