Effective management of patients with moderate to severe head injury

Oct. 05, 2019

After sustaining a moderate to severe head injury, patients will score less than 13 on the Glasgow Coma Scale (GCS) and may seem confused or disoriented — perhaps not knowing where they are at all — demonstrate decreased verbal abilities and difficulty following commands, or may be comatose.

Which patients need transfer to a Level I Trauma Center

Patients who experience mild head injury, concussed but with normal CT scan findings, don't require transfer to a Level I center, according to John L. Atkinson, M.D., neurosurgeon at Mayo Clinic's campus in Rochester, Minnesota. These patients can be observed at the local community hospital.

Oftentimes mechanism of injury can tell trauma providers a great deal about the patient's risk level and thus need for transfer, says Dr. Atkinson. For example, head injuries sustained while falling down stairs, tumbling from a second-story roof or crashing off a motorcycle at 75 mph are predictably more severe and may require more complex care.

A notable exception to this guideline would be the older patient who is taking an anticoagulant such as warfarin, who may be at high risk due to head injury from a simple fall out of a nursing home bed. While this injury may be minor in a younger patient who doesn't take this medication, for an anticoagulated patient, rapid transfer to a Level I Trauma Center may be warranted.

When transfer is questionable, trauma personnel may phone the Mayo Clinic neurosurgeon on call to discuss the head injury case and request patient film review. This process can be facilitated by calling the Admission and Transfer Center at 507-255-2910.

Important steps and interventions prior to transfer

Dr. Atkinson and Bo E. Madsen, M.D., M.P.H., emergency medicine specialist at Mayo Clinic's campus in Rochester, Minnesota, offer several tips for working with patients who've sustained moderate to severe head injuries and arrive at lower volume trauma centers.

Transport from scene to right care level

Prehospital staff utilize context from the mechanism of injury in decision-making about appropriate level of care for the patient. If it appears the patient has an intracranial problem, the patient would not stop at a Level IV hospital, but rather go directly to a Level I Trauma Center.

Stabilize the patient

For patients with head injury, professionals should follow airway, breathing and circulation assessment (trauma ABCs) and attend to patients' potential shock upon arrival at the local hospital. If the patient will need transfer later, however, these steps may be completed while en route to definitive care, if personnel are Advanced Trauma Life Support trained and available.

Use imaging to confirm no problems exist

CT should be performed on a patient with head injury at a lower volume trauma center only if treating personnel want to check the patient's status through imaging, yet aren't really anticipating problems, says Dr. Atkinson.

While overall emphasizing that imaging not be used for issues a center cannot treat, Dr. Madsen also suggests obtaining a chest X-ray to avoid transferring a patient with an untreated pneumothorax.

Move quickly to get the patient care

Speed and awareness of the local medical center's resources can be critical in a head injury patient's outcome, according to Dr. Atkinson.

"Time is of the essence," he says. "The difference in outcome is vast. Minutes to an hour is the golden rule. If they are deteriorating, transfer them to a higher level of care. If you can't treat it, and there's nothing you can do, why waste time? Send them on."

With the two extremes of age, however — the very young and very old, with whom getting a good exam can be challenging — the transfer threshold is lower than for other populations where decisions may be more clear-cut.

Dr. Madsen emphasizes the goal is to tip the balance in favor of overtriage and transfer to Level I, versus undertriage where either transfer is delayed or patients needing intervention at a higher level trauma center are not transferred at all.

Communicate with receiving provider about the injury

When transferring patients with head injury, convey the mechanism of injury to the receiving physician. This context provides important information on the injury type and severity.

Medically futile care

Trauma providers also need to be ready for when a patient's head injury is unsurvivable, says Dr. Atkinson.

"We get a fair number of essentially brain-dead patients transferred to Mayo Clinic, because the family or provider has angst," he says. "In some cases, it's humanitarian to do nothing and not get the family all worked up — transferring the patient is contraindicated."

Dr. Madsen says that when a patient's situation is futile, a number of ethical issues arise. If imaging makes clear the patient cannot survive, questions arise related to incurring transportation costs, safety and also giving false hope to loved ones when there is none.

In cases where a patient's injuries make survivability debatable, providers at lower volume trauma centers may send images to the Level I center for neurosurgical consult about the patient's status. When families know the determination that their loved one's injuries are not survivable is not just based on one individual's opinion, they feel more comfortable, says Dr. Madsen. Further, when they understand that nothing further can be done for the patient, many times they prefer to stay locally, he says.

Learning more about head injury

At centers where patients with moderate to severe head injury aren't seen often, assessing a case and determining status may be much more challenging, says Dr. Atkinson. He suggests providers working in lower volume trauma centers consider spending time at a Level I center to observe for a few days what providers do with patients, indicating that angst can be overcome with immersion. This exposure also would help understand differing resources among trauma centers and boost confidence in decision-making.

"There are clear-cut cases you'd treat at a Level IV and those you'd transfer," he says. "And exposure to a higher number of trauma cases and head injuries, in particular, could help with the gray zone."