Tbi

[Smash]

Ok, so tell me how and why you would manage this patient.

22 y/o male, no previous medical problems, no medications, no allergies.

Unrestrained rear seat passenger of car versus stationary truck on freeway, estimate speed 50mph+ Extricated by witnesses, lying on the road on your arrival.

Groaning and extends to pain, no eye opening. Airway: Trismus present, airway sounds soiled, blood and vomit from nose. Breathing: Laboured, tachypneic, equal chest wall movement, air entry to bases. SpO2 87% on NRB. Strong radial pulses, HR 90, sinus rhythm, BP 150/100.

Blood and CSF coming from R) ear, bilateral periorbital ecchymosis, some minor abrasions and haematomas to head and neck, no other significant injuries found.

You are 40 minutes transport time to nearest hospital (which luckily is the local trauma center) and there is no HEMS available.

What do you do, and why?

 

[MrBrown]

Collar and scoop him, move into the truck

Wait a minute and see if the trismus loosens up, if so suction and drop an LMA.

Begin transport and either way if we are able to ventilate him or not I'd call for an Advanced Paramedic trained in rapid sequence intubation provided that we can intercept enroute significantly faster than we can deliver the patient to the hospital.

The patient may not require RSI depending upon what his O2 sats are like and whether or not I can put an LMA in but I'd like an officer trained in it coming towards us anyway.

 

[itzfrank]

Collar, Immobilize, Transport. RSI... or Versed. I need to relieve the trismus if possible. Otherwise Cric em. Airway/Ventilation seems like the only immediate life threat. Get that resolved, put a couple of lines in just in case, and transport and monitor. If he has a chance at all, he needs surgery NOW. Rapid Transport is killer in importance. (no pun intended)

 

[Dominion]

Collar, Immobilize, Transport. RSI... or Versed. I need to relieve the trismus if possible. Otherwise Cric em. Airway/Ventilation seems like the only immediate life threat. Get that resolved, put a couple of lines in just in case, and transport and monitor. If he has a chance at all, he needs surgery NOW. Rapid Transport is killer in importance. (no pun intended)

Same as above, the thing around here is nasal. Attempt nasal before cric, we don't have the option of RSI. :glare:

 

[Akulahawk]

Sacramento area would be more like this:

• Collar & spine board
• Perform Nasotracheal intubation. Be very cautious because of likely basilar skull Fx.
• Use EtCO2 detector (for confirmation of successful intubation)
• GET OFF SCENE NOW!!!!
• Two Large Bore IV.
• Diesel. Lots of Diesel.

They do not allow medication assisted intubation here. Period. RSI in the field by Paramedics (in this system) would be absolutely outrageous. If the patient starts seizing, then midazolam can be administered for that... which might result in also relieving the patient's trismus.

Sacramento also does NOT include in their protocol any sort of guideline about what range to maintain the CO2 levels... it's just a device used to confirm placement. Sacramento is a bit behind on that... woefully so. Part of the reason for that has to do with how ALS came in to existence here.

 

[Ridryder911]

As previoulsy stated immobilization with RSI using Etomidate as it lowers ICP. I did not see the respiratory rate but after tracheal suctioning place patient possibly on PEEP as it too will reduce ICP, of course monitoring EtCo2.

The sedation of RSI is not only for airway but to decrease agitation usually associated w/closed head injury patients thus increasing the ICP.

Closely monitor nuero (detailed) assessment, and place Level I on neuro alert.

* nasal intubations are contraindicated in patients with possible basilar as reported CSF is many times usually linked to cribriform plate fractures. Thus, blind ETI can enter brain matter through opening.

R/R 911

 

[Melclin]

* nasal intubations are contraindicated in patients with possible basilar as reported CSF is many times usually linked to cribriform plate fractures. Thus, blind ETI can enter brain matter through opening.

R/R 911

Still without an airway he will die. If you nasal tube him, you might stick the tube in his brain. From what I hear the likelihood of tubing his brain is relatively low anyway....lower than his risk of death from not breathing.

I realise he has an airway of sorts. But I think you'd have to weigh the risk of him losing it with more vomiting and aspriation, to the risk of sticking his brain with the ETT.

