Avoiding the Three `H Bombs` of Prehospital TBI Management

Across the United States, traumatic brain injury (TBI) leads to 2.2 million emergency department visits, 280,000 hospitalizations, 52,000 deaths, and more than $60 billion in economic costs annually, according to the National Center for Injury Prevention and Control. Yet despite the undeniable consequences, research relating to evidence-based prehospital treatment is limited.

Ben Bobrow, MD, recently named chair of the UTHealth McGovern Medical School's Department of Emergency Medicine in Texas, is on a mission to stress the critical role of evidence-based prehospital TBI management in saving lives and maximizing long-term functional outcomes.

Bobrow collaborated with lead author Daniel Spaite, MD, professor and Virginia Piper Distinguished Chair of Emergency Medicine at the University of Arizona, on the Excellence in Prehospital Injury Care (EPIC) study, a widespread initiative conducted in partnership with the Arizona Department of Health Services. The project was funded by a $3.6 million grant from the National Institute of Neurological Disorders and Stroke (NINDS). EPIC trained EMS agencies across Arizona on current evidence-based TBI guidelines and compared patient outcomes before and after guideline implementation. All patients in the study experienced head injury with loss of consciousness.

After investigators reviewed encounters with 21,000 prehospital TBI patients, results showed that implementing the TBI guidelines did not affect overall survival in the group, which included patients who experienced moderate, severe, and critical injuries. 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 showed a tripling of survival in a subset of severe patients who required intubation," Bobrow says. "That's remarkable. It's not every day as a researcher that you see such a powerful difference in a study group."

Since 2012 EPIC has certified more than 600 master trainers, who have in turn trained over 11,000 frontline EMTs and paramedics across 130 agencies in the state, Bobrow says. The study was published May 8 in JAMA Surgery: The Journal of the American Medical Association.

The Three ‘H Bombs’

Through EPIC, first responders are taught to treat and prevent the three "H bombs” that lead to irreversible brain damage and potentially death following a brain injury.

• Hyperventilation—Prior to the implementation of EPIC, first responders were taught to hyperventilate people with a TBI, explains Bobrow. However, recent research has shown that while hyperventilation lowers intracranial pressure, it deprives the brain of blood and oxygen.
• Hypotension—Fast administration of IV fluids can prevent blood pressure from dropping to dangerous levels, thus keeping brain cells alive during rapid transport to a trauma center.
• Hypoxia—To combat hypoxia, which drastically increases the risk of death, first responders are taught to place high-flow oxygen on patients as soon as possible.

An Enormous Opportunity

Now that the study has been out for almost two months, Bobrow’s priority has shifted to disseminating the findings, stressing the importance of rigorous ongoing QI initiatives related to this patient population, helping EMS systems allocate resources, and making sure the lessons of EPIC don’t become lost to the next headline-grabbing study.

"I am committed to the widespread implementation of EPIC," Bobrow says. "How do we follow through?" The remarkable message of EPIC, stresses Bobrow, is that it validates a return to basic tenets of prehospital care for brain-injured patients. These are steps EMS services both small and large can take today to begin making a profound difference in their communities.

“The beauty of EPIC was that it only involved simple interventions. This wasn’t a million-dollar ‘un-obtainium’ drug,” says Spaite. “The EMS providers already know how to put oxygen on a patient and how to initiate IVs and how to intubate and ventilate. EPIC simply taught them how to optimize the use of these treatments for maximum benefit to the patients. It’s just those three simple interventions, done right.”

"What I want to happen is [that] people build it into the culture of their organization," concludes Bobrow, adding that because TBI affects children in their primes as well as the elderly, it increases the burden on families and health systems to care for them. "We have an enormous opportunity to make a profound impact on one of the leading causes of death in this country. Just like high-performance CPR, we have to insert this into the fiber of our organizations."

For a narrated training video depicting the steps of TBI care outlined in the EPIC project click here.

Jonathan Bassett is editorial director of EMS World. Reach him at jon@emsworld.com.