Interpretation of <i>Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition</i>_West China Medical Journal

Authors：

FANG Zhou ¹ , LIU Bofu ^1,2 ,  YU Haifang ^1,2

1. Department of Emergency Medicine and Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Disaster Medical Center, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

YU Haifang, Email: yuhaifang@wchscu.cn

Keywords：

Traumatic brain injury; prehospital management; prehospital assessment; prehospital treatment; prehospital decision-making

DOI：

10.7507/1002-0179.202310264

Video：

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Abstract Full text Figures/Tables Video References Cited by

Patients with severe traumatic brain injury (TBI) have a higher mortality rate, often dying within a few hours after injury. The management of trauma site, transportation, and early hospital stay is closely related to the outcome of TBI patients. The final success rate of TBI patients varies after different prehospital treatments, and the quality of prehospital treatment for TBI needs to be further improved. Therefore, the TBI prehospital management guideline emerged, and the third version of the guideline was released in April 2023. In order to provide better advice and guidance on the treatment of prehospital TBI, this article interprets the key points of updating the third edition of the prehospital TBI management guideline.

Citation： FANG Zhou, LIU Bofu, YU Haifang. Interpretation of Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. West China Medical Journal, 2023, 38(11): 1625-1631. doi: 10.7507/1002-0179.202310264 Copy

