Pre-Hospital Treatment of Traumatic Brain Injury

ABSTRACT

Pre-hospital management of traumatic brain injury (TBI) clearly influences the morbidity and mortality outcomes in patients with TBI. Recent clinical and laboratory evidence suggests that secondary brain injuries can be lessened with appropriate and expeditious interventions performed in the pre-hospital arena. Hypotension, even a single episode of systolic blood pressure < 90 mm Hg, and hypoxia have powerful negative effects on outcome. The recognition and treatment of these conditions can be fairly simple and uncomplicated, including fluid boluses with isotonic or hypertonic saline and field intubation. Other pre-hospital interventions, such as hyperventilation and steroid doses, have proved to be harmful or ineffective in the overall management of TBI. However, conflicting opinion and unclear evidence only demonstrate the need for better class I evidence in pre-hospital management of head trauma.

KEYWORDS

Hypotension - hypoxia - pre-hospital management - traumatic brain injury

REFERENCES

• 1 Sosin D M, Sniezek J E, Thurman D J. Incidence of mild and moderate brain injury in the United States, 1991.  Brain Inj . 1996;  10 47-54
• 2 Biros M H, Heegaard W. Pre-hospital and resuscitative care of the head-injured patient.  Curr Opin Crit Care . 2001;  7 444-449
• 3 Ross S T, Soltesz I. Selective depolarization of interneurons in the early posttraumatic dentate gyrus: involvement of the Na(+)/K(+)-ATPase.  J Neurophysiol . 2000;  83 2916-2930
• 4 Manley G, Knudson M M, Morabito D, Damron S, Erickson V, Pitts L. Hypotension, hypoxia, and head injury: frequency, duration, and consequences.  Arch Surg . 2001;  136 1118-1123
• 5 Taylor C P, Meldrum B S. Na⁺ channels as targets for neuroprotective drugs.  Trends Pharmacol Sci . 1995;  16 309-316
• 6 Hubschmann O R, Nathanson D C. The role of calcium and cellular membrane dysfunction in experimental trauma and subarachnoid hemorrhage.  J Neurosurg . 1985;  62 698-703
• 7 White B C, Krause G S. Brain injury and repair mechanisms: the potential for pharmacologic therapy in closed-head trauma.  Ann Emerg Med . 1993;  22 970-979
• 8 Maeda T, Katayama Y, Kawamata T, Yamamoto T. Mechanisms of excitatory amino acid release in contused brain tissue: effects of hypothermia and in situ administration of Co2+ on extracellular levels of glutamate.  J Neurotrauma . 1998;  15 655-664
• 9 Zhang H, Zhang X, Zhang T, Chen L. Excitatory amino acids in cerebrospinal fluid of patients with acute head injuries.  Clin Chem . 2001;  47 1458-1462
• 10 Zhang X, Qiu M, Zhang J, Zhang H, Kang D. Excitatory amino acids in cerebrospinal fluid and their relations with clinical features and outcomes in acute head injury.  Chin Med J (Engl) . 1998;  111 978-981
• 11 Gopinath S P, Valadka A B, Goodman J C, Robertson C S. Extracellular glutamate and aspartate in head injured patients.  Acta Neurochir Suppl (Wien) . 2000;  76 437-438
• 12 Jeremitsky E, Omert L, Dunham C M, Protetch J, Rodriguez A. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion.  J Trauma . 2003;  54 312-319
• 13 Chesnut R M, Marshall L F, Klauber M R. et al . The role of secondary brain injury in determining outcome from severe head injury.  J Trauma . 1993;  34 216-222
• 14 Fearnside M R, Cook R J, McDougall P, McNeil R J. The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables.  Br J Neurosurg . 1993;  7 267-279
• 15 Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in head injury.  J Trauma . 1996;  40 764-767
• 16 Kokoska E R, Smith G S, Pittman T, Weber T R. Early hypotension worsens neurological outcome in pediatric patients with moderately severe head trauma.  J Pediatr Surg . 1998;  33 333-338
