Subarachnoid bleed and hyperventilation

[Simusid]

This has been bugging me since the call a few days ago. We arrived on scene to an elderly female unresponsive following an unwitnessed fall. My parter very quickly said "head bleed" and off we went to the hospital. Within a very short time the ED confirmed a pretty severe subarachnoid hem and the next decision was either medflight to boston or IFT to Providence RI. The family wanted her to go to RI but the problem was that it's hard to get IFT quickly after 11 PM. We happened to still be there doing paperwork and cleaning up and the Dr. asked if we could do the IFT even though we're a 911 truck. We said of course (still have coverage in town) and off we go with a nurse and respiratory therapist.

That's all backstory. Here's my question. During the 15 minute transport I watched the RT bag this patient at a rate of no slower than once every two seconds and on average probably closer to once per second. Several times it was better than once per second as I was silently thinking "ONE Missi...". It has essentially been beaten into my head that it is bad to hyperventilate a patient by bagging too often, but for me that has always been in the context of a cardiac arrest patient (Note: my service is participating in a CCR study so we don't tube or bag any more during arrests)

BUT, I just read this http://emedicine.medscape.com/article/1164341-treatment which states "Patients with signs of increased ICP or herniation should be intubated and hyperventilated. " I have no idea how to assess ICP or herniation other than to look for posturing. She had no signs of posturing.

So the question is was the RT bagging too fast? I've asked several medics about this and their consensus is yes. One labeled the RT a "respiratory terrorist." But I don't want to second guess the RT in this situation. Is there more to the story here? This is my first head bleed case.

 

[RESQGUY]

Well, here in San Diego our protocol is the following:

Neurological Trauma ( head and spine injuries)
Ensure adequate oxygenation without hyperventilating PT.
Goal 6-8 ventilations/min

 

[Veneficus]

From one of my favorite sources:

"Hyperventilation. 

The use of hypocapnia has been reviewed in detail in the section on management of Paco2. Hyperventilation has long been a component of the management of TBI patients, and the effectiveness of acute hypocapnia in reducing ICP is well confirmed.[10] There is substantial evidence, however, that hyperventilation is potentially deleterious[23,24,29-31,283] and should not be overused. The evidence suggests that hyperventilation and the concomitant vasoconstriction can result in ischemia,[21,29-32] especially when baseline CBF is low,[32] as is likely to be the case in the first 48 to 72 hours after head injury.[23,33,38,39] The expert panel convened by the Brain Trauma Foundation specified that prophylactic hyperventilation is “not recommended,” and that “hyperventilation should be avoided during the first 24 hours after injury when CBF is often critically reduced.”[59] The available information argues that hyperventilation should be used selectively rather than routinely in the management of TBI patients. Maintaining ICP less than 20 mm Hg, preventing or reversing herniation, minimizing retractor pressure, and facilitating surgical access are still important objectives in the management of TBI patients and to the extent that hyperventilation contributes to these objectives, it is still appropriate. The anesthesiologist should agree on management parameters with the surgical team at the outset of a procedure."

Miller's Anesthesia exerpt from chapter 63

 

[NYMedic828]

"Hyperventilation. 

The use of hypocapnia has been reviewed in detail in the section on management of Paco2. Hyperventilation has long been a component of the management of TBI patients, and the effectiveness of acute hypocapnia in reducing ICP is well confirmed.[10] There is substantial evidence, however, that hyperventilation is potentially deleterious[23,24,29-31,283] and should not be overused. The evidence suggests that hyperventilation and the concomitant vasoconstriction can result in ischemia,[21,29-32] especially when baseline CBF is low,[32] as is likely to be the case in the first 48 to 72 hours after head injury.[23,33,38,39] The expert panel convened by the Brain Trauma Foundation specified that prophylactic hyperventilation is “not recommended,” and that “hyperventilation should be avoided during the first 24 hours after injury when CBF is often critically reduced.”[59] The available information argues that hyperventilation should be used selectively rather than routinely in the management of TBI patients. Maintaining ICP less than 20 mm Hg, preventing or reversing herniation, minimizing retractor pressure, and facilitating surgical access are still important objectives in the management of TBI patients and to the extent that hyperventilation contributes to these objectives, it is still appropriate. The anesthesiologist should agree on management parameters with the surgical team at the outset of a procedure."

