# TBI management



## Clare (Dec 30, 2012)

This is a patient I recently had to manage that greatly conflicted me.  

High speed road crash about 30 minutes from hospital; 20 year old unrestrained male driver with a huge spider web on the windscreen; initially trapped and extricated by the Fire Service.  

Primary survey – his head was munted, huge forehead laceration, otherwise unremarkable

BP 80/50, PR 140, RR 6, snoring with intermittent apnoea, GCS 8, ECG ST 

I presumed he had (1) a traumatic brain injury and (2) hypovolaemic shock from uncontrolled internal bleeding.  It is also possible that this bloke was hypotensive as a result of his brain injury i.e. loss of neural control of vascular tone or something and did not have significant internal haemorrhage however I would consider it more likely he was bleeding internally given his mechanism of injury.  

The treatment of TBI and presumed hypovolaemic shock in regards IV fluid therapy is conflicting because (1) the goal of TBI is achieve a relatively normal blood pressure to ensure sufficient MAP to avoid derangement of ICP/CCP while (2) fluid resuscitation in a patient with hypovolaemic shock should only be given if they have (a) no radial pulse, (b) a falling level of consciousness or (c) no recordable blood pressure however his radial pulse and blood pressure were recordable while his decreased level of consciousness was primarily due to brain injury rather cerebral hypoperfusion.  

Now this is one of those “grey” areas where a patient into a sort of treatment black hole and requires significant clinical judgement.  I presumed that the most critical problem was his traumatic brain injury given that the brain is significantly more sensitive to hypotension and a poorly managed TBI has much greater morbidity and mortality.  I figured that if he did have internal bleeding from an artery or ruptured spleen or whatever that while this was important it was less important than a poorly managed TBI as the destination hospital had 24 hour CT and surgical facilities so any operative control of bleeding would happen fairly rapidly as an early RT call was placed to the hospital so they activated the trauma team and were prepared for him.  

To that end my management was giving him enough fluid to achieve a BP of at least 110 mmHg – lower than our normal target for TBI is 120 mmHg and over what I have read as a target for uncontrolled Hypovolaemia (90 mmHg) but based upon what I felt was the most important aspect of care – i.e. preventing secondary brain injury.   Our CPG does not have a BP target for uncontrolled hypovolaemia but stresses that the patient must be given the minimum amount of fluid compatible with life (which I think has previously been stated to be presence of a radial pulse).  

I figured a BP of 110 mmHg would mean a MAP and CPP of at least 70 which are at the lower end of normal.

This is my first major trauma with significantly complex management and I feel very uneasy about it.  The others I have had have been fairly straightforward in terms of management i.e. bloke trapped under something or whatever; I am keenly aware of the significant disability that traumatic brain injury and more-over, poorly managed TBI, has and hate to think that this young guy ends up a vegetable and loses the next 60 years of normal life because of me. 

So what do you think? Do you agree with my reasoning or would you have done something differently?

PS An Intensive Care Paramedic with rapid sequence induction would have taken longer to locate and intubate than it was to take him directly to the hospital; he wouldn't take an LMA but did accept a naso-airway so with that and good old fashioned head positioning his oxygenation was relatively normal so calling for RSI wasn't really necessary, it would have been great to have but not absolutely necessary in this case.


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## VFlutter (Dec 30, 2012)

Clare said:


> To that end my management was giving him enough fluid to achieve a BP of at least 110 mmHg – lower than our normal target for TBI is 120 mmHg and over what I have read as a target for uncontrolled Hypovolaemia (90 mmHg) but based upon what I felt was the most important aspect of care – i.e. preventing secondary brain injury.   Our CPG does not have a BP target for uncontrolled hypovolaemia but stresses that the patient must be given the minimum amount of fluid compatible with life (which I think has previously been stated to be presence of a radial pulse).
> 
> I figured a BP of 110 mmHg would mean a MAP and CPP of at least 70 which are at the lower end of normal.
> 
> .



Tough situation. I think the ability to sedate, RSI, and titrate ETCO2 would have been beneficial. 

Hypotension during TBI is associated with a really poor prognosis. Chances are you were screwed from the get go. 

A Bp of 110 systolic? Assuming 110/70 that would be a MAP of ~83. 

CPP = MAP (83) - ICP (let's say a high normal of 15) = 68. The optimal level during a TBI is  above 70-80 mmHg. And that was calculating with an ICP of 15...what do you think it really was?  Lets say it was 25 (which is way conservative) then the CPP would be 58. Mortality increases 20% for each 10mmHg below 70. What if his ICP was 40......

I personally would have been more aggressive with the MAP. Remember Cushing's triad? Hypertension is the body's natural response to maintain cerebral perfusion with increased ICP. They actually give TBI patients pressors in the Neuro ICU to maintain CPP if necessary.

Also, Nasal airway in a patient with head trauma? (See picture under my username) Did he have battle signs, raccoon eyes, etc? Posturing? Any other findings with would indicate internal hemorrhage? Rigid abdomen?


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## Aprz (Dec 30, 2012)

Is 83 really a good estimate of the MAP at that HR?

Significant head trauma is a relative contraindication for nasal airways now-a-days. Fixing a bad airway is going to take precedents over the slim possibility of inserting it into the cranium.

In addition to what Chase said about other signs e.g. trismus, abnormal pupils, posturing, how did the vitals trend, and how did the patient respond to your treatments?


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## VFlutter (Dec 30, 2012)

Aprz said:


> Is 83 really a good estimate of the MAP at that HR?



Thanks, I totally forgot to account for the tachycardia. But even taking the arithmetic mean it would be 90. 

All that was assuming he did in fact have a TBI.


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## Clare (Dec 30, 2012)

Chase said:


> Tough situation. I think the ability to sedate, RSI, and titrate ETCO2 would have been beneficial.



He was 30 minutes by road to hospital; calling for RSI and then still have 30 minutes to hospital would have taken probably an hour.  



