Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Abstract

Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

Prospective observational cohort study on epidemiology, treatment and outcome of patients with traumatic brain injury (TBI) in German BG hospitals

“… 7 Neurological assessment including GCS, pupil reaction and signs of asymmetry performed repeatedly in the prehospital and emergency room setting is crucial to assess TBI severity and secondary deterioration due to intracranial complications with the need of a neurosurgical intervention. 23 It is therefore very reassuring that this was also found to be substantially improved in our study, with GCS being recorded in 94.5% of the patients when an emergency physician was present at the accident site.…”

Identification of Serious Adverse Events in Patients with Traumatic Brain Injuries, from Prehospital Care to Intensive-Care Unit, Using Early Warning Scores

“…Advanced airway management at the scene [42] using orotracheal intubation in those TBIs with a low GCS score, presence of convulsions, agitation, or in case of situations with other associated trauma, is a recognized practice approved by current brain injury treatment guides [43,44]. Similarly, the appropriate handling of hypotension from the initial moments helps to prevent secondary injuries and maintain adequate cerebral perfusion pressure [5,45,46]. The use of advanced measures at the scene for high-risk patients directly influences short-term (admission to ICU and early mortality) and long-term evolution (mitigation of after-effects) [47,48].…”

Benefits of Early Tracheostomy in TBI Patients

“…TBI management begins at the prehospital care, assuring that the patient has no signs of upper airway obstruction, maintaining Oxygen saturation (spO 2 ) > 90% and considering intubation in patients that presents Glasgow Coma Scale (GCS) < 9, altered swallowing reflex or contributing to hypoventilation [60,[62][63][64]. However, it is of substantial value that the prehospital team is technically qualified (within technical skills, medical devices/medication, and protocols) to perform airway management and control possible detrimental effects of therapeutic interventions (such as worsening of cervical spine injury during endotracheal intubation [65]).…”