Miller's Anesthesia exerpt from chapter 63

:unsure: Confuzzling read. Informative non the less after decyfering it lol.

in NYC we are required to intubate and hyperventilate patients with

Fixed or asymmetric pupils
Abnormal flexion or extension (neurological posturing)
Hypertension and bradycardia (Cushing’s Reflex)
Intermittent apnea (periodic breathing)
Further decrease in GCS score of 2 or more points (neurological deterioration)

to maintain an ETCo2 of 30-35mmHg.

If ETCo2 monitoring is not possible, BVM at one breath every 3-5s.



It seems in EMS we are always behind the 8ball with what current medical practices are. Its unfortunate. The fact that will still board and collar half our patients is a prime example.


What caused you guys to immediately rule out a bleed anyway? (other presenting s/s)

 

[MSDeltaFlt]

This has been bugging me since the call a few days ago. We arrived on scene to an elderly female unresponsive following an unwitnessed fall. My parter very quickly said "head bleed" and off we went to the hospital. Within a very short time the ED confirmed a pretty severe subarachnoid hem and the next decision was either medflight to boston or IFT to Providence RI. The family wanted her to go to RI but the problem was that it's hard to get IFT quickly after 11 PM. We happened to still be there doing paperwork and cleaning up and the Dr. asked if we could do the IFT even though we're a 911 truck. We said of course (still have coverage in town) and off we go with a nurse and respiratory therapist.

That's all backstory. Here's my question. During the 15 minute transport I watched the RT bag this patient at a rate of no slower than once every two seconds and on average probably closer to once per second. Several times it was better than once per second as I was silently thinking "ONE Missi...". It has essentially been beaten into my head that it is bad to hyperventilate a patient by bagging too often, but for me that has always been in the context of a cardiac arrest patient (Note: my service is participating in a CCR study so we don't tube or bag any more during arrests)

BUT, I just read this http://emedicine.medscape.com/article/1164341-treatment which states "Patients with signs of increased ICP or herniation should be intubated and hyperventilated. " I have no idea how to assess ICP or herniation other than to look for posturing. She had no signs of posturing.

So the question is was the RT bagging too fast? I've asked several medics about this and their consensus is yes. One labeled the RT a "respiratory terrorist." But I don't want to second guess the RT in this situation. Is there more to the story here? This is my first head bleed case.

Here's the deal. Though hyperventilation is appropriate at times in CVA/TBI pts, you don't really know what the effects are on your ICP's as you increase respirations unless you have a probe actively measuring ICP's. So, with that being said, one only has left to go on what's normal. Therefore, breathe for them normally. If you have the ability of ventilator, set it up to get PaCO2 to low side of normal - 35-40 torr. If you don't have that availability, just bag them as normal as possible.

 

[usalsfyre]

Not trying to be insulting, but this type of situation is why CCT is a separate discipline and shouldn't really be attempted by those not familiar with the transport environment.

 

[Simusid]

Not trying to be insulting, but this type of situation is why CCT is a separate discipline and shouldn't really be attempted by those not familiar with the transport environment.

I'm not positive, but I think if it had been a CCT truck, the same nurse and RT would have gone with the patient in which case the same quality of bagging would have taken place and I'd still have the same question.

If you're saying I had no business being on that transport, I guess I don't disagree with you except that it would have taken an hour or more to find a suitable CCT truck and the doctor didn't want to wait.

 

[18G]

Bagging at 40-60min is way too fast. Unless the pt. had obvious signs of >ICP, ventilations should have been given while using EtCO2 as the guide and maintaining on the low end of normal 35-37mmHg. Even with >ICP 40-60min is way too fast.

I've bagged a SAH patient literally for 2hrs on an IFT and used EtCO2 as the guide. The trauma doc was surprised that the ABG's were as good as they were with the patient not being on a vent and being bagged for 2hrs.

