1. 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

2. 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

3. 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

4. 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.

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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 = (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

18. 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.

19. 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

20. GCS Indicators of TBI Severity
GCS MILD
GCS MODERATE
GCS SEVERE
These are the 3 categories of TBI

21. 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

22. 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
% Yes
% 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:

23. 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?

24. 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

25. 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

26. 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.

27. 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!

28. 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

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

30. 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.

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

32. 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.

33. 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!”

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

35. 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.

36. SaO2 at Scene of Accident
Oxygen Saturation Mortality Severe Disability
>90% % 4.8%
60-90% % 27.3%
<60% % 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: , 1996

37. 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: , 1993

38. 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.

39. 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.

40. 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.

41. 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.

42. 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:

43. 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

44. 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

45. 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?

46. 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

47. 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: , 1993

48. 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

49. 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

50. 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

51. 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.

52. 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

53. 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).

54. 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.

55. 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?

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

57. 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.

58. 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

59. Destination Decisions
GCS Hospital Emergency Room
GCS Trauma Center
GCS < 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?

60. 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?

61. 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: , 1987

62. 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?

63. 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

64. 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!

65. 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!

66. Case Scenarios

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

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

69. 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

70. 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

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

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

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

74. 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

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

76. 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

77. 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

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

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

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

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

82. 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

83. 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

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

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