Managing severe TBI without ICP monitoring - guidelines development and testing

Management of intracranial hypertension (ICH) in patients with severe traumatic brain injury (TBI) is crucial to their survival and optimal recovery. The evidence-based Guidelines for the Management of Severe Traumatic Brain Injury, 3rd Edition recommends use of intracranial pressure (ICP) monitors to assess ICH and know when and how to intervene.  Unfortunately in most areas of the world there is no access to ICP monitor technology.  This means that most people with severe TBI are treated without use of ICP monitoring.

The objective of this project is to create guidelines for the treatment of severe TBI in the absence of ICP monitoring.  We propose to derive these guidelines by working with a team of physicians that practice in austere environments in low-to-middle income countries (LMICs) and routinely make decisions based either on a treatment protocol, their clinical experience, or both.  We will use a new, systematic and innovative technology and process to accomplish consensus for the guidelines among the physicians.  We will implement the Consensus-Based Guidelines (CBG) in resource-poor centers, some of which have prior exposure to protocols for treatment of TBI, and others that do not have prior exposure.  We will test the influence of the CBG on outcomes for patients with severe TBI in a before/after design.

Our aims are to conduct a prospective observational study of treatment and 1 and 6-month outcomes for patients with severe TBI in 2 set of centers – one with prior exposure to TBI treatment protocols (Prior Exposure Group) and one without (No Prior Exposure Group) – to determine the effects of treating according to a rudimentary protocol.

In accomplishing these aims, we will create and test a guideline for the treatment of severe TBI that could be used globally to improve outcomes for these patients..  We will validate in LMICs a new, systematic and innovative technology and process to accomplish consensus that was derived in an HIC.  Finally, we will train personnel in centers new to research in how to conduct high-quality scientific studies, and will extend the training for the personnel with whom we have been working, solidifying previous capacity-building efforts, and initiating new efforts.