Head Injury Care Research Articles

Nursing care of the acute head injury: a review of the evidence.

This article aims to review the current evidence in relation to acute head injury care. Head injuries are a frequent cause of death and disability in western society with the first 72 h being an important period for prevention of further brain damage. The underlying physiology behind head injury and intracranial pressure will be discussed. The monitoring of intracranial pressure and implications for practice will be addressed. The specialized nursing care and drug therapy management that is necessary for acute head injury patients will be highlighted. Recommendations for practice will be given.

Präklinische Versorgung von Traumapatienten in der Luftrettung

In a retrospective study of mission data of ADAC Air Rescue of the years 2000 and 2001 the quality of preclinical care of 1,946 patients with severe head injuries and 1,878 polytraumatized patients was examined. The actual preclinical care of these patients was compared with a catalogue of eleven thesis-like recommendations. These recommendations were previously derived from corresponding publications of national and international specialist companies and were introduced in a binding manner by the senior doctors of the participating air rescue centres. The results of the study show that 73.3% of the severe head injuries were preclinically intubated and 94.4% were supplied with oxygen, 82.2% were analgosedated. 94.8% could be delivered to the hospital of destination. 65.9% had a systolic blood pressure of >120 mmHg upon admission to the hospital. 71.4% of severe head injury victims were equipped with a cervical support, 23.3% had the blood pressure documented. 47.3% reached the hospital of destination in less than 60 minutes. Among polytraumatic patients the intubation was performed in 75.7%, the supply with oxygen in 90.7%, 88.6% of the patients were analgosedated. 78.7% of patients suffering from concomitant head injuries were provided with a cervical support and only 22.8% had a blood sugar measurement documented. A concomitant severe thorax trauma was treated by a thorax drainage in 59.2%. 35.6% of the polytraumata reached the hospital of destination in less than 60 minutes. The work describes the preclinical patient care of severe head injuries and polytraumata, pointing out deficits and presenting optimization possibilities, particularly in the area of training. Furthermore, the work shows the concept of the medical quality management in an air rescue enterprise. The total evaluation of all air rescue centres participating in data collection forms the basis of an external quality comparison. The data evaluation of a single station makes regional strengths and weaknesses visible, deficits can be proven and proposals for optimization be developed. The presentation of the time history of data yields continuous standard information on the state of the patient care at the relevant air rescue location and enables the analysis of improvement concepts based on the updated data.

Who cares for the patient with head injury now?

Objective—A recent report on head injury management from the Royal College of Surgeons of England suggests that surgeons are unsuited to the inpatient care of head injuries (ICHI) and should...

Implementing the Galasko Report on the management of head injuries: the Eastern Region approach

Objectives—The Royal College of Surgeons (RCS) Report on the management of patients with head injuries under the chairmanship of Professor Galasko, published in June 1999, made important recommendations that will...

The problem of informed consent in emergency medicine research

The CRASH Trial (Corticosteroid Randomisation After Significant Head injury), which started in April 1999 hopes to answer the question of whether or not there is any benefit to giving high...

Fears raised over head injury care

Fears raised over head injury care

Quality Management in Head Injury Care

Quality Management in Head Injury Care

Exploring the guidelines for the management of severe head injury.

A significant improvement in patient outcomes can be achieved by in-hospital interventions aimed at the prevention of secondary brain injury. The Guidelines for the Management of Severe Head Injury is a scientific, evidence-based document that evaluates the current evidence for practice and interventions to reduce secondary brain injury and improve outcome for traumatic brain injury (TBI) patients. The Guidelines covers a wide range of topics including trauma systems, oxygenation and blood pressure resuscitation, intracranial pressure monitoring, intracranial hypertension, nutrition, and pharmacological interventions for the severe TBI patient in the intensive care environment. Head injury care requires an interdisciplinary approach involving emergency room personnel, trauma nurses, and critical care nurses. Critical care nurses will find this document especially applicable because secondary brain injuries are often the result of events that occur in the ICU setting: hypoxemia, hypotension, and intracranial hypertension.

Snapshot view of emergency neurosurgical head injury care in Great Britain and Ireland

OBJECTIVESTo study the availability of neurosurgical intensive care for the traumatically brain injured in all 36 neurosurgical centres in the United Kingdom and Ireland receiving head injuries, the response times...

