Traumatic Brain Injury Module

for DSHS
Giles Gifford, EMT
Monica S. Vavilala, MD
1
ALS & BLS provider course
TBI Epidemiology: Nationally

Yearly 1.7 million people sustain Traumatic Brain Injury,(TBI)
~1.36 million are treated in ED and discharged.
275,000 are hospitalized
80,000 to 90,000 are disabled
52,000 die

Today, 5.3 million Americans (~ 2%) are living with TBI-
related disability and ~1% of people with severe TBI survive
in a persistent vegetative state

In 2000, the estimated lifetime direct medical costs and
indirect costs (such as loss of life long productivity) from TBI
amounted to 60 billion dollars

2
TBI Epidemiology: WA State

TBI ~ 10% of all injury related hospitalizations

TBI deaths are about 29% of all injury related fatalities

Nearly 123,750 residents with TBI related disabilities

~ 26,000 residents had TBI (20052009)

~ 5,500 hospitalizations and 1,300 deaths/year (20022006)

You will see TBI patients in your career
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Population; 6,664,195 - Jul 2009
Source: U.S. Census Bureau

WA Epidemiology: TBI Causes


From 2003-2007, falls, being struck by an object, and motor vehicle related TBI injuries
made about 90% of all TBI related hospitalizations and falls, firearms and motor vehicle
related injuries made about 91% of TBI deaths.

4
WA Epidemiology: TBI Hospitalizations by Cause
TBI Hospitalizations due to transport injuries of various types fell in the early years,
and then plateaued. Falls increased since the late 1990s, explaining the overall rise
in TBI Hospitalizations. TBI hospitalizations by firearm injury remains low due to
the low survival rate from the initial injury.
5
WA Epidemiology: Elderly Fall Related TBI
TBI related hospitalizations and deaths will steadily
increase over the next few decades as the baby-boom
generation (those born from 1946 to 1964) steadily ages
1 in 3 adults age 65+ falls each year
1 in 2 adults age 80+ falls each year

1 out of 5 falls causes a serious injury such as a head
trauma (TBI) or fracture

Only 1 in 5 people who are hospitalized for falls ever
return home

6
WA Epidemiology: TBI Hospitalizations by Age
Who is at Risk ?

Elderly
Age 15-24 years
Male gender
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Traumatic Brain Injury (TBI)
Injuries to the brain caused by physical trauma to the head.
Can be penetrating or blunt force injury

Two forms of injury
Primary
Direct trauma to brain and vascular structures
Examples: contusions, hemorrhages, and other direct
mechanical injury to brain contents (brain, CSF, blood).

Secondary
Ongoing pathophysiologic processes continue to injure
brain for weeks after TBI
Primary focus in TBI management is to identify and
limit or stop secondary injury mechanisms
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Secondary Injury
After initial TBI, priorities are:

Identification of secondary insults
Intracranial hypertension from expanding
intracranial hematoma / brain swelling results in
elevated intracranial pressure (ICP) and/or herniation
Hypoxia from ventillatory/circulatory failure, airway
obstruction, apnea, lung injury, aspiration
Hypotension associated spinal cord injury, blood loss
Inadequate cerebral blood flow can cause inadequate
oxygen and glucose delivery
Hypercarbia from inadequate ventilation, apnea

Rapid transport to a capable health care facility

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Signs and Symptoms
Signs Symptoms
diminished consciousness
convulsions or seizures
dilation of one or both pupils
slurred speech
repeated vomiting or nausea
increasing confusion,
restlessness, or agitation

headache
blurred vision
ringing in the ear
bad taste in the mouth
weakness or numbness in
extremities
loss of coordination
dizziness/lightheadedness

10


Scene Awareness
Include the following in the patient care report:

Kinematics leading up to the injury
MVC speed, restraints, intrusion, helmet
Assault head vs. object, repeat assault?
Sports related body position, speed at impact

Witness account of Patient Behavior after Injury
LOC, slurred speech, inappropriate behavior, duration

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Documentation
Complete documentation could have a positive impact
throughout a TBI patients life
Diagnosis and Treatment after the injury may depend on
thoroughness of PCR
Include events occurring pre and post injury and before
EMS arrival

Ensure a successful hand off of the run sheet to the patient
care providers in the ED.
After obtaining signature, if possible ensure a copy of the
PCR is included in the patient chart

