An advanced life support emergency services unit brought a 35-year-old man into the emergency department (ED) backboarded and collared. The patient was an unrestrained driver who was ejected from his car when it ran off the road and hit a tree. When a paramedic team arrived 10 minutes after the crash, the patient had a blood pressure (BP) of 90/50 mm Hg, heart rate (HR) 100 beats per minute (bpm), respiratory rate (RR) 20 breaths per minute, and oxygen saturation (SpO2) 96% on room air. His Glasgow Coma Scale (GCS) score was 7 (opened eyes to pain 2, moaned 2, abnormal flexion 3). Pupils were equal and reactive, and his mouth was clenched closed. The patient was given oxygen via a nonrebreathing face mask. Although the patient exhibited periods of extreme agitation with combative behavior during transport, intravenous (IV) access was obtained and an infusion of Lactated Ringers was begun.
After ensuring scene safety, the immediate management of the patient with traumatic brain injury (TBI) in a field setting should focus on stabilizing and maintaining oxygenation and blood pressure. All head-injured patients have potential cervical injury and should be immobilized. A fundamental premise in prehospital care is to anticipate and prepare for eventualities such as vomiting, seizures, and aberrations of blood pressure or oxygenation.
15.2.1 Should Tracheal Intubation Be Performed in the Field for This Patient?
In this patient, ensuring oxygenation via a patent airway is of paramount importance. Indications for a field intubation include inadequate ventilation or oxygenation despite supplemental oxygen administration or the inability of the patient to protect the airway. A relative indication for intubation is the risk of losing the airway during transport. Transport time and type of transport, that is, ground versus aeromedical, must be taken into consideration. Studies of the outcome of prehospital intubations have yielded conflicting results1,2,3-5 and, as discussed in Chapter 14, prehospital airway management protocols are currently being further investigated. In the case presented, the patient was maintaining oxygenation and ventilation. His clinical course could not be certain, and it was reasonable for the field team to consider tracheal intubation. However, the patient had clenched teeth and was predicted to pose a difficult laryngoscopic intubation based on his short neck and cervical spine immobilization. A decision to intubate would involve the use of a rapid-sequence intubation (RSI) protocol; considering the short transport time, RSI was not indicated.
15.2.2 What Additional Considerations Are Imposed by Field Conditions?
Several other priorities in clinical care must be addressed by the field team after initial patient stabilization.
Hypotension is a critical factor associated with an increased morbidity and mortality in patients with head injuries.6,7 Blood pressure in the field should be monitored closely with the goal of avoiding hypotension (systolic BP <90 mm Hg in adults); if present, it should be corrected immediately. This patient presented with a field BP of 90/60 mm Hg. As hypotension is strongly associated with poor outcomes in TBI patients, fluid resuscitation becomes a priority. However, the field team must weigh the benefit of delaying transport from the field to secure an IV with the risk of delayed transport to a trauma center. Ideally, IV access should be attempted as the patient is expeditiously transported to the trauma center. It should be emphasized that isolated brain injury rarely accounts for hypotension in trauma patients with multisystem injury;8 rather, if present, ...