title: Pre-hospital and initial management of head injury patients: An update.
abstract: BACKGROUND
  Most of the bad outcomes in patients with severe traumatic brain injury (TBI) are related to the presence of a high incidence of pre-hospital secondary brain insults. Therefore, knowledge of these variables and timely management of the disease at the pre-hospital period can significantly improve the outcome and decrease the mortality. The Brain Trauma Foundation guideline on "Prehospital Management" published in 2008 could provide the standardized protocols for the management of patients with TBI; however, this guideline has included the relevant papers up to 2006.
  
  
  METHODS
  A PubMed search for relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic, was conducted.
  
  
  RESULTS
  Based on the evidence, majority of the management strategies comprise of rapid correction of hypoxemia and hypotension, the two most important predictors for mortality. However, there is still a need to define the goals for the management of hypotension and inclusion of newer difficult airway carts as well as proper monitoring devices for ensuring better intubation and ventilatory management. Isotonic saline should be used as the first choice for fluid resuscitation. The pre-hospital hypothermia has more adverse effects; therefore, this should be avoided.
  
  
  CONCLUSIONS
  Most of the management trials published after 2007 have focused mainly on the treatment as well as the prevention strategies for secondary brain injury. The results of these trials would be certainly adopted by new standardized guidelines and therefore may have a substantial impact on the pre-hospital management in patients with TBI.
authors.affiliation: Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada.
authors.forename: Tumul
authors.initials: T
authors.lastname: Chowdhury
authors.affiliation: Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada.
authors.forename: Stephen
authors.initials: S
authors.lastname: Kowalski
authors.affiliation: Department of Intensive Care, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia.
authors.forename: Yaseen
authors.initials: Y
authors.lastname: Arabi
authors.affiliation: Anesthesia and Perioperative Medicine, Fortis Memorial Research Institute, Gurgaon, Haryana, India.
authors.forename: Hari Hara
authors.initials: HH
authors.lastname: Dash
keywords: Evidence; pre-hospital management; secondary brain injury; traumatic brain injury