Page 136 - Journal of Special Operations Medicine - Fall 2017

make it difficult to follow the neurologic examina- ➤ o Colloids (e.g., albumin) have demonstrated a trend to-
tion. Obtain a telemedicine consultation if possible. ward worsening outcomes in brain-injured patients.
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If in doubt, treat for elevated ICP according to ICP Hetastarches are associated with coagulopathy and
management outlined in the next section. increased risk of kidney injury in trauma patients.
➤ o Close control of Etco is critical for severe TBI Avoid colloids and hetastarches in TBI patients; how-
2
patients. Plan and ensure the capability to moni- ever, they can be used if no alternative is available.
tor Etco is available whenever advanced airway is ➤ o Avoid hypotonic fluids (including lactated Ringer’s)
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placed. Goal Etco is 35–40mmHg. whenever possible; they can make brain swelling
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worse.
Cushing’s triad (i.e., increased SBP and/or widening pulse Most trauma patients with moderate or severe TBI will
pressure, bradycardia, and irregular respirations) is a physi- have other traumatic injuries. A careful search for bleeding
ologic response that can occur with elevated ICPs, resulting should be performed in any hypotensive trauma patient.
in medullary compression. It is a late finding of severe brain
injury with brainstem herniation. Cushing’s triad should be
viewed as a sign of cerebral herniation and addressed imme- Brain injury with associated hemorrhagic shock is a com-
diately when recognized (see ICP Management). plicated scenario with a high risk of death. Balancing hem-

orrhage control (which is easier with lower blood pressure)
Management with maintaining cerebral perfusion pressure (which requires
higher blood pressure) should be guided with expert telecon-
➤ ➤ Hemodynamic Control sultation (i.e., critical care, neurocritical care, neurosurgical)
■ ➤ Goal: Maintain SBP >110mmHg. In polytrauma pa- whenever possible.
tients with ongoing bleeding, aggressively control hem-
orrhage using all means available and restore circulating ➤ ➤ Airway, Oxygenation/Ventilation Management
blood volume by using blood products. Note: An SBP ■ ➤ Goal: Manually maintain or secure the patient’s airway
>90mmHg has traditionally been targeted in TBI pa- and avoid hypoxia, hypocapnia, or hypercapnia to re-
tients, though recent literature has suggested better duce the risk of secondary brain injury. If GCS score is
outcomes may occur when SBP is maintained above ≤8 or there is facial trauma with compromised airway,
110mmHg in TBI patients. 10,11 a definitive airway is most likely needed. The provider
■ ➤ Best: If there is evidence of bleeding, transfuse whole should place the type of airway (i.e., cricothyroidotomy
blood or, if not available, transfuse blood products per or endotracheal tube [ETT]) that they have the most con-
TCCC guidelines. Target is an SBP >110mmHg. fidence in placing, based on their training and practice.
■ ➤ Better: If there is evidence of bleeding and no blood ■ ➤ Best: Cricothyroidotomy or ETT followed by continu-
products are available, administer 1L 0.9% sodium ous sedation and airway maintenance, supplemental
chloride (NaCl). Target is an SBP >90mm Hg. oxygen, portable ventilator. Targets: Spo >95% and
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■ ➤ Minimum: Stop all external bleeding. Manage internal Etco 35–40mmHg. Check arterial blood gas results
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bleeding to the extent possible with available resources. and correlate with Etco within 30 minutes of intuba-
2
Administer tranexamic acid (TXA) per TCCC guide- tion if laboratory capability is available. A positive end-
lines. Avoid medications that may lower the blood pres- expiratory pressure (PEEP) of 5cmH O should be used
2
sure (e.g., narcotics). routinely. PEEP can be safely increased up to 15cmH O
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■ ➤ Hemodynamic Control Notes if needed to improve Spo , but be alert for problems
2
➤ o Do not neglect scalp bleeding. This can become a caused by increased intrathoracic pressure (e.g., lower
significant source of blood loss. Scalp lacerations blood pressure or increased ICP). 16
should be sutured or stapled as soon as possible. ■ ➤ Better: Perform a cricothyroidotomy/ETT placement or
➤ o Take caution if an underlying skull fracture is present place a supraglottic airway (e.g., laryngeal mask airway
or if there is obvious penetrating trauma. DO NOT [LMA], King laryngeal tube [LT]) followed by continu-
tightly pack or irrigate an open head wound. Su- ous sedation and airway maintenance, supplemental
ture or staple the skin closed, if bleeding. A pressure oxygen via oxygen concentrator, and portable ventilator
dressing may be placed if needed to control bleeding. to maintain an Spo >95% and Etco of 35–40mmHg.
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➤ o Hypotension is usually not caused by TBI except as ■ ➤ Minimum: Nasopharyngeal airway and bag-valve-mask
a late finding due to herniation. Always look for with PEEP valve as needed. Use supplemental oxygen, if
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other causes of hypotension, such as ongoing bleed- available. Maintain Spo >90%.
2
ing or tension pneumothorax. ■ ➤ Airway Management Notes
➤ o Urine output (UOP) provides an important as- ➤ o Patients with a GCS score ≤8 should undergo place-
sessment of blood supply to the organs. Monitor- ment of an advanced airway (i.e., cricothyroidotomy
ing continuously by a Foley catheter is ideal. If a or ETT) unless arrival to a higher level of care will
Foley catheter is not available, monitor by a gradu- occur in a timely manner or the airway can be manu-
ated cylinder. Goal UOP in a polytrauma patient is ally maintained. The risk versus benefit of advanced
30–50mL/h. 13 airway placement should be carefully considered and
➤ o The role of TXA in TBI patients is currently under discussed by telemedicine consultation whenever
investigation in the CRASH-3 trial. Limited data possible.
suggest TXA limits ICH expansion and may improve ➤ o Airway interventions may cause transient hypoxia
outcomes in TBI patients. Until more definitive during the procedure. Every effort should be made
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data are available, TXA can be used in TBI patients. to optimize airway placement on the first attempt by
132 | JSOM Volume 17, Edition 3/Fall 2017