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Traumatic Brain Injury

Date Last Search Run: Jan 14, 2025
Table last updated: Dec 22, 2024
Data last added: Dec 19, 2024

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)
3 (weak evidence exists)    


Interventions

Aggressive Crystalloids
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Mortality Patient PH-Paramedic Hussmann B., Heuer M., Lefering R., et al. Prehospital volume therapy as an independent risk factor after trauma. Biomed Res Int 2015; 354367. Medline
III Neutral (Yellow) ICU mortality Patient PH-Paramedic Lenartova L., Janciak I., Wilbacher I., Rusnak M., Mauritz W, Austrian Severe TBI Study Investigators. Severe traumatic brain injury in Austria III: prehospital status and treatment. Wien Klin Wochenschr 2007; 119(1-2):35-45. Medline

Blood transfusion
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) In-hospital Mortality Patient ED-MD Haltmeier T, Benjamin E, Gruen JP, Shulman IA, Lam L, Inaba K, et al. Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios. Injury 2018; 49(1):62-6. Medline
II Neutral (Yellow) Neurological outcome Patient PH-Paramedic & CCT Hernandez MC, Thiels CA, Aho JM, Habermann EB, Zielinski MD, Stubbs JA, et al. Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury. The journal of trauma and acute care surgery 2017; 83(3):398-405. Medline

Colloid Infusion
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Mortality Patient PH-Paramedic Tan PG., Cincotta M., Clavisi O., Bragge P., Wasiak J., Pattuwage L., et al. Review article: Prehospital fluid management in traumatic brain injury. Emerg Med Australas 2011; 23(6):665-676. Medline

Fluid Resuscitation
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Neurologic outcome Patient PH-Paramedic Bulger EM., May S., Brasel KJ., Schreiber M., Kerby JD., Tisherman SA., et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: A randomized controlled trial. JAMA 2010; 304(13):1455-64. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic & CCT Tan PG., Cincotta M., Clavisi O., Bragge P., Wasiak J., Pattuwage L., et al. Review article: Prehospital fluid management in traumatic brain injury. Emerg Med Australas 2011; 23(6):665-676. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Hussmann B., Heuer M., Lefering R., et al. Prehospital volume therapy as an independent risk factor after trauma. Biomed Res Int 2015; 354367. Medline
II Neutral (Yellow) Hypoxia Process PH-Paramedic Gravesteijn BY, Sewalt CA, Stocchetti N, Citerio G, Ercole A, Lingsma HF, et al. Prehospital Management of Traumatic Brain Injury across Europe: A CENTER-TBI Study. Prehosp Emerg Care 2021; 25(5):629–43. Medline
II Neutral (Yellow) Response to crystalloids and ionotropes. Patient ED-MD Scalea TM., Maltz S., Yelon J., et al. Resuscitation of multiple trauma and head injury: Role of crystalloid fluids and inotropes. Crit Care Med 1994; 22:1610-5. Medline
III Neutral (Yellow) ICU mortality Patient PH-Paramedic Lenartova L., Janciak I., Wilbacher I., Rusnak M., Mauritz W, Austrian Severe TBI Study Investigators. Severe traumatic brain injury in Austria III: prehospital status and treatment. Wien Klin Wochenschr 2007; 119(1-2):35-45. Medline
III Neutral (Yellow) Changes in ICP Patient ICU Schmoker JD., Shackford SR., Wald SL., et al. An analysis of the relationship between fluid and sodium administration and intracranial pressure after head injury. J Trauma 1992; 33(3):476-81. Medline

HEMS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Mortality at hospital discharge Patient PH-MD & CCT Hosomi S, Kitamura T, Sobue T, Nakagawa Y, Ogura H, Shimazu T. Association of Pre-Hospital Helicopter Transport with Reduced Mortality in Traumatic Brain Injury in Japan: A Nationwide Retrospective Cohort Study. J Neurotrauma 2022; 39(1-2):76–85. Medline

Hypertension Control
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) In-hospital mortality Patient PH-Paramedic Shibahashi K, Hoda H, Okura Y, Hamabe Y. Acceptable Blood Pressure Levels in the Prehospital Setting for Patients with Traumatic Brain Injury: A Multicenter Observational Study. World Neurosurg 2021; 149: e504–11. Medline

