# Scenario: Head Trauma (MVC)



## Code 3

*Objective:* Identify the descriptive name for the condition that the patient is displaying. State how you would treat a patient with this condition.

*Background Information:* You respond to a MVC and the FD has the patient completely packaged and ready to go on your arrival. You load the patient and do a rapid trauma assessment in the back. You note Battle's sign and get a positive Halo test for CSF draining from the ears. You also note decorticate posturing. You then assess vitals and get the following information:


*Pulse:* 50 Weak/Regular
*Respirations:* 6 Shallow/Irregular
*B/P:* 188/55
*Eyes:* Unequal R-4 L-7
*LOC:* U on the AVPU
*Lungs:* Clear bilaterally
*Skins:* Pale, cool, diaphoretic


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## LucidResq

A battle's sign is usually a late sign of a basal skull fracture. Vitals, CSF drainage and posturing all indicate she has a nasty head injury. 

Confirm that she has her ABCs, insert an OPA very carefully. Hyperventilate her at 20 breaths/min via BVM if protocol allows. Have suction ready. Consider calling for a helicopter. Obtain a GCS score if time permits. Get her the heck out of there.


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## Code 3

LucidResq said:


> Hyperventilate her at 20 breaths/min via BVM if protocol allows.



Perfect! Now can you tell me the name of the condition that relates to this patient's B/P, Pulse, and Respirations?


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## LucidResq

She has the cushing's triad, which is a pretty definitive sign of increased intracranial pressure. She's definitely bleeding somewhere intracranially.


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## Code 3

Good job! I'll accept Cushing's Triad or Cushing's Reflex 

I just realized that I didn't give anyone else the opportunity to reply to this scenario...whoops! :lol:


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## Topher38

LucidResq said:


> She has the cushing's triad, which is a pretty definitive sign of increased intracranial pressure. She's definitely bleeding somewhere intracranially.




Good call, and amazing how quick you pulled that scenario off. haha. Wow I dont know whether to say "Good job" or "WHAT THE FUDGE! NO ONE ELSE GOT A TURN!"

Good job though, I learned even though I didnt say anything, Well set up code3 ^_^ your scenario vitals look very pretty.

Battle sign = very bad


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## skyemt

cushing's reflex is identified by RISING bp and FALLING pulse, and irregular respirations...

you can NOT determine that with one set of vital signs....

while your setup was obvious for cushing's, in reality you would need to trend to make that determination.  

what if a patient was a very good athlete with a normally low pulse rate?

what if a patient had a problem with blood pressure, and there normal is very high?

if you want to note widening pulse pressures, you need at least two sets of vitals, not one.

well, then there would be NO cushing's, without the trend...

sorry, but it's just not that simple.


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## Arkymedic

LucidResq said:


> A battle's sign is usually a late sign of a basal skull fracture. Vitals, CSF drainage and posturing all indicate she has a nasty head injury.
> 
> Confirm that she has her ABCs, insert an OPA very carefully. Hyperventilate her at 20 breaths/min via BVM if protocol allows. Have suction ready. Consider calling for a helicopter. Obtain a GCS score if time permits. Get her the heck out of there.


 
Hyperoxygenate  Its not proper to hyperventilate anymore and believe it or not there really is a difference between the two (and I am sure that Rid or Flight will be more than happy to contribute even more than I ever can to this). With the increased intra-cranial pressure, you do not want to give the head injury more area to swell into by hyperventilation.


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## skyemt

Arkymedic said:


> Hyperoxygenate  Its not proper to hyperventilate anymore and believe it or not there really is a difference between the two (and I am sure that Rid or Flight will be more than happy to contribute even more than I ever can to this). With the increased intra-cranial pressure, you do not want to give the head injury more area to swell into by hyperventilation.



actually the mechanical act of moving the air in and out faster IS hyperventilation.  the end goal, we hope, is not hyperoxygenation, but hypocarbia, which will constrict the vessels in the brain.

this is still in protocol in NYS and many other areas, but it is contingent on a GCS < 8 and co-morbid factors...

in addition, getting a GCS in a head injured pt is of utmost importance, not something to do "if there is enough time" as someone incorrectly posted earlier.


