DROPPING THE H-BOMB TRAUMATIC BRAIN INJURIES

Bridgette Svancarek MD

FINANCIAL DISCLOSURE

None

OBJECTIVES

Understand the difference between primary and secondary brain injuries

Identify the ldquoH bombsrdquo and their impact on patients with traumatic brain injuries

Know the appropriate prehospital treatment of traumatic brain injuries

Understand why avoiding hyperventilation influences intubation

Understand why avoiding hypotension conflicts with the management of multisystem trauma patients

INTRODUCTION

25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death

FINANCIAL DISCLOSURE

None

OBJECTIVES

Understand the difference between primary and secondary brain injuries

Identify the ldquoH bombsrdquo and their impact on patients with traumatic brain injuries

Know the appropriate prehospital treatment of traumatic brain injuries

Understand why avoiding hyperventilation influences intubation

Understand why avoiding hypotension conflicts with the management of multisystem trauma patients

INTRODUCTION

25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death

OBJECTIVES

Understand the difference between primary and secondary brain injuries

Identify the ldquoH bombsrdquo and their impact on patients with traumatic brain injuries

Know the appropriate prehospital treatment of traumatic brain injuries

Understand why avoiding hyperventilation influences intubation

Understand why avoiding hypotension conflicts with the management of multisystem trauma patients

INTRODUCTION

25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death

INTRODUCTION

25 million ED visitsyear 13 of trauma deaths 1 cause of trauma death

INTRODUCTION

Causes Falls- 352 MVC- 173 Struck byagainst- 165 Assault- 10 Unknownother- 21

At-risk age groups Newborn-4yo 15-19 gt75

INTRODUCTION

Traumatic Brain Injury (TBI)- brain dysfunction secondary to external mechanical force

Primary Brain Injury The initial injury from the mechanical forces Shearing or compression of nerve cells andor

vessels Bleeding edema etc No prehospital treatment for this

INTRODUCTION

Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing

secondary brain injury

THE H-BOMBS OF TRAUMATIC BRAIN INJURIES

Hypotension Hypoxia Hyperventilation

INTRODUCTION

Secondary Brain Injury Additional damage that occurs to at risk areas Results from H-bombs Prehospital care focuses on preventing

secondary brain injury

THE H-BOMBS OF TRAUMATIC BRAIN INJURIES

Hypotension Hypoxia Hyperventilation

THE H-BOMBS OF TRAUMATIC BRAIN INJURIES

Hypotension Hypoxia Hyperventilation

HYPOTENSION

HYPOTENSION

Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury 1 prehospital SBP lt90mmHg mortality 2x

higher Did worse if not corrected in the field

Manley et al Arch Surg 2001 107 patients with moderate to severe TBI 1 SBP lt90mmHg increases mortality 2x 2 or more episodes increases mortality 8x

HYPOTENSION

If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)

HYPOTENSION

Should our threshold be higher than 90mmHg Berry et al Injury 2012

15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher

HYPOTENSION

Should our threshold be higher than 90mmHg Fuller et al Injury 2014

5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality

HYPOTENSION

If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)

HYPOTENSION

Should our threshold be higher than 90mmHg Berry et al Injury 2012

15733 patients with moderate to severe TBI Age 15-49 SBP lt110 mortality 198x higher Age 50-69 SBP lt100 mortality 22x higher 70 or older SBP lt110 192x higher

HYPOTENSION

Should our threshold be higher than 90mmHg Fuller et al Injury 2014

5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality

HYPOTENSION

If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)

HYPOTENSION

Should our threshold be higher than 90mmHg Fuller et al Injury 2014

5057 patients with moderate to severe TBI Admission SBP and 30 day mortality SBP lt120 mmHg 15x mortality SBP lt100 mmHg 2x mortality SBP lt90 mmHg 3x mortality SBP lt70 mmHg 6x mortality

HYPOTENSION

If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)

