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TraumaticBrainInjuryModule forDSHS

GilesGifford,EMT MonicaS.Vavilala,MD

BLSprovidercourse

TBIEpidemiology:Nationally
Yearly1.7millionpeoplesustainTraumaticBrain Injury,(TBI) ~1.36millionaretreatedinEDanddischarged. 275,000arehospitalized 80,000to90,000aredisabled 52,000die Today,5.3millionAmericans(~2%)arelivingwithTBI relateddisabilityand~1%ofpeoplewithsevereTBIsurvive inapersistentvegetativestate In2000,theestimatedlifetimedirectmedicalcostsand indirectcosts(suchaslossoflifelongproductivity)fromTBI amountedto60billiondollars

TBIEpidemiology:WAState
Population; 6,664,195 - Jul 2009 Source: U.S. Census Bureau

TBI~10%ofallinjuryrelatedhospitalizations TBIdeathsareabout29%ofallinjuryrelatedfatalities Nearly123,750residentswithTBIrelateddisabilities ~26,000residentshadTBI(20052009) ~5,500hospitalizationsand1,300deaths/year(20022006)

YouwillseeTBIpatientsinyourcareer

WAEpidemiology:TBICauses

From20032007,falls,beingstruckbyanobject,andmotorvehiclerelatedTBIinjuries madeabout90%ofallTBIrelatedhospitalizationsandfalls,firearmsandmotorvehicle relatedinjuriesmadeabout91%ofTBIdeaths.

WAEpidemiology:TBIHospitalizationsbyCause

TBIHospitalizationsduetotransportinjuriesofvarioustypesfellintheearlyyears, andthenplateaued.Fallsincreasedsincethelate1990s,explainingtheoverallrise inTBIHospitalizations.TBIhospitalizationsbyfirearminjury remainslowdueto thelowsurvivalratefromtheinitialinjury.

WAEpidemiology:ElderlyFallRelatedTBI
TBIrelatedhospitalizationsanddeathswillsteadily increaseoverthenextfewdecadesasthebabyboom generation(thosebornfrom1946to1964)steadilyages 1 in3 adultsage65+fallseachyear 1 in2 adultsage80+fallseachyear 1 outof5 fallscausesaseriousinjurysuchasahead trauma(TBI)orfracture Only1in 5 peoplewhoarehospitalizedforfallsever returnhome

WAEpidemiology:TBIHospitalizationsbyAge

WhoisatRisk? Elderly Age1524years Malegender

TraumaticBrainInjury(TBI)
Injuriestothebraincausedbyphysicaltraumatothehead. Canbepenetratingorbluntforceinjury Twoformsofinjury Primary Directtraumatobrainandvascularstructures Examples:contusions,hemorrhages,andotherdirect mechanicalinjurytobraincontents(brain,CSF,blood). Secondary Ongoingpathophysiologicprocessescontinuetoinjure brainforweeksafterTBI PrimaryfocusinTBImanagementistoidentifyand limitorstopsecondaryinjurymechanisms

SecondaryInjury
AfterinitialTBI,prioritiesare: Identificationofsecondaryinsults Intracranialhypertension fromexpandingintracranial hematoma/brainswellingresultsinelevated intracranialpressure(ICP)and/orherniation Hypoxia fromventillatory/circulatoryfailure,airway obstruction,apnea,lunginjury,aspiration Hypotension associatedspinalcordinjury,bloodloss Inadequatecerebralbloodflowcancauseinadequate oxygenandglucosedelivery Hypercarbia frominadequateventilation,apnea Rapidtransporttoacapablehealthcarefacility

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SignsandSymptoms
Signs
diminishedconsciousness convulsionsorseizures dilationofoneorbothpupils slurredspeech repeatedvomitingornausea increasingconfusion, restlessness,oragitation

Symptoms
headache blurredvision ringingintheear badtasteinthemouth weaknessornumbnessin extremities lossofcoordination dizziness/lightheadedness

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SceneAwareness
Includethefollowinginthepatientcarereport: Kinematicsleadinguptotheinjury MVC speed,restraints,intrusion,helmet Assault headvs.object,repeatassault? Sportsrelated bodyposition,speedatimpact WitnessaccountofPatientBehaviorafterInjury LOC,slurredspeech,inappropriatebehavior,duration

