Study: Can following guidelines improve traumatic brain injury outcomes?

Researchers have analyzed data on TBI mortality and outcomes from the Arizona State Trauma Registry before the guidelines were implemented and will compare those with outcomes after the guideline implementation

Updated June 2015

More than 7,000 EMTs, paramedics, flight medics and flight nurses from 80 EMS, fire and air medical agencies throughout Arizona have been trained in the evidence-based standards for treating prehospital brain injury. The training, conducted by a team from Arizona’s Excellence in Prehospital Injury Care (EPIC) project based at the University of Arizona, is a key step in a statewide initiative funded by the National Institutes of Health to determine if following the guidelines makes a difference in improving traumatic brain injury (TBI) outcomes.

Although guidelines for the treatment of TBI in the prehospital and hospital settings were first published by the Brain Injury Foundation in 2000 and updated in 2007, few EMS agencies had formally adopted them, says Bruce Barnhart, an R.N., paramedic and research coordinator at the University of Arizona College of Medicine in Phoenix. “The guidelines have never been implemented in an entire region, much less an entire state,” Barnhart says.

Key elements of the guidelines include:

  • Preventing hypoxia by maintaining an oxygen saturation of between 90 and 100 percent in all patients
  • Maintaining systolic blood pressure at 90 mm/Hg or above in adults to prevent hypotension
  • Avoiding hyperventilation by ventilating adult patients at a rate of 10 breaths per minute and by monitoring ETCO2 carbon dioxide levels between 35 and 45 mm/Hg, and preferably around 40 mm/Hg

Delivering only 10 ventilations per minute is tougher than it sounds, says Barnhart, an EPIC educator. “Any provider at any level, from EMT to anesthesiologist, when you have a bag in your hand, the tendency is to squeeze and ventilate the patient too fast,” he says. “Of the three interventions, hyperventilation is the most difficult to avoid; it is almost impossible to ventilate at only 10 breaths per minute unless the provider is meticulous in monitoring the rate and depth of each ventilation they deliver to the patient.”

To help with this, the EPIC project received a grant from the Ramsey Social Justice Foundation to supply pressure-controlled bag-valve masks and ventilation rate timers to all participating agencies in the state of Arizona. The devices limit hard, fast ventilation and feature a light that signals when to ventilate, Barnhart says.

As part of the project, researchers have analyzed data on TBI mortality and outcomes from the Arizona State Trauma Registry from 2007 through 2011 (before the guidelines were implemented) and will compare those with outcomes after the guideline implementation, starting with 2013 data. About 80 percent of TBI patients in the state are now being treated by at least one EPIC-certified agency, and a majority are treated by only EPIC agencies, Barnhart adds.

Read more about EPIC at

Video tells story of firefighter’s brain injury

To educate the public and EMS providers about the seriousness of TBI and the importance of the TBI guidelines, the EPIC team and the Phoenix Fire Department created a powerful video featuring one of their own: Phoenix Fire Department captain-paramedic Ernie Lizaragga.

In March 2010, Lizaragga suffered severe head trauma in a motorcycle accident. He and a group of fellow riders were stopped at a red light when a dump truck plowed into them, killing four riders. Lizaragga survived his injury and has been able to return to work, although he still has significant impairments. He shared his story in the video, which is a key part of EPIC training, says Bruce Barnhart, research coordinator at the University of Arizona College of Medicine in Phoenix.

The dump truck driver has been convicted of multiple counts of manslaughter and aggravated assault and sentenced to 26 years in prison.

View the video at

Energy drinks sending children and young adults to EDs

Emergency department visits due to adverse reactions to energy drinks or to energy drinks combined with other drugs doubled from 2007 to 2011, rising from about 10,000 to nearly 21,000 annually, according to a January report from the U.S. Substance Abuse & Mental Health Services Administration (SAMHSA). In other findings:

  • Males made up the bulk of energy drink-related ED visits (15,000), compared to 6,000 for females.
  • The age group most likely to visit the ED due to adverse reactions was 18- to 25-year-olds, followed by 26- to 39-year-olds.
  • In 2011, more than half of energy drink-related ED visits involved energy drinks only (58 percent), while 42 percent involved energy drinks combined with other drugs. Other drugs included pharmaceuticals, such as Adderall and Ritalin, and alcohol
  • The total amount of caffeine in energy drinks ranges from 80 mg to 500 mg, compared to about 100 mg in a cup of coffee. Research suggests that certain additives in energy drinks may compound the stimulant effects of the caffeine. The high levels of caffeine in energy drinks also can mask the effects of alcohol, causing some people not to realize just how intoxicated they are, according to studies cited in the report. “This report validates claims that energy drinks can be dangerous when used alone or in combination with other drugs or alcohol,” the report reads.

Read the full report at

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