Chase said:


> A Bp of 110 systolic? Assuming 110/70 that would be a MAP of ~83.
> 
> CPP = MAP (83) - ICP (let's say a high normal of 15) = 68. The optimal level during a TBI is  above 70-80 mmHg. And that was calculating with an ICP of 15...what do you think it really was?  Lets say it was 25 (which is way conservative) then the CPP would be 58. Mortality increases 20% for each 10mmHg below 70. What if his ICP was 40......



I don't know what his ICP was, in this case there was no sign it was elevated (e.g. seizure, pupil dysfunction, posturing).



Chase said:


> I personally would have been more aggressive with the MAP. Remember Cushing's triad? Hypertension is the body's natural response to maintain cerebral perfusion with increased ICP. They actually give TBI patients pressors in the Neuro ICU to maintain CPP if necessary.



There was no hypertension, BP was 80 so he was hypotensive 

I figured the more aggressive we are with his blood pressure to reach the CPG target of 120 mmHg then potentially the worse it is going to be for any internal haemmorhage.  No good having a guy with an intact noggin if he dies from bleeding into his chest, pelvis or abdomen but conversely the opposite is also true; no good having good control of his haemmorhage only to have him end up a vegetable.




Chase said:


> Also, Nasal airway in a patient with head trauma? (See picture under my username) Did he have battle signs, raccoon eyes, etc? Posturing? Any other findings with would indicate internal hemorrhage? Rigid abdomen?


[/quote]

Nasal airways are not contraindicated in head trauma and it is simply taught that we should exercise care and stop if significant resistance is encountered.  

There was no obvious signs of internal haemmorhage such as a rapidly distending, rigid abdomen but history of mechanism and physiological signs were highly indicative of somebody who could very well have been suffering from internal bleeding.  His hypotension could have been due to a neurogenic cause i.e. loss of neural control of vascular tone regulation or something but I am not sure how likely that is.  If he didn't have TBI but still had the hypotension and tachycardia then he is assumed to have uncontrolled internal haemmorhage.  



Aprz said:


> Is 83 really a good estimate of the MAP at that HR?
> 
> Significant head trauma is a relative contraindication for nasal airways now-a-days. A bad airway is going to take precedents over the slim possibility of inserting it into the cranium.
> 
> Were there any other signs of TBI e.g. abnormal pupils, trismus, posturing? How did the vital trends, and how did the patient respond to treatment?



There was no signs of significant head injury other than the stated big forehead laceration where his head hit the windscreen.

His blood pressure came up to just over 100 mmHg with one litre of fluid and the tachycardia decreased.  

This is a case involving somebody who is otherwise young, healthy and very much has his whole life ahead of him and upon whom mortality and morbidity will impact greatly.  It is my first case involving complex management of major trauma where doing right by one thing may negatively affect the other (cerebral ischaemia vs. permissive hypotension).  

Perhaps a few mmHg of blood pressure wasn't a major deciding factor, perhaps I am overthinking it, but I've not seen something like this before and it has, for the time being, greatly affected me.

I am not sure if my management is the real problem or if its more I am very unsure of myself because this is the first time I have encountered somebody of my own age who has significantly major trauma and whose quality of life, or even ability to lead any sort of a normal life, is likely to have been destroyed and that is very hard to see.  I am not sure a bit of blood pressure was really my concern.


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## VFlutter (Dec 30, 2012)

What makes you think he had a TBI then? Just the mechanism of injury? Neurogenic shock is associated with spinal cord injury not TBI. TBI usually presents with hypertension which is why I made the point about Cushing's triad and desired high MAP in TBI patients.


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## Clare (Dec 30, 2012)

Chase said:


> What makes you think he had a TBI then? Just the mechanism of injury? Neurogenic shock is associated with spinal cord injury not TBI. TBI usually presents with hypertension which is why I made the point about Cushing's triad and desired high MAP in TBI patients.



History of mechanism, the huge spider web on the windscreen where his head hit and physiological signs, particularly the respiratory rate and GCS all leaf me to believe he had a TBI.


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## VFlutter (Dec 30, 2012)

Clare said:


> History of mechanism, the huge spider web on the windscreen where his head hit and physiological signs, particularly the respiratory rate and GCS all leaf me to believe he had a TBI.



With bradypnea and ALOC then I would assume the ICP is increasing. And no other signs/symptoms? Pupils were PERRLA? 

I still think I would be more aggressive with the pressure but I could be wrong, there are arguments going both ways.


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## Handsome Robb (Dec 30, 2012)

NG tubes are the worry in head trauma. NPAs it's a caution. Basically don't force it, like Clare already said. 

I'm not someone who jumps to calling for HEMS constantly but was it an option? 30 minutes by ground is a long time to manage this patient without the ability to titrate ETCO2 not to mention that trauma is a surgical disease (sorry vene, I stole your line  ) and no matter what you do, if he doesn't get a surgeon to crack him open and stop the bleeding nothing is going to matter. 100-110 mmHg SBP is what I've always been taught. I can't remember what PHTLS/ITLS say about it, I want to say it's 110 mmHg but don't quote me. You say calling for RSI takes that time then the 30 minutes to the hospital. Why can't the ICP meet you en route? Kill two birds with one stone that way. You meet up, they hop in push some drugs, drop a tube then continue on your way...

Can't really titrate his CPP unless you are bolting him with an ICP monitor in the field... CPP = MAP-ICP

If he's buggered for the rest of his life, it's not your fault. No way you can twist that up and make it your fault, so drop that thought. You gave him every shot he had at a decent quality of life. Without you, he'd more than likely died in that car or in the bed of a pickup on the way to the band-aid box rural ER.

Doesn't sound like neurogenic shock unless he had an SCI along with his TBI, as Chase already said as well. Definitely very possible though. You gave him an 8 on the GCS, can you break it down more for us? (x/x/x) Was he moving his extremities? Doesn't have to be purposeful but where they all moving? Personally that'd steer me away from a SCI and ultimately neurogenic shock if he was. 

Without outwards signs of hemorrhage, be it internal or external, I'd personally lean towards TBI + SCI and neurogenic shock and would have been more aggressive with fluids but we can all sit here and monday morning quarterback your call to death, in the end we weren't there. 

