Page 139 - Journal of Special Operations Medicine - Fall 2017

➤ ➤ Sodium Management treated; however, the treatment of hyperglycemia is
■ ➤ Goal: Avoid hyponatremia, which can worsen brain not covered in this CPG.
swelling. The target serum sodium level in patients with
severe TBI is slightly above normal, between 145mmol/L Transportation Considerations
and 160mmol/L.
■ ➤ Best: Monitor serum sodium level via blood sampling. ➤ ➤ Goal: Safely prepare TBI patients for ground and/or air
In a stable patient, check sodium level every 6 hours. In transportation to higher levels of care.
an unstable patient, or in a patient receiving HTS, check ■ ➤ Best: Ensure transport assets are aware of the patient’s
sodium level every 3 hours. Adjust fluids as needed to brain injury in advance so appropriate accommodations
meet the sodium goals. and/or alterations to the travel plan can be made.
■ ➤ Minimum: Avoid the administration of any free water ➤ o Most patients are transported in a supine position.
or hypotonic fluids that will lower serum sodium levels. Every effort should be made to transport TBI pa-
■ ➤ Sodium Management Notes tients with the HOB elevated to at least 30°.
➤ o Several conditions can develop rapidly in brain-in- ➤ o For fixed-wing transport, TBI patients should be
jured patients that can lower serum sodium levels loaded with their head toward the front of the air-
(e.g., cerebral salt wasting, syndrome of inappropri- craft to minimize G-forces transmitted to the brain.
ate antidiuretic hormone secretion) or raise serum so- ➤ o Air transport of TBI patients requires additional con-
dium levels (e.g., diabetes insipidus). Sodium levels, siderations. For air movements that involve altitudes
fluid intake, and urine output should be monitored >8,000 ft, TBI patients are at risk for additional com-
closely. plications that may worsen brain injury, such as hy-
➤ o If laboratory testing for serum sodium level is not pobaric hypoxia and high-altitude cerebral edema.
29
available, then, as a reference, 250mL of 3% saline Preplanning with air assets is highly recommended.
can be expected to raise the serum sodium level of an ■ ➤ Minimum: Dose sedative/analgesic medications, os-
80kg patient approximately 2–3mmol/L. Assuming motic agent, and/or benzodiazepine before any signifi-
a normal serum level of 140mmol/L before starting cant ground or air transportation, as resources permit.
HTS therapy, it would take six 250mL bags of 3% ➤ o Neuromuscular blocking agents will mask seizures and
HTS to raise the serum sodium to concerning levels clinical examination changes; therefore, the risk versus
(i.e., >160mmol/L). This is without factoring in the benefit of use during transport must be considered.
regulation of serum sodium by the kidneys. If patient
is urinating, it will be difficult to raise serum sodium References
above 160mmol/L with 3% HTS. If patient is not 1. Marr AL, Coronado VG, eds. Central Nervous System Injury
urinating, more caution should be used because so- Surveillance. Data Submission Standards-2002. Atlanta, GA:
dium levels can build up more quickly. Centers for Disease Control and Prevention; 2004.
Obtain telemedicine consultation, preferably from a criti- 2. DuBose JJ, Barmparas G, Inaba K, et al. Isolated severe traumatic
cal care or neurocritical care expert, before giving more than brain injuries sustained during combat operations: demographics
mortality outcomes, and lessons to be learned from contrasts to
two 250mL boluses of 3% NaCl HTS. civilian counterparts. J Trauma. 2011;70:11–18.
➤ ➤ Blood Glucose Control 3. McHugh GS, Engel DC, Butcher I, et al. Prognostic value of sec-
■ ➤ Goal: Avoid both hypolgycemia and hyperglycemia. ondary insults in traumatic brain injury: results from the IMPACT
Target a blood glucose level of 180mg/dL via handheld study. J Neurotrauma. 2007;24(2):287–293.
glucometer. 4. Teasdale G, Murray G, Parker L, et al. Adding up the Glasgow
Coma score. Acta Neurochir Suppl (Wien). 1979;28:13–16.
■ ➤ Best: Check blood glucose level every 6 hours. If glu- 5. Raffiz M, Abdullah JM. Optic nerve sheath diameter measure-
cose level is <100mg/dL, give 20g of oral glucose (5 tea- ment: a means of detecting raised ICP in adult traumatic and non-
spoons of sugar or 4 teaspoons of honey) PO or by NG traumatic neurosurgical patients. Am J Emerg Med. 2017:35(1):
tube. Or administer 25g (50mL) dextrose 50% in water 150–153.
(D50) solution IV/IO. Recheck blood glucose in 1 hour, 6. Cho R, Bakken H, Reynolds M, et al. Concomitant cranial
then continue to check every 6 hours. and ocular combat injuries during Operation Iraqi Freedom. J
Trauma. 2009;34(3):516–520.
■ ➤ Minimum: Monitor for clinical signs and symptoms of 7. Groswasswer Z, Cohen M, Blankstein E. Polytrauma associated
hypoglycemia (e.g., sweating, confusion, tremor, gener- with traumatic brain injury: incidence, nature and impact on re-
alized weakness, generalized lethargy). If patient is hun- habilitation outcome. Brain Inj. 1990;4(2):161–166.
gry and able to safely swallow, allow the patient to eat 8. Bruce B. State of the Art Review: non-invasive assessment of
to avoid hypoglycemia. Avoid the administration of any cerebrospinal fluid pressure. J Neuroophthalmol. 2014;34(3):
substances that are excessively high in sugar or carbohy- 288–294.
drate content to prevent hyperglycemia. 9. Kushner DS, Alvarez G. Dual diagnosis: traumatic brain injury
■ ➤ Blood Glucose Control Notes with spinal cord injury. Phys Med Rehabil Clin N Am. 2014;25
(3):681–696.
➤ o Hypoglycemia is more harmful to the brain than 10. Berry C, Ley EJ, Bukur M, et al. Redefining hypotension in trau-
hyperglycemia. matic brain injury. Injury. 2012;43(11):1833–1837.
➤ o Hyperglycemia may occur in TBI as an acute stress 11. Brenner M, Stein DM, Hu PF, et al. Traditional systolic blood
response or as a result of brain-induced catechol- pressure targets underestimate hypotension-induced secondary
amine release. Early hyperglycemia (i.e., >180mg/dL) brain injury. J Trauma Acute Care Surg. 2012;72(5):1135–1139.
has been associated with poor neurologic outcome in 12. Van Wyck DW, Grant GA, Laskowitz DT. Penetrating traumatic
severe TBI. 28 brain injury: a review of current evaluation and management con-
cepts. J Neurol Neurophysiol. 2015;6(6):1–7.
➤ o The treatment of hyperglycemia requires insulin. If 13. Baker B, Powell D, Riesberg J, et al. Prolonged Field Care Work-
the appropriate medications, laboratory capability, ing Group fluid therapy recommendations. J Spec Oper Med.
and expertise are available, hyperglycemia may be 2016;Spring;16(1):117–122.

Guideline: TBI Management in PFC | 135