Head Injuries and ICP

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skyemt

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i wanted to talk about head injuries and ICP...

i know about cushing's triad, and what to look for S/S wise...

seems to me, though, that one of the best things we can do pre-hospital wise is try to prevent the things that cause ICP to rise from happening...

i know that CO2 is a strong vasodilator, so obviously preventing CO2 from getting too high is important... easy to say, but managing that might be a bit harder... we have SpO2, but do not have electronic Capnography, so that is a bit hindered?

also, PH getting too low also raises ICP...

can we discuss ICP management issues, and what can be done on both a BLS and ALS level..., as well as the best tools to monitor..

thanks...
 
On BLS/ALS level prehospitally without the aid of EtCO2 monitoring, or even ICP monitoring, you have to monitor possible ICP changes clinically. I found the following link that may help. Also any change in LOC is significant.

Assist their resp if need be, but don't hyperventilate. Breathe for them normally. Dropping their CO2 too low will cause cerebral vasoconstriction which will decrease the availability of O2 getting to the brain resulting in an ischemic episode not unlike unstable angina does to the heart.




http://www.merck.com/mmpe/sec21/ch310/ch310a.html
 
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Start with the basics first...if their LOC is depressed enough to warrant intubation, do it. If it's an RSI use lidocaine before the paralytics; it'll help blunt any increase in ICP due to the intubation though some say it's not completely neccasary.

Try and keep their head elevated by about 30 degrees, and, if they're conscious, (especially if you have a longer transport) be very ready for them to vomit and/or sieze on you. Neither of which is a good thing.

As far as the ETCO2...if you don't have any way to monitor it, then don't worry about it to much; don't hypoventilate the pt, or allow them to do it to theirself, but don't hyperventilate them either. Like you said, dropping the CO2 level to low will cause increase vasoconstriction which will drop cerebral perfusion even lower. If you can monitor it though, try and keep it between 30-35mmHg; just below normal.

And definetly don't forget to load them up with mannitol. :P
 
And if you do the mannitol and you have a significant transport time, you better be inserting a foley catheter.

A full bladder creates discomfort/pain and can increase the BP which is bad for the ICP.

I learned this one the hard way many years ago...

Also, go heavy on the pain meds. Unconciousness does not mean they do not feel pain, and when that pain hits, again the BP will start creeping up.

Be generous with the drugs!
 
akflightmedic said:
And if you do the mannitol and you have a significant transport time, you better be inserting a foley catheter.

A full bladder creates discomfort/pain and can increase the BP which is bad for the ICP.

I learned this one the hard way many years ago...

Also, go heavy on the pain meds. Unconciousness does not mean they do not feel pain, and when that pain hits, again the BP will start creeping up.

Be generous with the drugs!
Click to expand...

How many ALS units actually carry a foley catheter on their rig?
 
triemal04 said:
Start with the basics first...if their LOC is depressed enough to warrant intubation, do it. If it's an RSI use lidocaine before the paralytics; it'll help blunt any increase in ICP due to the intubation though some say it's not completely neccasary.

And definetly don't forget to load them up with mannitol. :P
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We touched a bit on this in class last week. New research shows that a spike in ICP shown with intubation is obviously not good, but is MUCH better than the sustained rate of high ICP. So, quick transport is vital.
 
ffemt8978 said:
How many ALS units actually carry a foley catheter on their rig?
Click to expand...

If you are in an area that has excessive transport times, it should be common equipment, otherwise you are doing a diservice to the patient and could actually be compromising the care or making the patient worse.

Simple lesson in A/P teaches you that one.

For the record, I was merely making a point as mannitol is not carried or used that much any more prehospitally in most areas. I only used the opportunity to educate and share a "Lessons Learned" moment.
 
akflightmedic said:
If you are in an area that has excessive transport times, it should be common equipment, otherwise you are doing a diservice to the patient and could actually be compromising the care or making the patient worse.

Simple lesson in A/P teaches you that one.

For the record, I was merely making a point as mannitol is not carried or used that much any more prehospitally in most areas. I only used the opportunity to educate and share a "Lessons Learned" moment.
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I'm not disagreeing with you, but I was curious. I know that none of the IFT services around here (the ones doing the 4-6 hour transports) carry foleys on them. That's why I was asking.
 
ffemt8978 said:
I'm not disagreeing with you, but I was curious. I know that none of the IFT services around here (the ones doing the 4-6 hour transports) carry foleys on them. That's why I was asking.
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What's the crew make up of your IFT services? If there's an RN or RRT on any of them, I can almost guarantee you won't be leaving any facility without a foley for a trip that long.
 
