What are the guidelines for prehospital hyperventilation of head injury patients?

Question: Paramedics in Canada, have in the past been told to hyperventilate head injury patients to decrease ICP. I know that I have recently read studies and different guidelines that do not recommend hyperventilation prehospital at all. I am interested in hearing any input either for or against. I have been searching the Canadian Heart and Stroke guidelines for anything related and I can't find what I am looking for. Also, if any medics from other countries have any protocals or guidelines for the same you could share.

Answers:
"Current Statewide Basic Life Support Adult and Pediatric Treatment Protocols stipulate that hyperventilation, at a rate of 20 breaths per minute in an adult and 25 breaths per minute in a child, should be employed in major trauma whenever a head injury is suspected, the patient is not alert, the arms and legs are abnormally flexed and/or extended, the patient is seizing, or has a Glasgow Coma Scale of less than 8. The State Emergency Medical Advisory Committee has reviewed these protocols, and concludes, on the basis of recent scientific evidence, that in the patient with severe traumatic brain injury (Glasgow Coma Scale score < or = to 8) following open or closed head injury, aggressive hyperventilation should be avoided in the prehospital setting, unless there are active seizures or signs of transtentorial herniation.

Although hyperventilation was used throughout the 1970s and 1980s in the acute management of severe traumatic brain injury, its use has undergone critical reappraisal in recent years. This has occurred following the publication of several reports linking excessive hyperventilation (PaCO2 < 25 mm Hg) to cerebral ischemia, as well as a large prospective randomized study which failed to demonstrate any benefit, but instead demonstrated a slight detriment, to head injured adult patients ventilated to achieve a PaCO2 of 25 mm Hg versus head injured adult patients ventilated to achieve a PaCO2 of 35 mm Hg."

Out of the New York Prehospital Protocols, United States

Other Answers:
From my experience, that would depend on the severity of the injury, and the current respiration rate of the patient. Our protocol is to hyperventilate only when suction is required. We will assist repirations if the rate, rythm, and quality are outside the acceptable range for the given patient. If they are 22 and shallow, or 6 and labored(eg.), we will assist ventiltion. It also greatly depends on the LOC and if the pt will tolerate an airway adjunct or assisted ventilations. I hope this helps. Let me know.

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