Head Injury Management (Two Things)

Managing head injury patients can be challenging. Actually they can be down right scary. Let’s face it, the closed head injury call can go sideways fast. They tend to be altered or unconscious. They can be angry and combative. They vomit. Their vital signs do weird things that are difficult to explain. They can breath too fast, too slow or not at all. (And sometimes they do all three.)

The next time you’re in the middle of managing a difficult head injury patient, I want you to think about two things.

There are limited things that we can do in the prehospital setting to fix a closed head injury. They need to be transported to an appropriate trauma facility. Our care is centered around managing them until we can get them to the definitive care that they need. With that in mind, here are the two cardinal sins of closed head injury care. These are the two things that need to be avoided at all costs.

Two things…

First thing. Never, ever, ever let a closed head injury become Hypoxic.

Hypoxia will make a bad head injury become worse in a big hurry. Remember that respiratory status can be a moving target in the closed head injury patient. Anything goes with the rate and depth of respiration as a patient intra-cranial pressure rises. And things can change fast. Be very agressive in the airway management of this patient. If their breathing is adequet, keep them on high flow oxygen. If they vomit, roll them and suction them aggressively. (Keep the oxygen flowing during suctioning.)

Manage hypoventilation immediately. Have the BVM standing by and use it as soon as they need it. Get those BLS airways out and use them. If the patient has a gag reflex, use a nasopharangeal airway. If they don’t have a gag reflex, use an oropharangeal airway and get an advanced airway in as soon as possible. (Intubate if you can, use a King airway or other dual lumen device if you can’t.)Ventilate the patient, but don’t hyperventilate them. Hyperventilating head injury patients is old school. Use capnography if you have it and keep that ETCO2 at a low-normal level. No capnography? That’s OK. One breath every six seconds. (Hint: It’s slower than you think.)

I know that new CPR guidelines are de-emphasizing airway management. This is not the case with head injury’s. Make the airway your number one priority and don’t neglect it for a second.

Second thing. Never, ever, ever let a closed head injury become Hypotensive.

Research tells us that even one episode of hypotension can be devastating in the presence of increased intracranial pressure. Start IV lines and administer fluid as needed. Use the shock position, but not trendelenburg. Preventing hypotension begins with aggressive monitoring. If you have an auto-cuff set it for every two minutes. This will give you almost constant blood pressure monitoring. Auscultate that pressure if anything on the monitor looks sketchy. No auto-cuff? That might be better. Wrap a coff around the patients arm and palpate the systolic pressure every few minutes. Auscultate if you find it trending toward hypotension territory.

When you call in to the hospital, the patients most current blood pressure should be the second thing you report on (Right after the status of the airway.)

When you keep these two things primary in your mind, your care priorities will become more obvious regardless of the complexity of the patients presentation or how rapidly their condition changes. Focus on the airway, monitor the blood pressure and transport to the appropriate facility. Everything else is but a footnote.

Now it’s your turn: I left several important notes regarding the care of head injuries out of this article. What other tidbits do you have on treating this challenging patient group? Leave a comment and let us know.

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  1. Micah Gray says:

    Steve, great point about the dangers of hyperventilation. That’s an important subject. Even though hyperventilation may reduce intracranial pressure, it also causes cerebral vasoconstriction and so, reduces blood flow to the brain – not a good thing for head injury patients. PHTLS is currently teaching to only hyperventilate if there are concrete signs of herniation – posturing, Cushing’s triad, etc – and even then, shoot for an ETCO2 of 30 (mild hyperventilation). Thanks for the important reminder of those two key components of managing head injuries!

  2. Not much else has proven to be truly important during the initial management of the head-injured patient, but having the head elevated at 30 degrees can decrease ICP if not contraindicated. It costs nothing, allows for better ventilation, and also decreases the incidence of ventilator-acquired pneumonia in the long run.

  3. administrator says:

    Great tip Vince. What’s your source on that?

  4. Tried to reply the other day, but I included links and it must have gotten gobbled up by your filter. I can email them to you if you’re interested

    Gah you just had to ask… Turns out it’s a bit trickier than I first assumed.

    I forget where I first heard about raising the head of the bed, but I remember being reminded in a great lecture from Dr. Bart Besinger at ‘Free Emergency Talks’ (link). There’s a nice summary and review of the talk available from the ‘Life in the Fast Lane’ blog (link).

    I tried to do a quick search to find a definitive article supporting the practice, but the problem is that for every one I find demonstrating that raising the head of the bed reduces ICP a couple of points, another one shows that it also drops the patient’s BP, resulting in either no-change or a net decrease in the cerebral perfusion pressure (CPP), which is the opposite of what we want.

    It’s something I’ll actually have to look into a lot further, and a good lesson that not everything that sounds great actually is. With that said, I think there’s a consensus and I feel pretty safe saying that it is good practice for those patients with brain injury and a markedly elevated BP in whom you have a high suspicion that the elevated ICP is malignant. Pretty much the same patients who we would have been told to hyperventilate 10 years ago in order to reduce the magnitude of their herniation. For everyone else I haven’t found a good answer yet.

    Of course this could all be a moot-point in the prehospital setting. Most of these brain-injured patients we’re seeing are going to end up needing immobilization, in which case elevating their head is rather difficult. Plus, in the acutely injured patient, having the head of their bed raised makes maintaining an airway in most ambulances rather difficult unless the patient is already intubated.

    Just to throw another wrench into things, there’s a couple of small studies out there showing that spinal immobilization with a hard-collar increases ICP. (link)
    Turns out nothing we do is simple or benign…

  5. I love the back-and-forth see-saw of ICP management. As Vince noted, everything that seems like a good idea ends up having enough negative effects on the other half of the equation that everyone just ends up throwing their hands and saying “do nothing.”

    My impression was similarly that after all is said and done, elevating the head a little seems to maybe be a decent idea sometimes. Likewise, mild hyperventilation as a last-ditch rescue measure when active herniation is apparent seems reasonable. (This is also codified in my state’s protocols.) Otherwise, in the end it seems like shooting for normality has the least chance of starting any landslides.

  6. John Avery says:

    Push that zofran as soon as you get a line.

  7. zofran has a tendency to drop BP.. assuming the head injury is hemorrhagic in nature, why would you want to push something on a patient that may or may not decrease LOA/LOC and lower systolic BP?

  8. Wayne Martin says:

    “zofran has a tendency to drop BP”….I have not seen this in my 20+ years or seen significant literature. What is your source for this?


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