Prehospital Emergency Care

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ipec20

Prehospital Electroencephalography to Detect

Traumatic Brain Injury during Helicopter
Transport: A Pilot Observational Cohort Study

David J. Barton, Patrick J. Coppler, Nadine N. Talia, Alexi Charalambides,

Brian Stancil, Ava M. Puccio, David O. Okonkwo, Clifton W. Callaway, Francis
X. Guyette & Jonathan Elmer

To cite this article: David J. Barton, Patrick J. Coppler, Nadine N. Talia, Alexi Charalambides,
Brian Stancil, Ava M. Puccio, David O. Okonkwo, Clifton W. Callaway, Francis X. Guyette &
Jonathan Elmer (2023): Prehospital Electroencephalography to Detect Traumatic Brain Injury
during Helicopter Transport: A Pilot Observational Cohort Study, Prehospital Emergency Care,
DOI: 10.1080/10903127.2023.2185333

To link to this article: https://doi.org/10.1080/10903127.2023.2185333

View supplementary material Published online: 13 Mar 2023.

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PREHOSPITAL EMERGENCY CARE
https://doi.org/10.1080/10903127.2023.2185333

Prehospital Electroencephalography to Detect Traumatic Brain Injury during

Helicopter Transport: A Pilot Observational Cohort Study
David J. Bartona , Patrick J. Copplera , Nadine N. Taliaa, Alexi Charalambidesb, Brian Stancilb,
Ava M. Puccioc, David O. Okonkwoc, Clifton W. Callawaya , Francis X. Guyettea , and Jonathan Elmera
a
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; bLifeware Labs, LLC, Pittsburgh, Pennsylvania;
c
Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania

ABSTRACT ARTICLE HISTORY

Objective: Early recognition of traumatic brain injury (TBI) is important to facilitate time-sensitive Received 21 November 2022
care. Electroencephalography (EEG) can identify TBI, but feasibility of EEG has not been evaluated Revised 9 January 2023
in prehospital settings. We tested the feasibility of obtaining single-channel EEG during air medical Accepted 21 February 2023
transport after trauma. We measured association between quantitative EEG features, early blood
biomarkers, and abnormalities on head computerized tomography (CT).
Methods: We performed a pilot prospective, observational study enrolling consecutive patients
transported by critical care air ambulance from the scene of trauma to a Level I trauma center.
During transport, prehospital clinicians placed a sensor on the patient’s forehead to record EEG.
We reviewed EEG waveforms and selected 90 seconds of recording for quantitative analysis. EEG
data processing included fast Fourier transform to summarize component frequency power in the
delta (0-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) ranges. We collected blood samples on day 1 and
day 3 post-injury and measured plasma levels of two brain injury biomarkers (ubiquitin C-terminal
hydrolase L1 [UCH-L1] and glial fibrillary acidic protein [GFAP]). We compared predictors between
individuals with and without CT-positive TBI findings.
Results: Forty subjects were enrolled, with EEG recordings successfully obtained in 34 (85%).
Reasons for failure included uncharged battery (n ¼ 5) and user error (n ¼ 1). Data were lost in
three cases. Of 31 subjects with data, interpretable EEG signal was recorded in 26 (84%). Mean age
was 48 (SD 16) years, 79% were male, and 50% suffered motor vehicle crashes. Eight subjects
(24%) had CT-positive TBI. Subjects with and without CT-positive TBI had similar median delta
power, alpha power, and theta power. UCH-L1 and GFAP plasma levels did not differ across groups.
Delta power inversely correlated with UCH-L1 day 1 plasma concentration (r ¼ -0.60, p ¼ 0.03).
Conclusions: Prehospital EEG acquisition is feasible during air transport after trauma.

