References
Prehospital osmotherapy in isolated traumatic brain injury: a systematic review
Abstract
Background:
Isolated traumatic brain injury (TBI) accounts for 30% of injury-related deaths globally, with significant cost to individual health, lifestyle and the economy. Despite advances in prehospital trauma care, frontline paramedics have limited options to manage cerebral oedema and herniation. Prehospital osmotherapy could limit cerebral oedema and subsequent secondary brain injury, but uncertainties remain of its benefit to patient outcomes.
Aim:
This study aimed to explore whether prehospital osmotherapy such as hypertonic saline (HTS) could improve mortality and neurological outcomes in adults with severe isolated TBI compared with other products.
Methods:
Multiple electronic databases (PubMed, MAG Online Library, EMBase and Cochrane Library) were searched to investigate the impact of prehospital osmotherapy on mortality and neurological outcome.
Findings:
9005 articles were identified, with six articles fully meeting the research aim. The majority of literature was high quality with an overriding consensus that administration of prehospital HTS or other hyperosmolar products had limited benefit to patient mortality and neurological outcome in isolated TBI.
Conclusion:
High-quality literature demonstrated that there is no current strong argument to adopt prehospital osmotherapy for isolated TBI. Paramedics should prioritise managing hypoxia and hypotension, which have proven impacts on long-term mortality and neurological outcomes. Future research should focus on the benefits of the expansion of rapid sequence intubation to advanced paramedics and appropriate analgesia (ketamine) for paramedics to enhance isolated TBI management in UK paramedic practice. However, paramedics should not disregard the importance of fundamental basic resuscitation skills in isolated TBI.
This systematic review aims to appraise the current body of literature to determine if prehospital osmotherapy such as hypertonic saline, compared with other hyperosmolar agents, can improve mortality and neurological outcomes in severe isolated traumatic brain injury (TBI). This could, in turn, enhance TBI management in paramedic practice.
TBI is the leading contributor to mortality, morbidity and disability globally, accounting for 30% of injury-related deaths in those aged 18–45 (Mangat, 2018). TBI is a national health priority, as patients survive with significant disabilities, creating a socioeconomic burden for individuals and families, as well as the NHS (Lawrence et al, 2016; Parsonage, 2016). Paramedics are the first responders to these patients and are therefore critical actors in improving long-term patient outcomes in TBI management (Badjatia et al, 2008).
TBI is commonly defined as a cerebral insult from an external mechanical force that results in temporary or permanent neurological deficit (National Institute for Health and Care Excellence (NICE), 2014). TBI severity is classified according to the patient's Glasgow Coma Scale (GCS): mild (GCS 13–15), moderate (GCS 8–12) or severe (GCS<8) (NICE, 2014). Primarily, TBI outcomes are measured according to mortality or neurological outcomes such as the five-item functional scale, Glasgow Outcome Scale (GOS) or the more detailed eight-category extended Glasgow Outcome Scale (GOS-E) (Weir et al, 2012). High-quality systematic reviews suggest that &60% of patients with severe TBI (GCS<8) had the worst mortality and GOS or GOS-E scores (Brown et al, 2004; Forslund et al, 2019). Therefore, severe isolated TBI requires prompt early treatment to prevent subsequent disability and mortality (Rosenfield et al, 2012).
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