Page 138 - Journal of Special Operations Medicine - Fall 2017

■ ➤ Best: Antibiotics should be used for open or penetrating ➤ o Nonconvulsive seizures (NCSs) should be considered
TBI. When available, use antibiotics with strong central in any TBI patient with a GCS score ≤8 and who
nervous system (CNS) penetration. does not improve with appropriate resuscitation and/
➤ o Ceftriaxone 2g IV/IO every 8 hours. or ICP management. NCSs may persist after convul-
➤ o Add metronidazole 500mg IV/IO every 8 hours for sive seizures are stopped and may be associated with
wounds that are grossly contaminated with organic higher morbidity and mortality. The most common
25
debris (e.g., dirt, debris, clothing). 17 signs of patients with NCS are coma, delirium, agita-
■ ➤ Minimum: Dress all wounds to prevent further intro- tion, aphasia (impairment of language affecting pro-
duction of infectious materials. Optimize wound and duction and/or comprehension of speech, reading,
patient hygiene to the extent possible given the environ- and/or writing) and/or “blank staring.”
mental and situational conditions. ➤ o Prompt initiation of seizure prophylaxis reduces
➤ o For penetrating head wounds, apply superficial dress- early seizures after TBI. In PFC settings, where pos-
26
ings and seal the dressing to the extent possible. sible, an antiepilepsy drug should be used early after
➤ o Bleeding head injuries must be sutured or stapled to injury to help prevent seizure.
control bleeding. ➤ o Midazolam has a high rate of seizure control and
➤ o DO NOT introduce any material into the wound cavity. works rapidly to terminate seizure activity. Mid-
27
➤ o DO NOT attempt to flush the wound. azolam is preferred because it is a short-acting medi-
➤ o Antibiotics are not necessary in TBI without open or cation (elimination time: 2–4 hours) and will allow
penetrating trauma. for more regular and comprehensive neurologic ex-
■ ➤ Infection Control Note: Ertapenem, while appropriate aminations. It can be given IM in patients who do
for infection management in other traumatic injuries, not yet have IV/IO access.
does not have sufficient evidence supporting adequate ➤ o If not already placed, strong consideration should be
CNS penetration and may increase the risk of seizure. given to placing an advanced airway (cricothyroid-
Ertapenem (1g IV/IO every 24 hours) should only be otomy or ETT) in any TBI patient who experiences
used in TBI patients when other antibiotics with proven seizures (place airway after seizures are controlled).
CNS penetration are not available. 23
➤ ➤ Fever Control
➤ ➤ Seizure Prophylaxis and Management ■ ➤ Goal: Maintain core temperature between 96°F and
■ ➤ Goal: Rapidly identify and manage seizure activity in 99.5°F. Treat fever aggressively in TBI patients with a
TBI patients. combination of medication, cold fluid boluses, and sur-
■ ➤ Best: For witnessed or suspected seizures, administer a face cooling techniques.
rapidly acting benzodiazepine (midazolam 5mg IV/IO/in- ■ ➤ Best: Acetaminophen 650mg every 4 hours orally (PO)
tramuscularly [IM]) plus a maintenance antiepilepsy drug. or rectally as needed for rectal temperatures >99.5°F.
Broad-spectrum IV agents such as levetiracetam (Keppra; Additionally, cold saline IV fluid bolus can be used for
UCB Pharma, http://www.ucb.com/) are preferred. refractory fever, if available.
➤ o Maintenance antiepilepsy-drug dosing: ■ ➤ Better: Apply cold packs to axillary regions, posterior
• Levetiracetam: 2000mg IV/IO loading dose over cervical region, and the groin.
15 minutes followed by maintenance dosing of ■ ➤ Minimum: Ensure patient has been removed from heat
500mg IV/IO every 12 hours. or sun. Remove clothes to allow evaporative cooling, Use
➤ o Alternate maintenance antiepilepsy drugs: surface-cooling measures (e.g., evaporative heat loss by
• Phenytoin (loading dose: 1.5g IV over 1 hour, misting and fan cooling) to reduce core body temperature.
then 100mg PO/IV/IO every 8 hours) ■ ➤ Fever Notes
• Phenobarbital (loading dose: 1.5g IV/IO over 1 ➤ o Fever will increase cerebral metabolism and may in-
hour, then 100mg PO/IV/IO daily). Be ready to crease ICP.
support ventilation if phenobarbital is used. ➤ o Although targeted temperature management (previ-
■ ➤ Minimum: For witnessed convulsive seizure activity, ously referred to as therapeutic hypothermia) is used
place the patient on his/her side and clear the area of to reduce ICP in a critical care setting, hypothermia
any potentially harmful objects. Suction the mouth if is part of the “lethal triad” in trauma patients, along
possible, but DO NOT attempt to place anything in- with coagulopathy and acidosis. Targeted tempera-
side a seizing patient’s mouth. Treat any witnessed or ture management strategies beyond what is outlined
suspected seizures with a rapid-acting benzodiazepine. in TCCC should NOT be attempted in the field or
➤ o Midazolam 5mg IV/IO/IM every 5 minutes until sei- Role 1 setting.
zure stops. ➤ o Hypothermia prevention and management kits
➤ o An alternate benzodiazepine can be used if available should continue to be used in all trauma patients. In
(diazepam 5mg IV every 5 minutes until seizure stops; TBI patients, however, warming measures should be
lorazepam 4mg IV every 5 minutes until seizure stops). avoided when the core body temperature is above the
■ ➤ Seizure Notes target range.
➤ o Not all seizures are easy to see. At times, the find-
ings may be obvious with generalized convulsions, or Avoid nonsteroidal antiinflammatory drugs (NSAIDs),
they may be subtle (e.g., persistent twitching of facial such as ibuprofen, naproxen, ketorolac. Although these
muscles, fingers). agents can effectively lower temperature, their antiplatelet ef-
➤ o Risk factors for seizures after TBI include: GCS score fect may increase bleeding in TBI if intracranial hemorrhage
<10, skull fractures, penetrating injuries, prolonged is present (e.g., epidural hematomas, subdural hematomas).
length of coma (>24 hours). 24

134 | JSOM Volume 17, Edition 3/Fall 2017