Handbook of Clinical Neurology, Vol. 127 (3rd series) Traumatic Brain Injury, Part I J. Grafman and A.M. Salazar, Editors © 2015 Elsevier B.V. All rights reserved
Chapter 23
The prehospital management of traumatic brain injury SCOTT A. GOLDBERG1, DHANADOL ROJANASARNTIKUL2,3, AND ANDREW JAGODA2,4* 1 Department of Emergency Medicine, Brigham & Women’s Hospital, Boston, MA, USA 2
Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA 3
Chulalongkorn University, Bangkok, Thailand
4
Brain Trauma Foundation, New York, NY, USA
INTRODUCTION Head injury and traumatic brain injury (TBI) are two distinct entities that are often, but not necessarily, related. A head injury is recognized by the presence of tenderness, ecchymoses, lacerations, deformities, cerebral spinal rhinorrhea or otorrhea. A traumatic brain injury refers to an injury to the brain itself and can occur without any external signs of trauma. Prehospital care providers are tasked with identifying both head and brain injuries, providing stabilization and transporting to an appropriate care facility. Prehospital providers are a vital link between injury and definitive care, responsible for initiating interventions that can minimize mortality and morbidity and making critical decisions regarding where, when, and how rapidly a patient is transported. TBI is a leading cause of death worldwide, particularly in those under the age of 40 (Jager et al., 2000). In the US, approximately 1.7 million cases of TBI occur annually, accounting for 30% of all injury-related deaths (Faul et al., 2010). Both the incidence of TBI as well as associated mortality is higher in rural populations (Gabella et al., 1997). TBI results in 275 000 annual hospitalizations and 52 000 deaths in the US, while over 20% of emergency department (ED) visits for TBI result in hospital admission (Faul et al., 2010). Conversely, 80% of patients treated in the ED for TBI are diagnosed with a “mild” injury and thus released. The incidence of head injury or TBI in individuals that do not seek medical care is unknown, but likely greatly exceeds the number reported from ED and hospital admissions. The prehospital management of patients with a TBI is critical and directly linked to outcomes. The brain is at
high risk for secondary injury related to local cerebral ischemia, disruption of cerebrovascular autoregulation, and cerebral edema during the immediate period following an injury, and prehospital interventions focus on limiting this secondary brain injury while optimizing cerebral physiology. Secondary injury greatly impacts outcome and can be minimized if proper resuscitative efforts are provided (Chesnut et al., 1993). Recognizing the important role prehospital providers play in the care of TBI patients, the US government provided a grant to the Brain Trauma Foundation to develop guidelines to assist prehospital care providers in assessing and managing TBI. A task force of experts in prehospital and in-hospital trauma care was assembled in 1998 and systematically searched and pragmatically analyzed the scientific literature to develop evidence-based recommendations. The first iteration of these guidelines was published in 2000 (Gabriel et al., 2002) and updated in 2005 (Badjatia et al., 2008). The process revealed a paucity of clinical research in prehospital care of patients with TBI, and prehospital management recommendations are based largely on observational studies or extrapolation of emergency department and in-hospital data. This chapter discusses the best evidence currently available for the prehospital evaluation and management of the patient with suspected traumatic brain injury.
Prehospital systems Prehospital care entails challenges that may not be encountered in traditional healthcare arenas. Patient care must occur rapidly, utilizing minimal equipment, often in a moving vehicle. Further, patient care occurs in
*Correspondence to: Andrew Jagoda, 1 Gustave Levy Place, Box 1620, New York, NY 10029, USA. Tel: +1-212-824-8053, Fax: +1-212-426-1946, E-mail: [email protected]
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unpredictable and uncontrolled environments, which inherently pose certain risks to both the patient and the healthcare provider. There is wide variability in prehospital emergency care systems worldwide. These systems are staffed with a variety of providers ranging from physicians to paraprofessionals including nurses, paramedics and emergency medical technicians. The US emergency medical services (EMS) system is primarily staffed with paramedics and emergency medicine technicians (EMTs); some advanced systems with aeromedical response are often staffed with flight nurses or physicians. While EMS systems vary from state to state or from region to region, most EMS services in the US consist primarily of ground transport vehicles, with some services including fixed wing or rotor air retrieval vehicles. Less common are waterborne craft. The EMS service itself may be public, private, or volunteer. All services are overseen by a physician medical director and protocols for field management may be developed at the regional, state or federal level.
