• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Treatment: airway, ventilation, and oxygenation. New York (NY): Brain Trauma Foundation; 2005. 10 p. [26 references]

This is the current release of the guideline.

"Degrees of Certainty" (Standards, Guideline, Options) and "Classification of Evidence" (Class I to III) and the correlation between the two are defined at the end of the "Major Recommendations" field.

Recommendations

1. Standards

   Data are insufficient to support a treatment standard for airway, ventilation, and oxygenation management techniques in the out-of-hospital or tactical environment.

2. Guidelines

   Routine or prophylactic hyperventilation is not recommended and should be avoided.

3. Options
   1. Airway management is crucial for the traumatic brain injury (TBI) patient and oxygen tension should be monitored and maintained at an oxygen saturation (SaO₂) >90. When the assessment indicates an obstructed airway, the management depends on the skills of the health care provider.
   2. Adequacy of ventilation is measured by carbon dioxide partial pressure (pCO₂) or to a lesser degree of accuracy by end-tidal carbon dioxide (EtCO₂) measurement. Endotracheal intubation (ETI) by an experienced provider using direct laryngoscopy (DL) is accepted as the optimal method of airway control. There is evidence that the Intubating Laryngeal Mask Airway (ILMA®), the Combitube®, and the Fiberoptic Intubation device (FI) may be useful for the less experienced care giver.
   3. While a chest radiograph is the traditional way to confirm endotracheal tube placement, there is evidence that the Self-Inflating Bulb (SIB) device and/or measurement of EtCO₂ (except in a cardiac arrest situation) are useful tools for confirming placement along with auscultation of the chest (when the environment would allow and when chest radiography is not an option).
   4. Hyperventilation should only be done if patients are exhibiting signs of cerebral herniation such as posturing with asymmetric or bilateral dilated pupils. If done, hyperventilation is defined as 20 breaths per minute for adults. Hyperventilation should be discontinued as soon as signs of herniation normalize.

Summary

The assessment and treatment of airway, ventilation, and oxygenation problems must be interwoven step by step to successfully manage the TBI patient. Treatment of an obstructed airway must precede the assessment of ventilation. Similarly, the treatment of a patient who is not breathing must precede the assessment of circulation. This concept in the combat scenario is the same as in the civilian arena. Tactical and logistical considerations dominate the tools available to address these issues for the combat injured, with different provider skill levels and treatment capabilities existing at each level of care. Regardless of the level of care, every effort must be made to maintain the SaO₂ above 90% in suspected TBI patients. It is equally important to avoid hyper- and hypoventilation in these patients.

A patent airway should be assured and endotracheal intubation performed for patients with a Glasgow Coma Scale (GCS) <9 or for those who are unable to maintain or protect their airway. Evidence indicates that routine hyperventilation should not be performed. If ventilatory assistance after endotracheal intubation is provided, a respiratory rate of 10 breaths per minute should be maintained. After correction for hypoxemia or hypotension, if the patient shows obvious signs of cerebral herniation, such as extensor posturing and pupillary asymmetry or bilateral dilated pupils, the medical provider should hyperventilate the patient at a rate of 20 breaths per minute. This hyperventilation may be performed as a temporizing measure until the patient arrives at a medical facility when blood gas analysis will guide the ventilation rate. The guideline authors believe that end tidal CO₂ monitors or the use of the SIB tool will help avoid improper endotracheal tube placements. Further EtCO₂ monitors will help avoid hyper- or hypoventilation.

The airway/ventilation/oxygenation treatment training for military personnel (whether they be combat medics, paramedics, nurses, or physicians) should highlight TBI as a special consideration because of its long term impact on patient outcome. Evidence suggests that airway management skills decline early after initial training. Independent practice combined with periodic feedback should be encouraged. New and emerging simulation technologies show promise for practical skills training and education.

Definitions:

Classes of Evidence

Class I: Evidence from good quality randomized controlled trials (RCT)

Class II: Evidence from moderate or poor quality RCT, good quality cohort, or good quality case-control studies

Class III: Evidence from moderate or poor quality cohort; or moderate or poor quality case-control; or case series, databases, or registries

Degrees of Certainty

Standards: Reflect a high degree of clinical certainty as indicated by the scientific evidence available (supported by Class I evidence).

Guidelines: Reflect a moderate degree of clinical certainty as indicated by the scientific evidence available (supported by Class II evidence).

Options: Reflect unclear clinical certainty as indicated by the scientific evidence available (supported by Class III evidence).

A clinical algorithm for "Field Management of Combat-Related Head Trauma" is provided in the original guideline document.

An evidentiary table appears at the end of each major section of the guideline document, which classifies each citation based on the quality of the evidence (Class I-III; see "Major Recommendations" for definitions). The recommendations in this summary are supported by nine Class III studies and one Class II study.

• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Treatment: airway, ventilation, and oxygenation. New York (NY): Brain Trauma Foundation; 2005. 10 p. [26 references]

Not applicable: The guideline was not adapted from another source.

2005

Brain Trauma Foundation - Disease Specific Society

Brain Trauma Foundation

Uniformed Services University of the Health Sciences

Not stated

Authors: Tom Knuth, MD, MPH, FACS, COL, Medical Corps, US Army, Chief, Combat Casualty Care Integrated Concepts Team, Directorate of Combat Doctrine and Development, Army Medical Department Center and School, Fort Sam Houston, Texas; Peter B. Letarte, MD, FACS, Neurosurgeon, Hines VA Medical Center, Loyola University Medical Center; Geoffrey Ling, MD, PhD, LTC, Medical Corps, US Army, Professor and Vice-Chair of Neurology, Director of Critical Care Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Leon E. Moores, MD, FACS, LTC, Medical Corps, US Army, Assistant Professor of Surgery and Pediatrics, Uniformed Services University of the Health Sciences, Chief of Neurosurgery, Director of Pediatric Neurological Surgery, Walter Reed Army Medical Center; Peter Rhee, MD, MPH, FACS, FCCM, CAPT, Medical Corps, US Navy, Professor of Surgery/Molecular Cellular Biology, Director, Navy Trauma Training Center, Los Angeles County Medical Center, University of Southern California; David Tauber, CCEMT-P, NREMT-P, I\C, Executive Director, Advanced Life Support Institute (New Hampshire) Medical Specialist/Hazardous Materials Technician, FEMA USAR Team MA1; Art Trask, MD, FACS, INOVA Regional Trauma Center, INOVA Fairfax Hospital

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on August 24, 2007. The information was verified by the guideline developer on January 28, 2008.

This is a limited license granted to NGC, AHRQ and its agent only. It may not be assigned, sold, or otherwise transferred. BTF owns the copyright. For any other permission regarding the use of these guidelines, please contact the Brain Trauma Foundation.