Page 30 - 2026 SMOG

HEAD INJURY/TBI
Signs and Symptoms
• Head pain, swelling, bleeding • Epidural/subdural hematoma
• Head deformity, ecchymosis • Subarachnoid hemorrhage
• Altered mental status • Abuse
• Respiratory distress/failure • Definitions
• Vomiting ˚ Mild TBI: GCS 13–15
• Spinal injury ˚ Moderate TBI: GCS 9–12
• Skull fracture ˚ Severe TBI: GCS 3–8
Treatment
• Consider spinal immobilization (minimize compression of neck veins)
• Resuscitate, follow TACTICAL EVACUATION PROTOCOL
• TXA 2g IV/IO over 10min in moderate to severe TBI
• Levetiracetam (Keppra) 1500mg IV/IO over 15min in severe TBI (seizure prophylaxis for transport)
• Airway compromise
˚ Establish airway (AIRWAY PROTOCOL) with supplemental O 2
˚ Monitoring goals
SpO >95%
■
2
■ EtCO 35–45mmHg (normo-ventilation)
2
• No obvious airway compromise
˚ Jaw thrust, NPA
˚ Supplemental O via BVM (SpO >95%)
2
2
˚
Low threshold to RSI if deteriorating GCS/mental status
• Evidence of elevated ICP
˚ Elevate the head of the bed 30°–45°
˚ 3% Hypertonic Saline, 250mL IV/IO over 10–20min followed by infusion of 50–100mL/hr
˚ Target vital signs
SBP >110
■
■ SpO >95%
2
■ EtCO 35–45mmHg (normo-ventilation, do not hyperventilate)
2
■ CCP >60 (CCP=MAP–ICP)
• Evidence of impending herniation [e.g., unilateral/bilateral dilated or fixed pupil, and/or presence of
Cushing’s Triad (Cushing’s Triad = (relative) bradycardia, hypertension/widening pulse pressures,
irregular respirations)]
˚ Continue elevated ICP treatment as above.
˚ Target ventilation to an EtCO of 35mmHg (normo-ventilation; avoid hyperventilation) for no
2
more than 20min. Request online medical control for further guidance on a prolonged flight.
Notes, Cautions, Warnings
• Ensure continuous monitoring q5–10min
• Active seizures: Lorazepam or Midazolam, see SEIZURE PROTOCOL
• Mannitol given as boluses: 1g/kg bolus followed by 0.5g/kg bolus q3hr
• Keep SBP >110; consider NS bolus
• Avoid hypo/hypercapnia through dedicated, closely managed ventilation
• Sedation: Ketamine is preferred over Propofol due to the hemodynamic effect of Propofol.
Monitor SBP
• Paralysis: Not preferred in head injury if avoidable; Vecuronium preferred; ensure pain control/
sedation is adequate to avoid increased ICP
References: CPG ID # 30 (TBI Management and Basic Neurosurgery in the Deployed Environment); CPG ID
#63 (TBI Management in PFC)
22 • TRAUMA