How Prehospital Management of Traumatic Brain Injury Varies by Country

After getting into a car accident on the way home from work, a man suffered from a severe traumatic brain injury. What happens during the next hour is critical to his survival and quality of life. Yet prehospital management of traumatic brain injury is not standardized, particularly internationally.

In a multicenter, longitudinal study published in Prehospital Emergency Care, Gravesteijn et al. examined the prehospital management of traumatic brain injury throughout Europe to determine how the characteristics of each care system affects the stability of patients after arriving at the hospital.

Here are some of the key takeaways from the study, which the authors consider one of the most comprehensive analyses comparing prehospital care for patients after TBI across Europe:

Guidelines for Prehospital Management of Traumatic Brain Injury Throughout Europe

The study authors evaluated 3,878 patients from 56 CENTER-TBI centers in 17 European countries, which the authors note are the equivalent of North American level 1 trauma centers. All patients had been transported to their respective hospitals by ambulance or helicopter; self-admitted patients were excluded.

Interventions

• • Overall, there was a large variation in therapies used between countries:
    • Intubation rates ranged from 10% (Serbia) to 88% (Sweden).
    • IV fluid administration ranged from 22% (United Kingdom) to 67% (Romania).
    • Use of helicopters ranged from 0% (Serbia, Romania, Latvia) to 31% (Norway), which has large areas of low population density.
  • There was a significant range in response times:
    • Response times adjusted for injury severity were 12 to 25 minutes.
    • Range of on-scene times was 16 to 36 minutes.
    • Range of travel times was 15 to 32 minutes.

On-Scene Time: Factors and Outcomes

• • Patients with longer on-scene times were found to be more severely injured and had more complex prehospital interventions.
  • France and the United Kingdom had the longest total prehospital times, at 101 minutes and 96 minutes respectively:
    • France had the highest case-mix adjusted rates of prehospital intubation
    • The United Kingdom had the highest travel times from on-scene to hospital. This, the study authors note, could be due to traffic conditions and/or the recent centralization of major trauma care to 30 out of 200 hospitals.
  • Sweden and Serbia had the shortest prehospital times at 49 and 44 minutes respectively.
  • Prehospital tracheal intubation and secondary referral had the largest associations with longer on-scene times.
  • The need for IV fluids at the scene was associated with hypotension at arrival, and prehospital time was found to predict hypoxia at arrival.

Secondary Insults

• • The largest association with secondary insults on arrival was major extracranial injury
  • Hypoxia and a higher Glasgow Coma Scale (GCS) score at the scene, which was associated with less hypotension, were independently associated with secondary insults on arrival.

Gravesteijn et al. note that the study highlights major variations in prehospital care across European countries largely unexplained by patient characteristics. This, the study authors believe, could be explained by the fact that national TBI guidelines vary significantly across countries. However, even within countries, local policies vary and may not align with actual practice, as research suggests that adherence to guidelines is low.

Additionally, resources for prehospital care vary largely across Europe—even for prehospital intubation, which has been proven to be beneficial for severe TBI patients.

They also note that in many countries, the academic basis for prehospital care is only now becoming part of training for paramedics and other healthcare providers when it has been an established part of hospital-based emergency medicine for 20 years.

Self-Reported Prehospital Care in Europe: How Does It Compare?

How do Gravesteijn et al.’s findings, which use patient data, align with clinicians’ reports on what prehospital measures are being taken for TBI patients?

In their study published in the Journal of Neurotrauma, Cnossen et al. sent a survey on prehospital trauma care to 68 neurotrauma centers in 20 European countries who were participating in the CENTER-TBI study. The centers were mainly level I trauma centers in an urban region.

Here are some of their key findings:

• • Around half of the centers reported using helicopters as a part of their general policy. Meanwhile Gravesteijn et al. found that helicopter ranged from 0% to 30%.
  • At the scene, around 50% of participants use a scoop-and-run policy (mainly used in the UK, the Baltic States and Israel), while the other 50% use a stay-and-play approach (mainly used in Western Europe, Southern Europe and Eastern Europe).
  • 41% of centers indicated that their target time between the call for help and arrival at the scene is less than 10 minutes, while 37% indicated that this time is less than 15 minutes.

The study authors note that this significant variation in prehospital care throughout Europe may be due to difference in socio-economic situations among counties; mobile medical teams and helicopters were found to be used much more frequently in higher-income countries compared to lower-income ones.