As emergency medicine continues to evolve, the importance of neuroprotection in pre-hospital care has become increasingly evident. For those of us who work in critical care, both inside and outside the hospital, the need to protect and manage patients with neurological injuries is paramount. This blog post aims to discuss neuroprotection in pre-hospital care using the framework of a real-life case study: a 13-year-old boy who suffered a traumatic brain injury (TBI) after being struck by a car.
This post accompanies the podcast “Paediatric Neuroprotection.” It was recorded live at the Hope Church in Winchester as part of the PREMIER conference. We are grateful to the organizing team for hosting us and allowing us to use the audio. The PIER and PREMIER websites are full of amazing resources for anyone working in Paediatric Emergency Medicine, and we highly recommend them.
Listening Time – 11:11
This case emphasizes the critical importance of timely interventions, efficient teamwork, and evidence-based protocols, all of which were key in ensuring this patient’s remarkable outcome. Along the way, we’ll discuss neuroprotection strategies, the challenges of pre-hospital care, and the future directions in managing paediatric head injuries.
The Case Study: The Initial Incident
It’s a Friday afternoon, and the time is 14:22. On the west side of Poole, there’s been a road traffic collision (RTC). A pedestrian, a 13-year-old boy, has been struck by a car. The emergency services are called, and at 14:24, the 999 call is made. Within three minutes, at 14:27, a paramedic ambulance arrives on the scene. This rapid response is made possible by the Ambulance Response Programme, implemented in 2017, categorising calls and prioritising life-threatening emergencies. In this case, the boy was found unconscious with noisy breathing, making him a Category 1 case.
Upon arrival, the paramedic crew—a paramedic and an emergency care assistant (ECA)—assess the situation. The child is GCS-3 and soon becomes increasingly agitated. The crew’s first task is to perform a jaw thrust to open his airway, resulting in the return of spontaneous breathing. They quickly apply high-flow oxygen. This marks the beginning of neuroprotection: preserving cerebral function by ensuring adequate oxygenation and ventilation. But this is just the start.
Pre-Hospital Neuroprotection Begins
Neuroprotection, particularly in the pre-hospital phase, is often an uphill battle. The paramedics on the scene are well-trained but limited by the resources and operating procedures available to them: additional critical care support might be scarce in some regions during off-peak hours. In this case, it’s fortunate that it’s a Friday afternoon when support is readily available. However, had this occurred at 2 a.m., it’s possible that only the paramedic crew would have been present, with no additional support.
The agitation and airway difficulties the paramedic crew faced are not uncommon in pediatric head injuries. A combination of trauma, confusion, and hypoxia can make these patients particularly challenging to manage. With no enhanced care available yet, the crew might have reasonably opted to transport the patient to the nearest trauma unit, even though it may not have been fully equipped to handle severe neurotrauma. In this case, that unit would have been Poole Hospital. However, this decision is made based on the limitations of pre-hospital care, not a lack of clinical judgment.
The Arrival of Enhanced Care
Fortunately, additional support arrived shortly after. At 14:39, a critical care paramedic reached the scene. This was a turning point in the patient’s neuroprotective management. The handover was swift and efficient, allowing the team to quickly comprehend the gravity of the situation. The patient was critically unwell, with signs of increasing neurological compromise.
The critical care paramedic initiated further interventions. The patient’s clothing was cut away to allow for a thorough examination, large-bore IV access was established, and tranexamic acid was administered. The dosage is weight-based for paediatric patients, but in this case, the standard adult dose is 1 gram. Though the paramedic team could only administer basic neuroprotective measures up to this point, these interventions helped stabilize the patient before more advanced care could be delivered.
One of the key features of neuroprotection is the prevention of secondary injury. In traumatic brain injury, secondary insults like hypoxia, hypercapnia, and hypotension can worsen outcomes. Managing these risks as soon as possible is critical. The paramedic’s efforts were invaluable in stabilizing the patient while awaiting further critical care.
The Arrival of the Air Ambulance: Advanced Neuroprotection
At 14:39, a critical care team arrived by helicopter. This team consisted of a consultant and a critical care paramedic or practitioner. Due to safety concerns, they had to land a short distance away and travel by foot to the scene, arriving at 15:04. Although just 40 minutes had passed since the initial call, this time was crucial for the patient, who was now showing signs of worsening neurological function. The team noted a large scalp hematoma and pupils dilated to 8 millimetres, indicating increasing intracranial pressure.
