I'd like to thank everybody for joining us today. I'm Kyle Cunningham. I'm the Associate Professor of Surgery here at Wake Forest School of Medicine in Charlotte at Carolinas Medical Center. I have the privilege today of moderating the first in a series of webinars on traumatic brain injury presented through the Education Committee of TCAA. Our first speaker today is going to be Dr. Eric Ernest. He's Associate Professor and Chief of the Division of Pre-Hospital Emergency Medical Services and the State of Nebraska Medical Director. So he's going to be speaking to us about traumatic brain injury from the pre-hospital setting as it stems in through emergency medicine into the inpatient setting. So without further ado, Dr. Ernest. Awesome. Well, thank you, Kyle. And I appreciate the invitation to come and speak to everyone today. So as you mentioned, my name is Eric Ernest and I work both clinically as an emergency physician at a level one trauma center, as well as a small community hospital. And then a large part of my activities is based in pre-hospital medicine. So kind of get to see that front end of a lot of different pathologies. But today will be specifically traumatic brain injury, which I've had grow near and dear to my heart here recently, especially with some of the things that EMS and the pre-hospital side are focusing on and trying to make a difference for these patients. Because as we know, with these patients, there comes a lot of morbidity and mortality. And I think the ability to focus on some of the things that we can do on the front end that really do have an impact on the back end and their ability to get back to normal life I think are very, very important. So just by way of quick disclosure that the opinions expressed here are my own and not attributed to TCAA, but hopefully this will all be found within evidence-based medicine, or references cited and whatnot. So I just want to provide the quick disclosure slide. So some of the goals and objectives for this talk will be recognize the difference between primary and secondary brain injury, which I think is important, especially on the secondary brain injury side of things and how we can mitigate some of the effects of secondary brain injury. And then specifically things like hypotension, hypoxia, and hyperventilation, and how those can either extremely help or extremely hurt these patients. And the importance of early intervention and improved outcomes. And so I think this will hopefully focus not only on the initial ED care, which is obviously important, especially if you're working at critical access hospital, but frequently we find a lot of our emergency medicine colleagues, whether they be EM boarded or family medicine or whatnot, who are overseeing EMS agencies and having that close interaction with EMS. And so making sure that we're advocating to those that has a lot of morbidity and mortality. I do want to recognize that a lot of these slides and material were drawn from the work done down at the University of Arizona with the EPIC-TBI trial, as well as the EPIC-II trial and the Arizona Emergency Medicine Research Center. They were the pioneers when it comes to, especially pre-hospital management and TBI, but I think this extends also into ED as to the things that we really need to be concerned about these patients. So we'll start off with a case, just kind of get our mindset in place of the type of patient that we're dealing with. So a 16-year-old male cutting a tree down in his backyard, partially cut branch broke loose and struck him in the back of the head. And the patient is currently unconscious. On EMS arrival, the patient's GCS is six with sonorous respirations. His initial vitals, 84 over 60, pulse of 110 respiration rate at six and SpO2 of 91% on room air. And so although our EMS patients don't typically come in hospital gowns, the picture that you see below is similar to how this patient is presenting in terms of his posturing. So with that, some things to think about, what are your first steps and what are your priorities in management? Does this posturing affect your ventilatory strategy? And we'll touch on the idea of hyperventilation for impending herniation, whether or not that's a good idea or not. And then the idea of permissive hypotension, which is obviously a thing that has been around in the trauma world for quite some time at this point. And this idea that we don't want to quote pop the clot, especially for multisystem trauma, but how does that specifically relate to traumatic brain injury and whether or not any form of hypotension is good for the brain, especially with isolated head injuries. So we'll get into all those topics here as we kind of move through the talk. So just to start out with some basic definitions to really define traumatic brain injury, I think we all have a sense of what that is, but I'm looking specifically at the definition. So this is caused by any kind of forceful bump, blow, jolts, anything to kind of impact the head. And not all of these things do result in traumatic brain injury, but when they do, obviously that becomes a much bigger deal. So subdividing that into two main categories, penetrating and non-penetrating TBI. And as you would imagine, penetrating TBI, anything that pierces through the skull, whether it be a bullet, piece of shrapnel, bone fragment, a specific weapon, anything that kind of enters the brain tissue from outside. And typically, unless it's a rather large insole, typically this is only damaging part of the brain. Whereas we contrast that with non-penetrating TBI, and this is basically anything to a force that's strong enough to move the brain within the skull. And this is the things that we think about in terms of falls, motor vehicle accidents, sporting injuries, especially impact sports, you know, football, hockey, that kind of thing. Blast injuries, and then any kind of object that struck the head that didn't necessarily penetrate it, but obviously imparted energy to the skull and the brain. So when we think about primary injury, this is the damage at the moment of impact, and we really cannot fix this. So I mean, the CT scan on the right is probably recognizable to a lot of you, but this is a gunshot wound to the head. You can see the track that was impacted by the bullets, and that area of the brain, there's nothing that a neurosurgeon or anyone else can do to go stitching neurons back together or healing the brain completely and making it back whole. And so the damage is already done at this point. We're not going to necessarily fix this part of it. It's really the secondary effects that are really what is going to impact this patient's overall outcome if the primary event wasn't enough to take their life initially. So that's where we really get into secondary brain injury, and that's really going to be the focus of this talk in terms of what can we do to mitigate the effects after that initial trauma. And so a lot of that secondary brain injury is caused by systemic hypoxia. So in our initial case, maybe someone was knocked unconscious, they have a depressed GCS, and maybe they're not respiring all the best or they're having an included airway because their neck or their head is scrunched down or something of that nature, as well as anything that causes poor CNS blood flow. So whether that be some kind of