Traumatic brain injury (TBI) is a major cause of disability and death worldwide. Public awareness of the importance of TBI and its sequelae has been increasing because of both the focus on head injuries observed among members of the military in the wars in Iraq and Afghanistan and head injuries seen among professional football players. This has led to new laws and policy changes regarding concussion screening and return-to-play rules in sports and an increase in the number of individuals seeking medical care and evaluation.
In the United States, there were more than 2.8 million TBI-related emergency department visits, hospitalizations, and deaths in 2014; this reflects a 54% increase in the number of emergency department visits between the years of 2006 and 2014. There has also been increased recognition of the importance of prehospital TBI care because nearly half of individuals who die of TBI die within the first 2 hours of injury. In this chapter we review the prehospital evaluation and management of patients with TBI.
Initial prehospital assessment and management
The most critical step in managing TBI is first recognizing that a TBI may have occurred. The inciting event may be subtle, such as elderly victim bumping a car door frame or seemingly insignificant fall during a sporting event when the patient’s head briefly hits the ground. If there is any suspicion that a TBI might have happened, the victim must be removed from further risk and assessed for TBI risk immediately. Ideally, assessment will be done using a TBI risk assessment tool and/or a neurologic examination by an advanced medical provider.
Initial management of TBI is focused on the ABCs of airway, breathing and circulation. This is followed by stabilizing the patient, determining severity of injury, and deciding what level of care is needed.
Mild traumatic brain injury/concussion
Concussion is mild TBI. There has been increased awareness of the seriousness of sports-related concussions. This in turn has resulted in implementation of policy and legal measures to reduce risk of further injury and safe return to play or work. The Centers for Disease Control and Prevention (CDC) reports that between 2001 and 2012, the number of children ages 19 years or younger who received treatment in an emergency room for sports-related head injury doubled, with an estimated 329,290 children treated for sports-related head injuries in 2012.
In the past, especially in youth sports, decisions regarding return to play were made on the sidelines in the prehospital setting, typically by a coach or parent. Fortunately, this is no longer the case. The CDC has helped increase public awareness of the importance of recognizing and properly managing sports-related concussions with the CDC’s Heads Up program, introduced in 2003. The Heads Up program provides educational material on prevention, recognition, and response to concussion to five target audiences: healthcare professionals, high school coaches, youth sports coaches, school professionals, and parents.
Recognition and identification of concussion at the time of injury is key to preventing further injury. To this end, the Sport Concussion Assessment Tool (SCAT) was first developed in 2004 and is now in its fifth iteration (SCAT5). The SCAT provides a brief objective and standardized assessment of concussion, including screening of neurocognitive and neurologic functions in addition to symptom assessment.
There are now laws governing the prehospital management of concussion. The first legislation addressing concussion education and victim management was ratified in 2009 when Washington state passed the Zackery Lystedt Law. , Mr. Lystedt was a high school football player who died after sustaining a number of concussions. By 2014, all 50 states and the District of Columbia passed similar laws governing return-to-play rules for athletes ages 18 years and younger. These laws all share three similar key elements:
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Mandatory education of athletes, coaches, and parents/guardians about concussion
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Removal of youth athlete from practice or play at the time of suspected concussion/head injury
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Return to practice or play only with the written permission of a licensed healthcare provider trained in the evaluation and management of concussion
These laws are intended to raise awareness about the seriousness of sports-related head injuries and on preventing second-impact syndrome (SIS). SIS is rapidly developing diffuse cerebral edema that primarily affects younger victims. SIS is a devastating condition with close to 50% mortality rate. The risk is greatest when a second concussion occurs before symptoms from the first concussion have resolved. More research is needed to clarify risk factors and outcomes after first and repeat injuries to better guide future recommendations for return-to-play rules for athletes.
An important aspect of prehospital management of presumed mild TBI involves identification of those individuals at risk of more serious TBI because they will need urgent evaluation at a medical facility. Clinical clues include multiple vomiting episodes, posttraumatic seizures, focal neurological deficits, and decrease in level of consciousness after an initial lucid interval.
Signs suspicious of skull fracture are raccoon eyes or clear watery nasal discharge concerning for cerebrospinal fluid (CSF) leak.
The SCAT5 should be administered as soon possible after the injury. If positive, the player must not return to play until he or she is evaluated by and receives written clearance for return to play from an advanced medical provider. This is both prudent and the law.
The need for neuroimaging depends on the level of clinical suspicion of intracranial pathology. According to CDC and American College of Emergency Physicians (ACEP) guidelines, the Canadian CT Head Rule, and the New Orleans Criteria for CT scanning in patients with minor head injury, noncontrast head computed tomography (CT) is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia if one or more of these is present:
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Headache
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Vomiting
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Age >60 years, drug/alcohol intoxication
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Posttraumatic seizure
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Glasgow Coma Scale (GCS) score <15
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Focal neurologic deficit
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Coagulopathy
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Evidence of trauma above the clavicle
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Deficits in short-term memory
It is important to note that fewer than 10% of patients with mild TBI have abnormalities detected on noncontrast head CT, and only approximately 1% of these patients need neurosurgery.
