Patient on the ground after a traffic accident - head trauma and the role of a portable suction unit

 

Head injuries have been receiving a lot of press lately. Between the wars in Iraq and Afghanistan on the one hand and the National Football League on the other, traumatic brain injuries (TBIs) have been elevated to front-page news. It’s been a long time coming. The rate of TBIs in America (and among Americans returning from war) is reaching frightening proportions. Here are a few statistics from the Centers for Disease Control and Prevention:¹


TBIs in the United States

  • An estimated 1.7 million people sustain a TBI annually; of these:
    • 52,000 die.
    • 275,000 are hospitalized.
    • 1.365 million, nearly 80 percent, are treated and released from an emergency department.
  • TBI is a contributing factor to almost a third (30.5 percent) of all injury-related deaths in the United States.
  • About 75 percent of TBIs that occur each year are concussions or other forms of mild traumatic brain injury (MTBI).
  • Direct medical costs and indirect costs of TBI, such as lost productivity, totaled an estimated $60 billion in the United States in 2000.

TBI by Age  

  • Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are likeliest to sustain a TBI.
  • Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years.
  • Adults aged 75 years and older have the highest rates of TBI-related hospitalization and death.

TBI by Sex

  • In every age group, TBI rates are higher for males than for females.
  • Males aged 0 to 4 years have the highest rates of TBI-related emergency department visits, hospitalizations, and deaths combined.

TBI by External Cause

  • Falls are the leading cause of TBI. Rates are highest for children aged 0 to 4 years and for adults aged 75 years and older.
  • Falls result in the greatest number of TBI-related emergency department visits (523,043) and hospitalizations (62,334).
  • Motor-vehicle-traffic injury is the leading cause of TBI-related death. Rates are highest for adults aged 20 to 24 years.

PHYSIOLOGY OF TBIs

An MTBI, often referred to as a concussion, is a traumatically induced physiological disruption of brain function, usually associated with at least one of the following signs and symptoms²:

  • Any loss of consciousness
  • Any loss of memory for events immediately before (retrograde) or after (anterograde) the event precipitating the injury
  • Any alteration in mental status at the time of the injury
  • Focal neurologic defects in which the patient is not unconscious for longer than 30 minutes; after 30 minutes, the patient has a GCS of 13 to 15

TBIs are generally divided into two categories³:


Primary brain injury – Direct trauma to the brain and associated structures, occurring at the time of injury

 

Secondary brain injury – Ongoing injuries that are set in motion by the primary injury. They typically include:

  • Mass effect: Swelling leading to elevated intracranial pressure and mechanical shifting; can lead to herniation
  • Hypoxia: From inadequate delivery of oxygen to injured brain tissue
  • Hypotension and inadequate cerebral blood flow: Reduces flow of oxygen and glucose to the brain
  • Cellular mechanisms, including energy failure and inflammation, leading to cell death

TYPES OF SKULL FRACTURES

TBIs do not necessarily involve skull fractures, but any patient who has sustained a head injury should be suspected until proven otherwise. Generally, types of skull fractures include:

  • Linear – Characterized by a single fracture line
    • Usually occurs at the suture line
    • Swelling and point tenderness at the site
    • Usually does not require surgical intervention
  • Depressed – When a portion of the skull is pushed inward
    • Scalp may or may not be torn
    • Swelling and bony step-off may be palpated at the site
    • Open versus closed, depending on whether the dura mater has been breached
  • Comminuted – Skull is splintered or shattered into many pieces
    • Pieces may act as projectiles, directly injuring the meningeal layers
    • Common in blunt-force injuries (e.g., baseball bat to the head)

THE ROLE OF SUCTION IN TREATING HEAD TRAUMA

The key to treating the head-injured patient is maintaining adequate oxygenation and perfusion in the brain. As with every patient, it all begins with a patent airway. That’s where suction plays a role. In head injuries, the patient may be unable to protect his or her airway from blood, secretions, or vomit. Utilizing your portable suction unit may be the only means of preventing aspiration or hypoxia.


In cases of diminished level of consciousness or unresponsiveness, you must remain vigilant until the airway is secured. If intubating, be sure to keep the suction handy, to visualize the cords, and remove bodily fluids. In many cases, the injury may not be restricted to the head; the face may be involved (Le Fort fractures), or the patient may be neurologically impaired, making airway patency difficult. Be sure to have the portable suction unit within reach.


By ensuring adequate oxygenation to the brain, you can preserve delicate tissues, reduce swelling, and possibly ward off secondary injuries. So, from now on, when you think of head injuries, think “portable suction unit!” It may be key to protecting the patient from further injury and death.

 

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¹ 2013, Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2007 and 2013, Centers for Disease Control and Prevention,

https://www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf


² 2011, Pollak, A., Ed.

Critical Care Transport, American College of Emergency Physicians, Jones and Bartlett.

 

³ 2011, Prehospital Trauma Life Support, American College of Surgeons, Committee on Trauma, MOSBY JEMS, Elsevier.