The international consensus protocol for the management of severe traumatic brain injury in the absence of intracranial pressure monitoring

Abstract

Background. Severe traumatic brain injury (TBI) remains one of the leading causes of mortality and disability, particularly in resource-limited settings where invasive intracranial pressure (ICP) monitoring is unavailable. The international Brain Trauma Foundation guidelines require specialized equipment, creating a substantial gap between evidence-based medicine and actual clinical practice in low-resource institutions. The aim. To present and analyze the international consensus protocol CREVICE (Consensus REVised ICE (Imaging and Clinical Examination)) – a modified management system for patients with severe TBI designed for use in the absence of ICP monitoring – and to evaluate its potential applicability in Russian healthcare facilities. Main provisions. The CREVICE protocol is a logical development of the ICE protocol, which was validated in the randomized BEST:TRIP trial. The protocol is based on the use of computed tomography (modified Marshall classification) and clinical-neurological criteria (motor response on the Glasgow Coma Scale, pupillary response) as surrogate markers of intracranial hypertension. The protocol includes clear criteria for initiating treatment of suspected intracranial hypertension, a hierarchical escalation therapy with dosing of hyperosmolar agents, an algorithm for managing neurological deterioration, and a detailed de-escalation system using visual decision-making matrices. Contraindicated therapeutic modalities (corticosteroids, prolonged hyperventilation, continuous mannitol infusion) are specifically addressed. Conclusion. The CREVICE protocol is a practical tool that enables the application of modern neurocritical care principles in the absence of invasive neuromonitoring. Its implementation into clinical practice may contribute to treatment standardization, reduced mortality, and improved functional outcomes in patients with severe TBI. For Russian healthcare facilities, the CREVICE framework can serve as a reference for the development and modernization of local clinical protocols.