 

[AnthonyM83]

While most RT's I've seen bagging patients in the emergency setting seem to have been hyperventilating inappropriately, I can't say specifically for your situation. Did the doctor order hyperventilation? Were they trying to keep capnography within a certain range? Were they just going off signs/symptoms, such as Cushing's Triad / other signs of herniation? Did they have some kind of imaging done confirming herniation? Was the RT simply excited or nervous or believed it didn't matter either way? Couldn't tell ya specifically in your case...

 

[Simusid]

While most RT's I've seen bagging patients in the emergency setting seem to have been hyperventilating inappropriately, I can't say specifically for your situation. Did the doctor order hyperventilation? Were they trying to keep capnography within a certain range? Were they just going off signs/symptoms, such as Cushing's Triad / other signs of herniation? Did they have some kind of imaging done confirming herniation? Was the RT simply excited or nervous or believed it didn't matter either way? Couldn't tell ya specifically in your case...

Her pulse was in the low 70's and got as low as 65. Her BP was 116/67, 110/65, 131/96 over the transport. Nobody said anything about herniation. She was not posturing. RT definitely did not seem nervous at all, more bored if anything. Transport time was about 25 minutes with no change in pt status throughout. I'm trying to keep my questions general and not about this specific patient and I think what I'm hearing is that bagging every 2 seconds or less is probably not indicated.

 

[usalsfyre]

I'm not positive, but I think if it had been a CCT truck, the same nurse and RT would have gone with the patient in which case the same quality of bagging would have taken place and I'd still have the same question.

If you're saying I had no business being on that transport, I guess I don't disagree with you except that it would have taken an hour or more to find a suitable CCT truck and the doctor didn't want to wait.

I'd you'd had a CCT truck the patient would've been on a vent eliminating the human factor all together .

The "hurry up and get them outta here" mentality is a huge problem. It's part of the reason for the explosion of HEMS and inappropriate transports.

 

[Dwindlin]

I don't know about everyone else but in the hospitals I frequent I see this often from the RTs. They all hyperventilate the patients. I can't recall the number of times bringing post-op patients to the ICU and I'm accompanying bagging the patient at 10-12/min, soon the as the RT takes over its a breath every 2 seconds.

Anyone else notice this from RTs, or is it just here?

 

[MS Medic]

I would suspect the "problem" your seeing is due to incongruity between EMS and hospital setting treatment methods. I'm not saying your calling it wrong but I've noticed things like that in the past when I brought a pt in. I would later ask the hospital staff why they did the issue in question. I would then get a honest answer from them that seemed to make perfect sense to everyone else in the room but left me walking out scratching my head thinking WTF.

 

[FLdoc2011]

Even in hospital setting I routinely see our RTs bagging way to fast during codes either because of adrenaline going or they just aren't paying attention.

But we do regularly use hyperventilation with goal pCO2 of ~28-32 on our bleeds when there is evidence of acute change and increased ICP. We don't do trauma so I can't comment specifically there, but we do a lot Non-traumatic bleeds. From what I've read it's a temporary measure usually only useful for less than 24hrs and can possibly even lower cerebral perfusion pressure so certainly some thought required before just routinely hyperventilating everyone.

In any case it sounds like they were bagging way to fast. On the vent we usually have rate around 22-26 which works well.

 

[Handsome Robb]

The only time we "mildly hyperventilate" is if we have signs of posturing or cushing's reflex.

Either way, like someone else said, 40-60 bpm is way too fast.

 

[Veneficus]

Did they have some kind of imaging done confirming herniation?

Imaging in a head injury patient with clinical signs of head injury in a facility that doesn't have neurosurgery is a disservice to the patient.

The only thing that would do is waste time by delaying transport to a facility that can care for him.

Upon arrival at the definitive facility, imaging would have to be done anyway.

I don't understand why EMS providers seem to think that having some kind of image of badness somehow makes everything all better.

My questions would be:

Why did this lady go to a facility without neurosurg to begin with?

Was some treatment done at the original facility that would improve this patients condition?

or did it just waste time and generate a needless bill while the ED went through its "suspected head injury protocol," on a patient it knew it couldn't help?