Given the patient’s condition, the team immediately administered 30 mg of IV ketamine for sedation. This not only helped control the agitation but also provided neuroprotection by reducing metabolic demands on the brain. The patient was well-packaged, and the next step was to proceed with emergency intubation and ventilation. Ketamine and rocuronium were used to facilitate intubation, and from this point, more advanced neuroprotection strategies could be implemented.
In the pre-hospital setting, neuroprotection primarily involves stabilising the patient’s airway, breathing, and circulation (the ABCs of trauma care). Once these are secured, more nuanced care can begin, including measures to reduce intracranial pressure (ICP) and maintain adequate cerebral perfusion pressure (CPP). Intubation allowed the team to fine-tune ventilation to avoid hypoxia and hypercapnia. They aimed for oxygen saturation levels of around 94%, preventing hypoxia without causing unnecessary hyperoxia. The team also performed regular blood glucose checks and actively worked to keep the patient normothermic using a blizzard blanket and heat pads.
The Decision to Transfer: Air vs. Road
At this point, the team faced a decision: transport the patient by air or road? While the air ambulance had the advantage of speed, there were logistical challenges that made road transport the better option in this case. Loading the patient into the aircraft would have taken time, during which critical care interventions would have been interrupted. Additionally, by the time the aircraft was ready to take off, the team could have been well on their way to Southampton Major Trauma Centre by road. Given that the journey would take less than 45 minutes by road, the decision was made to proceed via land ambulance. This allowed the team to continue managing the patient en route, maintaining a focus on neuroprotection without the distractions of air travel logistics.
Continued Care En Route and Arrival at the Trauma Centre
En route, the team administered hypertonic saline to reduce ICP, and the patient’s pupils returned to 4 millimetres—an encouraging sign. The team also placed a radial arterial line, allowing continuous blood pressure monitoring and frequent arterial blood gas sampling. These measures ensured that the patient’s ventilation and perfusion could be closely monitored and adjusted as needed. The patient was kept on propofol and fentanyl to maintain anaesthesia and analgesia throughout the journey.
At 16:11, the patient arrived at Southampton Major Trauma Centre, where he was handed over to the pediatric trauma team. The time from the initial injury to arrival at definitive care was just under two hours—an impressive feat given the complexity of the case. The patient was taken for a CT scan at 16:43, where the scan revealed significant brain injury. Shortly after that, the patient became bradycardic, and his pupils again became fixed and dilated. The team administered mannitol to reduce cerebral oedema, and the patient was rushed to neurosurgery straight from the CT scanner.
Outcome: A Success Story
Remarkably, despite the severity of his injuries, this patient made a full recovery with excellent neurocognitive function. He was eventually discharged with no significant neurological deficits, a testament to the effectiveness of the neuroprotection strategies employed both in the pre-hospital phase and upon arrival at the trauma centre. This case highlights the critical importance of timely and appropriate interventions in the pre-hospital setting and showcases the life-saving potential of an integrated trauma system.
Key Takeaways for Pre-Hospital Neuroprotection
This case underscores several key principles of neuroprotection in pre-hospital care. First and foremost, rapid and efficient airway management is critical. In this case, the patient’s airway was opened at the earliest opportunity, preventing hypoxia and hypercapnia—both of which can exacerbate brain injury. The early administration of oxygen and the timely transition to advanced airway management (intubation) were crucial steps in preventing secondary injury.
Secondly, the prevention of hypotension is a cornerstone of neuroprotection. Maintaining adequate blood pressure ensures that cerebral perfusion is preserved, reducing the risk of ischemic brain injury. In this case, close monitoring of blood pressure, along with the administration of fluids and medications like hypertonic saline, helped maintain adequate cerebral perfusion.
Thirdly, temperature management is essential. Hypothermia and hyperthermia can both worsen neurological outcomes, so maintaining normothermia is a priority in neuroprotective care. Active warming measures, such as blizzard blankets and heat pads, were crucial in preventing hypothermia in this patient.
Finally, timely transfer to a definitive care centre is paramount. In cases of severe TBI, every minute counts. The decision to transport this patient by road, despite the availability of air transport, was based on the practicalities of providing continuous care en route. This allowed the team to continue their neuroprotective strategies while ensuring the patient reached the trauma centre as quickly as possible.
