Monthly Prehospital Care Meeting

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Monthly Pre-hospital Care Meeting
Welcome
25th January 2008
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• Hosted by Pre-Hospital Care (www.pre-hospitalcare
  .co.uk) and Essex Police
• Sponsored
• Multi-disciplinary
• Open forum
• Sharing, developing and learning
• CPD
• Range of activities open to suggestions
• Linked to international PHC projects
• Networking

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• Themed evenings
• Keynote lecture (30 40 minutes)
• Short lecture (10-15 minutes)
• Case Review with discussion
• Literature / Journal Review
• Guidelines / practice update
• Practical demonstration / sessions

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So youre not an anaesthetist.. How do you
manage head injuries at scene?
Dr Aaron Pennell MBBS MSc Medical Advisor to
Tactical Firearms Group Essex Police
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Objectives

• Review the aetiology and pathology of brain
  injury
• Understand the basis for current treatments
• To review the current situation and
  recommendations
• To discuss other options of managing brain
  injuries
• To discuss how this may change in the future

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Aetiology and Pathology

• Around a million brain injuries a year in the UK
• 150 000 minor, unconscious for lt 15 mins,
  recovery in 3-6 months
• 10 000 moderate, unconscious for up to 6 hours,
  some long term sequlae
• 11 000 severe, unconscious for gt 6 hours, 4500
  will need long term care
• and only around 15 will return to work within
  5 years
• More than 120 000 people in the UK are currently
  suffering from the long term
• effects of a brain injury
• Around 2500 brain injuries a day in the UK

Source http//www.headwayessex.org.uk/facts/stati
stics.html
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Function and Anatomy
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Function and Anatomy
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Function and Anatomy
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Function and Anatomy
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Function and Anatomy
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Aetiology and Pathology
Causes of Brain Damage
Contusion
Haematoma
Hypoxia
Diffuse Axonal Injury
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Aetiology and Pathology
D.A.I
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Aetiology and Pathology
D.A.I
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Aetiology and Pathology
D.A.I
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Aetiology and Pathology
D.A.I
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Aetiology and Pathology
Haematoma
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Aetiology and Pathology
Haematoma
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Aetiology and Pathology
Haematoma
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Aetiology and Pathology
Hypoxia and ischemia

• Permanent damage to neurones occur after a few
  minutes if perfusion
• falls below a critical threshold
• Brain looses its capability to autoregulate in
  head injury and is particularly
• vulnerable to hypoxia and ischemia
• Reduction in MAP (lt60mmHg) especially with gt ICP
  causes acute damage
• Brain injury causing unconsciousness causes
  early respiratory deterioration
• and bradycardia and is a sinister cause of
  ischemic damage

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Management
MAP
CPP
HYPOXIA
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Management

• Early airway maintenance
• Early stabilisation of gas exchange
• Restoring and maintaining a functional perfusion
  pressure
• Minimising raising intracranial pressure

• RSI and Controlled ventilation
• Volume perfusion management
• Pharmacological manipulation

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Management

• Rapid Sequence Induction (of anaesthesia)
• Facilitates endotracheal Intubation in those
  with a GCS gt 3
• Permits controlled ventilation
• Maximising oxygenation
• Minimising increased ETC02
• Currently a doctor only skill in the UK
• Also
• Seizure control
• Agitation control
• Makes management more controlled

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Management

• Alternatives to RSI
• Effective airway control
• LMA, OPA, NPA X2
• High flow (15lpm) 02 /- ventilatory support
• Use of benzodiazepines / opiates .(Diazepam,
  Midazolam, Morphine etc)
• May be beneficial for the severely agitated
  patient
• Can have undesired haemodynamic effects if used
  in sufficient doses to
• try and create a psuedo RSI
• Respiratory depression not a problem allows
  for better ventilation IF
• YOU CAN MANAGE THE AIRWAY
• Hypotension will be detrimental if already a gt
  ICP but can use fluids to
• maintain SBP 80-90mmHg
• This is probably a useful alternative for the
  non RSI trained practitioner IF
• THEY HAVE THE AIRWAY AND VENTILATION SKILLS

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Management

• Establishing and maintaining a functional
  perfusion pressure
• IV access
• Current (sensible) debates on what type of
  fluid is best
• Hypertonic saline
• Normal Saline
• Aim to maintain SBP of 90-100mmHg
• Hypotension is bad !

Cooper DJ et al (2004) Prehospital hypertonic
saline resuscitation of patients with hypotension
and severe traumatic brain injury a randomized
controlled trial. JAMA. 2004 Mar
17291(11)1350-7. Lenartova L et al (2007)
Severe traumatic brain injury in Austria III
prehospital status and treatment Wien Klin
Wochenschr. Feb119(1-2)35-45. Links Myburgh J
et al. Saline or albumin for fluid
resuscitation in patients with traumatic brain
injury (2007) N Engl J Med. Aug
30357(9)874-84
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Management

• Pharmacological Adjuncts
• Mannitol NO
• Frusemide - Maybe
• Steriods NO
• Antibiotics Maybe (meningococcal disease)
• Vasoactive agents Maybe in ICU
• Seizures
• Treat with benzodiazepine
• Do not get fraught over resp depression
  ventilate !!!

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Summary

• Major head injuries are a challenge pre-hospital
• While anaesthetic skills are perhaps gold
  standard this DOES NOT
• preclude the delivery of other quality
  interventions
• Airway management and maximising
  oxygenation/ventilation
• Use of opiates and benzodiazepines for the
  difficult to manage agitated
• head injury (rememeer the caveats for this)
• Maintaining a functional perfusion pressure
• Treatment of seizures
• Triage to an appropriate centre

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Any Questions / Discussion ?
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Open Discussion Should ambulance paramedics
be taught RSI
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Journal Review
Strote J, Range Huston H (2006) Taser use in
restraint related deaths Pre Hospital Emergency
Care. 104 447-450
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• Case series of TASER related deaths
  convenience sample
• 2001 2005
• Identified through internet search PM reports
  requested
• Analysed for
• Demographics
• Pre-existing cardiac disease
• Toxicology
• Evidence of excitable delirium
• Restraint techniques used
• Listed cause of delirium

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• 75 cases identified
• 37 PM reports available
• All male 18 50 years
• CV disease found in 54.1
• Toxicology for illicit drugs found in 75.7
• TASER considered a contributory case of death in
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• Cause of death
• Intoxication/stimulant 18 (48.6)
• Cardiac Arrest/arrhythmia 12 (32.4)
• Excitable delirium 3 (11.1)
• Positional Asphyxia 2 (5.4)
• CCF 1 (2.7)
• Undtermined 1 (2.7)

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• Discussion
• Used standard search engines to seek data!
• Role of
• a) Restraint techniques
• b) Toxicology
• c) Pre-existing disease

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