 

[FLdoc2011]

Imaging in a head injury patient with clinical signs of head injury in a facility that doesn't have neurosurgery is a disservice to the patient.

The only thing that would do is waste time by delaying transport to a facility that can care for him.

Upon arrival at the definitive facility, imaging would have to be done anyway.

I don't understand why EMS providers seem to think that having some kind of image of badness somehow makes everything all better.

My questions would be:

Why did this lady go to a facility without neurosurg to begin with?

Was some treatment done at the original facility that would improve this patients condition?

or did it just waste time and generate a needless bill while the ED went through its "suspected head injury protocol," on a patient it knew it couldn't help?

A receiving facility is required at the very least to do screening exam per EMTALA and if there's suspected head injury you bet they're going to scan the patient. We accept brain bleeds all the time from outside facilities and there is no way our neurosurgeons or neurointerventionalist would accept without knowing what the underlying pathology is. And we may or not rescan them depending on if we have the film and on the pt's clinical condition.

Even at a facility without neurosurg there is still stuff that they could do there in the meantime.... manage comorbidities, non invasive management of ICP, or even emergent burr hole if needed.

We don't admit peds but the ER will see peds and they can't just transfer a ped pt out before some sort of workup and stabilization.

 

[Veneficus]

A receiving facility is required at the very least to do screening exam per EMTALA and if there's suspected head injury you bet they're going to scan the patient.

Going to, yes, of significant benefit, I have my doubts.

We accept brain bleeds all the time from outside facilities and there is no way our neurosurgeons or neurointerventionalist would accept without knowing what the underlying pathology is..

Why?

"I'm sorry, but until you diagnose the brain pathology I am afraid our neuro facility is not willing to help your suspected head injury patient."

That sounds sort of off kilter to me.

That would assume the facility has a working/available CT at all hours. I know of smaller hospitals in major US cities that shut down their CT at 9pm, with nobody on staff to run it in the building.

Not every ED is set up to dx and manage critical patients. I have seen multiple smaller hospitals in the US that do not even have CTs.

And we may or not rescan them depending on if we have the film and on the pt's clinical condition. .

Or if the image quality or rendering is not acceptable to the receiving facility.

I could not possibly recount all the times I have seen rescans because of questionable or outright poor quality from community facilities.

Even at a facility without neurosurg there is still stuff that they could do there in the meantime.... manage comorbidities, non invasive management of ICP,..

That is why I asked.

or even emergent burr hole if needed..

Forgive me, but from what I have seen, most outlying facilities and providers in any nation, even if they do have the equipment in the back room somewhere, would never consider such a procedure if they do not perform it regularly.

But I will put it to an informal poll to all of the EMs on my FB page just to get some more feedback on it.

We don't admit peds but the ER will see peds and they can't just transfer a ped pt out before some sort of workup and stabilization.

Do you think it is medically beneficial to a patient to receive a workup if they cannot be helped or is it just an administrative thing?

Stabilization is a rather tricky term. What does it mean to you?

 

[Handsome Robb]

Not every ED is set up to dx and manage critical patients. I have seen multiple smaller hospitals in the US that do not even have CTs.

The hospital where I grew up didn't and still doesn't have a CT scanner. I have fond and not so fond memories of that hospital but honestly they are equipped to handle a runny nose or a flu bug and that's about it. More like an urgent care that can work a code and do emergent airways if needed but I'd be willing to bet the Paramedics would have done it before they got there or would be high on the list of candidates considered for the job if they were still at the hospital for the simple fact that many if not all of them have more recent experience with airways of that nature.

 

[AnthonyM83]

Imaging in a head injury patient with clinical signs of head injury in a facility that doesn't have neurosurgery is a disservice to the patient.

The only thing that would do is waste time by delaying transport to a facility that can care for him.

Upon arrival at the definitive facility, imaging would have to be done anyway.

I don't understand why EMS providers seem to think that having some kind of image of badness somehow makes everything all better.

Imaging was the most unlikely of the explanations when I brainstormed ideas on things that could have influenced their judgment. The reply also wasn't very scenario specific.