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## LucidResq

Hm... I see the value of trending but I learned that cushing's triad was simply hypertension, bradycardia and irregular respirations (especially cheyne-stokes). Also, I would of course try to obtain a GCS score, but in this situation it seems possible that other priorities would take precedence... my main concern with this patient would be making sure they keep breathing and getting them the hell out of there. Of course if I had the GCS memorized I could probably do it in my head in about 5 seconds, but at this time, about 4 classes into my EMT-B class, I don't have it memorized yet.


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## skyemt

Cushing's Triad is hypertension, bradycardia, and irregular resps...

Cushing's REFLEX is the body's way of trying to keep the brain perfused as ICP rises... this occurs over time, indicated by trending. 

also, an accurate GCS is CRITICAL for head injured patients.  Please don't take it so lightly.


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## Onceamedic

PS..  that posturing is a very bad sign... this patient needs a neurosurgeon ASAP - don't waste any time on scene and don't stop at any facility that doesn't have the resources to take this patient to the OR immediately..

things do not look good.


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## Flight-LP

skyemt said:


> Cushing's Triad is hypertension, bradycardia, and irregular resps...
> 
> Cushing's REFLEX is the body's way of trying to keep the brain perfused as ICP rises... this occurs over time, indicated by trending.
> 
> also, an accurate GCS is CRITICAL for head injured patients.  Please don't take it so lightly.



Well spoken in all of your responses!

Determining neurological status is the first priority on this pt. 

The scenerio was nice and "textbook", but as previously pointed out, trends will make the determination of a rise in ICP. However, just remember the 3 P's, pupils, pulse, and posturing. These alone will tell you just about everything you need to know to make your transport decision. Also, don't worry about trying the halo test. #1 most cannot do it right and #2 it's not going to change anything. If you have time to play around with fluid from the ears, then you are wasting precious time on a scene. Save it for your next keg party.........................


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## LucidResq

I'm not taking it lightly at all. However if the hospital staff or flight nurses or whoever really wanted the scene GCS score they could easily determine it based on the information given. If her AVPU is U then she gets 1 for eye-opening. She gets a 1 on the verbal response (possibly a 2). If she has decorticate posturing she gets a 3 for motor response. I may be wrong but it seems that saying she was in decorticate posturing and unresponsive at arrival would be a slightly longer way of saying she has a GCS of 5.

All I'm saying is that if the chopper was ready to load and go I wouldn't be telling the flight nurses "hold on, I need a GCS." 

But I'm just a student. I mean there may be something you know about that I don't. I'm just assuming that they would want a scene GCS for trending purposes and to determine the level and possibly the type of head injury, but I would think that posturing, CSF otorhhea, unequal pupils, battle's signs, and her vitals would say it all considering the MOI.


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## disassociative

The systolic is rising to compensate for the lack of 02 in the brain. 

There are three things that lie within the cranial vault: Blood(10%), Brain(80%), CSF(10%).

The monroe-kelli doctrine holds that if there is a change in the volume of any of these components one or both of the others MUST change volume to maintain the constant pressure.(Brain Swells).

Since it is true that objects under pressure will follow the path of least resistant, it can be logically inferred that the brain attempting to herniate from the Foramen Magnum, and the respiratory centers that lie within are taking a blow, along with other autonomic centers. Let us not forget about the cribriform plate of the ethmoid bone and it's rather sharp protuberances which can further injure the brain within the cranial vault(Coupe, Contra Coupe).

Signs of Herniation and increased ICP(intra-cranial pressure) include: Decreased GCS by 2 points or greater, posturing(decoricate or decerebrate). (Note if the patient is posturing at the scene; it might be time to get a chopper if you are more than 15 minutes out from a Trauma I), dilation of the pupils, and of course Cushing's Triad. 

The primary goal of the neuro assessment, is to discover where the patient is and where they are heading(baseline condition; changes)

Proper Neuro Exam Demonstration: neuroexam.com


Furthermore, there are many more things to worry about such as free radicals floating around causing more secondary injury, as well as conditions stemming from the primary injury(hypercarbia, acidosis, hypoxia, to name a few.)

The violent displacement of the brain tissue can result in lacerated vessels(epidural, subdural haematoma). 




