Recommendations of the Colombian Consensus Committee for the Management of Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol [BOOTStraP])

Abstract

<jats:title>Abstract</jats:title><jats:p> Background Traumatic brain injury (TBI) is a global public health problem. In Colombia, it is estimated that 70% of deaths from violence and 90% of deaths from road traffic accidents are TBI related. In the year 2014, the Ministry of Health of Colombia funded the development of a clinical practice guideline (CPG) for the diagnosis and treatment of adult patients with severe TBI. A critical barrier to the widespread implementation was identified—that is, the lack of a specific protocol that spans various levels of resources and complexity across the four treatment phases. The objective of this article is to present the process and recommendations for the management of patients with TBI in various resource environments, across the treatment phases of prehospital care, emergency department (ED), surgery, and intensive care unit.</jats:p><jats:p> Methods Using the Delphi methodology, a consensus of 20 experts in emergency medicine, neurosurgery, prehospital care, and intensive care nationwide developed recommendations based on 13 questions for the management of patients with TBI in Colombia.</jats:p><jats:p> Discussion It is estimated that 80% of the global population live in developing economies where access to resources required for optimum treatment is limited. There is limitation for applications of CPGs recommendations in areas where there is low availability or absence of resources for integral care. Development of mixed methods consensus, including evidence review and expertise points of good clinical practices can fill gaps in application of CPGs. BOOTStraP (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol) is intended to be a practical handbook for care providers to use to treat TBI patients with whatever resources are available.</jats:p><jats:p> Results Stratification of recommendations for interventions according to the availability of the resources on different stages of integral care is a proposed method for filling gaps in actual evidence, to organize a better strategy for interventions in different real-life scenarios. We develop 10 algorithms of management for building TBI protocols based on expert consensus to articulate treatment options in prehospital care, EDs, neurological surgery, and intensive care, independent of the level of availability of resources for care.</jats:p>

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

“…Further more, comparative effectiveness research could exploit this heterogeneity to identify best practices and facilitate the design of clinical practice guidelines tailored to the resources available. 43 Such efforts should be mindful that a holistic approach across the entire health system (including prevention, pre-hospital care, surgery, intensive care, and rehabilitation) is likely to be required to truly address the complexity of improving care for TBI, surgical or otherwise, worldwide. 33,44 The main strength of the study is the geographical and socioeconomic diversity of the patient population, with approximately half being from medium HDI or low HDI countries, and 57% originating from the South Asia, sub-Saharan Africa, or Latin American and Caribbean regions.…”

Management of severe traumatic brain injury in regions with limited resources

“…The search identified 1903 publications, of which six fulfilled the inclusion criteria (12)(13)(14)(15)(16)(17). Three additional publications were found, which did not fulfill all inclusion criteria, but were found to be useful, of which one focused on neuromonitoring in emerging economies (not specific for patients with sTBI) (18), another with a definite recommendation for performing a decompressive craniectomy in patients with sTBI in low-resource settings (19), and lastly, one which provided comprehensive policy recommendations for head and spine injury care in LMICs (20).…”

The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in Low- and Middle-Income Countries: A Provider-Based Survey

“…For example, Rubiano et al. 40 have recently published the BOOTStraP protocol which uses consensus from regional experts to adapt the best evidence-based treatment algorithms to the capabilities of low resource emergency facilities. Such efforts towards “Resource-Based Guidelines” are an important adjunct to the dissemination of the already available high-quality neurosurgical evidence-based guidelines.…”