The grades of evidence (I-III) and levels of recommendations (I-III) are defined at the end of the "Major Recommendations" field.
Level I
There are insufficient data to support a treatment standard for this topic.
Level II
Intracranial pressure (ICP) should be monitored in all salvageable patients with a severe traumatic brain injury (TBI; Glasgow Coma Scale [GCS] score of 3 to 8 after resuscitation) and an abnormal computed tomography (CT) scan. An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns.
Level III
ICP monitoring is indicated in patients with severe TBI with a normal CT scan if two or more of the following features are noted at admission: age over 40 years, unilateral or bilateral motor posturing, or systolic blood pressure (BP) <90 mm Hg.
Summary
There is evidence to support the use of ICP monitoring in severe TBI patients at risk for intracranial hypertension (ICH). ICP cannot be reliably predicted by CT scan alone. ICP data are useful in predicting outcome and guiding therapy, and there is an improvement in outcomes in those patients who respond to ICP lowering therapies. The limited data on improvement in outcome in those patients that respond to ICP lowering treatment warrants ICP monitoring to treat this group of patients. Not monitoring ICP while treating for elevated ICP can be deleterious and result in a poor outcome.
Definitions:
Grades of Evidence
Class I - Good quality randomized controlled trial (RCT)
Class II - Moderate quality RCT, good quality cohort, or good quality case-control
Class III - Poor quality RCT; moderate or poor quality cohort; moderate or poor case-control: case series, databases or registries
Levels of Recommendation
Levels of recommendation are Level I, II, and III, derived from Class I, II, and III evidence, respectively.
Level I - recommendations are based on the strongest evidence for effectiveness, and represent principles of patient management that reflect a high degree of clinical certainty.
Level II - recommendations reflect a moderate degree of clinical certainty.
Level III - recommendations for which the degree of clinical certainty is not established.