Neurologic injuries can be challenging to assess and treat in the prehospital environment.
Of course, there are signs and symptoms that will allude to the presence of an insult to the brain. It can, however, be difficult to determine exactly what is occurring. When responding to a call, such as a motorcycle accident, knowing even the basics of traumatic brain injury treatment may just save lives.
Without a CT scan, it is often a guessing game based on patient presentation, history of current illness or mechanism of injury, and current mentation. Some of the common neuro injuries we might face in the field are the subdural, epidural and subarachnoid hematomas. This is just a brief overview of the common signs and symptoms and pathophysiology of those injuries.
The epidural hematoma occurs when blood accumulates between the inner periosteum and the dura mater. Most of these injuries are arterial in nature, resulting from disruption of the middle meningeal artery. Blood accumulates rapidly because of the high arterial pressure. One of the common signs and symptoms of an epidural hematoma is a brief loss of consciousness, followed by a period of lucidity that could last minutes to several hours.
Once the lucid period has passed, the patient experiences a rapid deterioration in mental status.
Increases in intracranial pressure and brain herniation are major concerns with this injury.
The subdural hematoma typically results from a high-energy impact. Blood accumulates between the dura and the arachnoid matter. These types of injuries are far more common than an epidural hematoma and are a result of disruption of the bridging veins rather than an arterial bleed.
Often the patient has sustained an injury, such as a fall, that involves hitting his or her head in the process. Patients may have thought they were fine at the time, but subdural bleeds are slow because of the venous involvement.
It might be days or up to two weeks before patients have a gradual deterioration in mental status.
The subarachnoid bleed occurs usually as a result of an aneurysm or arteriovenous malformation. Blood, usually arterial in nature, accumulates in the subarachnoid space where the patient experiences what they often describe as “the worst headache of my life.”
The patient also might experience:
- loss of consciousness
- nuchal rigidity
If intracranial pressure continues to rise, the patient might slip into a coma, where the mortality rate is quite high.
Traumatic brain injury treatment
Managing patients with any of these neurologic conditions will depend on how they are presenting.
Advanced airway management might be necessary if the patient has an altered mental status.
With a subdural hematoma, if the patient has no altered mentation, only supportive care could be warranted. Subarachnoid and epidural hematomas might require more aggressive treatment, although each case could present differently.
Cerebral perfusion pressure is a concern with patients showing signs of increasing intracranial pressure. A higher mean arterial pressure (MAP) might be necessary in that instance.
A thorough history to determine recent trauma or medical conditions that might predispose the patient is paramount.
Ultimately, timely treatment and transport to definitive care is the best thing to do for neurologically injured patients.