There is insufficient evidence to support an evidence-based recommendation for what patient and scene-related factors indicate a definitive airway is needed compared with no or non-invasive ventilation.

In the absence of direct scientific evidence, EXPERT CONSENSUS concluded that:

• A prehospital definitive airway (endotracheal intubation) should be initiated to improve outcomes when the Glasgow Coma Scale (GCS) is < 8, the airway is compromised due to associated maxillofacial trauma, or with longer transport times to the hospital. Definitive airway should be performed by appropriately trained prehospital personnel and with the use of accompanying O2 saturation monitoring, ETCO₂ monitoring, and frequent blood pressure monitoring. (96.7% consensus)
• Practitioners should adhere to the recommendations of the Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition36 and Brain Trauma Foundation (BTF) 4th edition adult Severe Traumatic Brain Injury (TBI) guidelines28 concerning prehospital and emergency department resuscitation strategies. (100% consensus)
• Select patients with penetrating TBI should undergo lateral decubitus positioning and close monitoring of oxygenation and ventilation or prehospital definitive airway placement. Select patients include those with wounds into the oropharynx associated with significant hemorrhage and airway compromise. (96.7% consensus)

No evidence or expert opinion supported distinct recommendations based on patient gender, age, wounding mechanism, or military vs. civilian context.

Prehospital airway management for patients with TBI has undergone intensive study. However, the published literature offers limited information to support recommendations specifically tailored to penetrating traumatic brain injury (pTBI). pTBI patients often present with specific conditions, such as open wounds that may extend into the oropharynx, accompanied by bleeding that could compromise the airway, especially in individuals who are obtunded. Additionally, open wounds penetrating the cranial vault may lead to massive external bleeding, hypovolemic shock, and an inability to tolerate positive pressure ventilation prior to achieving bleeding control and resuscitation with blood products. Exposure of the neck for penetrating injuries, and prompt removal of cervical collars without clinical or computed tomography (CT) evidence of cervical spine injury are important considerations.

The previous edition of the pTBI guidelines16 did not address what patient and scene-related factors indicate a definitive airway is needed compared with no or non-invasive ventilation. All recommendations of the 2023 Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition36 also apply to pTBI, with the additional considerations related to external bleeding as listed above. Note that the 2023 Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition36 do not recommend intubation for all TBI patients in the prehospital environment.

There are no prospective studies of airway management specific to pTBI. One study met inclusion criteria for inclusion as evidence for this topic (Table 4). This study by Kaufman et al37 studied gunshot wounds (GSW) to the head and reported intubation rates by whether the patient was admitted directly to the treating hospital or referred from another hospital and whether the patient was transported via ground or helicopter.37 This study was a retrospective review of 143 cases of gunshots wounds to the head treated by neurosurgery in one hospital in Houston, Texas between January 1980 and June 1982 that were entered into a national trauma registry. Whether patients were intubated or not before arriving at the hospital emergency department (ED) was known for 50 (35%) of the patients. Of these, most (80%) were intubated before arriving. Patients arriving directly by helicopter were more likely to be intubated (96%) than patients arriving by ground transportation (17%) or patients referred from another hospital (76%) who arrived by either mode of transport.

Six additional studies in patients with pTBI are noted which did not meet criteria for formal inclusion as evidence for this topic. These studies report intubation for various reasons (being comatose or obtunded,38-41 not following commands,42 respiratory distress,41,43 and low Glasgow Coma Scale score44) but did not provide any detail that allowed inclusion as evidence.

Another retrospective study reported that airway control was often required in GSW to the face (29.5% of 247 patients were intubated in the ED) but less than 10% of patients in this study also had a brain injury (not specified whether closed or penetrating) and the airway status for these patients was not reported separately.45 Three reports of single cases provide minimal additional information in descriptions of definitive airways in initial management.39,46,47

The management of patients with pTBI presents unique challenges compared to those with non-penetrating TBI. Given the complexity and critical nature of these injuries, especially when open wounds extend into the oropharynx or penetrate the cranial vault, leading to potential airway compromise and hemorrhagic shock, the Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition offers essential guidance.36 These guidelines emphasize the importance of early intervention to prevent hypoxia, hyperventilation, and hypotension, which are pivotal in improving outcomes for pTBI patients.

The prior pTBI guidelines did not specifically address the factors indicating the need for a definitive airway in pTBI patients, highlighting a gap in the literature. However, the recommendations provided, based on existing studies and expert consensus, offer a framework for managing these critical conditions. Specifically, the guidelines underscore the importance of continuous oxygenation, monitoring, and appropriate airway management techniques to mitigate the severe consequences of pTBI. Scientific evidence, including retrospective studies on GSW to the head and the use of airway control in facial GSW, underscores the prevalence of intubation in these scenarios. These findingss, albeit limited, point to the necessity of a definitive airway in certain pTBI cases, particularly in the context of comatose or obtunded states, respiratory distress, and low GCS scores.

A critical aspect of managing pTBI involves decisions related to airway management. Despite the lack of strong evidence to recommend specific patient and scene-related factors to determine the need for a definitive airway over no or non-invasive ventilation, several key insights emerge from the literature and expert consensus. For instance, a definitive prehospital airway is likely to enhance outcomes in situations where prehospital providers are proficient in airway placement, when the GCS score is below 8 due to pTBI, in the presence of maxillofacial trauma compromising the airway, or during longer transports to medical facilities. Implementing oxygen saturation and ETCO₂ monitoring, along with frequent blood pressure monitoring, is advised as soon as possible after the injury and prior to establishing a definitive airway.

The expert consensus further clarifies practices in the absence of direct evidence. Adherence to the Prehospital Guidelines for the Management of Traumatic Brain Injury36 is recommended, along with specific interventions for pTBI patients. For example, cervical collars are deemed unnecessary in isolated pTBI without clinical or CT evidence of cervical spine injury. Additionally, in cases of significant hemorrhage and airway compromise, especially with wounds into the oropharynx, lateral decubitus positioning, close monitoring, or prehospital definitive airway placement may be necessary. In situations of hemorrhagic shock or massive external bleeding, controlling the bleeding and resuscitation with blood products precede the initiation of intubation as long as an airway can be maintained.

Future studies of TBI patients should clearly report the number of blunt vs penetrating TBI patients included and consider reporting specific characteristic of each sub-population as well as the outcome of each along with the outcome of the overall population. As sub-populations may not achieve statistical significance, it is also important to implement multi-center collaborative studies comparing the early treatment of both blunt and penetrating TBI patients. There is a need for randomized control trials (RCT) and comparative studies to evaluate the effectiveness of different airway management strategies (e.g., supraglottic airway devices vs endotracheal intubation) specifically in pTBI patients. This research should consider patient outcomes, the feasibility of implementation in prehospital settings, and the training required for emergency medical personnel.