Handtevy Minute: Severe Traumatic Brain Injury (TBI)

[@NoFutureZine]

I found this helpful. It helped me make connections between concepts I understood, but had not correlated. Thanks Dr. Handtevy and the Handtevy team.

[@TheHandtevy]

Thank you for the comment!🙏

[@MrAjc236]

Great information!

[@TheHandtevy]

Thanks for watching!

[@justinarnone2112]

Thank you for sharing this information. This challenges our thoughts on current clinical practices. The answer to the question that the brain takes priority over permissive hypotension for internal bleeding makes sense. I've always wondered how a BP of 100-110 (as recommended in PHTLS/TCCC for multisystem trauma w/ a head injury) is adequate in the presence of increased ICP. The math (MAP-ICP=CPP) shows CPP is not enough or too close to the threshold of keeping the brain perfused when your goal is a systolic of only 100-110 in the presence of increased ICP. I always felt like raising the BP more would be necessary, but did understand that internal bleeding could worsen. I never knew which was "more important". This clarity helps to answer that question of what's more important. I'm thankful for that. I've heard that the recommendation of not hyperventilating, as mentioned in the video, means that we shouldn't hyperventilate just because someone has a head injury, but you should hyperventilate if s/s progress suggesting impending herniation. I would like clarification on this just to be 100% certain I understand correctly. Which of the following statements is true/recommended? There has been so much back and forth on this in both the military and civilian settings that I am seeking evidence-based clarity. Hyperventilation should NEVER be performed. Even in the presence of s/s consistent with impending cerebral herniation (Cushing's Triad, Seizing, Posturing, Dilated pupil, etc.) or Hyperventilation should not be performed on patient's with a head injury UNLESS that have s/s consistent with impending cerebral herniation. Thank you for your time and your leadership.

[@TheHandtevy]

Justin, great comments and thank you for taking the time to watch the video. Regarding the question of hyperventilation, the EPIC-TBI authors put out education that says "Never Hyperventilate." Why? They state that most patients who fall into the "severe TBI" category are not herniating. They go on to say It is RARE in the prehospital environment. We know it has a very bad prognosis no matter what you or the Neurosurgeon does. Their bottom line: Most severeTBI patients are not herniating and therefore we should treat the most likely...not the rare. You can find their PPT slides here: arizona.app.box.com/s/rbonok7kt121gjqh5k5t3roa8vhq2v9g The EPIC-TBI main site is here: epic.arizona.edu/training Lots of great information on their website. Let me know your thoughts. Thanks Peter

[@justinarnone2112]

@@TheHandtevy Thank you for the quick reply. This is a good perspective on this. I will be using this when I teach from here on out. Thanks for the references as well.

[@dustylynn5113]

great info! I am a new HT instructor and am happy to share such great knowledge and expertise. My back ground is PICU, CVICU Peds Trauma etc. We always taught that if a pediatric pt could tolerate an OPA, they should be ventilated (BVM, SGA or intubation) this pt is not a peds patient, but could you elaborate on that topic bit? If this is a prehospital peds pt and they take an OPA, is it ok to just put a NRB on them and watch ETCO2? What if an agency didnt monitor ETCO2 (gasp! I know, right??) but it happens..... thoughts please...

[@85cmallen]

I tried to get our organization in Utah to adopt these treatments. I was shut down by our medical director and the protocol committee board. One of the medical directors stated this was a poor study cause they measured so many things at once. I disagreed but lost. my proposed change was denied. Lost and confused paramedic rolling the stone wheel in Utah.

[@TheHandtevy]

These recommendations are basic at their core. Avoid the 3-H Bombs. I’m sorry they didn’t listen but don’t stop trying. We just had an incredible save 2 weeks ago because of these recommendations. Thanks for caring! PA

[@danielsalerno1571]

excellent video. will the 15 lpm NRB O2 to prevent the episode of hypoxia cause too much cerebral vasoconstriction?

[@TheHandtevy]

Daniel, great question. In general I’m against using 100% FiO2 in patients who have normal O2 sats, or even any oxygen for that matter. However because of the significant negative impact of even one episode of hypoxia, the benefits of O2 administration far outweigh the risks.

[@oxfd611]

Why are we using 0.9% Sodium chloride in place of lactated ringers? With Sodium chloride having a lower pH then ringers won’t that promote more coagulopathy and Metabolic acidosis, Hypothermia? Won’t this be a contributing factor to worsening outcomes? The newly updated Navy fire emergency services protocol has Replaced ringers with Sodium chloride. Oh and I was going to ask Our medical control Director the same question. Why use sodium chloride when it has a lower pH and patients that are in shock do poorly as we create a greater metabolic acidosis?

[@TheHandtevy]

Michael - great question and I just had this conversation yesterday. It turns out that with TBI LR may be detrimental.. www.ncbi.nlm.nih.gov/pmc/articles/PMC4892214/

[@adamperricone8035]

Great video, thank you. I was thinking intubation in order to protect the airway in the pt who is unresponsive, with no gag reflex. Can you help me understand why that is not indicated?