Hypertonic Saline
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Inflammatory markers Process PH-Paramedic Rhind SG., Crnko NT., Baker AJ., et al. Prehospital resuscitation with hypertonic saline-dextran modulates inflammatory, coagulation and endothelial activation marker profiles in severe traumatic brain injured patients. J Neuroinflammation 2010; 7:5-2094-7-5. Medline
I Supportive (Green) Change in maximum ICP Patient ICU Shackford SR., Bourguignon PR., Wald SL., et al. Hypertonic saline resuscitation of patients with head injury: A prospective, randomized clinical trial. J Trauma Injury, Infection & Crit Care 1998; 44:50-59. Medline
I Supportive (Green) Survival to discharge Patient PH-Paramedic & CCT Vasser MJ., Perry CA., Gannaway WL., et al. 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport. Arch Surg 1991; 126:1065-1072. Medline
I Neutral (Yellow) Neurologic outcome Patient PH-Paramedic Bulger EM., May S., Brasel KJ., Schreiber M., Kerby JD., Tisherman SA., et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: A randomized controlled trial. JAMA 2010; 304(13):1455-64. Medline
I Neutral (Yellow) All-cause mortality Patient ED-MD Burgess S., Abu-Laban RB., Slavik RS., Vu EN., Zed PJ. A systematic review of randomized controlled trials comparing hypertonic sodium solutions and mannitol for traumatic brain injury: Implications for emergency department management. Ann Pharmacother 2016; 50(4):291-300. Medline
I Neutral (Yellow) Neurological function at 6 months Patient PH-Paramedic Cooper DJ., Myles PS., et al for the HTS study investigators. Prehospital Hypertonic Saline Resuscitation of Patients with Hypotension and Severe Traumatic Brain Injury. A Randomized Controlled Trial. JAMA 2004; 11:1350-6. Medline
I Neutral (Yellow) Neurological status at 6 months based on the Extended Glasgow Outcome Scale Patient PH-Paramedic Junger WG., Rhind SG., Rizoli SB., et al. Prehospital hypertonic saline resuscitation attenuates the activation and promotes apoptosis of neutrophils in patients with severe traumatic brain injury. Shock 2013; 40(5):366-74. Medline
I Neutral (Yellow) Mortality Patient ICU Miyoshi Y, Kondo Y, Suzuki H, Fukuda T, Yasuda H, Yokobori S. Effects of hypertonic saline versus mannitol in patients with traumatic brain injury in prehospital, emergency department, and intensive care unit settings: a systematic review and meta-analysis. J Intensive Care 2020; 8:61. Medline
II Supportive (Green) Mortality Patient PH-MD & CCT Codorniu A, Charbit E, Werner M, et al. Comparison of mannitol and hypertonic saline solution for the treatment of suspected brain herniation during prehospital management of traumatic brain injury patients. Eur J Emerg Med April 2024. Medline
III Neutral (Yellow) ICU mortality Patient PH-Paramedic Lenartova L., Janciak I., Wilbacher I., Rusnak M., Mauritz W, Austrian Severe TBI Study Investigators. Severe traumatic brain injury in Austria III: prehospital status and treatment. Wien Klin Wochenschr 2007; 119(1-2):35-45. Medline

Hyperventilation
Level Direction Primary Outcome Patient/Process Setting Reference
I Opposes (Red) Favorable neurological outcome Patient ED-MD Muizelaar P., Marmarou A., Ward J., et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: A randomized clinical trial. J Neurosurg 1991; 75:731-9. Medline
III Neutral (Yellow) ICU mortality Patient PH-Paramedic Lenartova L., Janciak I., Wilbacher I., Rusnak M., Mauritz W, Austrian Severe TBI Study Investigators. Severe traumatic brain injury in Austria III: prehospital status and treatment. Wien Klin Wochenschr 2007; 119(1-2):35-45. Medline

