Blast TBI and other TBI pearls

1.  Battlefield injury without breach of cranium thought to have different pathology than standard CHT or penetrating injury.  Its due to a concussive pressure wave. 

2.  Battle armor and helmets, and medical care on the scene have reduced the kill wounded ration to less than 1:10, v 1:4 in WWII. 

3.  Secondary injury factors are the focus of treatment. 

4.  Mild , moderate and severe TBI is defined by GCS.  Mild is 13 or above, moderate is 8-13, and severe is < 8.

5.  Second impact syndrome has a high mortality, up to 50 % but the mechanism is not well understood

6.  Early mgmt recommendations include avoiding hypotension and hypooxygenation in addition to ABC. 

7. The role of hemicraniectomy is being studied in the RESCUE trial

8.  Indications for ICP monitoring include abnormal CT scan, hypotension (SBP < 90), or age > 40.

9.  Hypertonic saline boluses may be as effective as mannitol.  Give through a central line.  2-3 % hypertonic saline through a peripheral line is given half NACL, half Na acetate. 

10. Pseudoaneurysms and vasospasm are very common.