Strength of Recommendations: Weak.
Quality of Evidence: Low, from Class III studies, contradictory findings, and indirect evidence.

Adult

1. All regions should have an organized trauma care system.
2. Protocols are recommended to direct Emergency Medical Service (EMS) personnel regarding destination decisions for patients with severe traumatic brain injury (TBI).
3. Patients with severe TBI should be transported directly to a facility with immediately available CT scanning, prompt neurosurgical care, and the ability to monitor intracranial pressure (ICP) and treat intracranial hypertension.
4. The mode of transport should be selected so as to minimize total prehospital time for the patient with TBI.

Pediatrics

1. In a metropolitan area, pediatric patients with severe TBI should be transported directly to a pediatric trauma center if available.
2. Pediatric patients with severe TBI should be treated in a pediatric trauma center or in an adult trauma center with added qualifications to treat children in preference to a Level I or II adult trauma center without added qualifications for pediatric treatment.

Prehospital recognition of TBI and the subsequent response are paramount to the patients' recovery. Decisions made in the prehospital setting by EMS dispatchers and care providers in the field occur in a stepwise fashion, and include:

1. Information gathered by EMS call-takers and dispatchers to determine if a patient potentially has a significant brain injury.
2. Dispatcher decisions about the type of personnel to be dispatched, resources to be deployed, and assignment of priority for a response.
3. Prehospital care provider assessment of the overall neurologic situation through evaluation of the mechanism of the injury (i.e., vehicular deformation, windshield violation, the use or nonuse of seat belts or other safety devices), the scene, and the patient examination.
4. Based on the overall assessment, prehospital interventions are initiated to prevent or correct hypotension or hypoxemia and to address other potential threats to life or limb. At this step, the decision regarding the level of responder dispatched to the scene impacts patient care.
5. Prehospital care providers select a transport mode (e.g., ground ambulance versus helicopter, red lights and siren versus neither).
6. Prehospital care providers select the appropriate destination facility.

For this update Medline was searched from 1996 through July 2006 using the search strategy for this question (see Appendix B), and results were supplemented with literature recommended by peers or identified from reference lists. For adult studies, of 39 potentially relevant publications, 10 were added to the existing table and used as evidence for this question. For pediatric studies, of 14 potentially relevant publications, 2 were included as evidence for this topic (see Evidence Tables).

Adult

1. All regions should have an organized trauma care system.
2. Protocols are recommended to direct Emergency Medical Service (EMS) personnel regarding destination decisions for patients with severe traumatic brain injury (TBI).
3. Patients with severe TBI should be transported directly to a facility with immediately available CT scanning, prompt neurosurgical care, and the ability to monitor intracranial pressure (ICP) and treat intracranial hypertension.
4. The mode of transport should be selected so as to minimize total prehospital time for the patientwith TBI.

Foundation

Dispatch

While there is no definitive evidence that formal interrogation of callers requesting emergency aid (i.e., calls to 9-1-1 or the local emergency access number) can assist dispatchers in accurately identifying TBI patients, evidence for other disease processes supports its potential for TBI patients.12 It is critical for a well functioning EMS system to consistently match the right providers to the patient. Formalized interrogation of callers by specially trained dispatchers is capable of sorting patients based on need.2,6,25 However, other researchers have found that the accuracy is not as high compared to the findings of providers who evaluate the patient for need in person.20,22 This discrepancy indicates that the ideal interrogation system may not yet have been developed.

A secondary roll of emergency medical dispatchers is their ability to provide pre-arrival instructions. At this time it is unknown what instructions, if any, dispatchers could provide to callers that might improve outcomes for patients with TBI. However, it has been shown that callers expect to receive instructions from the dispatchers.4

Level of Care

Determining the necessary resources to send to the scene depends on the effect those resources will have on patient outcome. The primary choice is the level of care that is needed. This has traditionally been stated as basic life support (BLS) or advanced life support (ALS). However, since the skills taught to BLS and ALS providers can vary by state and even by region it is difficult to provide a universal definition for these provider types.