PREHOSPITAL PATIENT ASSESSMENT Patients with potential TBI fall into two general categories: low risk and high risk for having an injury that will require neurosurgical management. Low risk patients generally have a Glasgow Coma Scale (GCS) score of 14 or 15, and have no signs or symptoms suggestive of an intracranial injury such as vomiting or severe headache. Further, low risk patients will have normal pupils and no visual complaints, age under 60, and will not be taking anticoagulants (Luerssen et al., 1988; Marshall et al., 1991; Signorini et al., 1999; Davis et al., 2007; McMillian and Rogers, 2009). For these patients, the goal of the prehospital provider is to perform the careful history and physical examination needed to direct transport to an appropriate facility. Patients in the high risk category are those with multiple system trauma or a GCS of 13 or less. In this group, the priorities of the prehospital provider are on appropriate management of life-threatening conditions and a targeted resuscitation.
Initial evaluation and examination On arrival, the prehospital care provider must first establish that the scene is safe and any immediate threats to personal safety are minimized. Body substance isolation in accordance with local guidelines is fundamental. The traditional paradigm of trauma resuscitation is “ABCC”: Airway, Breathing Circulation, and Cervical spine (ATLS, 2008). When approaching the patient with TBI, the prehospital provider must be diligent in first addressing immediately correctable respiratory and
circulatory deficits. Since secondary insult from hypoxia or hypoperfusion contributes to brain injury, careful attention must be paid to maintaining adequate oxygenation and perfusion. While surrogate markers for adequate perfusion including mental status, capillary refill time, and peripheral pulses are useful, the Brain Trauma Foundation guidelines recommend continuous pulse oximetry as well as frequent blood pressure monitoring (Badjatia et al., 2008). Despite apparent stabilization, prehospital research suggests that unidentified episodes of hypoxemia and hypotension are more common than often appreciated (Davis et al., 2004b). The field evaluation of a patient with a head injury includes a careful examination of the head and neck looking for the presence of any open scalp wound or skull fracture. Clinical findings suggestive of a basilar skull fracture include hemotympanum, otorrhea, clear rhinorrhea, and ecchymosis over the mastoid or infraorbital regions. A helmeted athlete must have the helmet carefully removed by someone trained in this skill, or the helmet is best left in place for transport (Waninger and Swartz, 2011). While the use of cervical spine immobilization devices in all patients with a head injury is considered standard of care by most services, they may be overutilized by prehospital providers (Domeier et al., 2005; Rhee et al., 2006), and recent literature questions their utility or effectiveness in select situations (Horodyski et al., 2011; Stuke et al., 2011). It is the role of the EMS medical director to develop, implement, and monitor cervical spine immobilization protocols within their system.
The pupil examination A key component of the field assessment of the patient with a head injury is an evaluation of the patient’s pupils for asymmetry (>1 mm difference in diameter) and reactivity ( 29
Penetration trauma to head, neck, torso and extremities proximal to the elbow or knee Two or more long bone fractures Crshed, degloved or mangled extremity Flail chest
Fall>20 feet (adult) or 2-3 times height (child) Auto crash with intrusion, ejection, death in same vehicle, telemetry showing high speed Auto versus pedestrian run over, thrown, or>20mph Motorcycle accident>20mph
Age>55 Anticoagulation or bleeding disorders Burns with other trauma mechanism Time sensitive extremity injury End stage renal disease requiring dialysis Pregnancy>20 weeks
Transport per protocol
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or may staff response units with higher level providers. While aeromedical response requires a significantly longer scene time (Baxt and Moody, 1987; Berlot et al., 2009), it may be a viable option for systems with long ground transport times and has shown some improved mortality in TBI patients (Baxt and Moody, 1987; Berlot et al., 2009). However, this improved mortality may be a function of the increased skill of the prehospital providers on these vehicles.
EMS Provider Judgement
Fig. 23.1. CDC field triage algorithm. (Adapted from Sasser et al., 2012.)
