PFC: Closed Head Injury From ATV Crash

Max D

Corvus Training Group
Weekly Case Discussion #2: Closed Head Injury From ATV Crash

Before getting in to this weeks case I want to thank Justin for putting all of these cases together. I usually start any PFC lecture I give with one or more of these cases to drive home the realities of the operational context; a small team operating in the middle of nowhere dealing with a very sick patient with little to no support.

Remember the “Rules”

Cases will be intentionally vague.

There is no “right” answer, it’s a discussion.

You will have each patient for 24 to 72 hours.

Plan for the worst-case scenario. Murphy’s Law is in effect.

No crazy CT or MRI studies. You might possibly, maybe, have an ultrasound. You are in an austere environment and have what a medic would bring. If you aren’t familiar, search the site for “PFC Pelican Packing List” for a basic layout. (It’s at the bottom of that page.)

We want to improve morbidity as well as mortality. Imagine the patient is your own family member.

You will likely have to fly with your patient for 8 hours on a “slick” (no med crew or equipment) aircraft. Be sure to consider both patient and equipment preparation.

You have one junior medic and a handful of non-medics as helpers.

Local blood supply and pharmacy are questionable at best. The primitive lab in town has a turn-around of at least 4 hours for the most basic tests.

Feel free to address the “no-evac-possible” scenario.

Now, on to the case…

A U.S. service member sustains a TBI / Closed Head Injury from an ATV crash (a very common MOI for deployed Special Operations Forces). The patient had a transient loss of consciousness, without any other significant associated injuries. The patient complains of a severe headache, and the medic notices a decreasing trend in GCS while waiting for evacuation…

I’ll add some of the concerns we need to address directly on the blog post this week in the case that you are reading this on Facebook or another site:

Does the medic have a strategy to secure his airway without RSI medications?

Does he know how to properly task his team to help?

Will he devote one person to watch the airway at all times?

What is the plan to keep the patient comfortable with his ET tube for the next 24 hours?

Will he call for help? Will he remember the Clinical Practice Guidelines for management of the head injury?

Does he know how to properly trend a GCS?

What other concerns do you have?
Just thinking out loud here. My immediate concern would be airway compromise and a possible spinal injury. Secure the airway and immobilize the head and spine first. Because of the high possibility of a head bleed I would be watching hard for signs of increasing intracranial pressure with the worst case scenario being herniation. So a well detailed and accurate log of vitals every 5 minutes, including: blood pressure, heart rate, respiratory rate, lung sounds, pulse ox, capnography, pupils, blood sugar, and GCS would be extremely valuable to me to be able to monitor and detect any patterns in changes. Increased BP, nausea/ vomiting, headache, blurred vision, decreasing mental status, confusion, sluggish/ nonreactive/ unequal pupils, irregular breathing patterns, these are all signs of increasing ICP to be looking out for. If there were signs of Increasing ICP I have to intervene and breathe (hyperventilate) for them to keep their capnography reading lower than normal, shooting for around 30 instead of 35-45. This is only a temporary treatment though and as soon as it is stopped ICP and pH will increase again. Have an airway kit with suction in arms reach and be ready to intubate if needed. I would be pretty hesitant to give anything to eat or drink even prolonged field care due to the possibility of vomit or airway obstruction and especially since they are altered you should give nothing by mouth. I'd also be hesitant to give any fluids or glucose because they could increase intracranial pressure, but the other half to that possibility is a low BP so give enough fluid needed to keep a systolic BP of at least 90. And I'd be hesitant to give any sedatives in place of RSI medications because they are altered and I want to know their true GCS. But, if they are conscious and you need to intubate a gag reflex can also increase ICP so it may be necessary to use a sedative. Working as a civilian medic I have the luxury of making base hospital contact early and I'm not more than an hour away from even specialty hospitals by ground or by air so for me prolonged field care is not something I am familiar with but would like to become familiar with. This person would go to the closest and highest level (preferably level 1 if available) trauma center. Please feel free to correct me or ask me to clarify anything. And please add anything I that missed. I would also be interested in hearing some prolonged field care treatment suggestions because that's all brand new to me.