USA Today: The report also said that doctors concluded Piazza suffered from "multiple traumatic brain injuries," including a fractured skull and.

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USA Today: The report also said that doctors concluded Piazza suffered from "multiple traumatic brain injuries," including a fractured skull and a lacerated spleen, which resulted in 80 percent of his blood supply in his abdominal cavity.

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Source: 2016 MIEMSS Protocols

Source: 2016 MIEMSS Protocols

Traumatic Brain Injuries Primary Brain Injury: immediate damage to the tissue from the direct injury Secondary Brain Injury: hypoxia from increased perfusion from the primary injury The brain swells, vessels vasodilate and blood accumulates and causes increased pressure a decrease in blood flow over several hours Do Not Let Them Get Hypoxic!! This is our moment to literally save their life

Intracranial Pressure (ICP): the pressure of the brain and contents within the skill > 15 mmHg is dangerous > 25 mmHg will cause cerebral herniation Cerebral Perfusion Pressure (CPP): the pressure of the blood flowing through the brain

Cushing’s Reflex The body’s protective response to maintain constant perfusion pressure ↑ICP → ↑BP to force blood to the brain Then the body slows down the HR to try and control the BP This cycle continues until ICP ≅ Mean Arterial Pressure and then there is no cerebral perfusion and the brain dies

How Do We Fix It Maintain a higher than standard blood pressure Ideally SBP 110-120 mmHg Control the Airway! Intubation!? Control respiratory rate Prevent hypoxia! Secondary Brain Injury Prevent rapid loss of a patent airway Hyperventilation as a last ditch effort Signs/Symptoms clearly indicated a TBI Corrected hypoxia and hypotension This will only briefly fix cerebral swelling temporarily

Hyperventilation From ITLS 7th Edition: TBI with GCS < 9 with extensor posturing (decerebrate) TBI with GCS < 9 with asymmetric (or bilateral), dilated, or nonreactive pupils TBI with initial GCS < 9 and a subsequent drop > 2 points Source: 2016 MIEMSS Protocols

But Why? Normal blood CO2 is 35-45 mmHg measured by waveform capnography Increased CO2 (hypoventilation) causes vasodilation as the body tries to self- correct Lowering the CO2 by hyperventilation to 30-35 mmHg causes vasoconstriction and decreases blood flow Only a slight impact on brain swelling but a significant decrease in cerebral perfusion from vasoconstriction