Traumatic Brain Injury Basics

Why This Is Hard

The brain hates hypoxia and hypotension. Secondary injury after the initial trauma is where EMS can help or harm. Aggressive hyperventilation as routine “brain treatment” is outdated for most patients — reserved for signs of herniation in many education frameworks.

Field Priorities

1. Airway protection — vomiting and decreased LOC are common.
2. Oxygenation; avoid hypoxia.
3. Blood pressure support per protocol — prevent hypotension (hemorrhage control still first if bleeding).
4. Spinal motion restriction when indicated.
5. Rapid transport to appropriate trauma/neurosurgical destination per system plan.
6. Glucose check if AMS and protocol supports.
7. Seizure management per protocol if they occur.

Herniation Red Flags (Education)

• Declining LOC, unilateral dilated pupil, posturing, Cushing-type patterns (bradycardia + hypertension + irregular breathing) — late and ominous.
• Brief hyperventilation strategies may appear in protocols for impending herniation only — not routine for every TBI.

Key Points for Paramedics

• Hypotension and hypoxia double damage — treat them aggressively within protocol.
• EtCO₂ can guide ventilation quality when available.
• Anticoagulant history is critical for the trauma team.
• Do not sit on scene for prolonged packaging theater.

Field Pitfalls

• Routine hyperventilation of every head injury.
• Missing extracranial hemorrhage while fixated on GCS.
• Inadequate suction setup.

Practice

State three secondary injury preventers you control on scene. Related: Massive hemorrhage, Capnography.

Sources & Further Study

• Brain Trauma Foundation / ATLS education themes; your trauma protocols.