• Randall M Chesnut, Nancy Temkin, Walter Videtta, Silvia Lujan, Gustavo Petroni, Jim Pridgeon, Sureyya Dikmen, Kelley Chaddock, Terence Hendrix, Jason Barber, Joan Machamer, Nahuel Guadagnoli, Peter Hendrickson, Victor Alanis, Gustavo La Fuente, Arturo Lavadenz, Roberto Merida, LoraFreddy SandiFSMedicina Intensiva, Hospital Obrero No 1, La Paz, Bolivia., Ricardo Romero, Oscar Pinillos, Zulma Urbina, Jairo Figueroa, Marcelo Ochoa, Rafael Davila, Jacobo Mora, Luis Bustamante, Carlos Perez, Jorge Leiva, Carlos Carricondo, Ana Maria Mazzola, and Juan Guerra.
• University of Washington, Harborview Medical Center, Seattle, Washington, USA.
• Neurosurgery. 2023 Mar 1; 92 (3): 472480472-480.

BackgroundMost patients with severe traumatic brain injury (sTBI) in low- or-middle-income countries and surprisingly many in high-income countries are managed without intracranial pressure (ICP) monitoring. The impact of the first published protocol (Imaging and Clinical Examination [ICE] protocol) is untested against nonprotocol management.ObjectiveTo determine whether patients treated in intensive care units (ICUs) using the ICE protocol have lower mortality and better neurobehavioral functioning than those treated in ICUs using no protocol.MethodsThis study involved nineteen mostly public South American hospitals. This is a prospective cohort study, enrolling patients older than 13 years with sTBI presenting within 24 h of injury (January 2014-July 2015) with 6-mo postinjury follow-up. Five hospitals treated all sTBI cases using the ICE protocol; 14 used no protocol. Primary outcome was prespecified composite of mortality, orientation, functional outcome, and neuropsychological measures.ResultsA total of 414 patients (89% male, mean age 34.8 years) enrolled; 81% had 6 months of follow-up. All participants included in composite outcome analysis: average percentile (SD) = 46.8 (24.0) nonprotocol, 56.9 (24.5) protocol. Generalized estimating equation (GEE) used to account for center effects (confounder-adjusted difference [95% CI] = 12.2 [4.6, 19.8], P = .002). Kaplan-Meier 6-month mortality (95% CI) = 36% (30%, 43%) nonprotocol, 25% (19%, 31%) protocol (GEE and confounder-adjusted hazard ratio [95% CI] = .69 [.43, 1.10], P = .118). Six-month Extended Glasgow Outcome Scale for 332 participants: average Extended Glasgow Outcome Scale score (SD) = 3.6 (2.6) nonprotocol, 4.7 (2.8) protocol (GEE and confounder-adjusted and lost to follow-up-adjusted difference [95% CI] = 1.36 [.55, 2.17], P = .001).ConclusionICUs managing patients with sTBI using the ICE protocol had better functional outcome than those not using a protocol. ICUs treating patients with sTBI without ICP monitoring should consider protocolization. The ICE protocol, tested here and previously, is 1 option.Copyright © Congress of Neurological Surgeons 2022. All rights reserved.

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