Safety and Effectiveness of Standardized Care for Adult Population with Moderate or Severe Traumatic Brain Injury in Lower- and Middle-Income Countries: A Systematic Review

BackgroundTraumatic brain injury (TBI) is a leading cause of death and permanent disability, with the burden being higher in low- and middle-income countries (LMICs). Effective management during the acute phase is critical for improving survival and long-term outcomes. For this reason, evidence-based decision-making is essential to delivering consistent, high-quality care. The objective of this review is to assess the safety and effectiveness of standardized care in adults with moderate or severe TBI in LMICs.Materials and MethodsA literature search was conducted in MEDLINE/PubMed, Embase, CENTRAL, LILACS, ClinicalTrials.gov and WHO-ICTRP. Conference proceedings from NCS, SCCM, and ESICM were searched for unpublished studies. Randomized controlled trials (RCTs) and non-randomized (NRSs) controlled studies comparing protocolized with non-protocolized care for patients 14 years or older with acute moderate or severe TBI in LMICs were included. Studies were independently assessed for inclusion, data extraction, and risk of bias. Study flaws were assessed using the Cochrane risk of bias tool, and quality-of-evidence using the GRADE approach.ResultsSeven studies were included, involving a total of 1821 participants. Five of these employed a quasi-experimental before-and-after design, while two used a quasi-experimental design with a non-equivalent control group. NRS recruited participants from Cuba, Argentina, Bolivia, Ecuador, Venezuela, Uruguay, Colombia, Brazil, Egypt, and Thailand. All included studies were deemed to have a high risk of bias. Very low to low-quality evidence suggests that protocolized care may provide benefits for adults with moderate to severe TBI in LMICs, including reduced mortality, improved cognitive outcomes, decreased hospitalization-related complications, and increased satisfaction with the care process. However, there appears to be little or no effect on quality-of-life scores and length of hospital stay. The impact of standardized care on functionality, language processing abilities, and ICU stay remains uncertain.ConclusionsVery low-quality evidence suggests that protocolized care may provide benefits for adults with moderate to severe TBI in LMICs. Higher-quality research is imperative to rigorously assess the safety and effectiveness of this intervention.PROSPERO registration numberCRD 420251074998.