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DROPPING THE H-BOMB TRAUMATIC BRAIN INJURIES
Bridgette Svancarek MD
FINANCIAL DISCLOSURE
None
OBJECTIVES
Understand the difference between primary and secondary brain injuries
Identify the ldquoH bombsrdquo and their impact on patients with traumatic brain injuries
Know the appropriate prehospital treatment of traumatic brain injuries
Understand why avoiding hyperventilation influences intubation
Understand why avoiding hypotension conflicts with the management of multisystem trauma patients
INTRODUCTION
25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death
INTRODUCTION
Causes Falls- 352 MVC- 173 Struck byagainst- 165 Assault- 10 Unknownother- 21
At-risk age groups Newborn-4yo 15-19 gt75
INTRODUCTION
Traumatic Brain Injury (TBI)- brain dysfunction secondary to external mechanical force
Primary Brain Injury The initial injury from the mechanical forces Shearing or compression of nerve cells andor
vessels Bleeding edema etc No prehospital treatment for this
INTRODUCTION
Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing
secondary brain injury
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
FINANCIAL DISCLOSURE
None
OBJECTIVES
Understand the difference between primary and secondary brain injuries
Identify the ldquoH bombsrdquo and their impact on patients with traumatic brain injuries
Know the appropriate prehospital treatment of traumatic brain injuries
Understand why avoiding hyperventilation influences intubation
Understand why avoiding hypotension conflicts with the management of multisystem trauma patients
INTRODUCTION
25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death
INTRODUCTION
Causes Falls- 352 MVC- 173 Struck byagainst- 165 Assault- 10 Unknownother- 21
At-risk age groups Newborn-4yo 15-19 gt75
INTRODUCTION
Traumatic Brain Injury (TBI)- brain dysfunction secondary to external mechanical force
Primary Brain Injury The initial injury from the mechanical forces Shearing or compression of nerve cells andor
vessels Bleeding edema etc No prehospital treatment for this
INTRODUCTION
Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing
secondary brain injury
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
OBJECTIVES
Understand the difference between primary and secondary brain injuries
Identify the ldquoH bombsrdquo and their impact on patients with traumatic brain injuries
Know the appropriate prehospital treatment of traumatic brain injuries
Understand why avoiding hyperventilation influences intubation
Understand why avoiding hypotension conflicts with the management of multisystem trauma patients
INTRODUCTION
25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death
INTRODUCTION
Causes Falls- 352 MVC- 173 Struck byagainst- 165 Assault- 10 Unknownother- 21
At-risk age groups Newborn-4yo 15-19 gt75
INTRODUCTION
Traumatic Brain Injury (TBI)- brain dysfunction secondary to external mechanical force
Primary Brain Injury The initial injury from the mechanical forces Shearing or compression of nerve cells andor
vessels Bleeding edema etc No prehospital treatment for this
INTRODUCTION
Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing
secondary brain injury
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
INTRODUCTION
25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death
INTRODUCTION
Causes Falls- 352 MVC- 173 Struck byagainst- 165 Assault- 10 Unknownother- 21
At-risk age groups Newborn-4yo 15-19 gt75
INTRODUCTION
Traumatic Brain Injury (TBI)- brain dysfunction secondary to external mechanical force
Primary Brain Injury The initial injury from the mechanical forces Shearing or compression of nerve cells andor
vessels Bleeding edema etc No prehospital treatment for this
INTRODUCTION
Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing
secondary brain injury
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
INTRODUCTION
Causes Falls- 352 MVC- 173 Struck byagainst- 165 Assault- 10 Unknownother- 21
At-risk age groups Newborn-4yo 15-19 gt75
INTRODUCTION
Traumatic Brain Injury (TBI)- brain dysfunction secondary to external mechanical force
Primary Brain Injury The initial injury from the mechanical forces Shearing or compression of nerve cells andor
vessels Bleeding edema etc No prehospital treatment for this
INTRODUCTION
Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing
secondary brain injury
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
INTRODUCTION
Traumatic Brain Injury (TBI)- brain dysfunction secondary to external mechanical force
Primary Brain Injury The initial injury from the mechanical forces Shearing or compression of nerve cells andor
vessels Bleeding edema etc No prehospital treatment for this
INTRODUCTION
Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing
secondary brain injury
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
INTRODUCTION
Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing
secondary brain injury
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
THE H-BOMBS OF TRAUMATIC BRAIN INJURIES
Hypotension Hypoxia Hyperventilation
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOTENSION
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOTENSION
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x
higher Did worse if not corrected in the field
Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOTENSION
Should our threshold be higher than 90mmHg Berry et al Injury 2012
15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOTENSION
Should our threshold be higher than 90mmHg Fuller et al Injury 2014
5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOTENSION
If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
ldquoPERMISSIVE HYPOTENSIONrdquo
Contraindicated in patients with significant TBI
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOXIA
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOXIA
Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases
mortality 2x Prehospital hypoxia common
46 of the patients
Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during
transport Prehospital hypoxia increased mortality 266x
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPOXIA
Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation
common Dunford et al Annal Emerg Med 2003
54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during
intubation 84 of the intubations described as ldquoeasyrdquo
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPERVENTILATION
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPERVENTILATION
Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF
Intrathoracic pressure Cardiac Output
CBF
pH Oxyhemoglobin dissociation curve shift
to the left O2 delivery to tissue
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPERVENTILATION
Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003
39 of hyperventilated patients died or discharged in a vegetative state
25 of patients with normal ventilation died or discharged in vegetative state
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPERVENTILATION
Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010
65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPERVENTILATION
Reduces blood flow and oxygen delivery to the brain
Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates
Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
HYPERVENTILATION
If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very
common Aufderheide et al Circulation 2004
Ventilation rate electronically recorded in cardiac arrest patients
Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003
40 patients with TBI intubated prehospital 70 unintentionally hyperventilated
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
No evidence to support it Decreases ICP
Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo
Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign
Systolic HTN bradycardia irregular respirations
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
Target ETCO2 30-35mmHg Initial rates
Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo
If unsurehellipDONrsquoT HYPERVENTILATE
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
SHOULD TBI PATIENTS BE INTUBATED
Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301
intubated in ER TBI ptrsquos intubated in the field worse outcomes
4x mortality 2x moderate to severe functional impairment
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
SHOULD TBI PATIENTS BE INTUBATED
Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to
severe TBI 277x higher mortality if intubated prehospital
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
BUT WAIThellip
Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned
to be intubated prehospital vs ED 13x more likely to have favorable outcome if
intubated in the field
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
SO IF YOU INTUBATE
Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
SUMMARY
Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs
The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI
MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation
Prehospital intubation of TBI needs particular attention to avoiding the H-bombs
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
RESOURCES
httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf
httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E
pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi
101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R
Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective
analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
RESOURCES
Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM
J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB
httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi
101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf
RESOURCES
httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf
httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf