Notes – Head Injury

Head Injury

Patient Safety Considerations

  1. Do not hyperventilate patient unless signs of herniation
  2. Assume concomitant cervical spine injury in patients with moderate/severe head injury
  3. Geriatric Consideration: Elderly patients with ankylosing spondylitis or severe kyphosis should be padded and immobilized in a position of comfort and may not tolerate a cervical collar

Notes/Educational Pearls

Key Considerations

  1. Head injury severity guideline:
    1. Mild: GCS 13-15 / AVPU = (A)
    2. Moderate: GCS 9-12 / AVPU = (V)
    3. Severe: GCS 3-8 / AVPU = (P) or (U)
  2. Important that providers be specifically trained in accurate neurologic status assessment [see Appendix VII – Neurologic Status Assessment]
  3. If endotracheal intubation or invasive airways are used, continuous waveform capnography is required to document proper tube placement and assure proper ventilation rate
  4. Signs of herniation
    1. Decreasing mental status
    2. Abnormal respiratory pattern
    3. Asymmetric/unreactive pupils
    4. Decorticate posturing
    5. Cushing’s response (bradycardia and hypertension)
    6. Decerebrate posturing

Pertinent Assessment Findings

  1. Neurologic status assessment findings
  2. Pupils
  3. Trauma findings on physical exam

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914101 – Injury-Head

Key Documentation Elements

  • Adequate oxygenation
  • Airway status and management
  • ETCO2 monitored and documented for moderate/severe head injury (avoidance of inappropriate hyperventilation)
  • Neurological status with vitals: AVPU, GCS
  • Exams: Neurological and Mental Status Assessment

Performance Measures

  • No oxygen desaturation 90%
  • No hypotension:
    • Adults: 90 mmHg
    • Pediatrics:
      • 1 month:  60 mmHg
      • 1-12 months: 70 mmHg
      • 1-10 yo: 70 + 2x age in years
    • No EtCO2 lower than 35 for mild head injury, 30 if severe head injury with signs of herniation
    • Appropriate triage to trauma center
    • EMS Compass® Measures (for additional information, see http://www.emscompass.org)
      • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
      • Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
      • Trauma-02: Pain re-assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
      • Trauma-04: Trauma patients transported to trauma center. Trauma patients meeting Step 1 or 2* or 3** of the CDC Guidelines for Field Triage of Injured Patients are transported to a trauma center
        • *Any value documented in NEMSIS eInjury.03 – Trauma Center Criteria
        • **8 of 14 values under eInjury.04 – Vehicular, Pedestrian, or Other Injury Risk Factor match Step 3, the remaining 6 value options match Step 4

References

  1. Ambrosi PB, Valença MM, Azevedo-Filho H. Prognostic factors in civilian gunshot wounds to the head: a series of 110 surgical patients and brief literature review. Neurosurg Rev. 2012;35(3):429-35; discussion 435-6.
  2. Badjatia N, Carney N, Crocco TJ, et al; Brain Trauma Foundation; BTF Center for Guidelines Management. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care. 2008;12 Suppl 1:S1-52.
  3. Berlot G, La Fata C, Bacer B, et al. Influence of prehospital treatment on the outcome of patients with severe blunt traumatic brain injury: a single-centre study. Eur J Emerg Med. 2009;16(6):312-17.
  4. Davis DP, Koprowicz KM, Newgard CD, et al. The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale scores of 8 or less. Prehosp Emerg Care. 2011;15(2):184-92.
  5. Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma. 2010 Jul;27(7):233-41.
  6. Franschman G, Peerdeman SM, Andriessen TM, et al; Amsterdam Lifeliner: Analysis of Results and Methods–Traumatic Brain Injury (ALARM-TBI) Investigators. Effect of secondary prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma care. J Trauma. 2011;71(4):826-32.
  7. Haut ER, Kalish BT, Cotton BA, et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Ann Surg. 2011;253(2):371-7.
  8. Jagoda AS, Bazarian JJ, Bruns JJ Jr, et al; American College of Emergency Physicians; Centers for Disease Control and Prevention. Clinical policy: neuroimaging and decision making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52(6):714-48.
  9. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S876-908.
  10. Reed D. Adult Trauma Clinical Practice Guidelines: Initial Management of Closed Head Injury in Adults: 2nd Edition. New South Wales Institute of Trauma and Injury Management; 2011.
  11. Roberts I, Schierhout G. Hyperventilation therapy for acute traumatic brain injury. Cochrane Database Syst Rev. 1997;(4):CD000566.
  12. Stocchetti N, Maas AIR, Chieregato A, van der Plas AA. Hyperventilation in head injury a review. Chest. 2005;127(5):1812-27.
  13. Wakai A, Roberts IG, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev. 2007;(1):CD001049.
  14. Zebrack M, Dandoy C, Hansen K, Scaife E, Mann NC, Bratton SL. Early resuscitation of children with moderate-to-severe traumatic brain injury. Pediatrics. 2009;124(1):56-64.