Critical Nursing Care in the Head Trauma Patient
When a head trauma patient enters the hospital, a whirlwind of panic, stress and emotions may ensue.
Incorporating the information below into your ER triage and treatment will improve patient comfort and outcome.
ER Triage Care
Handle with Care
Before even touching the patient, remember this rule. Avoid pressure and blood collection from the jugular vein which can decrease venous return to the brain and then increase intracranial pressure. Also, it is important to be aware of the vaccination status of these patients. They can and do bite out of fear, pain or potentially during a seizure episode.
Elevate the cranial end of the body, not just the head, by 30 to 40 degrees which will help with decreasing intracranial pressure and avoiding intracranial hypertension and aspiration pneumonia.
Assess blood pressure
Blood pressure may appear increased which causes alarm, especially in these patients, because an increase in blood pressure may cause an increase in intracranial pressure. However, pain may be the underlying cause of hypertension and should be assessed and treated first before solely relying on vasopressors and inotropic agents. Hard-hitting fluid resuscitation is also commonly necessary in head trauma patients to achieve a MAP of 80-100 mmHg. [i] The technician should be cognizant of the Cushing’s reflex, a response to an increase in intracranial pressure, which will result in a reduction in heart rate and an increase in blood pressure. The attending veterinarian should be notified promptly at the possibility of a Cushing’s reflex being present as it can lead to brain herniation.
Assess Oxygen Levels
Oxygenation should be assessed as well via arterial blood gas analysis and keep in mind that even if a patient is not cyanotic, they can still be unstable and hypoxic. [ii]
Briefly Examine the Patient’s Neurological Status (in particular their level of awareness and pupillary light response (PLR)/pupil size/posture/brainstem reflexes/motor activity).
Being able to assess these parameters can give the doctor a lot of information regarding prognosis and severity of injury. The Modified Glasgow Coma Scale makes measurements based off of motor activity, brainstem reflexes and level of consciousness. Click here for more information about the Modified Glasgow Coma Scale. Each aspect of the coma scale has a grading system from 1-6. The higher the score, the better the prognosis for the patient. Motor activity is evaluated based off of the patient’s gait, posture and spinal reflexes. Brainstem reflexes are evaluated by PLRs, oculocephalic reflexes and pupil size. Oculocephalic reflex is judged by moving the patient’s head quickly from side to side and watching their eyes. The eyes should lag behind their head movement and then eventually move slowly to midline slowly. Miosis presents as a higher score than the gravest state of bilateral, unresponsive mydriasis. Level of consciousness is evaluated by their alertness or semicomatose/comatose state as well as how they respond to visual, auditory and noxious stimuli.[iii]
Posture can also help provide clues to the location and severity of trauma. Decerebrate rigidity occurs when a patient has opisthotonus and hyperextension of all limbs. In contrast, decerebellate posture when there is extensor rigidity present in the thoracic limbs and the pelvic limbs are flexed.
Remember that Steroids are Contraindicated
From studies in people, there has been no beneficial effect and they may even worsen the patient’s condition. Sequellas to steroid use may include immunosuppression, hyperglycaemia and GI complications.[iii]
Once hospitalized, the patient should be rotated every 4 hours to avoid decubital ulcers. Padded bedding is vital as well.
Perform Range of Motion Exercises
Muscle wasting may also be a problem for these patients as they are not able to participate in normal movement and exercise. Range of motion exercises, conducted every 6 to 8 hours, can be very beneficial. Just be sure that the patient is stable enough to move forward with these exercises before jumping in.
Keep Eyes Lubricated
Patients in this condition may not blink and ulcers and dry eye can develop. Ocular wash can be used to flush eyes, along with artificial tear ointment every 4 hours to help with lubrication.
Clear Out The Mouth
Comatose patients can find difficulty in swallowing causing saliva and debris to build up. The oral cavity can be wiped out every 4 to 6 hours with water or an oral cleansing spray. Diluted liquid glycerin can help keep the mouth moist. A suction machine can be used to remove larger amounts of secretions.
Express the Bladder Regularly
Due to many head trauma patients being unable to walk or stand and eliminate, the bladder can be expressed every 3 to 6 hours or a urinary catheter can be placed. Urine output should be monitored every 4 hours to ensure that the patient is producing adequate amounts of urine.
Pay Special Attention to Temperature
Any patient incurring injury to the brain may have difficulty regulating their temperature. Be sure to monitor regularly and provide outside heat or cooling support as needed. Patient’s lungs should also be ausculted and the technician should be on alert for abnormal breathing patterns as discussed earlier. Patients exhibiting Cheyne-Stokes breathing patterns need to be intubated and provided with continuous ventilation which will help prevent respiratory and cardiac arrest.[i]
Nutrition is Very Important
Make sure the patient’s caloric needs are being met. As a technician, it is important to describe in detail the quality of the patient’s appetite and quantity being consumed. If necessary, an esophageal tube may be placed, but use of nasogastric tubes are contraindicated (this may cause sneezing, which can increase intracranial pressure).
In ALL Emergency Situations
Remember your ABC’s. Ensure that the airway is patent (including checking for blood clots), breathing and circulation appear normal and check for pulse deficits and dehydration.
Place an IV catheter to be able to provide fluids and medications as directed by your Doctor.
Some abnormal breathing patterns to be aware of include Cheyne-Stokes (rapid breaths followed by apnea), agonal (labored gasps) and apneustic breathing (inhaling with a deep gasp, pausing, and then a shortened exhalation).
[i] Campbell, M. (2010, November). Traumatic brain injury. CVC in San Diego Proceedings, San Diego, CA. Retrieved from http://veterinarycalendar.dvm360.com/avhc/Medicine/Traumatic-brain-injury-Proceedings/ArticleStandard/Article/detail/769112.
[ii] Basilio, P. (2008, July). What to assess when triaging patients with head trauma. Retrieved from https://www.vetlearn.com/veterinary-forum/what-to-assess-when-triaging-patients-with-head-trauma.
[iii] Platt, Simon, and Laurent Garosi. Small Animal Neurological Emergencies. 1. London: Manson Publishing, 2012. 363-382. Print.