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Documentation
Completedocumentationcouldhaveapositiveimpact throughoutaTBIpatientslife DiagnosisandTreatmentaftertheinjurymaydependon thoroughnessofPCR Includeeventsoccurringpreandpostinjuryandbefore EMSarrival Ensureasuccessfulhandoffoftherunsheettothepatient careprovidersintheED. AfterobtainingsignatureensureacopyofthePCRis includedinthepatientchart

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Documentation
Specificitemstodocumentinclude: MechanismofInjury/LOC? Primarysymptoms/associatedsymptoms Serialvitalsigns HR,BP,RR ComponentGCSandPupils Procedurespreformed Transportationdecisions

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Assessment:Overview

Airway:
Priorities

Breathing:
Oxygenation Hypoxemia

Circulation:
Hypotension Shock Glasgow Coma Scale (GCS): Priorities Patient Interaction Components Motor Component Score Pupils: Value Pathophysiology Abnormalities Cerebral Herniation:

Indicators

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Airway:Priorities
Determinethatairwayisopenandmaintainpatency Assessneedforartificialairway ForBLSproviders,isaMedicevaluationneeded? Reassessevery5minutesandasneeded Maintaincervicalspineprecautions Usecervicalcollarduringtransport

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Breathing:Oxygenation
Assessrate,rhythm,depth,quality,andeffectivenessof ventilation(movementofairinandoutofthelungs)every5 minutesandasneeded IfpossibleusecontinuousSpO2 monitoring Avoidinadvertenthyperventilation IfnoSpO2 monitoringlookforapneaandslow/irregular breathingtoindicateadequatetissueoxygenationandcarbon dioxideremovallevels

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Breathing:Hypoxemia
Assessandmonitorforhypoxemia(SpO2<90%) Occursin40%ofTBIcases Ifpulseoximetrynotavailable,observepatientforindirect signsofhypoxia PotentialSignsandSymptomsofHypoxia: Blueorduskymucusmembranes Impairedjudgment Confusion,delirium,agitation Decreasedlevelofconsciousness Tachycardiaheartrate>100beatsperminuteforadult Cyanosisoffingernailsandlips Tachypnea Atorabove20breathsperminuteforadult

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Circulation:Hypotension
Monitorforhypotension inadequatecerebralbloodflowcan causeinadequateoxygenandglucosedelivery
Adulthypotension,systolicbloodpressure(SBP)<90mmHg

Monitorforhypertension mayindicateraisedICPwhen associatedwithbradycardiaandirregularrespiration Usecorrectcuffsizetomeasuresystolicanddiastolicblood pressure Cufftoosmall(falsehighornormal),toolarge(falselow) AssessSBPevery5minutes Continuousmonitoringifpossible

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Circulation:Shock
Itisveryimportanttorecognizethesignsandsymptomsof shockanditissomethingthateveryEMSprovidercando SignsandSymptomsofShock:
Skincyanosis,pallor Restlessness,anxiety,changeinlevelofconsciousness Tachycardia rapidheartrate,greaterthan100beatsperminuet Tachypnea rapid,shallowrespiratoryrate Narrowedpulsepressure reductionintherangebetweenthe systolicanddiastolicbloodpressure Coolextremities Hypotension SBP<90mmHg

Ifspinalshockisassociatedpatientmaybehypotensive withbradycardia

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GlasgowComaScale(GCS):Priorities
GCSpreferredmethodtodeterminelevelofconsciousness AVPU(Alert,Verbal,Pain,Unresponsive)istoosimpleto determineLOC&notquantifiable FollowABCsbeforemeasuringGCS Ifpossible,assessGCSpriortointubation MeasureGCSbeforeadministeringsedativeorparalytic agents,orafterthesedrugshavebeenmetabolized ReassessandrecordGCSevery5minutes

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GCS:PatientInteraction
GCSobtainedbydirectpatientinteraction Prehospitalprovidermustaskdirectquestionsand performspecificactionsforaccurateGCSscore Donotsimplysaysqueezemyhands (reflexive) Insteadsayshowmetwofingers TheEMTneedstoillicitaresponsethatdemonstrates cognition,ortheabilityofthepatienttothink Ifeyeopeningdoesnotoccurtovoice,useaxillarypinch orfingernailbedpressure

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GCS: Components
GCSshouldbemeasuredbyprehospitalproviderswho areappropriatelytrained

