Traumatic brain injury (TBI) is a common cause of death and disability. Primary prevention is focused on injury prevention programs, education, and policies. Prehospital care is focused on rapid identification and prevention of secondary brain injury through appropriate volume resuscitation and maintaining adequate oxygenation and ventilation. Evidence does not support prehospital intubation for pediatric patients with TBI. Prehospital intubation by ground transport services in adult patients with severe TBI is also not supported, but may be of benefit in some systems with resources to ensure appropriate training and monitoring. Available evidence does not support the use of hyperosmolar agents in the prehospital setting. Concussions are a form of mild TBI and EMS personnel are often the first on scene for sports-related concussions. A structured approach to evaluating these patients is encouraged. Transportation and destination protocols for trauma and TBI patients should be implemented to support decision making. Adult patients with moderate and severe TBI should be transported to a Level I or Level II trauma center, and pediatric patients should be transported to a pediatric trauma center when available.