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Prehospital Hypertonic Saline Administration After Severe Traumatic Brain Injury

      Abstract

      A 25-year old male paient was critically injuried in a high speed motor vehicle collision over an hour from the nearest trauma center. Paramedics diagnosed the patient with a traumatic brain injury and increasing intracranial pressure and transported the patient to a predesignated landing zone for helicopter intercept. During transport paramedics initiated a severe traumatic brain injury protocol which included the adminisration of 3% hypertonic saline. The flight crew continued 3% hypertonic saline managment which was later transferred to the receiving trauma team. Upon trauma center arrival the patient was diagnosed with a skull fracture and subdural hematoma. The patient was transitioned to a 3% hypertonic saline infusion for the next 24 h. The need for integrating systems of care is particularly important when managing patients with severe traumatic brain injury. This case report describes a patient with a severe TBI who received prehospital 3% hypertonic saline based on an integrated protocol developed between multiple prehosptial systems and a tertiary care trauma center.
      Severe traumatic brain injuries (TBIs) are a potentially catastrophic event, and morbidity can rise precipitously without early interventions to prevent hypoxia and hypotension and control for rising intracranial pressure. In recent years, hypertonic saline (HTS) has shown efficacy in lowering intracranial pressures for patients experiencing TBIs, the leading cause of death and disability among children and young adults in the United States.

      Thurman DJ, Alverson C, Browne D, et al. Traumatic brain injury in the United States. Centers for Disease Control and Prevention Report to Congress. Available at: https://www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.html#:∼:text=Incidence%20and%20Prevalence%20of%20Traumatic,million%20Americans%20sustain%20a%20TBI. Accessed 15 July 2021.

      Integrating care between health care providers across the acute care continuum, from prehospital systems to discharge, is paramount in providing the best patient outcomes possible, especially in health care system expansions such as air medical transport. The need for integrating systems of care is particularly important when managing patients with severe TBI. Statewide prehospital care protocols vary greatly; 78% provide ventilation guidance, 77.3% have targeted end-tidal carbon dioxide levels below < 35 mm Hg, and only 1 (of 38 reviewed) includes HTS (3%).
      • Chuck CC
      • Martin TJ
      • Kalagara R
      • Shaaya E
      • Kheirbek T
      • Cielo D.
      Emergency medical services protocols for traumatic brain injury in the United States: a call for standardization.
      One barrier to consistency in protocol development is the available literature. One trial demonstrated that a prehospital bolus of 7.5% HTS in severe TBI did not improve mortality.
      • Bulger EM
      • May S
      • Brasel KJ
      • et al.
      Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial.
      However, the Brain Foundation guidelines continue to recommend the prehospital use of hyperosmolar therapy for patients with severe TBI and evidence of impending herniation.
      • Carney N
      • Totten AM
      • O’Reilly C
      • et al.
      Guidelines for the management of severe traumatic brain injury, fourth edition.
      Hyperosmolar therapy is also recommended as an inpatient strategy for lowering increased intracranial pressure (ICP).
      • Carney N
      • Totten AM
      • O’Reilly C
      • et al.
      Guidelines for the management of severe traumatic brain injury, fourth edition.
      One reason for this apparent disconnect is because the ideal timing of HTS administration and its concentration have not been determined.
      • Carney N
      • Totten AM
      • O’Reilly C
      • et al.
      Guidelines for the management of severe traumatic brain injury, fourth edition.
      A meta-analysis previously determined no one prehospital fluid is superior to another in improving the outcomes of patients with severe TBI.
      • Bergmans SF
      • Schober P
      • Schwarte LA
      • Loer SA
      • Bossers SM.
      Prehospital fluid administration in patients with severe traumatic brain injury: a systematic review and meta-analysis.
      However, none of the reviewed research investigated the continued use of HTS across an integrated system of care. This case report describes a patient with a severe TBI who received 3% HTS initiated in the prehospital setting with the infusion continued upon arrival at the trauma center using a system-wide integrated protocol.
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