What to do when pt comes into ER with closed head injury?

  1. Hello, I have sim lab in a few days. I reviewed and studied material for ICP. I gathered information on what I learned and put them in the order on how to assess and treat the injury in an emergency.

    I am looking for help with this. If I did something out of order, please let me know what it is and how it should be. If I missed something, pleas let me know or if you suggest something else. The info below is the pt sim:
    Pt is a 16 yr old and was riding in the back of a friends pickup truck on a rural dirt road to visit friends. the friend driving had a couple of beers, and swerved to avoid hitting a branch on the road. the teen was standing up in the back of the pickup truck and was ejected, landed about 5 feet away. when his friends got to him, they said he was looking around and seemed ok and that there was no bleeding anywhere. his gf was hysterical and insisted that they'd take him to the ER, and here he is.
    there are no medications listed (they always list them. so idk why they didn't this time).

    labs: CT scan of the head (but doesn't tell us what until day of sim)
    the learning objectives kind of give us the answers away on what to do but not always, which is fine:
    perform an accurate assessment on there teen who is admitted following a traumatic head injury.
    identifies nursing interventions for a teen with increased ICP.
    evaluates the teens response to interventions and responds appropriately.

    so this is how I would assess and treat the injury:
    -once we walk into the room, introduce ourselves. ask him for his name, DOB and A&O (this will help me with LOC and airway)
    -ask him or his friends what happened, what symptoms he presented during the incident and on the way to the hospital
    -we would simultaneously get continuous vitals on him and administer O2 per orders AND blood glucose?
    -elevate HOB 20-30 degrees
    -ask if he is allergic to anything (although it says NKDA on his paper)
    -assess pupils (PERRLA)
    -assess cranial nerves (THIS is where I am a little stuck. do I perform all of the cranial nerves or is there only certain cranial nerves to assess in this situation?)
    -glascow coma scale assessment
    -administer any meds per order (now .. since there are no meds on the paper, I am assuming we would have to call the doctor for an order once we give an SBAR of the pt.)
    the meds I remember in the lecture usually given in increased ICP, is mannitol to decrease ICP, decadron to decrease cerebral inflammation, and dilantin if the pt starts seizing, and insulin to prevent elevate glucose levels.

    I feel like I need more? or I am missing something? or out of order by prioritization. Please let me know if I am out of order and kind of insert where or whatever. Any rationales is perfect too, sometimes I don't know why or have a different rationale to things and thats why I get answers wrong lol.

    I hate doing neuro and a lot of my classmates are afraid of doing it, just because we get confused or don't know how to do a "focused" neuro assessment, or we forget which cranial nerves and this is and that. I am thinking I would do the PERRLA, have the pt do the cat whisker assessment

    what are common deficits in closed head injuries?
    •  
  2. 11 Comments

  3. by   blondy2061h
    This kid is 16. What issues do you have regarding consent? Head trauma often requires surgery. What are some of your general "prepare for surgery" nursing interventions?
  4. by   canoehead
    Well, this might be an issue of real life vrs the book. Here's my real life answer. Pt walks into triage, no emesis bag, steady gait. He's able to articulate what happened and how he feels. No LOC, nausea, dizziness, headache. Eyes tracking, clear speech. Assuming no prexisting conditions, like a clotting disorder, he gets triaged a 4. He and his friends are asked to let me know if things change for him, and given a post concussion handout with symptoms to watch for pointed out.

    I would not give 02 or do a glucoscan, unless he had a change in LOC, or prexisting issue.

    I would not do continuous vitals, or cranial nerves, as the fist signs of trouble will be headache, confusion and nausea. I get a baseline on his pupils, maybe, but you will see huge neuro changes before the pupils are different.

    Your instructor may pass out if you do it this way, be warned.
  5. by   KelRN215
    Why do you think the patient needs ANY meds? The most likely reason why no meds are listed is because your patient is an otherwise healthy 16 year old, he's probably not on any meds nor does he need any. If the CT scan is negative for a bleed or a fracture, at most I'd expect him to get monitored for a few hours and then be discharged.

