Hemodynamic  Control

Goal: Maintain SBP >110mmHg. In polytrauma patients with ongoing bleeding, aggressively control hemorrhage using all means available and restore circulating blood volume by using blood products. Note: An SBP >90mmHg has traditionally been targeted in TBI patients, though recent literature has suggested better outcomes may occur when SBP is maintained above 110mmHg in TBI patients.10,11

Hemodynamic  Control  Notes

Most trauma patients with moderate or severe TBI will have other traumatic injuries. A careful search for bleeding should be performed in any hypotensive trauma patient.

Brain injury with associated hemorrhagic shock is a complicated scenario with a high risk of death. Balancing hemorrhage control (which is easier with lower blood pressure) with maintaining cerebral perfusion pressure (which requires higher blood pressure) should be guided with expert teleconsultation (i.e. critical care, neurocritical care, neurosurgical) whenever possible.

Airway,  Oxygenation/Ventilation  Management

Goal: Manually maintain or secure the patient’s airway and avoid hypoxia, hypocapnia, or hypercapnia to reduce the risk of secondary brain injury. If GCS score is ≤8 or there is facial trauma with compromised airway, a definitive airway is most likely needed. The provider should place the type of airway (i.e. cricothyroidotomy or endotracheal tube [ETT]) that they have the most confidence in placing, based on their training and practice.

In the JTS Traumatic Brain Injury Management and Basic Neurosurgery in the Deployed Environment CPG, a goal of >93% is recommended, However, in order to establish a safety buffer in the prolonged field care setting often characterized by equipment challenges and limited personnel, in addition to anticipated transport challenges, a goal SpO2 of > 95% for ventilated patients is recommended.

Airway  Management  Notes

ICP  Management

Goal: Suspect high ICP in any head injury patient with GCS score ≤8 OR declining findings on neurologic examination (unless explained by sedation, hypotension, hypoxia, hypercarbia, high fever). Minimize factors that contribute to elevated ICP, such as pain, anxiety, and fever. Rapidly recognize and manage elevated ICP, and maintain an adequate cerebral perfusion pressure.

The optimum duration of hyperventilation and frequency that can be repeated are not known. If performed, assess response (i.e. pupils, GCS score, and so forth). If patient responds, consider performing again if needed, guided by expert teleconsultation, if possible

In addition to analgesics, consider administration of a rapid-onset, short-duration anxiolytic. Midazolam 1–2mg IV/IO as needed for agitation or anxiety.

Seek additional medical direction as soon as possible and evacuate to neurosurgical care at the earliest opportunity.

ICP  Management  Notes

Always treat hypotension before treating elevated ICP. Cerebral blood flow is more affected by a decrease in blood pressure than an increase in ICP.

Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP; mmHg) − ICP (mmHg)

Hyperventilation reduces CO2 and rapidly lowers ICP by causing cerebral vasoconstriction and decreasing the overall cerebral blood volume. However, hyperventilation also damages the brain by causing ischemia and should only be performed for brief periods. Avoid hyperventilation unless all other interventions have been ineffective.22

Although there are invasive interventions to help assess and treat elevated ICP, evacuate hematomas, and so forth, such as decompressive craniectomy, extraventricular drains, intracranial bolt monitors, and burr holes, such procedures are not recommended unless the PFC provider has training and experience in performing these procedures and is directed by expert teleconsultation.

Infection  Control

Goal: Dress all wounds to prevent further exposure to environmental pathogens and administer antibiotic prophylaxis to all patients with penetrating TBI.

Ertapenam and moxifloxacin may increase the risk of seizure and ertapenam may not penetrate an intact blood-brain barrier.  This combination, while commonly available, should only be used in TBI patients when the antibiotics with proven CNS penetration are not available.

 Infection Control Notes

Seizure  Prophylaxis  and  Management

Goal: Rapidly identify and manage seizure activity in TBI patients.

Seizure  Notes

Fever  Control

Goal: Maintain core temperature between 96°F and 99.5°F. Treat fever aggressively in TBI patients with a combination of medication, cold fluid boluses, and surface cooling techniques.

Fever  Notes

Avoid non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, ketorolac. Although these agents can effectively lower temperature, their antiplatelet effect may increase bleeding in TBI if intracranial hemorrhage is present (e.g., epidural hematomas, subdural hematomas).

Sodium  Management

Goal: Avoid hyponatremia, which can worsen brain swelling. The target serum sodium level in patients with severe TBI is slightly above normal, between 145mmol/L and 160mmol/L.

Sodium  Management  Notes

Obtain telemedicine consultation, preferably from a critical care or neurocritical care expert, before giving more than two 250mL boluses of 3% NaCl HTS.

BLOOD  GLUCOSE  CONTROL

Goal: Avoid both hypoglycemia and hyperglycemia. Target a blood glucose level of 180mg/dL via handheld glucometer.

Blood  Glucose  Control  Notes