GUIDELINES FOR PREHOSPITAL MANAGEMENT OF TRAUMATIC BRAIN INJURY PROVIDER COURSE Introduction of Course- As instructors, you now have a basic understanding of the concepts and theories of evidence based medicine, adult learning, and brain anatomy and physiology. Are there any questions before we continue with the content for the course you will be teaching? Reminder: All the content discussed is for patients with a severe TBI. This means patients who are comatose (GCS < 9). Brain Trauma Foundation

Assessment Lesson 1 Things are not always as they appear… Good assessment is the key. If you can recognize a severe TBI patient, then you have taken the first step towards appropriate treatment. What are the assessment skills you currently use when you encounter a severe TBI patient? Assessment

Assessment Objectives Describe the signs and symptoms of hypoxia in TBI Approximate the SaO2 by pulse-oximetry and assessment of clinical signs Discuss the effects of hypotension on the TBI patient Ask by show of hands, how many are using pulse oximetry in the prehospital setting. This shows an interest in their current practice, and will help you to adapt your lecture accordingly. Ask by a show of hands, “Is hypotension in the severe TBI patient any worse than hypotension for any other patient. For example, a 70 yo CHF patient vs a 20 yo TBI patient- both with BP sustained < 90mmHg for 5 minutes. Who fares worse, why? Don’t give them the answer, return to this question after slides # 93 & # 94

Assessment Objectives Calculate an accurate GCS score Name a GCS score that indicates severe TBI Differentiate between flexor/decorticate and extensor/decerebrate posturing Perform an accurate pupil exam Identify prehospital signs of herniation Use of GCS in prehospital setting is emphasized in this course, in order to diagnose presumptive herniation. Ask by a show of hands, how many routinely use GCS in TBI assessments? If they do not use it, ask why. And entice them with telling them how easy the GCS scoring really is. This will be covered in slides # 62 & 63 Prehospital herniation “diagnosis” is new concept, not yet in most EMS texts or courses.

Definitions Oxygenation: delivery of oxygen to tissues from red blood cell hemoglobin Hypoxia: inadequate level of oxygen available to tissues Oxygen Saturation: percent of hemoglobin that is saturated with oxygen; measured by oximetry Ventilation: movement of air in and out of the lungs Ask audience for their definitions of these terms before showing the actual definitions. “Hypoxia” is used on all slides in this course, meaning either “hypoxemia” (poor blood oxygenation) or tissue hypoxia. Hypoxemia- inadequate amounts of oxygen in the arterial blood Hypoxia- inadequate amounts of oxygen in the tissues Hypoxemia leads to hypoxia

Airway Maintain C-spine precautions Determine that airway is open Assess the need for artificial airway Assess every 5 minutes and as needed Always start with the basic principles of ABC’s Place emphasis on good airway management within the skills and “scope of practice” of the various levels of prehospital providers. Course includes information on advanced airway practices that may not be relevant to all audience members. Use this as an opportunity to teach something new to those who are unfamiliar with advanced airways.

Breathing Assess rate, depth, quality, and effectiveness of ventilation every 5 minutes and as needed Hypoxia occurs in 40% of severe TBI Assess for hypoxia Review s/s of hypoxia with audience. Ask them for the signs and symptoms they most often use. S/S include: Hypoxia impaired judgment confusion, delirium, agitation unconsciousness tachycardia Cyanosis of fingernails and lips peripheral vasoconstriction tachypnea

Pulse Oximetry Advantages- provides method of estimating oxygenation to tissues Disadvantages- can be unreliable in certain circumstances, such as…Poor distal perfusion (shock) [false low], cold environment [false low], carbon monoxide poisoning [false high] Give other examples of false high and low readings.

