Head Trauma

[RedAirplane]

You are dispatched on foot to the "subway station entrance, PD on scene, unknown medical." Dispatch doesn't have a better location.

That describes about every block of the city, so after about 20 minutes of backtracking, turning around, and asking various cops at subway stations whether they have a patient, you finally arrive at your patient.

PD found the pt being carried out of the subway station by bystanders. The bystanders saw the pt fall, hit his head, and lose consciousness for a couple minutes, and when he regained consciousness, he was unable to walk, so they carried him looking for help.

PD advises that ALS/transport has been requested. You begin your assessment and find an alert but confused patient. He gives his age as 22 but his birthdate some time in 1975. His V/S are BP 120/P, HR 100. You can't get a good RR because the pt keeps babbling, which at least means his airway is open.

The pt has been drinking EtOH and taking marijuana, and is unclear about last food/water and past medical history.

Physical exam is negative except for a 2cm laceration to the back of the head, open but not bleeding enough to be concerned at all.

Pupils are pinpoint, but you're unsure if that's just the extreme ambient lighting.

You continue reassessing the patient. After about 30 minutes, you call and ask the status of the ALS/transport unit. The supervisor comes back and advises that the system is delayed. Units are available for code 3 (high priority) calls only, and currently your call is categorized as code 2 (non-emergent). Given that the pt seems to be forgetting some of the things you told him initially, you request the higher priority.

Another 20 minutes later and your unit shows up. The paramedics thank you for your help but tell you that they think that the pt is just drunk, not suffering from head trauma.

Is "confused, head trauma, EtOH" usually considered minor? I know that all of the mental status issues could have been EtOH related, but they could have also been head trauma related. As an EMT-Basic, is there any way to know? Would you have requested a unit from the Code 3 pool, or would you have been comfortable waiting with the patient for up to an hour (or more) longer, with only BLS equipment/skills?

 

[EMSComeLately]

Per our selective spinal, ams plus mechanism plus etoh gets a c-collar at least. I would have checked a sugar, at least as well if allowed by your state under bls. Your other vitals didn't necessarily spell doom. As long as the airway was patent and RR good, it probably could have waited unless he was also getting combative.

Now, if the pulse was falling while pressure was rising plus irregular breathing as a trend, that is when you'd be worried and exclude etoh as the explanation.

 

[Clare]

I require no further information to make a firm recommendation this pt should be transported to ED by ambulance.

He needs to be observed for several hours in ED (if not overnight) and may, or may not, receive a CT scan.

Somewhere I read that only about 2% of TBI patients will have an expanding cerebral haemorrhage that requires urgent neurosurgery but it is not possible to differentiate between those that do and those that do not in the early stage. This is the rationale for frequent observations and early CT scanning if indicated. There have been a number of case reports of amenable mortality due to missing cerebral bleeding following trauma.

In my clinical judgement,

1) He needs to reach hospital within the next one hour
2) If a choice of hospital is available he should direct go to a neurosurgery capable hospital
3) He requires no specific treatment
4) He is suitable for transport by ambulance personnel at any clinical level
5) His condition is moderate (i.e. not critical, serious or minor)
6) An RT call to hospital is not required

Take the time to get a good, proper GCS and another one en-route. The motor score is the most prognostic in patients with TBI.

Oh, the term you should use to describe his problem is traumatic brain injury (TBI) not "head trauma". TBI is more specific, if his neurological status is because of his fall, he has a TBI, whereas "head trauma" is a general term for injury to the superior structures and not the brain itself.

 

[Carlos Danger]

Per our selective spinal, ams plus mechanism plus etoh gets a c-collar at least. I would have checked a sugar, at least as well if allowed by your state under bls. Your other vitals didn't necessarily spell doom. As long as the airway was patent and RR good, it probably could have waited unless he was also getting combative.

Now, if the pulse was falling while pressure was rising plus irregular breathing as a trend, that is when you'd be worried and exclude etoh as the explanation.

No, cushing's triad is a very late sign which indicates imminent herniation and death. No way you can use normal VS to exclude a head injury.

Is "confused, head trauma, EtOH" usually considered minor? I know that all of the mental status issues could have been EtOH related, but they could have also been head trauma related. As an EMT-Basic, is there any way to know? Would you have requested a unit from the Code 3 pool, or would you have been comfortable waiting with the patient for up to an hour (or more) longer, with only BLS equipment/skills?

These are tricky calls and you have no choice but to assume that a brain injury may exist, and transport. Sure, it's much more likely that he's just drunk, but you have no way of knowing that's what it is. Saying "he's just drunk" and walking away is lazy and negligent.

