Brain Trauma Guidelines for Emergency Medicine

In April 2023, the third edition of the Brain Trauma Foundation’s evidence-based guidelines for the prehospital management of traumatic brain injury (TBI) was published in Prehospital Emergency Care.1 The practice guidelines were written by a multi-disciplinary group of experts and went through an extensive peer review process. This document is an update of guidelines first published in 2000, and then updated in 2007. These guidelines present the best available evidence to support clinical decision making in the prehospital setting when TBI care may have the most significant impact on outcomes; they also establish a research agenda for future investigations.

TBI ASSESSMENT

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