In a study by Di Bartolomeo and colleagues in Italy, outcome of TBI patients cared for by nurses who transported by ground ambulance was compared to physicians treatment in helicopter transport.8 The authors found no significant difference in patient outcome between the transport protocols. Lee et al. looked at mortality from TBI among those treated and transported by BLS providers compared to those treated and transported by paramedic or physician level providers.15 This group found no significant difference in outcome among patients admitted to the intensive care unit. Those who died in the first 24-hours were more likely to have been treated and transported by physicians or paramedics, but this finding may have been due to selection bias since the dispatch process selected the more severely injured for their response. Therefore, the most appropriate level of provider to care for a patient with TBI is unknown.

Identification of Traumatic Brain Injury

Recognition of patients who have a high potential for TBI involves consideration of physiologic (e.g., GCS score) and anatomic (e.g. depressed skull) signs and symptoms as well as mechanisms of injury (e.g., falls of greater than 20 feet) that result in sufficient force to increase the potential for injury.

In general, the American College of Surgeons Committee on Trauma Field Triage Decision Scheme is used by most states to identify patients that require transport to a trauma center.24,26

Transport Mode

Determining the most appropriate mode of transport requires providers to determine whether to transport the patient by ground ambulance or helicopter and if the patient is transported by ground ambulance whether or not to use lights and siren. The primary advantage of one transport mode over another is a reduction in transport time. However, the entire prehospital time interval must be considered and not just the time interval from departure from the scene to arrival at the hospital.

The effect of delayed prehospital time on outcome from TBI is unknown. Prehospital providers are typically trained that all patients must be transported so that they are able to receive surgery within the first hour after injury. This concept, referred to as the golden hour, is an excellent teaching tool for prehospital providers but the exact effect of time on patient outcome is unknown.16

It has been shown that acute subdural hematomas in severe TBI patients are associated with a 90% mortality if the patient undergoess surgery more than 4 hours after injury, and 30% mortality if evaluated earlier.28 One study reported a 70% decrease in mortality if subdural evaluation is performed within two hours of injury.29 Wilberger et al. evaluated the effect of time from injury to operative care among patients with subdural hematoma.27 They found no statistically significant difference. However, for those patients who were treated within 4 hours there was a 10% absolute reduction in mortality compared to those treated greater than 4 hours. Further, this study only looked at time to operative treatment and did not look at the potential positive effects of other hospital interventions that were being provided earlier. In the study conducted by Di Bartolomeo, described above, there was an almost 60 minute difference in time to arrival at the receiving facility, yet the authors did not identify a difference in patient outcome.8 Lokkeberg and Grimes, while controlling for confounding variables like injury severity score, found that among patients with severe blunt TBI time to definitive care was not a significant predictor of patient outcome.17

Alternatively, Baxt and Moody found a 9% reduction in mortality for TBI patients transported by helicopter compared to ground ambulance.3 In the Baxt study, helicopters were staffed by a physician and a nurse, while the ground ambulance was staffed by a paramedic. Davis et al. assessed 10,314 patients with a head Abbreviated Injury Score of 3 or more and found that those who were transported by helicopter had a better odds of survival (1.90; 95% confidence interval 1.6 to 2.25) compared to ground transport, after controlling for a number of potential confounding variables.7

Transport Destination

Evidence suggests that mortality for TBI patients decreases when patients are transferred directly to a Level I trauma center.19 In most regions the treatment destination decision is made in the context of a formalized trauma system. In comparisons between organized and nonorganized EMS and trauma systems, patient outcome was worse without organization.4,20 Although the need for the immediate attention of a neurosurgeon has been questioned,9 recent literature about general trauma patients suggests that the outcomes for trauma patients improve when they are treated at a Level I trauma center.18

A retrospective study that compared TBI outcome before and after the implementation of a trauma system in Oregon reported an odds ratio of 0.80 for mortality after system implementation.30 A report of preventable deaths in San Diego County compared non-TBI and TBI deaths before and after instituting a regional trauma care system.10 Reviewers were blinded to the facility where care was rendered. Preventable deaths for non-TBI cases decreased from 16/83 (20%) to 2/211 (1%) (p < 0.005), and for TBI cases, preventable deaths decreased from 4/94 (5%) to 1/149 (0.7%) (p < 0.10), respectively, before and after the trauma system was put in place. Another before-and-after study compared outcome of injured patients in a rural hospital before it met American College of Surgeons Committee on Trauma guidelines for a level II trauma center with outcome after it received that designation.21 Survival for all patients who had a calculated probability of survival of 25% was 13% before and 30% after meeting Level II trauma center criteria. For patients with TBI, the survival was 15.4% before and 32% after meeting the criteria. In New York State, Hannan found that patients with TBI had lower odds of death (0.67, 95% confidence interval 0.53-0.85) when treated at a regional trauma center compared to other hospitals.11 Cornwell et al., evaluated the change in trauma patient mortality using a before-and-after design to determine the effect of having made systematic changes to achieve a Level I trauma center designation.5 Among severe TBI patients they found a 7% decrease in mortality rates that was not statistically significant. Finally, Hunt et al., compared survival rates among TBI patients before and after a regionalized trauma system was put into place. They found that mortality fell from 42% to 26%, but this difference was not statistically significant.13