Intubation by non-CCT
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Glasgow scale at 6 months Patient PH-Paramedic Bernard SA., Nguyen V., Cameron P., Masci K., Fitzgerald M., Cooper DJ., et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg 2010; 252(6):959-65. Medline
I Supportive (Green) Functional recovery (GOS-E at 6 months) Patient PH-Paramedic Denninghoff KR, Nuño T, Pauls Q, Yeatts SD, Silbergleit R, Palesch YY, et al. Prehospital Intubation is Associated with Favorable Outcomes and Lower Mortality in ProTECT III. Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2017; 21(5):539-44. Medline
I Supportive (Green) Mortality Patient PH-Paramedic Shafique MA, Haseeb A, Asghar B, Kumar A, Chaudhry ER, Mustafa MS. Assessing the impact of pre-hospital airway management on severe traumatic Brain injury: A systematic review and Meta-analysis. Am J Emerg Med January 2024; 78:188-195. Medline
I Neutral (Yellow) Morbidity and mortality Patient PH-Paramedic Shafique MA, Haseeb A, Asghar B, Kumar A, Chaudhry ER, Mustafa MS. Assessing the impact of pre-hospital airway management on severe traumatic Brain injury: A systematic review and Meta-analysis. Am J Emerg Med January 2024; 78:188-195. Medline
II Supportive (Green) Short term mortality Patient PH-Paramedic Choffat C, Delhumeau C, Fournier N, Schoettker P. Effect of Pre-Hospital Intubation in Patients with Severe Traumatic Brain Injury on Outcome: A Prospective Cohort Study. J Clin Med 2019; 8(4). Medline
II Supportive (Green) Survival Patient PH-Paramedic Winchell RJ., Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 1997; 132:592-597. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Baxt W., Moody P. The impact of advanced prehospital emergency care on the mortality of severely brain-injured patients. J of Trauma 1987; 27:365-9. Medline
II Neutral (Yellow) In-hospital mortality Patient PH-Paramedic Bendinelli C, Ku D, Nebauer S, King KL, Howard T, Gruen R, et al. A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury. ANZ J Surg 2018; 88(5):455-9. Medline
II Neutral (Yellow) Prehospital time delay Process PH-Paramedic Cudnik MT., Newgard CD., Wang H., Bangs C., Herrington R. Endotracheal intubation increases out-of-hospital time in trauma patients. Prehosp Emer Care 2007; 11:224-9. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Davis D., Peay J., Serrano J., Buono C., Vilke G., Sise F., Kennedy F., Eastman B., Velky T., Hoyt D. The Impact of Aeromedical Response to Patients With Moderate to Severe Traumatic Brain Injury. Ann Emerg Med 2005; 46(2):115-22. Medline
II Neutral (Yellow) Functional neuro status Patient PH-Paramedic Gravesteijn BY, Sewalt CA, Nieboer D, Menon DK, Maas A, Lecky F, et al. Tracheal intubation in traumatic brain injury: a multicentre prospective observational study. Br J Anaesth 2020. Medline
II Neutral (Yellow) Hospital mortality Patient PH-Paramedic Kempema J., Trust MD., Ali S., et al. Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma. Am J Emerg Med 2015; 33(8):1080-3. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Stiell IG., et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ 2008; 178:1141-52. Medline
II Neutral (Yellow) In-hospital mortality Patient PH-Paramedic von Elm E., Schoettker P., Henzi I., Osterwalder J., Walder B. Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence. Br J Anaesth 2009; 103(3):371-386. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Bossers SM, Verheul R, van Zwet EW, Bloemers FW, Giannakopoulos GF, et al. Prehospital Intubation of Patients with Severe Traumatic Brain Injury: A Dutch Nationwide Trauma Registry Analysis. Prehosp Emerg Care 2022:1–7. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Bukur M., Kurtovic S., Berry C., Tanios M., Margulies DR., Ley EJ., et al. Pre-hospital intubation is associated with increased mortality after traumatic brain injury. J Surg Res 2011; 170(1):e117-21. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Fevang E., Perkins Z., Lockey D., Jeppesen E., Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. Crit Care 2017; 21(1) 192. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Haltmeier T, Benjamin E, Siboni S, Dilektasli E, Inaba K, Demetriades D. Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. European journal of trauma and emergency surgery: official publication of the European Trauma Society 2017; 43(6):731-9. Medline
II Opposes (Red) Survival to hospital discharge Patient PH-Paramedic Jung E, Cho YS, Ryu SJ, Kim DK, Lee JH, Han JH. The impact of prehospital endotracheal intubation on mortality in traumatic brain injury. Am J Emerg Med 2022; 55:152–6. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Murray JA., Demetriades D., Berne TV., et al. Prehospital intubation in patients with severe head injury. J Trauma 2000; 49(6):1065-70. Medline
II Opposes (Red) Hypotension Patient PH-Paramedic Shafi S., Gentilello L. Prehospital endotracheal intubation and positive pressure ventilation in association with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the national trauma data bank. J Trauma 2005; (59)5:1140. Medline
II Opposes (Red) 28-day moratlity Patient PH-Paramedic Wang HE., Brown SP., Macdonald RD., Dowling SK., Lin S., Davis D., et al. Association of out-of-hospital advanced airway management with outcomes after traumatic brain injury and hemorrhagic shock in the ROC hypertonic saline trial. Emerg Med J 2014; 31(3):186-91. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Wang HE., Peitzman AB., Cassidy LD., Adelson PD., Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emer Med 2004; 44:439-50. Medline
III Opposes (Red) Survival to hospital discharge Patient PH-Paramedic Sobuwa S., Hartzenberg HB., Geduld H., Uys C. Outcomes following prehospital airway management in severe traumatic brain injury. S Afr Med J 2013; 103(9):644-646. Medline
X Not Yet Graded (White) - Kolaparambil Varghese LJ, Völlering JJ, De Robertis E, Hinkelbein J, Schmitz J, Warnecke T. Efficacy of endotracheal intubation in helicopter cabin vs. ground: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med May 2024; 32(1):40. Medline