Future Directions: Direct-to-CT Pathways
Looking forward, there are several exciting developments on the horizon for pre-hospital neuroprotection. One such advancement is the potential for direct-to-CT pathways. For adult patients, this option is becoming increasingly available, allowing for faster diagnosis and intervention. In Southampton, this pathway is already in place for adults with isolated head injuries, but it is not yet widely available for pediatric patients. Implementing direct-to-CT pathways for pediatric patients could significantly reduce time to definitive care, allowing for earlier neurosurgical intervention and potentially improving outcomes.
Conclusion
The success of this case demonstrates the importance of well-coordinated, evidence-based neuroprotection strategies in the pre-hospital setting. From the early management of airway and breathing to the advanced interventions provided by critical care teams, every step of the patient’s journey contributed to his remarkable recovery. As we continue to refine our approach to neuroprotection, both in and out of the hospital, we can look forward to more success stories like this one.
Thank you for reading, and remember: timely, effective neuroprotection starts in the field and can make all the difference for patients with traumatic brain injuries.
Podcast Transcription
I’m going to talk to you about neuroprotection in the pre-hospital phase. I work for three organisations. I’m an EM trainee in Wessex, currently working at UHS. I work for Dorset and Somerset Air Ambulance as one of their critical care practitioners, and I happen to work for HeartSK services, where we undertake a lot of pre-hospital critical care in the event sector. Neuroprotection as part of that is quite important because we see presentations there that we don’t see anywhere else.
We know that pediatric head injury carries a significant burden, and it’s one of the most common reasons for attendance to the emergency department, certainly in relation to trauma. It also accounts for around 30% of traumatic childhood deaths. It’s Friday afternoon, it’s 22 minutes past 2, and you’re on the west side of Poole. There is an RTC at that junction, and a pedestrian has been hit by a car. He’s 13 years of age. The 999 call gets made at 14:24, and a paramedic ambulance arrives at 14:27. For those of you that don’t know, since 2017, there’s the ambulance response programme that categorises calls. This child was found to be unconscious with noisy breathing, categorising him as category one.
So the call taker is rapidly entering information and dispatching an ambulance while gathering more details for us to know. They have seven minutes to arrive under the new times, and the ambulance arrives on time. This is where neuroprotection begins. They arrive with a paramedic, and you’ve got an emergency care assistant—a paramedic being your ALS provider in essence, and your emergency care assistant being your BLS provider. They find a 13-year-old boy, GCS-3, who becomes increasingly agitated shortly afterward. They perform a jaw thrust to open his airway. That is the first point at which the patient’s airway has been opened. He starts to have regular, spontaneous breathing, so they apply high-flow oxygen, and oxygenation and ventilation neuroprotection strategies begin.
Assuming there’s no enhanced and critical care available, you’ve got a paramedic ambulance, and these guys are great. They deal with difficult situations. You can imagine the chaos on scene at this point in time, and they’re the only two healthcare workers present. If they had no further support, and assuming this was possibly out of hours—beyond 2 a.m., really, in our region—you wouldn’t get any additional support beyond an ambulance crew. This child is agitated and difficult to manage, with a difficult airway. So realistically, that ambulance crew would be correct to take the child to their local trauma unit, which would have been Poole.
That means that you, working in a trauma unit, may receive a poorly ventilating, highly agitated child. It’s not due to a lack of willingness from the paramedic crew to do more for the patient—they just physically can’t, as it’s outside their scope of practice to add much more in terms of neuroprotection. But thankfully, it’s Friday afternoon and everyone’s at work. A critical care paramedic arrives at 14:39, and this is where neuroprotection can continue. They get a quick handover, realising that this child is critically unwell with a neurological injury. They get the child’s skin exposed, his clothes cut off, establish large-bore IV access, administer tranexamic acid—under a standard paramedic’s scope, that’s currently one gram. Our guidelines suggest two grams for an adult, and weight-based for children—and they continue with neuroprotection strategies.
We have a really good system in Dorset, so the critical care paramedic knew that the critical care team was flying in. Their strategy was to get this patient to definitive care as quickly as possible, but they also needed to package and stabilise him. This child is very agitated, so they prepare for an intubation and emergency anaesthetic, with possible sedation beforehand. At 14:39, the aircraft lands with a critical care team consisting of a consultant and a critical care paramedic or practitioner. They land a short distance away in a field, as we couldn’t land right next to the patient due to safety concerns.
