Texas EMS Magazine, Volume 17, Number 3, May/June 1996 Page: 32
66 p. : col. ill.View a full description of this periodical.
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Blood Pressure
Pulse
Respirations
Level of ConsciousnessEducAtion
Decreased
Increased
Increased
DecreasedIncreased
Decreased
Erratic
Decreasedcontrolled by whatever means neces-
sary. Assessment of breathing and
control of major bleeding should be
your next concern. Following this ini-
tial assessment a decision should be
made as to the patient's transport pri-
ority. Altered mental status is the
most common finding which should
lead you to a rapid transport decision.
Any patient with suspected CHI and
altered mental status should be trans-
ported rapidly to a surgical facility.
An assessment tool that is widely
recognized for head-injured patients
is the Glasgow Coma Scale (GCS).
The GCS measures mental status, mo-
tor and verbal response (Table 1). It
has been closely linked to patient out-
come and helps trend change in pa-
tient status. The GCS should be noted
as soon as you evaluate the patient
and after each intervention. Repeated
GCS values are very helpful in deter-
mining patient progress. A phrase as-
sociated with the GCS can help with
the decision of how to control the air-
way; "GCS of less than eight, intu-
bate."
Vital signs associated with isolat-
ed head injury are unique. Blood pres-
sure increases to perfuse the swelling
brain. Decreases in blood pressure are
usually preterminal signs in head in-
jury and should typically be associat-
ed with fluid loss and not increased
ICP. The respiratory patterns associat-
ed with increased ICP are variable.
They can be accelerated or slow, but
usually the pattern is erratic. The va-
gus nerve, which branches from the
brain at the brain stem, is the para-Texas EMS Magazine May/June 1996
32
sympathetic nerve which innervates
the heart. As increases in ICP occur,
the vagus nerve releases more neu-
rotransmitter acetylcholinee) into the
heart. This increase in vagal stimula-
tion causes bradycardia. These can be
used to differentiate head injury from
other forms of shock (Table 2). This
set of vital signs associated with a rise
in intracranial pressure is called Cush-
ing's triad. These are not early signs of
head injury and their absence should
not rule out head trauma.
The most important intervention
for any patient, especially those with
closed head injury, is airway manage-
ment. Patients with altered mental
status who must be supine on a back
board are at a increased risk of airway
obstruction and aspiration. Therefore,
good management is essential to pre-
vent complications of aspiration and
hypoxia. Proper maintenance of the
airway is crucial in those patients
with increased ICP. As carbon diox-
ide levels in the blood increase from
hypoventilation, the vessels attempt
to remove the excess CO2 by dilation.
This dilation in patients with head
trauma may cause increased cerebral
edema. Therefore, lowering carbon
dioxide levels may cause vasocon-
striction and reduce swelling. Insur-
ing adequate ventilation may reduce
CO2 levels by eliminating it through
the lungs. Respiratory rates of 20-24
with good tidal volume is sufficient to
maintain CO2 at acceptable levels (25-
30 torr). Hyperventilation in excess of
24 breaths per minute may cause too
much vasoconstriction and lead to tis-
sue hypoxia which is a major problem
in head injury.
Basic airway measures can often
maintain adequate airway control;
however, in the patient with altered
mental status, endotracheal intubation
is the definitive adjunct to control the
airway. In those patients with ade-Tahle 2
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Texas. Department of State Health Services. Texas EMS Magazine, Volume 17, Number 3, May/June 1996, periodical, May 1996; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth1507922/m1/32/: accessed June 26, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.