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A Hartford Hospital publication addressing articles of interest to emergency and critical care personnel Vol. XI No. 3, Winter 2003 CASE STUDY: help the other patient. I noticed Kelly’s event, she improved steadily. After a parents, Fred and Sandy, standing near long hospitalization and rehabilitation, TRAUMATIC BRAIN INJURY the back of the ambulance looking on Kelly was discharged home and has By Wendy Lord, RN, CCRN, EMT-P in disbelief. And strangely enough, I almost fully recovered from her injuries. No one could foresee the unusual turn recognized them. Three years prior Sadly, Kelly’s friend succumbed to January 11th, 2003, would take for me as a nurse in the pediatric ICU at her injuries. and a family in crisis for a second time. Connecticut Children’s Medical Center, I believe each patient you Looking forward to an I remembered caring for Kelly’s older care for impacts you in some way. This afternoon of outdoor winter fun with sister Kate, a young red-haired girl patient, indeed this family, will stay with her church group, eleven year old Kelly battling acute lymphocytic leukemia. me for as long as I am a nurse. Doyle and her best friend raced to be Moreover,I remembered her family–the the first pair to tube down the icy hill. Doyles. Much to my surprise, Fred also Discussion: Unable to control their speed on the recognized me. slippery slope, the girls perilously slid On scene, Kelly had a Glascow Traumatic brain injury is a prevalent, head-on into a tree. Coma Score of 5, decorticate posturing, devastating problem in the United and unequal pupils. She had States. Annually, this injury claims more agonal respirations supported than 56,000 lives and leaves another by bag-valve-mask ventilation. 99,000 people with permanent sequelae. Her pupils were unequal Generating more than 370,000 and her right eye was hospitalizations each year, the impact of swollen and ecchymotic. traumatic brain injury on society and our Neurologically depressed health care system cannot be ignored. and unable to protect her Subarachnoid hemorrhage, such as Kelly airway, Kelly required sustained, is present in 23-39% of severe intubation. Rapid sequence head injury patients and is the most induction medications were common traumatic brain injury found y Kate Doyle, Nurse Wendy Lord, Kelly Doyle given by the LIFE STAR team and on autopsy. As both girls lay unconscious in an orotracheal tube was placed. Subarachnoid hemorrhage the snow, bystanders immediately called Additional paralytics and sedatives were (SAH) is described as a collection of 911 to activate the Colchester Hayward administered as Kelly was prepared for blood within the meningeal layers of Volunteer Fire Department. Colchester transport. Her mom accompanied us in the brain. It occurs when cerebral vessels EMS Captain Kevin McManus quickly flight. After a full trauma evaluation at are disrupted (either from trauma or assessed the critically injured girls then Hartford Hospital, Kelly was diagnosed aneurysm rupture) causing blood to requested two helicopters to transport with a large diffuse subarachnoid fill the subarachnoid space, a space the friends to a pediatric trauma center. hemorrhage, a right pneumothorax, generally filled with cerebrospinal fluid. Within 15 minutes, LIFE STAR a right temporal fracture, and a right A CT scan of the head is typically used and UMASS Life Flight landed on scene. orbit fracture. to diagnose SAH. My partner Diana Dlugolenski and I Over the next few weeks, Little can be done to repair were directed to Kelly’s side as the I frequently checked on Kelly’s progress. the brain once a traumatic injury has UMASS team made their way over to Despite a devastating neurological occurred. Therefore, acute care of Continued on page 2 A Hartford Hospital publication addressing articles of interest to emergency and critical care personnel 2 Continued from page 1 40mmHg, cerebral ischemia develops patients with severe head injury is and Cushing’s triad (increase RR, NEW CREW: Review aimed at preventing further brain widening pulse pressure, decrease HR) Michael Vaclavik, Pilot: insult. Preventing hypoxia and may be seen. Mike joined the LIFE maintaining an adequate airway are Cerebral perfusion pressure STAR team in March, key. Any patient who demonstrates an (CPP) can be maintained by 2003. He has been flying inability to protect their airway or has manipulating mean arterial pressure helicopters for the last 21 a Glascow Coma Score less than 8 (MAP) and ICP. Assuring an adequate years including 17 years of flight duty should be intubated. To blunt the to slightly elevated BP can help with the United States Army and several sympathetic response that occurs with preserve CPP when an increased years experience transporting crew and this procedure, the LIFE STAR team intracranial pressure exists. Numerous equipment to off-shore drilling platforms can administer Lidocaine1.5mg/kg IV strategies exist to reduce ICP. in the Gulf of Mexico. and/or a