Case Presentation: BLS to ALS Handoff

•21 year old male•Unrestrained driver, single vehicle

MVC•20mph; sedan vs. concrete barrier•No airbag•Starred windshield•+ LOC

Initial Assessment

•Patient has clear airway•Bilateral breath sounds•Strong radial pulse of 100•Blood Pressure 120/80•Speaking spontaneously

Additional information?•Respiratory rate/ quality–16 good

movement •O2 sat – 100%

Physical and Neurological Evaluation

•Found out of vehicle walking near accident scene

•3x5cm Hematoma/ contusion left forehead•Opens eyes spontaneously•Alert to person & place, but confused to month

and year•Follows motor commands•GCS =

▫14Additional information?•Pupils

Treatment and Interventions

• Immobilization with cervical collar and backboard

•Reassess vital signs & neuro exam Q5 min•Administer supplemental oxygen as needed to

maintain SaO2 > 90%•Rule out other causes of altered mental status

•BLS - Medic Eval?

•ALS - establish IV access

Causes of Altered Mental Status

•Hypovolemia•Hypoxia•Hypoglycemia•Pain/Discomfort•Traumatic Brain Injury

Additional causes?•Alcohol•Drugs

Transport Decisions

•Destination▫Mild TBI▫GCS 14

•Emergency Department

Reassessment enroute: ABC’s

•Vital signs remain stable▫Patent airway▫Bilateral breath sounds▫Pulse 96▫BP 116/76

Additional information?▫Respiratory rate/ quality – 12 regular▫O2 sat – 92%

Reassessment: Neuro Exam

•Eyes open to painful stimuli•Speech is incomprehensible•Localizes to painful stimuli•Pupils 3mm bi-lat. with brisk reaction to

light

•GCS = ▫9

Treatment and Interventions

•Cervical spine immobilized•Backboard in place•O2 administered via NRM

▫ Critical value – SpO2 < 90%

•BLS- Medic Eval?

•ALS - IV access established with NS infusing▫Critical value – SBP < 90mm Hg

Transport Decisions

•Destination▫Moderate TBI▫GCS 9

•Trauma Center

Reassessment: ABC’s•Changes in vital signs

▫Respiratory rate 8▫SaO2 90% on NRM▫Pulse 112▫BP 80/60

•Additional Information?▫Respiratory effectiveness –

Irregular/ poor air exchange

Reassessment: Neuro Exam• Patient is unresponsive

▫Eyes – no response▫Motor – bilateral extensor posturing▫Verbal – no response

• Pupils▫Right 4mm & reactive▫Left 3mm & reactive

• GCS =▫4

• BLS to ALS Handoff

ALS Treatment Interventions

o Establish a patent airwayo Vigorous IV fluid administration (Keep SBP > 90mm Hg)o Supplemental oxygeno Hyperventilation @ 20 breaths/minuteo Only when suspected cerebral herniation

o Capnography/ ETCO2 used to: ▫ Confirm endotracheal tube placement▫ Measure the adequacy of ventilation.

Target range: 35 – 40 mm Hg▫ Guide hyperventilation therapy

Severe hyperventilation: < 30 mm Hg ETCO2 < 25 mm Hg is not recommended

Transport Decisions

•Destination▫Severe TBI▫GCS 4

•Level One Trauma Center with TBI capabilities

Transport Decisions

•Level One Trauma Center with TBI capabilities▫24 hour available CT scan▫24 hour available operating room▫Prompt neurosurgical care▫Ability to monitor intracranial pressure▫Ability to treat intracranial hypertension

Summary• Provide oxygen and ventilation to maintain oxygen

saturation >90%• Provide adequate fluid to maintain SBP >90mm Hg• Continuously look for S & S of Cerebral herniation

▫ Pupil abnormalities▫ HA, N/V▫ Cushings Triade - SBP, HR, Irreg. resps.

• Select the most appropriate facility and mode of transportation for admission of the TBI patient

Additional information?• Continually reassess and document:

▫ Component GCS, VS, post intubation RR, and Capnography values .