Circulation for hypotension Look for visible signs of “shock” Assess SBP every 5 minutes & as needed Adult critical threshold level < 90 mm Hg Child and infant levels are lower Use age/size appropriate BP cuff Knowledge of equipment- appropriate size cuff based on upper arm diameter. Cuff too small- false high, cuff too large-false low. Ask class to list clinical signs of shock: skin signs-cyanosis, pallor restlessness, anxiety, level of consciousness changes tachycardia tachypnea- rapid, shallow respiratory rate narrowed pulse pressure hypotension reduced urinary output Emphasis here on BP is because it is a simple concept. Real issue is recognizing the presence of shock. Shock is a BIG deal is brain injury, and is something EMS providers often can do something about. If you get questions from the audience about “fluid restriction” in trauma patients with abdominal injuries vs TBI patients—Click on the Purple text “ Delayed Resuscitation”. The issue of delayed fluid resuscitation is only specific to a certain sub-group of trauma patients; not relatable to severe TBI patients. Delayed Resuscitation and Hypotension

SBP Thresholds Hypotension should be considered according to age groups: <65 mmHg (0-1 year) <75 mmHg (2-5 years) <80 mmHg (6-12 years) <90 mmHg (13-16 years) Adult hypotension systolic blood pressure <90 mmHg Differences between ATLS and BTF regarding BP values are easily explained. ATLS values refer to the treatment goals of “normal” for the age of the patient. BTF values are the minimum thresholds for SBP that are related to poor outcome.

Mean Arterial Pressure MAP = (SBP + 2DBP) 3 Illustrates how MAP is calculated. This is important only to show how CPP is determined (on next slide). Not suggesting that students memorize this formula or use it in the field. MAP is displayed on some BP monitors used in some ACLS ambulances. Mean Arterial Pressure is somewhere between systolic and diastolic pressures

Cerebral Perfusion Pressure MAP – ICP = CPP 70 – 30 = 40 CPP of 60 = the critical minimum threshold MAP is necessary to calculate CPP, when ICP is known. In the prehospital setting you don’t have the luxury of knowing ICP, but maintaining MAP is still vitally important. If a patient appears to have a head injury, you can ASSUME that their ICP is rising above normal, and thus maintaining BP is critical. Take Home Message: Maintaining Blood Pressure is Critical

Why is BP important? Adequate BP insures adequate cerebral perfusion, done indirectly thru CPP. CPP based on MAP In the ICU setting, these are the parameters monitored in the severe TBI patient

D - Level of Consciousness Level of consciousness is an important predictor of TBI GCS After assessing ABC’s- move on to LOC ( D = disability/neuro) AVPU- too simple, not quantifiable, questionable validity and reliability among users GCS- more reliable when performed correctly, it is quantifiable, it is valid

The ONLY meaningful measure for TBI Glasgow Coma Scale A reproducible measure of level of consciousness Assess every 5 minutes & as needed Deterioration by 2 or more points is significant GCS is obtained by direct patient interaction, not simply patient observation. You must ask direct questions and perform specific actions to obtain GCS score. Good sign: GCS goes up by 2 points or more Bad sign: GCS goes down by 2 points or more Regular re-assessment is important. Do GCS before intubation.( ask audience why this is important ) The ONLY meaningful measure for TBI

Use It Right!!! After initial assessment After airway, breathing and circulation Prior to sedation and muscle relaxants Ask why? Perform ABC’s before going on to assess GCS. Sedation and paralytics alter the initial evaluation of GCS

Total = E + V + M GCS – Adult & Child Eye Opening 4 spontaneous 3 to speech/sound 2 to pain 1 no response Verbal Response 5 oriented 4 confused 3 inappropriate 2 incomprehensible 1 none Motor Response 6 obeys 5 localizes 4 withdraws from pain 3 abnormal flexion 2 abnormal extension 1 no response How to score-take them through GCS scoring Eyes-are they open or closed? Do they open to painful stimuli? Verbal- what is the month / year? Motor- most important part of GCS. “Show me 2 fingers”, do not use “squeeze my hands” Why? Because squeezing hands/ fingers is reflexive. Even babies do it without knowing what they are doing. You need to illicit a response that demonstrates cognition or the ability of the patient to think. Motor response of the GCS was designed to look at the best upper extremity response. Abnormal posturing ( decerebration & decortication) look similar in the lower extremities. It is possible for the patient to exhibit abnormal flexion on one side of the body and abnormal extension on the other side of the body. Painful stimuli- axillary, trapezius, nail bed pressure Go over in detail- Easy way to remember 4..5..6..= (maximum scores for Eyes, Verbal, Motor) Eyes swollen shut makes eye exam impossible. Still do other two assessments. Pre-verbal child, mute person, intubation, chemical paralysis, or someone not speaking your language makes verbal assessment difficult or impossible. Spinal cord injury, chemical paralysis, or excessive pain makes motor assessment impossible. Total = E + V + M