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released into the systemic circulation after disruption of the blood–brain barrier (Vos et al., 2010; Sharma and Laskowitz, 2012). While these biomarkers have demonstrated high sensitivity, specificity is still lacking and cost is relatively high (Ruan et al., 2009). While biomarkers show promise for use in the prehospital arena, particularly as a triage tool dictating transport to specialty centers, their ultimate role in the prehospital management of TBI remains unclear. In the setting of TBI, sonographic evaluation of optic nerve sheath diameter has been demonstrated to accurately identify patients with increased ICP (Tayal et al., 2007; Dubourg et al., 2011; Rajajee et al., 2011) and ultrasound may even be useful in identifying skull fractures (Rabiner et al., 2013). While prehospital data are currently lacking, ultrasound has been demonstrated to have a variety of applications in the prehospital setting (Nelson et al., 2011) and will undoubtedly have a future role in the prehospital management of TBI. The current standard of care for the prehospital management of the brain-injured patient with a compromised airway is endotracheal intubation. Recent studies, however, have raised questions about the appropriate airway intervention. The prehospital use of extraglottic airways may provide a valid alternative to endotracheal intubation in cardiac arrest (Kajino et al., 2011); however, there is some evidence suggesting that endotracheal intubation remains the management method of choice (Wang et al., 2012). Still other studies have demonstrated that bag mask ventilation might prove superior to either (Hasegawa et al., 2013). It remains to be seen what implications this changing landscape of airway management in out of hospital cardiac arrest will have on the prehospital management of TBI. The prehospital use of hyperosmolar fluids both for resuscitation (Vassar et al., 1990, 1991, 1993b) and for management of suspected increased intracranial pressure (Doyle et al., 2001; Kerwin et al., 2009; Bulger et al., 2010) has been previously discussed. While current data are insufficient to recommend routine use in either
case, future research will hopefully establish evidencebased indications and dosing recommendations for the use of hyperosmolar fluids in the field. Induced hypothermia has emerged as the standard of care in maximizing neurologic recovery after cardiac arrest and there has been some recent investigation into initiation in the prehospital setting for this condition (Suffoletto et al., 2008; Hammer et al., 2009; Peberdy et al., 2010). However, while induced hypothermia has been shown to decrease ICP and CBF (Marion et al., 1993) it has shown no overall outcome benefit in its current form for patients with TBI (Marion et al., 1993; Clifton et al., 2001; Harris et al., 2002). Research suggests that early initiation (Clifton et al., 2001) and extended duration (McIntyre et al., 2003; Peterson et al., 2008) may improve neurologic outcomes in TBI patients and this benefit of early initiation lends itself well to the prehospital environment. While the ultimate role of induced hypothermia in TBI remains elusive, it is an area of ongoing research. Finally, with the continuing regionalization of prehospital care centers specializing in the evaluation and management of suspected TBI are likely to emerge. TBI research has established a link between time to definitive care and outcomes (Berlot et al., 2009) and advancements in prehospital triage tools and algorithms, utilization of appropriate aeromedical transport and enhanced diagnostic tools will improve accurate selection of transport destination and decreased future transport times.
CONCLUSIONS Outcome from a traumatic brain injury is linked not only to the destination to which the patient is taken but also to the care provided in the field. Current evidence supports an assessment including meticulous attention to oxygenation and perfusion with intervention as indicated, as well as assessment of pupils and serial GCS or SMS (Table 23.3). During transport, prehospital providers need to continue focused efforts to prevent secondary
Table 23.3 Key concepts of prehospital traumatic brain injury management Assessment
Airway
Pulse oximetry Maintain pulse oximetry > 90% Blood pressure Intubate if unable to GCS maintain adequate Pupils airway, maintain pulse ETCO2 (if intubated) oximetry > 90%, or if GCS < 9
Breathing
Circulation
Decision making
Avoid hyperventilation Maintain normotension Minimize out of hospital time Transport directly to center with Maintain ETCO2 35–40 with isotonic neurosurgical capabilities crystalloids In children, BVM equal Transport pediatric patients to Hypertonic saline is to intubation pediatric trauma center or adult treatment option for Hyperventilation (ETCO2 trauma center with additional hypotensive adults 30–35 mmHg) option pediatric qualifications with GCS < 9 for signs of herniation
ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Score; BVM, bag valve mask.