You said his abdomen was soft and not distended correct? How were his lung sounds? Pelvis intact? How about both femurs? Not saying these things are the end all to "ruling out" internal hemorrhage but if everything listed above is good you've covered the large cavities that are generally involved in fatal internal hemorrhage. Maybe this is the wrong way to think about it and someone smarter than me feel free to tell me I'm an idiot and correct me. 

Pardon my grammar. It's late. I also realized I kinda contradict myself. Just looking at all the angles.


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## medichopeful (Dec 30, 2012)

Chase said:


> Also, Nasal airway in a patient with head trauma? (See picture under my username) Did he have battle signs, raccoon eyes, etc? Posturing? Any other findings with would indicate internal hemorrhage? Rigid abdomen?



Do you have a link to that picture or article?  I'd like to get a look at it and read the article if there is one!


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## Veneficus (Dec 30, 2012)

*Many things to talk about...*

*The game of resuscitation.*

As you mentioned, many trauma treatments compete, it is not just cardiovascular and brain.

Just last night my wife again commenting it is amazing I don't drink regularly. 

I explain it like this:

Think of a chess game, only with many more pieces. Once the patient starts losing the game, you are asked to try and turn it into a win. The goal isto win as often as possible, but sometimes the position is so bad, nothing you can do will turn it around.

*Blood pressure, and MAP, and perfusion. Oh my...*

Based on what was described, I thinkn TBI is a good assumption, the mechanism, while not reliably predictable, also indicates potential SCI. The old guys who remember steel cars prior to airbags, seatbelts, etc. will fondly remember these findings.

I have read the post twice, I see no signs of herniation. That is not to be confused with increased ICP. Herniation is a late sign. We must also remember, GCS is not meant to decide ifwe intubate or not, it is meant to be a quantitative scoring of prognosis from brain injury. An 8 is a severe brain injury.

It is widely said in trauma surgery there are onl 5 locations that a person can die from hemorrhage. The cranial vault is not one of them. In the prehospital environment, it is not easy to find acute hemorrhage until it is very advanced. Based on the vital signs and presnetation, I  would make great efforts to identify the potential site of bleeding, even by exclusion, but I personally would consider this patient bleeding until proven otherwise. 

A trial of saline is not out of order. Especially an amount as small as a liter. Since Class I shock responds to saline bolus, Class II does so transiently, the bolus itself can be diagnostic. If the patient transiently responded, I would assume them still bleeding and not do it again.

I am a big supporter of permissive hypotension, but we must be realistic on what is possible or advisable without a lot of diagnostics. I would say  if the patient didn't respond to the fluid bolus, or actually got worse, don't do that anymore. 

Eitherway, I would not maintain a fluid infusion to maintain numbers. That I would say is a bigger concern for increased cerebral edema than 1 one time bolus.

*Target numbers *

Many different groups advocate different target numbers. These guidlines are designed for safety and are extremely conservative. 

Permissive hypotension has a time factor depending on the pressures involved. but 80systolic for several hours is not unreasonable. 70sys for maybe an hour or two. While there will likely be loss of urine production during this time, I have consulted extensively with very respected nephrologists, one in particular with an international reputation, and I am assured the kidney can recover from this. As far as I am concerned, their experience and knowledge is significant enough to make decisions from it.

As for the effect on cerebral perfusion, perfusion assumes oxygen delivery, not just a number. I have said many times, I can normalize blood pressures on a corpse, it does not bring them back to life. 

When you are thinking about maintaining a number with water, keep in mind that brain tissue as defense mechanism forms osmotically active protein, which means isotonic fluid will be drawn into the brain cell. Cellular swelling is bad. After all, it is the first step in cell injury. 

A decrease in pH right shifts the saturation curve. This helps with tissue oxygenation. If you do not add any oxygen carrying capacity, and use water to increase pH, you manipulate oxygenbinding towards hemoglobin and away from tissue.

While you certainly can normalize numbers doing this, keep in mind it is a physiological defense response. When you exercise, you need more tissue oxygen. Why on earth would you do something that would lessen tissue oxygen to somebody whos life may depend on it?

*Please assume crash position...* 

If I ever hear this on a plance, the flight attendant and I will be locked in mortal combat for one of those rear facing seats.

An unrestrained high speed accident victim is subject to forces in every direction. An aortic tear is certainly a possibility. 

They come in 2 flavors.

1. Where you bleed out in damn near seconds.

2. The more commmon small tear, held together by ligament tension, can wait to be repaired for hours and hours, sometimes measured in days.  The lower the intravascular pressure, the longer it takes to bleed out. 

If you do not see a obvious bleed location, keeping in mind the occult locations like this with a slow bleed I think is a good idea.

*Bottom line: * 

Sounds like you did your best. No worries.


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## TheLocalMedic (Dec 30, 2012)

To throw something in from left field from a logistics point of view...

I work in a rural area that gets lots of good grinders.  We routinely deal with at least one major traffic collision per shift, so we've gotten pretty slick at dealing with major traumas and small-scale MCIs.  What are your thoughts on immediately requesting a helicopter on initial dispatch?  Case in point, last week we had a three car collision with a head-on and 7 patients (3 major, 2 moderates, 2 minors).  Initially all we got was that it was an MVA, but my policy is that (since we're roughly 20 mins from a rural hospital and 90 minutes from a trauma center) I automatically request a helo.  And I was glad I did, by the time we got to scene the helo was 10 out.  I had to request two additional ambulances and an extra helo in all, but having that first bird nearby was great so that I could get that first-go trauma out of there so I could deal with the others.  

I always advocate for early requests for resources if you're facing a potential trauma and you're a ways out from your hospital.  If it turns out it's nothing major, you can always call everyone off, but early requests save a lot of time!


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## VFlutter (Dec 30, 2012)

medichopeful said:


> Do you have a link to that picture or article?  I'd like to get a look at it and read the article if there is one!



For some reason I was thinking about naso-tracheal intubation not a NPA






Link to article at the bottom of the page 
http://www.impactednurse.com/?p=2235

I know you can not get ICP without a bolt but you can make an assumption based off signs/symptoms. It sound like increased but not yet herniation. Also, bradycardia is typically present with neurogenic shock but not always.


