Oxygenation, Blood Pressure, Ventilation

• Patients with suspected traumatic brain injury (TBI) should be carefully monitored in the prehospital setting for hypoxemia (<90% arterial hemoglobin saturation), hypotension (<100 mmHg systolic blood pressure [SBP]), hypertension (150 mmHg SBP or higher), hyperventilation (end tidal CO2 reading less than 35) and hypo- or hyperthermia.
• Blood oxygen saturation should be continuously measured in the prehospital setting with a pulse oximeter and supplemental oxygen administered to maintain blood oxygen saturation above 90%.
• Systolic and diastolic blood pressure should be measured in the prehospital setting using the most accurate method available and should be measured frequently (every 5-10 min) or monitored continuously if possible.
• Ventilation should be assessed in the prehospital setting for all patients with an altered level of consciousness with continuous capnography to maintain end tidal CO2 values between 35 and 45 mmHg.
• Temperature should be measured in the prehospital setting and efforts should be undertaken to maintain euthermia in the patient equating to temperatures of 36-37 degrees Celsius.
• In non-resource-limited settings, appropriately sized equipment to measure oxygenation, blood pressure, and temperature in children and adults should be maintained and available for routine use by trained prehospital professionals.

Glasgow Coma Scale Score

• 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.
• The GCS score should be reported every 30 minutes in the prehospital setting and whenever there is a change in mental status to identify improvement or deterioration over time. Confounders to the GCS such as seizure and post-ictal phase, ingestions and drug overdose, as well as medications administered in the prehospital setting that impact GCS score should be documented.
• 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).
• 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.
• The GCS should be measured prior to administering sedative or paralytic agents when possible and when not delaying airway stabilization, or after these drugs have been metabolized as they may obscure correct scoring.
• The GCS should be measured by prehospital professionals who are appropriately trained in how to administer the GCS to both adults and children.
• The GCS of the prehospital patient, including any changes in score, should be communicated to receiving facilities during all communications and upon arrival.
• Prehospital assessment of neurologic status using the Simplified Motor Score (SMS), or the isolated motor component of the GCS may provide similar diagnostic and prognostic utility to the complete GCS in adults and may be used in trauma systems organized to incorporate these measures.

Pupil Examination

Pupils should be assessed in the prehospital setting after the patient has been resuscitated and stabilized, with the examination recorded and relayed to the receiving facility. When assessing pupils, the following should be examined for and documented:

• Evidence of orbital and ocular trauma
• Comparison of left and right pupillary findings. Clinically significant asymmetry is defined as > 1mm difference in diameter
• Presence of unilateral or bilateral dilated pupil(s)
• Presence of fixed and dilated pupil(s). A fixed pupil is defined as < 1mm response to bright light
• Confounders to pupil exam

Airway, Ventilation, and Oxygenation

• All patients with suspected severe TBI should be placed on continuous oxygen supplementation via nasal cannula or face mask in the prehospital setting in order to minimize secondary insults related to hypoxia.
• Hypoxemia (oxygen saturation [SpO2] < 90%) should be monitored using continuous pulse oximetry and corrected immediately upon identification by 1) ensuring appropriate airway positioning and 2) administering continuous, supplemental oxygen.
• If signs of hypoxia persist (central cyanosis and/or hypoxemia on pulse oximetry) despite increasing the flow and concentration of continuous supplemental oxygen, the following stepwise strategies should be undertaken with re-evaluation of oxygen saturation and respiratory effort following each strategy:
  • 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.
• An airway should be established, by the most appropriate means available, in patients who have signs of severe TBI, GCS < 9, or 9 and decompensating, the inability to maintain an adequate airway, or if hypoxemia is not corrected by supplemental oxygen.
• Emergency Medical Service (EMS) systems implementing endotracheal intubation protocols including the use of rapid sequence intubation (RSI) protocols should confirm endotracheal tube placement in the trachea by the presence of bilateral breath sounds on auscultation, ETCO2 detection and/or capnography. Intubated patients in the prehospital setting require continuously monitored oxygenation, ETCO2, and frequent blood pressure monitoring.
• Patients requiring respiratory support with positive pressure ventilation should be maintained with normal breathing rates (approximately 10 breaths per minute with ETCO2 35-45 mmHg), and hyperventilation (ETCO2 < 35 mmHg) should be avoided. Ventilatory adjuncts such as pressure-controlled bags, ventilation-rate timers, ETCO2 monitoring, and ventilators should be used to support appropriate ventilation and minimize the risk of secondary insults by avoiding hypo- and hyperventilation.

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.

Dispatch and Destination, On-scene, and Transportation

• All regions should have an organized trauma care system with comprehensive documentation of each encounter including time, assessment, and care provided.
• Emergency Medical Services (EMS) should establish specific protocols directing destination decisions for patients with suspected traumatic brain injury (TBI).
  • Pediatric patients with suspected 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.

• Patients with suspected moderate-severe TBI should be transported directly to a facility with immediately available computed tomography (CT) neuroimaging capabilities, prompt neurosurgical care, and the ability to monitor intracranial pressure and treat intracranial hypertension.
  • While direct transport to a trauma center is preferable for most patients, in the event that this transport is not possible, stabilization at a non-trauma center with subsequent transfer within an established trauma system may occur.
  • In a metropolitan area, pediatric patients with severe TBI should be transported directly to a pediatric trauma center if available.
  • The mode of transport should be selected to minimize the time to definitive interventions for the patient with TBI.