Current pre-hospital traumatic brain injury management in China

doi:10.5847/wjem.j.issn.1920-8642.2014.04.001

Abstract

Abstract:

BACKGROUND: Traumatic brain injury (TBI) is associated with most trauma-related deaths. Secondary brain injury is the leading cause of in-hospital deaths after traumatic brain injury. By early prevention and slowing of the initial pathophysiological mechanism of secondary brain injury, pre-hospital service can significantly reduce case-fatality rates of TBI. In China, the incidence of TBI is increasing and the proportion of severe TBI is much higher than that in other countries. The objective of this paper is to review the pre-hospital management of TBI in China.
DATA SOURCES: A literature search was conducted in January 2014 using the China National Knowledge Infrastructure (CNKI). Articles on the assessment and treatment of TBI in pre-hospital settings practiced by Chinese doctors were identified. The information on the assessment and treatment of hypoxemia, hypotension, and brain herniation was extracted from the identified articles.
RESULTS: Of the 471 articles identified, 65 met the selection criteria. The existing literature indicated that current practices of pre-hospital TBI management in China were sub-optimal and varied considerably across different regions.
CONCLUSION: Since pre-hospital care is the weakest part of Chinese emergency care, appropriate training programs on pre-hospital TBI management are urgently needed in China.

Key words: Traumatic brain injury, Pre-hospital, China, Emergency medicine

Kou Kou, Xiang-yu Hou, Jian-dong Sun, Kevin Chu. Current pre-hospital traumatic brain injury management in China[J]. World Journal of Emergency Medicine, 2014, 5(4): 245-254.

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Intervention	Number of papers	Proportion (%)	Reference
Assessment of oxygenation
Clinical observation	34	52.3	20-53
Pulse oximetry	9	13.8	34,38,46,48,54-58
Overall	39	60.0	20-58
Airway management
Basic
Manual clearing	57	87.7	20-36,38-46,48,49,51-53,55-80
Suction	15	23.1	25,26,33,38,40,46-48,52,58,63,67,70,79,81
Airway manoeuvres (head tilt chin lift; jaw thrust; cervical collar)	19	29.2	23,26,28,29,31,38,39,41,46,51,54,57,61,62,64,66,67,69,77
Airway adjuncts (oropharyngeal airway, nasopharyngeal airway)	26	40.0	26,28,29,33,35,38,40,42,46-48,52,57,58,60,61,73,74,76-83
Turning patient's head to one side	27	41.5	21,24-31,33,36,41-43,45-47,52,53,57,60,61,65,76,77,79,80
Pulling out tongue with tongue forceps	14	21.5	25,33,36,38,40,43,48,52,53,57,58,67,75,78
Advanced
Endotracheal intubation	54	83.1	20-22,25-32,34-36,38-42,44-54,56,58,60-65,67-71,73-80,82-84
Cricothyrotomy (needle, surgical)	9	13.8	45-48,52,58,65,73,84
Tracheotomy	3	4.6	47,62,84
Overall	64	98.4	20-36,38-84
Ventilation
Bag valve mask (BVM)	17	26.2	26,28,29,32,33,40,44,52,60,63,64,66,70,73,74,79,83
Mechanical resuscitator	6	9.2	38,50,52,53,55,67
Capnography	0	0	-
Overall	22	33.8	26,28,29,32,33,38,40,44,50,52,53,55,60,63,64,66,67,70,73,74,79,83
Medication
Respiratory stimulant	11	16.9	26,27,30,31,33,44,50,52,53,64,69

Intervention	Number of papers	Proportion (%)	Reference
Non-objective indications (when necessary; if conditions permitted)	19	29.2	20-22,26,30,31,36,39,45,46,49,51-54,61,65,69,76,80,83
Hypoventilation	11	16.9	29,32,34,35,52,60,62,67,73,79,82
Respiratory rate < 10/minute	1	1.5	26
Respiratory arrest	4	6.2	29,42,52,60
Severe airway obstruction	8	12.3	28,38,40,48,58,63,70,78
Vomiting	5	7.7	34,40,63,70,79
Coma	5	7.7	25,34,40,63,70
Cardiac arrest	6	9.2	41,52,56,68,71,75
Chest injury	1	1.5	62
Overall	46	70.8	20-22,25,26,28-32,34-36,38-42,45,46,48,49,51-54,56,58,60-63,65,67-71,73,75,76,78-80,82,83

