This TBI Awareness Month, review the latest traumatic brain injury protocols for assessment and management in the field.
FieldBrief Issue 1
Published March 24, 2026
Traumatic Brain Injury in the Field
During TBI Awareness Month, it’s a good time to revisit best practices for traumatic brain injury care in the field.
“While emergency providers continue to follow the Brain Trauma Foundation’s Guidelines for Prehospital Management of TBI and the American College of Surgeons’ Best Practices Guidelines for Traumatic Brain Injury,” says Michael Kelly, MD, Department Chair of Neurosurgery, MetroHealth, “field care continues to evolve as new technologies and protocols emerge.”
Early assessment and stabilization remain critical. The actions taken in the first minutes after injury can significantly affect outcomes.
Evolving TBI Field Assessment
The core features of TBI care remain true:
- Assess the ABCs (Airway, Breathing, Circulation).
- Obtain the patient’s GCS score.
- Conduct a secondary survey for other injuries.
Scene details can also provide valuable context for injury severity. Pay attention to:
- Height of a fall
- Velocity or mechanism of impact
- Medication use (especially anticoagulants)
- Time of injury
Emerging Assessment Tools
New tools on the horizon show early promise for supplementing clinical evaluation and scene interpretation in the field for TBI assessment. These include:
- Handheld Near-infrared Spectroscopy to assess brain pathology
- Portable EEG to evaluate seizures
- Pupilometer to estimate elevated intracranial pressure
- Transcranial Doppler to measure the speed of blood flow
Managing TBI in the Field
“EMS providers play an essential role in maximizing patients’ clinical condition to lower the risk of secondary injury to the brain,” Dr. Kelly says. “Focus on maintaining stable physiology before hospital arrival.”
Dr. Kelly suggests keeping these key targets in mind while in the field:
- Avoid hypotension: Keep systolic pressure above 90 mmHg.
- Manage hypoxia: Hold oxygen saturation above 90%.
- Safely ventilate: Monitor end-tidal CO2 to stay between 35 and 45 mmHg. Early overventilation can cause vasoconstriction and cerebral ischemia.
The inflammatory cascade that follows from the primary injury complicates care for TBI patients. Maintaining the perfusion of brain tissue lowers the risk of secondary injury.
Trauma Considerations During Secondary Survey
From a trauma standpoint, first responders might find multiple injuries to TBI patients during their secondary survey.
During your assessment, remember to:
- Control hemorrhage quickly to prevent hypotension and lower the risk of secondary brain injury
- Consider how extremity injuries may affect the neurological exam
- Maintain a high suspicion for spinal injury, especially in pediatric and older patients
- Neutralize the spine even if the patient can move their extremities
Taking a System of Care Approach
Time matters in traumatic brain injury.
Studies have repeatedly demonstrated the importance of trauma systems in TBI and the need to get patients to an appropriate trauma center as quickly as possible to improve outcomes. Getting patients to definitive Level I care has been shown to reduce mortality by 5% for severe TBI patients. Close collaboration with first responders can help identify these patients and get them to rapid evaluation, stabilization, and surgery. It’s this rapid, system-driven treatment of TBI patients that leads to survival.
Dr. Kelly explains that trauma care at MetroHealth is built around a full continuum of treatment, including:
- Emergency stabilization
- Neurosurgical care
- Intensive care
- Rehabilitation and recovery services
“Trauma systems matter—not just for surgery, but for the spectrum of care,” Dr. Kelly says. “EMS providers are the critical first step in assessing, stabilizing and getting patients to hospital care quickly. From there, patients can get definitive hospital-based treatment that allows transfer to rehabilitation and eventual reintegration into their communities.”
“Getting patients to the right place for TBI, one that spans the full spectrum of care, is the first step toward recovery.”
First responders start the chain of treatment. Connecting our TBI patients to the full continuum of care from the time of injury onward is the best way to help them get back to the lives and the people they love.
To claim EMS Continuing Education for this edition of FieldBrief, please visit metrohealth.org/fieldbrief and complete a brief survey. The survey link is located below the list of articles.
MetroHealth Medical Center is a State of Ohio Approved Continuing Education Site #1202
Key Takeaways
- Early, Stabilizing Field Care Is Crucial
- New Technologies Are Enhancing TBI Assessment
- Trauma Systems and Rapid Transport Improve Survival
