The Head and the Heart: Hemodynamic Derangement in Isolated TBI

The Head and the Heart: Hemodynamic Derangement in Isolated TBI

We know that alterations in hemodynamics do not only occur in hemorrhagic shock.  Both obstructive (such as from tension pneumothorax) and neurogenic shock (for example, from a spinal cord transection), can result in hemodynamic compromise that would not be corrected by blood product administration.  There have been some studies that have shown isolated traumatic brain injury (TBI) can also cause hemodynamic derangements. This article looks at a paper which attempts to examine the incidence of cardiovascular instability in patients with TBI.

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Air Care Series: Burns Management

Air Care Series: Burns Management

Severely burned patients can be intimidating for even the most seasoned critical care transport providers. These patients often require aggressive resuscitation and multiple procedures in a relatively short period of time. It is often easy for providers to become overwhelmed, necessitating an algorithmic approach to the patient, similar to traumatically injured patients, is crucial. By advancing through the primary survey and stabilizing the patient while starting aggressive but goal directed crystalloid resuscitation, critical care transport providers can bring ICU level care to one of the sickest pre-hospital patient populations.

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When That 1% Makes All the Difference

When That 1% Makes All the Difference

Just prior to SMACC (the Social Media and Critical Care Conference), we were lucky enough to have Dr. Brian Burns of Sydney HEMS stop through Cincinnati.  In the video below you can see his lecture on when the 1% makes all the difference.  Dr. Burns talks about how we should strive for excellence in prehospital care not simply meeting minimum standards.  Watch the lecture below to hear Dr. Burns discuss the importance of incremental changes, cognitive offloading, checklists, and continuous improvement and training through simulation.

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Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Thanks to everybody who contributed to an excellent discussion of the care of the patient on our second “flight.”  If you didn’t get a chance to check out the case and the discussion, check it out here.  Below is the curated comments from the community and a podcast from Dr. Hinckley and Flight Nurse Practitioner Jason Peng

Q1 - Walk through your initial assessment of this patient.  What are the critical aspects of the assessment of this patient?

In response to this question, most everybody wanted to first act on the bleeding wound in the patient’s right antecubital fossa.  As explained by Dr. Renne, “I would want to be systematic but efficient, probably using a C-ABCD approach to these kind of critical patients, with the first C being any sort of life-threatening but "C"ontrollable hemorrhage.”  Dr. Renne also had a fine point with regards to checking for other potential, as of yet unseen, injuries.  This is a patient with multiple stab wounds, it is crucial to conduct a quick, but thorough search for stab wounds to the back, axilla, groin, and/or other locations where significant blood loss could be caused by a stab wound.

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Prehospital TBI - Beyond the "Code"

Prehospital TBI - Beyond the "Code"

Of the injuries that one will care for in the pre-hospital setting, traumatic brain injury is one of the most challenging.  Quite often, more than one organ system has been injured and they require rapid, thoughtful, and precise management of their airway and hemodynamics.  In addition, TBI patients require frequent reassessment to detect progression of the primary neurologic injury.  This is easier said than done in the dynamic, unpredictable, and resource-limited prehospital environment.

To help simplify their care, the following “Code of Care” forms the core principles that characterize optimal TBI care:

  1. NO Hypoxia (SpO2 < 90%) – therefore, apneic oxygenation for all TBI patients
  2. NO Hypotension (sBP < 90 mmHg) – greatest iatrogenic risk is with induction and provision of positive pressure ventilation
  3. Blown pupil -> Hyperosmotic therapy + Hyperventilate
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