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Documentation

Specific items to document include:
Mechanism of Injury/ LOC?
Primary symptoms/associated symptoms
Serial vital signs HR, BP, RR
Component GCS and Pupils
Procedures preformed
Transportation decisions
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Assessment: Overview

Airway:
Priorities
Breathing:
Oxygenation
Hypoxemia
Circulation:
Hypotension
Shock

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Glasgow Coma Scale (GCS):
Priorities
Patient Interaction
Components
Motor Component
Score
Pupils:
Value
Pathophysiology
Abnormalities
Cerebral Herniation:
Indicators
Airway: Priorities
Determine that airway is open and maintain patency

Assess need for artificial airway

Reassess every 5 minutes and as needed

Maintain cervical spine precautions
Use cervical collar during transport

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Breathing: Oxygenation

Assess rate, rhythm, depth, quality, and effectiveness of
ventilation (movement of air in and out of the lungs) every 5
minutes and as needed
If possible use continuous SpO
2
monitoring
Avoid inadvertent hyperventilation

If no SpO
2
monitoring look for apnea and slow/irregular
breathing to indicate adequate tissue oxygenation and carbon
dioxide removal levels


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Breathing: Hypoxemia

Assess and monitor for hypoxemia (SpO
2
<90%)
Occurs in 40% of TBI cases

If pulse oximetry not available, observe patient for indirect
signs of hypoxia

Potential Signs and Symptoms of Hypoxia:
Blue or dusky mucus membranes
Impaired judgment
Confusion, delirium, agitation
Decreased level of consciousness
Tachycardia-heart rate > 100 beats per minute for adult
Cyanosis of fingernails and lips
Tachypnea - At or above 20 breaths per minute for adult

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Circulation: Hypotension
Monitor for hypotension - inadequate cerebral blood flow can
cause inadequate oxygen and glucose delivery
Adult hypotension, systolic blood pressure (SBP) <90mm Hg

Monitor for hypertension - may indicate raised ICP when
associated with bradycardia and irregular respiration

Use correct cuff size to measure systolic and diastolic blood
pressure
Cuff too small (false high or normal), too large (false low)

Assess SBP every 5 minutes
Continuous monitoring if possible


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Circulation: Shock
It is very important to recognize the signs and symptoms of
shock and it is something that every EMS provider can do
Signs and Symptoms of Shock:
Skin cyanosis, pallor
Restlessness, anxiety, change in level of consciousness
Tachycardia rapid heart rate, greater than 100 beats per minuet
Tachypnea rapid, shallow respiratory rate
Narrowed pulse pressure reduction in the range between the
systolic and diastolic blood pressure
Cool extremities
Hypotension SBP < 90 mm Hg

If spinal shock is associated patient may be hypotensive
with bradycardia

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If TBI patient takes anticoagulant medication/s this
information must be communicated to the receiving
facility and rapid transport should be initiated

Anticoagulant medications include
Warfarin - brand name Coumadin
Tinzaparin - brand name Innohep
Heparin
Enoxoparin
Dalteparin
Bivalirudin
Lepirudin
Argatroban
Desirudin
Fondaparinux



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Glasgow Coma Scale (GCS): Priorities
GCS preferred method to determine level of consciousness
AVPU (Alert, Verbal, Pain, Unresponsive) is too simple to
determine LOC & not quantifiable

Follow ABCs before measuring GCS

If possible, assess GCS prior to intubation

Measure GCS before administering sedative or paralytic
agents, or after these drugs have been metabolized

Reassess and record GCS every 5 minutes
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GCS: Patient Interaction
GCS obtained by direct patient interaction

Pre-hospital provider must ask direct questions and
perform specific actions for accurate GCS score
Do not simply say squeeze my hands (reflexive)
Instead say show me two fingers
The EMT needs to illicit a response that demonstrates
cognition, or the ability of the patient to think

If eye opening does not occur to voice, use axillary pinch
or finger nail bed pressure



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GCS: Components

GCS should be measured by pre-hospital providers who
are appropriately trained




GCS 14-15: Mild TBI GCS 9-13: Moderate TBI GCS 3-8: Severe TBI
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GCS: Motor Component

Important part of GCS

Motor response was designed to look a
the best upper extremity response

Spinal cord injury, chemical paralysis or
excessive pain makes motor
assessment impossible