Mannitol
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) All-cause mortality Patient ED-MD Burgess S., Abu-Laban RB., Slavik RS., Vu EN., Zed PJ. A systematic review of randomized controlled trials comparing hypertonic sodium solutions and mannitol for traumatic brain injury: Implications for emergency department management. Ann Pharmacother 2016; 50(4):291-300. Medline
I Neutral (Yellow) Mortality Patient ICU Miyoshi Y, Kondo Y, Suzuki H, Fukuda T, Yasuda H, Yokobori S. Effects of hypertonic saline versus mannitol in patients with traumatic brain injury in prehospital, emergency department, and intensive care unit settings: a systematic review and meta-analysis. J Intensive Care 2020; 8:61. Medline
I Neutral (Yellow) Systolic pressure change Process PH-Paramedic & CCT Sayre M., Daily S., Stern S., et al. Out-of-hospital administration of mannitol to head-injured patients does not change systolic blood pressure. Academic Emerg Med 1996; 3:840-8. Medline
I Neutral (Yellow) Mortality Patient ED-MD Wakai A., McCabe A., Roberts I., Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev 2013; 8:CD001049. doi: 10.1002/14651858.CD001049.pub5; 10.1002/14651858.CD001049.pub5. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic Wakai A., Roberts I., Schierhout G . Mannitol for traumatic brain injury (review). The Cochrane Library 2008, Issue 2. The Cochrane Library
X Not Yet Graded (White) - Codorniu A, Charbit E, Werner M, et al. Comparison of mannitol and hypertonic saline solution for the treatment of suspected brain herniation during prehospital management of traumatic brain injury patients. Eur J Emerg Med April 2024. Medline

Oxygen
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) In-hospital mortality Patient PH-Paramedic Hong WP, Hong KJ, Shin SD, Song KJ, Kim TH, et al. Association of Flow Rate of Prehospital Oxygen Administration and Clinical Outcomes in Severe Traumatic Brain Injury. J Clin Med 2021; 10(18). Medline

Plasma infusion
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) In-hospital Mortality Patient ED-MD Haltmeier T, Benjamin E, Gruen JP, Shulman IA, Lam L, Inaba K, et al. Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios. Injury 2018; 49(1):62-6. Medline
II Supportive (Green) Neurological outcome Patient PH-Paramedic & CCT Hernandez MC, Thiels CA, Aho JM, Habermann EB, Zielinski MD, Stubbs JA, et al. Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury. The journal of trauma and acute care surgery 2017; 83(3):398-405. Medline