Paramedic and an EMT.
 
VentMedic said:
What's the crew make up of your IFT services? If there's an RN or RRT on any of them, I can almost guarantee you won't be leaving any facility without a foley for a trip that long.
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I think there's a difference, though, between placing and monitoring a foley. The company I worked for didn't stock any foley caths in the RN gear, but it wasn't uncommon for even basics to monitor foleys for transfers. Longest CCT I've been on, though, was about 1.5 RN/RT post op transfer (by post op, I mean hours, not days. The family should have let the patient stay in the treating hospital overnight, but they wanted him to recover at a closer hospital).
 
Personally, I do not know why EMS wants to make a Foley a big deal? I personally rather not be wading in piss in the back of the ambulance or helicopter. It amazes me that one that is sole head strong on patient care and treatment would shun a procedure that would benefit both the patient and provider.

Let me administer 80mg of Lasix, or infuse 1-2 liters of fluid and place you on a stretcher, LSB in a back of a bumpy EMS unit and I tell you to deal with it. Remember, I am helping you....right?

The only reason medics have not been taught or do not routinely place them is because most feel they are above that or feel uncomfortable about it. Even CNA's and tech's have been taught on the proper procedure.

Should it be routine? No. Does it have a place.. YES! What is the best monitor for shock? ... yep, urine output. Treat severe burn patients? Want urine on open wounds? CHF, CHI with treatment of diuretics.. better have them.

I have no problem placing them. I much rather treat my patients for their comfort level than mine. You know really it is supposed to be about them.. As well, instead of transporting that nursing home patient at 3 a.m. from the nursing home, I get an order and replace it myself. Saves the patient anguish and money.. Wow..something for the patient!

Quit thinking inside the box! Time is changing, better be prepared!

R/r 911
 
Don't get me wrong, as with everything foleys have a time, place, and situation. I don't think that comparing CCT teams to emergency teams is a completely fair comparison. If your picking up a patient from a hospital, then the hospital is probably going to be the one to place a foley prior to arrival, not the transport team. If one isn't placed, then I don't see why the hospital couldn't provide the team a foley set-up to use. I don't imagine that a foley is something that is placed during transport, but is more of an on-scene type treatment (back of the unit, of course, for modesty purposes).

Similarly, the utility of such a treatment modality is going to be different between frontier, rural, and urban environments. A transport time measured in in hours is going to have a much greater use of this than one measured in minutes.

Personally, I think that all providers should have to assist in putting in no less than 5 foleys. You get past any sort of modesty/personal zone mental barrier real quick when helping to place them.
 
JPINFV said:
Don't get me wrong, as with everything foleys have a time, place, and situation. I don't think that comparing CCT teams to emergency teams is a completely fair comparison. If your picking up a patient from a hospital, then the hospital is probably going to be the one to place a foley prior to arrival, not the transport team. If one isn't placed, then I don't see why the hospital couldn't provide the team a foley set-up to use. I don't imagine that a foley is something that is placed during transport, but is more of an on-scene type treatment (back of the unit, of course, for modesty purposes).
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The foley is within the scope of practice for paramedics in most states. It is just not taught in most curriculums.

As I said in my previous post, we don't leave without a foley in place if it is a flight or extended ground transport. Either myself or my RN partner can place the foley. And yes, we will get it from the hospital we are picking the patient up at. We don't carry them because most hosptial do have them.

Monitoring the foley is not always on the list of "skills" either for many EMTs or EMT-Ps and it should be. Very few check the urinary output of the nursing home patients. Understanding the value of Input and Output is also not in the curriculum. Many don't realize the patient has a foley until they trip on it.
 
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Wow...didn't expect that. :P

Just to toss my 2 cents in...there are ground services here that use foley's, though they tend to have extended transport times...in the 2-3 hour zone for the most part. Which is appropriate; if you're in the middle of an urban area, the odds of needing a foley due to lasix administration or to check the function of the kidneys in a trauma aren't that high. Not to say that it won't be needed, just that it can wait the few minutes until the pt is at the ER. With a long transport though...definetly a good thing to do, and, here at least, completely within the paramedic scope.

Just out of curiosity, anybody actually carry mannitol anymore?
 
triemal04 said:
Wow...didn't expect that. :P

Just out of curiosity, anybody actually carry mannitol anymore?
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This medicine has fallen out of favor within most neuro's. Most rather rehydrate the brain rather than dehydrate. Some have adjusted the dosage.

I carried it on the helo but usually most receiving Trauma Centers did not want it to be infused. On the ground, I have not seen it in a while.

R/r 911
 
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