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!