SEDATION

There is a delicate balance when sedating patients with TBI. When transferring casualties to a neurosurgical capability for initial assessment, avoid long-lasting sedation or paralysis as this impedes the ability to evaluate the patient. However, medication selection should not override the need to safely transport the casualty.

- Propofol can be used for sedation, but caution must be used to avoid hypotension.25
- Ketamine is also useful for sedation (and can also provide some analgesia) as it avoids the significant hypotension associated with propofol and there is evidence it lowers intracranial pressure (ICP).34-40
- When narcotics are utilized for pain management, intermittent narcotic doses are preferred over continuous infusion.
- Routine paralysis of TBI patients should be avoided. If paralytics are needed, vecuronium is preferred because it is readily available in the austere environment and does not require refrigeration. Bolus dosing is preferred over continuous infusion. The recommended initial dose is 0.08 to 0.1 mg/kg given as an intravenous bolus injection. Paralytics should only be used if the patient is appropriately sedated. In general, paralytics should only be used for high-risk transport.