GCS Motor Scale Motor Response 6 obeys 5 localizes 4 withdraws from pain 3 abnormal flexion 2 abnormal extension 1 no response Describe differences between localizes, withdrawal, and two types of posturing responses Localization- crosses midline, organized attempt to locate and remove painful stimulus from their environment Withdrawal- more generalized response, patient attempts to withdraw the extremity from the painful stimulus Motor exam is part of GCS that is most difficult and has less inter-rater reliability, BUT…… Motor score of GCS is the most valuable component in assessing neurological status.

Total = E + V + M GCS – Infant Eye Opening 4 spontaneous 3 to speech/sound 2 to pain 1 no response Verbal Response 5 coos or babbles 4 irritable crying 3 cries to pain 2 moans to pain 1 none Motor Response 6 obeys 5 localizes 4 withdraws from pain 3 abnormal flexion 2 abnormal extension 1 no response Only difference is verbal scoring. The two kinds of cries may be difficult to tell apart. Fear may interfere with level 5 verbal score. Total = E + V + M Full verbal score (5) is assigned for spontaneous cooing after stimulation in children < 2 yrs old

GCS Indicators of TBI Severity GCS 14-15 --- MILD GCS 9-13 --- MODERATE GCS 3-8 --- SEVERE These are the 3 categories of TBI

GCS Reliability Most widely employed method for reporting serial neurologic evaluations Indicator of level of consciousness & head injury severity Moderately reliable by prehospital emergency medical care providers1 A single field measurement of the GCS cannot predict outcome Serial GCS scores provide valuable information to the ED staff about the patients neurologic condition Menegazzi JJ, Davis EA, Sucov AN, et al: Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics. J Trauma 1993; 34:46-48

Admission GCS In a severe TBI patient, a decline in the GCS score over time can be indicative of the need for acute management and neurosurgical intervention1 Field ED Mortality Surgical Evacuation 8.4 6.7 56% Yes 7.2 7.2 20% No In the prehospital setting- a drop of two or more points in GCS score- bad thing! Patient is getting into trouble. This research paper shows that TBI patients with a drop of 2 or more points in GCS score usually need to go to the OR and these patients have a greater chance of dying, than those patients where GCS remains unchanged. Servadei F, Nasi MT, Cremonini AM, et al: Importance of a reliable admission Glasgow Coma Scale score for determining the need for evacuation of posttraumatic subdural hematomas: A prospective study of 65 patients. J Trauma 1998; 44:868-873

Pupil Response Assess every 5 minutes & as needed Pupil size Symmetry Reactivity to light What size are the pupils? Are the pupils reactive to light?

Measuring Pupil Response Document these findings: Bilateral symmetry (asymmetric pupils differ more than 1 mm) Reactivity to light (a fixed pupil shows <1mm change in response to bright light) Dilation (greater than or equal to 4mm diameter in adults) 4 mm = pencil eraser diameter

Research Findings In-Hospital Studies Single fixed and dilated pupil 45% poor outcome Bilateral fixed and dilated pupils 82% poor outcome What is the mechanism that causes a dilated pupil? Answer: Explain that the presence of a blood clot causes downward displacement of the brain, until it puts pressure on the cranial nerve responsible for pupil dilatation. Braakman R,Gelpke G, Habbema J, et al. Systemic selection of prognostic features in patients with severe head injury. Neurosurgery 6: 362 – 370, 1980

Pupil Abnormalities hypoxia hypothermia orbital trauma Conditions that can mimic pupil abnormalities: hypoxia hypothermia orbital trauma pharmacological treatment cataract surgery hypotension illegal drug use toxic exposure artificial eye congenital abnormality anisocoria Ask the audience for their answers before you show the slide.

Blown Pupil Suggests herniation, which is compression of the brain stem Usually indicative of same- side mass Treat increased ICP, hypoxia & hypotension Why is pupillary assessment important? Can indicate impending cerebral herniation. A fixed and dilated pupil is a warning sign!