GCS 14-15: Mild TBI

GCS 9-13: Moderate TBI

GCS 3-8: Severe TBI

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GCS:MotorComponent
ImportantpartofGCS Motorresponsewasdesignedtolooka thebestupperextremityresponse Spinalcordinjury,chemicalparalysis orexcessivepainmakesmotor assessmentimpossible Abnormalposturing(decerebration& decortication)looksimilarinthelower extremities Motor Response
6- Obeys 5- Localizes-(purposeful movements towards painful stimuli) 4-Withdraws from pain 3 Abnormal flexion - Image A 2-Abnormal extension - Image B 1-No response

A: Abnormal flexion (decorticate rigidity)

B: Extension posturing (decerebrate rigidity)

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GCS:Value
GCSprovidesbasisfordeterminingthemethodof transportandthepreferredreceivingfacility Comparetopreviousscorestoidentifytrendovertime Asinglefieldmeasurementcannotpredictoutcome RepeatedGCSscorescanbevaluabletoEDstaff Deteriorationof> 2pointsisabadsign GCS<9indicatesapatientwithasevereTBIand requiretrachealintubation

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Pupils:Value
Pupillarysizeandtheirreactiontolightshouldbeusedin thefieldasitcanbehelpfulindiagnosis,treatmentand prognosis Afixedanddilatedpupilisawarningsignandcan indicateandimpendingcerebralherniation Pupillarysizeshouldbemeasuredafterthepatienthas beenstabilized

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Pupils:Pathophysiology
Whydopupilsdilate?
Thepresenceofintracranialhematoma cancausedownwarddisplacementof thebrain,untilitputspressureonthecranialnerveresponsibleforpupil dilation

Othercausesofabnormalpupils:
Hypoxia Hypotension Druguse(opiates) Hypothermia ToxicExposure Artificialeye Orbitaltrauma Congenitalabnormality Pharmacologicaltreatment,CataractSurgery (e.g.Atropine)

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Pupils:Abnormalities
Unequalordilatedandunreactive suspectbrainherniation Unilateralorbilateralpupils
(asymmetricpupilsdiffer>1mm)

Dilatedpupils
(dilationmorethanorequalto4mm)

Fixedpupils
(fixedpupillessthan1mmchangein responsetobrightlight)

Evidenceoforbitaltraumashouldberecorded

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CerebralHerniation:Indicators
Unresponsivepatient(noeyeopeningorverbalresponse) Unilaterallyorbilaterallydilatedorasymmetricpupils Abnormalextension(decerebrateposturing) Nomotorresponsetopainfulstimuli Deterioratingneurologicexamination,bradycardia(heart rate<60bpm),andhypertensionshouldbeviewedasa partofCushingsresponseandimpliesimpending herniation CushingsTriad(Reflex)isaLATEsignofherniation: ElevatedsystolicBP Bradycardia Irregularrespirations

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AdditionalConsiderations
Patients with other illness/injury can have signs and symptoms similar to those of TBI ETOH / drug abuse Sports related injury / concussion Violence / domestic violence Has your partner hit or grabbed you are two questions EMT can ask to identify a possibly abusive situation Decreased mental status in the elderly

These patients can also have a TBI!

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Treatment:Overview
Airway:
Priorities

Ventilation:
Priorities Hyperventilation

FluidResuscitation:
Priorities

CerebralHerniation:
SignsandSymptoms Hyperventilation AdditionalConsiderations

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Airway:Priorities
ALS/Mediceval? Protectcervicalspinealignmentwithmanualinline stabilization,bewarefacialtrauma WhenairwaycannotbesecuredbyEndotrachealtube; consideralternateairwaydevices
Accordingtocountyprotocol

Providecombitubeorsupraglotticairwayifnotcertifiedto provideadvancedairwayadjuncts
Accordingtocountyprotocol

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Ventilation:Priorities
Assessrate,rhythm,depth,andqualitytodeterminethe effectivenessofrespirations AssistventilationsasnecessarywithBagValveMaskand supplementalO2 ALS/Mediceval? Adult normalventilationrates:1012breathsperminute

