That’s One EPIC Head Injury

We have all heard “epic” when referring to something that is extraordinary, some of us have even used the EPIC EHR. There are several other uses of the word epic, but what about EPIC in reference to head injuries? No, we are not talking about “wow…look at that head injury!”, but a better way to manage those patients with…well…an epic TBI.

A few years ago, a group in Arizona, aptly named Excellence in Prehospital Injury Care (EPIC), started looking at the implications of prehospital care on head injuries. Following best practice guidelines from the Brain Trauma Foundation, they looked at several measurable variables including blood pressure, pulse ox, and ETCO2. The group implemented prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Collectively these are referred to as the “H bombs.” This was a large endeavor which included over 130 EMS agencies, both ground and air, throughout Arizona.

After the participating agencies went through training specific to these guidelines, they enrolled over 6,500 patients. These were compared to a control group of over 15,000 patients prior to education and implementation. See end of post for summary of the guidelines/protocol.

So, what did they find? In the severely injured group, there was a 2x increase in survival to discharge and a 3x increase in survival to discharge in severe injury intubated subgroups. The data is summarized below:

Regional severity score-head of 3-4:

Non-intubated: aOR 2.03; 95% CI 1.52-2.72; P

Intbutaed: aOR 3.14; 95%CI 1.65-5.98; P

ISS of 16-24:

Non-intubated: aOR 1.61; 95%CI 1.07-2.48; P=0.02

Intubated: aOR 3.28; 95%CI 1.19-11.34; P=0.02

 

This study shows a lot of promise for improving the care we provide to our severe head injured patients. You’ll notice the guidelines probably look a little familiar as this study was the basis for our region 5 head injury protocol. This is also the basis for the new state model protocol that is being introduced with the latest update this winter. These guidelines are included in our quick reference card set. Don’t forget to download a copy for your mobile device!

 

Excellence in Prehospital Injury Care – epic.arizona.edu

West Michigan Air Care Quick Reference Cards - download PDF

Airwaves blog EPIC TBI.jpg

 

EMS Care of moderate and severe TBI

Treatment and Monitoring Guidelines/Protocols

ADULTS

 

--Definitions: --Adults: Age ≥18

 

--The prehospital identification of moderate or severe TBI: Anyone with physical trauma and a mechanism consistent with the potential to have induced a brain injury and:

--Any injured patient with loss of consciousness, especially those with GCS

OR

--Multisystem trauma requiring intubation whether the primary need for intubation was from TBI or from other potential injuries

OR

--Post-traumatic seizures whether they are continuing or not

 

--Overall approach to monitoring and continuous evaluation:

Continuous O2 saturation (sat) via pulse oximetry, continuous quantitative end-tidal CO2 (ETCO2) monitoring in intubated patients, and systolic blood pressure (SBP) every 3-5 minutes.

 

--Specific, guideline-based therapy:

I.Management of airway/oxygenation:

--CLINICAL AXIOM: A single non-spurious O2 sat of independently associated with a doubling of mortality. Hypoxia kills neurons!

A.Management is initiated by continuous high-flow O2 for all potential TBI cases. Emphasis is placed on prevention, identification, and treatment of hypoxia (O2 sat 1-6 If high-flow O2 fails to correct hypoxia, basic maneuvers for airway repositioning will be attempted, followed by reevaluation. If this does not restore O2 sat to 90% or greater, or if there is inadequate ventilatory effort, bag-valve-mask ventilation will be performed using appropriate airway adjuncts (e.g., oropharyngeal airway).

B.If airway compromise or hypoxia persists after these interventions, ETI will be performed when

an experienced ALS provider is available.1,2,5,7-10 Following ETI, tube placement will be confirmed via multiple means including ETCO2 detection and/or capnography.

 

II.Management of ventilation: Special emphasis is placed on identifying and treating hypoventilation as well as preventing hyperventilation when assisting ventilation.

--CLINICAL AXIOM: In intubated patients, hyperventilation is independently associated with at least a doubling of mortality and some studies have shown that even moderate hyperventilation can increase the risk of dying by six times. Hyperventilation kills neurons!

--COROLLARY: It has been shown repeatedly that inadvertent hyperventilation happens reliably if not meticulously prevented by proper external means. No one, no matter how experienced, can properly ventilate without ventilatory adjuncts (Pressure-Controlled BagsPCBs, Ventilation Rate Timers (VRTs), ETCO2 monitoring, ventilators). PCBs/VRTs should be used immediately after intubation and until the patient can be placed on a mechanical ventilator even if this will only take 3-5 minutes (note: that’s all the hyperventilation it takes to begin killing neurons).

