Emergency
treatment guidelines improve survival of people with severe head injury

NewYork. 08^th
May 2019. A large study of more than 21,000 people finds that training
emergency medical services (EMS) agencies to implement prehospital guidelines
for traumatic brain injury (TBI) may help improve survival in patients
with severe head trauma. The findings were published in JAMA Surgery, and the
study was supported by the National Institute of Neurological Disorders and
Stroke (NINDS), part of the National Institutes of Health.  

“This
demonstrates the significance of conducting studies in real-world settings and
brings a strong evidence base to the guidelines,” said Patrick Bellgowan,
Ph.D., program director at NINDS. “It suggests we can systematically increase
the chances of saving lives of thousands of people who suffer severe traumatic
brain injuries.”

Based on
scores of observational studies, guidelines for prehospital management of
TBI that were developed in 2000, and updated in 2007, focused on preventing
low oxygen, low blood pressure, and hyperventilation in people with head
injury. Collectively, the studies suggested that controlling those factors
before patients arrived at the hospital could improve survival, but actual
adherence to the guidelines had not been examined.

The Excellence
in Prehospital Injury Care (EPIC) Study, led by Daniel Spaite, M.D.,
professor of emergency medicine at the University of Arizona in Tucson, trained
EMS agencies across Arizona in the TBI guidelines and compared patient outcomes
before and after the guideline implementation.

All patients
in the study experienced head injury with loss of consciousness. This public
health initiative was a collaboration between the university and the Arizona
Department of Health Services. The EPIC study is the first time that the
guidelines were assessed in real-world conditions.

The results showed that implementing the guidelines did not affect overall survival of the entire group, which included patients who had moderate, severe, and critical injuries.

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However,
further analysis revealed that the guidelines helped double the survival rate
of people with severe TBI and triple the survival rate in severe TBI patients
who had to have a breathing tube inserted by EMS personnel. The guidelines were
also associated with an overall increase in survival to hospital admission.

“We found a therapeutic sweet spot and showed that the guidelines had an enormous impact on people with severe TBI. The guidelines did not make a difference in the moderate TBI group because those individuals would most likely have survived anyway and, unfortunately, the extent of injuries sustained in many critical patients was too extreme to overcome,” said Dr. Spaite.

Bentley
Bobrow, M.D., professor of emergency medicine at the University of Arizona and
co-principal investigator for the study said, “It was exciting to see such
dramatic outcomes resulting from a simple two-hour training session with EMS
personnel.”  

Although the
guidelines provide specific recommendations for oxygen levels and blood
pressure, researchers will examine whether those ranges should be revised. More
research is needed to determine the best strategies for airway management and
breathing support to optimize ventilation. Additional studies will investigate
the best methods for national and global adoption of the TBI guidelines.

This work was supported by the NINDS.