Finally, a Consensus on the Management of Severe Traumatic Brain Injury

Visitor restrictions during COVID-19 made care decisions even more difficult in the Neuro ICU. Yet even before the pandemic, management of severe traumatic brain injury was already challenging due to the lack of evidence-based protocols. For example, when is the right time to remove an intracranial pressure (ICP) monitor?

Recognizing this need, a set of expert physicians from around the world formed the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) to create a consensus-based algorithm for the management of severe traumatic brain injury (sTBI) using multimodality monitoring.

These recommendations are not to be considered a new standard of care, but rather “curbstone consults with 42 internationally known experts,” says Dr. Randall Chesnut, a professor of neurotrauma at the University of Washington and co-chair of the SIBICC. “It’s a suggestion of what they might do in a similar situation.”

First, they announced consensus-based recommendations for sTBI patients managed with ICP monitor alone and more recently, they published a follow-up set for when brain oxygenation monitoring is used in tandem with ICP monitoring.

The experts hope that their algorithm will be able to assist clinicians in the management of severe traumatic brain injury patients and guide them in their decision-making process regarding patient care.

Severe Traumatic Brain Injury Treatment and ICP Monitoring

Acknowledging that the current guidelines for the management of severe traumatic brain injury were not clinically useful, the SIBICC selected 42 physicians to develop a consensus on severe brain injury management protocols that could be used by physicians in neurological and general ICUs that were not trained in neurointensive care.

These physicians formed the consensus working group (CWG) for the SIBICC algorithm, and included 10 neurointensivists, 23 neurosurgeons, five neurologist/neurointensivists, two trauma surgeons and two emergency medicine specialists.

Physicians were chosen based on the following criteria:

• • Over ten years of clinical experience in sTBI
  • Active involvement in acute care management of severe traumatic brain injury
  • Representation of involved disciplines,
  • Geographic diversity
  • Ability to commit time to the algorithm development process

In 2019, the CWG created a three-tier algorithm to help guide clinicians when dealing with increased intracranial pressure management, establishing 18 interventions as fundamental and ten treatments not to be used. Tier 0 involves basic severe brain injury care and is not ICP dependent. Tiers 1 through 3 involve intracranial pressure monitoring and interventions.

Read through recommendations for each tier here.

All recommendations included in their algorithm were required to reach an 80% agreement from at least 80% of the panelists.

Unable to reach a definitive consensus on ICP removal, the CWG combined everyone’s opinions into a heatmap. They found that the more severe the TBI, the more likely physicians were to leave their patient’s ICP monitor in, as prolonged monitoring meant prolonged treatment.

Other recommendations include inter-tier recommendations for when to move between tiers, a list of fundamental care interventions as well as severe traumatic brain injury treatment methods that should not be used, recommendations for critical neuroworsening and guidance for autoregulation-based ICP treatment.

Severe Traumatic Brain Injury Treatment and Brain Oxygenation Monitoring

Having previously established a protocol for the treatment of patients with ICP monitoring alone, in 2020, the SIBICC published additional recommendations for sTBI patients who have a brain oxygenation monitor in addition to an ICP monitor. Similar to their initial report, they devised a set of tiered interventions that are considered fundamental in sTBI patient care.

Each tier provides recommendations for three types of patients:

• • Patients presenting with elevated ICP when brain oxygenation is normal
  • Patients with brain hypoxia and normal ICP
  • Patients with intracranial hypertension as well as brain hypoxia

The CWG noted that monitoring both brain oxygenation and ICP constitutes a step towards multimodality monitoring. As with their previous recommendation, SIBICC notes that these do not reflect either a standard-of-care or a substitute for thoughtful individualized management.

Instead, their goal was to formalize the sharing of what well-respected, clinically active peers would do in similar severe brain injury cases.

Evolution of Increased Intracranial Pressure Management in sTBI Patients

Historically, when and how to use ICP monitoring in this patient population was often debated, despite the fact that it was recommended in the Brain Trauma Foundation’s guidelines. But a 2015 study published in the Journal of Trauma and Acute Care sought to determine the impact of ICP monitor placement on inpatient mortality within a regional trauma system.

Researchers examined 822 patients who had been admitted to an LA County Trauma Center with Severe TBI from 2009 to 2010. Of these patients, 378 had an ICP monitor placed. These patients were found to have a much lower rate of inpatient mortality than patients who did not have an ICP monitor (30.7% vs. 45.7%). The presence of an ICP monitor was also found to be associated with an 8.3 percentage point reduction in the risk-adjusted mortality rate.

The study authors noted that their researched showed that while severely injured patients may be the least likely to receive an ICP monitor, they are among the most likely to benefit from it. In the future, they hoped to see further research on determining which patients would be most likely to benefit from ICP monitoring as well as a creation of guidelines that would encourage the most effective patient care.