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Case Presentation: BLS to ALS Handoff
•21 year old male•Unrestrained driver, single vehicle
MVC•20mph; sedan vs. concrete barrier•No airbag•Starred windshield•+ LOC
Initial Assessment
•Patient has clear airway•Bilateral breath sounds•Strong radial pulse of 100•Blood Pressure 120/80•Speaking spontaneously
Additional information?•Respiratory rate/ quality–16 good
movement •O2 sat – 100%
Physical and Neurological Evaluation
•Found out of vehicle walking near accident scene
•3x5cm Hematoma/ contusion left forehead•Opens eyes spontaneously•Alert to person & place, but confused to month
and year•Follows motor commands•GCS =
▫14Additional information?•Pupils
Treatment and Interventions
• Immobilization with cervical collar and backboard
•Reassess vital signs & neuro exam Q5 min•Administer supplemental oxygen as needed to
maintain SaO2 > 90%•Rule out other causes of altered mental status
•BLS - Medic Eval?
•ALS - establish IV access
Causes of Altered Mental Status
•Hypovolemia•Hypoxia•Hypoglycemia•Pain/Discomfort•Traumatic Brain Injury
Additional causes?•Alcohol•Drugs
Transport Decisions
•Destination▫Mild TBI▫GCS 14
•Emergency Department
Reassessment enroute: ABC’s
•Vital signs remain stable▫Patent airway▫Bilateral breath sounds▫Pulse 96▫BP 116/76
Additional information?▫Respiratory rate/ quality – 12 regular▫O2 sat – 92%
Reassessment: Neuro Exam
•Eyes open to painful stimuli•Speech is incomprehensible•Localizes to painful stimuli•Pupils 3mm bi-lat. with brisk reaction to
light
•GCS = ▫9
Treatment and Interventions
•Cervical spine immobilized•Backboard in place•O2 administered via NRM
▫ Critical value – SpO2 < 90%
•BLS- Medic Eval?
•ALS - IV access established with NS infusing▫Critical value – SBP < 90mm Hg
Transport Decisions
•Destination▫Moderate TBI▫GCS 9
•Trauma Center
Reassessment: ABC’s•Changes in vital signs
▫Respiratory rate 8▫SaO2 90% on NRM▫Pulse 112▫BP 80/60
•Additional Information?▫Respiratory effectiveness –
Irregular/ poor air exchange
Reassessment: Neuro Exam• Patient is unresponsive
▫Eyes – no response▫Motor – bilateral extensor posturing▫Verbal – no response
• Pupils▫Right 4mm & reactive▫Left 3mm & reactive
• GCS =▫4
• BLS to ALS Handoff
ALS Treatment Interventions
o Establish a patent airwayo Vigorous IV fluid administration (Keep SBP > 90mm Hg)o Supplemental oxygeno Hyperventilation @ 20 breaths/minuteo Only when suspected cerebral herniation
o Capnography/ ETCO2 used to: ▫ Confirm endotracheal tube placement▫ Measure the adequacy of ventilation.
Target range: 35 – 40 mm Hg▫ Guide hyperventilation therapy
Severe hyperventilation: < 30 mm Hg ETCO2 < 25 mm Hg is not recommended
Transport Decisions
•Destination▫Severe TBI▫GCS 4
•Level One Trauma Center with TBI capabilities
Transport Decisions
•Level One Trauma Center with TBI capabilities▫24 hour available CT scan▫24 hour available operating room▫Prompt neurosurgical care▫Ability to monitor intracranial pressure▫Ability to treat intracranial hypertension
Summary• Provide oxygen and ventilation to maintain oxygen
saturation >90%• Provide adequate fluid to maintain SBP >90mm Hg• Continuously look for S & S of Cerebral herniation
▫ Pupil abnormalities▫ HA, N/V▫ Cushings Triade - SBP, HR, Irreg. resps.
• Select the most appropriate facility and mode of transportation for admission of the TBI patient
Additional information?• Continually reassess and document:
▫ Component GCS, VS, post intubation RR, and Capnography values .
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