TBI post: 23.4% Hypertonic Saline "Bullet" for the field

Sep 22, 21
TBI post: 23.4% Hypertonic Saline 'Bullet' for the field

 



@nardoctor TBI post: 23.4% Hypertonic Saline

Lighter, smaller, faster, easier to use than a bag of 3% or 5% saline for TBI…. The saline bullet! This article lays out a strong case for using 23.4% saline over 3-5% saline in the prehospital setting for TBI. Here is a rundown.
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Prehospital Treatment of TBI: Focus on preventing HYPOTENSION and HYPOXIA. Treat increased ICP with position (elevated head) and hypertonic saline(HTS). Prevent seizures (use Keppra for prevention and midazolam for treatment).
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How it works: Increases blood osmolality which then draws fluid from brain tissue into the vasculature. Mannitol works as well but more side effects, heavier and more difficult to dose and administer prehospital and has no significant advantage (in fact it may be less effective).
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Indications: Impending or Ongoing Herniation (IOH). Clinical signs are- pupillary asymmetry, unilateral or bilateral fixed and dilated pupils, decorticate or decerebrate posturing, respiratory depression, and Cushings triad (Hypertension, Bradycardia and Irregular Respiration).
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23.4% HTS: Smaller/lighter-80gm/55cm3 vs 570gm/500cm3 with 3-5%. Dosing 30ml IV slow push over 10 minutes which can be delivered via peripheral IV or IO (just make sure you flush both after). Evidence shows it is just as effective as 5% (lowers ICP 10+ mmHg at 1 hr and 24hrs).
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Great job Doc Rush and @pjmedicine! Will keep you all updated as this goes to a vote at @tc3committee.

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