The management of acute neurotrauma in rural and remote locations: A set of guidelines for the care of head and spinal injuries

The Neurosurgical Society of Australasia through its Trauma Committee has a long involvement in the problem of neurotrauma. The management of acute neurotrauma in rural and remote locations is of particular interest and is part of a general policy which includes education, prevention, organization of an integrated neurotrauma system and support for the Early Management of Severe Trauma (EMST) programme instituted by the Royal Australasian College of Surgeons. The management of acute neurotrauma requires a consultative approach especially in the multiple injured patient and where transfer or retrieval is necessary. As acute neurotrauma may present to general practitioners, rural surgeons or emergency departments in country hospitals, a set of guidelines has been developed to assist in the early management of acute neurotraum. These guidelines have been previously published by the Neurosurgical Society of Australasia and the Royal Australasian College of Surgeons. They have been extensively used since 1992 by rural health and distance education groups, Royal Flying Doctor Service Emergency Management of Severe Trauma Course of the Royal Australasian College of Surgeons and by overseas education programs for neurotrauma care. This revision updates the guidelines and makes them accessible through the Journal. Reprints are available for practitioners in rural and remote settings, trauma course participants and others.

Five decades of head injury care – a neurosurgeon’s perspective

Successive wars in Europe and the Far East have taught neurosurgeons the importance of early wound debridement after open head injury to minimise infection even since the availability of antibiotics. Recognition of the importance of secondary brain damage due to systemic hypoxia and hypotension and raised intracranial pressure was the first major post-war development, leading to intensive medical treatment of patients in coma. The Glasgow Coma and Outcome Scales facilitated multi-centre data collection to study the effectiveness of such treatment. In the mid-1970s CT scanning led to earlier detection and treatment of acute intracranial haematomas, with improved outcomes. Pharmacological agents to prevent or control secondary pathological processes in the brain have so far proved disappointing. Epidemiological studies indicate different causes for mild and severe injuries and indicate how to target preventive measures. Severe head injuries due to road accidents are now less common in developed countries due to legislation to reduce accidents and to protect the brain in accidents. Co-ordinated rehabilitation is an important recent development in improving outcome after severe head injury.

Five decades of head injury care -- a neurosurgeon's perspective

Five decades of head injury care -- a neurosurgeon's perspective

The intensive care of severe head injury: a survey of non-neurosurgical centres in the United Kingdom

A bstract Few data exist regarding the management of severe head injury in non-neurosurgical centres within the UK. We aimed to discover the number of intensive care units admitting head injury patients, the number of patients admitted annually, and the monitoring and treatment methods followed. Questionnaireswere sent to the senior nurse and consultant in 263 intensive care unitswithin non-neurosurgical hospitals. The response rate was78.8%, with at least one response received from 93.2% of hospitals. The severely head injured were routinely admitted in 56.7% of units. Approximately 2100 patientsare admitted annually, a mean of 15 per unit. Intracranial pressure monitoring isroutine in only 9% of unitsand 7% are without 24-h facilities for CT, a cause for concern. More encouragingly, 63% of hospitals have access to rehabilitation facilities. Distribution of guidelines to all intensive care units participating in the care of head injury may improve management and outcome.

Patient management in head injury care: a nursing perspective.

Through a review of the literature, this article provides a consideration of nursing responsibilities and nursing care in the management of patients with head injuries. A brief review of the pathophysiology of head injury is followed by a description of intracranial pressure (ICP) monitoring and cerebral perfusion pressure (CPP) measurement, using the Camino fibreoptic catheter and monitor, with exploration of pulse and trend waveforms and their significance in assessing cerebral compliance. Jugular venous bulb saturation (SjO2) monitoring adds another dimension to the assessment of neurological damage by demonstrating cerebral tissue perfusion and cerebral metabolic rate, and this is also discussed. After identification of assessment as a crucial part of the nursing role, aspects of nursing care of head-injured patients are discussed. The discussion of respiratory support measures includes the controversial use of hyperventilation in reducing ICP, the prevention of hypoxia, the risk of respiratory complications, the use of suctioning and turning to prevent these and the problems associated with these nursing care measures. Other aspects of care are also considered, including careful positioning and temperature control, and the benefits of mild hypothermia.

Survey of intensive care of severely head injured patients in the United Kingdom

To study practice in intensive care of patients with severe head injury in neurosurgical referral centres in United Kingdom. Structured telephone interview of senior nursing staff in intensive care unit of adult neurosurgical referral centre. 39 intensive care units in hospitals that accepted acute head injuries for specialist neurosurgical management, identified from Medical Directory and information from professional bodies. Details of organisation and administration of intensive care and patterns of monitoring and treatment for patients admitted with severe head injury. Patients were managed in specialist neurosurgical intensive care units in 21 of the centres and in general intensive care units in 18. Their intensive care was coordinated by an anaesthetist in 25 units and by a neurosurgeon in 12. Annual case-load varied between units: 20 received > 100 patients, 12 received 50-100, and seven received 25-49. Monitoring and treatment varied considerably between centres. Invasive arterial pressure monitoring was used routinely in 36 units, but central venous pressure monitoring was routinely used in 24 and intracranial pressure was routinely monitored in only 19. Corticosteroids were used to treat intracranial hypertension in 19 units. Seventeen units routinely aimed for arterial carbon dioxide pressure of 3.3-4.0 kPa, and one unit still used severe hyperventilation to a pressure of < 3.3 kPa. The intensive care of patients with acute head injuries varied widely between the centres surveyed. Rationalisation of the intensive care of severe head injury with the production of widely accepted guidelines ought to improve the quality of care.

