INDICATIONS OF MODERATE OR SEVERE TBI DEFINED AS:

Anyone with physical trauma and a mechanism consistent with the potential to have induced a brain injury, AND:

• Any injured patient with loss of consciousness, especially those with GCS < 15 or confusion, OR
• Multisystem trauma requiring intubation, whether the primary need for intubation was from TBI or from other potential injuries, OR
• Post-traumatic seizures, whether they are continuing or not.

EMT Standing Order:

• PREVENT / CORRECT the following if present:
  • HYPOXIA
  • HYPERVENTILATION
  • HYPOTENSION
• Routine Patient Care. See Advanced Spinal Assessment Procedure (52 Skills) and Spinal Motion Restriction Protocol (14 Trauam).
• Continuously monitor oxygen saturation via pulse oximetry.
• Administer continuous, high-flow oxygen via NRB for all moderate or severe TBI cases.
• If breathing is inadequate, ventilate with 100% oxygen via BVM, utilizing normal ventilation parameters, maintaining SpO² > 94%.
  • Adult: 10 breaths per minute.
  • Child: 12 - 20 breaths per minute.
  • Infant: 20 - 30 breaths per minute.
• Utilize Pressure-Controlled BVM (PCB) and Ventilation Rate Timer (VRT), if available.
• If staffing allows, assign a ventilation monitor.
• Target tidal volume is 7 cc/kg (Utilize 2-finger bagging technique for adult patients; 1-finger bagging technique for pediatric patients.)
• Check systolic blood pressure (SBP) every 3 - 5 minutes.

If the patient is not hypotensive (systolic BP > 100 mmHg), elevate the head of the stretcher 30 degrees (12 to 18 inches), if possible.

• Check blood glucose; if hypoglycemic, see Diabetic Emergencies (Hypoglycemia) Protocol - Adult or Diabetic Emergencies (Hypoglycemia) Protocol - Pediatric.
• Call for AEMT/Paramedic intercept. & Assisst AEMT/Paramedic in patient care.
• See Trauma Triage and Transport Decision Policy.

AEMT/PARAMEDIC Standing Order - ADULT:

• Maintain systolic BP. Avoid hypotension.
  • Adult - maintain SBP:
    • Age > 10 years: ≥ 110 mmHg
  • Pediatric - maintain SBP:
    • Age < 1 month: > 60 mmHg
    • Age 1 - 12 months: > 70 mmHg
    • Age 1 - 10 years: > 70 + 2x age in years.
• Establish IV/IO access.

  To prevent hypotension, administer IV fluid for any SBP < 90 or any signs of down trending SBP:

  • Adult: Fluid bolus 1,000 mL 0.9% NaCl IV. See Shock Protocol - Adult (56 Medical).
  • Child and Infant: Fluid bolus 20 mL/kg 0.9% NaCl IV. See Shock Protocol - Pediatric (60 Medical).
  • Administer 20 mL/kg 0.9% NaCl IV fluid bolus in a pediatric patient with normal systolic blood pressure and who has other signs of decreased perfusion including tachycardia, loss of peripheral pulses, and delayed capillary filling time of >2 seconds. See Shock Protocol - Pediatric (60 Medical).
  • If continuous waveform capnography is available:
    • Ventilate to strictly maintain an ETCO2 level of 35 - 45 mmHg (target = 40).
• Consider supraglottic airway (SGA) or intubation if GCS is < 8 and unable to maintain airway with BVM.
• Utilize continuous waveform capnography to strictly maintain an ETCO2 level of 35 - 45 mmHg.
• Consider sedation for patients that are combative and may cause further harm to self and others
  • Midazolam 2.5 mg IV/IO/intranasal, may repeat once in 5 minutes OR 5 mg IM, may repeat once in 10 minutes OR
  • Diazepam 5 mg IV/IO, may repeat once in 5 minutes.
• For seizures, refer to Seizure Protocol - Adult.

PARAMEDIC Standing Order - PEDIATRIC:

• Consider sedation for patients that are combative and may cause further harm to self and others.
• For adult administer Midazolam 2mg IV slow, or 5mg IM/IN.
• For pediatric age group administer 0.1mg/kg IV slowly.
• For patient < 65 years of age administer half started for adult IV dose and repeat every 5 minutes and in the event of IM/IN use administer half of adult dose IM/IN dose and repeat every 5 minutes too.
• For seizures, refer to Seizure Protocol - Pediatric.

NOTE:

Most patients with severe head injury retain airway reflexes. Rapid transport to hospital without intubation is appropriate when possible.

PEARLS:

• Prevention of hypoxia and hypotension are imperative to prevent secondary brain injury.
• Intubation should be approached with extreme caution as it has been associated with worse outcomes when performed in the out-of-hospital environment for patients with traumatic brain injury.
• A single non-spurious O2 sat of < 90% is independently associated with a doubling of mortality.
• Hyperventilation is independently associated with at least a doubling of mortality and some studies have shown that even moderate hyperventilation can increase the risk of dying by six times.
• A single episode of SBP < 90 mmHg is independently associated with at least a doubling of mortality. Repeated episodes of hypotension can increase the risk of dying by as much as eight times.
• Implementation of this practice bundle has been shown to double the survival rate of severely head-injured patients and triple the rate of survival for intubated patients.