Paramedics are called to a skating rink, where a 45y/o female patient, Judy, has slipped on ice and struck her head. When they arrive, they find her sitting on a bench, alert and oriented with a GCS of 15. She is able to recall the events immediately leading up to the incident, and witnesses report a 30s loss of consciousness with no seizure activity. She has vomited once and continues to feel nauseated. She rates her pain as 5/10. On exam, there is a sizeable goose-egg to the back of her head, but no deformity or signs of basilar skull fracture, PEARL, and stable vital signs. She is able to ambulate and denies neck or back pain.[bg_faq_start]
About Sirens to Scrubs
Sirens to Scrubs was created with the goal of helping to bridge the disconnect between pre-hospital and in-hospital care of emergency patients. The series offers in-hospital providers a glimpse into the challenges and scope of practice of out-of-hospital care while providing pre-hospital providers with an opportunity to learn about the diagnostic pathways and ED management of common (or not-so-common) clinical presentations. By opening this dialogue, we hope that these new perspectives will be translated into practice to create a smoother, more efficient, and overall positive transition for patients as they pass through the ED doors.[bg_faq_end]
- Review considerations for pre-hospital management of isolated minor head injury
- Introduce the Canadian CT Head Rule as a guide for decision-making in minor head injury
- Discuss return-to-activity guidelines for patients with concussions
What pre-hospital treatments may be considered for Judy?
Spinal motion restriction
Although spinal cord injury is always considered in patients who have fallen and/or struck their head, Judy is an otherwise healthy patient who suffered a simple mechanical fall from standing and has no obvious neurological deficits or neck pain. In fact, it has been identified that the practice of placing patients on spinal boards is neither effective in its goal of preventing secondary injuries caused by motion, nor safe, as it has been linked to harmful sequelae, such as aspiration, impaired respiratory function, decubitus ulcers, and increased intracranial pressure1. for long periods of time brings with it a series of medical complications, and many EMS services have gone away from using spinal boards altogether (instead, using a combination of cervical collars, head rolls, tape, and other materials as necessary.) Thus, spinal motion restriction would generally not be recommended for Judy.
Judy is has vomited once and complains of ongoing nausea. The administration of dimenhydrinate for nausea and vomiting can be given by most pre-hospital providers in Canada and should be considered for Judy. In some areas, other anti-emetic agents such as metoclopramide and ondansetron are also within paramedic scope of practice.
Judy is complaining of moderate, 5/10 pain. Options for pre-hospital analgesia are growing as the medical community has begun to recognize and study the negative effects of oligoanalgesia. Although the availability of specific analgesics varies significantly across Canada, these agents may include acetaminophen, NSAIDs, opioids, ketamine, or nitrous oxide.
Judy isn’t sure if she wants to go to the hospital with the paramedics. She asks ‘what will the hospital do for me?’
This can be a challenging question for paramedics to navigate, and they should certainly follow any local guidelines on how to approach this situation. To provide some background, however, these are some elements of care that the emergency physician will likely consider:
What are the indications for a CT scan in head injuries?
The first item in Choosing Wisely Canada’s top ten recommendations for Emergency Medicine addresses the use of CT scans in head injuries2. Specifically, they recommend not ordering one unless it is indicated by a validated clinical decision rule. Not only do CT scans take up limited resources, but they also deliver about 2000 times as much radiation to the patient as an x-ray of their arm would. This is not inconsequential, as radiation carries serious risks, most notably certain types of cancer or birth defects.
The Canadian CT Head Rule is one such rule that is commonly used to guide decision-making around ordering CT scans on adult patients (>16yrs) presenting after a ‘minor head injury’ from blunt trauma within the previous 24h3. The rule is outlined below.
Here is a post that does a great job of explaining the difference between ‘minimal’ and ‘minor’ head injuries, and here is another link to a mnemonic you can use to remember the rule!
Of course, as with any clinical decision rule, these are meant to guide decision-making, not replace it; clinical judgement should always be applied.
Based on the Canadian CT Head Rules, the Emergency Physician decides that she is at low risk for significant brain injury, and a CT scan would not be beneficial for Judy. She is diagnosed with a mild traumatic brain injury, or a concussion, and discharged home.
What advice will the physician give Judy about post-concussion recovery?
Regardless of the patient’s daily vocation, they should be advised to avoid participating in any activities that put them at risk for another concussion while recovering, especially in the first 7 to 10d after injury.
There are no standard instructions for return-to-work following a concussion, as the process will be unique to each individual and each vocation; the patient needs to work with their primary care physician and employer to develop a safe plan, which should be re-assessed regularly and adjusted based on recovery. General, evidence-based guiding principles may include4:
- An initial period of rest to recover from initial symptoms in the 24-48hrs immediately following the injury may be helpful.
- The practice of waking the patient up every hour or two in the 24hrs following a concussion is not recommended anymore.
- It is important for the patient to return-to-work at maximal capacity early, as delays can have negative effects on the patient’s recovery and quality of life.
- Restrictions should be placed only on work activities that exacerbate symptoms (note, this doesn’t include symptoms that are present at baseline).
Return-to-play and return-to-school
There are more structured guidelines for athletes returning to play and post-secondary students returning to school – these can be found here.
Children aren’t just little adults! Guidelines specific to children under 18y/o can be found here.
That’s it! If you have any questions, thoughts, alternative perspectives, or requests for future topics, feel free to comments below or send me an email at [email protected].
Please keep in mind that, although I will do my best to publish information that is accurate across Canada, there will inevitably be some regional differences in both pre-hospital and in-hospital management of emergency patients. As a paramedic and Emergency Medicine resident in Ontario, some posts may wind-up being somewhat Ontario-centric, hence, I encourage anyone whose experiences differ from mine to contribute to the conversation by commenting below.