increased intracranial pressure or decreased cardiac output, any of those types of things that overall decrease CNS perfusion. And this really is where the major impact is found in terms of our outcomes and traumatic brain injury. And this is where we can actually make a huge difference. So the goal is really to try to prevent any kind of secondary brain injury as much as we can. And so the why. So no offense to our neurosurgical colleagues, but a live brain is worth a roomful of neurosurgeons, meaning that if we deliver a patient either initially to the ED or transfer them to a tertiary care facility, and we haven't paid attention to some of these things that revolve around traumatic brain injury, and the patient basically arrives brain dead, it's kind of all for naught. And so this is really where excellent EMS care, that initial care in the emergency department can really improve traumatic brain injury outcomes. And the stakes are high, right? I think we can all relate to the idea that at some point in time in our careers, we either have encountered a patient or we know a family member or some kind of acquaintance that has had a traumatic brain injury. And we know that these are a huge burden, right, to the health care system. These are patients that stay for extended periods of time in long-term rehabilitation. They may need long-term care back at home, and a lot of these people won't return to their normal lives, going back to work, that kind of thing. And so the idea being the stakes are high that we can take a mild to moderate primary TBI and convert that into a severe traumatic brain injury just due to improper management. And so again, let's not make the damage any worse than it originally is, and let's do what we can to try and improve that as much as possible for these patients. So as I mentioned, a lot of this is coming from the EPIC trial. So a huge shout out to Dr. Spade and Dr. Bowbrow from University of Arizona, two emergency physicians and EMS physicians who really took this to task and tried to figure out on a systemic level how to improve traumatic brain injury care and outcomes. And so this was a huge statewide effort, primarily focusing on some of the big cities within Arizona, but then it did expand to an entire statewide effort. And that is where the EPIC TBI trial came out of. So what is EPIC? It was, as I mentioned, statewide implementation of the Brain Trauma Foundation as well as National Association of EMS Physician Guidelines that basically kind of laid out what are best practices in terms of managing these patients and the idea of linking both the pre-hospital and hospital outcome data, which is not as always easy as it may seem, and really trying to garner some good data as to how these patients do when their care is transferred from the pre-hospital realm into the hospital realm. And this really was the first ever project of this kind. And so, you know, I'm sure a lot of you are very familiar with the NIH funded studies and other big things. And usually this is revolving around cancer care or cardiac care or these other huge topics. And the fact that a pre-hospital study got picked up by the NIH and had the funding and the backing that it did, at least for those of us in pre-hospital medicine, we're quite ecstatic when this happened just because we don't, you know, stuff that happens pre-hospital doesn't often get picked up by the NIH. So and at the end of the day, it demonstrated that that initial care that these patients receive, especially from EMS, can dramatically improve their survival. And we'll go through some of the statistics here in a second. So just a quick background on EPIC, the EPIC trial, so this is a little over 20,000 patients. Their pre-implementation phase included about 15,000 patients and post was about six and a half thousand patients, a small cohort of those, 4,000 of which were intubated. So data collection was going on from 2007 to 2015. They did all their analysis, cleaning all the pre-publication stuff through 2019. Then they eventually published in 2019. They did a subset analysis and looked specifically at pediatrics and published a second study called EPIC for Kids that really focused on how we can help our pediatric population as well. So again, you know, for those of us in academic medicine, we're very, very familiar with JAMA and other things. But the fact that pre-hospital studies are making it into a, you know, having a manuscript in a journal like JAMA is huge. And so this was the initial EPIC study published, like I said, back in 2019, and basically that they said that if we implement these pre-hospital guidelines to try to target our severe traumatic brain injury patients, that we were pretty much doubling survival amongst those with severe traumatic brain injury and then tripling the survival in the severe intubated cohorts. So, I mean, you talk about making huge leaps in not only pre-hospital care, but overall trauma care. This really was kind of a foundational study that really kind of moved the needle. This was the second study published in Annals of Emergency Medicine that focused on the kiddos. And so basically they showed even better improvements when utilizing these guidelines or protocols. And, you know, a lot of that probably has to do with the plasticity of a pediatric brain. But the fact that, you know, we can make even better or do even better for our pediatric patients and have better outcomes really was amazing. So that was published in Annals of Emergency Medicine. So kind of the key takeaways without digesting all those articles in a huge amount of depth is that overall we found a lower rate of intubation despite greater injury severity. There is a much higher rate of BVM only airway management. So less focus on definitive airway management, which, you know, depending on your EMS system and the success rate of your people that are intubating, sometimes intubation can actually do more harm than good. And so the patients coming into the ED had a much higher likelihood of having a SpO2 of 100%, which we'll talk about why that's important here in a little bit, and that they had a greater reversal of hypoxia by the time they arrived at a trauma center. So also going along with just the overall resuscitation of these patients, a greater likelihood of them receiving a fluid bolus for being either hypotensive or near hypotensive, and also a greater volume of fluid boluses in the hypotensive and near hypotensive patients. And then also decreasing our rate of hyperventilation, which I think any of us who do any kind of airway management realize that especially in a charge situation, you have someone with significant injuries that our adrenaline as providers is going. And so the ease of which that our hands, especially if we're doing the bag valve mask, go way faster than they should is not helpful. And so we'll look at why hyperventilation and lowering the rate of hyperventilation helps the patients as well. So not getting too far into the weeds, this is not an overall evidence-based medicine talk, but it is worth noting some of the statistical stuff that came out of the epic trial. And this was looking at the adult cohort. And so when we looked at the severe TBI patients, we basically we you know, so for those who are not familiar, basically when we looked at adjusted odds ratios, we kind of