Guidelines for Prehospital Management of Traumatic Brain Injury 3rd Edition: Executive Summary

Abstract

Prehospital care markedly influences outcome from traumatic brain injury, yet it remains highly variable. The Brain Trauma Foundation's guidelines informing prehospital care, first published in 2002, have sought to identify and disseminate best practices. Many of its recommendations relate to the management of airway, breathing and circulation, and infrastructure for this care. Compliance with the second edition of these guidelines has been associated with significantly improved survival. A working group developed evidence-based recommendations informing assessment, treatment, and transport decision-making relevant to the prehospital care of brain injured patients. A literature search spanning May 2005 to January 2022 supplemented data contained in the 2nd edition. Identified studies were assessed for quality and used to inform evidence-based recommendations. A total of 122 published articles formed the evidentiary base for this guideline update including 5 providing Class I evidence, 35 providing Class II evidence, and 98 providing Class III evidence for the various topics. Forty evidence-based recommendations were generated, 30 of which were strong and 10 of which were weak. In many cases, new evidence allowed guidelines from the 2nd edition to be strengthened. Development of guidelines on some new topics was possible including the prehospital administration of tranexamic acid. A management algorithm is also presented. These guidelines help to identify best practices for prehospital traumatic brain injury care, and they also identify gaps in knowledge which we hope will be addressed before the next edition.

For patients with TBI-related ICH, a shorter mannitol and tranexamic acid administration interval may contribute to VTE risk

“…Since then, research focused on the prehospital setting and yielded some different conclusions: two large convincing RCTs indicated that TXA administration in pre-hospital does not help 6-month neurologic function recovery among severe TBI patients or even increased the mortality of severe TBI patients [7,8]. Thus, the newest prehospital TBI management guideline reminds readers of the judicious use of TXA [9]. Further studies on TXA administration are guaranteed.…”

“…As intracranial hemorrhage (ICH) is a common but complicated commodity for severe TBI, to prevent increased intracranial pressure (ICP) leading to brain herniation, guidelines, and studies suggest both TXA using and the timely, fast, and large dose of dehydration agent administration for active TBI-related ICH during prehospital-transferring [9,10,11]. However, as the dehydration and the anti-brinolytic are…”