If he lost it all together, nasal has to be on the cards regardless of the possibility of cribriform fractures..unless you could cric him.

 

[Ridryder911]

Still without an airway he will die. If you nasal tube him, you might stick the tube in his brain. From what I hear the likelihood of tubing his brain is relatively low anyway....lower than his risk of death from not breathing.

I realise he has an airway of sorts. But I think you'd have to weigh the risk of him losing it with more vomiting and aspriation, to the risk of sticking his brain with the ETT.

If he lost it all together, nasal has to be on the cards regardless of the possibility of cribriform fractures..unless you could cric him.

If one is properly educated and well clinically trained, crich is not that big of an issue. I have performed this procedure at least 4-5 times on patients directly related to head injuries and due to it was contraindicated for that specific reason. Actually, with the newer kits if one has been through advanced airway courses (w/cadavers) it is not a difficult procedure.

I went through a trauma cadaver lab that demonstrated that it was much easier to intubate the brain stem that had been predicted. The same reason that NG tubes is not utilized rather again OG tubes would be placed.

With the development of other airways; even after RSI in my opinion would be a much better way to provide an airway than moving a tube blindly through passages that may have openings and weak spots, with less risk.

R/r 911

 

[VentMedic]

Sacramento also does NOT include in their protocol any sort of guideline about what range to maintain the CO2 levels...

We have gotten away from hyperventilating or blowing off a patient's CO2. We will instead maintain toward the lower side of normal. As well, if a patient has aspirated or there are still secretions present, that much be taken into consideration when looking at the numbers on an ETCO2.

RSI, suction and oral intubation would be the preferred but understandably not possible in some parts of the country. Yes, the CDC guidelines recommends that all tubes to be oral for a variety of reasons but again that may not be possible in prehospital.

PEEP is controversial. If we see a need in the ICU to go much of 5 cmH20, all the cerebral monitoring devices will be placed. Primarily PEEP should be used only if there is an oxygenation problem and the head of the bed can be slightly elevated. Increases in Mean Airway Pressure can increase ICP. The Mean Arterial Pressure must be maintained to adjust for the increase in Mean Airway Pressure. PEEP can elevate PaCO2 and lower pH by extending the FRC.

Adequate Cerebral Perfusion Pressure is the goal. Ischemia results from decreased CPP.

CPP is essentially Mean Arterial Pressure - ICP. So if MAP is decreased from a change in Mean Airway Pressure, CPP is decreased. If the Mean Airway Pressure increases the ICP, CPP is decreased.

There is a cycle that will result from each parameter.

*The body's response to a decreased CPP is to raise blood pressure and dilate blood vessels in the brain.

*This increases cerebral blood volume.

*This increases ICP.

*This decreases CPP.

*This causes the body to respond again and the cycle start over.

 

[bstone]

Use EEG for prehospital monitoring of brain electrical activity.

 

[Ridryder911]

Use EEG for prehospital monitoring of brain electrical activity.

Heck, why not do a burr hole and place a ICP device in it as well?

R/r 911

 

[bstone]

Heck, why not do a burr hole and place a ICP device in it as well?

R/r 911

Nah, we carry neurosurgeons on all our buses. They do that sort of work. I can be bothered to get my hands dirty.

 

[Sasha]

Use EEG for prehospital monitoring of brain electrical activity.

Learned that at Harvard, did you?

 

[bstone]

Learned that at Harvard, did you?

Best care anywhere!

 

[Akulahawk]

We have gotten away from hyperventilating or blowing off a patient's CO2. We will instead maintain toward the lower side of normal. As well, if a patient has aspirated or there are still secretions present, that much be taken into consideration when looking at the numbers on an ETCO2.

RSI, suction and oral intubation would be the preferred but understandably not possible in some parts of the country. Yes, the CDC guidelines recommends that all tubes to be oral for a variety of reasons but again that may not be possible in prehospital.

PEEP is controversial. If we see a need in the ICU to go much of 5 cmH20, all the cerebral monitoring devices will be placed. Primarily PEEP should be used only if there is an oxygenation problem and the head of the bed can be slightly elevated. Increases in Mean Airway Pressure can increase ICP. The Mean Arterial Pressure must be maintained to adjust for the increase in Mean Airway Pressure. PEEP can elevate PaCO2 and lower pH by extending the FRC.

