**4. Prehospital care and oxygenation**

TBI management begins at the prehospital care, assuring that the patient has no signs of upper airway obstruction, maintaining Oxygen saturation (spO2) > 90% and considering intubation in patients that presents Glasgow Coma Scale (GCS) < 9, altered swallowing reflex or contributing to hypoventilation [60, 62–64]. However, it is of substantial value that the prehospital team is technically qualified (within technical skills, medical devices/medication, and protocols) to perform airway management and control possible detrimental effects of therapeutic interventions (such as worsening of cervical spine injury during endotracheal intubation [65]).

Studies examining the impact of prehospital intubation have conspicuously conflicting results. A Finnish [66] comparison between physician-staffed prehospital team and paramedics team (PM) demonstrated that the physician team performed 98% of advanced airway management against 16% in paramedics patient's group. Hypoxia was higher in the PM group at the emergency department arrival. Furthermore, one-year mortality rate was higher in the PM group. Singularly, anesthetics were available for physician teams only, while PM were limited to the sedatives. Patients that were submitted to emergence intubation during prehospital care presented an increased risk of morbidity and mortality (poor neurologic outcome [67, 68] and decreased survival rate [68–71]).

The French Society of Anesthesia and Intensive Care Medicine strongly recommends a prehospital medicalized team to assess patients, claiming higher survival rates [72]. Divergently, an Australian study [73] indicated that rapid sequence intubation performed by paramedics increased the 6 months rate of favorable neurologic outcome. The Trauma Research and Education Foundation of San Diego [74] also demonstrated improved survival in patients intubated in the field. Meanwhile, any benefit or harm of pre-hospital intubation could be stated [63].

Marehbian et al. [75] inferred that these inconsistencies may be attributed to multiple factors: GCS applied as a single scale to identify intubation candidates (can be misinterpreted by illegal substances or sedative effects), variability of protocols, and inadequate intubation or ventilation approaches, that can lead to hypo or hyperventilation.

Hyperventilation is commonly revealed as a higher incidence among prehospital intubated patients. Hemodynamically, hyperventilation rises the intrathoracic pressure, leading to a decrease in cardiac output [76–78]. Regarding the cerebral perfusion, hypocapnia decrease the cerebral blood volume (CBV), which directly decrease the cerebral blood flow (CBF), and lower ICP [79–82]. Studies had shown regional and local ischemia with tissue lactic acidosis immediately after hyperventilation, suggesting harmful effects in cerebral tissue due to cerebral vasoconstriction [7, 81, 82]. Currently, hyperventilation should be reserved to

**159**

**Figure 4.**

*Benefits of Early Tracheostomy in TBI Patients DOI: http://dx.doi.org/10.5772/intechopen.93849*

**5. Tracheostomy and oxygenation**

properties [7, 83–85].

**Figure 4**.

refractory cases immediately before surgical intervention. It should not be used in ICU management of refractory ICP because of its detrimental hypoperfusion

site) of the trauma can have a great influence in the decision making.

The use of supplemental oxygen is required to correct hypoxemia and attempt to avoid secondary injury. Therefore, initial management for severe traumatic brain injury involves intubation and ventilation for airway management [7, 72]. However, the decision to perform invasive procedures on the trauma stage should be evaluated in a case to case basis since the experience of the team involved together with the conditions of the patient/surroundings (patient inside a car wreckage or in a war

To prevent or reverse hypoxemia and provide oxygen to the tissues during acute respiratory failure, airway access is often provided by translaryngeal endotracheal tube. When mechanical ventilation is expected to be prolonged, TQT tube is frequently chosen as part of the airway management care plan [86–88].

