Paramedics in UK ambulances will soon test whether a simple finger-prick blood test can tell them, within minutes, whether a patient with a mild head injury needs to go to hospital. Over 90% of patients sent to Emergency Departments after a mild traumatic brain injury have no visible damage on CT scans and are sent home. This clogs emergency care and exposes patients to unnecessary radiation and travel. Current prehospital decision-making is blunt, especially for older adults, people with dementia, or those on blood thinners—groups where paramedics are especially cautious. No study has yet collected blood samples from mild TBI patients before they reach hospital, so it is unknown how quickly brain injury biomarkers appear in the bloodstream after injury. If this feasibility study shows that prehospital sampling works, it could lead to a rapid point-of-care test that paramedics use at the roadside. That would let them safely divert low-risk patients away from Emergency Departments, reducing crowding and freeing resources for those who truly need them. The research builds directly on a larger NIHR-funded study already underway in 10 UK Emergency Departments, and ambulance services have already expressed interest in joining.
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The majority of patients who sustained a traumatic brain injury (TBI) are classified as mild (mTBI).1 When prehospital teams assess these patients one of their key decisions is whether or not a patient requires assessment in an Emergency Department (ED) to consider whether they need a CT to detect significant intracranial traumatic lesions which may need neurosurgical intervention. However, over 90% of patients have no lesions on their CT and are often sent home.2 Improved assessment of whether a significant brain injury has occurred in the prehospital phase may help reduce the number of patients who need to attend an ED. In addition to helping reduce crowding, this may be particularly important for patients who have specific risk factors e.g. older age, dementia and/or anticoagulants where the threshold for transfer is particularly low.3 Proteomic biomarkers have been shown to be sensitive to intracranial injuries, correlate with injury severity, aid prognostication and offer particular promise to help discern who has a significant injury in the prehospital setting.4-7 This is a rapidly evolving area with point of care devices are now being developed which could be potentially used in the prehospital setting. For example, the Abbott i-Stat Alinity platform uses whole blood and can give a result in ~15 minutes. While multiple studies have explored biomarkers in the EDs there is a paucity of data in the prehospital setting. A recent US study showed elevated biomarkers in patients with moderate-to-severe TBI sampled within 30 minutes of injury, indicating potential utility for hyperacute-phase sampling.8 However, to our knowledge there has been no study to date on prehospital biomarker sampling in mTBI patients. This proposal aims to take advantage of a unique opportunity to build on the NIHR EME funded BRAINS-TBI (Biomarkers for Rational Investigation for Neurological Decision Support in TBI) observational cohort study with embedded RCT, due to start in 2025 based in 10 UK Emergency Departments (https://fundingawards.nihr.ac.uk/award/NIHR159241). We propose to assess the feasibility of extending biomarker sampling to the prehospital phase with collection of samples before a patient arrives at the hospital. Understanding how quickly biomarkers are released is essential is to assess whether it would be safe to use them in the hyperacute phase after a TBI to decide disposition. Ambulance services who convey patients to hospitals planned to be involved in BRAINS-TBI have indicated interest in being involved in this study. Patient and Public Involvement (PPI) has already been conducted for the BRAINS-TBI study, highlighting concerns about the lack of diagnostic and prognostic tools in mTBI during the acute phase. Further PPI via planned focused groups will be undertaken throughout this project to assess patient acceptability of prehospital biomarker sampling. The proposal has been discussed with key stakeholders including paramedics, prehospital physicians, and emergency physicians, all of whom support both the feasibility study and future research if feasibility is demonstrated.
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