Abnormal posturing (decerebration &
decortication) look similar in the lower
extremities

A: Abnormal flexion (decorticate rigidity) B: Extension posturing (decerebrate rigidity)

Motor Response

6- Obeys

5- Localizes-(purposeful movements
towards painful stimuli)

4-Withdraws from pain

3 Abnormal flexion - Image A
2-Abnormal extension - Image B
1-No response

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GCS: Value
GCS provides basis for determining the method of
transport and the preferred receiving facility

Compare to previous scores to identify trend over time
A single field measurement cannot predict outcome
Repeated GCS scores can be valuable to ED staff
Deterioration of > 2 points is a bad sign

GCS < 9 indicates a patient with a severe TBI and
require tracheal intubation
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Pupils: Value
Pupillary size and their reaction to light should be used in
the field as it can be helpful in diagnosis, treatment and
prognosis

A fixed and dilated pupil is a warning sign and
can indicate and impending cerebral
herniation

Pupillary size should be measured after the patient has
been stabilized



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Pupils: Pathophysiology
Why do pupils dilate?
The presence of intracranial hematoma can cause downward displacement of
the brain, until it puts pressure on the cranial nerve responsible for pupil
dilation


Other causes of abnormal pupils:
Hypoxia Hypotension
Drug use (opiates) Hypothermia
Toxic Exposure Artificial eye
Orbital trauma Congenital abnormality
Pharmacological treatment, Cataract Surgery
(e.g. Atropine)

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Pupils: Abnormalities
Unequal or dilated and unreactive -
suspect brain herniation
Unilateral or bilateral pupils -
(asymmetric pupils differ > 1 mm)
Dilated pupils -
(dilation more than or equal to 4mm)
Fixed pupils -
(fixed pupil less than 1 mm change in
response to bright light)
Evidence of orbital trauma should be recorded
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Cerebral Herniation: Indicators
Unresponsive patient (no eye opening or verbal response)
Unilaterally or bilaterally dilated or asymmetric pupils
Abnormal extension (decerebrate posturing)
No motor response to painful stimuli

Deteriorating neurologic examination, bradycardia (heart
rate < 60 bpm), and hypertension should be viewed as a
part of Cushings response and implies impending
herniation

Cushings Triad (Reflex) is a LATE sign of herniation:
Elevated systolic BP
Bradycardia
Irregular respirations
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Additional Considerations




30
Patients with other illness/injury can have signs and
symptoms similar to those of TBI

ETOH / drug abuse
Sports related injury / concussion
Violence / domestic violence
Has your partner hit or grabbed you are two
questions EMT can ask to identify a possibly
abusive situation
Decreased mental status in the elderly

These patients can also have a TBI!

Treatment: Overview
Airway:
Priorities
When to intubate
Capnography
Ventilation:
Priorities
Hyperventilation
End-tidal CO
2

Fluid Resuscitation:
Priorities
Vascular Access
Cerebral Herniation:
Signs and Symptoms
Hyperventilation
Additional Considerations
Pharmacological concerns
31
Bullet point key:
Normal Text For ALS & BLS providers
Text in Blue For ALS providers only
Airway: Priorities
Protect C-spine alignment with manual in-line
stabilization, beware facial trauma
Maintain airway patency
Administer O
2

If possible monitor with SpO
2
Provide combitube or supraglottic airway if not certified to
provide advanced airway adjuncts (according to county protocol)

Indication for Intubation GCS < 9
Rapid sequence intubation with manual inline stabilization of
cervical spine.

Intubation medications and doses per discretion of MPD
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Airway: When to Intubate

Secure airway (e.g. endotracheal tube, cricothyroidotomy) if:
GCS < 9 in an unconscious and unresponsive patient
Unable to maintain adequate airway
Hypoxemia (SpO
2
< 90%) not corrected by supplemental oxygen
Respiratory failure or apnea

Intubate and normoventilate: (~12 breaths per min)
If pupils are symmetric and reactive accompanied by localization,
withdraw, or flexion responses


Intubate and hyperventilate: (~20 breaths per min)
If pupils are asymmetrical (differ more than 1 mm)
If dilated (greater or equal to 4 mm) and fixed
If accompanied by extensor posturing or flaccid motor response
Considered signs of herniation
The motor component of the GCS exam is used to determine signs of
cerebral herniation.