THE PREHOSPITAL MANAGEMENT OF TRAUMATIC BRAIN INJURY brain injury from hypoxia and hypotension and perform frequent patient assessments while facilitating rapid transport to the most appropriate facility. When there is evidence of increasing intracranial pressure and impending herniation EMS providers may also consider treatment with hyperosmolar therapy or a brief trial of hyperventilation. Yet despite the critical role played by prehospital providers in the management of TBI, there has been a surprisingly limited amount of high quality prehospital research in this area. Continued investigations into resuscitation fluids including hypertonic saline and hemoglobin substitutes, further evaluation of the neuroprotective role of the early initiation of therapeutic hypothermia, and novel techniques for advanced prehospital airway management are just some of the many innovations that can be expected. These future endeavors will help to further shape the prehospital management of patients with traumatic brain injury, decreasing secondary injury and improving outcomes.
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Thompson D, Hurtado T, Liao M et al. (2011). Validation of the simplified motor score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med 58: 417–425. Tien HC, Jung V, Pinto R et al. (2011). Reducing time-totreatment decreases mortality of trauma patients with acute subdural hematoma. Ann Surg 253: 1178–1183. Vassar MJ, Perry CA, Holcroft JW (1990). Analysis of potential risks associated with 7.5% sodium chloride resuscitation of traumatic shock. Arch Surg 125: 1309–1315. Vassar MJ, Perry CA, Gannaway WL et al. (1991). 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport. Arch Surg 126: 1065–1072. Vassar MJ, Fischer RP, O’Brien PE et al. (1993a). A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride. The effect of added dextran 70. The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients. Arch Surg 128: 1003–1011. Vassar MJ, Perry CA, Holcroft JW (1993b). Prehospital resuscitation of hypotensive trauma patients with 7.5% NaCl versus 7.5% NaCl with added dextran: a controlled trial. J Trauma 34: 622–632. Vos PE, Jacobs B, Andriessen TM et al. (2010). GFAP and S100B are biomarkers of traumatic brain injury: an observational cohort study. Neurology 75: 1786–1793. Wakai A, McCabe A, Roberts I et al. (2013). Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev 8: CD001049. http://dx.doi.org/10.1002/14651858. CD001049.pub5. Wang HE, Szydlo D, Stouffer JA et al., ROC Investigators (2012). Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest. Resuscitation 83: 1061–1066. Waninger KN, Swartz EE (2011). Cervical spine injury management in the helmeted athlete. Curr Sports Med Rep 10: 45–49. Weingart SD, Levitan RM (2012). Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 59: 165–175, 2011 Nov 1. White JR, Farukhi Z, Bull C et al. (2001). Predictors of outcome in severely head-injured children. Crit Care Med 29: 534–540. Winchell RJ, Hoyt DB (1997). Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 132: 592–597. Winkler JV, Rosen P, Alfry EJ (1984). Prehospital use of the Glasgow Coma Scale in severe head injury. J Emerg Med 2: 1–6. Zane RD, Murphy MF (2008). Airway management in the prehospital setting. In: RM Walls, MF Murphy (Eds.), Manual of Emergency Airway Management. Lippincott Williams and Wilkins, Philadelphia, pp. 303–312.
