An Advanced Life-Support Emergency Services unit brought a 35-year-old male 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) 95% 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 tightly clenched. The patient was given oxygen via nasal prongs and a non-rebreathing face mask. Although the patient exhibited episodic agitation with combative behavior during transport, intravenous (IV) access was obtained and an infusion of Lactated Ringer's 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 patients with head injuries have potential cervical injury and should be assessed for the need to be immobilized. A fundamental premise in pre-hospital care is to anticipate and prepare for eventualities such as vomiting, seizures, and aberrations of blood pressure or oxygenation.
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 tracheal 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, for example, ground versus aeromedical, must be considered. Studies of the outcome of pre-hospital airway management have yielded conflicting results leaving little consistent evidence indicating a benefit to field tracheal intubation in most patients with head injury who are oxygenated and ventilating1-7; as discussed in Chapter 16, pre-hospital 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 also pose difficult direct laryngoscopic intubation based on his short neck and cervical spine (C-spine) immobilization. A decision to intubate would involve the use of a rapid sequence intubation (RSI) protocol; considering the short transport time, field RSI was not indicated.
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.