[Paramedic40]

As far as I know, in a field setting (even with ALS protocols and equipment) the only thing we can do to manage brain injuries is to support life functions. Some systems allow Mannitol, but from what I remember, it seemed to be going out-of-favor (this from my own recollection, my father, a 20-year paramedic) and my paramedic instructor). Like Swatsurgeon said, we can't actually measure ICP in the field, even based on mechanism of injury or mental status, because we have no way of knowing whether any deficits or abnormalities are being caused by increasing intracranial pressure or hypoxia, tissue damage, or even psychomotor causes. If we see something like Cushing's Triad (increased BP, decreased pulse, and irregular respirations) or deteriorating mentation/LoC/GCS, we can presume that they've sustained some insult to their brain that may be swelling- but will this actually change any of our treatments? Remember that we're already limited in what we can give/do by the nature of the injury.

1. Rapid Evac: As with all other emergent trauma, we can't help anything, at any level, in the field (even if you're a surgeon, working out of an aid bag isn't going to help).
2. BLS (support the airway, manage breathing/ventilations)
3. C-Spine/Immobilization! I was taught this simple mantra: If it's hard enough to knock them out, you need to control where they're going. If we're looking at some sort of gross deficit, we need to have them fully immobilized, because we have no way of knowing what the cranial vault's integrity is like, even with palpation.
4. IV access, fluids to maintain BP. I was taught by the Army to run fluids to keep a radial pulse. My civilian training was to keep their BP even lower (80-90mm systolic). I do have a question on Hextend- the Army told me it was indicated, civilian world said stick to NS for this. I would imagine that it could help by drawing off interstitial fluid/edema- but I am unsure and would like a second opinion.
5. If we're going to medicate, do it in accordance with SOPs and protocols. I personally was taught (civilian-side) not to use analgesics if we can't see the bleed, and I agree. If my SOPs allow me to push Mannitol and I know that a patient will be in the hands of a surgical team within a half-hour or so, I would give it if I felt it to be in the patient's benefit, but in general terms, I don't see a real need to go pushing meds into trauma patients. IV fluids should be very closely monitored and considered, and we should be mindful of positioning.
6. REASSESS! We must continuously monitor a patient with injuries that we suspect to have caused increases in ICP. In a MASCAL, unfortunately, this patient might be triaged to expectant, but if at all possible, we should get them out ASAP.

The sad fact is that there's no magic procedure or tool in any field provider's bag to manage increasing intracranial pressure. We can't evacuate the cranial vault, we can't puncture, drain, or remove it, and we can't medicate it away for very long. The only thing we can do is to get them somewhere that has people who can.