Page 102 - JSOM Fall 2022

Hypertonic Saline for Severe Traumatic Brain Injury With Herniation

A Military Prehospital Case Report

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Randy Michael, DO *; Matthew Gaddy, NRP ; Nicholas Antonino, DO ;
Ryan Payne, NRP ; Erik DeSoucy, DO ; Stephen Rush, MD 6
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ABSTRACT
Severe traumatic brain injury (TBI) is a devastating injury with pathophysiology of post­TBI cerebral edema and the diagnosis
limited prehospital therapies available. The Joint Trauma Sys­ of IOH while exploring the role of prehospital HTS in the
tem (JTS) Clinical Practice Guidelines recommend hypertonic management of patients with severe TBI.
saline (HTS) for casualties with TBI and signs of impending or
ongoing herniation (IOH), but its use by combat medics has Mission Report
never been reported in the literature. This report details the
management of a pregnant patient with severe TBI and signs This encounter occurred during a security forces operation
of IOH, including the use of HTS, by US Air Force pararescu­ in a mountainous region with fair weather (dry and 65°F). A
men in an austere prehospital setting. Treatment with HTS was barricaded shooter was engaged and fragments from concus­
followed by improvement in the patient’s neurologic exam and sion grenades hit a partner force member and a local national.
successful evacuation to definitive care where her child was de­ The local national, a pregnant woman in her 20s, was assessed
livered alive. Additionally, we review the pathophysiology and within 5 minutes of injury. There were no signs of massive
signs of herniation, the mechanism of action of hyperosmotic hemorrhage. Her airway was clear, but respirations were ir­
therapies, and the rationale behind the use of HTS in the com­ regular and agonal with initial pulse oximetry of 88%. There
bat setting. was a 1 cm bleeding scalp wound to the right temporoparietal
region with clot and bone fragments in the hair around the
Keywords: severe traumatic brain injury; TBI; impending or on- wound. The left shoulder and arm had small lacerations and
going herniation; IOH; hypertonic saline; hypertonic sodium penetrating injuries with minimal bleeding, Her pupils were
chloride; prehospital unequal (left 3 mm, right 5 mm) and sluggish to react on the
right side. She was producing unintelligible sounds and was re­
sponsive only to painful stimuli with eye opening and decorti­
cate posturing on the right; Glasgow Coma Scale (GCS) score
Introduction = 7 (E2 V2 M3). The gravid uterus extended to her subxiphoid
Morbidity and death from TBI are the result of primary tis­ region indicating she was in the third trimester.
sue disruption and a secondary cascade of metabolic and
physiologic insults. The primary early therapeutic goal in the The airway was secured with a cricothyrotomy and 6.0 cuffed
management of moderate and severe TBI is prevention of sec­ endotracheal tube. An EMMA in­line capnometer (Masimo
ondary brain injury from the deleterious effects of hypotension Corp, https://www.masimo.com/) was placed, and bag venti­
and hypoxemia. Poor perfusion and oxygenation compound lations were provided at 10 breaths per minute by a partner
cerebral edema lead to elevated intracranial pressure (ICP), a force medic. A sternal intraosseous (IO) needle was placed in
decrease in cerebral perfusion, and, if left untreated, progres­ addition to an 18­gauge intravenous catheter in the right an­
sion to herniation and death. Hyperosmotic agents, such as tecubital fossa. A left humeral head IO was placed after the
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HTS are critical in the management of elevated ICP and are sternal IO failed to flow. The patient was placed inside of a
recommended for management of IOH. The Tactical Com­ Hypothermia Prevention and Management Kit (HPMK, North
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bat Casualty Care (TCCC) and JTS guidelines recommend ad­ American Rescue, https://www.narescue.com/) with her head
ministering a bolus of HTS to patients with IOH in order to elevated 15 degrees on a folded blanket. The scalp wound was
reduce intracranial pressure and arrest herniation. 6,7 left open to air and the left upper extremity injuries were man­
aged with compressive dressings. Elevated intracranial pres­
This report describes a case of severe TBI with signs of IOH sure was suspected; therefore 250mL of 3% hypertonic saline
managed by combat medics with a HTS infusion in an aus­ was administered via the humeral head IO over 5 minutes.
tere prehospital setting. To our knowledge, this is the first Sedation and pain control were provided with IV pushes of
report of prehospital administration of HTS published in midazolam and ketamine. One gram of tranexamic acid and
the military medical literature. Additionally, we review the 2g ceftriaxone were given.

*Correspondence to randymichaeldo@gmail.com
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1 Capt Randy Michael and Capt Nicholas Antonino are affiliated with the Department of Surgery, David Grant US Air Force Medical Center,
Travis Air Force Base, Fairfield, CA. 2d Lt Matthew Gaddy is affiliated with the 212th Rescue Squadron, Joint Base Elmendorf­Richardson,
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Anchorage, AK. SSgt Ryan Payne is affiliated with the 48th Rescue Squadron, Davis­Monthan Air Force Base, Tucson, AZ. Lt Col Erik DeSoucy
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is affiliated with the Department of Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, TX. Lt Col Stephen Rush is affiliated with
the 106th Rescue Wing, Westhampton Beach, NY.
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