Introduction severe thoracoabdominal injuries, and is insensitive for

Traumatic brain injury (TBI) is a leading cause of death in
children and young adults (1). Rapid identification of TBI by
medical personnel is important to appropriately triage these
patients and guide time-sensitive therapeutic interventions.
Simultaneously, the ability to rule out clinically significant
TBI allows focused treatment of other known or suspected
injuries and enables improved transport destination decisions.
Prehospital identification of TBI is difficult; a systematic
review of eight studies evaluating prehospital triage accuracy
demonstrated low sensitivity (19.8% to 87.9%) and specifi-
city (41.4% to 94.4%) of various methods to identify TBI
(2). Computerized tomographic (CT) brain imaging is the
current standard for diagnosing and detecting surgical path-
ology in patients with acute TBI. Unfortunately, CT is not
available in prehospital or resource-limited settings, is unsafe
in hemodynamically unstable patients with concomitant
detection of axonal injury (3). Point-of-care strategies to
screen for mass lesions in TBI are urgently needed. Prior
studies have explored vital signs (4, 5), clinical examination
(6), full or multi-channel clinical electroencephalography
(EEG) (7, 8), and blood-based biomarkers (9) as indicators
of TBI. These studies have mostly focused on patients with
mild injuries and used diagnostics acquired after hospital
arrival. These modalities require further study in major
trauma patients and in the prehospital setting.
Prehospital care offers a window of opportunity for early
resuscitation and appropriate triage of TBI patients. We
tested the feasibility of using a wearable digital device to col-
lect single-channel EEG data in the prehospital setting.
Secondarily, we explored associations between prehospital
EEG, blood-based biomarkers sampled on hospital arrival,
and TBI on CT imaging.

CONTACT David J. Barton bartond2@upmc.edu

Supplemental data for this article is available online at https://doi.org/10.1080/10903127.2023.2185333
ß 2023 National Association of EMS Physicians
2 D. J. BARTON ET AL.
Methods
Study Design
We performed a prospective, observational study to test the
feasibility of collecting physiological data including EEG
using a novel biosensor device (Apollo, Lifeware Labs, LLC,
Pittsburgh, PA, USA) during prehospital patient care and
transport. We included all trauma patients 18 years of age
(or who appeared post-pubescent if age was initially
unknown) treated and transported directly from the scene of
injury to a single Level I trauma center via helicopter by a
regional critical care transport service (STAT MedEvac) in
western Pennsylvania. We excluded patients known to be
prisoners and/or pregnant. Three Apollo devices were used,
and we distributed one device each to three air ambulance
bases that carried the devices continuously. Patients from
these three bases were eligible. We targeted a sample size of
40 patients with the goal of allowing each base to use these
devices at least 10 times each to ensure the ability of person-
nel to learn and appropriately use the device. Patients were
enrolled consecutively from January to June 2021.
The University of Pittsburgh Human Research Protection
Office approved this research (STUDY20080103), and
granted a waiver of the requirement for obtaining informed
consent given this was a minimal risk study, and a consent
process would not be practical in the time frame needed
under emergency conditions necessitating EMS transport.
Funders had no role in study design, data analysis, or deci-
sion to publish.
Biosensor Device for EEG Recording
The Apollo device (Figure 1) measures photoplethysmogra-
phy and electrocardiography (ECG) at 200 Hz each
(MAX86150, Maxim Integrated), and motion at 100 Hz
(LSM6DS3, ST Microelectronics). The raw data is transmit-
ted via Bluetooth Low Energy to an Android app. Although
the sensor is intended for ECG, the frequency range of EEG
(0.5 Hz to 30 Hz) is similar to that of ECG (0.5 Hz to
150 Hz), and so we placed electrodes on the scalp (one
frontal, one temporal) aiming primarily to collect EEG. To
validate this use prior to field deployment, we tested the
device against a standard clinical EEG amplifier (CNS-210)
Figure 1. EEG device (Lifeware Labs).
with subdermal electrodes and visually confirmed equivalent
signals recognizable as EEG were acquired.
Study Procedures
Prior to study initiation, EMS personnel completed a 5-
minute introductory training to the research study back-
ground, study design, and impact, in addition to the EEG
device via a PowerPoint presentation and brief quiz. After
80% of EMS personnel in the service completed the training
and quiz, we started study enrollment.
Flight crews enrolled patients meeting inclusion/exclusion
criteria and being transported to our Level I trauma center.
Patients were enrolled by treating air medical clinicians dur-
ing prehospital transport. We defined enrollment as place-
ment of the electrodes on the patient. After initial patient
resuscitation and stabilization, flight crews were instructed
to place the device while enroute to prevent delay to defini-
tive care. Crewmembers placed the biosensor device onto
the patient’s right forehead using two standard ECG electro-
des placed on the temporal region and the forehead. The
device takes <1 minute to apply. The device was paired via
Bluetooth technology to a Google Pixel 3XL cell phone car-
ried by the crew to allow waveform visualization and
recording. Crewmembers were instructed to only apply the
device and initiate phone application recording, and not to
monitor any device data. Upon arrival at the emergency
department, the Apollo device was removed and cleaned for
re-use. Investigators transferred recording data from the cell
phone to cloud-based storage.
Investigators received prehospital trauma alert pages con-
currently with the ED trauma team, and one of two investi-
gators (DJB or NNT) responded to the ED to initiate study
procedures after patient arrival.
Investigators collected demographic and clinical data via
medical chart abstraction, and all data were recorded using
REDCap (10, 11). Neuroradiologists interpreted and reported
all head CT scans. We reviewed written CT reports for the
presence of TBI findings, including subarachnoid hemorrhage,
subdural hemorrhage, epidural hemorrhage, intracerebral
hemorrhage, intraventricular hemorrhage, and contusion. We
categorized subjects with any of these findings as CT-positive
TBI. Isolated skull or facial fractures were not included. We