Chapter 23
The prehospital management of traumatic brain injury SCOTT A. GOLDBERG1, DHANADOL ROJANASARNTIKUL2,3, AND ANDREW JAGODA2,4* 1 Department of Emergency Medicine, Brigham & Women’s Hospital, Boston, MA, USA 2
Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA 3
Chulalongkorn University, Bangkok, Thailand
4
Brain Trauma Foundation, New York, NY, USA
INTRODUCTION Head injury and traumatic brain injury (TBI) are two distinct entities that are often, but not necessarily, related. A head injury is recognized by the presence of tenderness, ecchymoses, lacerations, deformities, cerebral spinal rhinorrhea or otorrhea. A traumatic brain injury refers to an injury to the brain itself and can occur without any external signs of trauma. Prehospital care providers are tasked with identifying both head and brain injuries, providing stabilization and transporting to an appropriate care facility. Prehospital providers are a vital link between injury and definitive care, responsible for initiating interventions that can minimize mortality and morbidity and making critical decisions regarding where, when, and how rapidly a patient is transported. TBI is a leading cause of death worldwide, particularly in those under the age of 40 (Jager et al., 2000). In the US, approximately 1.7 million cases of TBI occur annually, accounting for 30% of all injury-related deaths (Faul et al., 2010). Both the incidence of TBI as well as associated mortality is higher in rural populations (Gabella et al., 1997). TBI results in 275 000 annual hospitalizations and 52 000 deaths in the US, while over 20% of emergency department (ED) visits for TBI result in hospital admission (Faul et al., 2010). Conversely, 80% of patients treated in the ED for TBI are diagnosed with a “mild” injury and thus released. The incidence of head injury or TBI in individuals that do not seek medical care is unknown, but likely greatly exceeds the number reported from ED and hospital admissions. The prehospital management of patients with a TBI is critical and directly linked to outcomes. The brain is at
high risk for secondary injury related to local cerebral ischemia, disruption of cerebrovascular autoregulation, and cerebral edema during the immediate period following an injury, and prehospital interventions focus on limiting this secondary brain injury while optimizing cerebral physiology. Secondary injury greatly impacts outcome and can be minimized if proper resuscitative efforts are provided (Chesnut et al., 1993). Recognizing the important role prehospital providers play in the care of TBI patients, the US government provided a grant to the Brain Trauma Foundation to develop guidelines to assist prehospital care providers in assessing and managing TBI. A task force of experts in prehospital and in-hospital trauma care was assembled in 1998 and systematically searched and pragmatically analyzed the scientific literature to develop evidence-based recommendations. The first iteration of these guidelines was published in 2000 (Gabriel et al., 2002) and updated in 2005 (Badjatia et al., 2008). The process revealed a paucity of clinical research in prehospital care of patients with TBI, and prehospital management recommendations are based largely on observational studies or extrapolation of emergency department and in-hospital data. This chapter discusses the best evidence currently available for the prehospital evaluation and management of the patient with suspected traumatic brain injury.
Prehospital systems Prehospital care entails challenges that may not be encountered in traditional healthcare arenas. Patient care must occur rapidly, utilizing minimal equipment, often in a moving vehicle. Further, patient care occurs in
*Correspondence to: Andrew Jagoda, 1 Gustave Levy Place, Box 1620, New York, NY 10029, USA. Tel: +1-212-824-8053, Fax: +1-212-426-1946, E-mail: [email protected]
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unpredictable and uncontrolled environments, which inherently pose certain risks to both the patient and the healthcare provider. There is wide variability in prehospital emergency care systems worldwide. These systems are staffed with a variety of providers ranging from physicians to paraprofessionals including nurses, paramedics and emergency medical technicians. The US emergency medical services (EMS) system is primarily staffed with paramedics and emergency medicine technicians (EMTs); some advanced systems with aeromedical response are often staffed with flight nurses or physicians. While EMS systems vary from state to state or from region to region, most EMS services in the US consist primarily of ground transport vehicles, with some services including fixed wing or rotor air retrieval vehicles. Less common are waterborne craft. The EMS service itself may be public, private, or volunteer. All services are overseen by a physician medical director and protocols for field management may be developed at the regional, state or federal level.
PREHOSPITAL PATIENT ASSESSMENT Patients with potential TBI fall into two general categories: low risk and high risk for having an injury that will require neurosurgical management. Low risk patients generally have a Glasgow Coma Scale (GCS) score of 14 or 15, and have no signs or symptoms suggestive of an intracranial injury such as vomiting or severe headache. Further, low risk patients will have normal pupils and no visual complaints, age under 60, and will not be taking anticoagulants (Luerssen et al., 1988; Marshall et al., 1991; Signorini et al., 1999; Davis et al., 2007; McMillian and Rogers, 2009). For these patients, the goal of the prehospital provider is to perform the careful history and physical examination needed to direct transport to an appropriate facility. Patients in the high risk category are those with multiple system trauma or a GCS of 13 or less. In this group, the priorities of the prehospital provider are on appropriate management of life-threatening conditions and a targeted resuscitation.
