Prehospital Assessment and Triage of Traumatic Brain Injury: A Narrative Review of Strategies and Tools

Traumatic brain injury (TBI) is a common cause of morbidity and mortality worldwide. Early identification of potential TBIs by emergency medical services (EMS) clinicians is critical to improving outcomes. Numerous tools have been developed to support prehospital decision-making, but their diagnostic accuracy and real-world applicability remain unclear. We conducted a systematic review of English-language studies published between January 1, 2015, and December 31, 2024, using MEDLINE, Embase, ClinicalTrials.gov, and Grey literature sources. Eligible studies evaluated tools or protocols used by EMS clinicians caring for suspected or confirmed patients with TBI to help diagnose, prognosticate, or triage these patients. Study selection, data extraction, and risk of bias assessment were performed independently by at least two reviewers. Due to heterogeneity, findings were synthesized narratively. From 961 initial records, 32 studies met inclusion criteria. Studies varied in design, population, and EMS setting. There were 37 unique prehospital TBI assessment tools or strategies. The Glasgow Coma Scale was the most frequently studied tool, though its performance was limited in older adults and patients with mild symptoms. Emerging machine learning-based triage algorithms and point-of-care devices showed promise but lacked large-scale validation. Sensitivity and specificity varied widely, and overtriage was common. Undertriage was more common in geriatric and anticoagulated populations. Current prehospital TBI assessment practices are highly variable, and commonly used tools may fail to detect clinically significant injuries. While novel technologies and decision-support tools show potential, robust prospective studies are needed to confirm their effectiveness in diverse, real-world EMS environments, accounting for population-specific differences.