Indicators of Herniation An unresponsive patient (comatose) with: Bilateral dilated unresponsive pupils OR Asymmetric pupils AND Abnormal extension (decerebrate posturing) OR No motor response to painful stimuli Cushing’s Triad (Reflex) is a LATE sign of herniation Elevated systolic BP Widening pulse pressure Bradycardia Irregular respirations

Take Home Messages ABCs Level of Consciousness – GCS Herniation – Pupils and Motor Exam Thresholds: 90 / 90 / 9 Use assessment to determine treatment

GCS Skills Practice Video Break into small groups Show at least GCS and pupil exam portion of longer BTF video. Break into small groups, each group elect a leader, then work through GCS exercises. Achieve group consensus. Record answers on separate paper. Discuss as entire group and try to find out why any difference occurred.

Lesson 2 Treatment Can someone describe the traditional treatment techniques used in severe TBI patients?

Treatment Objectives Demonstrate normal and hyperventilation rates for adults and children Describe proper fluid resuscitation in TBI List two field treatments for brain herniation “Hyper”ventilation rates in this course are not nearly as fast as most prehospital personnel are used to.

Treat Airway Protect C-spine alignment Airway support per scope of practice Intubate severe TBI patients Correct hypoxia Consider C-spine and facial trauma When the airway cannot be secured by ETT; recommendations include PtL, LMA and Combitube. If the group is unfamiliar with these devices, take a few minutes to explain them Hypoxia must be corrected by administering supplemental oxygen to maintain the oxygen saturation >90%. The best airway adjunct allowed by scope of practice and protocols should be used for severe TBI patients (GCS<9) – this does not mean “cric ‘em!”

When should you intubate? GCS < 9 (severe TBI) Rapid Sequence Intubation (RSI) is useful to facilitate intubation for TBI patients with GCS scores 6-7-8.

Treat Breathing Rate, depth, quality, and effectiveness Administer oxygen Appropriate ventilation rate… Age Herniation The severe TBI patient will need adjunct airway support; if you cannot intubate use bag-mask with 100% O2, LMA, PtL or combitube (as scope of practice permits) When available use SaO2 to determine oxygenation; strive to maintain SaO2 >90%. Remember to “bag” or “ventilate” the patient at rates appropriate for their age and clinical condition.

SaO2 at Scene of Accident Oxygen Saturation Mortality Severe Disability >90% 14.3% 4.8% 60-90% 27.3% 27.3% <60% 50.0% 50.0% Review results: Important point SaO2< 60 =50% mortality, the remaining 50% of patients with SaO2 < 60 are left with severe disability The best outcomes occur when TBI patients are adequately ventilated and oxygenated Stocchetti N, Furlan A and Volta F: Hypoxemia and arterial hypotension at the accident scene in head Injury. J Trauma 40: 764-767, 1996

Vegetative Severe Disability Secondary Insults No. of Patients Good Moderate Disability Vegetative Severe Disability Dead Hypoxia 78 45% 22% 33% Hypotension 113 26% 14% 60% Both 52 6% 19% 75% Hypoxemia if untreated results in the majority of patients (adding vegetative and dead groups = 55% ) either dying or being left with severe impairments. Total number of severe head injury patients in study was 717. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe brain injury. J Trauma 34: 216-222, 1993

Normal Ventilation Rates Approximate normal ventilation rates: 10 bpm Adult 20 bpm Child 25 bpm Infant With regards to respiratory rates, the BTF values of 10, 20, and 25 are ventilation rates when bagging a patient to maintain normocarbia. This is different than the normal breathing rates in an adult, children or infant. The BTF numbers are close to the American Heart Association’s CPR values for assisted breathing. Before I show you the rates for hyperventilation, let’s first talk about the effects of hyperventilation in the severe TBI patient.

CO2 and Hyperventilation Hyperventilation produces a rapid decrease in the arterial partial pressure of carbon dioxide, which causes cerebral vasoconstriction, decreased cerebral blood flow, and lower intracranial pressure (ICP), giving the brain more room to swell. Hyperventilation can decrease the cerebral blood flow, potentially to the point of ischemia. Take Home Message: Monitor End-Tidal CO2 closely if capnography is available. Because hyperventilation causes cerebral vasoconstriction, it reduces the volume of blood flow into the brain. This causes cerebral ischemia because the arteries are constricted and the brain is being deprived of oxygen.

