Podcast Episode 18: Traumatic Brain Injury

Prolonged Field Care PFC TBI Traumatic brain Injury podcast discussion head multi system fluid resuscitation colloid crystalloid hextend lactated ringers LR normal saline NS Fresh Whole Blood FWB herniation hyperventilation raccoon eyes echymosis battles sign

“We were assigned to train the Colombian military in Reconnaissance operations. It was the rainy season, so travel was limited to trucks, ATVs, and good ol’ fashioned walking. We were about two days into our training mission/jungle slog, when we happened upon a vehicle at the base of the mountain that had been pushed off the road by a

mudslide.

When I got to the vehicle, I found an unconscious male with obvious decerebrate posturing. The vehicle, at least appeared stable enough, so I climbed inside to assess the driver. While the team fanned out to look for others and make a litter, I started on the driver. He didn’t appear to be bleeding, though he had a nasty gash on the side of his head. He reacted to a sternal rub with some noises. He was breathing spontaneously (12 deep and Irregular), but he had sonorous breath sounds. I decided to attempt an OPA… and sadly it went in without problem. His HR was 58 bpm and BP was 138/88. By then the team had brought a pole-less litter reinforced with some branches. Thankfully, the fall had ripped open the driver-side door, so after removing the driver seat, extraction was straight forward. When we got the driver out, I could assess for other injuries. Other than an obvious TBI, his pelvis felt unstable, which I splinted with his jeans and a branch as a windlass. On reassessment he had a GCS of 6 (E2/V2/M2), BP 132/86, HR 60 SR, RR 14 Deep/Irreg., SPO2 95%,and Temp 101.5°F.

The Captain was on the radio requesting MEDEVAC, but with the weather, the birds would not fly. The roads were impassable with the recent rains and mudslides. Our choices were to hunker down, make a clearing, and wait for the weather to clear enough for helos or walk back… Welcome to Prolonged Field Care.
We decided it was more dangerous for the patient to walk back. Between the Colombian medic (TCCC trained) and I, we had:

  • EMMA (Capnometry)
  • King LT
  • ET tube 8.0
  • Cric Kit
  • BVM w/ PEEP
  • Cefazolin
  • Ertapenam
  • Blood collection kit
  • Tranexamic Acid
  • Ondansetron
  • Lactated Ringers, 2L
  •  0.9% NS, 2 Liters
  • 2 – 8.4% Sodium Bicarb 50ml
  • 2-3% HTS 250ml
  • Dexamethasone
  • Flumazenil
  • Narcan
  • Midazolam
  • Diazepam
  • Ibuprophen
  • Tylenol tabs + Ofirmev
  • 2% lidocane
  • Fentanyl
  • Ketamine

Things to think about:

  • What would your first priorities be when you arrived on scene?
  • When would you use the 3% HTS, early or as needed?
  • Do you have any concerns about the airway?
  • Would you choose to take the airway with a Cric or other advanced airway, knowing he has a GCS of 6?
  • If you choose NOT to use an advanced airway, what can you do to mitigate any airway issues?

We want you to be able to have more knowledge on this topic and more confidently be able to answer these questions and plan for it, as well as implement this into your training for hands on and trauma patient assessment skills.

Traumatic Brain Injury (TBI) is physical damage to the brain caused by a blow to the head, penetrating objects, motor vehicles crashes and explosions, or a combination of these, which are all familiar scenarios we encounter in our community. This is especially true for Motor Vehicle Crash, the number one cause of death of our Operators on peacetime deployments, and still 5% of deaths even in warzones. To make matters worse, the force that caused the TBI also created other injuries such as a hemothorax, making it even more of an animal to treat. It’s more difficult to understand what is going on because there isn’t an artery spurting blood we can address, so we have to put on our thinking caps and understand what is going on at the cellular level.

First, please answer these anonymous poll questions so we can see where our audience is at on the subject of Traumatic Brain Injury.  This will give us more to discuss at our upcoming round table discussion on TBI which will be a follow-up podcast:

This video and podcast references the Clinical Practice Guidelines that will soon be published to address this topic.  We will keep updating as more evidence comes out:

Audio Only:


Now that you have listened, test your knowledge to see what you retained:


After the scenario, podcast, and quiz, what are your thoughts? Comments, questions?

Let us know in the comments below or on our Facebook post.

 

4 thoughts on “Podcast Episode 18: Traumatic Brain Injury

  1. There are some reports in the literature about an association between hyperoxygenation and poor outcomes in TBI patients. Can you comment on this? Specifically, on the recommendation to keep sats > 95% without defining an upper limit of normal for our pre-hospital providers? Should we be training the keep sats 95-99% if possible (i.e. In our ventilated patients when a blender is available)?
    Many thanks! Great podcast!

  2. Great talk!
    Question regarding sat parameters: There is some literature that suggests an association between hyperoxygenation and poorer outcomes in patients with TBI. Can you comment on this? Should our sat goals be 95-99% (when titration of supplemental O2 is possible) to reduce the incidence of this complication?
    Many thanks!

  3. Can you comment on some of the literature that suggests hyperoxia during the first 24 hours after TBI can be deleterious as well? Should our sat parameters be 95-99% instead of an open-ended > 95% to reduce the incidence of causing an injury? Thanks!

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