TBI question

[Bjorn, Pret]

Mike, 

Your instincts are correct.  There is no protocol specific to these patients, because these cases are complex balancing games.

Think of "permissive hypotension" as mostly a matter of a) dispensing with blood pressure as a useful marker of perfusion, and b) admitting that fluids are not a logical remedy for real and refractory hypoperfusion in trauma.  

The practical upshot is that yes, your head-injured patient will suffer mightily for every minute of inadequate systemic perfusion; but fluids offer only fleeting (if any) remedy, and with predictable costs on the other end.  As with all of the conventional, historical, and occasionally hysterical approaches to severe brain injury (mannitol, hyperventilation, steroids...) temporizing measures are at best debatable, and of no use at all if you're any distance from a decent general/trauma surgeon.

1. Airway, Breathing, and Acceleration.  
2. Set course for a trauma surgeon.
3. Call a neurosurgeon once the injuries to the brain are of a DIRECT variety.

There's your protocol.

Pret Bjorn, RN
Bangor, ME USA


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Mike Smertka
Sent: Monday, June 30, 2008 12:01 AM
To: Trauma & Critical Care mailing list
Subject: TBI question





Hello again everyone.
 
I just finished reading an article on TBI and was hoping somebody here would help me out. It seems to me that in a multisystem trauma (serious enough to require surgical intervention) where there is also a head injury, treatments like permissive hypotension and preventing secondary brain injury are at odds. Does it become some sort of complex balancing game, or is there a protocol that I haven’t seen yet on the matter? Any input would be greatly appreciated.
 
Mike


      
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