Hyperventilation and the Brain Injured Patient Important Points: Research identifies potential harm that can come from hyperventilating a TBI patient without signs of brain herniation Hyperventilation is a short term measure used in specific severe TBI patients (herniation) until definitive diagnostic or therapeutic interventions can be initiated. Immediately after a severe TBI the brain (because of the nature of the injury) is already ischemic, further reducing blood flow with hyperventilation causes even more vasoconstriction and more ischemia. This is why hyperventilation should only be used for short term management and only in patients showing signs of herniation.

Hyper-Ventilation Rates Approximate hyper-ventilation rates: 20 bpm Adult 30 bpm Child 35 bpm Infant These are the recommended values for hyperventilation, which may seem low to most prehospital providers.

Capnography and End-Tidal CO2 Continuous end-tidal CO2 measurements are used to measure the adequacy of ventilation. Many systems require a measurement of end-tidal CO2 after endotracheal tube placement as a method to confirm appropriate tube placement. Does not correlate perfectly with PaCO2. The level of CO2 measured by capnometry approximates 2 to 5 torr above or below the level in arterial blood, but is not as accurate. For hyperventilation, aim for a CO2 around 35 mmHg. Below 30 mmHg is considered severe hyperventilation. Below 25 mmHg is not recommended. So, if you must hyperventilate a severe TBI patient, you can use end-tidal CO2 monitoring to guide your therapy in the prehospital setting. Colorimetric detectors that fit on the end of the endotracheal tube are only useful for confirming correct tube placement. For a comprehensive article written by on End-tidal CO2 go to: http://www.critical-care-nurse.org/aacn/jrnlccn.nsf/(Articles)/215CoverTitle?OpenDocument

Take Home Messages Early post-injury episodes of hypoxia greatly increase mortality and morbidity Evidence defines hypoxia as an oxygen saturation <90% Intubating unconscious and unresponsive TBI patients improves outcome

Ventilation Rates Practice Match your bag squeeze rate to the audio tape rate Use the audiotape; do this as a class exercise. Important that they learn to feel the differences in rates of ventilation. We all have a tendency to “bag” patients too fast in emergent situations

Treat Circulation - Hypotension Maintain SBP > 90mmHg in adults (lower for infants and children) Use isotonic IV fluids Assess patient response to IV fluid bolus Ask the audience what are the definitions of isotonic, hypotonic and hypertonic fluids. Can they give an example of each type. Ask why only isotonic fluids are given to TBI patients?

Infuse volume to achieve normal BP Fluid Resuscitation Do not KVO the IV once SBP reaches 90mmHg. This is rarely a “normal” value for most adult patients. The goal of prehospital fluid resuscitation is to AVOID hypotension! Infuse volume to achieve normal BP

Vegetative Severe Disability Secondary Insults No. of Patients Good Moderate Disability Vegetative Severe Disability Dead Hypoxia 78 45% 22% 33% Hypotension 113 26% 14% 60% Both 52 6% 19% 75% If you could do one thing to in the prehospital setting to decrease severe TBI mortality- it would be to avoid hypotension. Hypotension doubles mortality! Total number of severe head injury patients in study was 717. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe brain injury. J Trauma 34: 216-222, 1993

Take Home Messages Evidence defines hypotension as a single observation of SBP < 90mm Hg (in adults) A single episode of hypotension doubles mortality and increases morbidity Goal is to maintain SBP >90mmHg in adults Goes back to ABC’s Airway- ventilation Breathing- oxygenation Circulation- fluid resuscitation

Brain-Targeted Therapy Glucose for hypoglycemia Sedatives for agitation Analgesics for pain Paralytics for ET intubation Controversial: Mannitol Lidocaine Hypertonic Saline These therapies are specific for the severe TBI patient and will be reviewed individually. One note of caution, some of these treatments are known to cause hypotension, therefore they must be weighed in light of the patients hemodynamic state with hypotension being avoided at all costs. No data showing the transient rise in ICP from intubation without lidocaine is detrimental to the TBI patient Prehospital administration of Mannitol does not improve mortality The studies looking at Hypertonic saline are still mixed. Some studies show it elevated BP which may improve outcome, other studies show no difference in survival

Other Factors Affecting ICP Fear and anxiety Pain Vomiting Straining Environmental stimulation Endotracheal intubation Airway suctioning Significance of these factors is largely unknown in terms of outcome

Brain-Targeted Therapy-Glucose Perform rapid blood glucose determination Rule out  level of consciousness due to hypoglycemia Give IV glucose Empiric glucose administration should not be done unless there is a high suspicion of hypoglycemia. Get patient history if possible, look for bracelet or anklet indicating diabetes mellitus, check a finger stick glucose level if at all possible before giving glucose.