Earlier TQT records were found in the Edwin Smith Papyrus (1600 BC), whereas an emergency airway was performed after a trauma [89]. The first surgical description of successful case of TQT was performed by Antonio Musa Brasavola (1546) [90] and a full book dedicated to this procedure, previously known as bronchotomy, was published in 1620 [91] by Nicolas Habicot, who pictured it as demonstrated in

*[92] Patient's tracheostomy by Nicolas Habitot. A: the patient; B: the larynx; C: bronchotomy insertion; D: bronchotomy's instrument; E: the cannula; F: cannula's strap; G: a band to apply over the cannula to control the* 

*air leakage; H: the needle to suture the wound when needed.*

*Benefits of Early Tracheostomy in TBI Patients DOI: http://dx.doi.org/10.5772/intechopen.93849*

*Advancement and New Understanding in Brain Injury*

**4. Prehospital care and oxygenation**

outcome [67, 68] and decreased survival rate [68–71]).

any benefit or harm of pre-hospital intubation could be stated [63].

ered to the brain [61].

risk of mortality of 75%, when associated with hypotension [7].

Considering that the brain is susceptible to ischemic injury, cerebral perfusion and oxygenation are vital to be maintained. In TBI setting, cerebral ischemia occurs due to different mechanisms: damage to blood vessels, hypotension, mechanical compression, and reduced perfusion (impaired autoregulation, which leads to greater propensity to hypoperfusion) [16, 59]. Hypoxemia can represent a relative

According to the Brain Trauma Foundation [60], patients with severe TBI present pulmonary aspiration risks or compromised airway function, and initial treatment goals include early airway protection, adequate supplemental oxygen, and circulation support, ensuring that adequate oxygen and blood flow are deliv-

TBI management begins at the prehospital care, assuring that the patient has no signs of upper airway obstruction, maintaining Oxygen saturation (spO2) > 90% and considering intubation in patients that presents Glasgow Coma Scale (GCS) < 9, altered swallowing reflex or contributing to hypoventilation [60, 62–64]. However, it is of substantial value that the prehospital team is technically qualified (within technical skills, medical devices/medication, and protocols) to perform airway management and control possible detrimental effects of therapeutic interventions (such as worsening of cervical spine injury during endotracheal intubation [65]). Studies examining the impact of prehospital intubation have conspicuously conflicting results. A Finnish [66] comparison between physician-staffed prehospital team and paramedics team (PM) demonstrated that the physician team performed 98% of advanced airway management against 16% in paramedics patient's group. Hypoxia was higher in the PM group at the emergency department arrival. Furthermore, one-year mortality rate was higher in the PM group. Singularly, anesthetics were available for physician teams only, while PM were limited to the sedatives. Patients that were submitted to emergence intubation during prehospital care presented an increased risk of morbidity and mortality (poor neurologic

The French Society of Anesthesia and Intensive Care Medicine strongly recommends a prehospital medicalized team to assess patients, claiming higher survival rates [72]. Divergently, an Australian study [73] indicated that rapid sequence intubation performed by paramedics increased the 6 months rate of favorable neurologic outcome. The Trauma Research and Education Foundation of San Diego [74] also demonstrated improved survival in patients intubated in the field. Meanwhile,

Marehbian et al. [75] inferred that these inconsistencies may be attributed to multiple factors: GCS applied as a single scale to identify intubation candidates (can be misinterpreted by illegal substances or sedative effects), variability of protocols, and inadequate intubation or ventilation approaches, that can lead to hypo or

Hyperventilation is commonly revealed as a higher incidence among prehospital intubated patients. Hemodynamically, hyperventilation rises the intrathoracic pressure, leading to a decrease in cardiac output [76–78]. Regarding the cerebral perfusion, hypocapnia decrease the cerebral blood volume (CBV), which directly decrease the cerebral blood flow (CBF), and lower ICP [79–82]. Studies had shown regional and local ischemia with tissue lactic acidosis immediately after hyperventilation, suggesting harmful effects in cerebral tissue due to cerebral vasoconstriction [7, 81, 82]. Currently, hyperventilation should be reserved to

**158**

hyperventilation.

refractory cases immediately before surgical intervention. It should not be used in ICU management of refractory ICP because of its detrimental hypoperfusion properties [7, 83–85].

The use of supplemental oxygen is required to correct hypoxemia and attempt to avoid secondary injury. Therefore, initial management for severe traumatic brain injury involves intubation and ventilation for airway management [7, 72]. However, the decision to perform invasive procedures on the trauma stage should be evaluated in a case to case basis since the experience of the team involved together with the conditions of the patient/surroundings (patient inside a car wreckage or in a war site) of the trauma can have a great influence in the decision making.
