Prehospital Guidelines for the Management of Traumatic Brain Injury – 3rd Edition

This 3rd Edition of the Brain Trauma Foundation's prehospital guidelines provides an evidence-based framework for the management of traumatic brain injury (TBI) from the point of injury through hospital handoff. Recognizing that TBI is a leading cause of morbidity and mortality worldwide, the expert workgroup utilized a systematic review of literature from 2005 to 2021 to update clinical recommendations for assessment, treatment, and system-level decision-making.

The guidelines emphasize the prevention of secondary brain injury—pathophysiologic insults such as hypoxia, hypotension, and hyperventilation that occur after the primary trauma. The workgroup stresses that prehospital providers should move beyond historical thresholds. For instance, systolic blood pressure targets should be maintained at 110 mmHg or higher for adults, and oxygen saturation should be kept at 90% or greater. The document highlights the importance of continuous monitoring, including capnography to avoid hypocapnia, and the use of standardized assessment tools like the Glasgow Coma Scale (GCS) and pupillary exams to guide triage and prognosis.

The guidelines advocate for a stepwise approach to airway management, prioritizing oxygenation and ventilation before considering advanced airway maneuvers. If intubation is required, providers must confirm placement with waveform capnography and avoid hyperventilation, which is associated with worse outcomes. Regarding system-level care, the guidelines recommend that patients with moderate-to-severe TBI be transported to facilities with immediate neurosurgical and CT imaging capabilities. Pediatric patients should ideally be directed to specialized pediatric trauma centers.

Prehospital care is the first link in the chain of survival for TBI patients. By standardizing practices—such as the active correction of physiological derangements and the appropriate triage to trauma-capable centers—EMS systems can significantly reduce the incidence of secondary brain injury. This update provides a clear, actionable roadmap for EMS agencies to improve the quality of care and, ultimately, the survival rates of patients suffering from TBI.