Intended for healthcare professionals

Clinical Review

Prehospital management of severe traumatic brain injury

BMJ 2009; 338 doi: (Published 19 May 2009) Cite this as: BMJ 2009;338:b1683
  1. Clare L Hammell, specialist registrar anaesthesia and intensive care medicine13,
  2. J D Henning, consultant anaesthesia and intensive care23
  1. 1Royal Liverpool University Hospital, Liverpool L7 8XP
  2. 2James Cook University Hospital, Middlesbrough TS4 3BW
  3. 3Great North Air Ambulance Service, Darlington DL1 5NQ
  1. Correspondence to: C Hammell cham37uk{at}
  • Accepted 23 February 2009

Summary points

  • Management of severe traumatic brain injury is focused on rapid transfer to secondary care while preventing secondary brain injury

  • Airway compromise and inadequate ventilation are common and should be addressed immediately

  • Prehospital endotracheal intubation should be undertaken with the assistance of anaesthetic drugs by appropriately trained physicians

  • Hypotension is an independent risk factor for mortality; small boluses of isotonic crystalloid fluids should be given if it occurs

  • Patients may be best managed in a neurosurgical centre where they should receive definitive neurosurgical treatment within 4 hours of injury

  • There is no role for the routine use of corticosteroids in patients with head injury

Sources and selection criteria

We searched Medline 1980-2008, Pubmed and the Cochrane library for clinical trials and reviews. The medical subject headings “head injury”, “brain injury”, “trauma”, “prehospital”, and combinations thereof were used. Individual therapeutic options (such as “mannitol”) were also searched for. Search results were individually reviewed and manually cross referenced. Reference lists were searched for additional works. Priority was given to review articles, meta analyses, and well designed large trials. The websites,, and were also searched for additional information.

Traumatic brain injury is a substantial cause of morbidity and mortality in the UK. An estimated 11 000 people per year sustain a severe traumatic brain injury, mostly between ages 15 and 29 years.1 Patients with severe traumatic brain injury have a high mortality rate (30-50%) and many survivors will have persistent severe neurological disability.2 Prompt identification and appropriate early management of traumatic brain injury is essential to optimise outcome, however, few guidelines are available for clinicians on management in the challenging prehospital environment. The 2007 report by the national enquiry into patient outcome and death on the provision of trauma services in the UK3 highlighted concerns about prehospital management of airways and …

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