 

A.Hypoventilation (ineffective respiratory rate, shallow or irregular respirations, or periods of apnea): If there is evidence of hypoventilation despite high-flow O2 therapy, assisted ventilation will be performed via BVM (PCB/VRT) and, if ineffective, ETI will be performed if an experienced ALS provider is present.1,2,11,12

 

B.Intubated patients: After ETI, PCB/VRT is used immediately for ventilation and ETCO2 levels will be strictly maintained between 35 and 45 mmHg when monitoring is available (target = 40).1,2,12-15

1.All agencies are strongly encouraged to use PCBs/VRTs. In agencies without ETCO2

monitors, maintain a respiratory rate of 10 breaths per minute to prevent inadvertent hyperventilation.1,2,10-12,16-24 Agencies with ETCO2 monitors should use PCBs/VRTs for the initial rate of manual ventilation and then gently modify the ventilation to obtain the target ETCO2 of 40 mmHg. Beware of the tendency to only use the ETCO2 monitor to verify tube placement and then to fail to carefully maintain ETCO2 in target range.

2.Ventilators will be used post-intubation whenever available to optimize ventilatory mechanics and O2 therapy.11,12,25-27 This is the best way to care for an intubated TBI patient. PCBs/VRTs should be used immediately after intubation and until the patient is placed on the ventilator even if this will only take several minutes.

--Target tidal volume (TV) will be 7cc/kg with vent rates adjusted to keep the ETCO2 within target range (35-45 mmHg). This is consistent with the National TBI guidelines and with the recent literature showing that intrathoracic pressure, lung mechanics, hemodynamics, and ICP are optimized by this TV compared to the “classical” 10-12 cc/kg that remains common in many settings.11,16,27-34

 

C.Impending cerebral herniation:

--The EPIC guidelines do not encourage even mild hyperventilation for “impending cerebral herniation” for the following reasons:

--There is no evidence that it improves outcome in any setting

--There is much evidence that even mild hyperventilation harms moderate and severe TBI patients

--The “practical application” of this “treatment” is that many patients who do not have actual impending herniation end up being hyperventilated since the real-world interpretation often ends up thinking…“The worse a TBI is, the faster you should ventilate.” Thus, many patients who will be harmed by hyperventilation may end up with the misapplication of this “treatment.”

 

D.Non-intubated patients: All relevant monitoring/treatment will be applied except ETCO2 monitoring.

 

III.Management of blood pressure: In patients with a potential for TBI, SBP ≥ 90 mmHg should be maintained. Strong emphasis is placed on preventing and aggressively treating even a single episode of SBP1-5,35-48

--CLINICAL AXIOM: A single episode of SBP independently associated with at least a doubling of mortality. Amazingly, repeated episodes of hypotension can increase the risk of dying by as much as eight times. Hypotension kills neurons!

 

A.Treatment of hypotension: Even a single SBP measurement1,2 If the rapid infusion of the first liter of crystalloid does not correct the hypotension, there should be no hesitation to continue aggressive fluid resuscitation.

--Note: Do not wait for the patient to become hypotensive. If the SBP is dropping, or if there are any other signs of compensated shock such as increasing heart rate with decreasing SBP, begin aggressive treatment before the patient becomes hypotensive. --Intraosseous access should be attempted if all three of the following criteria are met: 1) there is hypotension or other signs of shock, 2) peripheral venous access cannot be quickly established, and 3) the patient’s mental status is such that they can tolerate the procedure without undue pain.

 

B.Treatment of hypertension: In TBI, treatment of acute hypertension is not recommended.1,2,49 However, IV fluids should be restricted to a minimal “keep open” rate in patients with SBP ≥140 mmHg.

 

IV.Assessment and management of hypoglycemia: In patients with any alteration in mental status, always

check for hypoglycemia early in the clinical course. Hypoglycemia can mimic TBI as a cause of altered mental status. It can also can cause TBI (e.g., Diabetic on insulin who misses a meal à low blood sugar à leads to decreased LOC à leads to a motor vehicle crash in a hypoglycemic driver).

 

--Obtain fingerstick or serum glucose level. If <70mg/dl then:

1.Administer 50ml 50% dextrose (D50) IV

2.Repeat blood sugar in 10 minutes and, if still

--If no response then contact medical direction

3.If IV access unsuccessful, dextrose may be given IO.

4.If IV and IO unsuccessful, administer glucagon 1.0 mg IM

 

--NOTE:

--If there are differences between your regional/agency protocols/standing orders for treating hypoglycemia in the setting of TBI, you may use either the EPIC protocol above or your regional/local protocol. If in doubt, check with your medical director.

