Your protocol/standard for head injury?

Specialties Emergency

Published

Specializes in Emergency Nursing.

Does your facility have some standard protocol for a head injury? For example, if a person came in from a MVA where his head hit the windshield and bounced off, and the patient presented with a head wound, what would be done?

A friend of ours went by ambulance from the site of a MVA to a local ED with the above injury, did not receive an x-ray or CT scan. The ED was packed, of course, and he was seen in the hallway, his head stitched up, and given a script for ABX and sent home. On his follow up with the PCP, he was sent to a surgeon because there was glass stitched inside his scalp.:o

So, I am wondering if every hospital has standards to follow for specific injuries. Like there are algorithms for ACLS situations to follow? I am thinking anyone with an impact head injury should at least get a CT scan?

And more importantly, I am wondering if I was the nurse that day and I was ordered to discharge a patient in that condition without a scan, how do I advocate for the patient? What would you say to the doc if you felt the patient needed further testing? Have you ever had to stand up to a doc because you felt the patient did not get treated appropriately?

Specializes in Trauma ICU, MICU/SICU.

I work at a Level 1 Trauma Center. In addition to a CT of the head, this pt. would have received plain films of his cervical, thoracic, lumbar spines, CXR, CT Chest, Abd, Pelvis. The mechanism of injury of a person hitting a windshield would have warrented the other scans.

I'm sure there would be more such as Trauma Labs, etc. I don't work in the trauma bay, I work on the floor.

To stitch and say goodbye sounds down right dangerous.

Skull and c-spine films for starters, with CT of the head. At our facility, because we don't have neuro, he would have at least had his case discussed with a neuro at a tertiary care facility. The wound would have been explored and irrigated copiously before suturing.

Specializes in Pediatric ER.
does your facility have some standard protocol for a head injury? for example, if a person came in from a mva where his head hit the windshield and bounced off, and the patient presented with a head wound, what would be done?

a friend of ours went by ambulance from the site of a mva to a local ed with the above injury, did not receive an x-ray or ct scan. the ed was packed, of course, and he was seen in the hallway, his head stitched up, and given a script for abx and sent home. on his follow up with the pcp, he was sent to a surgeon because there was glass stitched inside his scalp.:o

so, i am wondering if every hospital has standards to follow for specific injuries. like there are algorithms for acls situations to follow? i am thinking anyone with an impact head injury should at least get a ct scan?

and more importantly, i am wondering if i was the nurse that day and i was ordered to discharge a patient in that condition without a scan, how do i advocate for the patient? what would you say to the doc if you felt the patient needed further testing? have you ever had to stand up to a doc because you felt the patient did not get treated appropriately?

if he was seen by our er doc, definitely a skull series, c-spine, possible ct head/neck depending on pt presentation. if seen by the trauma surgeon (as most of our mvc's are, unless they're scene calls), ct head, neck, chest, abd, pelvis, trauma rainbow, amylase/lipase, the works.

i can't believe they didn't at least do a skull series to check for foreign bodies. sounds neglectful.

if i was the nurse, i would have said something to the effect of: "there's probably a pretty good chance of some glass being in the lac, don't you think?" some docs get defensive and do the opposite of what you want if it seems like you're trying to dictate care, so i've found that if you ask in such a way that it makes it seem like you're not stomping on their ground, they're more open to suggestions. otoh, sometimes you have to deal with real knotheads who don't get it, and you have to flat out ask "don't you think we should get an x-ray?" thankfully most docs i work with are very capable and don't skip stuff just to get someone otd quicker. and the majority are open to suggestions from the nurses.

oh, to answer the last question, yes, i've had to stand up to a doc before. one time a pt i had (who had gotten 3 tx's and was still satting in the 80's) was "cured" according to the doc, and he wanted to send him home (he's a big believer in getting pt's out quickly). he kept insisting, i kept reminding him of the pt's condition, when finally i said "i don't feel comfortable sending him home, and neither does his mom. if you send him home, he's just going to be back, and next time he'll be worse". about 15 min. later i had admit orders in my hand.

Specializes in RN, BSN, CHDN.

I was involved in a five car pile up and I wasnt given much in the way of emergency treatment, I picked my own glass out of my eye. I was discharged, and four months later we come to last last week _ and they found I have a broken vertabrae!!!!!!!!!!!!!!I have been accused of being a drug seeker because I have no reason for my symptons and pain!!!!! Now can you imagine how I feel, after living 40 years and never having any problems and then to be accused of being a drug seeker

Specializes in Nephrology, Cardiology, ER, ICU.

Different places have different protocols. In our level I ER, we would never do plain skull films. However, we would have done a head CT and cervical spine series. If there was no loss of consciousness and no intoxication was noted, that probably would have been it. Of course we would stitch them up too - antibiotics not necessarily.

Different places have different protocols. In our level I ER, we would never do plain skull films. However, we would have done a head CT and cervical spine series. If there was no loss of consciousness and no intoxication was noted, that probably would have been it. Of course we would stitch them up too - antibiotics not necessarily.