I won't go into things such as the Davson's equation as this is an EMT forum; however I will provide the method for calculating MAP(Mean Arterial Pressure)

2(Diastolic) + (Systolic)  / 3

As their is no method in the field short of placing a "brain bolt" to read ICP correctly, I will not go into calculating CPP, however--for further reference

CPP = MAP - ICP

The normal value at the least is 

> 60 mmHg


This patient needs a trauma I and fast.

We cannot repair damaged tissue, we can only take steps to ensure that
the current surviving tissue remains viable(and we cannot even do that alot of the time.)


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## TKO

Cerebral Herniation Syndrome.  

Should have been marked by a bounding pulse, not a weak regular radial.  BP is peaked so you should feel it unless there is an injury to the extremity (but then you'd be checking both pulses for comparison).

Hyper-oxygenate (high-flow) pt to reduce cerebral-ischemic insults.

G-L-H to the big H.


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## disassociative

TBI, is by far my favorite etiology. 

For those of you interested in learning a tad more, I recommend you check out the following article from _Ems Magazine_ entitled, "Beyond The basics: brain injury"(Mistovich, Limmer, Krost.)

Unfortunately, their site is down right now; however, to find the article once it is up; simply go to emsresponder.com, click search and enter "Beyond the basics: Brain Injury" to pull up the full article.

Also, from the journal of EMS; you will find an interesting article, entitled, "Understanding the Cushing Reflex"(Bledsoe. 2007) at the following link.

http://www.jems.com/news_and_articles/columns/SMS/Understanding_the_Cushing_Reflex.html


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## Arkymedic

disassociative said:


> TBI, is by far my favorite etiology.
> 
> For those of you interested in learning a tad more, I recommend you check out the following article from _Ems Magazine_ entitled, "Beyond The basics: brain injury"(Mistovich, Limmer, Krost.)
> 
> Unfortunately, their site is down right now; however, to find the article once it is up; simply go to emsresponder.com, click search and enter "Beyond the basics: Brain Injury" to pull up the full article.
> 
> Also, from the journal of EMS; you will find an interesting article, entitled, "Understanding the Cushing Reflex"(Bledsoe. 2007) at the following link.
> 
> http://www.jems.com/news_and_articles/columns/SMS/Understanding_the_Cushing_Reflex.html


 
Thanks man TBI is strongly being looked at by my state and has been a hot topic across OK for years. Nice article


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## skyemt

disassociative said:


> Signs of Herniation and increased ICP(intra-cranial pressure) include: Decreased GCS by 2 points or greater, posturing(decoricate or decerebrate). (Note if the patient is posturing at the scene; it might be time to get a chopper if you are more than 15 minutes out from a Trauma I), dilation of the pupils, and of course Cushing's Triad.
> 
> The primary goal of the neuro assessment, is to discover where the patient is and where they are heading(baseline condition; changes)



my point, is that in a head injured patient, a baseline GCS is VITAL... How can you record a decrease of 2 or more if you didn't get one in the first place...
can't trend without an accurate GCS on scene...

my issue is that whenever this comes up (and it has happened several times out here) i am told BY BASICS that GCS is something that is not urgent, and only if "time permits", as if it was a pulse-ox reading or something... drives me nuts...

of course, the medics want a GCS NOW... but the basics, eh.. if time permits...

and then they say that 120 hours of education is enough!!!

and yes, before i get accused of putting down basics, i am a basic, and a volly... but i am first and foremost a provider who wants to learn and improve.


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## disassociative

Well, there are many factors to take into consideration as well as assessments to be made; such as determination of the integrity of the corpora quadragemina,   Paramedian pontine reticular formation efferency(particularly with regard to horizontal gaze and saccadic eye movement.), etc.


Stick with NeuroExam.com, and you will learn some interesting techniques.(This site is a resource for an M.D. Textbook much like EMT-B is to Emergency Care and Transport of the Sick and Injured.)


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## certguy

Good scenerio but you're still missing some info . What were fire's baseline vitals ? Thier baseline and any others would help establish a pattern . What was the MOI ? Was she restrained ? We know she has a life threatening head injury but could we be looking at major chest or abd injury also ? Don't get tunnel vision and miss something else that could be killing her too . Basal skull fx could be from a rear ender or a hit from flying debris in a head on .


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