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## TheLocalMedic (Dec 30, 2012)

Yowza!  Oops!


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## VFlutter (Dec 30, 2012)

TheLocalMedic said:


> What are your thoughts on immediately requesting a helicopter on initial dispatch? I automatically request a helo.  And I was glad I did, by the time we got to scene the helo was 10 out.  I had to request two additional ambulances and an extra helo in all, but having that first bird nearby was great so that I could get that first-go trauma out of there so I could deal with the others.
> 
> I always advocate for early requests for resources if you're facing a potential trauma and you're a ways out from your hospital.  If it turns out it's nothing major, you can always call everyone off, but early requests save a lot of time!



Do you mean requesting actual response or standby? I totally agree with a standby request but calling them to scene just in case and then calling them off is a bad policy IMO.


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## Dwindlin (Dec 30, 2012)

Chase said:


> Do you mean requesting actual response or standby? I totally agree with a standby request but calling them to scene just in case and then calling them off is a bad policy IMO.



While I generally agree with this, talk to the helo service.  The service here does not like stand-by, they would rather just take-off and be canceled.


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## IrightI (Dec 30, 2012)

TheLocalMedic said:


> To throw something in from left field from a logistics point of view...
> 
> I work in a rural area that gets lots of good grinders.  We routinely deal with at least one major traffic collision per shift, so we've gotten pretty slick at dealing with major traumas and small-scale MCIs.  What are your thoughts on immediately requesting a helicopter on initial dispatch?  Case in point, last week we had a three car collision with a head-on and 7 patients (3 major, 2 moderates, 2 minors).  Initially all we got was that it was an MVA, but my policy is that (since we're roughly 20 mins from a rural hospital and 90 minutes from a trauma center) I automatically request a helo.  And I was glad I did, by the time we got to scene the helo was 10 out.  I had to request two additional ambulances and an extra helo in all, but having that first bird nearby was great so that I could get that first-go trauma out of there so I could deal with the others.
> 
> I always advocate for early requests for resources if you're facing a potential trauma and you're a ways out from your hospital.  If it turns out it's nothing major, you can always call everyone off, but early requests save a lot of time!



I too work in the rural, with three trauma centers and a burn center about 30-40mins via helo, 2.5 by ground. For your particular call, I would have launched an aircraft, and rolled a second ambulance. All of this after recieving the first dispatch tone. Our service has a great working relationship with the area Helo EMS and they dont mind at all getting launced, and then cancelled enroute. As others have stated, its great to know that they are ten out after youve done your primary assesments. 

You are correct in seeing that the pt has a head injury, however your assessment doesnt support a TBI in its entirity. When I think of a TBI, im looking for unequal pupils, MOI, possible seizures, CSF from the ears, and battle signs. With RR of 6 with periods of apnea, im curious to see how you obtained a GCS of 8...I was thinking lower. These, you state, were all clear. Another concern for me is the V/S that you obtained. They are trending for Cushings Triad, but not neurogenic shock. With Neurogenic shock, V/S will appear to be normal due to the loss of Sympathetic tone due to the spinal injury. Human nature is to have an elevated BP and Pulse due to experienceing pain, so I would be expecting to see those refelcted in my VS upon inital hook-up. I would attribute the hypotension to internal bleeding, my guess would be a hot belly, spleen...how was his pelvis? 

For your pt, RSI would have been done rather quickly. Having him knocked down, allows us to control many things that would be geared with ETCO2. For this head injury pt, the target goal of 30-35 should be obtained with an 02 sat of at least 96%. All can be titrated with proper bagging and o2 admin. We would solve the pressure problem hopefully with two large bore IVs, both runnin NS or if evidence of significant blood loss, hang one line NS and the other run Ringers through blood tubing. Our Helos carry blood, so thats all ready for them if they choose to use it. From that point forward, it would be supportive until the bird arrives....as others have said....he needs a surgeon.


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## Veneficus (Dec 30, 2012)

IrightI said:


> You are correct in seeing that the pt has a head injury, however your assessment doesnt support a TBI in its entirity. When I think of a TBI, im looking for unequal pupils, MOI, possible seizures, CSF from the ears, and battle signs. With RR of 6 with periods of apnea, im curious to see how you obtained a GCS of 8...I was thinking lower. These, you state, were all clear..



What you describe are either late signs or a very massive injury. 

Waiting to see if a person has unequal pupils or a seizure after a blow to the head is a fail in my opinion.



IrightI said:


> We would solve the pressure problem hopefully with two large bore IVs, both runnin NS or if evidence of significant blood loss, hang one line NS and the other run Ringers through blood tubing.



How does that solve the problem?


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## IrightI (Dec 30, 2012)

Veneficus said:


> What you describe are either late signs or a very massive injury.
> 
> Waiting to see if a person has unequal pupils or a seizure after a blow to the head is a fail in my opinion.
> 
> ...



Exactly, signs of Herniation. No where did I say that I would wait and not do anything until I saw these signs. These are things that Im going to be expecting my pt to demonstrate while in my presence if im going down a TBI road with a significant head bleed. If, in fact, you do have those late signs than thats a whole different ball game. Trying to maintain a perfusing pressure without worsening the herniation is key. read: 190/110. That, of course is not solved with NS infusions, but labetalol. Im sure im preaching to the choir on this subject.

Again, didnt say that was my end all, be all solution. That would be just a start. Just as you mentioned in your earlier post, if the first liter doesnt work, then shut it down and move on. Im with ya on that.


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## VFlutter (Dec 30, 2012)

IrightI said:


> Exactly, signs of Herniation. No where did I say that I would wait and not do anything until I saw these signs. These are things that Im going to be expecting my pt to demonstrate while in my presence if im going down a TBI road with a significant head bleed. If, in fact, you do have those late signs than thats a whole different ball game. Trying to maintain a perfusing pressure without worsening the herniation is key. read: 190/110. That, of course is not solved with NS infusions, but labetalol. Im sure im preaching to the choir on this subject.
> 
> Again, didnt say that was my end all, be all solution. That would be just a start. Just as you mentioned in your earlier post, if the first liter doesnt work, then shut it down and move on. Im with ya on that.