determined Rotterdam CT scores on all patients with available
data. Injury Severity Scores (ISS) and Abbreviated Injury Scale
(AIS) scores were later obtained from the UPMC Trauma
Registry.
Blood Collection and Biomarker Assays
Study personnel collected venous blood samples from patients
in the emergency department immediately upon arrival using
tri-potassium ethylenediaminetetraacetic acid coated tubes.
We obtained second blood samples at approximately 72 hours
post-injury in patients who were still hospitalized. Blood sam-
ples were obtained at the time of clinical blood draws or
from existing intravenous catheters to avoid excessive veni-
punctures. We kept samples at room temperature for 30–
60 minutes (five samples were placed on ice for up to several
hours when logistically required due to investigator availabil-
ity), then centrifuged samples for 10 minutes at 1500x relative
centrifugal force. Plasma supernatants were aliquoted and
immediately frozen at 80 C for batch analysis.
Samples were sent for commercial measurement to Abbott
Laboratories on dry ice. Plasma levels of glial fibrillary acidic
protein (GFAP) and ubiquitin C-terminal hydrolase L1
(UCHL1) were measured using the Abbot Alinity immuno-
assay platform. Both assays have <10% coefficients of vari-
ation. The laboratory was blinded to clinical data, and
biomarker data were analyzed by the authors.
Data Analysis
All data, including EEG, were analyzed post-hoc and not
during patient care. An investigator experienced at EEG
interpretation visually inspected EEG waveform recordings
to determine if interpretable EEG was recorded. For each
interpretable recording, we visually selected one 90-second
period of the most artifact-free data for quantitative analysis.
In this pilot study, we focused on frequency decompositions
of the EEG signal, since this has been used successfully in
past research to identify brain hypoperfusion (1), preclinical
signs of concussion (2), and risk of traumatic encephalop-
athy (2), and can be used to grade TBI severity in both the
acute and chronic phases (3). We used the eegkit package
(12) and R version 4.0.4 (13) to conduct Fast Fourier trans-
form for frequency decomposition. A Fourier transform
decomposes a complex waveform into its component fre-
quencies (i.e., the original waveform is treated as a sum of
multiple sinusoidal functions). Each of these functions has
an amplitude and frequency. The signal decomposition we
performed uses this approach to approximate the sum of the
total power with specific clinically relevant frequency bands.
We applied a bandpass filter from 0.1 to 30 Hz, and then
used a notch-filter (using the signal package (14)) to exclude
non-physiological electromechanical interference attributable
to harmonics of the helicopter rotor blades or other invariant,
high-amplitude, non-physiological spikes occurring at fixed
frequencies. We summarized results of the frequency decom-
position by considering total band-pass filtered spectral power
PREHOSPITAL EMERGENCY CARE 3
in the delta (0–4 Hz), theta (4–8 Hz), and alpha (8–13 Hz)
ranges, as well as the ratio of alpha/delta power.
We performed statistical analyses with Stata SE 17.0,
including descriptive statistics and bivariate analyses. We
tested categorical variables for between-group differences
using Pearson exact tests due to low expected cell counts.
We assessed continuous variables for normal distribution
using Shapiro-Wilk tests; variables with significant test val-
ues were reported as medians (interquartile range [IQR])
and analyzed using non-parametric tests (e.g., Mann-
Whitney tests and Spearman correlation coefficients). All p-
values were considered significant at <0.05.
Results
Cohort Information
A flow diagram of patients eligible during the study period is
in Figure 2. Four of six missed enrollments came within the
first 2 months of study initiation, and the rate of missed
enrollments decreased over time. One missed enrollment was
due to crewmembers not having time to do so because the
patient required continuous resuscitation. Otherwise, no spe-
cific injuries precluded placement or use of the device. All
patients tolerated the device, and there were no observed
cases of patients removing the leads, requiring additional sed-
ation, or harm. Device battery failure occurred in five cases;
this was addressed by providing EMS flight crews with in-
helicopter charging cords to keep the EEG device constantly
charged. After this intervention, no battery failures occurred.
Overall, we included 34 subjects in whom EEG and/or
blood was collected. Clinical characteristics of the cohort are
summarized in Table 1. Subjects were mostly male (79%),
had a mean age of 48 y (range 17–79 y), and were most fre-
quently injured due to falls (38%). Median (IQR) ISS was 9
(2–17). Twelve subjects had AIS head region scores > 0,
and the median (IQR) of these 12 subjects was 2 (1–3).
Eight subjects (24%) had initial CT imaging with evidence
of TBI; six of these individuals had presenting Glasgow
Coma Scale (GCS) scores of 15 (Table 2). One individual
with CT-positive TBI developed delayed low-pressure hydro-
cephalus and coma requiring placement of an external ven-
tricular drain and ventriculoperitoneal shunt.
EEG Measures
Mean (standard deviation) electrographic recording time was
9.5 (7.4) minutes. Twenty-six of 31 individuals (84%) had
90 second periods of interpretable EEG for quantitative ana-
lysis. Five subjects (16%) had uninterpretable recordings, all
of whom were enrolled in the first half of the study. The five
subjects with uninterpretable EEG recordings were older than
those with interpretable EEG (median age 64 vs 44 years;
p ¼ 0.02 by Mann-Whitney test), but there was no difference
in subjects’ sex, race, mechanisms of injury, endotracheal
intubation, presence of intoxication, or presence of TBI on
CT (p > 0.05 for all comparisons via Fisher exact tests).
4 D. J. BARTON ET AL.