Initial evaluation and examination On arrival, the prehospital care provider must first establish that the scene is safe and any immediate threats to personal safety are minimized. Body substance isolation in accordance with local guidelines is fundamental. The traditional paradigm of trauma resuscitation is “ABCC”: Airway, Breathing Circulation, and Cervical spine (ATLS, 2008). When approaching the patient with TBI, the prehospital provider must be diligent in first addressing immediately correctable respiratory and
circulatory deficits. Since secondary insult from hypoxia or hypoperfusion contributes to brain injury, careful attention must be paid to maintaining adequate oxygenation and perfusion. While surrogate markers for adequate perfusion including mental status, capillary refill time, and peripheral pulses are useful, the Brain Trauma Foundation guidelines recommend continuous pulse oximetry as well as frequent blood pressure monitoring (Badjatia et al., 2008). Despite apparent stabilization, prehospital research suggests that unidentified episodes of hypoxemia and hypotension are more common than often appreciated (Davis et al., 2004b). The field evaluation of a patient with a head injury includes a careful examination of the head and neck looking for the presence of any open scalp wound or skull fracture. Clinical findings suggestive of a basilar skull fracture include hemotympanum, otorrhea, clear rhinorrhea, and ecchymosis over the mastoid or infraorbital regions. A helmeted athlete must have the helmet carefully removed by someone trained in this skill, or the helmet is best left in place for transport (Waninger and Swartz, 2011). While the use of cervical spine immobilization devices in all patients with a head injury is considered standard of care by most services, they may be overutilized by prehospital providers (Domeier et al., 2005; Rhee et al., 2006), and recent literature questions their utility or effectiveness in select situations (Horodyski et al., 2011; Stuke et al., 2011). It is the role of the EMS medical director to develop, implement, and monitor cervical spine immobilization protocols within their system.
The pupil examination A key component of the field assessment of the patient with a head injury is an evaluation of the patient’s pupils for asymmetry (>1 mm difference in diameter) and reactivity ( 29
Penetration trauma to head, neck, torso and extremities proximal to the elbow or knee Two or more long bone fractures Crshed, degloved or mangled extremity Flail chest
Fall>20 feet (adult) or 2-3 times height (child) Auto crash with intrusion, ejection, death in same vehicle, telemetry showing high speed Auto versus pedestrian run over, thrown, or>20mph Motorcycle accident>20mph
Age>55 Anticoagulation or bleeding disorders Burns with other trauma mechanism Time sensitive extremity injury End stage renal disease requiring dialysis Pregnancy>20 weeks
Transport per protocol
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or may staff response units with higher level providers. While aeromedical response requires a significantly longer scene time (Baxt and Moody, 1987; Berlot et al., 2009), it may be a viable option for systems with long ground transport times and has shown some improved mortality in TBI patients (Baxt and Moody, 1987; Berlot et al., 2009). However, this improved mortality may be a function of the increased skill of the prehospital providers on these vehicles.
EMS Provider Judgement
Fig. 23.1. CDC field triage algorithm. (Adapted from Sasser et al., 2012.)
