From Death we Learn.

By Kane Guthrie

Speak for the dead, to protect the living.

Objectives

• To understand and learn from a coroner’s case’s.

• Review some of the emergency nursing literature.

• Better understand of the head-injured patient in the ED

The Case

• 28 year old male (country town)• Drinking heavily all afternoon• 2000 – involved in a fight-kicked to the head

x3 times with steel capped boots• Police called-arrived 10mins later• Well known to police- placed under arrest• Ambulance called, taken to ED

At the ED

• Handed over to ED staff- via SJA• Un-arrested by police• Seen by nurse 2045, Dr @2100• Documented head injury post assault @1800• Both nurse and Dr record GCS 15, but pt slurring words and

difficult to understand.• No CT ordered, given fluids to rehydrate, Lac sutured.• Becoming agitated, abusive towards staff. • Pt DAMA @2215, Dr Happy as thinks 4/24 post injury, given

head injury advice sheet, still intoxicated and left with intoxicated brother.

What are the Issues??

What are the issues?

• Handover• When is CT indicated• Duty of care• DAMA• The difficult patients (Punks &Drunks)

How important is Handover?

When is CT head Indicated?

Canadian Head CT Rule:

High Risk Medium Risk For Consideration

GCS <15 at 2/24 post injury

Amnesia >30mins Anticoagulated

Suspected open/depressed skull #

Dangerous mechanism

Seizure

Signs of Basal skull #

Focal neuro deficit

Vomiting >x2 Drug or ETOH

Age >65 Trauma above clavicle

Zero Tolerance or Conflict?

Zero Tolerance Policy

• Concept from the USA • Brought in to manage gangs in high schools• Adopted poorly by hospitals early 2000• Fundamentally flawed policy for hospitals• We need to be able to:

•Demonstrate a willingness to listen, problem solve, negotiate

•Provide thorough assessment and disposition

•Enact therapeutic engagement and establish rapport

•Resort to duty of care/detain to achieve in circumstances

•Zero tolerance can be used for families/visitors

The Patient that DAMA

• What is your role?• Why do patients DAMA?• When can a patient DAMA?• What are the repercussions to you?

Duty of Care in the ED.

Are Patient’s becoming moredifficult.

Police Involvement

• Police then re-arrest pt outside hospital after told pt was medically cleared, not informed Pt DAMA

• Taken to police station (charged)• Police felt Pt was to intoxicated to be bailed• Placed in cell over-night

In the Lock-up.

• Placed in cell around 2330• Police checked on patient during night• Decision was to release the patient at 0600• During cell check 0440, Pt found face down

will pool of blood coming from mouth• SJA arrive 0505, pt seizing taken to hospital,

arrived 0520

At the same hospital

• Failed to respond to benzo’s and phenytoin• Intubated• Taken for CT-Head• Showed:– Large Intracerebral bleed– R & L temporal bone # T/F by RFDS>Perth for Neurosurg

At BIG Perth Hospital

• Fixed dilated pupils• Not for intervention• RIP

• We owe respect to the living;To the dead we owe nothing but truth.’

-Volatire

TBI in the EDWhat are the issues?

TBI in the EDWhat are the issues?

• Classification (Minor-moderate-severe)• Management severe TBI• Patients at risk of talking then dying• Monitoring the head injured patient in ED• D/C the Pt with a head injury• Post Concussion Syndrome• Second Impact Syndrome

TBI ClassificationEurope USA Australia

Incidence per 100 000 hospitalised patients

235 103 226

Severity (%mild,moderate,severe)

79/12/9 80/10/10 76/12/11

External Cause(%fall,MVA,violence)

37/40/7 21/25/6 49/25/9

The Patient that Talks and Dies!

Managing Severe TBI in the ED

• Avoid Hypoxia and Hypotension/?Hypertension?• Prevent ∧ICP & impaired cerebral perfusion• Reverse anticoagulation• Protect and secure airway• Rule out C-spine injuries• Monitor for further neurologic deterioration• Administer anticonvulsants• VTE, SUP, VILI prophylaxis

D/C Head Injured Patients

• Guidelines generally state 4 hours post injury• Patients in the ED should have hourly GCS, pupillary

reactions and vital signs.• Unsure were the evidence has come from for the 4

hours of monitoring in the ED has come from, maybe the same place as the 4 hour rule evidence?

• Generally if patients are alert and orientated, have a responsible adult to supervise them, and aren’t intoxicated, after a period of observation are fit for discharge.

Grades of Concussion

• Grade 1: (mild)– Transient confusion without loss of consciousness, symptoms

generally resolve within 15mins.– Most common symptoms or mental state abnormalities in the

immediate post injury period are delayed verbal or motor responses, disorientation, slurred speech, inco-ordination, memory loss and headaches, nausea, vomiting and vertigo.

• Grade 2: (moderate)– Transient confusion without loss of consciousness. Symptoms or

mental state abnormalities associated with concussion last more that 15 minutes.

• Grade 3: (Severe)– Loss of consciousness of any duration less than 30 minutes.

Post-Concussion Syndrome

• Post-concussion syndrome consists of a constellation of sometimes disabling symptoms, mainly headache, dizziness, and trouble concentrating in the days and weeks following concussion.

• The frequency and natural history of the disorder is unclear, symptoms often persist for months, are resistant to treatment but eventually will

Second Impact Syndrome

• Involves an athlete/patient suffering post-concussive symptoms following a head injury.

• If, within several weeks, the athlete/ patient sustains a second head injury, diffuse swelling, brain herniation, and death can occur.

• Emergency nurses need to be aware of this condition and counsel patients accordingly.

The Final Word

• “To thrive in emergency nursing- you must recognise what the specialty is, the provision of

nursing care to anyone and anytime – emergency has little to do with it most of the

time.”

Thank-you