Big biker dude strained against the double layers on tape across his forehead and it occurred to me that the act of c-spine seemed pointless if the patient insisted on fighting violently against the tape and straps. Three firefighters were still holding big biker dude (BBD) down and the firefighter closest to his head was yelling, “calm down. … CALM DOWN!” This wasn’t working, but I understood. Sometimes the urge is irrisistible. For his part, big biker yelled back in disorganized consonants and vowels, “uaaaaghhh”.
BBD had laid his Harley down just before an intersection at the corner of our district. Medic units from three different providers would be responding to the intersection to establish who’s patient he really was. This was often a recipe for conflict, but not tonight. The second medic on scene was happy to assist me with setting up IV’s and the third drove by without stopping. From his position in the road, BBD clearly wasn’t in my response area, none-the-less, big biker dude was all mine.
Maybe it was all the leather, or perhaps it was the Harley, or the time of night, but I assume from their demeanor that most folks on scene thought that big biker dude was really drunk or really mean or both. In reality he was neither. Big biker dude had a closed head injury and he was in his combative phase. Combative closed head injuries can be easily mistaken for aggressive patients by emergency responders and, if we’re not careful, the confusion can lead to incidents like this one and profoundly inappropriate care.
So what makes closed head injury patients fight us?
I found surprisingly little information addressing this specific question. While there is plenty of information to be found regarding the debate over how to treat these challenging patients, exactly why they fight is left unexamined. The reasons for combativeness are primarily theoretical. They are likely a combination of the following:
- Hypoxia. Both swelling of brain tissue and disruptions in the patient’s respiratory patterns can lead to increasing hypoxia.
- Direct damage to brain tissue from the initial insult. Whether diffuse axonal damage has occurred across the cerebral tissues or localized damage such as a contusion, damage to brain tissues can effect cognitive function and contribute the patients irrational responses to care.
- Confusion. Either or both of the above etiologies can lead to confusion and an inability to understand the external stimuli that the nervous system is attempting to process.
- Fear. With an inability to understand the actions and intentions of the care providers around them, patient’s respond with fear and aggressive resistance.
- Pain. The patient may be experiencing tremendous pain secondary to their injuries and may believe the care providers and interventions are the source of the pain.
- Reflexes. In the presence of intracranial pressure, the brains reflex response to external stimuli may be to resist against the stimuli.
Put it all together and the end result is one very large, very angry biker dude who is having a medical emergency and needs careful intervention despite the fact that he is fighting like mad. Is it any wonder why the third medic unit kept driving? Combative head injury patients present a unique challenge to the prehospital provider and create quite a bit of debate within the medical community.
Here are a few of the patient care controversies you’ll need to weigh enroute to the trauma center.
Oxygenation
- There’s no argument that high flow oxygen is indicated, but if a mask over the patients face doubles the patients agitation and dramatically increases their oxygen consumption, are you doing them a favor? Try to oxygenate in a manner that does not increase agitation. (I know, easier said than done.)Consider placing the mask near the face in a manner that doesn’t agitate. If you assume ventilations, resist the urge to hyperventilate the patient.
Spinal Immobilization
- Most sources recommend forced immobilization of the spine, however, use your judgment and consult your physician. If the patient remains relatively still with his head free and fights aggressively against head restraint, leaving the head untaped, using gentle manual immobilization and even forgoing the c-collar may be the most effective immobilization. The goal is to reduce head movement. Consider the most effective end to that goal might not be your typical technique.
Sedation
- Many interventions and diagnostic tests will not be possible without sedation. In house, there is debate over the type and degree of sedation appropriate for these patients. Don’t delay transport to wait for sedation on scene or ALS level resources.
- Our sedation technique will be limited by protocol. If your protocols guide you to narcotics and benzodiazepines, remember to monitor for respiratory depression and hypotension. Either could be devastating for this patient. If Haldol or Droperidol are available, they are preferred, though they come with additional concerns like dystonia and possible adverse interactions with alcohol and street drugs. Take care with sedation and monitor the patient closely.
On the non-controversial side of treatment
- Do a detailed secondary on these patients and don’t get caught off guard by injuries that may have been missed in the struggle for initial control.
- Protect the airway and be ready for the possibility of vomiting. Projectile vomiting is common with closed head injuries.
- Establish at least one IV line in a location that will remain patent even if the patient has a seizure or postures. (Not at the AC).
- Recheck pupils and neurological function often.
- If the airway is controlled most systems will recommend transport to the trauma center. Some systems allow for transport of the isolated head injury to non-trauma centers for initial stabilization. Multi-system trauma will still go directly to the designated trauma center.
Above all, don’t beat yourself up over difficulties in managing the combative head injury patient. This patient is extremely challenging to manage, especially without the aid of sedation, so do what you can for the patient and stay safe.