defasiculating dose of a Mannitol, sedation, ventriculostomy non-depolarizing neuromuscular placement to drain excess fluid in the Jerry Mosimann, Pilot: blocking agent, along with typical subarachnoid space, elevating the head Jerry has been a pilot for rapid sequence induction doses of of the bed 30 to 45 degrees and 19 years. He has just Etomidate and Anectine. keeping the head in a neutral midline recently returned home to Optimizing cerebral perfusion position can all help reduce ICP. Connecticut after spending pressure (CPP) and controlling Since increased blood carbon dioxide 13 years in Alaska as a senior line pilot and company flight instructor with intracranial pressure (ICP) are effective levels cause cerebral vessels to dilate, TEMSCO. He joined the LIFE STAR strategies in preventing secondary maintaining normal to slightly lower team in March 2003. brain injury. The skull and its contents PCO2 levels can reduce ICP by function in a finite space. The brain reducing excess brain blood flow, Flight Nurse James occupies approximately 80% of that resulting in improved CPP. Marcelynas, RN, CCRN, space, with the cerebrospinal fluid Seizure prevention, assuring EMT-P: Jim has been with and blood evenly distributed in the euglycemia and normothermia, close the LIFE STAR team since remaining space. The balance of these hemodynamic monitoring and November 2002. Prior to three components creates a baseline frequent neurological checks are joining LIFE STAR, he was a flight nurse intracranial pressure (ICP) of about also important. with Care Force based in Columbia, South 10mmHg. Limited, protective Overall prognosis for those Carolina. Jim has solid cardiothoracic and compensatory mechanisms exist to who have suffered a traumatic pediatric ICU experience. He is a graduate accommodate small changes in the subarachnoid hemorrhage is poor. of Western Connecticut State University balance of the three components, Clinical research has found that 46- and has been actively involved in EMS meaning, as one component expands 78% of these patients have severe since 1993. one or both of the remaining disabilities, live in a vegetative state, components decrease. However, when or succumb to their injury. The most Flight Nurse Samantha this balance is dramatically disrupted, effective treatment of a severe head VanVoorhis, RN, EMT-P: such as in the case of subarachnoid injury is prevention such as the use Joining LIFE STAR in April 2003, Samantha hemorrhage, intracranial pressure of seat belts, helmets and other brings 10 years of (ICP) rises and cerebral perfusion can protective gear when indicated. Early experience to the team. She graduated be compromised. Cerebral perfusion recognition of a head injury and rapid from Quinnipiac College in 1993 with pressure (CPP) is the difference transport to neurosurgical specialty an Associate’s Degree in Nursing. between the mean arterial pressure care may help maximize patient Samantha has extensive ICU and (MAP) and the intracranial pressure outcomes. With this in mind, the keen Emergency Department experience, (ICP). CPP=MAP-ICP.A cerebral assessment and quick actions of the and served as a volunteer EMT with perfusion pressure (CPP) of 50- Colchester Hayward Volunteer Fire the Stafford Ambulance Corps. for 60mmHg must be maintained to Department undoubtedly played a key many years. ensure adequate blood flow to the role in Kelly’s positive outcome. brain. Should the CPP fall below 3 A Hartford Hospital publication addressing articles of interest to emergency and critical care personnel Flight Nurse Steven NEW LANDING ZONE: Revised Dimensions Neher, RN, EMT-P: Steve moved from sunny When establishing a LIFE Arizona in May 2003 to STAR landing zone, please join our team. He has note that the LZ size been a nurse for seven years, including requirement has been three years of experience as a flight changed to 85ft x 75ft, nurse with Guardian Air in Flagstaff, slightly larger than the Arizona. He worked as a paramedic for previous 60ft x 60ft a 911 service in Colorado for many dimensions. years and has a strong background in both ICU and emergency nursing. He has a Bachelor of Science Degree in Nursing from the University of Southern California. Flight Respiratory Therapist Patrick Dowd, RRT, EMT: Patrick has worked as a respiratory y LIFE STAR en route, therapist since graduating photo by Scott Palmer Quinsigamond College in 1996. Prior to joining LIFE STAR in February 2003, Patrick gained experience in the NICU, pediatric and adult settings at UMASS RACE FOR THE CURE: 10th Annual Susan G. Komen 5K Memorial Hospital and Massachusetts A team of 30 athletes from LIFE STAR, Cure’. Held in May in New Britain, the General Hospital. Hartford Hospital’s emergency and 5K race raised more than $800,000 for critical care units, Connecticut breast cancer research. Respiratory Flight Respiratory Children’s Medical Center and the Therapist Scott Ely was the top LIFE Therapist William Hartford School District were among STAR finisher with a time of 21:23.