Moderate to severe traumatic brain injury
All moderate to severe TBI patients should be considered as having a potential life-threatening injury. Thus 9-1-1 must be called because these patients invariably will require airway and ventilation management. After emergency medical services (EMS) stabilization in the field, these patients will be taken to a level 1 trauma center where neurointensive care and neurosurgical services can be rendered by a multidisciplinary team of neuro specialty nurses, neurointensivists, neurosurgeons, and trauma specialists. If the patient survives, long-term care will be by neurorehabilitation specialists.
Clinical practice guidelines (CPGs) for moderate to severe TBI have been developed, and the Brain Trauma Foundation has published updated evidence-based guidelines. In the prehospital setting, all severities of TBI victims undergo an initial assessment based on the CPGs of Advanced Trauma Life Support (ATLS) primary survey guidelines. The primary survey is defined using the ABCDE mnemonic : a irway and cervical spine stabilization, b reathing and ventilation, c irculation, d isability/neurologic status, and e xposure/environment.
First responders need to verify a patent airway to ensure adequate oxygenation and ventilation, paying close attention for signs of airway obstruction including stridor, gurgling, hoarseness, and altered mental status. The cervical spine should be immobilized using a hard collar. Assessment of breathing and ventilation includes inspection, palpation, and auscultation. Circulation is assessed by blood pressure, heart rate, mental status, and inspection for signs of hemorrhage. Disability/neurologic status is assessed by examining pupils, GCS, and assessing for spinal cord injury. After the initial survey is completed, patients should be covered in warm blankets and administered warm intravenous fluids to avoid hypothermia from environmental exposure and transported to trauma medical center. After the primary trauma survey is performed and the patient is stabilized, first responders can proceed to perform a secondary survey, which includes gathering information on the patient’s medical history, medications, and allergies, and performing a complete physical examination.
Airway, ventilation, oxygenation, and blood pressure
The Brain Trauma Foundation guidelines recommend that patients with suspected severe TBI be monitored in the prehospital setting for signs of hypoxemia (<90% oxygen saturation) and hypotension (<90 mm Hg systolic blood pressure [SBP]). Hypoxemia and hypotension have been shown to be strong predictors of poor outcome among patients with severe TBI.
Avoiding hypoxemia (<90% oxygen saturation) in the prehospital setting is recommended because hypoxemia has been shown to be a strong predictor of poor outcome after TBI. Supplemental oxygen can be used in patients who are protecting their airways, whereas patients who are unable to protect their airways (often indicated by GCS score ≤8) or patients with persistent hypoxemia despite supplemental oxygen should be endotracheally intubated using rapid-sequence intubation protocols. During intubation, blood pressure, oxygenation, and end-tidal carbon dioxide (ETCO 2 ) should be measured, and endotracheal tube placement should be confirmed using lung auscultation and ETCO 2 measurement. Normocapnia is recommended (ETCO 2 35–40 mm Hg), and hyperventilation (ETCO 2 <35 mm Hg) should be avoided unless the patient shows signs of cerebral herniation.
Circulation and fluid resuscitation
Fluid resuscitation should be used to treat TBI patients with hypotension (SBP <90 mm Hg) because hypotension has been associated with poor outcomes. Isotonic or hypertonic fluids should be used for resuscitation, and hypotonic fluids should be avoided because of the risk for increased intracranial pressure and cerebral herniation.
Neurological examination
Pupillary reflex
The pupillary examination is an important part of the post-TBI prehospital neurological examination and consists of examination of the size, symmetry, and reaction to light of each pupil. The pupillary light reflex is dependent on the function of cranial nerve III (oculomotor nerve). Asymmetry (defined as >1 mm difference in pupil diameter) or fixed, dilated pupils (defined as <1 mm response to bright light) may suggest a herniation syndrome or brainstem ischemia, indicating a need for emergent treatment of increased intracranial pressure.
Glasgow Coma Scale
Prehospital measurement of the GCS score is a reliable measure of the severity of TBI. , The GCS is a measurement of the severity of neurological impairment based on assessment of eye opening, verbal responses, and motor responses (score range 3–15) ( Table 9.1 ). Categories of TBI severity using the GCS are defined as 13 to 15 for mild injuries, 9 to 12 for moderate injuries, and 3 to 8 for severe injuries. It is important to routinely reassess the GCS of the patient to monitor for neurological changes. The GCS is limited by provider subjectivity, obscuration of level of consciousness in the acute setting by confounders such as medical sedation or intoxication, and the loss of the verbal response component after intubation.
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