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Shadowflyer- great thread. Thanks for posting.
A few points about the case-
1. TBI: With traumatic brain injury the most important things you can do in the pre-hospital environment is to insure good cerebral perfusion pressure (the pressure driving blood to the brain), and good oxygenation. With TBI there are areas of brain that are injured, but have the potential to recover. With hypotension or hypoxia you end up not getting enough oxygen and nutrients to the area of potential salvageable brain, thus causing irreversibly injury. Although current teaching is to use hypotensive resuscitation, this patient does have a TBI and he should receive aggressive fluid resuscitation. Because of the need for optimal oxygenation, and given that this guy is not protecting his airway he probably needs be intubated. A nasotracheal intubation should not be attempted because of his likely facial fractures.
2. Other injuries- In the IED scenario it is very easy to overlook injuries because you are distracted by the significant head injury. Yes this guy has a very bad head injury that might eventually be fatal. However, he might also have shrapnel wound to his upper back causing a tension pneumothorax that could be fetal in the next few minutes. Important things like small entry wounds can be very easily missed when there is a big distracting injury. That is why primary and secondary surveys are important, and why you always want to evaluate trauma in the same systematic way so you do not miss anything. Obviously being in a combat environment makes this even more difficult, and not always possible.
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