 

[Brandon O]

A good neuro exam is helpful, but in the end you're never going to know for sure. Try to figuree out his baseline (maybe he always thinks it's 1975) and whether there are other apparent deficits.

Don't stress, but transport, and perhaps immobilize depending on your protocols.

 

[ERDoc]

So you are on foot and not in an ambulance? I think calling in for immedaite transport is approipriate. Head injury with loss of consciousness is serious. Intoxication is a diagnosis of last resort and should never be the top one. The fall is also concerning. Why did he fall? Was it just the intoxication or did he have an arrhythmia? Always remember that even drunk and/or crazy people get sick and die. Don't attribute everything to alcohol.

 

[RedAirplane]

Yea I was erring on the side of rapid ALS because he hit his head, LOC, etc. The comment from the paramedic made me wonder if I over triaged the patient.

 

[ERDoc]

Personally, I would have taken the first available ambulance ALS or BLS. If this is a true intracranial emergency, they need rapid transport. There is not much an ALS unit is going to add.

 

[RedAirplane]

Ambulances are all ALS unless mutual aid is activated, so in this discussion asking for ALS is the same as asking for transport.

So do you think the medic was wrong?

 

[ERDoc]

I think his attitude it wrong. He may be correct in his diagnosis but there is no way for him to know for sure.

 

[Carlos Danger]

I think his attitude it wrong. He may be correct in his diagnosis but there is no way for him to know for sure.

Exactly.

A guess is still just a guess, even if it turns out that this dimwitted medic guessed right.

 

[Clare]

Intoxication is a diagnosis of last resort, just like hyperventilation, just like indigestion/GERD or unspecified abdominal pain / gastroenteritis.

There have been many case reports of catastrophic misdiagnosis leading to death, specifically

- Cranial haemorrhage being misdiagnosed as intoxication (or psychiatric problems),
- Pulmonary embolism or sepsis being misdiagnosed as hyperventilation,
- Myocardial infarction being misdiagnosed as indigestion or GERD,
- Aortic aneurysm or dissection being misdiagnosed as "tummy ache" or gastroenteritis,

An excellent, relevant example (although almost 20 years old now) is http://www.hdc.org.nz/media/2839/98HDC13685dhb.pdf

 

[Tigger]

A fall resulting in altered mentation would get processed through as a delta level call (a step below cardiac/respiratory arrest) by a dispatch center and the ambulance would be dispatched emergent. I don't think there is anything wrong with asking the same courtesy even though it's not as clear cut here. The patient needs to go to the hospital with a degree of haste.

 

[Clare]

If he was unconscious at the time of the call, Control would code the call as red (immediate response with lights and siren) otherwise if not or unknown then it would be an orange (can wait up to thirty minutes).

I would call him moderate (ATS 3 - needs to be seen by a doctor within thirty minutes of arrival at hospital).

 

[Tigger]

If he was unconscious at the time of the call, Control would code the call as red (immediate response with lights and siren) otherwise if not or unknown then it would be an orange (can wait up to thirty minutes).

I would call him moderate (ATS 3 - needs to be seen by a doctor within thirty minutes of arrival at hospital).

Our call takers have much less discretion than in NZ. If the individual was ever altered, had some sort of irregular breathing, or anything at all, it's lights and sirens.

 

[RedAirplane]

If unknown they wouldn't dispatch lights & sirens...?

 

[Clare]

rest

If unknown they wouldn't dispatch lights & sirens...?

Not necessarily no. There is very little benefit in using lights and siren and the average time saving is, from memory, about two minutes which in only a fraction of cases is clinically significant.

The dispatch grid was reconfigured in 2012 so we moved away from the old system of assigning MPDS detriments to priority 1, 2 or 3 to a colour coded system based on historical patient acuity for that particular cohort of patients, specifically:

Purple - cardiac arrest; respond within 8 minutes
Red - immediate life threat; respond within 8 minutes
Orange - urgent and potentially serious; can wait up to 30 minutes
Green - not medically urgent; can wait up to two hours
Grey - no response generated; for enhanced telephone assessment

Somebody who has fallen over, is not in cardiac arrest, has no major haemorrhage etc. can wait up to 30 minutes, from a pure "threat to life" perspective, they can wait up to two hours, however it is not reasonable for this to occur hence why these are coded orange and not red.

 

[Tigger]

If unknown they wouldn't dispatch lights & sirens...?

In America an unknown life status is nearly always an emergent response.

But in this case that has been resolved. The only real difference here is that an emergent ambulance will continue to your call no matter what sort of call drops around it while a non emergent ambulance may get s higher priority call. That's where the time savings lies. And an altered fall should warrant that.