Handtevy Minute: Severe Traumatic Brain Injury (TBI)

60,000 people die from TBI every year in the United States, and as EMS professionals we can have a big impact in outcomes.

How can EMS impact care?

Dr. Antevy makes a strong case for all EMS agencies to adhere to the recommendations made by the 2019 EPIC-TBI study and the 2022 follow-up study that was published in July.

While the recommendations may appear simple, they are difficult to adhere to unless you are actively focusing on them, even prior to arrival on scene.

Here is a summary of the EPIC-TBI recommendations (2019 & 2022)
For Severe TBI:
• Avoid Hypoxia - place a NRB on all patients immediately
• Avoid Hypotension - place 2 large bore IVs and aim for a SBP of 130 mmHg (not 90!)
• Permissive hypotension is not an option in TBI.
• Avoid Hyperventilation - Keep the ETCO2 b/w 35-45

We recommend that you review every TBI case and look for the above parameters.
One episode of hypoxia or hypotension significantly increases the odds of a bad outcome.

The Key Takeaways:
1. Avoid the 3 H-Bombs in Severe TBI
2. Reconsider the BP threshold of 90 mmHg in favor of higher SBPs (130’s)
3. CQI every TBI Case looking for these items.

[MichaelBrown-oxve]

I appreciate 100% any and all research and understanding of human I had 3 severe traumatic brain injuries at 16 comatose paraplegic etc etc . At 43, I am of course happy to be alive but in exactly the same feeling wish I didn't come back after the 4 minute no sign of life. A lifelong disability which torments me continually comorbid refractory and a ghost that lives in my body. Severe traumatic brain injury is permanent it has made me and others I have associated with over the years lost in a world of medication treatment and self resentment which is supposed only by the major depressive disorder that challenges my thought s and obliterates any actions

[Ravageritualx]

I found this helpful. It helped me make connections between concepts I understood, but had not correlated. Thanks Dr. Handtevy and the Handtevy team.

[justinarnone]

Thank you for sharing this information. This challenges our thoughts on current clinical practices. The answer to the question that the brain takes priority over permissive hypotension for internal bleeding makes sense. I've always wondered how a BP of 100-110 (as recommended in PHTLS/TCCC for multisystem trauma w/ a head injury) is adequate in the presence of increased ICP. The math (MAP-ICP=CPP) shows CPP is not enough or too close to the threshold of keeping the brain perfused when your goal is a systolic of only 100-110 in the presence of increased ICP. I always felt like raising the BP more would be necessary, but did understand that internal bleeding could worsen. I never knew which was "more important". This clarity helps to answer that question of what's more important. I'm thankful for that.

I've heard that the recommendation of not hyperventilating, as mentioned in the video, means that we shouldn't hyperventilate just because someone has a head injury, but you should hyperventilate if s/s progress suggesting impending herniation.

I would like clarification on this just to be 100% certain I understand correctly. Which of the following statements is true/recommended? There has been so much back and forth on this in both the military and civilian settings that I am seeking evidence-based clarity.

Hyperventilation should NEVER be performed. Even in the presence of s/s consistent with impending cerebral herniation (Cushing's Triad, Seizing, Posturing, Dilated pupil, etc.)
or
Hyperventilation should not be performed on patient's with a head injury UNLESS that have s/s consistent with impending cerebral herniation.

Thank you for your time and your leadership.

[usefulrandomness]

Thank you for these videos. They are so valuable

[cmallen]

I tried to get our organization in Utah to adopt these treatments. I was shut down by our medical director and the protocol committee board. One of the medical directors stated this was a poor study cause they measured so many things at once. I disagreed but lost. my proposed change was denied.
Lost and confused paramedic rolling the stone wheel in Utah.

[dustylynn]

great info! I am a new HT instructor and am happy to share such great knowledge and expertise. My back ground is PICU, CVICU Peds Trauma etc. We always taught that if a pediatric pt could tolerate an OPA, they should be ventilated (BVM, SGA or intubation) this pt is not a peds patient, but could you elaborate on that topic bit? If this is a prehospital peds pt and they take an OPA, is it ok to just put a NRB on them and watch ETCO2? What if an agency didnt monitor ETCO2 (gasp! I know, right??) but it thoughts please...

[oxfd]

Why are we using 0.9% Sodium chloride in place of lactated ringers? With Sodium chloride having a lower pH then ringers won’t that promote more coagulopathy and Metabolic acidosis, Hypothermia? Won’t this be a contributing factor to worsening outcomes? The newly updated Navy fire emergency services protocol has Replaced ringers with Sodium chloride. Oh and I was going to ask Our medical control Director the same question. Why use sodium chloride when it has a lower pH and patients that are in shock do poorly as we create a greater metabolic acidosis?

[danielsalerno]

excellent video. will the 15 lpm NRB O2 to prevent the episode of hypoxia cause too much cerebral vasoconstriction?

[adamperricone]

Great video, thank you. I was thinking intubation in order to protect the airway in the pt who is unresponsive, with no gag reflex. Can you help me understand why that is not indicated?

[michellekline]

Great informative video. Recently had a 3 year old with TBI, I know in the video you spoke of a systolic of greater than 130 When were talking about PEDS, what's a good MAP

[shanaejohnson]

In MD we would use LR for a trauma esp a multiple system trauma to replace products of blood lost I.e electrolytes etc . Both LR and NS are isotonic fluids; would NS still be more appropriate since it’s an TBI involved ?

[tommyvelar]

Dr. Antevy, I completely agree with your video but I am stuck in a conundrum. Recently had a patient who had a GCS of three post pedestrian accident. Respiratory rate was 8 to 10 per minute. SpO2 was in the mid 80's and ETCo2 once intubated was in the 60s. Blood pressure was normal. We only have pediatric BVMs. SpO2 stayed in the 80's with non-rebreather at 15lpm and N/C at 15lpm with apneic oxygenation. He was intubated very quickly with Ketamine only. My question, is when faced with hypoxia AND hypercapnia and an Fio2 at 100%, how long should we ventilate at 10 per minute before we increase the rate to increase the minute volume and get his Spo2 in the 90's? My initial response was to hyperventilate to get the ETCo2 to come down and the SpO2 to come up. At best, he was 91% with 100% supplemental oxygen. Unfortunately, we do not have a mechanical ventilator.

Would this be one of those instances where hyperventilation would be of benefit considering the low Spo2?

[nathanboone]

.. MR Handtevt, big fan here of yours. So don't take this with any disrespect. I agree with most of this. But not all. But here's the deal, if my patient has a gcs of 3. If they vomit, that patient WILL have a hypoxic event. And I'll be behind the 8 ball and have to SALAD my way out of it with a tube.. =death. I agree with NRB, but let's add a NC at 15 to it and start nitrogen washout so we have prolonged time to intubate WITHOUT having a hypoxic event. These are the patients, where you should only get 1 attempt, if not go straight to a SGA. These patients are going to get intubated before going to surgery anyway. Why delay care in the field? This just puts the patient at risk. Next. The NS....BE CAREFUL, make sure this is an isolated TBI. Because if they have any other type of trauma, I'd rather have plasma and PRBCs. Then maintain a higher BP. These are the ones I won't wait to give blood products to in the field, just for that fact. Even if they have a lower shock index, better safe then sorry later. Also in the scenario if the provider had a period of hypotension after intubation, did he vagal him out and cause it without drugs?? I get where you're going with this. I agree with the Hs of death here. But I also think that a controlled hyperventilation with a CO2 of 30-35 with these patients are helpful. Not saying 20-30, where you cause vasodilation. But just a minimal amount for increased oxygen demand from the bleed itself to carry the RBCS.