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

Randall M. Chesnut, Nancy Temkin, Sureyya Dikmen, Carlos Rondina, Walter Videtta, Gustavo Petroni, Silvia Lujan, Victor Alanis, Antonio Falcao, Gustavo De La Fuenta, Luis Gonzalez, Manuel Jibaja, Arturo Lavarden, Freddy Sandi, Roberto Mérida, Ricardo Romero, Jim Pridgeon, Jason Barber, Joan Machamer, Kelley Chaddock

Producción científica: Contribución a una revistaArtículorevisión exhaustiva

47 Citas (Scopus)

Resumen

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.

Idioma originalInglés
Páginas (desde-hasta)54-63
Número de páginas10
PublicaciónJournal of Neurotrauma
Volumen35
N.º1
DOI
EstadoPublicada - 1 ene. 2018
Publicado de forma externa

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