Prehospital treatment of patients with acute intracranial pathology: adherence to guidelines and blood pressure recommendations by the Danish Air Ambulance

Joachim Juelsgaard, Leif Rognås, Lars Knudsen, Troels Martin Hansen, Mads Rasmussen

Hypoxia and hypotension may be associated with secondary brain injury and negative outcomes in patients with traumatic and non-traumatic intracranial pathology. Guidelines exist only for the prehospital management of patients with severe traumatic brain injury (TBI). In patients with non-traumatic intracranial pathology, TBI guideline recommendations may be applied to assess whether hypoxia and hypotension should be avoided during prehospital treatment. The main study objective was to assess the extent to which Danish Helicopter Emergency Medical Service (HEMS) critical care teams adhere to the prehospital TBI guideline recommendations for the management of patients with a clinical diagnosis of non-traumatic intracranial pathology or isolated TBI. Furthermore, in the same two groups of patients, we evaluated the adherence of the Danish HEMS critical care teams to recommendations aiming to maintain systolic blood pressure (SBP) > 110 mmHg and > 120 mmHg. In total, 211 prehospital patient records were studied. All patients were treated for non-traumatic intracranial pathology or isolated TBI by the Danish HEMS critical care teams from October 1, 2014, to January 1, 2017. Adherence to the prehospital TBI guideline recommendations and the SBP recommendations above was assessed in non-TBI and TBI populations. The adherence rates to TBI guideline recommendations among Danish HEMS critical care teams were 69% (n = 106 [95% CI: 61-77%]) in the non-TBI population and 74% (n = 43 [95% CI: 61-85%]) in the TBI population. SBP > 110 mmHg was observed in 74% (n = 113 [95% CI: 66-81%]) and 69% (n = 40 [95% CI: 56-81%]) of cases in the non-TBI and TBI population, respectively. SBP > 120 mmHg was observed in 55% (n = 84, [95% CI: 47-63%]) of patients in the non-TBI population and 55% (n = 32 [95% CI: 42-68%]) of the patients in the TBI population. Due to a lack of comparative data, it is difficult to determine the performance quality of the Danish HEMS critical care teams. Our findings may suggest that adherence to TBI guidelines and SBP recommendations needs to be a continuous focal point for the Danish HEMS to avoid secondary brain damage.