Download AEMT Transition - Unit 40

TRANSITION SERIES
Topics for the Advanced EMT
CHAPTER
40
Head and Traumatic
Brain Injury
Objectives
• Discuss the incidence and death rates
for brain injuries.
• Review the pathophysiology behind the
types of brain injuries.
• Define assessment considerations and
findings for patients with brain injuries.
• Review current treatment standards for
brain injuries.
Introduction
• Brain injuries may manifest themselves
now, or weeks later.
• The physiology of the brain and
surrounding structures leaves itself
open to certain types of brain injuries.
Introduction (cont’d)
• The task for the Advanced EMT is to
understand the physiology of the brain
and pathophysiology of brain injuries to
provide optimal treatment.
Epidemiology
• 1.5 million head injuries occur per year
in the U.S.
• It is the leading cause of death in
accident victims younger than 45.
• 50,000 people die each year from brain
injury.
Pathophysiology
• Intracerebral hemorrhage
– Extraaxial hemorrhage
 Epidural, subdural, subarachnoid
– Intraaxial hemorrhage
 Occurs within brain tissue itself
 Intracerebral hemorrhage
– Intraparenchymal hemorrhage
– Intraventricular hemorrhage
Pathophysiology (cont’d)
• Diffuse axonal injury (DAI)
– Most devastating of traumatic brain
injuries
– Acceleration-deceleration mechanism
– Frequent outcome is coma
– Stretching and swelling of axons
Pathophysiology (cont’d)
• Concussion
 Mild DAI
 GCS 13-15
– Epidural hematoma
 Serious complication of head injury
 Bleeding between dura and skull
Epidural hematoma
Pathophysiology (cont’d)
• Subdural hematoma
 Bleeding between arachnoid and dura
 Low-pressure bleed
 Acute, subacute, chronic
Subdural hematoma
Pathophysiology (cont’d)
• Subarachnoid hemorrhage
 Brain tissue becomes ischemic
 Severe headache common
 May rapidly progress to seizures and
cardiac arrest
Assessment Findings
• Dispatch information
– Seizures, headache, trauma, etc.
• Soft-tissue injuries to skull
• Closed or open skull injuries
• Alteration in mental status
Assessment Findings (cont’d)
• Possible loss of airway patency
• Breathing may become irregular and
slow
• Changes to vitals (Cushing response)
Assessment Findings (cont’d)
• Response to painful stimuli
– Purposeful vs. nonpurposeful
– Decorticate vs. decerebrate
Nonpurposeful responses to painful stimuli include (a) flexion
(decorticate) posturing and (b) extension (decerebrate) posturing.
Assessment Findings (cont’d)
• Assess and reassess mental status.
– Compute GCS, look for trends.
Glasgow Coma Scale
Assessment Findings (cont’d)
• Assess vital signs
– Trends of vitals may also help identify
brain injury.
Implications of Changes in Vital Signs with Head Injuries.
Emergency Medical Care
• Manual cervical spine considerations
• Assess and maintain the airway.
• Determine breathing adequacy.
– High-flow via NRB with adequate
breathing.
– High-flow via PPV @ 10-12/min if
inadequate.
– Avoid intubating head injured patients
unless apneic – tend to worsen outcomes.
Emergency Medical Care
– Consider hyperventilation with brain
herniation.
– Do not routinely hyperventilate –
Reserve for signs of herniation
 Controversial
 May produce short-term improvement
 No role in long-term mgt of elevated ICP
 May produce vasoconstriction and
worsening of brain injury – use only
when concerned about herniation.
Emergency Medical Care (cont’d)
• Assess circulatory components.
– Check pulse, skin characteristics.
– Control major bleeds.
Emergency Medical Care (cont’d)
• Transport immediately to an
appropriate medical facility.
– Initiate a large-bore intravenous
catheter.
– Administer fluids to keep SBP >90
mmHg.
– Do not cause hypertension with IV
fluids.
Emergency Medical Care (cont’d)
• Be prepared to manage seizure activity.
• Constantly monitor airway, breathing,
and circulation.
• Mental status changes are key to
determining improvement or
deterioration.
Case Study
• You are called to a motorcycle accident
where a rider not wearing a helmet lost
control of his cycle on a turn and hit a
tree. When you arrive, the patient is
lying supine, blood covering his face
and shirt, and the patient is actively
seizing. PD is already on scene and you
can hear the wail of the FD sirens
approaching.
Case Study (cont’d)
• Scene Size-Up
– Standard precautions taken.
– Scene is safe, police stopped traffic on
road.
– 43-year-old male patient, 200 lbs.
– Patient found supine, blood on face and
shirt.
Case Study (cont’d)
• Scene Size-Up
– Patient entry made, egress not
problematic.
– Paramedic summoned now for backup
assistance.
– PD on scene, FD pulling up.
Case Study (cont’d)
• Primary Assessment Findings
– Patient unresponsive, active tonic-clonic
seizures.
– Mouth clenched shut, blood on face,
sonorous breath sounds with gurgling.
– Breathing is ineffective due to seizure
activity.
Case Study (cont’d)
• Primary Assessment Findings
– Carotid and radial pulses present.
– Peripheral skin warm and sweaty.
– No major bleeds noted to body.
Case Study (cont’d)
• Is this patient a high or low priority?
Why?
• What interventions should be provided
at this time?
Case Study (cont’d)
• Medical History
– Unknown
• Medications
– Unknown
• Allergies
– Unknown
Case Study (cont’d)
• Pertinent Secondary Assessment
Findings
– Pupils unequal, sluggish to light.
– Airway patent, breathing still ineffective.
– Patient is still unresponsive and seizing.
– Pulse oximeter reading 82% with
attempts at PPV.
Case Study (cont’d)
• Pertinent Secondary Assessment
Findings
– B/P 198/90, heart rate 64, spontaneous
respirations 4 and irregular.
– Crepitus noted to posterior vertebrae.
– Depressed right frontal skull fracture
noted.
Case Study (cont’d)
• What type of brain injury could this be?
• Is this patient displaying any
indications of herniation?
Case Study (cont’d)
• Care provided:
– Patient’s cervical spine manually
immobilized.
– High-flow oxygen via PPV.
– Airway suctioned with catheter, manual
airway technique applied.
Case Study (cont’d)
• Care provided:
– Following cessation of seizure, full body
immobilization provided.
– Expeditious transport to appropriate
facility.
– Initiation of intravenous access.
Summary
• Brain injuries are a common cause of
death and disability following traumatic
events.
• Prehospital recognition and proper
management can help reduce the longterm effects of brain injuries.
• As with any trauma, focus first on
supporting lost function.