use this cut point of one. And so anything below one is more of kind of a deleterious effect that we're not getting what we want. We're not having the outcomes we want. Anything above one, we start getting excited. And, you know, a 1.2, a 1.5, I mean, this is saying that the study is doing what we're hoping it does. We've made some kind of intervention and we're seeing a positive result from that. When we start getting into these ranges of two, three and greater with these patients, that's, you know, that's when researchers are getting really, really excited. And, you know, we're not using some kind of weird outcome measure that survival of the hospital discharge, which is what we all want, is, you know, that the patient can go home and hopefully lead somewhat of a normal life. You know, this is really kind of what we're looking for. And so the adjusted odds ratio for the severe TBI and then the cohort that was intubated, we're seeing some pretty good improvements. And what they found overall is that on average, twenty nine minutes of EMS care was able to affect survival of the hospital discharge, which there's not a lot of things that we do in the pre-hospital realm that, you know, can have that kind of an impact. And so, you know, to see that we were we were pretty excited by that. So when we look at the kiddos, we're seeing even better results in terms of their outcomes. So in the TBI, severe TBI cohort, our adjusted odds ratio is up at five. If they got positive pressure and ventilation, we're moving up to almost seven and a half. If they got an advanced airway, again, five. And then if they had endotracheal intubation up above five. So, I mean, these these these numbers are huge for those that maybe don't get themselves involved in statistics on a regular basis. Just I guess you can trust me to say that with these adjusted odds ratios, this is exciting stuff. So. So number one takeaway that, you know, this this is something where we see a quantum leap, so to speak, in in overall outcomes. Right. So when we do things in medicine, like sometimes, you know, we see the slow incremental change. We'll make little changes here or there. We get, you know, get maybe a little bit better outcome. We change things again. And it's kind of a slow stair-stepping process. And when the results of this came out and just seeing how big of an outcome difference this was, you talk about just this huge leap in quantum leap almost in outcome. So, again, very, very exciting stuff. And then the also the awesome thing about this is that the interventions are they're they are very, very simple, so to speak. There are things that we already do that we train EMS to do. The things that we we should be doing in the emergency department, I stress with my residents and my staff where I work that, you know, we have all kinds of fancy machines. We, you know, ultrasound and all this fancy stuff. And sometimes it's just doing the basic things correctly. That's and if we forget some of those things, all the fancy machines and expensive things, it doesn't really matter at the end of the day. So the great thing, especially for EMS, is that this is not a new drug. This is not a new device, if you will, that EMS providers and also emergency department staff, we know. I get access, we know how to get fluids, we know how to invade and ventilate. And it's just these simple interventions that are done really, really well that are going to make the difference here. So, as I said, interventions are simple, no expensive equipment, don't require extensive training, and they're very implementable across a wide variety of EMS systems, critical access hospitals, even at tertiary care centers where we are receiving these patients for definitive care, making sure we're doing the simple things right is most important. The thing is, though, that just because they're simple interventions does not mean that they are easy, and I think anyone in medicine who's been doing this for any amount of time knows that to try to keep, you know, on top of something and to keep doing it consistently and well every single time does take someone to look at that and takes observation and monitoring and things of that nature. And so making sure that we're keeping everyone in tune with that, that is really where the challenge becomes a lot more significant. So, for the sake of this span to kind of talk about the patients that we're dealing with, and this kind of alludes to our initial case, is so who is an EPIC patient? And basically it's someone who's experienced some kind of trauma, even ground level fall with either sufficient enough injury to be transported to a hospital and any kind of loss of consciousness. And so sometimes this can be a little bit difficult. EMS has a tough time figuring this out. We have probably even more difficult time once they hit the hospital because we're relying heavily on the EMS report. But really any kind of, if the patient is alluding to any kind of transient alteration in their consciousness, so they were out for a few seconds or I saw stars or I'm not remembering, repetitive questioning, which is a common one, especially when we see these patients initially in the pre-hospital realm, when they're asking, how did I get here? What happened to my car? How did I get off the highway again? Where they have just that perseverating questioning can be one of our first indicators of some traumatic brain injury. Altered mental status, but that doesn't, just because they may have a GCS of 15, that doesn't exclude major TBI as we probably have all seen that there are pathologies, intracranial bleeding, things of that nature where someone may start out with a GCS of 15 and they quickly decompensate. And so really having a strong kind of suspicion and really trying to get into the story of what exactly happened and keeping that bar relatively low to try and initiate some of these treatments in order to stave off or prevent any worsening of their traumatic brain injury really comes into play there. Also patients that had any kind of seizure associated with their trauma, obviously we have the patient cohort that, they have a known history of say epilepsy or seizures at baseline, maybe alcohol withdrawal. And certainly that can be the cause of their trauma. They can be driving their car, have a seizure and then they go crash off the road. But obviously the ones that are more concerning is that if they didn't have a seizure history and they suffered some kind of trauma, blow to the head and they have a post-traumatic seizure, certainly we want to be concerned about those folks. And then any multi-system trauma requiring positive pressure ventilation. So when you think about the pathophys, if someone's respiratory center in their brain is not working so well because of that injury pattern to the point that we need to assist them with positive pressure ventilation, either basic with a BVM or we're putting in an advanced airway, any of those types of things we would want to consider these patients as a potential traumatic brain injury patient. And then risk factors. So I hate to say this now that I'm over the age of 40, but older age, so anyone over 40, and then certainly our population that are on anticoagulants, whether it be Coumadin, Eliquis, any of your DOACs, things of that nature, those are all going to be predisposing