• 17 Pigula F A, Wald S L, Shackford S R, Vane D W. The effect of hypotension and hypoxia on children with severe head injuries.  J Pediatr Surg . 1993;  28 310-314
• 18 Feldman J A, Fish S. Resuscitation fluid for a patient with head injury and hypovolemic shock.  J Emerg Med . 1991;  9 465-468
• 19 Scalea T M, Maltz S, Yelon J, Trooskin S Z, Duncan A O, Sclafani S J. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes.  Crit Care Med . 1994;  22 1610-1615
• 20 Wade C E, Kramer G C, Grady J J, Fabian T C, Younes R N. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies.  Surgery . 1997;  122 609-616
• 21 Vassar M J, Fischer R P, O'Brien P E. et al . A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride. The effect of added dextran 70. The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients.  Arch Surg . 1993;  128 1003-1011
• 22 Vassar M J, Perry C A, Gannaway W L, Holcroft J W. 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport.  Arch Surg . 1991;  126 1065-1072
• 23 Vassar M J, Perry C A, Holcroft J W. Analysis of potential risks associated with 7.5% sodium chloride resuscitation of traumatic shock.  Arch Surg . 1990;  125 1309-1315
• 24 Vassar M J, Perry C A, Holcroft J W. Pre-hospital resuscitation of hypotensive trauma patients with 7.5% NaCl versus 7.5% NaCl with added dextran: a controlled trial.  J Trauma . 1993;  34 622-632
• 25 Bickell W H, Wall Jr J M, Pepe P E. et al . Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.  N Engl J Med . 1994;  331 1105-1109
• 26 Gabriel E J, Ghajar J, Jagoda A, Pons P T, Scalea T, Walters B C. Guidelines for pre-hospital management of traumatic brain injury.  J Neurotrauma . 2002;  19 111-174
• 27 Alspaugh D M, Sartorelli K, Shackford S R, Okum E J, Buckingham S, Osler T. Pre-hospital resuscitation with phenylephrine in uncontrolled hemorrhagic shock and brain injury.  J Trauma . 2000;  48 851-863
• 28 Silverston P. Pulse oximetry at the roadside: a study of pulse oximetry in immediate care.  BMJ . 1989;  298 711-713
• 29 Cooke R S, McNicholl B P, Byrnes D P. Early management of severe head injury in Northern Ireland.  Injury . 1995;  26 395-397
• 30 Marion D W, Puccio A, Wisniewski S R. et al . Effect of hyperventilation on extracellular concentrations of glutamate, lactate, pyruvate, and local cerebral blood flow in patients with severe traumatic brain injury.  Crit Care Med . 2002;  30 2619-2625
• 31 Winchell R J, Hoyt D B. Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma Research and Education Foundation of San Diego.  Arch Surg . 1997;  132 592-597
• 32 Bochicchio G V, Ilahi O, Joshi M, Bochicchio K, Scalea T M. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury.  J Trauma . 2003;  54 307-311
• 33 Davis D P, Hoyt D B, Ochs M. et al . The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury.  J Trauma . 2003;  54 444-453
• 34 Murray J A, Demetriades D, Berne T V. et al . Pre-hospital intubation in patients with severe head injury.  J Trauma . 2000;  49 1065-1070
• 35 Israel R S, Marx J A, Moore E E, Lowenstein S R. Hemodynamic effect of mannitol in a canine model of concomitant increased intracranial pressure and hemorrhagic shock.  Ann Emerg Med . 1988;  17 560-566
• 36 Muizelaar J P, Lutz 3rd A H, Becker D P. Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head-injured patients.  J Neurosurg . 1984;  61 700-706
• 37 Sayre M R, Daily S W, Stern S A, Storer D L, van Loveren R H, Hurst J M. Out-of-hospital administration of mannitol to head-injured patients does not change systolic blood pressure.  Acad Emerg Med . 1996;  3 840-848
• 38 Hamill J F, Bedford R F, Weaver D C, Colohan A R. Lidocaine before endotracheal intubation: intravenous or laryngotracheal?.  Anesthesiology . 1981;  55 578-581
• 39 Rosen C L, Ratliff A F, Wolfe R E, Branney S W, Roe E J, Pons P T. The efficacy of intravenous droperidol in the pre-hospital setting.  J Emerg Med . 1997;  15 13-17
