Take Home Points
- If you get a heads up from EMS on an incoming trauma, take the lead time you get to clearly delineate everyone’s roles to help ensure the resuscitation runs smoothly.
- In the severe TBI patient, the key is in preventing secondary injury to the brain. We do this by guarding against hypoxia, hypercarbia, hypotension and aspiration. Max your pre-ox, get the ETT in quickly to prevent oxygenation and ventilation issues and keep the head up if possible
- Hypotension is rarely seen in isolated head trauma. If the patient is or becomes hypotensive, reassess for any sources of hemorrhagic shock that may have been missed and consider whether the meds you gave may have caused the problem.
- Hypertension is much more common and despite extensive research, we haven’t shown that dropping the patient to normal levels is beneficial. Keeping the SBP < 180 seems reasonable but check your local protocol as well.
- If the patient’s ICP spikes or your concerned about herniation, administer mannitol or hypertonic saline and get your neurosurgeon to the bedside since the patient is gonna need decompression
- Finally, make sure to reverse any anticoagulant the patient may have on board as this will hopefully prevent hematoma expansion.
emDocs: Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI
Core EM: Podcast 31.0 – Rocuronium vs. Succinylcholine
Core EM: Intensive Blood Pressure Lowering in Intracerebral Hemorrhage (ATACH-2 Trial)
PulmCCM: Hyperosmolar Therapy for Increased Intracranial Pressure (Review)
EM Cases: Episode 89 – DOACs Part 2: Bleeding and Reversal Agents
Hopper AH. Hyperosmolar therapy for raised intracranial pressure. NEJM 2012; 367(8): 746-52. PMID: 22913684
Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; 28(6): 821-7. PMID: 24859931
Zeiler FA et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014; 21(1): 163-73. PMID: 24515638