    If this kid was admitted to my old floor from the ER (I worked peds neuro for 5 years), I'd expect him to be on q 4hr VS and neuro checks, if Neurosurg thought he might need to go to the OR, he'd be NPO, otherwise he'd be ordered for a regular diet and if he tolerated it with no nausea/vomiting and had no neuro changes, he'd probably go home the next day. I would not expect orders for decadron, dilantin or insulin. MAYBE PRN ativan depending on if the results of the CT scan made anyone think he was at risk for seizures and PRN tylenol for headache. If the head CT had shown any kind of significant bleed that needed to be evacuated, I'd expect him to go to the OR straight from the ER.
  6. by   offlabel
    Better clear his c spine one way or another. Kind of an automatic fail to miss a neck fracture.
  7. by   JKL33
    This is why I hate SIM.

    With the information given, he could've been "ejected" and landed on both feet for all we know, or had one of dozens of other injuries. Maybe the best thing to do is r/o calcaneus fxs, lol. The vignette doesn't even suggest that there was any blow to the head or LOC. Dx could be nothing more than "hysterical girlfriend."

    Okay, sorry for not helping.
  8. by   xmilkncookiesx
    Quote from JKL33
    This is why I hate SIM.

    With the information given, he could've been "ejected" and landed on both feet for all we know, or had one of dozens of other injuries. Maybe the best thing to do is r/o calcaneus fxs, lol. The vignette doesn't even suggest that there was any blow to the head or LOC. Dx could be nothing more than "hysterical girlfriend."

    Okay, sorry for not helping.
    lol I've always hated SIM, I feel like it is no help.

    Can you tell me this .. when performing neuro assessment on patients with head injury, would you assess ALL cranial nerves? or will that take too much time and just want to focus on certain cranial nerves such as 2,3,4,6,10 for example?
  9. by   Here.I.Stand
    A lot is going to depend on the results of the CT. He could be released with the advice to limit physical activity rigorous schoolwork until he's asymptomatic for a few days (if CT negative but concussion suspected.) The hospital could be calling the organ procurement org to make a referral (if it's obviously a non-survivable injyry)... or anything in between.

    Hopefully the paramedics put a c-collar on before getting into the rig; with that kind of accident he could also have a spinal cord injury. You wouldn't elevate the HOB until his T&L spines are cleared by the MD -- although you can reverse Trendelenberg him if he's more comfortable that way.

    In many of these cases, associated swelling doesn't happen right away, but peak 3 or 4 days later. Think about if you sprain your ankle or have your wisdom teeth out; the cankle or chipmunk face doesn't appear immediately, right? Similar principle with TBIs. It is possible to have elevated ICP initially, if there is a significant amount of intracranial bleeding, or if the blow is extremely severe (I have seen initial head CTs where the cortex and ventricles look nonexistent, the brain tissue is so swollen.) BUT, it's very common to have normal ICPs for a few days, but then elevate as the brain swells.

    I haven't worked in the ED, but have a lot of ICU experience in this area. Our docs like to Keppra load pts to prevent seizures (I very rarely if ever see Dilantin used)

    Hypertonic saline is given fairly often as a 3% or 2% drip to keep the serum Na level in prescribed range. We give 23% as a 30 ml one time dose for high ICPs, providing the pt doesn't have a high Na level already. I've given Mannitol 2 or 3 times in my career.

    BUT, generally the ED RN isn't going to know what the ICP is. If it's severe enough, the pt would be taken emergently to the OR. If severe but not immediately life threatening, the pt will be admitted into the ICU and will have an ICP monitoring device (EVD, fiberoptic device etc) will be placed at the bedside. ICP is never monitored on the floor, and in the ED the device hasn't been placed yet. Meds to quickly decrease the ICP aren't given without knowing what the ICP is.

    Sedating meds are often limited -- unless the ICP is high. In that case, the benefit of reducing that ICP outweighs the risk of losing the neuro exam.

    All of our neuro pts are on the same insulin sliding scale as anyone else not on an insulin drip. We only treat BG if it goes over 150.

    Depending on the CT results, the RN may need to anticipate and prep for transfer to the OR/ICU/floor.
    What is something important the hospital needs regarding a minor child and consent? What lab value(s) are uniquely important to neuro pts (hint: I just discussed it.) What vital signs are important to keep in range? Hint: think of what is contained within the cranium -- brain tissue, blood/vessels, and CSF. Also consider what abnormal VS you want to prevent with regards to the brain's metabolic needs.)