TBIs like anything else are on a continuum of severity. Not every TBI will result in herniation. What she described is at least a moderate-severe TBI based on GSC and LOC. 

If the hypotension was refractory to fluids then what would you do? If this was indeed neurogenic then is the problem volume or something else? Phenylephrine anyone?

Edit: You sure labetalol is the drug to use? Are there any potential complications in a TBI patient 

On a side note: I spent last semester in the Neuro Step down and ICU. That was by far the most depressing and challenging experience of my healthcare career.


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## Veneficus (Dec 30, 2012)

Chase said:


> On a side note: I spent last semester in the Neuro Step down and ICU. That was by far the most depressing and challenging experience of my healthcare career.



A vegetable garden


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## VFlutter (Dec 30, 2012)

Veneficus said:


> A vegetable garden



IMO the vegatables were in many ways the lucky ones. It is the ones who held on to just enough that got to me. The people who could no longer recognize family members, were constantly aggressive, or just followed your with their eyes and babble.


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## Handsome Robb (Dec 30, 2012)

IrightI said:


> I too work in the rural, with three trauma centers and a burn center about 30-40mins via helo, 2.5 by ground. For your particular call, I would have launched an aircraft, and rolled a second ambulance. All of this after recieving the first dispatch tone. Our service has a great working relationship with the area Helo EMS and they dont mind at all getting launced, and then cancelled enroute. As others have stated, its great to know that they are ten out after youve done your primary assesments.
> 
> You are correct in seeing that the pt has a head injury, however your assessment doesnt support a TBI in its entirity. When I think of a TBI, im looking for unequal pupils, MOI, possible seizures, CSF from the ears, and battle signs. With RR of 6 with periods of apnea, im curious to see how you obtained a GCS of 8...I was thinking lower. These, you state, were all clear. Another concern for me is the V/S that you obtained. They are trending for Cushings Triad, but not neurogenic shock. With Neurogenic shock, V/S will appear to be normal due to the loss of Sympathetic tone due to the spinal injury. Human nature is to have an elevated BP and Pulse due to experienceing pain, so I would be expecting to see those refelcted in my VS upon inital hook-up. I would attribute the hypotension to internal bleeding, my guess would be a hot belly, spleen...how was his pelvis?
> 
> For your pt, RSI would have been done rather quickly. Having him knocked down, allows us to control many things that would be geared with ETCO2. For this head injury pt, the target goal of 30-35 should be obtained with an 02 sat of at least 96%. All can be titrated with proper bagging and o2 admin. We would solve the pressure problem hopefully with two large bore IVs, both runnin NS or if evidence of significant blood loss, hang one line NS and the other run Ringers through blood tubing. Our Helos carry blood, so thats all ready for them if they choose to use it. From that point forward, it would be supportive until the bird arrives....as others have said....he needs a surgeon.



Where are you seeing Cushing's triad in this besides the respirations? The patient was tachycardic and hypotensive rather than bradycardic and hypertenive wit a widening pulse pressure. Although, admittedly I don't know which compensatory mechanism going to 'win' in the presence of increased ICP/impending herniation as well as hypovolemic shock. 

Like vene said, everything you described is a late finding, including cushing's in it's entirety and you're behind the 8-ball if you're seeing them.

Neurogenic shock generally presents with hypotension and sometimes bradycardia...not normal vitals. The loss of sympathetic tone results in systemic vasodilation. The loss of sympathetic tone can cause bradycardia because you've effectively removed the "gas pedal" and all that's working is the "brake pedal".


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## VFlutter (Dec 30, 2012)

NVRob said:


> Where are you seeing Cushing's triad in this besides the respirations? The patient was tachycardic and hypotensive rather than bradycardic and hypertenive wit a widening pulse pressure. Although, admittedly I don't know which compensatory mechanism going to 'win' in the presence of increased ICP/impending herniation as well as hypovolemic shock.
> 
> Like vene said, everything you described is a late finding, including cushing's in it's entirety and you're behind the 8-ball if you're seeing them.
> 
> Neurogenic shock generally presents with hypotension and sometimes bradycardia...not normal vitals. The loss of sympathetic tone results in systemic vasodilation.



In the first stage of increasing ICP the patient is usually tachycardic (and hypertensive). The patient only becomes bradycardic as a response to the increasing blood pressure and response by baroreceptors in the carotid. It is a reflex from the hypertension not a direct result of increasing ICP. Without the hypertension there is no bradycardia (unless there is physical distortion of the vagus nerve which is unlikely unless they are herniating). Chances are the patient's BP never got high enough to enduce the reflex. 

Long story short Cushing's triad of symptoms is not always present and lack of those symptoms does not rule out increasing ICP, especially with multisystem insults. The GCS and RR are the defining symptoms in this case. 

Also, Like I said before if the hypotension was neurogenic I wouldn't expect a drastic improvement with fluid especially only a liter. But it does sound like there may be a SCI component


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## mycrofft (Dec 30, 2012)

Clare said:


> History of mechanism, the huge spider web on the windscreen where his head hit and physiological signs, particularly the respiratory rate and GCS all leaf me to believe he had a TBI.



Clare's Triad. I'd add front of car demolished/steering column bent (Mycrofft's Quadrad). Alternate: interior rearveiw mirror either clearly imprinted, or actually embedded, into the face or head. 

BTW, If you sit around and wait for Battle's Sign, you may be there a while, longer than the pt will live without respiration. Up to 36 hrs or, occasionally, more. A Battle's sign _*at the scene*_ might be evidence of earlier trauma, or the skull will feel mushy and the pt probably deceased in short order.

Took guts to balance probable neck trauma, intolerance of oro-tracheal airway and agonal breathing, and go for the respirations at any cost over likely iatrogenic cervical insult.

