Preventing/reducing secondary brain injury in the prehospital setting.

[usafmedic45]

Brown thinks there was a study from Israel that said ketamine was safe for head injuries

That would be the one I cited.

 

[18G]

The most important thing you can do is prevent hypotension and hypoxia. A single episode of either has been shown to double mortality in TBI.

I agree. This is my main focus with a head injury. Nothing can be done about the primary insult obviously since what's done is done. But death or serious impairment from TBI can largely come from secondary injury.

It is well recognized that a single instance of hypotension (<90) or a single episode of hypoxia can double mortality. The goal for B/P in the TBI patient is often cited at 110mmhg as to maintain a MAP sufficient to overcome the ICP and to ensure cerebral perfusion. EtCO2 monitoring is useful as to avoid hyperventilation and to target EtCO2 on the low end of normal right around 35. If the patient is not intubated its a good idea to place a EtCO2 nasal line to be able to detect in real time any rise in CO2 and the immediate need to ventilate.

 

[Ravemtech]

In regards to reducing secondary injury in TBI, here is a recent study on RSI with improved outcome for early RSI prehospital for TBI, which showed worse outcome when RSI was delayed to hospital. It shows a high level of training, appropriate monitoring devices including ETCO2, and a protocol (including pre fluid loading to prevent hypotension, Fentanyl, Midazolam, Sux, and post RSI, Midaz/Morph infusion and Pancuronium) can have good outcome prehospital ......

Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury A Randomized Controlled Trial

(Ann Surg 2010;252:959–965)

Objective: To determine whether paramedic rapid sequence intubation in patients with severe traumatic brain injury (TBI) improves neurologic outcomes at 6 months compared with intubation in the hospital.
Background: Severe TBI is associated with a high rate of mortality and longterm morbidity. Comatose patients with TBI routinely undergo endo-tracheal intubation to protect the airway, prevent hypoxia, and control ventilation. In many places, paramedics performintubation prior to hospital arrival. However, it is unknown whether this approach improves outcomes.

Methods: In a prospective, randomized, controlled trial, we assigned adults with severe TBI in an urban setting to either prehospital rapid sequence intubation by paramedics or transport to a hospital emergency department for intubation by physicians. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end-points were favorable versus unfavorable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge.

Results: A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%. At 6 months, the median GOSe score was 5 (interquartile range, 1–6) in patients intubated by paramedics compared with 3 (interquartile range, 1–6) in the patients intubated at hospital (P = 0.28). The proportion of patients with favorable outcome (GOSe, 5–8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% confidence interval, 1.00–1.64; P = 0.046). There were no differences in intensive care or hospital length of stay, or in survival to hospital discharge.

Conclusions: In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.

The full study is attached for those wanting to read the full document. For those interested in the actual RSI protocol used in the study, here is the link - http://www.rav.vic.gov.au/Media/doc...0906-a04da8a1-e0b5-4b30-8f1d-ce979e76d996.pdf

Victoria is also about to undertake the POLAR trial (prehospital therapeutic coolong) to see if this further improves TBI outcome.