Managing head injury patients can be challenging. Actually they can be down right scary. Let’s face it, the closed head injury call can go sideways fast. They tend to be altered or unconscious. They can be angry and combative. They vomit. Their vital signs do weird things that are difficult to explain. They can breath too fast, too slow or not at all. (And sometimes they do all three.)
The next time you’re in the middle of managing a difficult head injury patient, I want you to think about two things.
There are limited things that we can do in the prehospital setting to fix a closed head injury. They need to be transported to an appropriate trauma facility. Our care is centered around managing them until we can get them to the definitive care that they need. With that in mind, here are the two cardinal sins of closed head injury care. These are the two things that need to be avoided at all costs.
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First thing. Never, ever, ever let a closed head injury become Hypoxic.
Hypoxia will make a bad head injury become worse in a big hurry. Remember that respiratory status can be a moving target in the closed head injury patient. Anything goes with the rate and depth of respiration as a patient intra-cranial pressure rises. And things can change fast. Be very agressive in the airway management of this patient. If their breathing is adequet, keep them on high flow oxygen. If they vomit, roll them and suction them aggressively. (Keep the oxygen flowing during suctioning.)
Manage hypoventilation immediately. Have the BVM standing by and use it as soon as they need it. Get those BLS airways out and use them. If the patient has a gag reflex, use a nasopharangeal airway. If they don’t have a gag reflex, use an oropharangeal airway and get an advanced airway in as soon as possible. (Intubate if you can, use a King airway or other dual lumen device if you can’t.)Ventilate the patient, but don’t hyperventilate them. Hyperventilating head injury patients is old school. Use capnography if you have it and keep that ETCO2 at a low-normal level. No capnography? That’s OK. One breath every six seconds. (Hint: It’s slower than you think.)
I know that new CPR guidelines are de-emphasizing airway management. This is not the case with head injury’s. Make the airway your number one priority and don’t neglect it for a second.
Second thing. Never, ever, ever let a closed head injury become Hypotensive.
Research tells us that even one episode of hypotension can be devastating in the presence of increased intracranial pressure. Start IV lines and administer fluid as needed. Use the shock position, but not trendelenburg. Preventing hypotension begins with aggressive monitoring. If you have an auto-cuff set it for every two minutes. This will give you almost constant blood pressure monitoring. Auscultate that pressure if anything on the monitor looks sketchy. No auto-cuff? That might be better. Wrap a coff around the patients arm and palpate the systolic pressure every few minutes. Auscultate if you find it trending toward hypotension territory.
When you call in to the hospital, the patients most current blood pressure should be the second thing you report on (Right after the status of the airway.)
When you keep these two things primary in your mind, your care priorities will become more obvious regardless of the complexity of the patients presentation or how rapidly their condition changes. Focus on the airway, monitor the blood pressure and transport to the appropriate facility. Everything else is but a footnote.
Now it’s your turn: I left several important notes regarding the care of head injuries out of this article. What other tidbits do you have on treating this challenging patient group? Leave a comment and let us know.