Sedatives, analgesics, neuromuscular blockers Include etomidate, fentanyl, midazolam, thiopental for sedatives and induction. Succinylcholine, vecuronium, atracurium, pancuronium for neuromuscular blocking agents. Always follow local EMS protocols for medication administration If you are able to administer these drugs under your scope of practice and local protocols- remember to use short acting rather than long acting agents. Meds and doses per local EMS protocol

Take Home Messages Manage ABCs Airway and intubation Oxygenation Blood pressure Hyperventilate (when indicated) Glucose when appropriate Sedatives and analgesics per protocol The instructor should review each bullet point- asking the class for the correct answers. Examples: Oxygenation- Ask the class what is the Sa02 value that indicates poor oxygenation? What are some factors that incorrectly alter Sa02 values? Airway/ Intubation- Ask the class, if you cannot intubate a severe TBI patient (because of scope of practice) what is the best way to maintain their airway. If they are showing signs of herniation, at what rate should you ventilate them (assume adult).

Triage and Transport Lesson 3 You must remember to follow your local EMS protocols regarding transport; in rural areas the options may be few, and the reality of the situation ultimately dictates transport decisions.

Triage and Transport Objectives List 3 attributes of a trauma center with severe TBI capabilities Identify local and regional trauma centers with severe TBI capabilities Ask the audience to participate- what do they think the attributes are?

Knowledgeable Dispatch Good dispatch may send most appropriate unit to scene in some systems (ALS, helicopter).

Transport Considerations Dispatch ALS transport if patient is unconscious and unresponsive Rendezvous with air medical service to decrease en route times Transport decisions predetermined by local EMS authority. Speak to your EMS Director about the course.

Transportation and Outcome Study: Patients transported directly to trauma center compared with those first taken to a rural hospital and later transferred Finding: Outcome of those taken directly to trauma center was better. Transport to trauma center vs a rural hospital provides the TBI patient with immediate access to the necessary personnel and required treatments We need additional research. Young JS, Bassam D, Cephas GA, et al: Interhospital versus direct scene transfer of major trauma patients in a rural trauma system. Am Surg 64:88-92, 1998

Destination Decisions GCS 14-15 --- Hospital Emergency Room GCS 9-13 --- Trauma Center GCS < 9 --- Trauma Center with severe TBI capabilities Are all “Trauma Centers” of equal quality in caring for TBI at all times? Which centers in your area preferentially care for pediatric trauma, severe TBI? Which have appropriate specialists?

Trauma System Fewer preventable trauma deaths with an organized trauma system Better patient outcomes when treatment provided at trauma center “Practice makes perfect” phenomena. How can you influence positive change in your EMS system to alleviate problems in routing severe brain injuries to the most capable center?

Trauma System Predicted survival was 18% Actual survival was 29% using a trauma system Improved survival attributed to integration of prehospital and hospital care and access to expeditious surgery Goes back to the “Continuum of Care” phenomena. Best care at scene and best care in the ICU= GOOD outcome for severe TBI patients Shackford SR, Mackersie RC, Hoyt DB, et al: Impact of a trauma system on outcome of severely injured patients. Arch Surg 122:523-527, 1987

Severe TBI Trauma Center 24 hour CT scanning 24 hour OR and prompt neurosurgery Intracranial pressure monitoring Treat ICP as in Management and Prognosis of Severe Traumatic Brain Injury Does the highest level trauma center in your area routinely do ICP monitoring on serious brain trauma, and use detailed CPP protocols for treatment decisions?

