ABSTRACT
Every scene, independent of the potential for head injury should begin with the establishment of an airway, ensuring breathing and circulation. The deleterious influence of hypotension (<90 mmHg systolic blood pressure) and hypoxemia (<90% arterial hemoglobin oxygen saturation) on the outcome of patients with severe Traumatic Brain Injury (TBI) was analyzed prospectively on data collected by the Traumatic Coma Data Bank and were among the most profound predictors of outcome.(1)
In accordance with ATLS guidelines, securing of the airway is the initial objective. The TBI patient is unique in that necessity for intubation is not dependent solely upon pulmonary function, but rather the inability to protect the airway secondary to a depressed level of consciousness. Endotracheal intubation is the route of choice as NT intubation may result in further neurological injury in the face of unknown basilar skull fractures. It is also important to note that the nasal-pharyngeal approach should be reserved until after radiographic evaluation for basilar skull fractures. In the setting of the combative patient, intubation is frequently early before further deterioration, as airway protection, oxygen and carbon dioxide exchange is of the utmost importance in the management of the TBI patient. The GCS should be measured after airway, breathing, and circulation are assessed, and after necessary ventilatory or circulatory resuscitation has been performed preferably prior to administering sedative or paralytic drugs.
