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Patients with serious head injuries on the rise in EDs
Take immediate action to rule out brain injury
ED nurses at Denver's University of Colorado Hospital knew the following from the emergency medical services (EMS) call: The 70-year-old woman had fallen that day from a standing position and was alert and oriented when paramedics arrived at her home. But on the way to the ED, she became unconscious and went into respiratory distress. The patient had a history of recent frequent falls, and she had developed a massive subdural hematoma.
The ED nurse receiving the report thought first about ruling out a stroke, as opposed to a traumatic brain injury, which the patient was later found to have had, says Jean M. Marso, RN, BSN, trauma coordinator. "With the push for rapid recognition of stroke patients gaining much attention nationwide, that was the initial algorithm followed by the nursing staff," she says.
If a trauma alert had been called before the woman arrived in the ED, trauma surgeons would have been present when the patient arrived, and she would have immediately been seen in the resuscitation room, says Marso. In addition, X-ray, electrocardiogram, and respiratory therapy technicians would have been in the resuscitation room, and the operating room (OR) and trauma intensive care unit would have been notified, she adds.
Hospital admissions for serious brain injuries increased nearly 38% from 2001 to 2004, says a new report from the Agency for Healthcare Research and Quality.1 (To access a complete copy of the report, go to www.hcup-us.ahrq.gov/reports/statbriefs/sb27.jsp.) Patients hospitalized for Type 1 traumatic brain injuries, the most serious type of brain injury, totaled 144,700 in 2004, and 82% of these cases came through the ED.
Severe traumatic brain injuries have a 13% rate of in-hospital death, and many patients that survive require rehabilitation or nursing home care, says Claudia Steiner, MD, MPH, one of the study's authors. "ED nurses need to know that the majority of cases are the most severe type, and that many of these are the result of either falls or motor vehicle crashes," says Steiner. "These very severe head injuries will need immediate and expert care."
Always rule out trauma first for elderly patients who fall, especially those on anticoagulant therapy, says Marso. "These patients have an increased risk for a traumatic head bleed, regardless of the significance or insignificance of the fall," she says. When patients have a history of frequent falls involving hitting their head or have a coagulopathy, a mechanical fall can be enough of a mechanism for a severe head bleed to develop, Marso explains.
With the above patient, the nurse who received the EMS report thought that the woman's fall didn't seem to indicate a mechanism severe enough to cause an acute injury, says Marso. "Therein lays the problem," she says. "This woman had had several recent falls. This last fall caused a subacute subdural hematoma, which she had from her previous falls, to expand into an acute subdural hematoma."
Time is of the essence in head-injured patients for reducing morbidity and mortality, says Marso. "Watch the clock. Head-injured patients need to get a CT scan safely and expediently," she says. She advises the following:
"This is of the utmost importance for the rapid, smooth sequence of events needing to occur for head-injured patients," says Marso. "Notify CT scan of the need for an emergent head CT as soon as possible so that they can clear the table for this patient." In addition, if you anticipate that the patient will be intubated, you'll need a chest X-ray to confirm tube placement. "Give X-ray a heads-up so they can be standing by," says Marso. "And if the CT indicates an emergent need for operative intervention, let the OR know immediately so they can prepare an OR suite."
Your ED should have a policy for head-injured patients that specifies the frequency of neurological checks, advises Marso. "Adhere to those checks, so that any adverse trend in a patient's status is readily noted," she says. (See the ED's policy for head-injured patients.)
The baseline frequency of neurological checks must be followed consistently for all head-injured patients, regardless of how minor the mechanism might seem, warns Marso. "Never omit or decrease baseline neurological checks as outlined in your policy. That policy is a safeguard against missing a declining trend in a patient's neurological status," she says.