Peter Antevy presents an EMS protocol to prevent secondary brain injury by avoiding hypoxia, hypotension, and hyperventilation. Keep SpO2 above 90%, maintain systolic BP around 120-130 mmHg, and hold ETCO2 at 35-45 mmHg. A single episode of either hypoxia or hypotension increases mortality by roughly 150%.
Questions this video answers
SpO2 of 90% or greater.
Non-rebreather at 15 liters per minute (apply to all head-injured patients unless they require ventilatory support).
Maintain systolic blood pressure between 120 and 130 mmHg in adults.
End-tidal CO2 (ETCO2) of 35 to 45 mmHg.
2 grams TXA in a 50 mL bag of normal saline IV/IO using a 60-drop set, run wide open.
Chapters
Let's talk about the TBI protocol. This EMS protocol is focused on preventing secondary injury in patients with head injuries. One of the main goals is to avoid the big three Hypoxia, hypotension, hyperventilation Hypoxia can be prevented by maintaining an SpO2 of 90% or greater. To do this, simply put all trauma patients on a non rebreather at 15 liters automatically. Normally I don't advise the use of liberal oxygen administration, but TBI patients are the exception. The second of the big three is hypotension. This is also to be avoided with the goal of maintaining a systolic blood pressure between 120 and 130 in adults and age appropriate SBP in pediatric patients. These patients can receive whole blood, normal saline and even a pressor to maintain normal tension if needed. Lastly, hyperventilation is to be avoided with the goal of maintaining an end tidal CO2 of 35 to 45 for patients with decreased lock. Maintaining a patent airway is critical to preventing secondary injury. The delayed sequence induction protocol can be considered for patients who are unable to maintain a patent airway and the behavioral emergencies protocol can be used for patients who become combative. Remember, all head injured patients should receive 15 liters of oxygen via non rebreather regardless of SpO2 unless they require ventilatory support. Normal saline should be administered to maintain SBP in adults and age appropriate SBP in pediatric patients. Precautions must be taken in patients with significant coronary heart disease, CHF and renal failure. For patients with a GCS of less than 12, TXA may be indicated. The recommended dose for adults is 2 grams of TXA in a 50 ML bag of normal saline IV IO using a 60 drop set. Run it in wide open. The recommended dose for pediatric patients for TXA is 15 milligrams per kilo diluted in a 50 bag of normal saline. Max single dose of a gram administered iv IO with a 60 drop set. Again, run wide open. Remember, the contraindications for TXA are an injury time of greater than three hours and any medical hemorrhagic shock.
It's important to note that a single instance of hypotension or hypoxia, any SpO2 less than 90 in patients with TBI can increase the mortality rate by 150%. Pressure dressing should not be applied to depressed or open skull fractures unless there is significant hemorrhage present as this can cause an increase in their icp. So in conclusion, this emest protocol emphasizes the importance of preventing secondary injury in patients with head injuries. By avoiding the big three hypoxia, hypotension and hyperventilation and maintaining an appropriate SBP level, we can help minimize the risk of mortality and improve our patient outcomes. Remember to always assess the patient's gcs, consider TXA infusion when indicated and be cautious with pressure dressings in cases of depressed or open skull fractures. Thanks again for watching and stay safe.