risk factors for TBI. So what if we don't know if they had an LLC? So again, head injury patients, they can be poor historians. They can have that repetitive question. They may not know what exactly happened. And so that's really where we consider the whole scene and where it's incumbent upon EMS to consider the whole scene but then also being able to relate that whole scene to the emergency department as to what they're seeing and to kind of put those pieces together. So what was the trauma specifically? What kind of physical exam, especially initial physical exam? Were they moving everything initially and then now they're not moving everything? Certainly the mechanism can kind of lead us down that road. Although I try to caution people that just because the car rolled doesn't mean that they need a backboard, a seatbelt and everything else, that we consider that with our physical exam. But certainly mechanistic factors, crash the car at 80 miles an hour certainly will have a higher degree of suspicion in those patients. And then reports from others of loss of consciousness. So if the police bystanders, people of that nature. And I always encourage, when we're in the trauma bay with my residents or if I'm out in the community, I always try to ask people who are coming in, whether it be EMS that's dropping the patient off, if it's the state patrolman who's come in after cleaning up the rec scene and talking to them and find out what they know about it. Certainly any bystanders that they happen to be available, all important sources of information. And then if the patient is perseverating, again, that repetitive questioning, and then we talked about the risk factors. So when in doubt, we treat with the EPIC protocol and there'll be some QR codes at the end of this and this is all publicly available information. So I'm not sharing anything out of turn from the University of Arizona, but this is their algorithm that they came up with. And we'll go through all these pieces. So I'm not gonna spend too much time right now on this, but just suffice it to say that there is a nice algorithm out there to help kind of guide us in this. So this presentation was initially developed for EMS. I say the joke about EMS being the express mail service. So if you've ever ordered anything from China, that is the people that use it. And so delivery time created seven business days, which isn't all that fast. But all jokes aside, obviously getting a live body with a dead brain to the hospital is really just a dead body. And so we really wanna focus how do we not only deliver a live brain, but keep that brain alive until they can get definitive care and hopefully be able to leave the hospital. So we're gonna talk about the three H-bombs. And again, going back to why I've kind of developed a passion for this, especially with my pre-hospital folks, but I think this applies just as much to ED in terms of the three very simple things, right? And I mean, it's easy to get caught up in all the goings on of a trauma bear or a cessation or whatnot. And some of these things can just be overlooked. Or we think about after, you know, say hypoxemia, it's like, oh, now we're thinking about after they've already dropped their O2 sets into the 80s. Or, you know, we noticed that they're having a slightly declined blood pressure. Are we aggressively treating that right off the bat? So again, simple things, but making sure that we're in tune with those when these patients come in is gonna make all the difference. So the three H-bombs of TBI, hypoxemia, hyperventilation, and hypotension as things we all want to try to avoid. And so we'll go through these things in turn. So oxygen administration is critical. And I think there's been, the tide has shifted, especially in O2 administration. We used to give oxygen to everything that moved, and then we pulled that back, realizing that we were maybe causing damage. And this is actually one area where the risk of any kind of untoward effects of oxygen are far outweighed by the benefits and the potential damage that we do if these patients do experience an episode of hypoxia. So one episode of hypoxia in this patient cohort can up to double the mortality of these patients. And so that's worth remembering. And that good BLS airway management skills are critical, that if there's any concern that this patient even may get hypoxic, or they're starting to get sleepy, or they're kind of nodding off, anything that would depress their respiratory drive, making sure that we're intervening on those things early. And realizing that patients can deteriorate rapidly, right? I think we've all seen that patient that comes in walkie-talkie, and all of a sudden they are not so responsive, and maybe showing signs of brain herniation, or lateralizing symptoms, things that to suggest that they're having something neurologically going on. And so really trying to prepare for that unexpected crash. And just like when we think about with advanced airway management, we always talk about pre-oxygenation, and realizing that the patient may not be breathing so well after we paralyze them or whatnot. Along the similar lines that we really are trying to make sure that if they do start to deteriorate, that that O2 set stays up, and that we are not experiencing any hypoxia. So not to be too extreme about it, but I don't think there's any such thing as too much oxygen in a traumatic brain injury patient. So, and as I mentioned, the risk of hyperoxia in the short term is dwarfed by the risk of failing to pre-oxygenate and prevent hypoxia in these patients. So the idea of aggressively preventing and treating this. So we do want to try to keep the threshold above 90, and the approach is that any potential TBI patient that we are considering this. So if it's someone that came, initially their SATs were maybe 99%, and they've gradually been kind of trending down, maybe they got some narcotics for their pain that they experienced from something from their trauma, and maybe they're a little bit, they're not respiring as well, making sure that we're anticipating that, especially for anyone that's lost consciousness. So, and especially if they're, even if they're exhibiting normal mental status and have a good pulse ox, again, we want to make sure we're considering those things. What I tell the EMS folks is that, you know, we want to be thinking about these things even before the patient is extricated from the car, at least getting a pulse oximeter on them if it's going to be a prolonged thing, or if there's any concern and getting the oxygen on them sooner than not. And usually we do this via high flow O2 by not wearing their mask. So we already talked about no such thing as hyperoxygenation for these patients. We'll see how well this plays on the webinar here, but, so I just highlight this one. So this is a motor vehicle wreck, head-on collision. The patient that was pulled out had to be extricated, and they keep asking, you know, what's happening, what's happening? The other vehicle, there's no survivors, which that's the other vehicle. So what is your assessment? So we see the flight crew loading this patient up, and you can see, you know, that this patient is on no monitoring, right? And obviously he's moving his arms, but, you know, we think, oh, okay, so they're awake, they're alert, you know, what's