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.
1
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%).
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.
2
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.
3
However, the Brain Foundation guidelines continue to recommend the prehospital use
of hyperosmolar therapy for patients with severe TBI and evidence of impending herniation.
4
Hyperosmolar therapy is also recommended as an inpatient strategy for lowering increased
intracranial pressure (ICP).
4
One reason for this apparent disconnect is because the ideal timing of HTS administration
and its concentration have not been determined.
4
A meta-analysis previously determined no one prehospital fluid is superior to another
in improving the outcomes of patients with severe TBI.
5
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.To read this article in full you will need to make a payment
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References
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.
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Article Info
Publication History
Published online: May 31, 2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2022 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