EDIT:
read about the history and some of the various affects and interpretations of it (Cushing's Reflex, the mechanism indicated and create by the triad).
http://en.wikipedia.org/wiki/Cushing_reflex


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## rexbanner (Dec 30, 2012)

TheLocalMedic said:


> To throw something in from left field from a logistics point of view...
> 
> I work in a rural area that gets lots of good grinders.  We routinely deal with at least one major traffic collision per shift, so we've gotten pretty slick at dealing with major traumas and small-scale MCIs.  What are your thoughts on immediately requesting a helicopter on initial dispatch?  Case in point, last week we had a three car collision with a head-on and 7 patients (3 major, 2 moderates, 2 minors).  Initially all we got was that it was an MVA, but my policy is that (since we're roughly 20 mins from a rural hospital and 90 minutes from a trauma center) I automatically request a helo.  And I was glad I did, by the time we got to scene the helo was 10 out.  I had to request two additional ambulances and an extra helo in all, but having that first bird nearby was great so that I could get that first-go trauma out of there so I could deal with the others.
> 
> I always advocate for early requests for resources if you're facing a potential trauma and you're a ways out from your hospital.  If it turns out it's nothing major, you can always call everyone off, but early requests save a lot of time!




Our provincal EMS dispatch system has initiated a protocol for 29 Delta MVC's that if they meet specific critieria as obtained by information given by the caller, will trigger a standby or launch of STARS (medivac) directly to the scene.

I don't have any stats on this but have 'heard' that it is a huge success and drasticly reduces times.


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## shfd739 (Dec 31, 2012)

rexbanner said:


> Our provincal EMS dispatch system has initiated a protocol for 29 Delta MVC's that if they meet specific critieria as obtained by information given by the caller, will trigger a standby or launch of STARS (medivac) directly to the scene.
> 
> I don't have any stats on this but have 'heard' that it is a huge success and drasticly reduces times.



Our company's air med dispatchers sit in the main comm center and watch every call put out to the ground units. If they see a call that may benefit they'll auto launch a helicopter. Ground crew can cancel it once they get onscene. Seems to be beneficial over in that state.  

The local air resource here does something similar by listening to what the county dispatches out.


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## Handsome Robb (Dec 31, 2012)

shfd739 said:


> Our company's air med dispatchers sit in the main comm center and watch every call put out to the ground units. If they see a call that may benefit they'll auto launch a helicopter. Ground crew can cancel it once they get onscene. Seems to be beneficial over in that state.



Same here. I'm not sure if they have an "auto-dispatch" protocol or if it's the dispatcher's discretion though. 

Technically we are the only people that can cancel them but if Fire marks on scene and advises they aren't needed our dispatch asks us if it's OK if they cancel. Depends on the department that's on scene and making the initial assessment. I love vollies and commend them for what they do but they cancelled our helo on a TCA OD in BFE and we ended up dropping a tube, pushing bicarb and returning code...We don't technically have to be on scene to cancel the helicopter but after that little incident I try to wait until I get on scene and do my own assessment before I decide if I need them or not. 

We can request either a ground or airborne standby but until you put them on a "go" they can be diverted. Ground gets the crew to the chopper and preflighted however they do not spin up. Airborne is exactly what it sounds like, they lift and fly in the general direction of the call until they are cancelled, put on a "go" or diverted. 

I listened to an interesting podcast on iTunes U the other day about HEMS and benefits. As to time you have to be >10 miles by ground and have them dispatched simultaneously with ground EMS to be faster, assuming average spin up and lift times and >45 (I'm 90% sure this was the number, I will try to find it in the podcast to be sure) miles by ground to have them be faster than ground EMS if they are requested once the EMS unit marks on scene, again assuming average spin up and lift times.


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## shfd739 (Dec 31, 2012)

NVRob said:


> Same here. I'm not sure if they have an "auto-dispatch" protocol or if it's the dispatcher's discretion though.
> 
> Technically we are the only people that can cancel them but if Fire marks on scene and advises they aren't needed our dispatch asks us if it's OK if they cancel. Depends on the department that's on scene and making the initial assessment. I love vollies and commend them for what they do but they cancelled our helo on a TCA OD in BFE and we ended up dropping a tube, pushing bicarb and returning code...We don't technically have to be on scene to cancel the helicopter but after that little incident I try to wait until I get on scene and do my own assessment before I decide if I need them or not.
> 
> ...



Sounds similar to us. Fire can launch and cancel. Fire tends to over launch as do some of our crews. It's kinda fun to get onscene and cancel the standby or go by ground of the helo is still a certain amount of time away cuz the volley just insists they be flown. 

It kills me to hear the helo be put on a flying standby and they have a 25-30 min eta to the scene when the unit is 20 mins away. Just put the person in your unit quickly and go ground. At that point there is no overall time saved so why tie up that air resource. the flight crew burns up the time difference during load/unload. 

Those times sound about right. Ive been told to estimate flight time at 2 miles/min which usually factors in enough launch time. Most of the time around here helos are overused but some folks just insist that patients have to be flown.


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## mycrofft (Dec 31, 2012)

Chase said:


> For some reason I was thinking about naso-tracheal intubation not a NPA
> 
> 
> 
> ...



Nasal glioma IS exceedingly rare. However, such mistubations if you will have been known in anterior facial GSW's;l I bet if someone crammed yor nasal septum and associated cartilages hard enough anterior to posterior with a steering wheel, you might rupture the cribiform plate.

Bet it lessened ICP though! (ewww)


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## Merck (Dec 31, 2012)

IrightI said:


> Exactly, signs of Herniation. No where did I say that I would wait and not do anything until I saw these signs. These are things that Im going to be expecting my pt to demonstrate while in my presence if im going down a TBI road with a significant head bleed. If, in fact, you do have those late signs than thats a whole different ball game. Trying to maintain a perfusing pressure without worsening the herniation is key. read: 190/110. That, of course is not solved with NS infusions, but labetalol. Im sure im preaching to the choir on this subject.



Can't really jump on board with you here.  Treatment of a TBI with a BP of 190/110 might not necessarily call ofr the use of labetalol.  We use labetalol when indicated but that is usually with an SAH.  TBI has different considerations and not all ICP is created equal.  With no way of knowing what our ICP is then all we are really doing is guessing at what the 'ideal' MAP might be.  Perhaps the MAP with 190/110 (around 136) is exactly what the brain needs.  Autoregulation of CBF is not always disrupted in TBI and throwing labetalol at it may cause harm.

