Pre-hospital Airway Management

? Effect of various
airway maneuvers in pre-
hospital care of
children after TBI
Hypoxemia leads to
poorer neurological
outcome
less success in pre-
hospital intubation
No change in outcome
from pre-hospital
intubation
Class 2
MANAGEMENTUL PACIENTULUI
CU TCC

CURS
 Pre-hospital Airway Management

Standard: Insufficient data to

support treatment
Guidelines: Avoid & correct
hypoxemia
Pre-hosp. BVM vs. ETI: No
advantage
Options: Pre-hospital
endotracheal intubation
ETI: Training in intubation &
EtCO2 monitoring
 BP, paO2, Pre-hosp. Brain-Specific Therapy

Presence of hypoxia had

no effect on mortality
(Class 3)
?Resistance to hypoxia
?Efficient pre-hosp care
 BP → Poorer Outcome
(Class 3)
BP → Better outcome
(Class 2)
BP, paO2, Pre-hosp. Brain-Specific Therapy

Pre-hosp. brain
specific Rx: (NMBA,
sedation, mannitol,
hyperventilation):
No scientific literature
Battle’s Sign: posterior fossa basal skull fracture
Tailor to patient’s
needs
Mannitol for brain
herniation without
hypovolemia
 BP, paO2, Pre-hosp. Brain-Specific Therapy

Standard: None
Guidelines: Identify & correct  BP
Options: GCS <8 - control airway
(pulse oximetry, EtCO2)
Correct: paO2, hypotension
Sedation, NMBA: Useful in
transport
Mannitol: Not recommended
Mild hyperventilation: Not
recommended
 ICP Monitoring in TBI

Standard: None
Guidelines: None
Options: ICP
monitoring is appropriate in
infants & children with
severe TBI & GCS<8
Class 3 recommendation
except for decompressive
craniotomy Class 2
 Threshold for Treatment of ICP

ICP > 20 mm Hg
ICP elevation > 20
should be
corroborated by
frequent clinical
exam, physiologic
variables eg. CPP,
cranial imaging
 Threshold for Treatment of ICP

Standard:
Insufficient data to
support
Guidelines:
Insufficient data to
support
Options: Treatment
for ICP elevation
> 20 mm Hg
Class 3
recommendation
 Temperature control in TBI
Standard: None
Guidelines: None
Options:
1. Extrapolation from
adult data: Avoid
Hyperthermia
(>38.50C)
2. Hypothermia (<350C)
may be considered
for refractory  ICP
(Class 3) Burst Suppression EEG Pattern
 Temperature control in TBI

Mechanism:
Reductions in:
Cerebral metabolism
Inflammation,
Lipid peroxidation,
Seizures,
Excitotoxicity
 Surgical Treatment of  ICP

Standard: None
Guidelines: None
Options: Consider
decompressive
craniectomy in TBI
(includes abuse TBI),
diffuse brain swelling,
refractory  ICP despite
adequate medical
therapy (Class 3)
Extradural hematoma
 Surgical Treatment of  ICP

Favorable group:
1. Secondary
deterioration of GCS
2. Evolving cerebral
herniation within the
first 48 hours after injury
Unfavorable
group:
Unimproved GCS 3

Monitors: ICP, Oxygen, &

temperature
 GCS<8

Insert ICP Monitor

Maintain CPP
(Age Appropriate)

NO ICP Consider CT
Carefully withdraw
ICP treatment Sedation & Analgesia
HOB@300

NO ICP
Drain CSF if Ventriculostomy
May continue if is present May continue if S. Osm<360
S. Osm<320
NO ICP
Neuromuscular Blockade

Mannitol PRN ICP HTS 3%

Second Tier
Mild Hyperventilation PaCO2 30-35 mm Hg ICP Therapy
 Second Tier Therapy

 ICP despite first tier Rx

Working Ventriculostomy Active EEG?