    As far as neuro assessment: in the real world -- and particularly in the ED and critical care settings -- you will never ever be testing all of the cranial nerves. The most thorough assessment I have seen was as a pt in a neuro clinic. (I had developed what he believed to be a viral neuropathy; my sx mimicked MS though, so hence the wormup.) He didn't check my olfactory nerve...possibly a couple others, but can't remember 100%.

    The most detailed I've seen is assess orientation (if pt able) and LOC. I check pupils for a baseline, although a blown pupil is of course a late sign. Test all limbs for motor response and ataxia. This is where you note motor response for the GCS -- does the pt follow these "commands?" Do they withdraw, localize, posture? Does the pt report any sensory changes such as visual or sensory changes. Assess the pt's face/eyes for droop or deviated eyes

    I may be leaving something out, but am literally falling asleep... hope this was helpful though!
  10. by   xmilkncookiesx
    Quote from Here.I.Stand
    A lot is going to depend on the results of the CT. He could be released with the advice to limit physical activity rigorous schoolwork until he's asymptomatic for a few days (if CT negative but concussion suspected.) The hospital could be calling the organ procurement org to make a referral (if it's obviously a non-survivable injyry)... or anything in between.

    Hopefully the paramedics put a c-collar on before getting into the rig; with that kind of accident he could also have a spinal cord injury. You wouldn't elevate the HOB until his T&L spines are cleared by the MD -- although you can reverse Trendelenberg him if he's more comfortable that way.

    In many of these cases, associated swelling doesn't happen right away, but peak 3 or 4 days later. Think about if you sprain your ankle or have your wisdom teeth out; the cankle or chipmunk face doesn't appear immediately, right? Similar principle with TBIs. It is possible to have elevated ICP initially, if there is a significant amount of intracranial bleeding, or if the blow is extremely severe (I have seen initial head CTs where the cortex and ventricles look nonexistent, the brain tissue is so swollen.) BUT, it's very common to have normal ICPs for a few days, but then elevate as the brain swells.

    I haven't worked in the ED, but have a lot of ICU experience in this area. Our docs like to Keppra load pts to prevent seizures (I very rarely if ever see Dilantin used)

    Hypertonic saline is given fairly often as a 3% or 2% drip to keep the serum Na level in prescribed range. We give 23% as a 30 ml one time dose for high ICPs, providing the pt doesn't have a high Na level already. I've given Mannitol 2 or 3 times in my career.

    BUT, generally the ED RN isn't going to know what the ICP is. If it's severe enough, the pt would be taken emergently to the OR. If severe but not immediately life threatening, the pt will be admitted into the ICU and will have an ICP monitoring device (EVD, fiberoptic device etc) will be placed at the bedside. ICP is never monitored on the floor, and in the ED the device hasn't been placed yet. Meds to quickly decrease the ICP aren't given without knowing what the ICP is.

    Sedating meds are often limited -- unless the ICP is high. In that case, the benefit of reducing that ICP outweighs the risk of losing the neuro exam.

    All of our neuro pts are on the same insulin sliding scale as anyone else not on an insulin drip. We only treat BG if it goes over 150.

    Depending on the CT results, the RN may need to anticipate and prep for transfer to the OR/ICU/floor.
    What is something important the hospital needs regarding a minor child and consent? What lab value(s) are uniquely important to neuro pts (hint: I just discussed it.) What vital signs are important to keep in range? Hint: think of what is contained within the cranium -- brain tissue, blood/vessels, and CSF. Also consider what abnormal VS you want to prevent with regards to the brain's metabolic needs.)

    As far as neuro assessment: in the real world -- and particularly in the ED and critical care settings -- you will never ever be testing all of the cranial nerves. The most thorough assessment I have seen was as a pt in a neuro clinic. (I had developed what he believed to be a viral neuropathy; my sx mimicked MS though, so hence the wormup.) He didn't check my olfactory nerve...possibly a couple others, but can't remember 100%.

