To BB or not

[Akulahawk]

I actually had a scenario like this occur at a baseball tournament when I was working as a firefighter first responder. Pt was ~30 year old male, was hit by a baseball on his forehead at high velocity, then fell unconscious for ~1 minute and upon waking was confused for 2-3 minutes with somewhat shallow breathing. We stabilized his head, applied a cervical collar, gave him high flow oxygen, tried to do a rapid motor/sensory exam, and checked his pupils. It was not clear if his pupils were PERRLA. Pulse was rapid. He did become more alert after but complained of dizziness. We backboarded the patient and then transferred him to paramedics for transport. I followed my protocols and that's it.

About the only thing that concerns me in the above description is that the pupils may or may not have been PERRL. The rapid pulse may indicate that the player's body is still dealing with athletic activity. While I do worry about the possibility of ICH, I don't see a strong mechanism for it. Had he been hit in the temple, I'd have greater concerns about both ICH and skull fracture. Personally, I'd call it a Grade 2 Concussion, maybe a Grade 3 or 3b depending upon which system you'd want me to use to grade them. He's likely to not remember what knocked him out, or even being knocked out. I'm going to watch for how quickly he reorients, if he needs frequent reorientation, whether he's developing amnesia beyond the immediate time of impact, and so on. Ever done a Field Sobriety Test? Concussed people often fail it too. I'm going to be doing serial FSTs and look at the trend.

In case you're wondering, yes, this means I'm going to be actively observing this guy for a while. And yes, I have done exactly that quite a few times. Would I do ANY of the above in my role as a Paramedic? Absolutely not. Why? There's nothing in the protocols that address this type of problem and very few (if any) Paramedics get sufficient education to more closely evaluate CHI. My Paramedic education basically glossed over pretty much everything except the bleeds.

I also don't see any evidence of diffuse axonal injury...

I still wouldn't have put this guy into spinal precautions unless I was forced to by protocol.

 

[FirstResponderCAD]

Do your protocols call for SMR in isolated head injuries? If so, you need new protocols.

Critical thinking question: how will spinal motion restrictions assist in the treating of a head injury?

If there is any noticeable issue with LOC (AVPU, AOx4, GCS), neural/pupil exam, or ABCs associated with the head injury, then the protocols call for backboarding. I'm well aware that the evidence for the widespread use of backboard immobilization is actually practically non-existent except for a fraction of trauma cases involving specific injuries to the spine accompanied by neurological findings but the protocols haven't caught up. You have to also realize that the organizations I've volunteered for (fire departments and event first response services) are staffed mainly by people with EMR and EMT-b certifications and we transfer care to paramedics. In many cases, if we are uncertain if spinal immobilization is necessary, we just wait for the paramedics to arrive and discuss our findings. Often, if the paramedics are unsure, they vac mat the patient which basically takes 2 minutes (paramedics in my province use vacmats way more commonly than spine boards).

 

[Medic Tim]

No board. Even if the pt was altered . No need to even go through our clearance protocol.