You are dispatched for a report of a motorcycle vs vehicle. As you arrive on scene, you note two teenage patients ejected 50-75 feet from where the accident occurred. It appears they were traveling at a high rate of speed through a red light and were struck by another vehicle. You approach a motionless patient lying prone on the pavement, you note obvious head trauma, and presume multi-system trauma given the mechanism of injury. Your first blood pressure reveals a MAP of 55 and the pelvis is unstable.
While we know aiming for a normal blood pressure in the presence of non-compressible hemorrhage is likely not ideal, a primary concern for this patient is that permissive hypotension may compromise cerebral perfusion pressure (CPP) and put the patient at further risk of a secondary brain injury.
A single episode of hypotension in the TBI patient nearly doubled their mortality (Spahn, et al., 2019).
The clinical conundrum most emergency medical providers face is having to manage both injuries and the repercussions of both management strategies.
The European Guidelines on Management of Major Bleeding and Coagulopathy following Trauma: Fifth Edition published the following recommendations:
For hemorrhagic shock: Hypotensive fluid resuscitation with a goal of a systolic blood pressure between 80-90 mmHg (MAP of 50-60 mmHg) without evidence of brain injury
For TBI: Maintain a MAP of > 80 mmHg
Both recommendations received a Grade 1C recommendation, meaning it was a recommended practice. However, this was a recommended practice for each respective clinical presentation, not with both etiologies present at the same time (Spahn, et al., 2019). What the literature has suggested from numerous pre-hospital and in-hospital studies is that reduced or restricted fluid administration in trauma was shown to be less harmful overall than large volume resuscitation (Carrick, et al., 2016). For patients presenting with both insults, it is necessary to accommodate both management strategies.
TBI insult and subsequent management should take priority over the hypotensive approach for hemorrhage as any single episode of hypotension increases the mortality to nearly 50%.
To accommodate both, the MAP should be kept near 80 mmHg with limited fluid resuscitation to achieve that status. Secondarily, patients with TBI and hemorrhagic shock were also found to have worsening coagulopathy compared to those with TBI and hemorrhagic shock alone (Galvagno, et al., 2017). Furthering the premise that maintaining a fluid restriction resuscitation along with a MAP at or just above 80 mmHg in a patient with both insults is theoretically the best way to manage these patients. This is a field of medicine that does require future studies for best practice advice.
In this podcast, I sit down with Tyler & Sam to discuss TBI + Multisystem trauma management.
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Spahn, D. R., Bouillon, B., Cerny, V., Duranteau, J., Filipescu, D., Hunt, B. J., Komadina, R., Maegele, M., Nardi, G., Riddez, L., Samama, C.-M., Vincent, J.-L., & Rossaint, R. (2019). The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical Care, 23(1). https://doi.org/10.1186/s13054-019-2347-3