Case Presentation: BLS to ALS Handoff

1. Case Presentation: BLS to ALS Handoff • 21 year old male • Unrestrained driver, single vehicle MVC • 20mph; sedan vs. concrete barrier • No airbag • Starred windshield • + LOC

2. Initial Assessment • Patient has clear airway • Bilateral breath sounds • Strong radial pulse of 100 • Blood Pressure 120/80 • Speaking spontaneously Additional information? • Respiratory rate/ quality–16 good movement • O2 sat – 100%

3. Physical and Neurological Evaluation • Found out of vehicle walking near accident scene • 3x5cm Hematoma/ contusion left forehead • Opens eyes spontaneously • Alert to person & place, but confused to month and year • Follows motor commands • GCS = • 14 Additional information? • Pupils

4. Treatment and Interventions • Immobilization with cervical collar and backboard • Reassess vital signs & neuro exam Q5 min • Administer supplemental oxygen as needed to maintain SaO2 > 90% • Rule out other causes of altered mental status • BLS - Medic Eval? • ALS - establish IV access

5. Causes of Altered Mental Status • Hypovolemia • Hypoxia • Hypoglycemia • Pain/Discomfort • Traumatic Brain Injury Additional causes? • Alcohol • Drugs

6. Transport Decisions • Destination • Mild TBI • GCS 14 • Emergency Department

7. Reassessment enroute: ABC’s • Vital signs remain stable • Patent airway • Bilateral breath sounds • Pulse 96 • BP 116/76 Additional information? • Respiratory rate/ quality – 12 regular • O2 sat – 92%

8. Reassessment: Neuro Exam • Eyes open to painful stimuli • Speech is incomprehensible • Localizes to painful stimuli • Pupils 3mm bi-lat. with brisk reaction to light • GCS = • 9

9. Treatment and Interventions • Cervical spine immobilized • Backboard in place • O2 administered via NRM • Critical value – SpO2 < 90% • BLS- Medic Eval? • ALS -IV access established with NS infusing • Critical value – SBP < 90mm Hg

10. Transport Decisions • Destination • Moderate TBI • GCS 9 • Trauma Center

11. Reassessment: ABC’s • Changes in vital signs • Respiratory rate 8 • SaO2 90% on NRM • Pulse 112 • BP 80/60 • Additional Information? • Respiratory effectiveness – Irregular/ poor air exchange

12. Reassessment: Neuro Exam • Patient is unresponsive • Eyes – no response • Motor – bilateral extensor posturing • Verbal – no response • Pupils • Right 4mm & reactive • Left 3mm & reactive • GCS = • 4 • BLS to ALS Handoff

13. ALS Treatment Interventions • Establish a patent airway • Vigorous IV fluid administration (Keep SBP > 90mm Hg) • Supplemental oxygen • Hyperventilation @ 20 breaths/minute • Only when suspected cerebral herniation • Capnography/ ETCO2 used to: • Confirm endotracheal tube placement • Measure the adequacy of ventilation. • Target range: 35 – 40 mm Hg • Guide hyperventilation therapy • Severe hyperventilation: < 30 mm Hg • ETCO2 < 25 mm Hg is not recommended

14. Transport Decisions • Destination • Severe TBI • GCS 4 • Level One Trauma Center with TBI capabilities

15. Transport Decisions • Level One Trauma Center with TBI capabilities • 24 hour available CT scan • 24 hour available operating room • Prompt neurosurgical care • Ability to monitor intracranial pressure • Ability to treat intracranial hypertension

16. Summary • Provide oxygen and ventilation to maintain oxygen saturation >90% • Provide adequate fluid to maintain SBP >90mm Hg • Continuously look for S & S of Cerebral herniation • Pupil abnormalities • HA, N/V • CushingsTriade -  SBP,  HR, Irreg. resps. • Select the most appropriate facility and mode of transportation for admission of the TBI patient Additional information? • Continually reassess and document: • Component GCS, VS, post intubation RR, and Capnography values .