After a short trip across some roads, they arrive at the patient at 15:04. We are still relatively early in this child’s journey at this point. The team arrives to find an increasingly cerebral-agitated child with a large scalp hematoma and sluggish pupils, which are dilating to around eight millimetres. They provide sedation with 30 milligrams of IV ketamine to gain control and calm the scene, which the critical care paramedic was already considering. They arrive to a well-packaged patient who has had a lot of interventions done. They then progress to an emergency anaesthetic, administering ketamine and rocuronium, and then start to consider more nuanced neuroprotection strategies.
We also use KetPrep for all children that we intubate with a head injury. So, what does the neuroprotection strategy look like in the pre-hospital phase? Well, it’s very similar to what we would do in the hospital. The challenge is that you’re doing it with two, three, or four people, under a lot of stress, while transporting the patient to an appropriate emergency department. Now, as you can imagine, he’s on a ventilator, and we can do more nuanced things, such as avoiding hypotension. We’re adequately ventilating this child, obtaining arterial blood gases, and maintaining oxygenation with target sats of 94%. We can adjust our ventilation strategies to maintain appropriate CO2 levels. Blood sugar was checked by the paramedic crew and was fine, and we are actively trying to keep this patient warm. Maintaining normothermia is particularly challenging in our environment, so the patient was wrapped in a blizzard blanket with heat pads, and active warming was initiated.
Next, we want to think about transporting to definitive care. There’s still some work to be done, but time is of the essence, and we are heading to our major trauma centre at Southampton. The team performed further interventions en route. Sometimes it’s better to transport by road, allowing us to do certain things, although we have a larger aircraft now, and pre-hospital talks wouldn’t be complete without mentioning that! While we can do some things in the aircraft, sometimes it’s easier by road.
You might ask why we didn’t fly the patient, considering it would take 45 minutes to an hour to reach Southampton. The reality is that it takes time to load patients into the aircraft, which distracts us from clinical tasks. By the time the aircraft is airborne, we would have already been 15 minutes down the road, and the same applies upon landing with the added delay of moving the patient to the hospital. Typically, if the journey is less than 45 minutes, we elect to travel by road.
Hypertonic saline was administered shortly after intubation, pupils returned to four millimetres, and a radial arterial line was established. Increasingly, we use arterial lines for neurocritical patients to manage their blood pressure accordingly. We also obtained an arterial blood gas to fine-tune ventilation strategies. The child was maintained on anaesthesia with propofol and fentanyl for analgesia. At 16:11, the child arrives at definitive care at Southampton, is handed over to the pediatric trauma team, and at 16:43 goes to CT. The child becomes significantly bradycardic, pupils dilate and become fixed again. Manitol is given, and the child is transferred to neuro-theaters straight from CT.
Remarkably, this child was eventually discharged with excellent neurocognitive recovery, a true success story. I’ve highlighted the times from our database at the top right of the screen, and I think it’s essential to recognize how long it takes to perform these tasks in the hospital, even with a large team. Our critical care team’s on-scene time was just 13 minutes. When everything comes together—a capable ambulance crew, a critical care practitioner, and the arrival of a critical care team—it makes a significant difference.
This brings me to the end of discussing neuro-critical care outside the hospital. It’s very similar to what happens inside, but it’s all about getting the patient where they need to be, doing what we can along the way, and ensuring seamless care by getting the basics right—opening the airway, applying oxygen, and refining strategies as we proceed.
Looking towards the future, direct-to-CT pathways could be valuable. This child could have gone directly to CT if such a pathway were available. It’s something that’s becoming available for adults, and in Southampton, we have it for isolated head injuries. However, in paediatrics, this is not yet an option, and implementing such pathways could get patients to neuro-theatres sooner.
Thank you very much.
The Speaker
Ed is a Speciality Trainee in Emergency Medicine in Wessex and a trainee Critical Care Practitioner with Dorset and Somerset Air Ambulance. Ed is also the co-founder and Managing Director of Enhanced Care Services, a Southampton-based company delivering enhanced and critical care to the event medical sector, providing frontline ambulance services across Hampshire and clinical education at all levels, employing over 200 clinicians. Ed holds the Diploma in Immediate Medical Care (RCSEd) and, having promised to not take on any more work, is currently undertaking a Masters in Resuscitation, Pre-hospital and Emergency Medicine at QMUL.
Enhanced Care Services
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