[@TheHandtevy]

Gag reflex has been debunked as an indication for, or against, the need to intubate. The consensus is that if a patient is oxygenating and ventilating sufficiently with a RR of at least 10 bpm then there is no indication to intubate immediately in the field. However, if intubation is indicated, extreme care should be taken to avoid the 3 H-bombs.

[@michellekline7512]

Great informative video. Recently had a 3 year old with TBI, I know in the video you spoke of a systolic of greater than 130 When were talking about PEDS, what's a good MAP

[@TheHandtevy]

For TBI in kids I would not use an SBP of 130. To make it an age based value I'd use 80 + 2x age (which is 10 mmHg higher than the 5% value that is often quoted).

[@michellekline7512]

@@TheHandtevy thank you. I used the 70 + 2xage for her. Thank you for your reply and I will use the 80!

[@shanaejohnson9777]

In MD we would use LR for a trauma esp a multiple system trauma to replace products of blood lost I.e electrolytes etc . Both LR and NS are isotonic fluids; would NS still be more appropriate since it’s an TBI involved ?

[@TheHandtevy]

Shanae, great question. There is a small study that showed LR was more harmful in TBI than NS. For that reason I'd stick with NS if severe TBI was involved. PA

[@TheHandtevy]

Here is the study: www.ncbi.nlm.nih.gov/pmc/articles/PMC4892214/

[@tommyvelar4865]

Dr. Antevy, I completely agree with your video but I am stuck in a conundrum. Recently had a patient who had a GCS of three post pedestrian accident. Respiratory rate was 8 to 10 per minute. SpO2 was in the mid 80's and ETCo2 once intubated was in the 60s. Blood pressure was normal. We only have pediatric BVMs. SpO2 stayed in the 80's with non-rebreather at 15lpm and N/C at 15lpm with apneic oxygenation. He was intubated very quickly with Ketamine only. My question, is when faced with hypoxia AND hypercapnia and an Fio2 at 100%, how long should we ventilate at 10 per minute before we increase the rate to increase the minute volume and get his Spo2 in the 90's? My initial response was to hyperventilate to get the ETCo2 to come down and the SpO2 to come up. At best, he was 91% with 100% supplemental oxygen. Unfortunately, we do not have a mechanical ventilator. Would this be one of those instances where hyperventilation would be of benefit considering the low Spo2?

[@TheHandtevy]

Tommy, did the patient have multisystem trauma that could explain the hypoxia? Was there a hemo/pnuemo? Increasing the rate does help with pO2 but could come at the expense of cerebral hypoxia, yet in this case with an ETCO2 of 60 you have room to go up on the rate, with a goal of 35-45.

[@nathanboone2995]

.. MR Handtevt, big fan here of yours. So don't take this with any disrespect. I agree with most of this. But not all. But here's the deal, if my patient has a gcs of 3. If they vomit, that patient WILL have a hypoxic event. And I'll be behind the 8 ball and have to SALAD my way out of it with a tube.. =death. I agree with NRB, but let's add a NC at 15 to it and start nitrogen washout so we have prolonged time to intubate WITHOUT having a hypoxic event. These are the patients, where you should only get 1 attempt, if not go straight to a SGA. These patients are going to get intubated before going to surgery anyway. Why delay care in the field? This just puts the patient at risk. Next. The NS....BE CAREFUL, make sure this is an isolated TBI. Because if they have any other type of trauma, I'd rather have plasma and PRBCs. Then maintain a higher BP. These are the ones I won't wait to give blood products to in the field, just for that fact. Even if they have a lower shock index, better safe then sorry later. Also in the scenario if the provider had a period of hypotension after intubation, did he vagal him out and cause it without drugs?? I get where you're going with this. I agree with the Hs of death here. But I also think that a controlled hyperventilation with a CO2 of 30-35 with these patients are helpful. Not saying 20-30, where you cause vasodilation. But just a minimal amount for increased oxygen demand from the bleed itself to carry the RBCS.

[@TheHandtevy]

Hi Nathan, I greatly appreciate your comments and I always see it as a positive, never as something disrespectful. You make excellent points about the patient with a GCS of 3 who vomits and becomes hypoxic. The EPIC-TBI data does not state "No intubation" and in fact those who needed to be intubated (and were, safely) had a 3X improved chance of a good outcome. So if you need to intubate a patient in respiratory failure then you should. My advice would be to resuscitate first, then intubate. As for the NS question....the data shows that if severe TBI is part of a multisystem trauma, the brain takes precedent and the BP thresholds of 90 mmHg won't cut it. This is one of the reasons I made this video, to expose this data and encourage these types of conversations. The permissive hypotension data was all from penetrating trauma and none of those patients had TBI. The EPIC-TBI data demonstrates that even NS is beneficial in these patients. Now, of course, I'd agree that whole blood would be better and in fact we just had a save last week of a severe TBI patient who received WB in the field and is doing quite well. Here is a video we just recorded with Dr. Gaither, one of the authors of the EPIC-TBI who explains the paper in more detail. drive.google.com/file/d/1sJHQJolVEwWowzgoRSKPZmvpg2VeMb5D/view?usp=sharing . Let's continue the conversation and good to hear from you! Peter