Advanced Trauma Life Support ATLS Student Course Manual 2018

PRIMARY SURVEY AND RESUSCITATION 119
cause hemorrhagic shock. If the patient is hypotensive,
establish euvolemia as soon as possible
using blood products, or isotonic fluids as needed.
Remember, the neurological examination of patients
with hypotension is unreliable. Hypotensive patients
who are unresponsive to any form of stimulation
can recover and substantially improve soon after
normal blood pressure is restored. It is crucial to
immediately seek and treat the primary source of
the hypotension.
table 6-5 goals of treatment of
brain injury: clinical, laboratory
and monitoring parameters
CATEGORY PARAMETER NORMAL VALUES
Clinical
Parameters
Systolic BP
Temperature
≥ 100 mm Hg
36–38°C
Maintain systolic blood pressure (SBP) at ≥ 100 mm
Hg for patients 50 to 69 years or at ≥ 110 mm Hg
or higher for patients 15 to 49 years or older than
70 years; this may decrease mortality and improve
outcomes (III).
The goals of treatment include clinical, laboratory,
and monitoring parameters n TABLE 6-5.
Laboratory
Parameters
Glucose
Hemoglobin
International
normalized
ratio (INR)
80–180 mg/dL
≥ 7 g/dl
≤ 1.4
Na
135–145 meq/dL
Neurological Examination
PaO 2
≥ 100 mm Hg
As soon as the patient’s cardiopulmonary status is
managed, perform a rapid, focused neurological
examination. This consists primarily of determining
the patient’s GCS score, pupillary light response, and
focal neurological deficit.
It is important to recognize confounding issues in
the evaluation of TBI, including the presence of drugs,
alcohol/other intoxicants, and other injuries. Do not
overlook a severe brain injury because the patient is
also intoxicated.
The postictal state after a traumatic seizure will
typically worsen the patient’s responsiveness for
minutes or hours. In a comatose patient, motor
responses can be elicited by pinching the trapezius
muscle or with nail-bed or supraorbital ridge pressure.
When a patient demonstrates variable responses to
stimulation, the best motor response elicited is a more
accurate prognostic indicator than the worst response.
Testing for doll’s-eye movements (oculocephalic), the
caloric test with ice water (oculovestibular), and testing
of corneal responses are deferred to a neurosurgeon.
Never attempt doll’s-eye testing until a cervical spine
injury has been ruled out.
It is important to obtain the GCS score and perform
a pupillary examination before sedating or paralyzing
the patient, because knowledge of the patient’s clinical
condition is important for determining subsequent
treatment. Do not use long-acting paralytic and
sedating agents during the primary survey. Avoid
sedation except when a patient’s agitated state could
present a risk. Use the shortest-acting agents available
when pharmacologic paralysis or brief sedation is
Monitoring
Parameters
PaCO 2
35–45 mm Hg
pH 7.35–7.45
Platelets
CPP
Intracranial
pressure
PbtO 2
Pulse oximetry ≥ 95%
≥ 75 X 10 3 /mm3
≥ 60 mm Hg*
5–15 mm Hg*
≥ 15 mm Hg*
*Unlikely to be available in the ED or in low-resource settings
Data from ACS TQIP Best Practices in the Management of Traumatic
Brain Injury. ACS Committee on Trauma, January 2015.
Pitfall
A patient with TBI is
noted to be seizing when
the long-acting paralytic
agent wears off.
Solution
• Avoid long-acting paralytic
agents, as muscle
paralysis confounds the
neurologic examination
• Use benzodiazepines to
acutely manage seizures;
muscle relaxants mask
rather than control
seizures.
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