HYPOTENSION

If SBP lt90 mmHg start IV fluids lt60mmHg in neonates (0-28 days) lt70mmHg + (2 x age)

ldquoPERMISSIVE HYPOTENSIONrdquo

Contraindicated in patients with significant TBI

HYPOXIA

HYPOXIA

HYPOXIA

Chestnut et al J Trauma 1993 Evaluated 717 patients with severe head injury A single oxygen saturation lt90 increases

mortality 2x Prehospital hypoxia common

46 of the patients

Chi et al J Trauma 2006 150 patients with continuous BP and pulse ox during

transport Prehospital hypoxia increased mortality 266x

HYPOXIA

Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation

common Dunford et al Annal Emerg Med 2003

54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during

intubation 84 of the intubations described as ldquoeasyrdquo

HYPERVENTILATION

HYPOXIA

Apply high flow oxygen immediately on anyone with significant head injury Hypoxia during prehospital intubation

common Dunford et al Annal Emerg Med 2003

54 patients with severe head injuries Saturations lt70 occurred in 57 of patients during

intubation 84 of the intubations described as ldquoeasyrdquo

HYPERVENTILATION

HYPERVENTILATION

HYPERVENTILATION

Effects of hyperventilation on cerebral blood flow (CBF) and oxygen delivery CO2 Vasoconstriction CBF

Intrathoracic pressure Cardiac Output

CBF

pH Oxyhemoglobin dissociation curve shift

to the left O2 delivery to tissue

HYPERVENTILATION

Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003

39 of hyperventilated patients died or discharged in a vegetative state

25 of patients with normal ventilation died or discharged in vegetative state

HYPERVENTILATION

Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010

65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg

HYPERVENTILATION

Reduces blood flow and oxygen delivery to the brain

Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates

Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm

HYPERVENTILATION

If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very

common Aufderheide et al Circulation 2004

Ventilation rate electronically recorded in cardiac arrest patients

Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003

40 patients with TBI intubated prehospital 70 unintentionally hyperventilated

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

No evidence to support it Decreases ICP

Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

HYPERVENTILATION

Increases mortality and poor outcomes Lal et al Prehosp Disaster Med 2003

39 of hyperventilated patients died or discharged in a vegetative state

25 of patients with normal ventilation died or discharged in vegetative state

HYPERVENTILATION

Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010

65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg

HYPERVENTILATION

Reduces blood flow and oxygen delivery to the brain

Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates

Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm

HYPERVENTILATION

If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very

common Aufderheide et al Circulation 2004

Ventilation rate electronically recorded in cardiac arrest patients

Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003

40 patients with TBI intubated prehospital 70 unintentionally hyperventilated

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

No evidence to support it Decreases ICP

Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

HYPERVENTILATION

Increases mortality and poor outcomes Dumont et al J Neurotrauma 2010

65 Patients with severe TBI intubated prehospital Mortality 15 if ETCO2 35-45 mmHg Mortality 77 if ETCO2 lt35 mmHg Mortality 61 if ETCO2 gt45 mmHg

HYPERVENTILATION

Reduces blood flow and oxygen delivery to the brain

Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates

Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm

HYPERVENTILATION

If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very

common Aufderheide et al Circulation 2004

Ventilation rate electronically recorded in cardiac arrest patients

Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003

40 patients with TBI intubated prehospital 70 unintentionally hyperventilated

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

No evidence to support it Decreases ICP

Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

HYPERVENTILATION

Reduces blood flow and oxygen delivery to the brain

Keep ETCO2 at 40 mmHg (35-45) Proper ventilation rates

Adults and adolescents 10 breathsmin (bpm) Children 2-14 20 bpm Infants 0-24 month 25 bpm

HYPERVENTILATION

If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very

common Aufderheide et al Circulation 2004

Ventilation rate electronically recorded in cardiac arrest patients

Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003

40 patients with TBI intubated prehospital 70 unintentionally hyperventilated

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

No evidence to support it Decreases ICP

Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

HYPERVENTILATION

If need to intubate or BVM BE CAREFUL Unintentional hyperventilation is very

common Aufderheide et al Circulation 2004

Ventilation rate electronically recorded in cardiac arrest patients

Average ventilation rate 30 bpm Lal et al Prehosp Disaster Med 2003

40 patients with TBI intubated prehospital 70 unintentionally hyperventilated

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

No evidence to support it Decreases ICP

Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

No evidence to support it Decreases ICP

Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

No evidence to support it Decreases ICP

Secondary to cerebral vasoconstriction May result in worsening ischemia Increased morbidity and mortality