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Ventilation:Hyperventilation
Producesarapiddecreaseinarterial partialpressureofcarbondioxideandcauses cerebralvasoconstriction Decreasedcerebralbloodflow decreasedintracranialpressure(ICP) Hyperventilationisatemporarytreatmentusedonlyin patientsshowingsignsofherniationuntildefinitive diagnosticortherapeuticinterventionscanbeinitiated Hyperventilationratesage>9years:20BPM

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FluidResuscitation:Priorities
ALS/Mediceval? Avoidhypotensionandinadequatevolumeresuscitation tomaintainnormotensionandadequatetissueperfusion Hypotension(SBP<90mmHg)doublesmortality

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CerebralHerniation:Hyperventilation
Innormoventilated,normotensive,andwelloxygenated patientsstillshowingsignsofcerebralherniation, hyperventilationshouldbeusedasatemporizingmeasure andshouldbediscontinuedwhenclinicalsignsof herniationresolve

Rate 20BPMforadults(Every3seconds)

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CerebralHerniation:Signs&Symptoms
SignsSymptoms
Dilatedorunreactivepupils Asymmetricpupils Amotorexamthatidentifieseither extensorposturingornoresponse Progressiveneurologicdeterioration, decreaseinGCSscoremorethan2 pointsfrompatientspriorbestscore in patientswithinitialGCS<9

OtherfactorsincreasingICP
Fearandanxiety Pain Vomiting Straining Environmentalstimuli Endotrachealintubation Airwaysuctioning

Frequently re-evaluate patient neurologic status

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CerebralHerniation:AdditionalConsiderations
Ruleoutdecreasedlevelofconsciousnessdueto hypoglycemia Hypoglycemia bloodsugarbelow70mg/dL Performrapidbloodglucosedetermination Ifnecessary,giveIVglucose Followlocalprotocol

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Transportdecisions: Priorities Priorities Receivingfacilities

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TransportDecisions:Priorities
Minimizeprehospitaltimebyselectingappropriatemode oftransportation,rendezvouswithairmedicalserviceto decreaseenroutetimes Patientmayrequireemergentsurgeryforhematoma evacuation,earlytransportmustbetheprioritywhile resuscitationisongoing Ifnecessary,rendezvouswithairmedicalserviceto decreaseenroutetimes

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TransportDecisions:Priorities
Allregionsshouldhaveanorganizedtraumacaresystem ProtocolsarerecommendedtodirectEMSregarding destinationdecisionsforpatientswithsevereTBI Improvedsuccessattributedtointegrationofprehospital andhospitalcareandaccesstoexpedioussurgery

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TransportDecisions:Receivingfacilities
TransporttoappropriatereceivingfacilitybasedonGCS GCS14 15:HospitalEmergencyRoom GCS9 13:TraumaCenter GCS<9:TraumaCenterwithsevereTBIcapabilities PatientswithsevereTBIshouldbetransportedtoafacility withimmediatelyavailable: CTscanning Promptneurosurgicalcare TheabilitytomonitorICP Theabilitytotreatintracranialhypertension

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References
[authorlastname,firstname],2007.GuidelinesforPrehospitalManagementof SevereTraumaticBrainInjury,secondedition,BrainTraumaFoundation,. NationalAssociationofEmergencyMedicalTechnicians(NAEMT),2011. PHTLS:PrehospitalTraumaLifeSupport,7thed.,ElsevierHealthSciences, Chap9. Shorter,Zeynep,2009.TraumaticBrainInjury:Prevalence,ExternalCauses, andAssociatedRiskFactors,WashingtonStateDepartmentofHealth, http://www.doh.wa.gov/hsqa/ocrh/har/TBIfact.pdf (April1,2011) U.S.CentersforDiseaseControlandPrevention,2011.InjuryPrevention& Control:TraumaticBrainInjury,http://www.cdc.gov/traumaticbraininjury/ (May1,2011)

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Acknowledgements
MikeLopez,EMS/TraumaSupervisor;WashingtonStateDept.of Health MikeRoutley,EMSSpecialist/Liaison,WashingtonStateDept.of Health DeborahCrawley,ExecutiveDirectorandstaff, BrainInjuryAssociationofWashington WashingtonStateEMTsparticipatinginfocusgroupsandphone interviews. Peerreview:AndreasGrabinsky,MD,ArmaganDagal,MD,Deepak Sharma,MD,EricSmithEMTP,DaveSkolnickEMTB,RichardVisser EMTB