In our last two installments we looked at the way heads get injured and the various ways the brain tends to bleed. In this, our last installment in the head injury series, let’s take a look at basic treatment and management of the head injury patient.
There are a lot of variables that need to be considered when managing a head injury patient in the prehospital environment. Your treatment will be guided by considerations like the mechanism and severity of the head injury, other associated injuries, the patients mental status and their basic stability.
These are some guidelines when sizing up and prioritizing your care.
Airway Management
Head trauma management begins with the airway. The brain is sensitive to hypoxia and a poorly managed airway can turn a significant but recoverable head injury into a devastating head injury. Our brain injured patients can present some unique airway challenges. Seizures and posturing can produce trismus and spinal precautions prohibit proper tilting of the head.
In these cases, oral and nasal airway adjuncts are helpful in ensuring proper ventilation while keeping the head midline and neutral. If the Glasgow is less than eight, consider an advanced airway like a king tube, combi-tube or ET tube. All of these should be protected from the possibility of a clenched jaw with some sort of bite block type protection.
Our tendency is to over-ventilate head injuries. This can do more harm than good. Keep ventilations steady at 12 to 20 breaths per minute. If capnography is available, bravo. Maintaining the patient in the slightly hypocapnic range (ETCO2 around 35) is a good goal.
Head injury patients are prone to vomiting so you should have suction standing by and a plan for rolling the patient if the need arises.
While it’s sometimes unavoidable, we try to keep advanced airway interventions out of the nose when possible. ET tubes, suction catheters and NG tubes can increase ICP and aggravate nasal cavity injuries when inserted into the nose. When an oral option is available, use it first.
Spinal Immobilization
If you’re running the show, you have no business grabbing the patients head. Delegate manual immobilization and then push the pace of the c-spine operation. C-spine can be a blessing and it can be a curse. For patients with spinal injuries, c-spine can possibly prevent debilitating neurological compromise. For patients with significant multi-system trauma, scene delays from slow c-spine procedures could be a real detriment to their care.
In critical trauma, the name of the c-spine game is fast. Just get it done. And know that once you’ve decided to c-spine the patient you’ve made the choice to sacrifice comfort for safe, clinically appropriate, immobilization. Cinch those straps up tight. There’s no point in putting someone in full c-spine and then cinching the straps and tape to the snugness of a loose t-shirt. If you need to log roll the patient, you’re going to need those straps tight. If it’s comfortable and loose, it isn’t immobilization.
Circulation
While we’re immobilizing the spine we need to do a rapid trauma survey looking for critical bleeding and other injuries that may need immediate intervention. Control major bleeding and take a quick set of vitals. Trauma scene vitals are pulse, respiration, skin signs and level of consciousness.
We don’t take blood pressures on trauma patients while we’re still on scene. Say that with me, “We don’t take blood pressures on trauma patients while we’re still on scene.” The other four vitals will tell us all that we need to know. If you need a blood pressure to tell you if your patient is sick or not, your patient is in big trouble. Whether you take the blood pressure or not, your patient will still be in big trouble. Put the BP cuff back in the bag and help get the patient off the scene.
Hypotension in a closed head injury patient is an ominous sign. Head injury does not produce hypotension so consider other sources. Evaluate for hypovolemic and neurogenic shock.
Neurological Examination
All conscious head injury patients should get a detailed neurological evaluation. Note the size and shape of the pupils including abnormal constriction (pinpoint pupils), dilation, inequality or nystagmus. Assess for hemiparesis from head to toe and check distal motor, sensory and circulation in all limbs. Ask about loss of consciousness. Assess the patients short and long term memory and simple cognitive ability.
Fluid Therapy
Establish large bore IV lines but restrict fluid in head injury patients to minimize cerebral edema. If hypotension is present from other injuries then aggressive fluid administration is warranted.
As a general rule is that we should aim to keep head injury patients normotensive. 90-110 systolic is a reasonable goal. However, when we see hypotension developing, we have to consider that the underlying cause of the hypotension is probably more immediately life threatening than the closed head injury.
Hopefully these guidelines will help you on your next head injury call. Head injury patients present many unique challenges in the prehospital environment. Evaluating the mechanism, recognizing the potential for critical bleeding, detailed patient assessment and conservative treatment are your best bet for successful outcomes.
Thanks for taking part in this series. I’d love to hear your challenges and experiences with head injury patients. Why not leave a comment below. I’ll see you next time.
