Abstract：
Traumatic brain injury (TBIs) necessitates a rapid and comprehensive medical response to minimize secondary brain injury and reduce mortality. Emergency medical services (EMS) clinicians serve a critical role in the management of prehospital TBI, responding during an initial phase of care with significant impact on patient outcomes. We used versions two and three of the Brain Trauma Foundation (BTF) Prehospital Guidelines for the Management of Traumatic Brain Injury and the NASEMSO National Model Clinical Guidelines to determine key elements for a TBI prehospital protocol and included common factors across sources such as recommendations concerning patient monitoring, hypoxia, hypotension, hyperventilation, cerebral herniation, airway management, hyperosmolar therapy, and transport destination. We then conducted a cross-sectional evaluation of publicly available statewide EMS clinical protocols in the US to determine the degree of alignment with national guidelines. We calculated descriptive statistics for each factor in the state protocols. Despite adoption of some evidence-based recommendations for a standard approach to the prehospital management of patients with TBI, we found significant variability in statewide EMS treatment protocols for management of severe TBI, especially in the recommended frequency of patient reassessment and for the management of suspected herniation. Most statewide protocols provided guidance regarding oxygenation, ventilation, and blood pressure management that aligned with evidence-based guidelines. While most protocols did address management of oxygenation and ventilation, one in four protocols had no specific guidance for managing hypoxia and only 31% of protocols recommended avoiding hyperventilation. For the management of suspected cerebral herniation, over half of statewide protocols recommended hyperventilation, whereas only 31% explicitly advised against hyperventilation regardless of TBI severity. Interestingly, 94% of protocols do not mention the use of hyperosmolar therapy for TBI patients, neither recommending use or avoidance of hyperosmolar therapy. In conclusion, we found inconsistent adoption of national recommendations in available statewide protocols for prehospital TBI management. We identified significant gaps and variation in statewide protocols regarding patient monitoring and reassessment, as well as in several key areas of severe TBI management.
摘要：
创伤性脑损伤（TBI）需要快速而全面的医学反应，以最大程度地减少继发性脑损伤并降低死亡率。急诊医疗服务（EMS）临床医生在院前TBI的管理中起着至关重要的作用，在初始护理阶段的反应对患者预后有重大影响。我们使用了脑外伤基金会（BTF）院前创伤性脑损伤管理指南和NASEMSO国家示范临床指南的第二和第三版本，以确定TBI院前方案的关键要素，并包括了跨来源的共同因素，例如有关患者监测的建议。缺氧,低血压,换气过度,脑疝,气道管理,高渗疗法,和运输目的地。然后，我们对美国公开的全州EMS临床方案进行了横断面评估，以确定与国家指南的一致性程度。我们计算了州协议中每个因素的描述性统计数据。尽管对TBI患者的院前管理标准方法采用了一些基于证据的建议，我们发现全州范围内的EMS治疗方案对严重TBI的管理有显著差异，特别是在推荐的患者重新评估频率和可疑脑疝的处理中。大多数州范围内的协议都提供了有关氧合的指导，通风,和符合循证指南的血压管理。虽然大多数协议确实涉及氧合和通气的管理，四分之一的方案没有治疗缺氧的具体指导,只有31%的方案建议避免过度换气.对于疑似脑疝的治疗，超过一半的全州协议推荐换气过度,而无论TBI的严重程度如何，只有31％的人明确建议不要过度通气。有趣的是,94%的方案没有提到对TBI患者使用高渗性治疗，既不建议使用或避免高渗疗法。总之,我们发现,在现有的全州范围内的院前TBI管理方案中,国家建议的采纳不一致.我们确定了全州范围内有关患者监测和重新评估的协议的重大差距和差异，以及严重TBI管理的几个关键领域。