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2.	Lulla A, Lumba-Brown A, Totten AM, et al. Prehospital guidelines for the management of traumatic brain injury - 3rd edition. Prehosp Emerg Care, 2023, 27(5): 507-538.
3.	Stocchetti N, Maas AI. Traumatic intracranial hypertension. N Engl J Med, 2014, 370(22): 2121-2130.
4.	Davis DP, Meade W, Sise MJ, et al. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. J Neurotrauma, 2009, 26(12): 2217-2223.
5.	Chi JH, Knudson MM, Vassar MJ, et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma, 2006, 61(5): 1134-1141.
6.	Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma, 2004, 57(1): 1-10.
7.	Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma, 1993, 34(2): 216-222.
8.	Spaite DW, Hu C, Bobrow BJ, et al. Optimal Out-of-hospital blood pressure in major traumatic brain injury: a challenge to the current understanding of hypotension. Ann Emerg Med, 2022, 80(1): 46-59.
9.	Spaite DW, Hu C, Bobrow BJ, et al. The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury. Ann Emerg Med, 2017, 69(1): 62-72.
10.	Spaite DW, Hu C, Bobrow BJ, et al. Association of out-of-hospital hypotension depth and duration with traumatic brain injury mortality. Ann Emerg Med, 2017, 70(4): 522-530.e1.
11.	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.
12.	Shibahashi K, Sugiyama K, Okura Y, et al. Defining hypotension in patients with severe traumatic brain injury. World Neurosurg, 2018, 120: e667-e674.
13.	Shibahashi K, Hoda H, Okura Y, et al. Acceptable blood pressure levels in the prehospital setting for patients with traumatic brain injury: a multicenter observational study. World Neurosurg, 2021, 149: e504-e511.
14.	Jafari AA, Shah M, Mirmoeeni S, et al. Paroxysmal sympathetic hyperactivity during traumatic brain injury. Clin Neurol Neurosurg, 2022, 212: 107081.
15.	Barmparas G, Liou DZ, Lamb AW, et al. Prehospital hypertension is predictive of traumatic brain injury and is associated with higher mortality. J Trauma Acute Care Surg, 2014, 77(4): 592-598.
16.	Sellmann T, Miersch D, Kienbaum P, et al. The impact of arterial hypertension on polytrauma and traumatic brain injury. Dtsch Arztebl Int, 2012, 109(49): 849-856.
17.	Gaither JB, Chikani V, Stolz U, et al. Body temperature after EMS transport: association with traumatic brain injury outcomes. Prehosp Emerg Care, 2017, 21(5): 575-582.
18.	Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet, 1974, 2(7872): 81-84.
19.	Winkler JV, Rosen P, Alfry EJ. Prehospital use of the Glasgow Coma Scale in severe head injury. J Emerg Med, 1984, 2(1): 1-6.
20.	Davis DP, Vadeboncoeur TF, Ochs M, et al. The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation. J Emerg Med, 2005, 29(4): 391-397.
21.	Caterino JM, Raubenolt A. The prehospital simplified motor score is as accurate as the prehospital Glasgow coma scale: analysis of a statewide trauma registry. Emerg Med J, 2012, 29(6): 492-496.
22.	Lesko MM, Jenks T, O’Brien SJ, et al. Comparing model performance for survival prediction using total Glasgow Coma Scale and its components in traumatic brain injury. J Neurotrauma, 2013, 30(1): 17-22.
23.	Davis DP, Serrano JA, Vilke GM, et al. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury. J Trauma, 2006, 60(5): 985-990.
24.	Hoffmann M, Lefering R, Rueger JM, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg, 2012, 9(Suppl 1): 122-130.
25.	Thompson DO, Hurtado TR, Liao MM, et al. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med, 2011, 58(5): 417-425.
26.	Haukoos JS, Gill MR, Rabon RE, et al. Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg Med, 2007, 50(1): 18-24.
27.	Gill M, Steele R, Windemuth R, et al. A comparison of five simplified scales to the out-of-hospital Glasgow Coma Scale for the prediction of traumatic brain injury outcomes. Acad Emerg Med, 2006, 13(9): 968-973.
28.	Singh B, Murad MH, Prokop LJ, et al. Meta-analysis of Glasgow coma scale and simplified motor score in predicting traumatic brain injury outcomes. Brain Inj, 2013, 27(3): 293-300.
29.	Cornwell EE 3rd, Chang DC, Phillips J, et al. Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care. Arch Surg, 2003, 138(8): 838-843.
30.	Hunt J, Hill D, Besser M, et al. Outcome of patients with neurotrauma: the effect of a regionalized trauma system. Aust N Z J Surg, 1995, 65(2): 83-86.
31.	Wilberger JE Jr, Harris M, Diamond DL. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg, 1991, 74(2): 212-218.
32.	Tien HC, Jung V, Pinto R, et al. Reducing time-to-treatment decreases mortality of trauma patients with acute subdural hematoma. Ann Surg, 2011, 253(6): 1178-1183.
33.	Dinh MM, Bein K, Roncal S, et al. Redefining the golden hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient outcomes. Injury, 2013, 44(5): 606-610.
34.	Lokkeberg AR, Grimes RM. Assessing the influence of non-treatment variables in a study of outcome from severe head injuries. J Neurosurg, 1984, 61(2): 254-262.
35.	Denninghoff KR, Griffin MJ, Bartolucci AA, et al. Emergent endotracheal intubation and mortality in traumatic brain injury. West J Emerg Med, 2008, 9(4): 184-189.
36.	Haltmeier T, Benjamin E, Siboni S, et al. Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. Eur J Trauma Emerg Surg, 2017, 43(6): 731-739.
37.	von Elm E, Schoettker P, Henzi I, et al. Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence. Br J Anaesth, 2009, 103(3): 371-386.
38.	Lansom JD, Curtis K, Goldsmith H, et al. The effect of prehospital intubation on treatment times in patients with suspected traumatic brain injury. Air Med J, 2016, 35(5): 295-300.