Rapid Sequence Induction
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Mortality Patient PH-Paramedic Bulger E., Copass M., Sabath D., et al. The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J Trauma 2005; 58: 718-24. Medline
II Supportive (Green) Odds of death Process PH-Paramedic & CCT Davis DP., Ochs M., Hoyt DB., et al. Paramedic-administered neuromuscular blockage improves prehospital intubation success in severely head-injured patients. J Trauma 2003; 55:713-9. Medline
II Neutral (Yellow) In-hospital Mortality Patient PH-Paramedic Bendinelli C, Ku D, Nebauer S, King KL, Howard T, Gruen R, et al. A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury. ANZ J Surg 2018; 88(5):455-9. Medline
II Neutral (Yellow) Rate of oxygen desaturation/Hypoxia Patient PH-Paramedic Davis DP., Hwang JQ., Dunford JV. Rate of decline in O2 saturation at various pulse oximetry values with prehospital RSI. PEC 2008; 12:46-51. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Fouche PF., Jennings PA., Smith K., Boyle M., Blecher G., Knott J., et al. Survival in Out-of-hospital Rapid Sequence Intubation of Non-Traumatic Brain Pathologies. PEC 2017; 21(6):700-8. Medline
II Neutral (Yellow) Reduction in time from ED arrival to CT imaging in the setting of TBI Process PH-Paramedic Lansom JD., Curtis K., Goldsmith H., Tzannes A. The Effect of Prehospital Intubation on Treatment Times in Patients With Suspected Traumatic Brain Injury. Air Med J 2016; 35(5):295-300. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Davis DP., Hoyt DB., Ochs M., et al. The effect of paramedic RSI on outcome in patients with severe traumatic brain injury. J Trauma 2003; 54:444-53. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Davis DP., Stern J., Ochs M., Sise MJ., Hoyt DB. A follow-up analysis of factors associated with head-injury mortality after paramedic RSI. J Trauma 2005; 59:484-8. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Fevang E., Perkins Z., Lockey D., Jeppesen E., Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. Crit Care 2017; 21(1) 192. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Poste JC., Davis DP., Ochs M., et al. Air medical transport of severely head-injured patients undergoing paramedic rapid sequence intubation. Air Med J 2004; 23(4):36-40. Medline
III Supportive (Green) ETI success rate Process PH-Paramedic Ochs M., Davis D., Hoyt D., Bailey D., Marshall L., Rosen P. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med 2002; 40(2):159-67. Medline
III Neutral (Yellow) Incidence of post-intubation hypotension Process PH-Paramedic & CCT Fouche PF, Meadley B, St Clair T, Winnall A, Jennings PA, Bernard S, et al. The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out-of-hospital traumatic brain injury. Acad Emerg Med 2021. Medline
III Opposes (Red) Acute hemodynamic response Patient PH-MD & CCT Perkins ZB., Wittenberg MD., Nevin D., Lockey DJ., O'Brien B. The relationship between head injury severity and hemodynamic response to tracheal intubation. J Trauma Acute Care Surg 2013; 74(4):1074-80. Medline

Rate control
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Survival to DC Patient ICU Zangbar B., Khalil M., Rhee P., et al. Metoprolol improves survival in severe traumatic brain injury independent of heart rate control. J Surg Res. 2016;200(2):586-92. Medline

Restricted Crystalloids
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Odds of Mortality Process ED-MD Ko A., Harada MY., Barmparas G., Smith EJT., Birch K., Barnard ZR., et al. Limit Crystalloid Resuscitation after Traumatic Brain Injury. Am Surg 2017; 83(12) 1447-52. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Hussmann B., Heuer M., Lefering R., et al. Prehospital volume therapy as an independent risk factor after trauma. Biomed Res Int 2015; 354367. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Spaite DW, Hu C, Bobrow BJ, Chikani V, Sherrill D, Barnhart B, et al. Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold. JAMA surgery 2017; 152(4):360-8. Medline
III Neutral (Yellow) ICU mortality Patient PH-Paramedic Lenartova L., Janciak I., Wilbacher I., Rusnak M., Mauritz W, Austrian Severe TBI Study Investigators. Severe traumatic brain injury in Austria III: prehospital status and treatment. Wien Klin Wochenschr 2007; 119(1-2):35-45. Medline

