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In April 2023, the third edition of the Brain Trauma Foundation’s evidence-based guidelines for the prehospital management of traumatic brain injury (TBI) was published in Prehospital Emergency Care.1 The practice guidelines were written by a multi-disciplinary group of experts and went through an extensive peer review process. This document is an update of guidelines first published in 2000, and then updated in 2007. These guidelines present the best available evidence to support clinical decision making in the prehospital setting when TBI care may have the most significant impact on outcomes; they also establish a research agenda for future investigations.
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ACEP Now: Vol 42 – No 10 – October 2023TBI is a major public health concern and a leading cause of morbidity and mortality for both children and adults. There are at least 600 TBI-related hospitalizations and 175 TBI-related deaths per day.2,3 TBI outcomes are profoundly linked to the timing and quality of care provided before patients reach the hospital. Continuous cerebral blood flow is paramount and brief episodes of systemic hypotension, hypoxia, or inadvertent iatrogenic hyperventilation have been strongly associated with worse outcomes in both children and adults.4 Similar to out-of-hospital cardiac arrest, the actions of prehospital providers have enormous impact on survival and the degree of any long-term disability. Prehospital providers must be competent and proficient in both the recognition and the seamless management of TBI, as well as facile in determining the most appropriate receiving facility for the acutely brain injured patient.
Prognosis from brain injury results not only from the initial or primary injury, but also from secondary injury that occurs after the event, mainly, hypoxic/ischemic brain injury from under resuscitation or cerebral edema from the release of neurotoxic inflammatory mediators. These guidelines are designed to minimize secondary injury and thus maximize survival by addressing the actions that take place during that critical time from the primary event to arrival at the hospital.
This guideline revision is particularly timely as EMS systems have shown their abilities to dramatically improve survival and neurologic outcome after cardiac arrest, STEMI, acute stroke, and other time-sensitive conditions.
In creating these guidelines, the author team utilized a rigorous grading of the published evidence and provided detailed evidentiary tables that support the recommendations. Terminology used include Strength (rating of strong vs. weak) and Quality of Evidence (high, moderate, or low). These designations take into account not only the class of the evidence based on study design but also design flaws that weaken a study’s internal or external validity.
The recommendations in the first two editions of these guidelines were all graded as “weak” due to the lack of high-quality evidence. Since the last edition, evidence has grown supporting an outcome benefit of interventions; specifically, the statewide Excellence in Prehospital Injury Care (EPIC) initiative from Arizona which documented an outcome benefit for patients with moderate and severe TBI when prehospital treatment guidelines were followed.4 In addition, a number of meta-analyses have produced a higher level of evidence that consequently support a “strong” recommendation in several areas where the recommendation was rated “weak” in prior guideline editions.
The recommendations in the guidelines are divided into sections pertaining to “Assessment”, “Treatment” and “Decision Making”: Chapters within these sections are uniformly structured to include Recommendations, Evidence Tables, Scientific Foundations, and Key Issues for Future Investigation, and References. The following is a summary of the guidelines; An algorithm that synthesizes best practice recommendations based on the guidelines is available at https://doi.org/10.1080/10903127.2023.2187905 and from the Brain Trauma Foundation.
SUMMARY
The Brain Trauma Foundation’s guidelines for prehospital management of traumatic brain injury patients provide evidence-based recommendations for assessment, treatment, and transport decisions. The guidelines emphasize the importance of monitoring and treatment of airway, oxygenation, and ventilation, with caution against hyperventilation and recommendations for the use of ETCO2 to ensure appropriate ventilation. Close monitoring of oxygenation and blood pressure is also stressed, with interventions recommended based on the results of this monitoring. The guidelines also address issues related to EMS provider skill level, transportation modality, and destination for the patient. The recommendations are applicable to all types of EMS systems.
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Dr. Jagoda is professor and chair emeritus of emergency medicine at the Icahn School of Medicine at Mount Sinai.
Dr. Bobrow is professor and chair of the McGovern Medical School at UTHealth Houston department of emergency medicine and The John P. and Kathrine G. McGovern distinguished chair in emergency medicine.
Dr. Lulla is an assistant professor of emergency medicine in the Department of Emergency Medicine within the Division of Emergency Medical Services, Disaster and Global Health at UT Southwestern Medical Center.
Dr. Ghajar is president and founder of the Brain Trauma Foundation at the Stanford Brain Performance Center.
Dr. Hawryluk is a neurosurgeon at Cleveland Clinic and medical director of the Brain Trauma Foundation.
References
- Lulla A, et al. Prehospital Guidelines for the management of traumatic brain injury – 3rd edition. Prehosp Emerg Care. 2023; https://doi.org/10.1080/10903127.2023.2187905.
- Centers for Disease Control and Prevention. National Center for Health Statistics: Mortality Data on CDC WONDER. Accessed 2022, https://wonder.cdc.gov/mcd.html.
- Bell JM, Breiding MJ, DePadilla L. CDC’s efforts to improve traumatic brain injury surveillance. J Safety Res. 2017;62:253 -256.
- Spaite DW, Bobrow BJ, Keim SM, et al. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg. 2019;154(7):e191152.
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