going on there? And the reason I close with the helicopter scene is, as we know from our flight medicine colleagues, that as we go up in altitude, short of being in a pressurized cabin, which is not going to be for the helicopter, our partial pressure of oxygen is going to go down. So if you had someone who's already hypoxic, and we're starting to lift off and take those patients to definitive care, again, the risk of hypoxia can be great if we are not monitoring those things. So again, early monitoring is important. So any sign of inadequate oxygenation, BBM. If we need to use some kind of airway adjunct, either an OPA or an NPA, if possible, and then we don't want to over-ventilate these patients, and we'll talk about that here in a couple of slides. In terms of advanced airway, you know, this equation is slightly different for those who are working in the emergency departments, but at least if you're working with pre-hospital providers that trying to advocate that advanced airway only if inadequate. And a lot of times these patients can be managed quite successfully with something like a supraglottic airway or some other kind of airway adjunct, as well as bag valve mask ventilation. And the reason we kind of hesitate on the advanced airway, and I would say this also for critical access hospitals and whatnot, that if it's something where you are not sure if you can get the airway or there's concerns about maybe anatomy or just the ability to get the tube, you know, realizing that if they're not properly set up and, you know, pre-oxygenated and all the things in regards to advanced airway management, you can actually end up doing more harm than good just by trying to place that advanced airway and getting the endotracheal tube in. So obviously if someone's vomiting, if they have a high risk for aspiration, if we're talking about a long distance transfer to tertiary care, and that you're anticipating that advanced airway need, then obviously initiate that. But if they're able to be managed with less invasive means, or you have any question as to your ability to get that advanced airway, I'd say go less is more in this situation. So especially during intubation, we do not want hypoxia. And so again, we can double someone's mortality and really worsen that secondary injury. So making sure we are keeping our patients well oxygenated. And if we choose to intubate, this is, again, you know, we may give each other high fives and say, great, you know, we got the tube in, but again, the management post intubation is going to be key as well. And so making sure that we're meticulously monitoring things like rate and depth, adequate tidal volume, obviously any kind of advanced airway is going to deserve an end tidal CO2, but making sure that we're keeping that in range as well, and then monitoring their SPO2. And like I said, if you don't do those things correctly, this is actually worse than just a BLS maneuver and not having an airway in place. So got to make sure we monitor those things appropriately. Especially for the kiddos. And so for those who may not be familiar, the literature on advanced airway management for pre-hospital pediatric care is not great. It's unless you're a pediatric specialized transporter or your agency has a lot of training in this. We usually don't recommend intubation of pediatrics just because it is something that there's not a lot of exposure to and the risk of an esophageal intubation or just mismanagement, main stemming, the endotracheal tube, all those things can kind of come into play. So a lot of times with the kids and what came out of the Epic for Kids study is that basically the basic airway maneuvers are fine. BVM, O2, airway adjuncts as needed, and that it is safe in most instances. And that we should really be reserving superglottic airways or endotracheal intubation if the basic efforts fail. And again, high aspiration risk, long transport time may be more of a consideration if they're already in the ED, this may be, and you're planning on shipping them to like a level one trauma center or something like that. That's certainly a consideration, but just realizing that pediatric intubation is not always, I apologize, is not always available. So anyway, going on to the next one here. So next one is hyperventilation. And this really, I think, is another one where trying to coach those people that are directly intervening with the patient's airway is really important. I've gotten to the point where I have actually had to tell my respiratory therapist in the ED to slow their bagging down. And I got probably one of the nastiest looks I've ever gotten in my career, basically telling me to stay in my lane. But it's one of those things where, we don't just have anyone bag these patients because the idea of hyperventilation and restricting that cerebral blood flow really is a huge deal. So we wanna make sure that we're preventing any kind of hyperventilation. In the pre-hospital world, we coined the phrase, and this is not a kind of officially recognized title, but the ventilatory EMT. And unfortunately, pre-hospital, we usually give the bag to the least experienced person there, the probationary person, be like, here, here's the bag, squeeze this every so often. And that's probably not the right strategy. It's really trying to pay meticulous attention to your ventilatory strategy, making sure you have entire CO2 if available, and really trying to keep it titrated within a tight timeframe, or a tight window, excuse me, is really gonna be important. So, and then if you do properly ventilate, for me, those who have not had as much experience on the bag-belt mask, that you really do feel like you're hyperventilating these patients. Going once every five to six seconds feels like an eternity, especially if you have someone who's decompensating, who has a depressed GCS, some kind of major trauma, it really does feel like you're hyperventilating these patients. And often we're going too rapidly, we provide too much volume with the bag-belt mask, and too much pressure, and all those things are not helping our patients at all. So, I teach, in terms of adjuncts, some simple things, and again, none of this is requiring expensive equipment, or fancy ventilators, and things of that nature. What I teach my EMS folks, and I also tell the people that are working with me in the ED, that we don't need to empty the entire bag-belt mask into the patient, or the entire bag of the bag-belt mask into the patient. That we can use a two-finger technique, which really ends up being a three-finger technique, where you basically have your two fingers on the top, and your thumb on the bottom, and that much squeeze is usually enough for your average adult-size patient to ventilate them properly. And then stepping that down a little bit for kiddos, that anyone under the age of 15, the one-finger technique, which is really just finger and the thumb, and middle of the bag, and that's usually enough to get good chest rise and fall with these patients. So, we do want to make sure that we're using, if we have the ability to use a flow-control bag, we can, but it's not absolutely necessary. And then if you really want to get fancy, a ventilatory rate timer, which can be as simple as a flashing light, that can also help with these patients as before the pre-hospital folks. So, in