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released into the systemic circulation after disruption of the blood–brain barrier (Vos et al., 2010; Sharma and Laskowitz, 2012). While these biomarkers have demonstrated high sensitivity, specificity is still lacking and cost is relatively high (Ruan et al., 2009). While biomarkers show promise for use in the prehospital arena, particularly as a triage tool dictating transport to specialty centers, their ultimate role in the prehospital management of TBI remains unclear. In the setting of TBI, sonographic evaluation of optic nerve sheath diameter has been demonstrated to accurately identify patients with increased ICP (Tayal et al., 2007; Dubourg et al., 2011; Rajajee et al., 2011) and ultrasound may even be useful in identifying skull fractures (Rabiner et al., 2013). While prehospital data are currently lacking, ultrasound has been demonstrated to have a variety of applications in the prehospital setting (Nelson et al., 2011) and will undoubtedly have a future role in the prehospital management of TBI. The current standard of care for the prehospital management of the brain-injured patient with a compromised airway is endotracheal intubation. Recent studies, however, have raised questions about the appropriate airway intervention. The prehospital use of extraglottic airways may provide a valid alternative to endotracheal intubation in cardiac arrest (Kajino et al., 2011); however, there is some evidence suggesting that endotracheal intubation remains the management method of choice (Wang et al., 2012). Still other studies have demonstrated that bag mask ventilation might prove superior to either (Hasegawa et al., 2013). It remains to be seen what implications this changing landscape of airway management in out of hospital cardiac arrest will have on the prehospital management of TBI. The prehospital use of hyperosmolar fluids both for resuscitation (Vassar et al., 1990, 1991, 1993b) and for management of suspected increased intracranial pressure (Doyle et al., 2001; Kerwin et al., 2009; Bulger et al., 2010) has been previously discussed. While current data are insufficient to recommend routine use in either
case, future research will hopefully establish evidencebased indications and dosing recommendations for the use of hyperosmolar fluids in the field. Induced hypothermia has emerged as the standard of care in maximizing neurologic recovery after cardiac arrest and there has been some recent investigation into initiation in the prehospital setting for this condition (Suffoletto et al., 2008; Hammer et al., 2009; Peberdy et al., 2010). However, while induced hypothermia has been shown to decrease ICP and CBF (Marion et al., 1993) it has shown no overall outcome benefit in its current form for patients with TBI (Marion et al., 1993; Clifton et al., 2001; Harris et al., 2002). Research suggests that early initiation (Clifton et al., 2001) and extended duration (McIntyre et al., 2003; Peterson et al., 2008) may improve neurologic outcomes in TBI patients and this benefit of early initiation lends itself well to the prehospital environment. While the ultimate role of induced hypothermia in TBI remains elusive, it is an area of ongoing research. Finally, with the continuing regionalization of prehospital care centers specializing in the evaluation and management of suspected TBI are likely to emerge. TBI research has established a link between time to definitive care and outcomes (Berlot et al., 2009) and advancements in prehospital triage tools and algorithms, utilization of appropriate aeromedical transport and enhanced diagnostic tools will improve accurate selection of transport destination and decreased future transport times.
CONCLUSIONS Outcome from a traumatic brain injury is linked not only to the destination to which the patient is taken but also to the care provided in the field. Current evidence supports an assessment including meticulous attention to oxygenation and perfusion with intervention as indicated, as well as assessment of pupils and serial GCS or SMS (Table 23.3). During transport, prehospital providers need to continue focused efforts to prevent secondary
Table 23.3 Key concepts of prehospital traumatic brain injury management Assessment
Airway
Pulse oximetry Maintain pulse oximetry > 90% Blood pressure Intubate if unable to GCS maintain adequate Pupils airway, maintain pulse ETCO2 (if intubated) oximetry > 90%, or if GCS < 9
Breathing
Circulation
Decision making
Avoid hyperventilation Maintain normotension Minimize out of hospital time Transport directly to center with Maintain ETCO2 35–40 with isotonic neurosurgical capabilities crystalloids In children, BVM equal Transport pediatric patients to Hypertonic saline is to intubation pediatric trauma center or adult treatment option for Hyperventilation (ETCO2 trauma center with additional hypotensive adults 30–35 mmHg) option pediatric qualifications with GCS < 9 for signs of herniation
ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Score; BVM, bag valve mask.
THE PREHOSPITAL MANAGEMENT OF TRAUMATIC BRAIN INJURY brain injury from hypoxia and hypotension and perform frequent patient assessments while facilitating rapid transport to the most appropriate facility. When there is evidence of increasing intracranial pressure and impending herniation EMS providers may also consider treatment with hyperosmolar therapy or a brief trial of hyperventilation. Yet despite the critical role played by prehospital providers in the management of TBI, there has been a surprisingly limited amount of high quality prehospital research in this area. Continued investigations into resuscitation fluids including hypertonic saline and hemoglobin substitutes, further evaluation of the neuroprotective role of the early initiation of therapeutic hypothermia, and novel techniques for advanced prehospital airway management are just some of the many innovations that can be expected. These future endeavors will help to further shape the prehospital management of patients with traumatic brain injury, decreasing secondary injury and improving outcomes.
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