Introduction

In developed countries, the existence of organized trauma systems is the base for providing good care for trauma patients, from the scene of the accident through rehabilitation. Developing countries have adapted aspects of these systems, and further development of national or regional trauma management systems is likely to be a very cost-effective measure for reducing mortality and improving outcome for accident victims.

Trauma systems link organizations working in the field of acute care together, allowing uniformity of terminology and adapting the evidence-based guidelines. In most developed countries, well-trained paramedics are the backbone of the emergency medical system (EMS) and are responsible for the first part of the trauma chain, the prehospital phase. Under specific circumstances, paramedics are supported by physicians. In geographically dispersed regions, the use of helicopters helicopter emergency medical system (HEMS) as an adjunct for transportation is helpful.

The practice of medicine in the prehospital environment is quite different from what is encountered in the hospital. Potential risks from hazardous materials or environmental and climatic conditions must be considered, which could present risks for both patient and rescuer. In cases of entrapped patients, a multidisciplinary coordination between rescue and medical teams is mandatory. Paramedics or EMS personnel have a complex job, requiring intensive training in invasive procedures and decision making.

Focusing on the trauma patient with a traumatic brain injury (TBI), guidelines for the optimal protection of the damaged brain in the prehospital phase are evolving and are sometimes conflicting. In this chapter, generally accepted guidelines for the assessment and treatment of brain-injured patients as well as controversies will be discussed.

Other informations found during the initial physiological assessment of the patient gives further clues that the brain is injured in the accident. In all potentially traumatized patients, a simple algorithm is used assess the victim rapidly. The paramedic always starts his or her assessment by asking a simple question of the patient. If the answer is coherent and in a normal voice, it can be assumed that the airway is patent. If the patient does not answer, or his answer is inappropriate, further investigation into the level of consciousness is required. Increasing the intensity of the stimulus by talking louder and/or by administering a noxious stimulus is usually the next step in order to evaluate the level of consciousness.

The paramedic should categorize the patient as having a level of consciousness above or below a Glasgow Coma Scale (GCS) of 8. In patients with a GCS ≤ 8, the algorithm of the ABC starts with maintaining an open and secured airway according to the Manual of Prehospital Trauma Life Support [1]. This algorithm was developed during the early 1980s in the USA, was adopted by the American College of Surgeons in 1982, and has since become the international standard. The algorithm is revised every 4 years by an international group of experts, based on newly available evidence. In general, in patients with a GCS > 8, without other reasons for a compromised airway (facial or neck injury, inhalation injury), the focus on the airway is less prominent than in the group with a GCS ≤ 8.

The basic rules are always the same. The type and severity of the brain damage does not play a role in the initial assessment. The principle is “the best way to protect the injured brain is to optimize perfusion.” Maintaining or restoring cardiopulmonary stability is the next critical step in order to improve perfusion and oxygenation of all organs, including the brain.