Definitive Airway Needed

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Early neurologic imaging is essential for these patients, as it assists with prognostication and determination of the need for surgical intervention. A CT head should be performed for every patient with a GSW to the head or face, regardless of whether it appears that the projectile penetrated the skull, as there can be internal neurologic injury even without skull penetration.  A three-dimensional CT reconstruction is helpful in identifying the projectile’s path, especially with facial injuries. CTA is useful in identifying vascular complications and traumatic aneurysms. Repeat CT scans should be performed to identify any worsening injury; any change in neurologic status should also prompt repeat head imaging. Once brain imaging is obtained, early neurosurgical consultation is critical to evaluate for possible operative management.

Considerations for airway management should include avoiding worsening elevated intracranial pressure (ICP), as this is the leading cause of mortality in traumatic brain injury from a GSW. When intubating these patients, there is some weak, limited evidence that suggests that premedication with high doses of IV fentanyl (3 mcg/kg) can attenuate rises in blood pressure and heart rate, which will also blunt increases in ICP. Lidocaine has previously been thought to blunt increases in ICP during laryngoscopy, but this has not been proven in the literature and is not recommended. Propofol may be a good choice for induction and/or post-intubation sedation if the patient’s blood pressure is elevated, while ketamine is a better choice if the patient is hypotensive. Hyperventilation, raising the head of the bed, and hypertonic saline or mannitol may also be used if there is concern for impending herniation. Adequate post-intubation sedation can help prevent spikes in ICP.

In airway management, attention must also be given to the patient’s oxygenation. It has long been known that hypoxia in the setting of a traumatic brain injury is associated with worse mortality. Knowing this, the Guidelines for Field Management of Combat-Related Head Trauma recommend prehospital administration of oxygen despite there being no specific literature addressing its impact on patient outcomes. Care should be taken to avoid hypoxia throughout the patient’s ED course, particularly during the vulnerable period of rapid sequence intubation. Adequate preoxygenation should be administered prior to intubation, but the fraction of inspired oxygen (FiO2) should be rapidly de-escalated after the airway is secured, as hyperoxia has been shown to be equally detrimental to the recovery of traumatic brain injury patients. It is not uncommon for patients to be left on 100% FiO2 immediately post-intubation or for transport, so it is important for the clinician to be aware of this and make adjustments accordingly.

With regard to circulation, it is well established that hypoperfusion can cause secondary brain injury, and it is widely accepted that hypotension should be immediately addressed in traumatic brain injury patients. However, a 2022 secondary analysis of the EPIC traumatic brain injury study suggests a bimodal influence of systolic blood pressure (SBP). This study found worsening mortality <130 mm Hg and >180 mm Hg, with greater mortality in the 90 to 120 mm Hg range than in the 130 to 180 mm Hg range. Mortality rapidly increased in patients with SBP >180 mm Hg. With this in mind, early intervention should be directed at optimizing the patient’s blood pressure, whether too high or too low.