39.	Bossers SM, Schwarte LA, Loer SA, et al. Experience in prehospital endotracheal intubation significantly influences mortality of patients with severe traumatic brain injury: a systematic review and meta-analysis. PLoS One, 2015, 10(10): e0141034.
40.	Denninghoff KR, Nuño T, Pauls Q, et al. Prehospital intubation is associated with favorable outcomes and lower mortality in ProTECT III. Prehosp Emerg Care, 2017, 21(5): 539-544.
41.	Sarkar M, Niranjan N, Banyal PK. Mechanisms of hypoxemia. Lung India, 2017, 34(1): 47-60.
42.	Bendinelli C, Bivard A, Nebauer S, et al. Brain CT perfusion provides additional useful information in severe traumatic brain injury. Injury, 2013, 44(9): 1208-1212.
43.	Davis DP, Stern J, Sise MJ, et al. A follow-up analysis of factors associated with head-injury mortality after paramedic rapid sequence intubation. J Trauma, 2005, 59(2): 486-490.
44.	Bergmans SF, Schober P, Schwarte LA, et al. Prehospital fluid administration in patients with severe traumatic brain injury: a systematic review and meta-analysis. Injury, 2020, 51(11): 2356-2367.
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46.	Tan PG, Cincotta M, Clavisi O, et al. Review article: prehospital fluid management in traumatic brain injury. Emerg Med Australas, 2011, 23(6): 665-676.
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52.	Caulfield EV, Dutton RP, Floccare DJ, et al. Prehospital hypocapnia and poor outcome after severe traumatic brain injury. J Trauma, 2009, 66(6): 1577-1582.
53.	Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA, 2004, 291(11): 1350-1357.
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55.	Bossers SM, Loer SA, Bloemers FW, et al. Association between prehospital tranexamic acid administration and outcomes of severe traumatic brain injury. JAMA Neurol, 2021, 78(3): 338-345.
56.	Brito AMP, Schreiber MA, El Haddi J, et al. The effects of timing of prehospital tranexamic acid on outcomes after traumatic brain injury: subanalysis of a randomized controlled trial. J Trauma Acute Care Surg, 2023, 94(1): 86-92.
57.	Rowell SE, Meier EN, McKnight B, et al. Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury. JAMA, 2020, 324(10): 961-974.
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1. Dewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg, 2018, 130(4): 1080-1097.
2. Lulla A, Lumba-Brown A, Totten AM, et al. Prehospital guidelines for the management of traumatic brain injury - 3rd edition. Prehosp Emerg Care, 2023, 27(5): 507-538.
3. Stocchetti N, Maas AI. Traumatic intracranial hypertension. N Engl J Med, 2014, 370(22): 2121-2130.
4. Davis DP, Meade W, Sise MJ, et al. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. J Neurotrauma, 2009, 26(12): 2217-2223.
5. Chi JH, Knudson MM, Vassar MJ, et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma, 2006, 61(5): 1134-1141.
6. Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma, 2004, 57(1): 1-10.
7. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma, 1993, 34(2): 216-222.
8. Spaite DW, Hu C, Bobrow BJ, et al. Optimal Out-of-hospital blood pressure in major traumatic brain injury: a challenge to the current understanding of hypotension. Ann Emerg Med, 2022, 80(1): 46-59.
9. Spaite DW, Hu C, Bobrow BJ, et al. The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury. Ann Emerg Med, 2017, 69(1): 62-72.
10. Spaite DW, Hu C, Bobrow BJ, et al. Association of out-of-hospital hypotension depth and duration with traumatic brain injury mortality. Ann Emerg Med, 2017, 70(4): 522-530.e1.
11. 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.
12. Shibahashi K, Sugiyama K, Okura Y, et al. Defining hypotension in patients with severe traumatic brain injury. World Neurosurg, 2018, 120: e667-e674.
13. Shibahashi K, Hoda H, Okura Y, et al. Acceptable blood pressure levels in the prehospital setting for patients with traumatic brain injury: a multicenter observational study. World Neurosurg, 2021, 149: e504-e511.
14. Jafari AA, Shah M, Mirmoeeni S, et al. Paroxysmal sympathetic hyperactivity during traumatic brain injury. Clin Neurol Neurosurg, 2022, 212: 107081.
15. Barmparas G, Liou DZ, Lamb AW, et al. Prehospital hypertension is predictive of traumatic brain injury and is associated with higher mortality. J Trauma Acute Care Surg, 2014, 77(4): 592-598.
16. Sellmann T, Miersch D, Kienbaum P, et al. The impact of arterial hypertension on polytrauma and traumatic brain injury. Dtsch Arztebl Int, 2012, 109(49): 849-856.
17. Gaither JB, Chikani V, Stolz U, et al. Body temperature after EMS transport: association with traumatic brain injury outcomes. Prehosp Emerg Care, 2017, 21(5): 575-582.
18. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet, 1974, 2(7872): 81-84.
19. Winkler JV, Rosen P, Alfry EJ. Prehospital use of the Glasgow Coma Scale in severe head injury. J Emerg Med, 1984, 2(1): 1-6.
20. Davis DP, Vadeboncoeur TF, Ochs M, et al. The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation. J Emerg Med, 2005, 29(4): 391-397.
21. Caterino JM, Raubenolt A. The prehospital simplified motor score is as accurate as the prehospital Glasgow coma scale: analysis of a statewide trauma registry. Emerg Med J, 2012, 29(6): 492-496.
22. Lesko MM, Jenks T, O’Brien SJ, et al. Comparing model performance for survival prediction using total Glasgow Coma Scale and its components in traumatic brain injury. J Neurotrauma, 2013, 30(1): 17-22.
23. Davis DP, Serrano JA, Vilke GM, et al. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury. J Trauma, 2006, 60(5): 985-990.
24. Hoffmann M, Lefering R, Rueger JM, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg, 2012, 9(Suppl 1): 122-130.
25. Thompson DO, Hurtado TR, Liao MM, et al. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med, 2011, 58(5): 417-425.