 

EMS Care of moderate and severe TBI

Treatment and Monitoring Guidelines/Protocols

Infants and Children

 

--Definitions:

--Age Definitions for Monitoring and Management:1

--“Infant”: Age 0-24 months

--“Child”: Age 2-14 years

--“Late adolescence”: 15-17 years

 

--The prehospital identification of moderate or severe TBI: Anyone with physical trauma and a mechanism consistent with the potential to induce a brain injury and:

--Any injured patient with loss of consciousness, especially those with GCS

OR

--Multisystem trauma requiring intubation whether the primary need for intubation was from TBI or from other potential injuries

OR

--Post-traumatic seizures, whether they are continuing or not

OR

--In infants (where GCS may be difficult to obtain or interpret), decreased level of consciousness, decreased responsiveness, or any deterioration of mental status.

 

--Overall approach to monitoring and continuous evaluation:

--Continuous O2 saturation (sat) via pulse oximetry, continuous quantitative end-tidal CO2 (ETCO2) monitoring in intubated patients and systolic blood pressure (SBP) every 3-5 minutes.

 

--Specific, guideline-based therapy:

I.Management of airway/oxygenation:

--CLINICAL AXIOM: A single non-spurious O2 sat of independently associated with a doubling of mortality. Hypoxia kills neurons!

A.Management is initiated by continuous high-flow O2 for all potential TBI cases. Emphasis is placed on prevention, identification, and treatment of hypoxia (O2 sat 1-7 If high-flow O2 fails to correct hypoxia, basic maneuvers for airway repositioning will be attempted, followed by reevaluation. If this does not restore O2 sat to 90% or greater, or if there is inadequate ventilatory effort, bag-valve-mask (BVM) with a pressure-controlled bag (PCB) and a ventilation rate timer (VRT) will be performed using appropriate airway adjuncts (e.g., oropharyngeal airway). It should be noted that most infants and children can have their airway managed well using basic maneuvers and BVM.

B.If airway compromise or hypoxia persists after these interventions, ETI will be performed when an experienced ALS provider is available.1-3,6,8-13 Following ETI, tube placement will be confirmed via multiple means including ETCO2 detection and/or capnography.

 

II.Management of ventilation: Special emphasis is placed on identifying and treating hypoventilation as well as preventing hyperventilation when assisting ventilation. --CLINICAL AXIOM: In intubated patients, hyperventilation is independently associated with at least a doubling of mortality and some studies have shown

that even moderate hyperventilation can increase the risk of dying by six times.

Hyperventilation kills neurons!

--COROLLARY: It has been shown repeatedly that inadvertent hyperventilation happens reliably if not meticulously prevented by proper external means. No one, no matter how experienced, can properly ventilate without ventilatory adjuncts (Pressure-Controlled Bags-PCBs, Ventilation Rate Timers—VRTs, ETCO2 monitoring, ventilators). PCBs/VRTs should be used immediately after intubation and until the patient can be placed on a mechanical ventilator even if this will only take 3-5 minutes (note: that’s all the hyperventilation it takes to begin killing neurons).

 

A.Hypoventilation [ineffective respiratory rate for age, shallow or irregular respirations, periods of apnea, or measured hypercarbia (elevated ETCO2)]: If there is evidence of hypoventilation despite high-flow O2 therapy, assisted ventilation will be performed via BVM and, if ineffective, ETI will be performed if an experienced ALS provider is present.1-3,12-15

 

B.Intubated patients: After ETI, use PCB/VRT immediately for ventilation and ETCO2 levels will be strictly maintained between 35 and 45 mmHg when monitoring is available (target = 40)1-3,15-17

1.All agencies are strongly encouraged to use PCBs/VRTs. In agencies without ETCO2 monitors, maintain age-appropriate ventilatory rates and decrease the risk of inadvertent hyperventilation.1-3,11,14,15,18-26 Agencies with ETCO2 monitors should use PCBs/VRTs for the initial rate of manual ventilation and then gently modify the ventilation to obtain the target ETCO2 of 40 mmHg. Beware of the tendency to only use the ETCO2 monitor to verify tube placement and then to fail to carefully maintain ETCO2 in target range.

--Target ventilatory rates from the National TBI Guidelines:1,27

--Infants: (age 0-24 months): 25 breaths per minute (bpm);

--Children: (age 2-14): 20 bpm;

--Older adolescents: (age 15-17): 10 bpm (same as adults)

2.Whenever possible, ventilators should be used post-intubation to optimize ventilatory parameters and O2 therapy.1,14,15,28-30 This is the best way to care for an intubated TBI patient. PCBs/VRTs should be used immediately after intubation and until the patient is placed on the ventilator even if this will only take several minutes.

--Target tidal volume (TV) will be 7cc/kg with rates adjusted to keep the ETCO2 within target range (35-45 mmHg).