RSI (CCT)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Glasgow Outcome Scale at 6 months Patient PH-Paramedic Bernard SA., Nguyen V., Cameron P., Masci K., Fitzgerald M., Cooper DJ., et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg 2010; 252(6):959-65. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Bulger E., Copass M., Sabath D., et al. The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J Trauma 2005; 58: 718-24. Medline
II Supportive (Green) Mortality Patient PH-MD & CCT Choffat C., Delhumeau C., Fournier N., Schoettker P. Effect of Pre-Hospital Intubation in Patients with Severe Traumatic Brain Injury on Outcome: A Prospective Cohort Study. Journal of clinical medicine 2019; 8(4). Medline
II Supportive (Green) Laryngoscopy view Process PH-Paramedic Lyon RM., Perkins ZB., Chatterjee D., Lockey DJ., Russell MQ., Kent, Surrey & Sussex Air Ambulance Trust. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care 2015; 19:134-015-0872-2. Medline
II Supportive (Green) Success rate Process PH-MD & CCT Naumann DN., McLaughlin A., Midwinter MJ., Crombie N. Prehospital rapid sequence induction following trauma in the era of regional networks for major trauma. European Journal of Emergency Medicine 2017; 24(4):243-8. Medline
II Supportive (Green) Intubation Success Rate Process PH-Paramedic & CCT Sloane C., Vilke G., Chan T., et al: Rapid sequence intubation in the field versus hospital in trauma patients. J Emerg Med 2000; 19:259-264. Medline
II Neutral (Yellow) 30-day mortality in trauma patients Patient ED-MD Breindahl N, Baekgaard J, Christensen RE, Jensen AH, Creutzburg A, Steinmetz J, et al. Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29(1):136. Medline
II Neutral (Yellow) Rate of oxygen desaturation/Hypoxia Patient PH-Paramedic Davis DP., Hwang JQ., Dunford JV. Rate of decline in O2 saturation at various pulse oximetry values with prehospital RSI. PEC 2008; 12:46-51. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Davis DP., Stern J., Ochs M., Sise MJ., Hoyt DB. A follow-up analysis of factors associated with head-injury mortality after paramedic RSI. J Trauma 2005; 59:484-8. Medline
II Neutral (Yellow) Reduction in time from ED arrival to CT imaging in the setting of TBI Process PH-Paramedic Lansom JD., Curtis K., Goldsmith H., Tzannes A. The Effect of Prehospital Intubation on Treatment Times in Patients With Suspected Traumatic Brain Injury. Air Med J 2016; 35(5):295-300. Medline
III Supportive (Green) Success rate Process PH-Paramedic & CCT Fakhry SM., et al. Prehospital RSI for Head Trauma: conditions for a successful program. J Trauma 2006; 60:997-1001. Medline
III Supportive (Green) ETI success rate Process PH-Paramedic Ochs M., Davis D., Hoyt D., Bailey D., Marshall L., Rosen P. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med 2002; 40(2):159-67. Medline
III Neutral (Yellow) 30 day mortality Patient PH-Paramedic & CCT Mansvelder FJ, Bossers SM, Loer SA, et al. Etomidate versus Ketamine as prehospital induction agent in patients with suspectedsevere traumatic brain injury. Anesthesiology January 2024. Medline

TBI Score
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Predictive Value Process PH-Paramedic Gang MC, Hong KJ, Shin SD, Song KJ, Ro YS, Kim TH, et al. New prehospital scoring system for traumatic brain injury to predict mortality and severe disability using motor Glasgow Coma Scale, hypotension, and hypoxia: a nationwide observational study. Clin Exp Emerg Med 2019; 6(2):152-9. Medline
II Neutral (Yellow) Predictive Value Process PH-Paramedic van Rein EAJ, Jochems D, Lokerman RD, van der Sluijs R, Houwert RM, Lichtveld RA, et al. Diagnostic value of emergency medical services provider judgement in the identification of head injuries among trauma patients. Eur J Neurol 2019; 26(2):274-80. Medline

