You are dispatched to a rural ED interfacility transfer to the NSICU for a 68 year old female who fell on the ice while taking out the trash. She was found by her neighbor yelling out for help. At the OSH her mental status rapidly deteriorated. She was found to have a large subdural hemorrhage with 5mm midline shift on head CT. No interventions have been performed prior to arrival. Labs are notable for an INR of 3.4 and glucose of 86. At the time of your dispatch, she had two peripheral IVs, no drips, and no airway.
Vitals: HR 85 BP 190/95 RR 22 SpO2 96% on 4L NC
- General: female confused, garbled speech, sitting up in stretcher
- CV: regular rate and rhythm, no murmurs/rubs/gallops
- Pulm: clear bilaterally
- Abdomen: soft, non tender, non distended
- MSK: moves all extremities spontaneously
- Neuro: hematoma over right temple, garbled speech, withdraws to pain, opens eyes to verbal stimuli
Past Medical History:
Atrial Fibrillation (on warfarin), Hypertension (on beta blocker, ace inhibitor), Hyperlipidemia (on statin), Diabetes (on insulin), Coronary Artery Disease (on aspirin)
- What items do you want to bring into the outside hospital upon landing?
- What steps comprise your initial assessment?
- What are your treatment priorities and who will perform each of these?
- Does this patient require intubation? If so, who performs the procedure and how would you perform RSI?
- What if outside hospital providers request to perform RSI but have difficulty with intubation? When do you help and how do you intervene?
- What problems might you anticipate in flight?
Another great detailed discussion proceeded in response to the management questions in Case #2. This is a time-critical transport of an anticoagulated patient with isolated TBI and deteriorating mental status. It was a unanimous decision to bring the blood cooler to the patient at the OSH, as this patient would need reversal if not already initiated. If the patient was intubated, then the team would need to bring the vent. Using information from the pre-notification page, a pre-game plan with the flight nurse would be developed to aid in anticipating issues and ensuring the team is on the same page.
Initial assessment comprises of ABCDEs. With rapid deterioration, there was a general consensus that this patient required intubation for airway protection due to anticipated clinical course. The importance of avoidance of hypoxia and hypotension in TBI was discussed; therefore, in addition to the NC, the patient should be started on a NRB on flush rate for pre-oxygenation. Prior to intubation a thorough neurologic exam needed to be completed. Additionally, the patient warranted a head to toe exam to ensure we did not miss additional injuries.
There was an excellent conversation on who should perform the intubation, and everyone kept the patient's best interest in mind. If the procedure was deemed necessary, then we would either intubate or provide backup and support. Treatment priorities included reversing anticoagulation status (INR 3.4), intubation, and mitigating elevated ICPs. Utilizing the resources at hand, it was decided to divide and conquer the duties as well as use the OSH staff as able. While one person would set up to intubate, the other flight member would spike and hang plasma and draw up RSI medications. Additional reversal agents to be considered include vitamin K and PPCs, but administration of these would not delay transport if not readily available at the OSH.
To avoid hypotension the two "hemodynamically neutral" induction agents of choice were etomidate and ketamine. It was noted the evidence that ketamine elevates ICP and its use in TBI is harmful is weak and has largely been debunked. Therefore, it is safe to use. However, given the cardiac history of the patient, etomidate is a good alternative. Regarding the paralytic, it was determined that the shorter acting the better, as long as there are not contraindications to its use. Post intubation ventilator management should include rapidly titrating down O2 to avoid hyperoxia and monitoring end tidal.
Several methods to mitigate elevated ICP included HOB elevation, controlling pain with adequate analgesia and sedation, hypertonic saline, and monitoring end tidal to maintain eucapnea. With the decrease in mental status and known SDH, it was agreed this patient should be treated with hypertonic following intubation. It was astutely pointed out that hyperventilation (end tidal 30-35) should only be targeted if there are features suggestive of impending herniation, otherwise eucapnea should be preserved to prevent cerebral vasoconstriction and maintain perfusion.
During transport, the patient became hypoxic and cyanotic. The DOPE mnemonic for post-intubation deterioration and hypoxia was discussed as a good memory aid to work through the differential.
- D: Displacement of ETT (right main stem or dislodgement)
- O: Obstruction (mucus plugging, kink in tubing)
- P: Pneumothorax
- E: Equipment failure
- Check equipment, tubing, end tidal CO2, and ETT depth (address equipment failure and displacement).
- Disconnect patient from vent and use BVM. Assess need for suctioning (address equipment failure and obstruction).
- Assessing for pneumothorax in the helicopter can be difficult as we are unable to auscultate, therefore, look for absent or asymmetrical chest wall rise. We can use ultrasound to assess for lung sliding when available. Evaluate for tension physiology and needle decompress after other etiologies have been ruled out.
It was also pointed out to always think of possible medical causes of trauma as this patient may have a PE or other medical cause. There are several great learning points from this case. Nice work team!