(unable to follow commands with either evidence of head trauma or a blunt/blast mechanism)
a. Prevent hypoxemia (goal SpO2 >90-95%)
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- If basic airway maneuvers fail to maintain SpO2 >90% or are not tactically feasible, ensure low oxygen saturations are not due to tension pneumothorax or hemorrhage.
- Consider definitive airway if unable to maintain SpO2 >90%.
b. Prevent hypotension – maintain SBP 100-110 mmHg. Transfuse whole blood or plasma preferentially if casualty is in hemorrhagic shock. Otherwise use 1-2 L bolus of crystalloid if no evidence of hemorrhage or hemorrhagic shock.
c. Identify and treat herniation (declining neurologic status with asymmetric or fixed/dilated pupil(s), or posturing):
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- Interventions for signs of impending herniation should only be employed for up to 20 minutes, and if en route to surgical decompression.
- Administer 250ml of 3% or 5% OR 30ml of 23.4% hypertonic saline SLOW IV/IO push over 10 minutes followed by a saline flush. Repeat in 20 minutes if no response (max 2 doses).
- Monitor IV/IO site and discontinue if signs of extravasation.
- Elevate head 30 degrees if casualty not in shock and tactically feasible.
- Loosen cervical collar if present and keep head facing forward.
- Hyperventilate using continuous capnography (goal EtCO2 32-38 mmHg).