Advanced Trauma Life Support ATLS Student Course Manual 2018

EVIDENCE-BASED TREATMENT GUIDELINES 115
Pitfall
Patient suffers
second TBI soon after
treatment for initial
mild brain injury.
Prevention
• Even when a patient appears
neurologically normal,
caution him or her to avoid
activities that potentially can
lead to a secondary brain
injury (e.g., vigorous exercise,
contact sports, and other
activities that reproduce or
cause symptoms).
• Reassessment at outpatient
follow up will determine
timing of return to full activity
or the need for referral
for rehabilitative/cognitive
services.
Most patients with mild brain injury make uneventful
recoveries. Approximately 3% unexpectedly
deteriorate, potentially resulting in severe neurological
dysfunction unless the decline in mental status is
detected early.
The secondary survey is particularly important in
evaluating patients with mild TBI. Note the mechanism
of injury and give particular attention to any loss
of consciousness, including the length of time the
patient was unresponsive, any seizure activity, and
the subsequent level of alertness. Determine the
duration of amnesia for events both before (retrograde)
and after (antegrade) the traumatic incident.
Serial examination and documentation of the GCS
score is important in all patients. CT scanning is the
preferred method of imaging, although obtaining
CT scans should not delay transfer of the patient who
requires it.
Obtain a CT scan in all patients with suspected brain
injury who have a clinically suspected open skull
fracture, any sign of basilar skull fracture, and more
than two episodes of vomiting. Also obtain a CT scan
in patients who are older than 65 years (n TABLE 6-4).
CT should also be considered if the patient had a loss
of consciousness for longer than 5 minutes, retrograde
amnesia for longer than 30 minutes, a dangerous
mechanism of injury, severe headaches, seizures, short
term memory deficit, alcohol or drug intoxication,
coagulopathy or a focal neurological deficit attributable
to the brain.
When these parameters are applied to patients
with a GCS score of 13, approximately 25% will have
a CT finding indicative of trauma, and 1.3% will
require neurosurgical intervention. For patients
with a GCS score of 15, 10% will have CT findings
table 6-4 indications for ct
scanning in patients with mild tbi
Head CT is required for patients with suspected mild
brain trauma (i.e., witnessed loss of consciousness, definite
amnesia, or witnessed disorientation in a patient with
a GCS score of 13–15) and any one of the following factors:
High risk for neurosurgical
intervention:
• GCS score less than 15
at 2 hours after injury
• Suspected open
or depressed skull
fracture
• Any sign of basilar
skull fracture (e.g.,
hemotympanum,
raccoon eyes, CSF
otorrhea or rhinorrhea,
Battle’s sign)
• Vomiting (more than
two episodes)
• Age more than 65 years
• Anticoagulant use*
Moderate risk for brain
injury on CT:
• Loss of consciousness
(more than 5 minutes)
• Amnesia before impact
(more than 30 minutes)
• Dangerous mechanism
(e.g., pedestrian struck
by motor vehicle,
occupant ejected from
motor vehicle, fall from
height more than 3 feet
or five stairs)
Source: Adapted from Stiell IG, Wells GA, Vandemheen K, et al. The
Canadian CT Head Rule for patients with minor head injury. Lancet 2001;
357:1294.
*Patients on anticoagulation were excluded from the use of Canadian
CT Head Rule.
indicative of trauma, and 0.5% will require neurosurgical
intervention.
If abnormalities are observed on the CT scan, or if
the patient remains symptomatic or continues to have
neurological abnormalities, admit the patient to the
hospital and consult a neurosurgeon (or transfer to a
trauma center).
If patients are asymptomatic, fully awake and alert,
and have no neurological abnormalities, they may
be observed for several hours, reexamined, and, if
still normal, safely discharged. Ideally, the patient
is discharged to the care of a companion who can
observe the patient continually over the subsequent
24 hours. Provide an instruction sheet that directs
both the patient and the companion to continue close
observation and to return to the ED if the patient
develops headaches or experiences a decline in mental
status or focal neurological deficits. In all cases,
supply written discharge instructions and carefully
review them with the patient and/or companion
(n FIGURE 6-9). If the patient is not alert or oriented
enough to clearly understand the written and verbal
instructions, reconsider discharging him or her.
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