Page 53 - ATP-P 11th Ed

Table 9 Cont.
PCC Role-based Guidance for Head Injury/TBI Management
T T • Identify signs of elevated or rising intracranial pressure (ICP) per Appendix E. Initiate imn-
C C mediate treatment for signs of elevated ICP including initial bolus of 3% hypertonic saline SECTION 1
C C (HTS) 250–500mL if available. Alterative: 23.4% sodium chloride.
C C • Administer TXA as single 2g IV or IO bolus (no second dose required).
- - • Communicate evacuation requirements (need for TBI evaluation, neurosurgery).
C C • Communicate re-supply requirements.
M P Role 1b
C P • Re-assess and re-apply MARCH interventions.
• Administer appropriate antibiotics for any open head wounds or skull fracture (see anti-
biotics section).
• Maintain goal SBP >90mmHg with initial fluid/blood product resuscitation.
• Serial neurologic checks and identify signs of elevated or rising intracranial pressure
( Appendix E); If noted, the following interventions are recommended, if possible:
» HTS administration (intermittent bolus versus continuous infusion) per Appendix E. Al-
terative: 23.4% sodium chloride.
» Supplemental oxygen to maintain O sats >94% and <99%, EtCO if intubated with goal
2
2
of mild hyperventilation to 35–40.
» Brief (less than 30 minutes) moderate hyperventilation to goal pCO /EtCO 20–30 may
2
2
be performed for signs of impending/active herniation (pupil becomes fixed and dilated);
if there is a neurosurgical capability.
**Note: Use hyperventilation only as a temporizing measure while additional ICP treat-
ments are being administered or tactical evacuation is in process.
• Repeat primary and secondary survey for any abrupt decline in the Glasgow Coma Scale
(GCS) or change in pupil exam to rule out non-neurologic causes.
• Minimize analgesia and sedation agents, and avoid paralyses, if possible, to preserve abil-
ity to obtain neurologic exam, but medical and operational considerations should take pri-
ority if deeper sedation or paralysis required.
• Teleconsultation with Trauma Surgeon and/or Neurosurgeon as available.
• Upgrade evacuation priority and destination (facility with neurosurgical capabilities) for
any patient with initial mild TBI who deteriorates to moderate/severe TBI category.
• Repeat triage evaluation and identification of likely non-survivable condition (or associ-
ated injuries) based on injury types/severity and required vs available resources.
Role 1c
• Continue serial neurologic checks including GCS and pupil exam at least hourly.
• Immediate seizure treatment with benzodiazepines, consider ketamine for refractory seizures.
• Temperature management and aggressive fever control.
• Teleconsultation with trauma surgeon and/or neurosurgeon as available.
• Upgrade evacuation priority and destination (facility with neurosurgical capabilities) for
any patient with initial mild TBI who deteriorates to moderate/severe TBI.
• Re-assess and Re-apply MARCH interventions.
• Ensure all basic nursing interventions noted above are completed by non-medical TCCC
ASM and CLS personnel, CLS-trained service members and medics/corpsmen.
• Conduct inventory of all treatment supplies.
• Document all pertinent information on PCC Flowsheet (attached).
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42 SECTION 1 TACTICAL TRAUMA PROTOCOLS (TTPs) ATP-P Handbook 11th Edition 43