(unable to follow commands with either evidence of head trauma or a blunt/blast mechanism)

a.  Prevent hypoxemia (goal SpO2 >90-95%)

    1. 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.
    2. 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):

    1. 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).