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an unfavorable effect in patients with polytrauma. It is also 4. Todd MM. Some historical notes on hyperosmolar therapy. J
important to note that multiple high­quality vascular access Neurosurg Anesthesiol. 2013;25(1):86.
points are required as hyperosmolar agents must be adminis­ 5. Van Wyck DW, Grant GA. Penetrating traumatic brain injury: A
tered separate from blood products. review of current evaluation and management concepts. J Neurol-
ogy & Neurophys. 2015;6(6).
6. Tactical Combat Casualty Care (TCCC) Guidelines for Medical
The JTS severe TBI Clinical Practice Guideline, Advanced Personnel. 5 November 2020. https://learning­media.allogy.com/
Tactical Paramedic Protocols Handbook, and the Pararescue api/v1/pdf/9e7beef5­e713­472f­9eb3­1f7f0fdf33a3/contents. Ac­
Medical Operations Handbook (PJHB) advocate for its use in cessed 10 January 2022.
the treatment of TBI with clinical signs of increased ICP and 7. McCafferty R, Neal C, Marshall S, et al. Joint Trauma System
IOH in the prehospital setting. 7,19,20 Additionally, the TCCC Clinical Practice Guideline (JTS CPG): Neurosurgery and se-
guidelines have included a HTS bolus for similar indications vere head injury. 2 March 2017. https://jts.amedd.army.mil/
assets/docs/cpgs/Neurosurgery_and_Severe_Head_Injury_02_
6
since 2012. While the TCCC and JTS guidelines recommend Mar_2017_ID30.pdf. Accessed 10 January 2022.
a 250mL bolus of 3% or 5% HTS, the recently revised PJHB 8. Graham DI, Gennarelli TA, McIntosh TK. Trauma. Greenfield’s
advises for a 30mL bolus of 23.4% HTS; an advantage in Neuropathology. 7th ed. London, UK: Arnold Publishers; 2002:
21
terms of weight and cube. Although many prominent orga­ P733–P812.
nizations advocate for the use of HTS in the treatment of TBI 9. Berry C, Ley EJ, Bukur M, et al. Redefining hypotension in trau­
matic brain injury. Injury. 2012;43(11):1833–1837.
with IOH, it is important to note the absence of literature ex­ 10. Parikh U, Williams M, Jacobs A, et al. Delayed hypoxemia fol­
ploring the use of HTS in the prehospital environment. While lowing traumatic brain injury exacerbates white matter injury. J
more research is needed to fully understand the effect of pre­ Neuropathol Exp Neurol. 2016;75(8):731–747.
hospital HTS on herniating patients, it should be noted that 11. Chesnut RM, Marshall LF, Klauber MR, et al. The role of sec­
HTS has been investigated for the management of hypotension ondary brain injury in determining outcome from severe head
in prehospital trauma patients with no increases in mortality injury. J Trauma. 1993;34(2):216–222.
22
or safety issues identified on meta­analysis. In the hospital 12. Pélieu I, Kull C, Walder B. Prehospital and emergency care in
adult patients with acute traumatic brain injury. Med Sci (Basel).
setting, HTS has demonstrated efficacy in reducing elevated 2019;7(1):12.
ICP and preserving cerebral blood flow when given to reverse 13. Rajajee V, Riggs B, Seder DB. Emergency neurological life sup­
IOH. 23,24 port: airway, ventilation, and sedation. Neurocrit Care. 2017;27
(Suppl 1):4–28.
As a final note, in this case scenario two lives were at stake and 14. Bhimji S. “Brain Herniation” [Illustration]. https://www.ncbi.
it is important to remember that pregnancy alters a woman’s nlm.nih.gov/books/NBK542246/figure/article­18540.image.f1/
Accessed 10 January 2022.
physiology: increased plasma volume, cardiac output, oxygen 15. Mangat HS, Härtl R. Hypertonic saline for the management of
consumption, and systemic and renal vasodilation. In the con­ raised intracranial pressure after severe traumatic brain injury.
text of these physiologic changes, pregnant patients who have Ann N Y Acad Sci. 2015;1345:83–88.
sustained a TBI are at an increased risk of maternal and fetal 16. Sell SL, Avila MA, Yu G, et al. Hypertonic resuscitation improves
death due to competing demands on perfusion and oxygen­ neuronal and behavioral outcomes after traumatic brain injury
25
ation. Additionally, when in the supine position the gravid plus hemorrhage. Anesthesiology. 2008;108(5):873–881.
uterus can compress the inferior vena cava, reducing venous 17. Mangat HS, Chiu YL, Gerber LM, et al. Hypertonic saline reduces
cumulative and daily intracranial pressure burdens after severe
return to the heart and lowering cardiac output resulting in traumatic brain injury. J Neurosurg. 2015 Jan;122(1):202–210.
positional hypotension. Techniques used to mitigate this effect 18. Cottenceau V, Masson F, Mahamid E, et al. Comparison of ef­
are placing a rolled blanket under the right side of the patient’s fects of equiosmolar doses of mannitol and hypertonic saline on
abdomen, utilizing left lateral decubitus positioning, or man­ cerebral blood flow and metabolism in traumatic brain injury. J
26
ually displacing the gravid uterus to the patient’s left. Due Neurotrauma. 2011;28(10):2003–2012.
to the nature of the combat environment and litter exfil over 19. Pararescue Medical Operations Handbook. 7th ed. Breakaway
Media; 2018.
uneven terrain, these steps were not taken for our patient. 20. Advanced Tactical Paramedic Protocols Handbook. 10th ed.
Breakaway Media; 2017.
21. DeSoucy ES, Cacic K, Staak BP, et al. 23.4% hypertonic saline:
Conclusion a tactical option for the management of severe traumatic brain
This is the first published report of prehospital HTS for a se­ injury with impending or ongoing herniation. J Spec Oper Med.
vere TBI casualty with suspected herniation in a combat envi­ 2021;21(2):25–28.
ronment. Combat medics must be able to recognize the signs 22. Blanchard IE, Ahmad A, Tang KL, et al. The effectiveness of
prehospital hypertonic saline for hypotensive trauma patients: a
of brain herniation in TBI and be prepared to manage it in systematic review and meta­analysis. BMC Emerg Med. 2017;17
accordance with their level of training and available resources. (1):35.
23. Tyagi R, Donaldson K, Loftus CM, Jallo J. Hypertonic saline: a
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