Physiatry as a primary care specialty.

The ongoing changes in health care seek to create an affordable, accessible, and high-quality health care delivery system for all Americans. In response to this, Physical Medicine and Rehabilitation (PM&R) is re-examining its role in the provision of health care to the disabled, particularly the severely affected. We surveyed 100 physiatrists and 100 PM&R residents across the country regarding their opinions on the competence, qualifications, and desire of physiatrists to provide primary care for the disabled. Fifty-five physiatrists and 51 residents responded (55% overall). Thirty-nine percent of all respondents agreed that PM&R should be designated as a primary care specialty, and 53% believed that physiatrists should provide primary care to the severely disabled (e.g., spinal cord and head injury). Overall, 53% felt that physiatrists are competent in general medical care, but 38% are convinced that the current 4-yr PM&R residency training sufficiently prepares physiatrists to assume the role of a primary care provider. Of the patient populations considered, the respondents thought that physiatrists should manage the care of spinal cord injury (60%) and head injury (51%), but only 40% were willing to assume primary care responsibilities.

The Effect of Severe Head Injury on Whole Body Energy Expenditure and Its Possible Hormonal Mediators in Children

This study examines the effects of severe head injury in children on whole body energy expenditure and the mediators that influence this. One hundred five serial measurements of whole body energy expenditure and plasma adrenaline, triiodothyronine, glucagon, cortisol, insulin, and growth hormone concentrations were made in 18 children aged 2-15 y receiving neurointensive care for severe head injury. Energy expenditure was measured using indirect calorimetry by a modified Douglas bag technique, and hormones were measured by RIA or radioenzymatic assay. Energy expenditure varied markedly between and within children (mean 97% of predicted, range 60-137%) and was significantly lower in the four children with a poor outcome (p = 0.03). Within each child there were statistically significant positive relationships between energy expenditure and adrenaline (p < 0.0001), triiodothyronine (p < 0.0001), and glucagon (p < 0.0001). However, there was evidence that the effect of adrenaline on energy expenditure was attenuated. This may be due to the effects of the cerebral trauma itself on central nervous influences on energy expenditure, to interactions between hormones, or to a global impairment of O2 utilization by the body's tissues.

Neurocritical care for coma, intracranial pressure, head injury, and neoplasia.

Neurocritical care for coma, intracranial pressure, head injury, and neoplasia.

A practical approach to head injuries, including intracranial pressure monitoring and protection of damaged tissue

The immediate care of head injuries includes provision of a secure airway and prevention of inhalation of gastric contents. Hypovolaemia must be urgently treated and care taken to diagnose other injuries, especially those of the cervical spine and chest. After resuscitation, a neurological assessment should be made and the appropriate radiological investigations performed. Intracranial haematoma must be diagnosed promptly and treated without delay. If anaesthesia is required for radiology or surgery, it must include tracheal intubation and hyperventilation, attenuating the effects of intubation by the use of thiopentone plus a β-receptor blocking agent or lignocaine. Isoflurane should be used to maintain anaesthesia, although in patients with gun-shot injuries and children, a total intravenous technique may be preferable. The principles of intensive care for head injuries are prevention of hypoxia and hypercapnoea, maintenance of systemic blood pressure and reduction of elevated intracranial pressure (ICP), continued vigilance for expanding haematoma and prevention and treatment of fits. It is also important to treat pyrexia, infection and fluid and electrolyte disturbances. Hyperglycaemia should be avoided. To achieve these aims, blood pressure should be continuously monitored and many patients require monitoring of ICP. Any unexpected deterioration is an indication for ultrasound or CAT scan. Controlled ventilation and specific treatment for raised ICP may also be required. The outcome after head injury depends inter alia on the severity of the injury, the presence of other injuries and the age of the patient. It is not surprising that it has proven difficult to demonstrate the efficacy of the various modalities of treatment or identify those patients who might benefit from more aggressive therapeutic regimens.

Planning a system of care for head injuries.

Major improvements in the acute management and rehabilitation of patients with head injury have developed in recent years, particularly in the United States. Australia has lagged behind in these developments, but a co-operative programme between Bethesda Hospital and the Motor Accidents Board in Victoria has improved services for these serious injuries, at least for those resulting from road accidents. It is proposed that integration of services for head injuries would be improved by developing a system of care, based on the proven model for spinal cord injuries, which should not only allow better co-ordination of individual patient care, but also stimulate a more rational development of new services within the health system. The aim is to develop a co-ordinated total care concept for people with head injuries from time of injury, through acute care and rehabilitation to long-term follow-up in the community, a flexible system able to respond to the complexity and variability of these common and serious injuries.