DILEMMAS IN DAY-TO-DAY CARE
A tool for management of traumatic head injury?
By Jazmine Valencia, NNP-BC, RN, CCRN; Thomas Carrion, RN, CCRN; Mike Mendez, NRP;
Kori Martinez, RN, CCRN, CFRN; Greg Johnson, EMT-P; Aaron T. Britnell, EMT-P, CCEMT-P;
Larry D. Levy, MD, FAAEP, EMTP, ATP; Ken Davis, BA, EMT-P, FP-C & Ryan Hodnick, DO, NRP, FAWM
Your aeromedical EMS crew is dis- patched to Mexico for a head injury patient who’s an American citizen
being repatriated back home.
The patient is a 47-year-old male who was
found unresponsive on the side of the road in
Mexico the previous day and was diagnosed
with a subarachnoid hemorrhage. It’s unclear
what happened, but the patient may have fallen
or been hit by a car. There are no signs of external trauma noted. He was brought to the local
clinic where surgery was performed for a subarachnoid hemorrhage.
On arrival, the crew finds an intubated male
with a Glasgow coma scale (GCS) of 3 with
pupils of 4 mm and nonreactive bilaterally. On
physical exam, the crew notes a Foley catheter
coming from his skull with a glove containing
serosanguinous fluid tied to the other end. The
Foley catheter was placed within the patient’s
ventricle in an attempt to drain cerebral spinal
fluid (CSF) and decrease intracranial pressure.
The patient has no intracranial pressure
monitoring (ICP) in place. His vital signs are
as follows: Heart rate of 58, blood
pressure of 135/67, respiratory rate
of 16 on a ventilator, blood oxygen
saturation (SpO2) of 100% with a
fraction of inspired oxygen (FiO2)
of 90%. A midazolam infusion is
running for sedation.
Transportation from the clinic
to the airport was initially arranged
by means of a flatbed pick-up truck
followed by a three-hour jet flight
back to the United States.
The crew has concerns about
cerebral herniation and doesn’t want
to drain more fluid off via the Foley
catheter without knowing the ICP,
understanding that draining too
much fluid could be detrimental.
The decision is made to reduce ICP using
a medication approach. Both hypertonic saline
and mannitol are used clinically to reduce ICP;
however, the clinic and the flight crew don’t have
access to either of the medications. After consultation with medical direction, the decision
is made to use sodium bicarbonate mixed with
normal saline to obtain 3% hypertonic saline
solution. The patient is given the hypertonic
saline solution with no increase of ICP and is
able to complete the flight.
Increased ICP is a common problem faced by
EMS providers when working with trauma
patients with head injuries. An increase in
ICP compresses the brain within the rigid
skull, thereby reducing blood flow and worsening damage.
As the pressure in the head increases, the
brain can no longer stay within the rigid skull
and begins to herniate. On physical examina-
tion, this most often presents as posturing
(decerebrate or decorticate) with increasingly
nonreactive pupils and changes in vital signs
such as bradycardia, hypertension and irreg-
The Monro-Kellie doctrine states that the
volume of contents within the skull: Brain,
blood and CSF are constant. To maintain
balance, an increase in one should cause a
decrease in the other. 1 After a traumatic insult
to the brain, swelling of brain tissues ensues.
If the pressure is allowed to increase without change, the brain can herniate through
one of the dural folds or, even worse, through
the foramen magnum at the base of the skull.
At the same time, it’s important to optimize
the patient’s intravascular volume as well as
mean arterial pressure to maintain adequate
cerebral blood flow.
It’s also important to prevent hypoxia,
maintain eucapnia, and decompress the stomach as increases in intra-abdominal pressure
can translate to other compartments. 1 In the
prehospital setting, it’s difficult to optimize
cerebral perfusion without intracranial pressure monitoring or medication to
reduce cerebral swelling.
If the ICP remains high, cerebral injuries can worsen leading
to poor neurological outcomes.
Medications such as mannitol and
hypertonic saline may be useful in
reducing ICP. These medications
work by increasing the osmolal-ity of the blood thus pulling fluid
from within the brain tissue to the
The theory is that the fluid
involved in the brain swelling is
exchanged for perfusion of oxy-gen-carrying blood to the damaged parts of the brain.
Patients with traumatic head injuries are associated with high morbidity and
mortality. Photo courtesy Ryan Hodnick