Page 143 - Journal of Special Operations Medicine - Fall 2017

Appendix D Recommended Packing List
Assumptions: One patient with a moderate to severe traumatic ■ ➤ Better
brain injury. To calculate the amount of fluid or medication you ➤ o Equipment: portable vital sign monitor, capnometer,
would need for a single TBI patient, use your worst case, longest cricothyroidotomy kit and/or ETT plus laryngo-
possible evacuation extrapolated from your mission planning. scope/glidescope and/or laryngeal mask airway, cold/
ice packs, graduated cylinder to measure urine, oxy-
For example, if you think you might have a 36-hour evacua- gen concentrator
tion, you might need 3,500mg levetiracetam (a 2,000mg load- ➤ o Medications/Fluids: ketamine, IV hydromorphone,
ing dose and 500mg every 12 hours) IV fentanyl, midazolam
■ ➤ Best ■ ➤ Minimum
➤ o Equipment: portable monitor providing continuous ➤ o Equipment: vital-sign trending chart, BP cuff, stetho-
vital-signs display with capnography, cricothyroid- scope, wrist watch, pulse oximeter, capnometer,
otomy kit, and/or ETT plus laryngoscope/glidescope, cricothyroidotomy kit, bag-valve-mask with PEEP
portable point-of care-testing device such as an iStat valve, nasopharyngeal airway, disposable thermom-
(Abbott Point of Care; https://www.pointofcare eter, Nalgene bottle to measure urine
.abbott) or Epoch (Alere, http://www.alere.com) for ➤ o Medications/Fluids: ketamine, midazolam, loraz-
arterial blood gas samples, and electrolyte monitor- epam, acetaminophen, ceftriaxone, 3% hypertonic
ing, blood glucose monitor, Foley catheter kit, and saline
supplemental oxygen or oxygen concentrator ■ ➤ Other Packing List Considerations
➤ o Medications/Fluids: Fresh whole blood drawing sup- ➤ o Equipment: Portable ultrasound, nasogastric tube,
plies or stored blood products, 3% hypertonic saline, red- (or red/yellow-speckled) top test tubes to test for
mannitol, ceftriaxone, metronidazole, levetiracetam electrolytes if a host-nation laboratory is available
or phenytoin, acetaminophen, dextrose 50% in water ➤ o Medications/Fluids: TXA

MANAGEMENT OF TRAUMATIC BRAIN INJURY SUMMARY
Neurologic Assessment
Goal: Rapidly identify TBI Primary survey: Perform rapid trauma Secondary survey: Evaluate for Consider: If patient is
and associated injuries; survey to assess all injuries. Determine TBI red flags. Perform detailed unconscious, measure a baseline
assess TBI severity. and record Glasgow Coma Score. neurologic examination. optic nerve sheath diameter with
Assess pupils and motor function in ultrasound using a 10(–5)MHz
all four extremities. Recognize linear probe.
Cushing’s triad.
ONSD should not be attempted on any patient with an open globe injury to the eye.
Cushing’s triad: increased SBP/widened pulse pressure, bradycardia, irregular breathing (typically rapid/shallow)
GOAL BEST BETTER MINIMUM
Monitoring
Prevent secondary Portable monitor with continuous Blood pressure cuff, stethoscope,
brain injury, maintain vital-signs display, Foley catheter to pulse oximeter, method to monitor
adequate oxygenation monitor urine output. If advanced urine output. If advanced airway
and ventilation, avoid airway in place, monitor end-tidal is in place, monitor Etco with
2
hypotension, detect CO (Etco ) with capnography. capnometer. Check pupils and GCS
2
2
elevated ICP. Check pupils and GCS hourly. hourly or as often as possible.
Neurologic examination and vital-sign trends are essential to identifying a deteriorating patient with TBI.
Monitoring EtCO is critical for severe TBI patients. Bring the correct equipment whenever possible.
2
Management: Hemodynamic Control
Maintain systolic pressure If evidence of bleeding, transfuse If there is evidence of bleeding Stop all external bleeding. Manage
>110mmHg whole blood or, if not available, and no blood products are internal bleeding to the extent
transfuse blood products per TCCC available, 0.9% sodium chloride possible with available resources.
guidelines. 1L. Target SBP: >90mmHg Administer TXA per TCCC
Target SBP: >110mmHg guidelines. Avoid medications that
may lower the blood pressure.
Brain injury in the presence of hemorrhagic shock requires balancing hemorrhage control with cerebral perfusion. Telemedicine consultation
is strongly encouraged.
Do not neglect scalp bleeding. Take care to inspect for skull fractures. DO NOT tightly pack an open head wound.
Hypotonic fluids (to include lactated Ringer’s) should be avoided whenever possible because they can worsen cerebral edema.
Management: Airway, Oxygenation/Ventilation
Maintain or secure airway. Perform cricothyroidotomy/ETT Perform cricothyroidotomy/ Nasopharyngeal airway and
If GCS score ≤8 or there followed by continuous sedation, ETT or place supraglottic airway bag-valve-mask with PEEP.
is facial trauma or other supplemental O portable ventilator. followed by continuous sedation, Supplemental oxygen, if available.
2,
airway compromise, Target Spo >95%, Etco 35–40. supplemental O , portable Maintain Spo >90%.
2
2
2
2
consider definitive airway Check arterial blood gas values. ventilator. Target Spo : >95%,
2
placement. PEEP: 5cmH O (increase up to Etco : 35–40mmHg.
2
2
15cmH O if needed).
2
Avoid hyperventilation except in extreme cases where imminent cerebral herniation is suspected.
(continues)
Guideline: TBI Management in PFC | 139