Transport of the neurotrauma patient

Abstract

Traumatic brain injury (TBI) is a common problem in both civilian and military settings. While the initial injury can be devastating, additional physiologic insults are well known to potentiate the initial injury and worsen outcomes. New evidence suggests that the hypobaric environment of aeromedical transport can independently increase inflammation, cerebral edema, and alterations in the cerebral metabolic rate. Field responders and transport teams are instrumental in limiting physiologic second hits and minimizing subsequent injury. Although patient movement may be absolutely mandatory, transport should be approached as a high-risk procedure: patient selection and preprocedural planning are paramount to minimizing transport-related complications. Conditions to avoid for improved outcome include: hypotension, hypoxia, hypocarbia, hypercarbia, hypothermia, hyperthermia, intracerebral pressure elevations, and delays in transport. Emphasis should be on maintenance of the airway, protection of the cervical spine, transport to the definitive location when possible, and the qualifications and capabilities of the transport members. While ground transport by itself can introduce risk, air transport of the acute neurotrauma patient introduces additional complexity. The air transport environment is physiologically hostile. Environmental stressors include hypobarism, hypoxemia, gravitational and acceleration forces, noise, vibration, and decreased humidity. Depending on the distance to be traveled, the austerity of the transport environment can also have a profound effect on ability to diagnose and treat the deteriorating patient. Each of these environmental stressors can potentially exacerbate TBI and must be ameliorated. Ideally, neurocritical care principles and practice should be extended to the care of the patient during all phases of transport.