Do you follow guidelines for traumatic brain injury?
When guidelines for severe traumatic brain injury (TBI) are followed, deaths decrease by 50% and patients with poor outcomes decrease from 34% to 19%, according to a recent study.1
There is increasing compliance with the Brain Trauma Foundation's guidelines, says a new study looking at 413 trauma centers.2 "However, there are still high-compliance and low-compliance trauma centers," says Dale Hesdorffer, PhD, the study's lead author and associate professor of clinical epidemiology at Columbia University in New York City.
"Optimal ED management involves prompt evaluation of the severity of the brain injury and rapid initiation of needed treatments, including treatment for hypotension and hypoxia as well as referral for surgical interventions," says Hesdorffer.
Rural, suburban EDs have difficulty
Compliance with the guidelines is more difficult for rural or suburban EDs with smaller volumes of TBI patients, says Carol Ann Smith, RN, CNRN, program coordinator of Hennepin County Medical Center's Traumatic Brain Injury Center. "Change is difficult, and to get people to follow the guidelines can be hard," she says. "It is easier to follow guidelines when you have a large volume of patients and it's something you deal with every day."
Smith says if TBI is not managed correctly in the ED, adverse outcomes may include:
- increased residual deficits to death, caused by extension of the area of injury due to low blood pressure;
- diminished cerebral blood flow or low oxygen levels;
- increased secondary injury such as cerebral swelling;
- a delay in surgical intervention.
The goal is for the TBI patient to spend no more than 20 minutes in Hennepin County's ED, says Smith. "These severely injured patients move very quickly through the ED, CT scan, and off to either the operating room or surgical/trauma/neuroscience intensive care unit," she says.
If an intracranial pressure monitor (ICP) is inserted while the patient still is in the ED, monitoring the ICP and performing appropriate interventions to keep ICP under 15 mmHg are of utmost importance, she says.
There is no documented evidence of steroids being helpful in trauma, adds Smith. "Steroids have not been used in traumatic brain injury for many, many years. There is evidence of steroids being harmful," she says.
Assess and document the patient's Glasgow Coma Scale (GCS) score prior to the patient being intubated and sedated, says Smith. "Also try and obtain the GCS from the scene and document. This is extremely important for future decision making if the patient does not improve over time," she says.
Perform a rapid assessment
TBI patients are rapidly assessed for severity of injury, based on precipitating events, initial GCS, general level of consciousness, and appearance, says William W. Larson, RN, assistant nurse manager at Hennepin's ED.
Any patient who has a concerning story for mechanism of injury, initial loss of consciousness, altered mental status post-event, nausea, and/or vomiting is placed in the ED's stabilization room, he says. "There, they have the attention of the faculty physician, a senior emergency medicine resident, two nurses, and a supporting cast, which includes a health care assistant, residents, chaplain, and social services," says Larson.
A noncontrast head CT scan is done within 10-15 minutes for critically injured patients, says Larson. "Based on the results, the determination is made as to need for emergent surgical intervention," he says.
Condition can change quickly
Even if patients present as nonemergent, emergency surgery might be required, notes Larson. He gives the example of a patient who falls on the ice, receives a blow to the head, comes to the ED with a headache, but is otherwise alert and oriented.
The patient might suddenly begin vomiting, complain of increased headache pain or visual changes, or even become unresponsive, says Larson. "The patient would then be taken to the CT scanner where an epidural hematoma is discovered requiring emergency neurosurgical intervention," he says. "We call these 'talk-and-deteriorate' patients."
If patients are stable enough to complete their evaluation in the ED, they are placed in monitored beds and are assessed by nursing and physician staff with consult services from neurology and neurosurgery as appropriate, says Larson. "Frequent neurological examinations are completed and documented," says Larson.
If the patient is determined to have a mild TBI and discharge from the ED is a possibility, the patient is monitored for four to six hours and a repeat noncontrast head CT is obtained prior to discharge, says Larson. If there is any deterioration in the patient's condition, such as a decrease in level of consciousness, new onset vomiting, increase in symptoms such as headache, or any focal change in the neurologic exam, a repeat CT is obtained earlier, he says.
All patients discharged from the ED are sent home with head injury instruction teaching sheets, says Larson. "They are discharged to a responsible adult to observe them, with verbal instructions of when to return to the ED and follow-up instructions," he says.
References
- Faul M, Wald M, Rutland-Brown W, et al. Using a cost-benefit analysis to estimate outcomes of a clinical treatment guideline: Testing the Brain Trauma Foundation guidelines for the treatment of severe traumatic brain injury. J Trauma 2007; 63:1,271-1,278.
- Hesdorffer DC, Ghajar J. Marked improvement in adherence to traumatic brain injury guidelines in United States trauma centers. J Trauma 2007; 63:841-848.
Sources/Resource
For more information on caring for patients with severe traumatic brain injury, contact:
- Dale Hesdorffer, MD, Associate Professor of Clinical Epidemiology, Columbia University, Mailman School of Public Health, New York City. Phone: (212) 305-2392. Fax: (212) 305-2518. E-mail: [email protected].
- William W. Larson, RN, Assistant Nurse Manager, Emergency Department, Hennepin County Medical Center, Minneapolis. Phone: (612) 873-5410. E-mail: [email protected].
- Carol Ann Smith, RN, CNRN, Program Coordinator, Traumatic Brain Injury Center, Hennepin County Medical Center, Minneapolis. Phone: (612) 873-3284. Fax: (612) 904-4515. E-mail: [email protected].
To access the Guidelines for the Management of Severe Traumatic Brain Injury, Third Edition, go to The Brain Trauma Foundation's web site (www.braintrauma.org). After completing a free registration process, the guidelines can be accessed at no charge. Click on "View BTF's Traumatic Brain Injury Guidelines." Or to order a printed copy of the guidelines, click on "Order Materials." The cost is $125 plus $9.50 for shipping.
When guidelines for severe traumatic brain injury (TBI) are followed, deaths decrease by 50% and patients with poor outcomes decrease from 34% to 19%, according to a recent study.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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