--Note: This is consistent with the TBI guidelines and the recent literature showing that intrathoracic pressure, lung mechanics, hemodynamics, and ICP are optimized by this TV compared to the

“classic” 10-12 cc/kg that remains common in many settings.14,18,30-37

 

C.Impending cerebral herniation:

--The EPIC guidelines do not encourage even mild hyperventilation for

“impending cerebral herniation” for the following reasons:

--There is no evidence that it improves outcome in any setting

--There is much evidence that even mild hyperventilation harms moderate and severe TBI patients

--The “practical application” of this “treatment” is that many patients who do not have actual impending herniation end up being hyperventilated since the real-world interpretation often ends up thinking…“The worse a TBI is, the faster you should ventilate.” Thus, many patients who will be harmed by hyperventilation may end up with the misapplication of this

“treatment.”

 

D. Non-intubated patients: All relevant monitoring/treatment will be applied except ETCO2 monitoring.

 

III.Management of blood pressure: In patients with a potential for TBI, strong emphasis is placed on preventing and aggressively treating even a single episode of hypotension. --CLINICAL AXIOM: A single episode of hypotension is independently associated with at least a doubling of mortality. Amazingly, repeated episodes of hypotension can increase the risk of dying by as much as eight times. Hypotension kills neurons!

--Hypotension will be defined as systolic blood pressure (SBP) below the 5th percentile for age. This will be estimated using the following formula:1,38

--Infants/children age : 70 mmHg + (age X 2)

--Children age ≥10: 90 mmHg (same as adults)

--Good “rules of thumb” to remember:

--Infant = 70 mmHg

--5 year old = 80 mmHg

--10 and older = 90 mmHg

A.Treatment of hypotension: Even a single hypotensive measurement (for age) will initiate intravenous (IV) fluid resuscitation. For hypotension or other signs of shock, IV normal saline will be given. Sufficient volume (via 20cc/kg boluses every 5 minutes) will be given to return SBP to at least the 5th percentile estimate. --Once hypotension has been corrected, IV administration of NS should occur at sufficient rate to keep the patient non-hypotensive.

--Note: If the rapid infusion of the initial bolus of crystalloid does not correct the hypotension, do not hesitate to continue aggressive fluid resuscitation.

--Note: Do not wait for the patient to become hypotensive. If the SBP is dropping, or if there are any other signs of compensated shock such as increasing heart rate with decreasing SBP, begin aggressive treatment before the patient becomes hypotensive.

--Intraosseous access should be attempted if all three of the following criteria are met: 1) there is hypotension or other signs of shock, 2) peripheral venous access cannot be quickly established, and 3) the patient’s mental status is such that they can tolerate the procedure without undue pain.

 

B.Treatment of hypertension: In TBI, treatment of acute hypertension is not recommended.1-3,39 However, IV fluids will be restricted to a minimal “keep open” rate in infants/young children with SBP ≥100 mmHg and in older children/adolescents with SBP ≥130 mmHg.

 

IV.Assessment and management of hypoglycemia: In patients with any alteration in mental status, always check for hypoglycemia early in the clinical course. Hypoglycemia can mimic TBI as a cause of altered mental status.

--Obtain fingerstick or serum glucose level. If glucose level is <70mg/dl then:

1.Administer dextrose IV:

--Newborn (birth to 2 months):

--Administer 5ml/kg of D10 solution IV --Infants and toddlers (3 months to 3 years):

--Administer 2ml/kg of D25 solution, max dose = 100ml (25 g).

--Children age 4 and older:

--Administer 1ml/kg of D50 solution, max dose = 50ml

2.Repeat blood sugar in 10 minutes and, if still

--If no response then contact medical direction

3.If IV access unsuccessful, dextrose may be given IO.

4.If IV and IO unsuccessful, administer Glucagon 0.03mg/kg IM, max dose

1mg

 

--NOTES:

A.If there are differences between your regional/agency protocols/standing orders for treating hypoglycemia in the setting of TBI, you may use either the EPIC protocol above or your regional/local protocol. If in doubt, check with your medical director.

B.All dosing of dextrose and glucagon may be determined by length-based resuscitation tape rather than weight estimations if that is preferred by the agency/medical director

C.Mix D25 or D10 using either your regional/local protocols or the following: --D25: Make D25 by removing 25CC from a 50CC bag and inject 25 CCs of D50 into the bag. Then remove an appropriate amount of the D25 and administer volume according to weight.

--D10: Make D10NS by removing 50CC from a 250CC bag of NS and then injecting one amp (50CC) of D50 into the bag. Then remove an appropriate amount of the D10NS and administer volume according to weight.

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