terms of ventilatory rates in adults and kids, just being very mindful of at what rate we're ventilating them. So, for infants, anyone up to two years of age, we're sticking around 25 breaths per minute, kiddos, two to 14 at 20, and then adolescents and adults, basically anyone 15 and above is about 10 breaths per minute. And then really what we're going for is an entire CO2 of 40. And so, the range they can give is 35 to 45, but if we can try to titrate that to an entire 40, that is ideal. So, we talked about some of these things in terms of flow-control, reduced volume DVMs, the rate timer, target Intel CO2, just kind of going through all these things that coming up with a packaged way of trying to deal with this is really gonna be helpful. So, this whole idea about what about cerebral herniation, for those who may not be familiar, the old kind of thought on this is that if we did see signs of herniation, that we can somehow salvage these patients with hyperventilation. And the idea being that we would cause cerebral vasoconstriction and not allow as much blood to go into the brain, thereby decreasing intracranial pressure. And then hopefully that this patient's brain is not gonna herniate out through their foramen magnum. The problem is, is that if they have something that is causing this, i.e. usually it's a bleed, it can be epidural or otherwise, usually your ventilatory strategy is not going to salvage them from that. These patients need a neurosurgeon and an operating room sooner than not. And that this, the idea of trying to hyperventilate these patients really is not going to save them from their underlying pathology. So, and the other problem is that non-herniating patients can actually mimic herniation. And so sometimes the physical exam on these patients can be incredibly challenging. And unless we have a CT scan that can kind of confirm if they got blood on the brain or if they're having that midline shift or evidence of herniation, sometimes just by physical exam can be a little bit different. So, a lot of people can come in with posturing and they're not necessarily herniating. They can have unequal or dilated pupils. They can have decreased movement on one side. I mean, maybe it's like a Todd's paralysis where maybe they seized prior to their trauma and they're hemiplegic for a different reason. They can also have other breathing abnormalities due to metabolic reasons or things that may have nothing to do with their traumatic brain injury. And so, especially for the pre-hospital, but I'd say also in the ED, this idea of hyperventilation really has no chance of improving outcome. And actually the harm that you can cause in hyperventilating someone who's not necessarily herniating or has traumatic brain injury can actually be doing more harm to our patients. So the last H-bomb is going to be hypotension. And this is really for anyone 10 years of age or up, that our goal is going to be systolic blood pressure greater than 90. And so we can do this by initiating a 1,000 cc fluid bolus and then repeating that at 500 cc fluid boluses. Certainly if we have the privilege of being at a facility where we have access to blood products and we're concerned that this is some kind of hypovolemic event, certainly all the considerations for blood transfusion come into play at that stage. But if we're dealing with, say, critical access hospital, pre-hospital, and maybe we don't have ready access to blood products, trying to keep their blood pressure up as much as we can above 90 is really going to be important. And again, this all has to do with cerebral perfusion pressure. And obviously if we have low systemic pressure, that perfusion pressure of the brain is going to drop dramatically. And really we do want to try to consider this before the patient becomes hypotensive. So again, trending of the vital signs as that blood pressure may start to kind of dip down, maybe they started out 130, 140 systolic, and now they're 110, 105, if we're seeing that downtrending in systolic blood pressure, if we're having a downtrending MAP, that'd be something where we'd want to definitely consider initiating fluid boluses earlier than not. In terms of hypotension in our less than 10-year cohort, so there's a lot of different ways to figure out what pediatric vital signs should be, whether you're using a Braslow tape or some other kind of pediatric system, or you can just memorize a formula. So the one that I use most commonly is taking the number 70 and then adding two times their age. So if it's a five-year-old, two times five is 10, plus five is 10, plus five is 10, plus 70 is 80. So that's how we get our systolic blood pressure goals. So in the pediatric population, similar to other volume resuscitation that we initiate with these patients, starting out with a 20 cc per kilo bolus, and then repeating that at 10 cc per kilo, again, trying to keep them up above their systolic blood pressure threshold. So a quick caution about sedation and pain control, and obviously we don't want our trauma patients to become uncomfortable, but realizing that a lot of the medications that we give as a part of that can certainly cause precipitous drops in their blood pressure, even if the medication like fentanyl is relatively safe. If you're taking away some of that pain response, that may be stimulating them in kind of some pathomimetic way to keep their blood pressure up. If you give them a huge slug of some kind of, whether it be something like a benzodiazepine or opiate, that can take some of that drive away and you can plummet their blood pressure rather quickly. So I don't know if we ever use morphine in a trauma patient, I certainly would hope not, but if for some reason that's all you have, being very, very careful with something like that where you're going to get the histamine release. But even if you're using medications like fentanyl, Versed, Ativan, things of that nature, just being very, very careful with how much you're giving, maybe splitting up the dose or slow pushing it and monitoring vital signs on a regular basis. So obviously vasodilation and compensated shock can plummet the blood pressure. And so starting with very low doses, and this is for sedation and RSI, you know, maybe a quarter of the normal dose that you would use, you know, maybe a milligram of Versed versus five or off the bat, monitoring that blood pressure closely. And then if we notice that we're trending down anyway and having a drop in blood pressure, maybe withholding those medications altogether unless absolutely necessary. So in recap, High Flow II on all these patients, keeping their stats above 90, keeping at least for adults, systolic blood pressure above 90 and treating them before they become hypotensive, being cautious with any kind of sedative and narcotics, and then advanced airway only if the basic airway fails, or if we're concerned about aspiration one transport, and making sure that we are maniacal or just very, very attuned to hyperventilation and keeping that CO2 right around 40, especially for pre-hospital, but I have no doubt in the hospital that this will happen anyway, but making sure we're documenting frequent vital signs with the ongoing anti-CO2 is certainly trending in the GCS. Also making sure we're not forgetting about other medical things that can cause alteration in mental