Intubation rate (%)		Sample size	Reference
For all TBI patients^a
	29.5	105	27
	7.1	437	30
	3.8	418	46
Overall^a	8.1	960	-
For severe TBI patients^b
	83.3	30	82
	47.9	194	64
	18.7	316	39
	18.0	89	38
	17.2	1 268	73
	13.5	385	32
	5.9	202	68
Overall^b	19.1	2 484	-

Interventions	Number of papers	Proportion (%)	References
Assessment of blood pressure
Blood pressure monitoring	36	55.4	20-24,26,28,29,31-36,38-43,45,47,49-53,55,63,64,66-68,72,75,82
Treatment for hypotension
Hemostasis	54	83.1	20-26,28,29,32,34-36,39-43,45,47-73,75,78-84
Fluid resuscitation	41	63.1	23,24,26-31,33,35-38,40,41,44,47,48,51-53,55-58,60-69,74,75,79,82-84
Dextran	15	23.1	24,26,29,39,44,49,51,52,64,68,69,71,72,75,84
Balanced salt solution (BSS)	14	21.5	23,29,35,41,44,47,52,53,64,66-69,84
Hypertonic solutions (7.5% NaCl)	8	12.3	26,47,56,60,72-74,79
Hydroxyethyl starch	5	7.7	24,26,41,53,67
Normal saline	2	3.1	49,51
Freeze-dried plasma	1	1.5	44
Overall	27	41.5	23,24,26,29,35,39,41,44,47,49,51-53,56,60,64,66-69,71-75,79,84
Vasopressors (e.g. epinephrine, dopamine)	8	12.3	29,40,52,53,64,66,67,69
Elevation of lower limbs	2	3.1	26,61
Anticholinergic (anisodamine hydrochloride)	3	4.6	26,53,64
Overall	62	95.4	20-45,47-75,78-84

Interventions	Number of papers	Proportion	References
Assessment of brain herniation
Observation of pupils	34	52.3	21,23-32,34,36,37,39-46,49-55,64,66,69,70,77
Observation of consciousness	33	50.8	20,21,23,25-34,36,37,39-41,44,45,47,49-53,55,64,66,69,70,74,77
Assessment of GCS score	8	12.3	20,21,28,32,35,38,45,46
Overall	40	61.5	20,21,23-47,49-55,64,66,69,70,74,77
Methods to control intracranial pressure
Interventions implemented only for patients with clinical signs of brain herniation
Mannitol	32	49.2	20-22,24,27,29-31,38,40-42,45,47,48,50,53,56-60,65,66,76,78-84
Frusemide	17	26.2	24,29,37,38,40,41,47,48,50,52,53,58,65,66,76,78,83
Corticoteroids	14	21.5	22,24,29,37,38,40-42,47,50,52,53,56,65
50% glucose solution	3	4.6	20,21,45
Albumin	2	3.1	24,84
Glycerol and fructose	1	1.5	84
Hyperventilation	1	1.5	45
Overall	33	50.8	20-22,24,27,29-31,38,40-42,45,47,48,50,52,53,56-60,65,66,76,78-84
Interventions implemented for all patients
Mannitol	28	43.1	23,25,26,32-34,37,39,43,44,46,49,51,52,54,55,61-64,67-72,74,75
Frusemide	9	13.8	25,26,32-34,43,46,55,74
Corticoteroids	8	12.3	25,26,33,43,55,63,70,83
10% glucose solution	4	6.2	33,39,71,75
Overall	29	44.6	23,25,26,32-34,37,39,43,44,46,49,51,52,54,55,61-64,67-72,74,75,83
Overall	60	92.3	20-27,29-34,37-72,74-76,78-8420-27,29-34,37-52,54-72,74-76,78-84