Wilderness and Rescue Medicine 8th Edition

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Wilderness and Rescue Medicine

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 dehy- dration 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 environments. BLS in long-term care includes positioning your patient for airway control, main- taining hydration and calories, and preserving body core temperature. Traumatic Brain Injury A’: Increasing ICP Field Treatment: • Evacuation to hospital level care is ideal • Monitor 24 hours for increasing ICP • Sleep is OK, but not alone

indication of high-velocity impact. A cracked helmet, damaged bicycle, or broken ski suggests a significant mechanism. A more severe injury carries a higher risk of increased ICP. A history of previous brain injury with persis- tent symptoms, especially if recent, is an added concern. A patient taking blood thinning medica- tion like warfarin or aspirin is at greater risk for persistent intracranial bleeding. Extremes of age are also worrisome considerations; infants and toddlers cannot give reliable information and old- er adults are more prone to intracranial bleeding. Elements of a patient’s history 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 worried 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 them 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. They

• Anticipate vomiting and airway obstruction • Anticipate altered level of consciousness • Pain medications (APAP preferred)

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.

High - Risk TBI Wilderness Perspective

General Principles

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• S/Sx of increased ICP • Persistent abnormal mental status • History of previous brain injury • Skull fracture • High-risk mechanism • Anticoagulant medication

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Low Risk

High Risk

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