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

MILD ldquoTHERAPEUTIC HYPERVENTILATIONrdquo

Maybehellipif clear signs of impending herniation GCS lt9 One or both pupils dilated and nonreactive Extensor posturing or no response Cushingrsquos sign

Systolic HTN bradycardia irregular respirations

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

Target ETCO2 30-35mmHg Initial rates

Adults and adolescents 20 breathsmin Child 2-14 25 breathsmin Infant 0-24months 30 breathsmin

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

MILD ldquoTHERAPUETIC HYPERVENTILATIONrdquo

If unsurehellipDONrsquoT HYPERVENTILATE

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

SHOULD TBI PATIENTS BE INTUBATED

Wang et al Annal of Emerg Med 2004 1797 TBI intubated prehospital vs 2301

intubated in ER TBI ptrsquos intubated in the field worse outcomes

4x mortality 2x moderate to severe functional impairment

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

SHOULD TBI PATIENTS BE INTUBATED

Davis et al J Trauma 2005 Reviewed 13625 patients with moderate to

severe TBI 277x higher mortality if intubated prehospital

BUT WAIThellip

Bernard et al Annal Surg 2010 312 patients with severe TBI randomly assigned

to be intubated prehospital vs ED 13x more likely to have favorable outcome if

intubated in the field

SO IF YOU INTUBATE

Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension

SO IF YOU INTUBATE

Pay very close attention to your H-bombs Hyperventilation Hypoxia Hypotension

SUMMARY

Prehospital management of TBI focuses on the prevention of secondary injury through the prevention and management of the H-bombs

The ldquopermissive hypotensionrdquo concept of trauma care is contraindicated in TBI

MILD ldquoTherapeutic hyperventilationrdquo ONLY be used if clear signs of impending herniation

Prehospital intubation of TBI needs particular attention to avoiding the H-bombs

RESOURCES

httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf

httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E

pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi

101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R

Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective

analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M

RESOURCES

httpwwwepicarizonaedusitesdefaultfilesnewslettersEPIC_Newsletter_December_2014pdf

httpwwwcdcgovtraumaticbraininjurypdfBlueBook_factsheet-apdf httpwwwcdcgovtraumaticbraininjurypdfTBI_Report_to_Congress_E

pi_and_Rehab-apdf Ann Surg 2010 Dec252(6)959-65 doi

101097SLA0b013e3181efc15fPrehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury a randomized controlled trialBernard SA1 Nguyen V Cameron P Masci K Fitzgerald M Cooper DJ Walker T Std BP Myles P Murray L David Taylor Smith K Patrick I Edington J Bacon A Rosenfeld JV Judson R

Prehosp Disaster Med 2003 Jan-Mar18(1)20-3 Prehospital hyperventilation after brain injury a prospective

analysis of prehospital and early hospital hyperventilation of the brain-injured patient Lal D1 Weiland S Newton M Flaten A Schurr M

RESOURCES

Ann Emerg Med 2004 Nov44(5)439-50Out-of-hospital endotracheal intubation and outcome after traumatic brain injuryWang HE1 Peitzman AB Cassidy LD Adelson PD Yealy DM

J Trauma 2005 May58(5)933-9The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injuryDavis DP1 Peay J Sise MJ Vilke GM Kennedy F Eastman AB Velky T Hoyt DB

httpwwwmedscapecomviewarticle585165_3 J Neurotrauma 2010 Jul27(7)1233-41 doi

101089neu20091216Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortalityDumont TM1 Visioni AJ Rughani AI Tranmer BI Crookes B

RESOURCES

httpswwwbraintraumaorgpdfprotectedGuidelines_Management_2007w_bookmarkspdf

httpswwwbraintraumaorgpdfPrehospital_Guidelines_2nd_Editionpdf