33
Airway: Capnography
EMS systems implementing endotracheal intubation
protocols including RSI should monitor blood pressure,
oxygenation, and when feasible end tidal CO
2
(ETCO
2
)
monitoring (monitoring modality for ventilation)

After intubation confirm placement of tube with lung
auscultation and ETCO
2
determination

Maintain ETCO
2
35-40 mm Hg

Obtain multiple ETCO
2
readings

34

Ventilation: Priorities


Assess and record rate, rhythm, depth, and quality to
determine the effectiveness of respirations post intubation

Assist ventilations as necessary with Bag Valve Mask and
supplemental O
2


Adult normal ventilation rates: 10-12 breaths per minute

Ventilate to maintain SpO
2
> 90%
Patients with TBI normoventilate
Patients with TBI who are unconscious and unresponsive: intubate
and normoventilate
Patients with TBI and suspected brain herniation: Hyperventilate

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Ventilation: Hyperventilation

Produces a rapid decrease in arterial partial pressure of carbon
dioxide by increasing the pH or basicity of the blood. Causes:
cerebral vasoconstriction
Decreased cerebral blood flow
decreased intracranial pressure (ICP)

In normoventilated, normotensive, and well oxygenated patients still
showing signs of cerebral herniation, hyperventilation should be used
as a temporizing measure and should be discontinued when clinical
signs of herniation resolve

Prophylactic hyperventilation (PaCO
2
< 35 mm Hg) should
be avoided unless signs of cerebral herniation

36

Ventilation: End-tidal CO
2


Use ETCO
2
to:
Confirm endotracheal tube placement
Measure the adequacy of ventilation.
Target range: 35 40 mm Hg
Guide hyperventilation therapy
Hyperventilation: 30 34 mm Hg
RR 20 BPM > 9 years (every 3 seconds)
Severe hyperventilation: < 30 mm Hg
ETCO
2
< 25 mm Hg is not recommended
Avoid inadvertent Hypocarbia

37

Fluid Resuscitation: Priorities


Avoid hypotension and inadequate volume resuscitation
to maintain normotension and adequate tissue perfusion
Hypotension (SBP < 90 mm Hg) doubles mortality

Administer isotonic crystalloid solutions to maintain SBP
in normal range
Use dextrose free isotonic fluid
(0.9% NaCl or Lactated Ringers)
Administer isotonic fluids to maintain >SBP 90 mm Hg

Treat for shock as opposed to restricting fluids
ETCO
2
values may be low due to poor perfusion

38
Fluid Resuscitation: Vascular Access
Preferred percutaneous access site is forearm

Intraosseous can be alternative route for vascular access
For failed peripheral IV access
For delayed or prolonged transport

Transport should never be delayed to initiate IV lines
Focus should remain on rapid transport

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Cerebral Herniation: Additional Considerations
Agitation and combativeness can increase intracranial
pressure. Optimize patient transport by using short acting
sedation, analgesia, and neuromuscular blocks, that are
concurrent with local protocol and medical direction

Some of these treatments cause hypotension, consider
patients hemodynamic state and avoid hypotension

Rule out decreased level of consciousness due to
hypoglycemia
Hypoglycemia - blood sugar below 70 mg/dL
Perform rapid blood glucose determination
If necessary, give IV glucose
40


Cerebral Herniation: Signs & Symptoms


Signs Symptoms
Dilated or unreactive pupils
Asymmetric pupils
A motor exam that identifies either
extensor posturing or no response
Progressive neurologic deterioration,
decrease in GCS score more than 2
points from patients prior best score - in
patients with initial GCS < 9

Other factors increasing ICP
Fear and anxiety
Pain
Vomiting
Straining
Environmental stimuli
Endotracheal intubation
Airway suctioning

Frequently re-evaluate patient neurologic status
41

Cerebral Herniation: Pharmacological concerns

Controversial brain targeted therapy
Mannitol
The pre-hospital use of Mannitol currently cannot be
recommended

Hypertonic Saline
This investigational therapy, while showing promise in
hospital, is not yet recommended for prehospital use

Lidocaine
No literature to support use of lidocaine as a single agent
prior to intubation
42
Transport: Overview
Transport decisions:
Priorities
Priorities
Receiving facilities
43


Transport Decisions: Priorities
Minimize prehospital time by selecting appropriate mode
of transportation