Adequate Cerebral Perfusion Pressure is the goal. Ischemia results from decreased CPP.

CPP is essentially Mean Arterial Pressure - ICP. So if MAP is decreased from a change in Mean Airway Pressure, CPP is decreased. If the Mean Airway Pressure increases the ICP, CPP is decreased.

There is a cycle that will result from each parameter.

*The body's response to a decreased CPP is to raise blood pressure and dilate blood vessels in the brain.

*This increases cerebral blood volume.

*This increases ICP.

*This decreases CPP.

*This causes the body to respond again and the cycle start over.

I appreciate this review. I said nothing about blowing off CO2, just that Sacramento doesn't have within their protocols, anything beyond using an ETCO2 detector as a device to confirm ETT placement. About the only "newish" thing for me was Mean Airway Pressure effects upon MAP and from there, upon CPP. Even then, that was not exactly new to me. But like I said, I really do appreciate this review.

If anything it got me irritated at Sacramento EMS all over again about their lack of a policy wrt ETCO2 monitoring... it's pretty darned easy to over-ventilate the patient. This, as is known, can cause cerebral vasoconstriction, and therefore while it lowers ICP, it also can cause a drop in cerebral perfusion, possibly below the ischemic threshold.

 

[Akulahawk]

Use EEG for prehospital monitoring of brain electrical activity.

Some surprising results might be found if EEG monitoring is instituted on Residents, some Nurses, and most EMS personnel... who haven't been caffeinated.

 

[bstone]

Some surprising results might be found if EEG monitoring is instituted on Residents, some Nurses, and most EMS personnel... who haven't been caffeinated.

And even more interesting results found on those who publish to these forums.

 

[VentMedic]

I appreciate this review. I said nothing about blowing off CO2, just that Sacramento doesn't have within their protocols, anything beyond using an ETCO2 detector as a device to confirm ETT placement. About the only "newish" thing for me was Mean Airway Pressure effects upon MAP and from there, upon CPP. Even then, that was not exactly new to me. But like I said, I really do appreciate this review.

If anything it got me irritated at Sacramento EMS all over again about their lack of a policy wrt ETCO2 monitoring... it's pretty darned easy to over-ventilate the patient. This, as is known, can cause cerebral vasoconstriction, and therefore while it lowers ICP, it also can cause a drop in cerebral perfusion, possibly below the ischemic threshold.

Just because it is not specifically written out does not mean you should not know the many uses of your technology or what the numbers mean for different situations. Of course, this would also mean an understanding of deadspace ventilation an V/Q mismatching.

Just following the recipe is what has gotten some to fail to understand other equipment like the pulse ox. Too few learn about Hb, COHb, MetHB, vasoconstriction and cardiac output to adequately use the SpO2 number for assessment. It should be used to confirm what you are already thinking and not the basis of your whole diagnosis.

Some surprising results might be found if EEG monitoring is instituted on Residents, some Nurses, and most EMS personnel... who haven't been caffeinated.

Actually, they are usually the subjects for many studies and for those to gain more practice with.

However, the EEG is just like the pulse ox. Given the scenario:

Unrestrained rear seat passenger of car versus stationary truck on freeway, estimate speed 50mph+ Extricated by witnesses, lying on the road on your arrival.

Groaning and extends to pain, no eye opening. Airway: Trismus present, airway sounds soiled, blood and vomit from nose. Breathing: Laboured, tachypneic, equal chest wall movement, air entry to bases. SpO2 87% on NRB. Strong radial pulses, HR 90, sinus rhythm, BP 150/100.

Blood and CSF coming from R) ear, bilateral periorbital ecchymosis, some minor abrasions and haematomas to head and neck, no other significant injuries found.

one should not need an EEG to see this patient probably has a TBI and that will be the protocol you will be dealing with in prehospital.

 

[bstone]

I was being silly in saying prehospital EEG is needed. The man needs a neurosurgeon, not an EEG.

 

[VentMedic]

Previous EEG on ambulances thread:

http://www.emtlife.com/showthread.php?t=14290