Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Wilderness and Rescue Medicine

of memory after the event. There may be bruis- ing and swelling of the face and scalp or other indication of high velocity impact. A cracked helmet, damaged bicycle, or broken ski suggests a significant mechanism. More severe injury car- ries a higher risk of increased ICP. A history of previous brain injury, especially if recent, is another red flag. A patient taking blood thinning medication like coumadin or aspirin is at greater risk for persistent intracranial bleeding. Extremes of age are a red flag; infants and toddlers cannot give reliable information and older adults are more prone to intracranial bleeding. A red flag or two like these can make the diagnosis of TBI more serious. All of this helps to answer the essential questions: How severe is the TBI? Are there other factors that increase risk? How wor- ried am I about increased ICP? Field Treatment of Traumatic Brain Injury Generally, increased ICP from trauma will mani- fest within the first 24 hours or so if it is going to happen all. In a remote setting, it is ideal to evacuate a TBI patient early rather than waiting for increased ICP to develop, but this need not be an emergency. Simply moving your patient closer to medical care may be sufficient in low risk cases. If you choose to keep the patient in the field, it is important to monitor him closely during that first day. The patient should not use opioids or stimulant drugs or drink alcohol because this will confuse your assessment of mental status. Someone should always be with the patient, but it is not necessary to keep the patient awake. He will not sleep through the pain and vomiting of increasing ICP. High risk TBI should be evacuated directly to a level I or II trauma center, if possible. Because vomiting is one of the signs you’re watching for, you must include airway obstruction and dehydra- tion on your anticipated problem list. The patient will not be moving around much and is at risk for hypothermia in all but the warmest of environ- ments. BLS in long-term care includes position- ing your patient for airway control, maintaining

hydration and calories, and preserving body core temperature.

Traumatic Brain Injury A’: Increasing ICP

General Principles

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Field Treatment: • Evacuation toward medical care is ideal • Monitor 24 hours for increasing ICP • Sleep is OK, but not alone • Anticipate vomiting and airway obstruction • Anticipate dehydration and temperature problems • Anticipate altered level of consciousness • Pain medications (APAP preferred)

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Risk Versus Benefit in TBI Deciding what to do with an obvious high risk TBI, especially where increased ICP is already developing, is easy. This is a serious critical system problem and the patient needs to be in a hospital right now. If evacuation is impossible or extremely dangerous, the plan is still straightforward; good basic life support and protection until evacuation can be safely accomplished. Lower risk TBI creates more of a quandary when your evacuation options are less than ideal. Most of these will recover without serious problems and the risk and expense of emergency evacu- ation usually exceeds any real benefit. This cre- ates the common backcountry medical dilemma: Evacuate now, or wait and watch? There are no absolute rules to fit every situation, but there are some general guidelines to help with your risk/benefit assessment. As mentioned above, there is a low probability of increasing ICP when mental status returns to normal shortly after the event. By “normal” we mean awake, alert, and making sense. By “shortly”, we mean within three hours or so. During this observation period you should see steady improvement in memory and mental status. If so, there is no emergency and medical follow up can be delayed if necessary.