Patient may require emergent surgery for hematoma
evacuation, early transport must be the priority while
resuscitation is ongoing

If necessary, rendezvous with air medical service to
decrease en route times
44

Transport Decisions: Priorities


All regions should have an organized trauma care system

Protocols are recommended to direct EMS regarding
destination decisions for patients with severe TBI

Improved success attributed to integration of prehospital
and hospital care and access to expedious surgery


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Transport Decisions: Receiving facilities

Transport to appropriate receiving facility based on GCS
GCS 14 15: Hospital Emergency Room
GCS 9 13: Trauma Center
GCS < 9: Trauma Center with severe TBI capabilities

Patients with severe TBI should be transported to a facility
with immediately available:
CT scanning
Prompt neurosurgical care
The ability to monitor ICP
The ability to treat intracranial hypertension
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References

[author last name, first name], 2007. Guidelines for Prehospital Management of
Severe Traumatic Brain Injury, second edition, Brain Trauma Foundation,.

National Association of Emergency Medical Technicians (NAEMT), 2011.
PHTLS: Prehospital Trauma Life Support, 7th ed., Elsevier Health Sciences,
Chap 9.

Shorter, Zeynep, 2009. Traumatic Brain Injury: Prevalence, External Causes,
and Associated Risk Factors, Washington State Department of Health,
http://www.doh.wa.gov/hsqa/ocrh/har/TBIfact.pdf (April 1, 2011)

U.S. Centers for Disease Control and Prevention, 2011. Injury Prevention &
Control: Traumatic Brain Injury, http://www.cdc.gov/traumaticbraininjury/
(May 1, 2011)

47
Acknowledgements
48
Mike Lopez, EMS/Trauma Supervisor; Washington State Dept. of
Health

Mike Routley, EMS Specialist/Liaison, Washington State Dept. of Health

Deborah Crawley, Executive Director and staff,
Brain Injury Association of Washington

Washington State EMTs participating in focus groups and phone
interviews.

Peer review: Andreas Grabinsky, MD, Armagan Dagal, MD, Deepak
Sharma, MD, Eric Smith EMT-P, Dave Skolnick EMT-B, Richard Visser
EMT-B

Additional Slide: Hyperventilation
Hyperventilation causes hypocapnia;
important in reducing TBI morbidity/mortality
As your RR the expulsion of CO
2
from the body also
This in dissolved CO
2
levels in the blood also the pH level of
the blood

2H
2
O + CO
2
H
2
CO
3
+ H
2
O HCO
3
-
+ H
3
O
+

An increase in the reactants (CO
2
) will lead to an increase in the
products (H
+
) increasing the acidity of the blood
Chemo receptors will detect decrease in blood pH
The bodies automatic response is to dialate the blood vessels in
order to discharge CO
2
faster and regain pH equilibrium
Volumetric flow rate (Q = v A)
Increasing M/M from intracranial bleeding

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Audit Tool Indicators
Thorough Documentation Of:

MOI
Events leading up to injury
Kinematics
Witness accounts
Initial Impression of Pt.
TBI signs and symptoms
Loss of Consciousness
Serial VS - Q5
Serial GCS scores Q5
Pupillary exam Q5
ETOH/ drug use


C-Spine precautions
Hypoxia Prevention
o Intubation indicators
o Serial Capnography values
o Post intubation RR
o Supported ventilation rate
o IV fluid initiation
Glucose value
Transport decisions
50
BLS to ALS Handoff
First priority is to identify secondary insult
Request medic eval. if TBI Pt is Showing S & S of:
Intracranial Hypertension
Hypoxia
Hypotension



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Check all of the following prior to ALS intervention:
Blood Pressure
Heart rate
Respiratory rate
& effectiveness
O
2
saturation
TBI associated S & S
Level Of Consciousness
GCS - component parts
Pupils component parts
Glucose

BLS to ALS Handoff Intracranial HTN
Causes:
Ruptured blood vessel
Expanding Brain Bleed
Brain Herniation Mass
Effect


Signs and Symptoms:
HTN, N/V, HA Px, fixed &
dilated pupil,
GCS score, Agitiation or
Combativness
Cushings Triad
SBP, HR, Irreg. Resps.