On the OP not sure that I would have necessarily gone for much head movement to facilitate airway control either and you do want to be careful with the NPA.  RSI would likely have been indicated but one has to be considerate of the danger regarding a sat of less than 90 in TBI.

The question of hypotension with a possible concurrent injury is difficult.  Competing interests like these are hard to manage in the field.  Boluses of N/S to try to maintain a pressure may be just as harmful in other ways if there is trauma/major bleeding, but you do want to maintain a systolic of at least 90.  This can be a case where pressors could be used in trauma - not something normally advocated.

I recommend (if it hasn't been said already in this string - I'm tired and generally lazy) that folks review the Brain Trauma Foundation guidelines, both for prehospital and hospital care.  Nice evidence-based approach.

KCCO


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## Clare (Dec 31, 2012)

Both calling for a helicopter and an Intensive Care Paramedic with RSI would have taken significantly longer than just driving him to the hospital; he was 30 minutes by ground and at least twice as long by air; for the helicopter to be dispatched, prepare, fly, land, load, fly to the hospital and unload would take an hour; likewise for an Intensive Care Paramedic with RSI to respond, locate, intubate and then still have to drive to hospital would be probably an hour as well.  

Backup has its benefits but also drawbacks; backup takes time and it is often significantly quicker to just take the patient to the hospital with an early RT call placed to the hospital before leaving the scene if the patient has a life threatening, time critical problem such as traumatic brain injury, cardiogenic shock or life threatening asthma.  With the progressive upskilling of the Paramedic the requirements to actually need an Intensive Care Paramedic is becoming less, they are nice to have as they generally come with decades of experience dealing with very sick people are deal with sick people a lot however it is a balance of risk.  For this bloke yes, RSI and titrate ETCO2 would be most beneficial however I feel a good airway and oxysaturation was obtainable without RSI and that it was much faster to take him to the hospital rather than call for backup.  In hind sight if he had deteriorated significantly I would have been kind of screwed.

Despite reassurances I still feel significantly unsure about this patient; not because what I decided was "wrong" or harmful but that this is the first time I have encountered major trauma in somebody who is otherwise young and healthy and only a little younger than myself; I guess I've had a couple of people lately who have either died or committed suicide and I have been thinking a bit more about the quality of life, or rather lack of it, that some people have had and that this young guy for all intents and purposes might have had the opportunity to experience all the good things in life taken away from him and I'd hate to think that any part of that was due to what I decided.

Guess they don't prepare you for this stuff at uni eh?


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## medicsb (Dec 31, 2012)

Clare said:


> Both calling for a helicopter and an Intensive Care Paramedic with RSI would have taken significantly longer than just driving him to the hospital; he was 30 minutes by ground and at least twice as long by air; for the helicopter to be dispatched, prepare, fly, land, load, fly to the hospital and unload would take an hour; likewise for an Intensive Care Paramedic with RSI to respond, locate, intubate and then still have to drive to hospital would be probably an hour as well.



Just curious, are ICPs not automatically dispatched for certain calls?  Are the fire fighters able to request them if they think they're needed or do they have zero medical training?  I would think requesting an ICP on contact would give them time to get on scene while extrication is being performed.  Overall, I agree if you can get to the hospital sooner than an ICP can get to you, then by all means do so.


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## Veneficus (Dec 31, 2012)

Merck said:


> , but you do want to maintain a systolic of at least 90.  This can be a case where pressors could be used in trauma - not something normally advocated.



I respectfully disagree. 

It is my position that maintaining a number simply to do so has no point. 

As I understand pressors in hemorrhagic shock likely will have no effect and can actually be harmful. 

Furthermore, if you have an active hemorrhage, even with and especially, a BP below 70sys, adding water at best will do nothing and adding pressors on top of the physiologic response is also likely to do nothing at all, and possibly cause harm.

I realize there is the feeling of "needing to do something" but doing something to do something is a treatment for the provider, not the patient.


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## Veneficus (Dec 31, 2012)

Clare said:


> Both calling for a helicopter and an Intensive Care Paramedic with RSI would have taken significantly longer than just driving him to the hospital; he was 30 minutes by ground and at least twice as long by air; for the helicopter to be dispatched, prepare, fly, land, load, fly to the hospital and unload would take an hour; likewise for an Intensive Care Paramedic with RSI to respond, locate, intubate and then still have to drive to hospital would be probably an hour as well.
> 
> Backup has its benefits but also drawbacks; backup takes time and it is often significantly quicker to just take the patient to the hospital with an early RT call placed to the hospital before leaving the scene if the patient has a life threatening, time critical problem such as traumatic brain injury, cardiogenic shock or life threatening asthma.  With the progressive upskilling of the Paramedic the requirements to actually need an Intensive Care Paramedic is becoming less, they are nice to have as they generally come with decades of experience dealing with very sick people are deal with sick people a lot however it is a balance of risk.  For this bloke yes, RSI and titrate ETCO2 would be most beneficial however I feel a good airway and oxysaturation was obtainable without RSI and that it was much faster to take him to the hospital rather than call for backup.  In hind sight if he had deteriorated significantly I would have been kind of screwed.
> 
> ...



Trauma is a disease of the young. 

Arguably it is the most important disease in society because it takes from society producers and people with thier lives ahead of them. 

One of the things that I often wonder about is the seperation of pediatric and adult trauma. From the physiologic developmental point, most trauma is in people who are not fully developed yet. Shouldn't a trauma expert be more familiar with a developing human and then perhaps a geriatric than "healthy adults"?

It vexes me.


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## Merck (Dec 31, 2012)

Veneficus said:


> I respectfully disagree.
> 
> It is my position that maintaining a number simply to do so has no point.
> 
> ...



Vene,

Fair enough to disagree if that is your inference from my statement.  However I am quite aware of the fallacy of treating a number.  My point here by stating a systolic of 90 in TBI is that it is a generally supported and evidence-based goal.  It has been shown that hypotension less than 90 systolic is profoundly detrimental in TBI and that's where my stance comes from.

