From the Guidelines
Pre-hospital treatment for traumatic brain injury (TBI) should prioritize preventing secondary brain damage through proper airway management, breathing support, and circulation maintenance, with a focus on maintaining systolic blood pressure above 90 mmHg and SpO2 above 94%. First responders should secure the airway while maintaining cervical spine immobilization, ensure adequate oxygenation, and prevent hypotension using IV fluids like normal saline 1. Rapid assessment using the Glasgow Coma Scale helps determine TBI severity, and patients with moderate to severe TBI (GCS ≤13) may require intubation to protect the airway and ensure proper ventilation, avoiding both hyperventilation and hypoventilation as they can worsen outcomes.
Some key considerations in pre-hospital TBI management include:
- Maintaining adequate cerebral perfusion and oxygenation
- Preventing hypoxemia, which occurs in approximately 20% of patients with TBI and is associated with increased mortality and poor neurological outcome 1
- Managing seizures with benzodiazepines such as diazepam (5-10 mg IV) or midazolam (5-10 mg IM/IV)
- Elevating the head 30 degrees, if no spinal injury is suspected, to help reduce intracranial pressure
- Rapid transport to a trauma center with neurosurgical capabilities, with continuous monitoring of vital signs and neurological status en route 1
The use of tranexamic acid (TXA) in pre-hospital TBI management has been studied, with some evidence suggesting its potential benefit in reducing mortality and improving outcomes, particularly in patients with mild and moderate head injury 1. However, the evidence is not yet conclusive, and further research is needed to fully understand the role of TXA in pre-hospital TBI management.
Overall, the goal of pre-hospital TBI management is to minimize secondary brain injury and improve patient outcomes by maintaining adequate cerebral perfusion and oxygenation, preventing hypoxemia and hypotension, and rapidly transporting patients to a trauma center with neurosurgical capabilities.
From the Research
Prehospital Treatment of Traumatic Brain Injury
- The prehospital evaluation and management of traumatic brain injury (TBI) is crucial in reducing secondary injury and optimizing cerebral physiology 2.
- Prehospital interventions should focus on reducing further ischemic injury, with strategies including advanced airway management, oxygenation, ventilation, and fluid resuscitation 2, 3.
- Patient management strategies may also include prehospital strategies for the management of suspected or impending cerebral herniation, such as hyperventilation and brain-directed hyperosmolar therapy 2.
Oxygenation Levels in Prehospital Setting
- The optimal early oxygenation levels for patients with severe TBI are unknown, but high oxygenation levels may not be adversely associated with long-term neurologic status 4.
- A study found that patients with a PaO2 of 101 to 250 mmHg, 251 to 400 mmHg, or ≥401 mmHg were less likely to have poor neurologic status compared to those with a PaO2 of ≤100 mmHg 4.
Goals of Prehospital Care
- The primary goals of prehospital care for TBI patients are to recognize life-threatening raised intracranial pressure, prevent secondary injury, and optimize cerebral physiology 3, 5.
- Prehospital care should also focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated 5.