An Advanced Life-Support Emergency Services unit brought a 35-year-old male into the emergency department on a backboard with a cervical collar in place. The patient was the driver of an all-terrain vehicle that rolled off the road and ejected him into a ditch. When a paramedic team arrived at the scene, the patient had a blood pressure of 90/50 mmHg, a heart rate of 120 bpm, a respiratory rate of 24 breaths per minute, and an oxygen saturation of 95% without supplemental oxygen. His Glasgow Coma Scale score was 7 (opened eyes to pain-2, moaned-2, abnormal flexion-3). The patient was given oxygen via nasal prongs and a non-rebreathing face mask, intravenous access was obtained, and an infusion of crystalloid was begun.
The immediate management of the patient with traumatic brain injury (TBI) in a field setting should focus on stabilizing his condition while maintaining oxygenation and blood pressure. All patients with TBI have the potential for a cervical injury and should be immobilized at the scene and on transport to hospital.
Should Field Tracheal Intubation Be Performed in This Patient?
In this patient, ensuring oxygenation via a patent airway is of paramount importance, as hypoxia has a profound influence on neurological outcome. 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 and transport time must be considered. Studies of the outcome of prehospital airway management have yielded conflicting results, leaving little consistent evidence supporting field tracheal intubation in most patients with head injury who are oxygenated and ventilating at the time of transport.1–6 The success rate of field intubation is correlated with the experience of the providers, and patient mortality may be increased when providers of limited experience perform prehospital intubation.6–8 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 laryngoscopy (DL) intubation based on his short neck and cervical spine (C-spine) immobilization. A short transport time was anticipated, so field rapid sequence intubation (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.
Hypotension is a critical factor associated with an increased morbidity and mortality in patients with TBI.9–11 Blood pressure in the field should be monitored closely to avoid or correct hypotension. This patient presented with tachycardia and a field BP of 90/60 mmHg. With the ...