• 40 Rhee K J, O'Malley R J. Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the pre-hospital care of injured patients.  Ann Emerg Med . 1994;  23 37-42
• 41 Lam A M, Winn H R, Cullen B F, Sundling N. Hyperglycemia and neurological outcome in patients with head injury.  J Neurosurg . 1991;  75 545-551
• 42 Rovlias A, Kotsou S. The influence of hyperglycemia on neurological outcome in patients with severe head injury.  Neurosurgery . 2000;  46 335-342
• 43 Clifton G L, Allen S, Barrodale P. et al . A phase II study of moderate hypothermia in severe brain injury.  J Neurotrauma . 1993;  10 263-271
• 44 Clifton G L, Allen S, Berry J, Koch S M. Systemic hypothermia in treatment of brain injury.  J Neurotrauma . 1992;  9( suppl 2) S487-S495
• 45 Clifton G L, Miller E R, Choi S C. et al . Hypothermia on admission in patients with severe brain injury.  J Neurotrauma . 2002;  19 293-301
• 46 Gaab M R, Trost H A, Alcantara A. et al . "Ultrahigh" dexamethasone in acute brain injury. Results from a prospective randomized double-blind multicenter trial (GUDHIS). German Ultrahigh Dexamethasone Head Injury Study Group.  Zentralbl Neurochir . 1994;  55 135-143
• 47 Braakman R, Schouten H J, Blaauw-van Dishoeck M, Minderhoud J M. Megadose steroids in severe head injury. Results of a prospective double-blind clinical trial.  J Neurosurg . 1983;  58 326-330
• 48 Cooper P R, Moody S, Clark W K. et al . Dexamethasone and severe head injury. A prospective double-blind study.  J Neurosurg . 1979;  51 307-316
• 49 Dearden N M, Gibson J S, McDowall D G, Gibson R M, Cameron M M. Effect of high-dose dexamethasone on outcome from severe head injury.  J Neurosurg . 1986;  64 81-88
• 50 Braakman R, Avezaat C J, Maas A I, Roel M, Schouten H J. Inter-observer agreement in the assessment of the motor response of the Glasgow 'coma' scale.  Clin Neurol Neurosurg . 1977;  80 100-106
• 51 Rowley G, Fielding K. Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users.  Lancet . 1991;  337 535-538
• 52 Fielding K, Rowley G. Reliability of assessments by skilled observers using the Glasgow Coma Scale.  Aust J Adv Nurs . 1990;  7 13-17
• 53 Menegazzi J J, Davis E A, Sucov A N, Paris P M. Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics.  J Trauma . 1993;  34 46-48
• 54 Narayan R K, Greenberg R P, Miller J D. et al . Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure.  J Neurosurg . 1981;  54 751-762
• 55 Winkler J V, Rosen P, Alfry E J. Pre-hospital use of the Glasgow Coma Scale in severe head injury.  J Emerg Med . 1984;  2 1-6
• 56 Baxt W G, Moody P. The impact of advanced pre-hospital emergency care on the mortality of severely brain-injured patients.  J Trauma . 1987;  27 365-369
• 57 Massagli T L, Michaud L J, Rivara F P. Association between injury indices and outcome after severe traumatic brain injury in children.  Arch Phys Med Rehabil . 1996;  77 125-132
• 58 Meyer S, Gibb T, Jurkovich G J. Evaluation and significance of the pupillary light reflex in trauma patients.  Ann Emerg Med . 1993;  22 1052-1057
• 59 Sampalis J S, Lavoie A, Boukas S. et al . Trauma center designation: initial impact on trauma-related mortality.  J Trauma . 1995;  39 232-237
• 60 Mullins R J, Veum-Stone J, Hedges J R. et al . Influence of a statewide trauma system on location of hospitalization and outcome of injured patients.  J Trauma . 1996;  40 536-545
• 61 Guss D A, Meyer F T, Neuman T S. et al . The impact of a regionalized trauma system on trauma care in San Diego County.  Ann Emerg Med . 1989;  18 1141-1145
• 62 Smith R F, Frateschi L, Sloan E P. et al . The impact of volume on outcome in seriously injured trauma patients: two years' experience of the Chicago Trauma System.  J Trauma . 1990;  30 1066-1075