4. TRAUMA EMERGENCIES
4.3 HEAD TRAUMA / INJURIES
Head (brain) injury is the most frequent cause of vehicular death. Injury to the head occurs as a result of blunt or penetrating trauma. The primary concern in the pre-hospital setting is awareness of the potential for brain injury and recognition of the signs and symptoms of head, neck and spinal injury early in patient assessment. These signs and symptoms may include but are not limited to the following: agitation, loss of consciousness, bradycardia and hypertension, seizures, paralysis, vomiting and airway occlusion.
Head trauma can be categorized into the following elements: Superficial injury involving scalp, fascia, and skull. Internal injury involving brain and spinal cord. Sensory organ injury involving the eye and the ear. Neck injury involving skeletal and soft tissue structures. For this reason, all these conditions must be considered when managing patients with head injury. Therefore, cervical spine injury may accompany head injury; intubation may be required to secure the airway as protective gag reflexes may be lost; sudden death may result from brain herniation; severe bleeding from scalp wounds may occur; severe facial trauma may make airway management difficult, etc. Hyperventilation may help brain injury by reducing intracranial pressure. Hyperventilate the patient in suspected cases of herniation syndrome (e.g. - decorticate posturing; decerebrate posturing; fixed, dilated pupils, etc.). Due to all these factors, the treatment of head injury may require specialty care at a designated trauma center.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. Assume spinal injury and treat accordingly. Hyperventilation with 100% oxygen at a rate no less than 24/ minute with BVM if associated with a significant closed head injury and signs of herniation syndrome.
3. Administer high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition.
4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness (AVPU/Glasgow Coma Scale), ABCs, disability and Vital Signs. Examine head for presence of lacerations, depressions, swelling Battle Sign, Cerebrospinal Fluid (CSF) from ears/nose, and foreign (impaled) objects.
5. Treat all life threatening conditions as they become identified.
6. When multiple patients are involved, they need to be appropriately triaged.
7. Obtain appropriate history related to event, mechanism of injury, including Past Medical History, Medications, Drug Allergies, Substance abuse. NOTE: Family and friends my be useful during the assessment to determine normal or abnormal mental status.
8. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
9. If the scene time and/or transport time will be prolonged, and a landing site is available, consider transport by air ambulance from the scene to an appropriate Trauma Center. See Air Ambulance protocol.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. Assure cervical spine stabilization and immobilization. Airway management may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Hyperventilation with 100% oxygen at a rate no less than 24/ minute with BVM if associated with a significant closed head injury and signs of herniation syndrome.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.)
5. Activate ALS intercept, if deemed necessary and if available.
6. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
7. Initiate transport as soon as possible with or without ALS.
8. Notify receiving hospital of patient's status. (AVPU / Glasgow Coma Scale).
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. Assure cervical spine stabilization and immobilization. Airway management may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Hyperventilation with 100% oxygen at a rate no less than 24/ minute with BVM if associated with a significant closed head injury and signs of herniation syndrome.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.)
5. Activate Paramedic intercept, if deemed necessary and if available.
6. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
7. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Ventilate with 100% oxygen.
c. Initiate IV Normal Saline (KVO) while enroute.
8. Initiate transport as soon as possible with or without Paramedics.
9. Contact MEDICAL CONTROL to notify receiving hospital of patient's status. (AVPU / Glasgow Coma Scale).
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. Assure cervical spine stabilization and immobilization. Airway management may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Hyperventilation with 100% oxygen at a rate no less than 24/ minute with BVM if associated with a significant closed head injury and signs of herniation syndrome.
3. Admin S
a. Provide advanced airway management if indicated.
b. Initiate IV Normal Saline
c. Ventilation with 100% oxygen.
d. 75-100 mg Lidocaine IV push prior to intubation, if intubation is indicated.
7. Initiate transport as soon as possible.
8. Contact MEDICAL CONTROL to notify receiving hospital of patient's status. (AVPU / Glasgow Coma Scale).ister high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.)
5. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
6. ALS STANDING ORDER
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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