Managing Traumatic Brain Injury: Translating Military Guidelines to the Wilderness

Otten, Edward J.; Dorlac, Warren C.

doi:10.1016/j.wem.2017.02.008

Cited by 7 publications

(5 citation statements)

References 44 publications

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“…In well-equipped medical treatment facilities, cerebral edema and intracranial hypertension may be treated with hyperosmolar therapies, including mannitol and hypertonic saline (35)(36)(37)(38). However, mannitol is poorly suited for far-forward combat casualty care due to its tendency to precipitate and difficulty with reconstitution (39). Hypertonic saline is a more promising alternative in these environments and merits additional exploration as a potential complimentary therapy to WB resuscitation.…”

Section: Discussionmentioning

confidence: 99%

Prehospital Whole Blood Resuscitation Reduces Fluid Requirement While Maintaining Critical Physiology in a Model of Penetrating Traumatic Brain Injury and Hemorrhage: Implications on Resource-Limited Combat Casualty Care

Bailey

Leung

Yang

et al. 2020

Shock

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Prehospital resuscitation using whole blood (WB) is the standard of care for hemorrhagic shock (HS) but there is no consensus recommendation for resuscitation in the presence of traumatic brain injury (TBI) due to a lack of sufficient evidence. In order to evaluate the optimal resuscitation strategies for TBIþHS, Sprague-Dawley rats were randomized into four groups based on resuscitation fluid and prehospital mean arterial pressure (MAP) threshold (n ¼ 9-10/group): Lactated Ringer's (LR)-60 mm Hg (LR60), LR-70 mm Hg (LR70), WB-60 mm Hg (WB60), WB-70 mm Hg (WB70). All groups received a frontal penetrating ballistic-like brain injury followed by a 35-min period of HS. During the prehospital phase, rats received an initial bolus of resuscitation fluid (WB or LR) followed by LR as needed to maintain MAP above the designated threshold for 90 min. During the in-hospital phase, rats received definitive resuscitation with shed WB. Physiological parameters were recorded continuously and cerebral edema was measured at 3 and 24 h postinjury. The WB60 group demonstrated a significantly lower prehospital fluid requirement compared WB70, LR60, and LR70 (P < 0.05). Compared to the respective LR groups, both the WB60 and WB70 groups also demonstrated improved MAP, cerebral perfusion pressure, brain tissue oxygen tension, and cerebral edema. The edema benefits were observed at 3 h, but not 24 h postinjury, and were localized to the injury site. Together, these results provide evidence that prehospital WB resuscitation and lower MAP resuscitation thresholds can reduce the prehospital fluid requirement while still maintaining critical cerebral physiology in a model of HS and concomitant TBI.

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Section: Discussionmentioning

confidence: 99%

Prehospital Whole Blood Resuscitation Reduces Fluid Requirement While Maintaining Critical Physiology in a Model of Penetrating Traumatic Brain Injury and Hemorrhage: Implications on Resource-Limited Combat Casualty Care

Bailey

Leung

Yang

et al. 2020

Shock

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“…Generally, teams should evacuate all patients with head injury for assessment in a definitive care setting capable of neuro-imaging, with particular attention paid to moderate to severe traumatic brain injury (TBI) (i.e., GCS ≤12, and loss of consciousness ≥30 minutes to >24 hours). 88 Patients with mild TBI should receive ongoing serial monitoring to help identify those requiring more expedient medical evacuation. Physical examination in the austere setting (e.g., pupillary changes, level of consciousness) may identify signs of increased intracranial pressure, and POCUS optic nerve sheath diameter may recognize this process as well.…”

Section: Head Injurymentioning

confidence: 99%

Critical Care Anywhere: Principles for High-Functioning Management in Low-Resource Environments

Stankiewicz

Ward

McCurdy

2021

MRAJ

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Critically ill patients can present at any time and location, and they demand high quality care. Historical experiences from military, wilderness, and disaster medicine settings have helped shape the modern concept of caring for the most severely ill with limited available resources. We introduce a method to help design a successful critical care medical support endeavor, which includes properly defining components of Navigation, Environment, Resupply, Energy, Unconventional problems, and Support (NEREUS). Additionally, we provide recommendations for optimal team personnel composition, including utilization of paramedics, critical care providers, nurses, and respiratory therapists across the spectrum of care provided at point of injury, en route to definitive care, and definitive care. A review of critical care principles relevant to the austere setting proceeds with a systematic organization according to airway, breathing, circulation, and neurologic management. Lastly, we employ our proposed method of organizing a critical care medical support endeavor to a post-hurricane scenario. In summary, this review provides the historical background, modern definition, and practical framework for successfully administering critical care in scenarios with limited available resources. We emphasize the need to appropriately adapt critical care concepts to meet the unique demands of a specific scenario.

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“…In the guidelines published by Bratton et al, the treatment guidelines for brain injury patients were revised in 2017, but there were no changes in this topic [55]. The military trauma guidelines published in 2017 also recommend that hypoventilation and hyperventilation should be avoided in patients with brain injury [56].…”

Section: Evidence Summarymentioning

confidence: 99%

Part 3. Clinical Practice Guideline for Airway Management and Emergency Thoracotomy for Trauma Patients from the Korean Society of Traumatology

et al. 2020

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The following key questions and recommendations are presented herein: when is airway intubation initiated in severe trauma? Airway intubation must be initiated in severe trauma patients with a GCS of 8 or lower (1B). Should rapid sequence intubation (RSI) be performed in trauma patients? RSI should be performed in trauma patients to secure the airway unless it is determined that securing the airway will be problematic (1B). What should be used as an induction drug for airway intubation? Ketamine or etomidate can be used as a sedative induction drug when RSI is being performed in a trauma patient (2B). If cervical spine damage is suspected, how is cervical protection achieved during airway intubation? When intubating a patient with a cervical spine injury, the extraction collar can be temporarily removed while the neck is fixed and protected manually (1C). What alternative method should be used if securing the airway fails more than three times? If three or more attempts to intubate the airway fail, other methods should be considered to secure the airway (1B). Should trauma patients maintain normal ventilation after intubation? It is recommended that trauma patients who have undergone airway intubation maintain normal ventilation rather than hyperventilation or hypoventilation (1C). When should resuscitative thoracotomy be considered for trauma patients? Resuscitative thoracotomy is recommended for trauma patients with penetrating injuries undergoing cardiac arrest or shock in the emergency room (1B).

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Managing Traumatic Brain Injury: Translating Military Guidelines to the Wilderness

Cited by 7 publications

References 44 publications

Prehospital Whole Blood Resuscitation Reduces Fluid Requirement While Maintaining Critical Physiology in a Model of Penetrating Traumatic Brain Injury and Hemorrhage: Implications on Resource-Limited Combat Casualty Care

Prehospital Whole Blood Resuscitation Reduces Fluid Requirement While Maintaining Critical Physiology in a Model of Penetrating Traumatic Brain Injury and Hemorrhage: Implications on Resource-Limited Combat Casualty Care

Critical Care Anywhere: Principles for High-Functioning Management in Low-Resource Environments

Part 3. Clinical Practice Guideline for Airway Management and Emergency Thoracotomy for Trauma Patients from the Korean Society of Traumatology

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