status or checking blood sugar, and then making sure we're monitoring closely how much fluids that we've given to the patient. So in closing, in terms of the EPIC study, basically if we were to implement these guidelines of the three HBOMBs that we can, at minimal, double the adjusted odds of survival in severe traumatic brain injury and triple that in the severe intubated cohort, and again, just monitoring and keeping track and close eye of the three HBOMBs really does seem to be the ticket to staving off worsening traumatic brain injury. So we kind of went all through all that, I'm not going to re-hammer all that. So a couple of scenarios just to kind of think about. So the first one is a 12-year-old soccer player who took a knee to the head when trying to score a goal, experienced a three-minute loss of consciousness with no seizure reported. Now the GCS is 15, complaining of some headache as well as nausea and vomiting, vital signs are otherwise stable, on room air, sorry, I don't know what happened with the computer there. It's meant to say SpO2 of 98%. I don't know how the rest of the numbers ended up in there, so I apologize. So obviously we want to consider C-spine precautions, and this, again, these scenarios were developed pre-hospital, but you can think of this also if this patient walked into the emergency department. So, you know, do we transport oxygen, two liters by nasal cannula, IV, TKO, blood sugar and transport, oxygen, 15 liters by non-rebreather, and IV, TKO, and blood sugar and transport, or do we intubate this patient and saline wide open, blood sugar and transport? So answer for this one is obviously we want to be very aggressive with our treatments of hypoxia and having our, so initiating non-rebreather sooner than not, just to make sure, especially in the pre-hospital realm, that we're staving off any time hypoxia. So as the case moves on, the patient's level of consciousness starts to deteriorate rapidly and becomes deeply comatose. His pupils are equal and reactive to light. Respiratory rate drops to five and shallow. And so now what is our treatment? Do we bag him at 20, bag him at 10, bag them in preparation for intubation, then intubate, and then at 20 or bag him at 10, and I forgot this was a 12-year-old patient, this answer changes just slightly because he's a little bit smaller, but depending on, well, I guess size, no, he would actually be, yeah, so answer, correct answer on this one is bag him at 10. We want to try to avoid hyperventilation in this patient. So and then obviously if there's risk for aspiration or other considerations for long transport, we can consider intubation, but at least the initial phase is going to be bag them, mask at 10. So we did apply that non-rebreather immediately on arrival, and the patient ended up having an epidural hematoma, which was subsequently evacuated. Patient was discharged several days later, neurologically intact, and that would be true whether we went ALS or BOS on the airway. Had we delayed non-rebreather, the patient desaturated and ended up being difficult to correct with oxygen. Patient ends up with a complicated hospital course, high intracranial pressures, and ends up with some neurological and cognitive deficits, and could end up with lifetime care required by caregivers, parents, et cetera. So again, simple interventions that we can do right off the bat, especially in the pre-hospital realm or if the patient's initially presented with ED, that can have some dramatic outcomes long-term. Another patient, a five-year-old female who was a pedestrian struck by a car, seen as always safe and law enforcement is present. The initial GCS is three with obvious head trauma and a fractured lower leg, noting a closed left femur fracture and an unstable pelvis. Initial blood pressure 90 over 55, heart rate of 120, respirators are at 10, SATs are 94, and glucose is 95. The patient, because of the depressed GCS, does accept an oropharyngeal airway. So initial treatment, nasal cannula at four, non-rebreather at 15, BVM at 10, or intubate at 10. So, and again, this was developed for pre-hospital, so the answer might be slightly different that this patient's hitting in the ED, you know, in terms of probably moving more quickly to intubation given the markedly depressed GCS, but, you know, going back for a second, the patient is still respiring at 10 and SATs are doing okay. So at least a non-rebreather while we're getting prepared for everything else, if that respiratory drive starts to drop, you know, being very quick to BVM and then, you know, knowing the injury pattern, we're probably going to end up intubating this patient. So five minutes into her care, she's still breathing spontaneously at 10 to 12 breaths per minute and her O2 SATs are 100% and blood pressure has now dropped to 70 over 40 and her heart rate is 100 and, yeah, 70 over 40, heart rate's 140. So we can, number one, initiate a 20 mL per kilo bolus wide open to ensure blood pressure above 80, IV TKO to be above 80 or IV to maintain peripheral perfusion, titrated myelosin, skin condition, and the correct answer on this one is going to be the 20 mL per kilo bolus to try and maintain systolic blood pressure above 80 given her age and then 10 cc per kilo bolus is after that. So if you did give the fluids, patient does have a complicated course, but it appears on the way a good recovery and GCS improves to 14 and if the fluids were delayed or not given, patient becomes more hypotensive, significant brain damage, overall GCS 10 to 11 and likely to have a long-term poor prognosis. So I'll leave these up just for a second. This is the QR code to directly reference the EPIC-TBI study and all the protocols that were developed down at University of Arizona. So that's a link to their site. And then especially for EMS, so again, if any of you are involved in EMS outreach or working with EMS medical directors or are an EMS agency yourself, there's actually a provider training manual going through some of the things that I talked about here that really kind of distills those things down and how to train them. And then this is the protocol itself. So if you're looking for a pre-hospital protocol, again, if you're interacting with EMS, this is a good way to, or this is a good place to start in terms of protocol development if you don't already have this in place. And then of course, quality assurance, which could very much fall on the hospital role, especially if again, you're providing that oversight for EMS. They have a check sheet for quality assurance that basically goes through and goes through all the elements of the EPIC study and making sure that the patient got everything that they needed. So a good way to provide quality assurance as well. So with that, obviously not in front of a live audience, but certainly if any questions, but that's all I've got for today. So. Excellent. Well, thank you, Dr. Ernest. Really wonderful talk on the pre-hospital and initial care of TBI. I had a few questions as we went through things. I think, you know, just a wonderful job presenting some of the findings from EPIC and precisely, at least I think to bring out, you know, anytime we have a bundle of care, the real question is what are the pertinent parts of that bundle? And to me, you know, outlining the bullet points you have has been phenomenal. I did have