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How you can avoid unsafe head injury discharges
Normal vital signs can change quickly
Your patient reports a minor fall, and vital signs are 100% normal. Can this patient be safely discharged from your ED? Not necessarily.
"Anyone with a closed head injury is at greatest risk for falling through the cracks," according to Sanna Root, RN, MSN, trauma injury prevention coordinator at University of California — Irvine Medical Center. "This is especially true when there is not a significant external sign of injury."
According to the Centers for Disease Control and Prevention, 80% of head injuries in the United States are treated in EDs, and of those, about 17% require admission. More than 1 million patients come to the ED each year for traumatic brain injury or concussion.
Jennifer Maul, RN, CEN, clinical educator of the ED at Sutter Roseville (CA) Medical Center, has seen several patients with subtle changes in their symptoms. A repeat CT scan showed significant worsening of the initial injury. "These patients were taken immediately up to the operating room to evacuate the blood, drill Burr holes in the skull to relieve pressure, or had an intracranial monitor placed in the brain," she says.
Here are some types of patients at high risk for being unsafely discharged:
• Patients who appear normal.
Your patient might have vital signs and neurovascular signs within normal limits, but this status can change quickly, warns Root. "This is why it is so important to perform accurate assessments and observation prior to discharging the patient home," she says.
• Pediatric patients.
"Young children are at high risk, because we are unable to communicate as effectively as with older children and adults," says Root.
Mary Kay Bader, RN, neurological clinical nurse specialist at Mission Hospital in Mission Viejo, CA, cared for a 3-year-old who struck a wall while riding a tricycle. A short time later, the child decompensated from a medial meningeal arterial tear. "The staff did an outstanding job getting the child to the OR in record time," she says. "The child was discharged home a few days later."
Be an advocate for all patients who have temporal injuries, says Bader. "This is a vulnerable area for a bleed and warrants a CT scan, as these patients are often 'normal' at initial exam," she says.
• Patients under the influence of alcohol or drugs, or patients with dementia who might not realize how injured they are.
At St. Joseph Mercy Hospital in Ann Arbor, MI, "We have created a new neurological guideline in our ED specifically for this population, so their injuries and risks don't go unnoticed," says Mary Frazier, RN, an ED nurse. [The ED's "Neurological Monitoring Guideline" is included.]
When an intoxicated patient came to St. Joseph's ED after a fall, a bleed was found on the CT scan, but his baseline mental status was unclear. "Vital signs were done, and the patient was evaluated at intervals. When it was time to admit him to his inpatient room, he was found unresponsive with unstable vital signs," says Frazier. "He was subsequently intubated and taken to the intensive care unit. It was this case, and others like it, that prompted us to develop a guideline to monitor for this kind of thing."
ED nurses perform neurological checks on these patients every 15 minutes for four hours, then every 30 minutes for six hours, including Glasgow Coma Scale scores.
• Elderly patients.
The elderly are at higher risk for serious head injury, especially for subdural hematomas, says Madonna Walters, MS, RN, trauma program coordinator at St. Joseph. A subdural hematoma can occur with even a low fall and mild bump to the head in older adults, she explains, and the risk is even higher if the patient is taking an anticoagulant or antiplatelet agent.
"A subdural hematoma is an injury to the bridging veins in the brain, and older adults have more stress on their bridging veins as a result of the cerebral atrophy that occurs with age," says Walters. "Since older adults are both prone to falls and more likely to be anticoagulated, this magnifies their risk of a serious and life-threatening head bleed."
The anticoagulated patient who has experienced a fall should be rapidly triaged so that a stat head CT can be done and appropriate reversal of anticoagulation initiated, says Walters. "Even if the head CT is negative, these patients are usually observed for at least six hours," she adds.
Here are absolute must-dos with head injury work-ups
Subdural hematomas develop slowly
Your initial work-up for suspected head injury should include a CT scan, says Sanna Root, RN, MSN, trauma injury prevention coordinator at University of California — Irvine Medical Center.
"Acute traumatic intracranial injuries usually show up early after the injury; however, subdural hematomas have been found to develop slower and over a longer period of time," Root says. "This may not show up in the initial work-up."
However, not every patient that presents with a head injury will receive a CT scan, and not all traumatic brain injuries will show up on a CT scan, says Jennifer Maul, RN, CEN, clinical educator of the ED at Sutter Roseville (CA) Medical Center. "If a patient has a history that is suggestive of a brain injury and is symptomatic, but has a normal brain CT, often the ED physician will consult with the trauma surgeon, and the patient is admitted for additional observation," says Maul.
Watch for these early signs of intracranial injury, says Root: Lack of memory of the event, headache, nausea or vomiting, confusion, visual disturbances, and lethargy. Late signs of intracranial injury include pupil changes, unresponsiveness to pain or verbal stimuli, posturing, widening pulse pressure, increased systolic blood pressure, respiratory changes, and bradycardia, says Root.
She says warning signs that a patient does need immediate attention include the following: dilated nonreactive pupil, restless, drowsiness, changes in speech, unresponsive, posturing, increased systolic blood pressure, widening pulse pressure, changes in respiratory status, and bradycardia. Sheree Brown, RN, trauma service nurse clinician at St. Joseph Mercy Hospital in Ann Arbor, MI, says, "Loss of consciousness, along with the presence of a period of amnesia, are two very good determinants of head injury." Each is an important factor to assess, Brown says. "Warning signs are persistent confusion, one episode of vomiting, or worsening headache," she says.
To rule out a life-threatening head injury quickly, Brown says to look for the following: no loss of consciousness, no amnesia, no risk factors such as being on blood thinners or coagulopathic from a medical comorbidity, and no dangerous mechanism.
If the patient is discharged home, document all findings and assessments, says Root. Educate the patient and family regarding signs and symptoms that would make it appropriate to return to the ED or call 911, she says.
Maul says to be very clear that patients should return to the ED immediately if they experience severe nausea, vomiting, dizziness, decreasing level of consciousness, lethargy, confusion, are "just not acting right," have unequal pupils, blurred vision, or difficulty speaking or walking. [St. Joseph's discharge instructions for ED patients with mild head injury are included.]
Ask these questions of your head injury patient at triage, says Root:
Above all, learn as much as you can about the patient and the mechanism of injury, says Maul. Ask patients what they were doing when they hit their heads, when the injury happened, how the patients were acting when they woke up, and how they are acting now. Is their behavior normal for them? Have they previously had a brain injury? Did they wake up quickly and are now are becoming altered?
Assess mental clarity; long-term memory
A period of lucidity in a head-injured patient might be a hallmark of an epidural hematoma, warns Madonna R. Walters, MS, RN, trauma nurse specialist/injury prevention specialist at St. Joseph Mercy Hospital in Ann Arbor, MI. Epidural hematomas are characterized by a short loss of consciousness, mental clarity lasting minutes to hours, and then a rapid decline, she says.
"An epidural hematoma can be particularly lethal, because the patient feels fine at first and may not seek medical attention or may minimize their symptoms," says Walters. "The bleeding source is arterial, so the blood may accumulate rapidly."
Teri Arruda, MSN, FNP-BC, CEN, nurse specialist at Mission Hospital in Mission Viejo, CA, recommends asking head injury patients, "What did you have for dinner last night?" "This gives me a gauge of long-term memory," she says.
When a patient cannot recall common information such as what they ate the previous night, this is considered a concussive symptom, says Arruda. Any amnesia is abnormal and should lead to close follow-up such as a CT scan or continued observation, she adds.