Take Home Messages Dispatch appropriate EMS personnel Integrate the Guidelines for Prehospital Management of Traumatic Brain Injury into state/regional/local protocols Transport to appropriate receiving facility based on injury, GCS, and pupils

Course Take Home Messages Clinical practice should be evidence-based Do early and repeated neurological assessments Identify patients with severe TBI (GCS < 9) Avoid hypoxia, keep SaO2 > 90% Avoid hypotension, keep SBP > 90mmHg Hyperventilate only for clinical signs of herniation Triage and transport TBI to appropriate facilities based on severity Summary of Entire Course- the points in orange text are KEY!

The best therapy in the world is of no value unless there is a continuum of care. EMS Providers are the first link in the chain of appropriate and prompt care for the severe TBI patient. The potential for good outcome begins with YOU!

Case Scenarios

Case 1 21 year old male Unrestrained driver single vehicle MVC 20mph, sedan vs. concrete barrier No airbag Starred windshield No LOC

Initial Assesment Clear airway Bilateral breath sounds Strong radial pulse of 100 Blood Pressure 120/80 Speaking spontaneously

Physical & Neuro Evaluation Found out of vehicle walking near the accident scene 3x5 cm hematoma/contusion left forehead Opens eyes spontaneously Alert to person & place, but confused to month and year Follows motor commands GCS = ? Ask the class to participate by scoring the GCS

Treatment & Interventions Manual cervical spine stabilization Supplemental oxygen via non-rebreather mask Oxygenation with pulse oximetry (if available) Spinal immobilization with cervical collar and backboard Initiate transport Repeat vitals and neuro exam every 5 minutes and as needed IV access Rule out other causes of altered mental status

Causes of Altered Mental Status Hypovolemia Hypoxemia Drugs Alcohol Hypoglycemia Pain/Discomfort Traumatic Brain Injury (TBI)

Transport Decisions TBI severity? Destination? Ask the audience for the GCS score, and then where should the patient be transported to?

Transport Decisions GCS 14 TBI Severity? Mild TBI Destination? Emergency Department

Case 2 9 year old female Fell off jungle gym at community park Fell approximately 10 feet Witnessed by father Child landed on head Apparent “broken arm” + LOC

Initial Assessment Clear airway Color pale, lips cyanotic RR 10 bpm BP 72 palpable Radial pulse 110 Unresponsive

Physical & Neuro Evaluation Compound fracture left forearm 2 cm left temporal laceration Eyes open to painful stimuli Localizes to painful stimuli Speech incomprehensible words Pupils 4 mm, brisk reaction to light GCS = ? Ask the class to score the GCS

Treatment & Interventions Manual stabilization of cervical spine Ventilate via BVM with supplemental oxygen Monitor oxygenation and ventilation with pulse oximetry Spinal immobilization with cervical collar and backboard Initiate transport Vitals & neuro status every five minutes and as needed 2 large bore IV’s with LR open, rapid infusion to >90mmHg SBP Immobilize left forearm

Transport Decisions TBI severity? Destination? Ask audience- what is the GCS? What is the destination?

Transport Decisions GCS 9 TBI Severity? Moderate TBI Destination? Trauma Center

Case 3 30-year-old male Pedestrian struck by automobile while crossing busy intersection Thrown approximately 20 feet Multiple severe injuries + LOC

Initial Assessment Patient is unresponsive RR 6; cyanotic Radial pulse 132 BP 80/44 Right leg deformed Right foot traumatic amputation

Physical & Neuro Evaluation SaO2 84% Decreased breath sounds right chest Unresponsive Extensor posturing to painful stimuli Pupils unequal Right 3mm brisk Left 6 mm sluggish Right femur fracture GCS = ? Ask the class to score the GCS and assess her neurological status

Treatment & Interventions Manual stabilization of cervical collar Secure airway, intubate if possible Hyperventilate via BVM with supplemental oxygen 20 breaths/minute Monitor oxygenation and ventilation with pulse oximetry Immobilize with cervical collar and backboard Initiate transport Repeat vitals and neuro status every five minutes and as needed 2 large bore IVs LR, rapid infusion to >90mmHg SBP Immobilize right lower extremity

Transport Decisions TBI severity? Destination? What is the GCS? Where should the patient be transported to?

Transport Decisions GCS 4 TBI Severity? Severe TBI Destination? Trauma Center with Severe TBI Capabilities