Figure 2. Study sample flow diagram.

Table 1. Patient characteristics. Comparisons between subjects with and without CT-posi-
Patient characteristic Total N ¼ 34 tive TBI (Figure 3) demonstrated no significant differences
Age – y, mean (SD) 48 (16) between median values of alpha-power (63.0 vs. 72.1 mV;
Male sex, n (%) 27 (79)
Race, n (%)
p ¼ 0.74), theta-power (97.5 vs. 88.8 mV; p ¼ 0.41), delta-
White 30 (88) power (458.4 vs. 353.6 mV; p ¼ 0.79), or alpha-delta ratios
African-American/Black 4 (12) (0.19 vs. 0.20; p ¼ 0.41).
Mechanism of Injury, n (%)
Fall 13 (38)
Motor vehicle crash 9 (26)
Motorcycle crash 6 (18) Blood Biomarker Analysis
Pedestrian struck by vehicle 2 (6)
Gunshot wound 2 (6) We collected blood upon ED arrival (day 1; n ¼ 19) and
Amputation 1 (3) 72 hours after admission (day 3; n ¼ 17) and analyzed plasma
Hanging 1 (3)
Systolic blood pressure – mmHg, mean (SD) 138 (29)
levels of UCH-L1 and GFAP (Figure 4). Median (IQR) level of
Diastolic blood pressure – mmHg, mean (SD) 92 (25) UCH-L1 was 2242 (353.3-4624.1) pg/mL on day 1 and 123.7
Heart rate – min-1, mean (SD) 92 (20) (87.4-209.6) pg/mL on day 3 among all individuals. Median
Respiratory rate – min-1, mean (SD) 19 (4)
Prehospital intubation, n (%) 5 (15) (IQR) level of GFAP was 29.4 (19.2-77.6) pg/mL on day 1 and
Traumatic brain injury on CT scan 8 (24) 96.7 (28.4-330.8) pg/mL on day 3 among all individuals. Two
Clinical seizures within 3 days 1 (3) individuals with CT-positive TBI had blood available on day 1,
Clinical seizures within 30 days 4 (17)a
Length of hospital stay – days, median (IQR) 5 (2–10) and four had blood available on day 3. No significant differen-
Mortality at 30 days 0 (0)a ces in UCH-L1 or GFAP levels were noted between CT-posi-
a
29 patients had follow-up information available via medical record review. tive TBI vs. CT-negative groups at either time point (p > 0.05

Table 2. Characteristics of patients with CT-positive TBI.
Glasgow coma scale score, median (IQR)
CT injury types
Subarachnoid hemorrhage
Subdural hemorrhage
Intraventricular hemorrhage
Contusion
Diffuse axonal injury
Epidural hemorrhage
Intraparenchymal hemorrhage
Rotterdam CT score, median (IQR)
Neurosurgical intervention within 3 days
Neurosurgical intervention within 30 days
Figure 3. Quantitative EEG measures in non-TBI vs. TBI groups based on CT
imaging.
for all comparisons), although we had a low sample size for
this exploratory comparison (Supplemental Figure 1).
We calculated correlation coefficients between quantita-
tive EEG measures and day 1 biomarker levels (generally
collected < 1 hour after EEG recordings). Delta power was
inversely correlated with UCH-L1 levels upon ED arrival
(Spearman’s r ¼ 0.60; p ¼ 0.03), but other measures did not
have significant relationships (Figure 4).
Discussion
In this prospective observational cohort, we report on our
experience with single-channel EEG in trauma patients in the
prehospital helicopter ambulance setting. We find that EMS
clinicians can successfully acquire limited frontal EEG in the
prehospital (air medical) setting. Alternative calculations
could yield the success rate of obtaining interpretable EEG to
PREHOSPITAL EMERGENCY CARE 5
be as low as 26 of 40 (65%) if considering the entire enrolled
TBI, n ¼ 8 population as the denominator (Figure 2). Trauma victims