I've worked with a few ER docs who put every lac pt on Keflex, sometimes with a shot of Ancef before d/c. I always thought it was overkill. Super dirty wounds I understand, but most of them.....uh-uh.

It depends....if it were an impact injury as you are describing of course we would have done plain films of the CTLS to clear them and a stat head CT.If the patient was not complaining/not symptomatic and the scans /films were negative we'd have stitched him up and sent him home to follow up with his PCP.If he were the driver...we'd have done a UDS etc etc etc on him.

The key is....if ...if he were A&Ox3, MAEx4 with no motor/sensory deficts...and the scans were ok.....everybody wouldve stitched him up and sent him home to his PCP.With MVA's.....unfortunately......sometimes.....they do have bits of glass that work the way out years later.Some shards of glass go deep.....and its kinds like a shotgun victim...ideally...IDEALLY we'd all like to retrieve every lil bit of it.....but it's not realistic.I doubt that any doc/nurse wouldve intentionally left any visible "VISIBLE" piece of glass.....I dunno why in the heck they didnt clear the guys CTLS/head CT prior to letting him leave.I haVE had pt's refuse a head CT (lol) ..so are you sure this isnt what happened?the guy was p****d bc of the wreck and then refused everything but the suture job?i'd love it if every patient was compliant.....but we all know ...yada yad a yada etc etc etc etc...:wakeneo:

Specializes in Emergency Nursing.

Thanks for all the replies, it is very helpful to see what is done from facility to facility for stuff like this. I kept my mouth shut when our friend initially told us what happened, since I was pretty stunned, and then very worried for him. I was/am very reluctant to pass judgement on the nurses/doctors, but since more info came out about it from the patient and the EMS crew, I had to ask all of your opinions on it. I would not talkabout this in real life, for sure.

He is a very quiet guy, and he said the nurse initially told him he would be getting a CT scan. There was a 2 hr wait to be seen, he was seen in the hallway and stitched there, it was jam packed. But then apparently there was a shift change or something, and he had a new nurse after that. He said his head hurt and his body was starting to hurt so bad he just wanted to lay down, so after the suturing when they said he was discharged, he didn't argue. He knows he should have spoken up.

I asked him if he was being a big PIA(heh, plenty of those come in and then complain later they didn't get care, I'm sure!:uhoh3:) and didn't want to wait or something, since I could not imagine another reason for not getting at least a scan. He swears he was calm during the wait and did everything they told him, and he said he told them his shoulder hurt too, and he also turned out to have a busted shoulder.

Maybe there was some kind of confusion/communication error during shift change or something. I really, really, hope so, I hope there is a reasonable explanation for this.

Okay, I have to admit now that this is the ED I am hired to. :uhoh3: That's why it's bugging me. I'm hoping this is a totally isolated incident. One of the things I know I need to work on is communicating effectively with doctors, so I am hoping this sort of thing is not commonplace. I was so excited to get the position, and hear such great things about the unit from other nurses/docs.

I kinda wish my friend was lying, like he LWT or something. :o:o

Specializes in Emergency Nursing.
I was involved in a five car pile up and I wasnt given much in the way of emergency treatment, I picked my own glass out of my eye. I was discharged, and four months later we come to last last week _ and they found I have a broken vertabrae!!!!!!!!!!!!!!I have been accused of being a drug seeker because I have no reason for my symptons and pain!!!!! Now can you imagine how I feel, after living 40 years and never having any problems and then to be accused of being a drug seeker

OMG, that is awful! A broken vertabrae! And to be accused of drug seeking....just great. You know, it amazes me how narcs get practically thrown at some people, yet others are labeled so quickly as drug seekers.

I hope you are getting what you need for pain.

Specializes in Emergency Nursing.

if i was the nurse, i would have said something to the effect of: "there's probably a pretty good chance of some glass being in the lac, don't you think?" some docs get defensive and do the opposite of what you want if it seems like you're trying to dictate care, so i've found that if you ask in such a way that it makes it seem like you're not stomping on their ground, they're more open to suggestions. otoh, sometimes you have to deal with real knotheads who don't get it, and you have to flat out ask "don't you think we should get an x-ray?" thankfully most docs i work with are very capable and don't skip stuff just to get someone otd quicker. and the majority are open to suggestions from the nurses.

yeah, i am definitely working on my people skills. it's going to take some practice. i have a habit of being straightforward and to the point, and it seems like docs might get testy unless you present your nursing opinion in a certain way. i guess it all goes with the territory, though.

Specializes in Emergency Nursing.

Sorry for the multiple posts.;)

One more question: I am imagining there is a standard procedural manual for each unit which would explain protocols, but is there any publication for emergency nurses that makes recommendations for standards for situations other than ACLS? I am off to the ENA website to investigate, but figuered I would ask.

Thanks again for all your input. It is really nice to be able to talk with all of you vets. :) No one in my real life is supportive of me working in the ED (except my husband) so I don't have a mentor person yet.

+ Add a Comment