Pediatrics

1. In a metropolitan area, pediatric patients with severe TBI should be transported directly to a pediatric trauma center if available.
2. Pediatric patients with severe TBI should be treated in a pediatric trauma center or in an adult trauma center with added qualifications to treat children in preference to a Level I or II adult trauma center without added qualifications for pediatric treatment.

Foundation. There is no new information specific to prehospital care of pediatric patients since the publication of the Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents.1 The recommendations for this publication are duplicated from the pediatric guidelines.

Johnson et al. conducted a prospective, nonrandomized comparison of mortality among admitted patients, some of whom were transported directly to Children's Hospital in Washington, D.C. (CHOW), a Level I PTC, and some of whom were first transported to other hospitals and then transferred to CHOW.14 Patients included children from1 to 12 years of age treated in neurosurgical services between 1985 and 1988.

Fifty-six severe TBI patients received direct transport and 42 received indirect transport. However, statistical significance was only reported for the overall group, which included patients with mild and moderate TBI. Mortality rate for all patients was significantly greater in the Indirect Transport group (4.7%) than the Direct Transport group (1.9%).

The trauma score was significantly higher in the Direct Transport group (9) than the Indirect Transport group (7), indicating that the patients in the latter group were less stable physiologically, and constituting a baseline difference between groups. Authors suggest, however, that this is better viewed as an outcome than a baseline difference; that the physiological deterioration occurred as a function of delays in appropriate treatment due to the transfer.

This Class III study suggests that in this metropolitan area, pediatric patients with severe TBI are more likely to survive if transported immediately to a PTC than if transported first to another type of center and then transferred to a PTC.

Potoka et al.23 conducted a retrospective review of medical records of patients 0 to 16 years old treated at pediatric or adult trauma centers in the state of Pennsylvania between 1993 and 1997. Four patient groups were specified, according to the type of trauma center in which they were treated:

While the study included patients with mild and moderate TBI, this evaluation is baseduponthe patients with severe TBI (GCS from 3 to 8). Dependent variables were mortality, number of neurosurgical procedures, and mortality for patients who received neurosurgical procedures.

Method of and criteria for referral and transfer within the statewide system were not discussed in this study. Distributions for injury severity based upon injury severity score (ISS) were presented for the parent group of all traumas, but not for the subgroup of TBI. This Class III study suggests the following:

1. Pediatric patients with severe TBI are more likely to survive if treated in PTCs, or ATC AQs, than in Level I or Level II ATCs.
2. The pediatric patient with severe TBI who requires neurosurgical procedures has a lower chance of survival in Level II ATCs vs. the other centers.

Prospective, controlled Class I and II studies are needed to answer the following questions:

1. Can dispatchers accurately identify patients with TBI by interrogating callers? What questions are critical in determining the best resources to send to the scene? How do dispatch decisions affect patient outcome?
2. What pre-arrival instructions for callers who request emergency aid can improve patient outcome?
3. What effect do prehospital assessment, treatment, transport, and destination decisions have on the outcome of the patient with severe TBI?
4. Howis outcome affected when patients are treated by organized EMS systems within a trauma system vs. EMS systems without a trauma system? These studies should evaluate the various levels of EMS provider training and hospital preparation, and include patients with different degrees of severity of injury.
5. What is the impact of transport time on the outcome of patients with TBI, and under what conditions should a closer hospital be bypassed in order to bring a patient to a trauma center?
6. What are the minimum requirements for a facility that treats patients with severe TBI?
7. What is the optimum destination for patients with mild-to-moderate TBI based on patient outcome?
8. What specifically should prehospital TBI transportation destination guidelines include, and how can they be kept current, as new safety devices are introduced and engineering changes are made in vehicles and other places where injuries occur?