Page 137 - Journal of Special Operations Medicine - Fall 2017

preoxygenating with supplemental O , selecting the ➤ o Maintain SBP >90mmHg and ideally at >110mm Hg.
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most experienced provider available, and using the ➤ o Prevent or rapidly manage seizure activity.
technique most familiar to the provider. ➤ o If concerned for impending herniation (e.g., unre-
➤ o Patients typically require less sedation after cricothy- sponsive patient with unilateral dilated pupil, pres-
roidotomy than after ETT placement. This may help ence of Cushing’s triad), hyperventilate the patient
conserve resources if medications are limited. for no more than 20 minutes to an Etco target of
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➤ o Monitor Etco and adjust ventilations to achieve 30mmHg. Seek expert consultation immediately.
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the target range. Avoid hyperventilation (Etco ■ ➤ The optimum duration of hyperventilation and fre-
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<35mmHg) except in extreme cases where imminent quency that can be repeated are not known. If per-
herniation is suspected, because hyperventilation formed, assess response (i.e., pupils, GCS score, and so
worsens cerebral ischemia. Also avoid hypoventila- forth). If patient responds, consider performing again if
tion (Etco >45mmHg) that will increase ICP. needed, guided by expert teleconsultation, if possible.
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➤ o Gastric decompression with a nasogastric tube ■ ➤ ICP Management Notes
(NGT) or oral gastric tube (OGT) will decrease the ➤ o ICP cannot be directly measured without advanced
risk of aspiration in unconscious patients. If patients intracranial monitoring devices. Therefore, vigilant
required bag-masking, they may have a distended clinical observation and the use of noninvasive ICP
stomach, which, in some patients, contributes to bra- assessment modalities are critical to monitoring TBI
dycardia. NGT and OGT cannot be placed with a patients until neurosurgical placement of neuromon-
supraglottic airway. itoring devices can occur.
➤ o HTS bolus lowers ICP and has a duration of action
➤ ➤ ICP Management of approximately 3 hours. 19,20
■ ➤ Goal: Suspect high ICP in any head injury patient with ➤ o Mannitol, although effective, has several potentially
GCS score ≤8 OR declining findings on neurologic ex- adverse complications. It is a diuretic and might
amination (unless explained by sedation, hypotension, lower the blood pressure. Also, after repeated use,
hypoxia, hypercarbia, high fever). Minimize factors that it can cross a damaged blood–brain barrier and po-
contribute to elevated ICP, such as pain, anxiety, and tentially worsen ICP. For these reasons, HTS is pre-
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fever. Rapidly recognize and manage elevated ICP, and ferred to mannitol in TBI and polytrauma patients.
maintain an adequate cerebral perfusion pressure. ➤ o Some institutions have reported ICP-lowering bene-
■ ➤ Best: In addition to all minimum and better measures, fits from vertical positioning of patients, particularly
administer osmotic therapy via peripheral intravenous when high intraabdominal or intrathoracic pressure
(IV) or intraosseous (IO) access: is suspected. Lower intraabdominal and intratho-
➤ o Hypertonic saline (HTS) racic pressures may facilitate venous drainage from
• 3% NaCl 250mL bolus over 20 minutes; repeat the intracranial compartment. If safe to do so, this
every 3 hours as needed when concerned for el- can be attempted when other measures have failed.
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evated ICP.
➤ o Mannitol can be used if there is no sign of bleeding
and the SBP is >110mmHg. Always treat hypotension before treating elevated ICP.
• Mannitol 1g/kg IV/IO over 20 minutes. Repeat at Cerebral blood flow is more affected by a decrease in blood
0.5g/kg IV/IO every 3 hours as needed when con- pressure than an increase in ICP.
cerned for elevated ICP.
Seek additional medical direction as soon as pos- Cerebral perfusion pressure (CPP) = mean arterial pressure
sible and evacuate to neurosurgical care at the earliest (MAP; mmHg) − ICP (mmHg)
opportunity.
■ ➤ Better: Even unconscious patients may experience pain
and anxiety, manifested by hypertension (i.e., SBP Hyperventilation reduces CO and rapidly lowers ICP
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>160mmHg) and/or agitation. Anxiety and agitation by causing cerebral vasoconstriction and decreasing the
can increase ICP. In addition to all minimum measures, overall cerebral blood volume. However, hyperventilation
ensure adequate sedation and analgesia by targeting a also damages the brain by causing ischemia and should
Richmond Agitation and Sedation Score of −1 to −2. only be performed for brief periods. Avoid hyperventila-
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Refer to Joint Trauma System CPG on PFC analgesia tion unless all other interventions have been ineffective.
and sedation. 17
➤ o Ketamine 20mg IV/IO
➤ o Hydromorphone 0.5–2mg IV/IO Although there are invasive interventions to help as-
➤ o Fentanyl 25–50μg IV/IO sess and treat elevated ICP, evacuate hematomas, and so
• In addition to analgesics, consider administration forth, such as decompressive craniectomy, extraventricu-
of a rapid-onset, short-duration anxiolytic. Midazo- lar drains, intracranial bolt monitors, and burr holes, such
lam 1–2mg IV/IO as needed for agitation or anxiety. procedures are not recommended unless the PFC provider
■ ➤ Minimum: Use general measures to reduce ICP. has training and experience in performing these procedures
➤ o Elevate head of bed (HOB) 30°–60 . ° and is directed by expert teleconsultation.
➤ o Maintain neck in midline position.
➤ o Maintain arterial blood oxygen saturation (SpO ) ➤ ➤ Infection Control
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>90% (or >95% if receiving ventilatory support). ■ ➤ Goal: Dress all wounds to prevent further exposure to
➤ o Maintain Etco between 35mmHg and 40mm Hg. environmental pathogens and administer antibiotic pro-
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➤ o Maintain core temperature between 96°F and 99.5°F. phylaxis to all patients with penetrating TBI.
Guideline: TBI Management in PFC | 133