52
ALS Interventions:
Intubation & SpO
2
monitoring
ETCO
2
monitoring
Hyperventilation therapy
IV therapy
BLS to ALS Handoff - Hypoxia
Causes:
Vent or Circulatory failure
Airway Obstruction
Aspiration
Apnea with lung Injury
Signs & Symptoms
GCS score/ LOC
Confusion, delirium, agitation
Cyanosis
Tachycardia > 100 BPM
Tachypnea - rapid, shallow RR
Blue/ dusky mucus membranes
Abnormal pupils

53
ALS Interventions:
Intubation & SpO
2
monitoring
ETCO
2
monitoring
BLS to ALS Handoff - Hypotension
Causes:
Spinal cord injury
Blood loss

Signs & Symptoms
Tachycardia > 100 BPM
If spinal cord inj. Pt. may have HR
Tachypnea rapid shallow breathing
Hypotension < 90mm Hg
Narrowed pulse pressure
Abnormal Pupils
Change in mentation
Restlessness/ anxiety
Cyanosis
54
ALS Interventions:
Fluid Resuscitation
SpO
2
& ETCO
2
monitoring
Questions:
Topics:
1. Signs & Symptoms
2. Hypoxia & Hypotension
3. Hypoxia & Hypotension
4. Glasgow Coma Scale
5. Glasgow Coma Scale
6. Glasgow Coma Scale
7. Hyperventilation
8. Hyperventilation
9. Cerebral Herniation
10. Transport


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Questions: Signs & Symptoms
1. The following are signs and symptoms of ETOH and not
Traumatic Brain Injury

A) Slurred speech, vomiting, loss of coordination
B) Dialated pupils, convulsions, diminished conciouness
C) Lower extremity weakness, blurred vision, agitation
D) All of the above
E) None of the above












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Questions: Hypoxia & Hypotension

2. (True/False) Hypoxia and hypotension are recognizable
and preventable causes of secondary brain injury?


3. (T/F) Tachypnea, tachycardia, change in level of
conciousness, and cyanosis are all signs of shock, but not
hypoxia?


57
Questions: GCS
4. (True/False) The motor component of the GCS focuses
only on the upper extremities?


5. What is the GCS score for a patient whose eyes open to
pain, withdraws from painful stimuli, and makes
inappropriate sounds?

A) 3 + 4 + 3 = GCS of 10 (moderate TBI)
B) 3 + 3 + 3 = GCS of 9 (moderate TBI)
C) 2 + 4 + 2 = GCS of 8 (severe TBI)

58
Questions: GCS
6. To induce eye opening, prehospital providers may

A) Give patient a sternal rub
B) Give patient an axillary pinch
C) Use nail bed pressure
D) All of the above
E) B and C only


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Questions: Hyperventilation

7. (True/False) Prophylactic hyperventilation - (PaCO
2
<
35 mm Hg) should be initiated for every severe TBI
patient?


8. Patient presents with extensor posturing, fixed dilated
pupils, and SpO
2
at 90%, EMT should -
A) Intubate and hyperventilate
B) Intubate and normoventilate
C) Administer 25 Liters/min non-rebreather mask

60
Questions: Cerebral Herniation
9. All of the following are signs/symptoms of cerebral
herniation except:
A) Dilated pupils
B) Extensor posturing
C) Cyanosis of fingernails and lips
D) Cushings Triad
61
Questions: Transport
10. Patients with severe TBI should be transported to a
facility with immediately available:
A) CT scanning
B) Prompt neurosurgical care
C) The ability to monitor ICP
D) Two of the above
E) All of the above

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Answers:
1. E) None of the above. Patients with other illness/injury can have
signs and symptoms similar to those of TBI

2. True - After initial TBI, priorities are Identification of secondary
insults including hypoxia and hypotension
Perhaps the most important way a prehospital provider can impact
TBI outcome is the aggressive identification and treatment of hypoxia
and hypotension

3. False Shock and hypoxia can have similar signs and symptoms
including all those listed

4. True motor response was designed to look at the best upper
extremity response

5. (C) 2 + 4 + 2 = GCS of 8 (severe TBI)
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Answers:
6. E) B and C only. If eye opening does not occur to voice, use axillary
pinch or nail bed pressure

7. False - Hyperventilation is a temporary treatment used only in
patients showing signs of herniation until definitive diagnostic or
therapeutic interventions can be initiated

8. A) Intubate and hyperventilate

9. C) Cyanosis of fingernails and lips is a sign of hypoxia

10. E) All of the above


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