15 (12.5-15) comprise a sizable proportion of patients treated by helicopter
7 (88)
EMS. Identifying TBI can facilitate triage, trigger time-sensi-
2 (25) tive interventions, and reduce secondary injury. Recent guid-
2 (25) ance from the Excellence in Prehospital Injury Care-TBI
1 (12.5)
1 (12.5)
study reinforces the importance of evidence-based prehospital
0 (0) medical care for improving TBI-related outcomes (15).
0 (0) Limited prior work has assessed EEG in prehospital set-
2 (1-2)
0 (0) tings. Jakab et al. first reported on design and testing of a
1 (12.5) six-channel EEG system intended for rapid deployment;
they tested two healthy volunteers in an ambulance and
reported sufficient diagnostic recordings (16). In a small
military study of soldiers with closed head injury, authors
demonstrated the BrainScope One device (which uses EEG
as one component) may be a useful tool for identifying and
ruling out structural brain lesions in the battlefield; however
this study included only 13 subjects, and only three subjects
received CT scans (17). Most recently, a dry electrode EEG
system has been reported to have modest utility in prehospi-
tal detection of stroke with large vessel occlusion (18). There
remains interest in applying simplified, point-of-care EEG in
emergency and prehospital settings to screen for stroke
(19, 20) and non-convulsive status epilepticus (21–23),
which is frequently missed in prehospital settings (24). Such
applications could be helpful in guiding prehospital treat-
ments and determination of transport destination. However,
further work is needed to demonstrate feasibility and trans-
lation to the prehospital setting with its associated challenges
to implementation such as patient movement, electrode
placement, external bleeding, cranial trauma, intoxication,
combativeness, and helicopter motion. Our work adds to the
literature by demonstrating satisfactory EEG is possible des-
pite these operational barriers.
Prior literature demonstrates acute quantitative EEG
changes in mild TBI include reduction in alpha power and
increase in theta and delta power (25). In our exploratory
analyses, we did not detect significant differences in quanti-
tative EEG measures, with the significant limitation of our
small sample size, although our median values agree with
this relationship directionality in TBI vs. non-TBI. Thus, it
remains our hypothesis that these quantitative EEG meas-
ures are associated with presence of TBI. Alternatively, it is
possible that effect sizes are too small to show clinical effect
in the early post-trauma time course of prehospital care.
Larger studies are needed to better answer this question.
We provide novel data of UCH-L1 and GFAP relation-
ships with quantitative EEG measures, independent of radio-
graphic TBI. Delta power was inversely correlated with
UCH-L1 levels. While this analysis is unadjusted and
remains small in sample size, this exploratory finding is
interesting because of the proximate time between the EEG
recording and blood collection and the role of UCH-L1 in
maintaining neuron axonal integrity (26) and synaptic struc-
ture (27). Blood biomarkers of TBI remain an active area of
investigation. Currently, the FDA-approved assay for these
biomarkers is only available for plasma, not whole blood,
which would be necessary for prehospital use.
6 D. J. BARTON ET AL.