Tranexamic acid for isolated TBI
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Mortality Patient PH-Paramedic Coburn W, Trottier Z, Villarreal RI, Paulson MW, et al. Prehospital Pharmacotherapy in Moderate and Severe Traumatic Brain Injury: A Systematic Review. Med J (Ft Sam Houst Tex) 2023; (Per 23-1/2/3):47-56. Medline
I Supportive (Green) mortality Patient ED-MD CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. 2019; ahead of print Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic Brito AMP, Schreiber MA, El Haddi J, Meier EN, Rowell SE. The Effects of Timing of Prehospital Tranexamic Acid on Outcomes after Traumatic Brain Injury; Sub Analysis of a Randomized Controlled Trial. J Trauma Acute Care Surg 2022. Medline
I Neutral (Yellow) Favorable neurological outcome at 6 months. Patient ED-Paramedic & MD Rowell, Susan E et al. “Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.” JAMA vol. 324,10 (2020): 961-974. doi:10.1001/jama.2020.8958 Medline
II Neutral (Yellow) Overall mortality Patient PH-Paramedic Biffi A, Porcu G, Castellini G, et al. Systemic hemostatic agents initiated in trauma patients in the pre-hospital setting: a systematic review. Eur J Trauma Emerg Surg Dec 2022. Medline
II Neutral (Yellow) Adverse events Process In-Patient Harmer JW, Dewey EN, Meier EN, Rowell SE, Schreiber MA. Tranexamic acid is not inferior to placebo with respect to adverse events in suspected traumatic brain injury patients not in shock with a normal head computed tomography scan: A retrospective study of a randomized trial. J Trauma Acute Care Surg 2022. Medline
II Neutral (Yellow) 28 Day Mortality Patient PH-Paramedic Hoefer LE, Benjamin AJ, Polcari AM, Schreiber MA, Zakrison TL, Rowell SE. TXA does not affect levels of TBI-related biomarkers in blunt TBI with ICH: A secondary analysis of the Prehospital TXA for TBI Trial. J Trauma Acute Care Surg October 2023. Medline
II Opposes (Red) 30 day mortality Patient PH-MD & CCT Bossers SM, Loer SA, Bloemers FW, Den Hartog D, Van Lieshout EMM, Hoogerwerf N, et al. Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury. JAMA Neurol 2021; 78(3):338-45. Medline
X Not Yet Graded (White) - Deshpande DV, McKinley WI, Benjamin AJ, Schreiber MA, Rowell SE. The Association Between Tranexamic Acid and Seizures in Moderate or Severe Traumatic Brain Injury. J Surg Res. July 2024; 301:359-64. Medline
X Not Yet Graded (White) - Newman ZC, Ogbeifun VO, Barbosa CE, et al. Intravenous Versus Intraosseous Use of Tranexamic Acid in Patients With Traumatic Brain Injury. J Surg Res Sept 2024; 302:798-804. Medline

Tranexamic acid poly trauma including TBI
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Overall mortality at 24 hours and at 1 month. Patient PH-Paramedic Biffi A, Porcu G, Castellini G, et al. Systemic hemostatic agents initiated in trauma patients in the pre-hospital setting: a systematic review. Eur J Trauma Emerg Surg Dec 2022. Medline
II Neutral (Yellow) Patient benefit Patient PH-Paramedic Coburn W, Trottier Z, Villarreal RI, Paulson MW, et al. Prehospital Pharmacotherapy in Moderate and Severe Traumatic Brain Injury: A Systematic Review. Med J (Ft Sam Houst Tex) 2023; (Per 23-1/2/3):47-56. Medline
II Neutral (Yellow) Seizure within 72 hours Patient Other Deshpande DV, McKinley WI, Benjamin AJ, Schreiber MA, Rowell SE. The Association Between Tranexamic Acid and Seizures in Moderate or Severe Traumatic Brain Injury. J Surg Res. July 2024; 301:359-64. Medline
II Neutral (Yellow) In-hospital Mortality Patient PH-Paramedic Van Wessem KJP, Jochems D, Leenen LPH. The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury. Eur J Trauma Emerg Surg 2021; 1–11. Medline
X Not Yet Graded (White) - Rowell S, Meier EN, Gomez TH, Fleming M, et al. The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: a subgroup analysis from the prehospital TXA for TBI trial. J Trauma Acute Care Surg April 2024. Medline


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