No contraindication to
Consider lumbar drain Barb

Consider high dose Barb

Salvageable patient

Consider decompressive
Evidence of Hyperemia ? craniectomy Evidence of Ischemia?
No Evidence of Ischemia No evidence of
contraindication
to Hypothermia?
Consider Hyperventilation
To PaCO2 < 30 mm Hg Consider moderate
Consider monitoring CBF, hypothermia
SjO2, AFDO2
 Background
 Traumatic brain injury
 Blunt
• MVC
• Falls
• Abuse
 Anatomy
 Brain cross section
 Potential spaces
 Anatomy
 Intracranial
compartments
 Dural structures
 Tentorium cerebelli
 Falx cerebri
 Anatomy
 Pediatric
 Larger head in
proportion to BSA
 Stability dependent on
ligamentous structures
 Higher water content
• 88% vs 77%
• Prone to acceleration-
deceleration injury
 Unmyelinated
 Open sutures
 Pathophysiology
 Primary injury
 Secondary injury
 Pathophysiology
 Primary injury
 Scalp injury
 Skull fracture
 Basilar skull fracture
 Concussion
 Contusion
 Hematoma
 Epidural
 Subdural
 Hemorrhage
 Intraventricular
 Subarachnoid
 Diffuse axonal injury
Pathophysiology
 Pathophysiology
 Secondary injury
 Intracranial events
 Inflammatory changes
• Microciruculatory
disruption
• Neuronal disintegration
 Pathophysiologic
events
• Cerebral edema
• Traumatic axonal injury
• Ischemia
 Monro-Kellie doctrine
 V (I/c) = V (brain) + V(CSF) + V (blood)
 Prehospital
 Initial stabilization
 Assessment
 Blood pressure
 GCS
 Pupils
 SaO2
 History
 Injury mechanism
 Loss of
consciousness
 Amnesia
 Intoxication
 Bleeding diathesis
Military Context
 Blast Wave Physics

Courtesy of Keith Prusaczyk, Ph.D.

 Exam
 ATLSprotocol
 Remember cervical spine
 Remember tetanus
Exam
 Exam
 HEENT/face
 Soft tissue injury
 Basilar skull injury
 Pupil exam
 Facial injury
• Lefort
 Dental exam
 Exam
 Neck
 Cervical spine
stabilization
 Palpation
 NEXUS, CCR
 Classification
 Closed head injury
 Mild
 Moderate
 Severe
 Mild TBI
 Most common
 LOC <20 minutes (30 minutes)
 Brief retrograde amnesia (24 hours)
 GCS 13-15
 Change in mental status
 No focal neurological deficit
 No intracranial complications
 Normal CT findings
 ACEP definition
 Blunt head trauma within 24 hours
 Post traumatic LOC or amnesia
 GCS 15 on presentation
 Age >15
 Mild TBI
 Low risk for
intracranial injury
 No LOC
 No amnesia
 Not predictive
• Headache
• Dizziness
• Scalp hematoma
• Laceration, abrasion
 Mild TBI
 Moderate/high risk
 Progressive/severe HA
 Age <2 yo
 Post traumatic seizure
 Focal neuro deficit
 Skull fracture
 Multi trauma
 Blood dyscrasia
 Mild TBI
 Infants <2…
 Difficult to assess
 Absence of symptoms
 Low threshold for
scan
 Consider abuse
 Moderate/Severe TBI
 GCS 8-12
 GCS <8
 Treatment
 Airway management
 RSI
 Medications
 Ventilator management
 Eucapnia
 Prevent hypoxia
 Post intubation care
 Sedation
 Paralysis
 Analgesia
 Treatment
 Cardiovascular
management
 Euvolemia
 MAP > 90
• Pressors
 CPP 70-80 mm Hg
 CPP = MAP - ICP
 Treatment
 ICP management
 Elevate head of bed
 Sedation/paralysis
 Diuresis
• Osmotic
• Loop
 Hyperventilation
 Barbiturate
 Treatment
 Hyperosmolar therapy
 Mannitol
 320 mOsm
 Hypertonic saline
 360 mOsm
 Treatment
 Barbiturates
 Pentobarbital
 Thiopental
 Goals
 ICP <20 mm Hg
 Burst suppression on
EEG monitor
 Treatment
 Intracranial pressure
monitoring
 Intraparenchymal
 Intraventricular
• Direct CSF drainage
 Epidural