26. Haukoos JS, Gill MR, Rabon RE, et al. Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg Med, 2007, 50(1): 18-24.
27. Gill M, Steele R, Windemuth R, et al. A comparison of five simplified scales to the out-of-hospital Glasgow Coma Scale for the prediction of traumatic brain injury outcomes. Acad Emerg Med, 2006, 13(9): 968-973.
28. Singh B, Murad MH, Prokop LJ, et al. Meta-analysis of Glasgow coma scale and simplified motor score in predicting traumatic brain injury outcomes. Brain Inj, 2013, 27(3): 293-300.
29. Cornwell EE 3rd, Chang DC, Phillips J, et al. Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care. Arch Surg, 2003, 138(8): 838-843.
30. Hunt J, Hill D, Besser M, et al. Outcome of patients with neurotrauma: the effect of a regionalized trauma system. Aust N Z J Surg, 1995, 65(2): 83-86.
31. Wilberger JE Jr, Harris M, Diamond DL. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg, 1991, 74(2): 212-218.
32. Tien HC, Jung V, Pinto R, et al. Reducing time-to-treatment decreases mortality of trauma patients with acute subdural hematoma. Ann Surg, 2011, 253(6): 1178-1183.
33. Dinh MM, Bein K, Roncal S, et al. Redefining the golden hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient outcomes. Injury, 2013, 44(5): 606-610.
34. Lokkeberg AR, Grimes RM. Assessing the influence of non-treatment variables in a study of outcome from severe head injuries. J Neurosurg, 1984, 61(2): 254-262.
35. Denninghoff KR, Griffin MJ, Bartolucci AA, et al. Emergent endotracheal intubation and mortality in traumatic brain injury. West J Emerg Med, 2008, 9(4): 184-189.
36. Haltmeier T, Benjamin E, Siboni S, et al. Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. Eur J Trauma Emerg Surg, 2017, 43(6): 731-739.
37. von Elm E, Schoettker P, Henzi I, et al. Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence. Br J Anaesth, 2009, 103(3): 371-386.
38. Lansom JD, Curtis K, Goldsmith H, et al. The effect of prehospital intubation on treatment times in patients with suspected traumatic brain injury. Air Med J, 2016, 35(5): 295-300.
39. Bossers SM, Schwarte LA, Loer SA, et al. Experience in prehospital endotracheal intubation significantly influences mortality of patients with severe traumatic brain injury: a systematic review and meta-analysis. PLoS One, 2015, 10(10): e0141034.
40. Denninghoff KR, Nuño T, Pauls Q, et al. Prehospital intubation is associated with favorable outcomes and lower mortality in ProTECT III. Prehosp Emerg Care, 2017, 21(5): 539-544.
41. Sarkar M, Niranjan N, Banyal PK. Mechanisms of hypoxemia. Lung India, 2017, 34(1): 47-60.
42. Bendinelli C, Bivard A, Nebauer S, et al. Brain CT perfusion provides additional useful information in severe traumatic brain injury. Injury, 2013, 44(9): 1208-1212.
43. Davis DP, Stern J, Sise MJ, et al. A follow-up analysis of factors associated with head-injury mortality after paramedic rapid sequence intubation. J Trauma, 2005, 59(2): 486-490.
44. Bergmans SF, Schober P, Schwarte LA, et al. Prehospital fluid administration in patients with severe traumatic brain injury: a systematic review and meta-analysis. Injury, 2020, 51(11): 2356-2367.
45. Blanchard IE, Ahmad A, Tang KL, et al. The effectiveness of prehospital hypertonic saline for hypotensive trauma patients: a systematic review and meta-analysis. BMC Emerg Med, 2017, 17(1): 35.
46. Tan PG, Cincotta M, Clavisi O, et al. Review article: prehospital fluid management in traumatic brain injury. Emerg Med Australas, 2011, 23(6): 665-676.
47. Junger WG, Rhind SG, Rizoli SB, et al. Prehospital hypertonic saline resuscitation attenuates the activation and promotes apoptosis of neutrophils in patients with severe traumatic brain injury. Shock, 2013, 40(5): 366-374.
48. Shackford SR, Bourguignon PR, Wald SL, et al. Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial. J Trauma, 1998, 44(1): 50-58.
49. Wade CE, Grady JJ, Kramer GC, et al. Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and hypotension. J Trauma, 1997, 42(Suppl 5): S61-S65.
50. Davis DP, Dunford JV, Ochs M, et al. The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. J Trauma, 2004, 56(4): 808-814.
51. Dumont TM, Visioni AJ, Rughani AI, et al. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma, 2010, 27(7): 1233-1241.
52. Caulfield EV, Dutton RP, Floccare DJ, et al. Prehospital hypocapnia and poor outcome after severe traumatic brain injury. J Trauma, 2009, 66(6): 1577-1582.
53. Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA, 2004, 291(11): 1350-1357.
54. Smith HP, Kelly DL Jr, McWhorter JM, et al. Comparison of mannitol regimens in patients with severe head injury undergoing intracranial monitoring. J Neurosurg, 1986, 65(6): 820-824.
55. Bossers SM, Loer SA, Bloemers FW, et al. Association between prehospital tranexamic acid administration and outcomes of severe traumatic brain injury. JAMA Neurol, 2021, 78(3): 338-345.
56. Brito AMP, Schreiber MA, El Haddi J, et al. The effects of timing of prehospital tranexamic acid on outcomes after traumatic brain injury: subanalysis of a randomized controlled trial. J Trauma Acute Care Surg, 2023, 94(1): 86-92.
57. Rowell SE, Meier EN, McKnight B, et al. Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury. JAMA, 2020, 324(10): 961-974.
58. Guss DA, Meyer FT, Neuman TS, et al. The impact of a regionalized trauma system on trauma care in San Diego County. Ann Emerg Med, 1989, 18(11): 1141-1145.
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West China Medical Journal

Interpretation of Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition

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