Figure 4. Scatter plots of quantitative EEG measures and plasma UCH-L1 and GFAP levels.

Our work has associated limitations. First, we used a sin- improve spatial coverage would affect either signal quality
gle channel, two-electrode EEG device to simplify the moni- or feasibility. Second, we used CT-positive findings to desig-
toring as much as possible for EMS clinicians who used it as nate TBI comparison groups for logistical practicality. TBI is
a new tool. It is unknown if adding additional channels to not solely defined by CT findings, and symptom-based

measures may help better stratify groups. Nonetheless, CT-
positive findings of TBI are an important marker for potential
need for neurosurgical intervention and triage to a neurosur-
gery-capable center, so this remains a clinically important
group delineator. This study has a small sample size given
the pilot nature of the work, which limits our ability to test
for associations between our selected EEG and biomarker
measures, and relationships with TBI. As a single-center
study, confirmatory evaluation should precede larger-scale
implementation.
Given the current work is a pilot study, EEG analysis was
performed by investigators. Translation to clinical use would
necessitate machine learning methods (22, 28) that automat-
ically perform such processing in real time to provide clini-
cians with an interpretation as to the presence or absence of
brain injury.
Conclusions
We report preliminary data showing single-channel EEG is
a feasible monitoring modality in acute trauma for air med-
ical transport. Further study is needed to identify the most
useful multimodal biomarkers for identifying and monitor-
ing TBI in this population.
Acknowledgments
This work was presented at the Society of Academic Emergency
Medicine Annual Meeting on May 13, 2022 in New Orleans, LA.
Disclosure Statement
AC and BS are co-founders of Lifeware Labs, LLC which produced the
EEG devices used in this study.
Funding
This study was supported by the National Institutes of Health under
grant numbers T32HL134615, K23NS091629, and UL1TR001857
through the Clinical and Translational Sciences Institute at the
University of Pittsburgh. Biomarker measurements were provided as
gift-in-kind by Abbott Laboratories (Chicago, IL, USA).
ORCID
David J. Barton http://orcid.org/0000-0003-0976-0383
Patrick J. Coppler http://orcid.org/0000-0002-0731-7989
Clifton W. Callaway http://orcid.org/0000-0002-3309-1573
Francis X. Guyette http://orcid.org/0000-0002-9151-4896
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