How to manage traumatic brain injury without invasive monitoring?

The vast majority of severe traumatic brain injury (TBI) patients are managed in regions of low resources. Intracranial pressure (ICP) monitoring is, therefore, uncommon. There is insufficient literature to support evidence-based algorithm construction. We here explore current validated models for sTBI management in the absence of ICP monitoring.

Prospective trials in LMICs used ad hoc management algorithms for nonmonitored sTBI patients. Subsequent comparison of outcomes employing these algorithms against nonprotocolized care supported benefits from protocolization. Subsequent prospective validation testing of a consensus-based elaboration of ad hoc protocols into a comprehensive management (Consensus-Revised Imaging and Clinical Examination: CREVICE) approach demonstrated the benefits of protocolization on outcome and supported the efficacy of the CREVICE approach. Although at present the only prospectively validated sTBI management algorithm, its applicability is yet limited in generalizability due to resource requirements. Additionally, possible incorporation of noninvasive methods as potential guides for ICP care absent the currently invasive techniques remains untested.

Patients with sTBI in the aggregate can be effectively managed when ICP monitoring is not available using currently available validated algorithms. Efficacy in sTBI subgroups (e.g. established intracranial hypertension) is unexplored. Research into noninvasive ICP monitoring and further diminishing resources requirements is necessary.