    The most detailed I've seen is assess orientation (if pt able) and LOC. I check pupils for a baseline, although a blown pupil is of course a late sign. Test all limbs for motor response and ataxia. This is where you note motor response for the GCS -- does the pt follow these "commands?" Do they withdraw, localize, posture? Does the pt report any sensory changes such as visual or sensory changes. Assess the pt's face/eyes for droop or deviated eyes

    I may be leaving something out, but am literally falling asleep... hope this was helpful though!
    thank you so much!!! this was a great help. I was freaking out on if we need to assess ALL cranial nerves or just specifics like 2,3,4,6,10, you know, PERRLA, can they move them around, and also motor, speech, etc.

    But the main focus on a heady injury is the GCS along with other neuro?
  11. by   Silverdragon102
    Moved to the General Student discussion forum
  12. by   PixieRN1
    I would add to check his skin for abrasions and cuts, eyeball for limb deformity by watching his ROM, since he was ejected. Check for any lumps and bumps on his head. Yes, focused neuro is obviously key, but an ejection could have an abdominal injury that may be bleeding, splenic lac, etc., since you don’t know how he fell per se. So look for tachycardia or pain, quickly palpate the abdomen too.

    It’s been over 15 years since I was in a SIM lab, so I don’t know if they are only making you asses neuro, so forgive me if they wouldn’t want that. However, in real life, as a former pedi ER and ICU nurse, I’ve seen plenty of ejections that had head injuries plus an acute abdominal injury that may take its time to present of the bleeding is slow.

    If nothing else, add the assessment of the head and neck for gross deformities and assess his short and long term memory; DOB is good for long term memory, but asking about loss of consciousness and assessing his short term recall is an important addition.
    Last edit by PixieRN1 on Sep 25
  13. by   Here.I.Stand
    Quote from xmilkncookiesx
    thank you so much!!! this was a great help. I was freaking out on if we need to assess ALL cranial nerves or just specifics like 2,3,4,6,10, you know, PERRLA, can they move them around, and also motor, speech, etc.

    But the main focus on a heady injury is the GCS along with other neuro?
    Oh wow, holy typos in my other reply! Sorry about that!

    You should check with your instructor about expectations for assessments; I was merely stating how it looks in the real world.

    My thoughts on assessing the cranial nerves:
    I olfactory function is SO not a priority in the acute/critical phase
    II-VI Sure. Have the pt follow your finger with their eyes, check pupils, ask the pt if any visual changes present, check sensation in face
    VII Same as I
    VIII at some point sure, but a fresh trauma pt isn't going to be up TO assess their balance. Initially however, it would be the PT assessing balance -- they would then make recommendations for the RN to follow. The RN could ask the pt about his hearing/auditory changes though; you could ask the pt at the same time you ask about sensory and visual changes
    IX is more of a SLP assessment, as the SLP is going to be evaluating the pt's swallowing, if he had been NPO for aspiration risk
    X you're not going to TRY to get a vagal response. Hypotension and bradycardia typically isn't desired.
    XI a fresh trauma pt would be in a c-collar until c spine injury ruled out, so you DON'T want that pt to move his head!
    XII Sure: have pt stick out his tongue

    Of course if the pt can't follow commands, you won't be able to assess a lot of this.

    Yes, GCS info is huge. It's a quick, three item tool which gives info about the severity -- and also is a quick indication of worsening status.

    A couple of years ago I cared for a pt who was intubated, but eyes open and tracking family, and withdrawing from pain -- so GCS of 9. Shortly after, she ceased to have eye respinse and motor response -- so a GCS of 3. She had an EVD in, so I could also see that her ICP had gone up to 40... but had she NOT had the EVD I still would have noted the change in assessment.

    CABs too: you want to keep their BP high enough to perfuse their brain, but low enough to reduce to risk of intracranial bleeding or elevating their ICP. Someone with a severe TBI can't protect his airway or make sufficient respiratory effort.

    Family education is EXTREMELY important. They often don't know what is happening, and even just for safety -- no they can't bring the pt water, no the pt can't walk to the BR yet, the collar can't come off yet... if their ICPs are high, they shouldn't be stimulating the pt (I have had people think they were helping by talking to the pt or rubbing their feet -- that's fine if the pt's ICP and VS are stable, but harmful if not.)

close