one question though with that, if, you know, right now, and this has always been an issue anywhere I practice as well, it's getting people to slow down with the ventilation and really avoid the hyperventilation state. Do you have any tips with this aside from just telling the person to slow down or recommends like certainly in the pre-hospital setting, we're not there to remind them or really work on, you know, ventilation techniques. Sometimes people benefit from a crutch. I know I do. If I'm going to stop one, have it in my practice, it's helpful to have something to replace it with. Do you have any tips on that? I mean, for the pre-hospital realm, I mean, certainly they have little ventilatory timers that you can put on a bag valve mask. I would say a lot of agencies and places where I've provided medical direction, a lot of times at least the number for N-tile CO2 is allowed to be read by an EMT. And so getting that N-tile CO2 sensor on and really trying to titrate towards that 40 can really help kind of slow the ventilatory rate down. Obviously if that N-tile is going lower and lower and lower, that means you're probably going too fast. So again, and I think this all comes back to training, right? I think it's sitting down and really learning how to kind of, like you say, slow down and train on these scenarios and what to look for. And simple things like counting out loud. I actually, the one instance I had with this respiratory therapist, I actually asked her to count out loud to five. She was not happy with me, but I had to get her to stop doing this number with the bag valve mask. So whatever you have to do to get it slowed down. And I think also having someone overseeing it, and I think it's really easy to get, you know, kind of tunnel vision if you're in the moment, if you're the one doing the bagging or the resuscitation. I think having someone at the outside, like, you know, when someone's in the trauma bay, usually, you know, we as attendings are standing there making sure the 30,000 foot thing is being covered. You know, if you're pre-hospital or in that critical access hospital, having someone to just kind of take a step back and say, okay, is everything going like we should? And really kind of checking those things off of, you know, is it being done right? I know you put up a hypotension target of 90 millimeters of mercury. Do you have age-adjusted targets in your practice as well, or the same pediatrics, adult geriatrics? Yeah. So that's a great question. I pulled those numbers from the EPIC trial, and I would agree that, you know, a blood pressure of 120 in a 70 or 80 year old who happens to be hypertensive all the time anyway may be a relative hypotension. So I think if you have something to indicate that their blood pressure normally runs higher, we might consider that. But certainly keeping above 90 in all cases for adults, I think would be a good starting point and then kind of titrate based on that. I think I'm trying to remember, you know, I feel like the age-adjusted thing is, we haven't done that a lot. I don't know if you do that in your shop or trying to titrate more towards, and that we, to be honest, we probably more go off of MAP and try and get a MAP below 65 as opposed to the actual systolic number, but so. Yeah, I would say we do have age-adjusted targets for like just activation criteria in that. So we tend to hedge a little bit that way to make those our targets as well in the setting of, you know, TBI or recovery, targeted recovery from shock. But I know every place is a little bit different, and I was just kind of curious what your experience is. Yeah. Yeah. The other question I'll ask in emergency medicine, this is really difficult. I, you know, I do trauma. I do ICU care. Sure. It's different when you're downstairs because you're squeezed tighter between the two rocks sometimes with your H-bombs of hypotension and hypoxia, we're going to control the airway. So specifically post-inhibition hypotension, you know, it's kind of like the, that's the, you know, the elephant in the room for everybody right now. Walk me through kind of your thoughts and your approach when you have that patient come in that might have some risk factors for shock, but at the same time, you know, you need to take that airway. Yeah. So I think it starts with, you know, selection and, and, you know, I think it's that whole slowing down. I think there's, you know, and especially with the residents, sometimes it's a bit of a rushed feeling and sometimes just taking that deep breath and it's like, okay, so how can we optimize? Can we give them a fluid bullets? Do we need to start blood products? Do we need to even consider like maybe a little push dose presser to give them that little bump so that we're not dropping them? And then, you know, selection for, you know, induction agents. I'm a huge fan of ketamine in terms of, you know, induction agent to give that, you know, a little bit more blood pressure support. And then, right. I mean, you know, just being, just being very close monitoring of, you know, that post innovation phase where a lot of times they're going to drop and yeah, between fluids, blood occasionally pressers, which I know we try to stray away from at least in the initial trauma resuscitation. But again, if it's going to be, if we think it's medication induced or are intubation induced, you know, we might consider that at least in the short term. So, but yeah, especially with TBI, I think it's, it's easy to overlook and it's like, oh, well, their blood pressure slipped. We'll get back up. It's like, no, actually that's a, that's a, that's a big deal, especially if they stay down. So yeah. Well, last question I had for you, then I will, I will let you lose. You are an expert in pre-hospital care. You work with the EMS agencies routinely. You have experience in the field. As a trauma program director, trauma, you know, medical director, you know, our partners are always looking for ways to reach out and support our other teammates that are in the field in the pre-hospital setting. In the area of TBI, what, what would you say is the, you know, maybe the one or two ways we can reach out the best support our partners in the field? Yeah, no. So I think, you know, I think a lot of the trauma centers have close relationships with their EMS agencies. I know we do in our kind of neck of the woods. And so I think it really, as a part of that, putting out that, you know, kind of lecture series of, you know, what is TBI and making sure, you know, again, we're all kind of staying tuned to it and that close feedback of that traumatic brain injury patient and how they're doing and, you know, looking at the pre-hospital record, helping with the quality insurance part of it and making sure that they're meeting those targets, I think are, you know, all will help kind of that continuum of care. So awesome. Well, thank you very much, Dr. Ernest. I will turn things back over to Deb and thank you everyone for attending the first in our series of webinars on TBI for Trauma Center Association of America. Stay tuned for additional upcoming webinars. Thank you. Awesome.

traumatic brain injury

pre-hospital care

early interventions

EPIC TBI trial

airway management

hypoxia prevention

hyperventilation challenges

hypotension management

trauma center collaboration