I totally agree that pressors in trauma are generally verboten, but my inclusion of them here is only in support of managing the TBI.  A fluid-restrictive approach with no pressors might save the patient from the hypovolemia but to what end if they're a vegetable and/or die from the brain injury?

Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation.AUBrain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, Manley GT, Nemecek A, Newell DW, Rosenthal G, Schouten J, Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger JE, Wright DWSOJ Neurotrauma. 2007;24 Suppl 1:S7.

Cheers


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## Smash (Dec 31, 2012)

Notwithstanding the BTF guidelines, the data to support cerebral perfusion pressure in TBI is very sketchy.  The BTF appears to me to deal primarily with isolated head injury.  The polytrauma patient or patient with uncontrolled hemorrhage is a very different beast.  Pressors seem to me to do pretty much the polar opposite of what we really want to achieve.  We may be able to increase CPP for a time, but it will be at the cost of increased bleeding and probably of decreased cerebral blood flow.  
What limited animal data there is on these sorts of 'patients' shows worse outcomes with both early fluid resuscitation and with the use of pressors.

Alspaugh, D.M., Sartorelli, K., Shiffer, C., & Nees, A.V. (2000) Prehospital resuscitation with phenylephrine in uncontrolled hemorrhagic shock and brain injury.  J Trauma. 48(5)

Bourguignon, P. R., Shackford, S. R., Shiffer, C., Nichols, P., & Nees, A. V. (1998). Delayed fluid resuscitation of head injury and uncontrolled hemorrhagic shock. Archives of Surgery, 133(4), 390-398.


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## Merck (Dec 31, 2012)

I totally agree that pressors in trauma are not ideal and I'm not advocating their use.  However we end up transporting people for hours to a tertiary centre and sometimes you have to play a difficult game of balancing the competing interests in a polytrauma case.

There is also a wealth of studies out there that support the prevention of hypotension in TBI.  The method of dealing with the prevention is subject to consideration of other injuries.  As to the reference I think it is a pretty big leap to extrapolate 'simulated' pre-hospital pig findings into on-car clinical practice.  As well, the first study states that mortality was lowest in the phenylephrine group with secondary injury increasing.  Still not ideal either way.


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## mycrofft (Dec 31, 2012)

Clare said:


> Despite reassurances I still feel significantly unsure about this patient; not because what I decided was "wrong" or harmful but that this is the first time I have encountered major trauma in somebody who is otherwise young and healthy and only a little younger than myself; I guess I've had a couple of people lately who have either died or committed suicide and I have been thinking a bit more about the quality of life, or rather lack of it, that some people have had and that this young guy for all intents and purposes might have had the opportunity to experience all the good things in life taken away from him and I'd hate to think that any part of that was due to what I decided.
> 
> Guess they don't prepare you for this stuff at uni eh?



No they don't.  Just keep concerned and current in your skills and keep giving considered, professional feedback to your superiors about what works and what doesn't.

An army recruit was undergoing the old exercise where they had to dig a hole as a tank approached and jump in, letting the tank pass over. The drill sergeant had advice for them: keep your head down and if you dig a good hole, the tank will take care of itself.

In other words, quality of life will be a product of severity of insult, time to your arrival, then the rest of the stuff you can affect. Do your part, if you stop to worry or to identify with the pt you may not be able to do that...or not for very long.


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## Akulahawk (Dec 31, 2012)

Just reading the initial description of the patient, I'd say that the patient is in a very bad way, and given the circumstances, I don't think much of what you could do with what you had available would have made him any better. Honestly, I don't think you made him any worse, significantly. 

I also have the impression that there's three (minimum) issues going on.
The patient has at the minimum:
1) TBI - likely a severe/high grade concussion, possibly even diffuse axonal injury, if the patient doesn't have a frank bleed in the cranial vault. In any case, I'm not seeing signs of impending herniation/increased ICP yet. I don't think that this patient will survive long enough to herniate anyway.
2) SCI - High possibility of SCI. Starred windshield... Some what I see looks like neuro shock from SCI. While I don't necessarily have proof of this, I'm very suspicious of it.
3) Internal bleeding - again, from the heavily starred windshield - this tells me that the patient was likely unrestrained or poorly restrained. This leads me to think that the patient impacted elsewhere quite forcefully, thus leading to significant internal injury. 

Clearly we're seeing signs of shock. Given my suspicions, I'm going to want to maintain BP at a level indicated for shock from a traumatic injury rather than what might be indicated for TBI. I think the TBI will be the least of the patient's immediate problems. 

Do I have any studies at hand to back up my position? No. Just going off what I see and previous education. 

Honestly, I would be surprised if the patient survives.


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## mycrofft (Jan 2, 2013)

My quarter's on the square that says "WIthin the hour".


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## the_negro_puppy (Jan 2, 2013)

medicsb said:


> Just curious, are ICPs not automatically dispatched for certain calls?  Are the fire fighters able to request them if they think they're needed or do they have zero medical training?  I would think requesting an ICP on contact would give them time to get on scene while extrication is being performed.  Overall, I agree if you can get to the hospital sooner than an ICP can get to you, then by all means do so.



Over here ICPs and even Doctors in sedans are automatically dispatched to big trauma jobs. Obviously not the case outside of the wider metro area where the nearest ICPs are too far away.

Pretty good to have actually- docs carry packed red blood cells, F.A.S.T scanners, can RSI, put in chest tubes etc.

It's s shame really- statistically there are more trauma cases due to the metro population, but often the worse traumas (like 5 people in a car vs truck) occur on rural highways etc.

Our state (3 x the area of texas) is only covered by several choppers


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## Clare (Jan 2, 2013)

medicsb said:


> Just curious, are ICPs not automatically dispatched for certain calls?  Are the fire fighters able to request them if they think they're needed or do they have zero medical training?  I would think requesting an ICP on contact would give them time to get on scene while extrication is being performed.  Overall, I agree if you can get to the hospital sooner than an ICP can get to you, then by all means do so.



ICP are sent to certain calls including this one but not all Intensive Care Paramedics have RSI as it is an "add on" over and above the standard ICP skillset.  

The Fire Service have no actual medical training, they are first aiders and can't dictate who or what ambulance resources are sent.


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