To supplement the evidence-based recommendations produced in conjunction with the Brain Trauma Foundation's Guidelines for the Management of Penetrating Brain Injury, Second Edition, we developed protocols for care to help bridge published evidence with realities of care at the bedside. Our panel of over 30 diverse expert identified care, care pathways and key decisions relevant to pTBI management through discussion. A rigorous, blinded Delphi consensus process was then applied to determine the content and structure of our algorithms.

In early September, 2023, following two years of planning, topic refinement and progress informing PICOT questions with evidence from systematic reviews, our group of experts in the fields of adult and pediatric trauma neurosurgery, trauma surgery, neurology, neurocritical care, emergency medicine, physical medicine and rehabilitation, and plastic surgery met in Bethesda, Maryland. Half of this group was comprised of active-service or military members from around the world. The other half was civilian, many of whom were retired service members. Over a five day period, the evidence-based and consensus-based recommendations for pTBI were developed utilizing previously published methodology8. Another major thrust of our efforts was to develop a set of consensus-based algorithms that would help to guide clinical care beyond the limits of recommendations and consensus statements. We aimed to make the algorithms neither too complex nor too simple and also convenient and approachable amidst the maelstrom that often accompanies early pTBI care. These algorithms were created and repeatedly refined based on input from our diverse group of expert panelists.

The rigorous consensus process employed in the generation of the SIBICC algorithms was replicated for this project which included overlapping leadership and participants. Voting was used to ratify items for development of our consensus-based algorithms. As with the SIBICC algorithms5,6, SurveyMonkey was used for voting prior to and subsequent to the in-person investigator meeting. At the in-person investigator meeting Electronic Meeting Services was hired as an independent consultant without medical expertise to perform the blinded voting using electronic keypads in Bethesda. Prior to beginning our work panelists ratified a threshold of 80% to declare consensus as having been achieved where at least 80% of the panelists participate in the vote. This is the same threshold used for consensus in the recent SIBICC effort5,6. The meeting occurred in a conference center generously provided by the Henry Jackson Foundation on September 4 - 8 2023. The meeting involved intensive in-person discussion and work to advance all aspects of the project. Consensus voting also approved the final versions of the care pathways. Ultimately our algorithms achieved 100% consensus in blinded Delphi voting to ratify both their content and written description. Here we present the algorithms developed through this process, supplemented with a narrative description aimed at assisting clinicians caring for pTBI patients to achieve best possible outcomes.