• airway re-positioning,
• positive pressure ventilation as with bag-valve-mask ventilation in conjunction with appropriate airway adjuncts (e.g., oropharyngeal airway), and/or
• supraglottic airway or endotracheal intubation by a trained health care professional.

Fluid Resuscitation

• Intravenous fluids should be administered in the prehospital setting to treat hypotension and/or limit hypotension to the shortest duration possible.
• Hypotensive patients should be treated with blood products and/or isotonic fluids in the prehospital setting.
• Hypertonic fluid resuscitation may be administered to patients with a Glasgow Coma Scale Score (GCS) < 8 in whom increased ICP is suspected in the prehospital setting.

Hyperventilation and Hyperosmolar Therapy for Suspected Increased Intracranial Pressure (ICP)

• Hyperventilation should be avoided in the prehospital care of children and adults with TBI in the absence of signs of active cerebral herniation.
• Ventilation strategies should target eucapnia and avoid hypocapnia (i.e., ETCO2 of 35- 40) and be monitored using capnography.
• When used to address signs of active and imminent herniation, hyperventilation should target an ETCO2 of 30-35 using capnography.
• Hyperosmolar therapy should not be administered for the prophylactic treatment of suspected elevated ICP, with or without signs of cerebral herniation, in the prehospital setting at this time.
• Prehospital administration of TXA therapy is not generally and widely indicated for the prophylactic treatment of suspected ICH or elevated ICP at this time.[/sidebar]

References

1. Lulla A, et al. Prehospital Guidelines for the management of traumatic brain injury – 3rd edition. Prehosp Emerg Care. 2023; https://doi.org/10.1080/10903127.2023.2187905.
2. Centers for Disease Control and Prevention. National Center for Health Statistics: Mortality Data on CDC WONDER. Accessed 2022, https://wonder.cdc.gov/mcd.html.
3. Bell JM, Breiding MJ, DePadilla L. CDC’s efforts to improve traumatic brain injury surveillance. J Safety Res. 2017;62:253 -256.
4. 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.

DECISION-MAKING WITHIN THE EMS SYSTEM