Case Presentation: BLS to ALS Handoff 21 year old male Unrestrained driver, single vehicle MVC 20mph; sedan vs. concrete barrier No airbag Starred windshield + LOC

Initial Assessment Patient has clear airway Bilateral breath sounds Strong radial pulse of 100 Blood Pressure 120/80 Speaking spontaneously Additional information? Respiratory rate/ quality–16 good movement O2 sat – 100%

Physical and Neurological Evaluation Found out of vehicle walking near accident scene 3x5cm Hematoma/ contusion left forehead Opens eyes spontaneously Alert to person & place, but confused to month and year Follows motor commands GCS = ▫14 Additional information? Pupils

Treatment and Interventions Immobilization with cervical collar and backboard Reassess vital signs & neuro exam Q5 min Administer supplemental oxygen as needed to maintain SaO2 > 90% Rule out other causes of altered mental status BLS - Medic Eval? ALS - establish IV access

Causes of Altered Mental Status Hypovolemia Hypoxia Hypoglycemia Pain/Discomfort Traumatic Brain Injury Additional causes? Alcohol Drugs

Transport Decisions Destination ▫Mild TBI ▫GCS 14 Emergency Department

Reassessment enroute: ABC’s Vital signs remain stable ▫Patent airway ▫Bilateral breath sounds ▫Pulse 96 ▫BP 116/76 Additional information? ▫Respiratory rate/ quality – 12 regular ▫O2 sat – 92%

Reassessment: Neuro Exam Eyes open to painful stimuli Speech is incomprehensible Localizes to painful stimuli Pupils 3mm bi-lat. with brisk reaction to light GCS = ▫9▫9

Treatment and Interventions Cervical spine immobilized Backboard in place O2 administered via NRM ▫ Critical value – SpO2 < 90% BLS- Medic Eval? ALS - IV access established with NS infusing ▫Critical value – SBP < 90mm Hg

Transport Decisions Destination ▫Moderate TBI ▫GCS 9 Trauma Center

Reassessment: ABC’s Changes in vital signs ▫Respiratory rate 8 ▫SaO2 90% on NRM ▫Pulse 112 ▫BP 80/60 Additional Information? ▫Respiratory effectiveness – Irregular/ poor air exchange

Reassessment: Neuro Exam Patient is unresponsive ▫Eyes – no response ▫Motor – bilateral extensor posturing ▫Verbal – no response Pupils ▫Right 4mm & reactive ▫Left 3mm & reactive GCS = ▫4▫4 BLS to ALS Handoff

ALS Treatment Interventions o Establish a patent airway o Vigorous IV fluid administration (Keep SBP > 90mm Hg) o Supplemental oxygen o 20 breaths/minute o Only when suspected cerebral herniation o Capnography/ ETCO 2 used to: ▫Confirm endotracheal tube placement ▫Measure the adequacy of ventilation.  Target range: 35 – 40 mm Hg ▫Guide hyperventilation therapy  Severe hyperventilation: < 30 mm Hg  ETCO 2 < 25 mm Hg is not recommended

Transport Decisions Destination ▫Severe TBI ▫GCS 4 Level One Trauma Center with TBI capabilities

Transport Decisions Level One Trauma Center with TBI capabilities ▫24 hour available CT scan ▫24 hour available operating room ▫Prompt neurosurgical care ▫Ability to monitor intracranial pressure ▫Ability to treat intracranial hypertension

Summary Provide oxygen and ventilation to maintain oxygen saturation >90% Provide adequate fluid to maintain SBP >90mm Hg Continuously look for S & S of Cerebral herniation ▫Pupil abnormalities ▫HA, N/V ▫Cushings Triade -  SBP,  HR, Irreg. resps. Select the most appropriate facility and mode of transportation for admission of the TBI patient Additional information? Continually reassess and document: ▫Component GCS, VS, post intubation RR, and Capnography values.