Guidelines for Prehospital Management of TBI, 2nd Edition
View the complete Guidelines, including methods and detailed evidence review here
The index of Guideline recommendations can be found below
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Strength of Recommendations: Weak
Quality of Evidence: Low, primarily from Class III studies and indirect evidence
ADULT
A. Patients with suspected severe traumatic brain injury (TBI) should be monitored in the prehospital setting for hypoxemia (<90% arterial hemoglobin oxygen saturation) or hypotension (<90 mmHg systolic blood pressure [SBP]).
B. Percentage of blood oxygen saturation should be measured continuously in the field with a pulse oximeter.
C. Systolic (SBP) and diastolic blood pressure (DBP) should be measured using the most accurate method available under the circumstances.
D. Oxygenation and blood pressure should be measured as often as possible, and should be monitored continuously if possible.
PEDIATRICS
A. Pediatric patients with suspected severe TBI should be monitored in the prehospital setting for hypotension. Pediatric hypotension is defined as follows:
Age (SBP)
0 to 28 days (<60 mmHg)
1-12 months (<70 mmHg)
1-10 years (<70 + 2 × age in years)
>10 years (<90 mmHg)
B. Percentage of blood oxygen saturation should be measured continuously in the field with a pulse oximeter using an appropriate pediatric sensor.
C. SBP and DBP should be measured using an appropriately-sized pediatric cuff. When a blood pressure is difficult to obtain because of the child’s age or body habitus, documentation of mental status, quality of peripheral pulses, and capillary refill time can be used as surrogate measures.
D. Oxygenation and blood pressure should be measured as often as possible, and should be monitored continuously if possible.
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Strength of Recommendations: Weak
Quality of Evidence: Low, primarily from Class III studies and indirect evidence
ADULT
A. Prehospital measurement of the Glasgow Coma Scale (GCS) is a significant and reliable indicator of the severity of traumatic brain injury (TBI), and should be used repeatedly to identify improvement or deterioration over time.
B. The GCS must be obtained through interaction with the patient (i.e., by giving verbal directions or, for patients unable to follow commands, by applying a painful stimulus such as nail bed pressure or axillary pinch).
C. The GCS should be measured after airway, breathing, and circulation are assessed, after a clear airway is established, and after necessary ventilatory or circulatory resuscitation has been performed.
D. The GCS should be measured preferably prior to administering sedative or paralytic agents, or after these drugs have been metabolized.
E. The GCS should be measured by prehospital providers who are appropriately trained in how to administer the GCS.
PEDIATRICS
A. The GCS and the pediatric GCS (P-GCS, Table 1) are reliable indicators of the severity of TBI in children and should be used repeatedly to identify improvement or deterioration over time.
B. The adult protocol for standard GCS measurement should be followed in children over 2 years of age. In pre-verbal children, the P-GCS should be employed, with a full verbal score of 5 assigned to infants cooing or babbling.
C. Prehospital providers should determine the GCS or P-GCS after airway, breathing, and circulation are assessed and stabilized.
D. The GCS and P-GCS should be measured preferably prior to administering sedative or paralytic agents, or after these drugs have been metabolized.
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Strength of Recommendations: Weak
Quality of Evidence: Low, from Class III studies and indirect evidence
ADULT AND PEDIATRICS
A. Pupils should be assessed in the field for use in diagnosis, treatment, and prognosis.
B. When assessing pupils:
• Evidence of orbital trauma should be noted.
• Pupils should be measured after the patient has been resuscitated and stabilized.
• Left and right pupillary findings should be identified
◦ Unilateral or bilateral dilated pupil(s).
◦ Fixed and dilated pupil(s).
Asymmetry is defined as > 1mm difference in diameter. A fixed pupil is defined as < 1mm response to bright light
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Strength of Recommendations: Weak
Quality of Evidence: Low, primarily from Class III studies
ADULT
A. In ground transported patients in urban environments, the routine use of paralytics to assist endotracheal intubation in patients who are spontaneously breathing, and maintaining an SpO2 above 90% on supplemental oxygen, is not recommended.
ADULT AND PEDIATRICS
A. Hypoxemia (oxygen saturation [SpO2] < 90%) should be avoided, and corrected immediately upon identification.
B. An airway should be established, by the most appropriate means available, in patients who have severe traumatic brain injury (TBI) (Glasgow Coma Scale [GCS] < 9), the inability to maintain an adequate airway, or hypoxemia not corrected by supplemental oxygen.
C. Emergency Medical Service (EMS) systems implementing endotracheal intubation protocols including the use of rapid sequence intubation (RSI) protocols should monitor blood pressure, oxygenation, and when feasible, ETCO2.
D. When endotracheal intubation is used to establish an airway, confirmation of placement of the tube in the trachea should include lung auscultation and end-tidal CO2 (ETCO2) determination
E. Patients should be maintained with normal breathing rates (ETCO2 35-40 mmHg), and hyperventilation (ETCO2 < 35 mmHg) should be avoided unless the patient shows signs of cerebral herniation.
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Strength of Recommendations: Weak
Quality of Evidence: Low, from Class III studies, or Class II studies with contradictory findings
ADULT
A. Hypotensive patients should be treated with isotonic fluids.
B. Hypertonic resuscitation is a treatment option for TBI patients with a Glasgow Coma Scale Score (GCS) < 8.
PEDIATRICS
A. For the pediatric TBI patient, hypotension should be treated with isotonic solutions.
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Strength of Recommendations: Weak
Quality of Evidence: Low, from Class III studies, or Class II studies with contradictory findings
ADULT
A. Hypotensive patients should be treated with isotonic fluids.
B. Hypertonic resuscitation is a treatment option for TBI patients with a Glasgow Coma Scale Score (GCS) < 8.
PEDIATRICS
A. For the pediatric TBI patient, hypotension should be treated with isotonic solutions.
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Strength of Recommendations: Weak
Quality of Evidence: Low, from Class III studies, contradictory findings, and indirect evidence
ADULT
A. All regions should have an organized trauma care system.
B. Protocols are recommended to direct Emergency Medical Service (EMS) personnel regarding destination decisions for patients with severe traumatic brain injury (TBI).
C. Patients with severe TBI should be transported directly to a facility with immediately available CT scanning, prompt neurosurgical care, and the ability to monitor intracranial pressure (ICP) and treat intracranial hypertension.
D. The mode of transport should be selected so as to minimize total prehospital time for the patient with TBI.
PEDIATRICS
A. In a metropolitan area, pediatric patients with severe TBI should be transported directly to a pediatric trauma center if available.
B. Pediatric patients with severe TBI should be treated in a pediatric trauma center or in an adult trauma center with added qualifications to treat children in preference to a Level I or II adult trauma center without added qualifications for pediatric treatment.