Careful history and witness reports of the patient’s level of consciousness, as well as any loss of consciousness, are important to know in order to understand the injury’s severity. Some inter-ventions are also lifesaving in the initial minutes of care. With brain injuries, the timeline start-ing at the time of injury can sometimes dictate a point at which the injury will cause per-manent disability or death. The importance of “the golden hour” is often referred to in trauma care, or the need for rapid inter-vention during the first hour of care following major trauma.6This is essential when caring for a patient with a TBI because 50% of deaths from TBI occur within the first few hours of the primary injury.7Upon arrival to a scene where a patient has traumatic injuries, the basic life support protocol assessing airway (A), breath-ing (B), and circulation (C) is completed, and the airway is secured (if needed) before mov-ing further down the algorithm.7First responders will then go through basic protocols to secure the patient to a backboard with a cervical collar if cervical spine injuries are suspected; the patient is then moved to safety.Complications that can be quickly solved by skilled emer-gency personnel include airway obstruction and hypoxemia. A patient may need an advanced airway if his or her oxygen satu-ration is below 90%. Patients with severe external facial and/or head injuries are also assessed for the need for airway protection from blood or edema. Patients who are unconscious or have a severely altered mental status will also need an advanced airway. If a patient’s airway is secured with an endotracheal tube or if the patient requires ventilatory sup-port via bag-valve mask ventila-tion, a PaCO2between 35 and 40 mm Hg should be maintained.7Hyperventilating the patient is generally not recommended, according to the Brain Trauma Foundation.8If clinical signs of herniation are present, such as a unilateral dilated pupil or bilateral fixed and dilated pupils, hyperventilation can be used as a temporary measure until signs of herniation resolve or until ED providers reassess the patient.8Patients with a brain injury may hyperventilate on their own, requiring sedation to maintain a normal PaCO2level because hypocapnia causes cerebral vaso-constriction, reducing cerebral perfusion.7Depending on transport mode (ground or air) and transport time (rural or urban) to a trauma center, these early interventions can protect a patient from life-threatening complications such as respiratory arrest and herniation, and can prevent secondary injury from hypoxia.7Location of epidural, subdural, and intracerebral hematomasSource: Porth CM. Essentials of Pathophysiology: Concepts of Altered Health States.3rd ed.
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- Winter '16
- Nursing, Traumatic brain injury