When a patient who has experienced a brain injury arrives in the ER (Emergency Room), staff will want to quickly find out how serious the injury is and start the treatments necessary to prevent further injury. As the treatments are started, the doctors and nurses will be asking lots of questions. If the patient was in an automobile accident they will want to learn all they can about the accident. How fast was the car going? Were they thrown from the car? Were they wearing a seat belt? Did their head hit the windshield? Answers to these questions help the doctors and nurses predict what kinds of injury the patient has. These answers also help them to predict how serious the brain injury is.
Often by the time the patient reaches the ER, they may be unresponsive, may appear to be in a coma, or deep sleep. They may be confused. If they are like that in the ER, the staff will want to know how they were right after the accident. Did the patient lose consciousness; if so, for how long? The staff will also ask if the patient has had a history of seizures. Had the patient been drinking or taking any drugs, especially mind altering drugs, such as cocaine and marijuana. Even though it may be embarrassing to have these questions asked, the staff needs to know in order to provide the best care for the patient.
Shortly after the patient arrives in the ER he/she will be taken away to an examining room. All family and friends will be asked to wait in the waiting room. They will not see the patient again until all the doctors have finished their exams and treatments, the patient will never be left alone. During this time the nurses and doctors will be monitoring the patient very closely.
Neurosurgeons will examine the patient to determine the extent of the brain injury; trauma surgeons will examine the patient for additional injuries; and internal medicine doctors, ophthalmologists (eye doctors), or neurologists, may be called in to examine the patient. Lots of tests will be ordered. The patient will have one or two IVs started. The patient will have blood tests and x-rays, and will be taken for CT scans and MRIs. CT Scans (sometimes call "CAT scans") are tests similar to x-rays, which are done to see if there is any swelling or bleeding of the brain. A similar type of test is called MRI. Both the CT scan and MRI can be very useful and may be done several times while the patient is in the ICU (Intensive Care Unit). The machines that perform the CT scans and the MRIs may not be located in the ER or ICU so the patient may need to be transported in their bed to the place where these tests are done. Nursing and other staff will take the patient to these tests and stay while the tests are being performed.
The ER or ICU staff will keep family and friends informed about the patient's condition and where the patient is going. Doctors may be asking for family consent for some procedures. During the time all these tests are being done, the doctors will be treating the patient.
The test results may indicate the patient needs surgery in which case the patient will be taken directly to the operating room. If the patient doesn't need surgery, the doctors will keep treating him/her. These treatments may occur in the ER or after the patient has been transferred to the ICU depending on how critically ill the patient is. If the patient is stable, he may be transferred up to the ICU. If the doctors feel the patient needs treatment before being moved, then the treatments will occur in the ER.
After a brain injury, there may be swelling of brain tissue. The pressure of the brain and fluid inside the skull may rise. The blood circulation to the brain may decrease. All three of these problems will be treated to try to prevent further brain damage. A small tube, called an intra-ventricular catheter (also called an intracerebral pressure or "ICP" catheter) may need to be surgically placed through the skull into the brain to monitor the pressure inside the skull and drain excess cerebral spinal fluid. The ICP catheter is connected to a transducer, a device that transmits signals to a monitor above the bed. This allows the doctors and nurses to tell what the pressure is inside the head. The transducer is often taped to a rolled up towel or washcloth and placed to the patient's head. The ICP catheter is also connected to a drainage bag. This bag is hung on an IV pole at the head of the bed. Surgery may be done to remove a blood clot, or even a part of the brain tissue, to reduce swelling.
If the pressure inside the skull remains too high, medications may be given into the vein, through an IV, to treat the swelling of brain tissue and speed up the drainage of cerebral spinal fluid.
The brain controls and coordinates all of the body functions. A severe brain injury often affects the ability of the body to function. Often a patient will need to breathe. An ET (endotracheal) tube may be put through the nose or mouth into the lungs and hooked up to a ventilator, a machine that assists breathing.
If the ventilator is needed for more than two weeks, a tracheostomy may be performed. A small cut is made in the windpipe, or trachea, directly above the "Adam's Apple." A tube called a "trach" is placed in the opening. The ventilator is then hooked up to the trach, similar to the ET tube. Usually a patient on a ventilator will have wrist restraints to prevent him from pulling out the ET tube. Extra fluids and medications may be needed to regulate the amount of water, salt and potassium in the body. Blood pressure, if too high or too low, may also need to be regulated with medications. An IV inserted into the upper chest (called a Swan Ganz catheter) will be monitoring how effective the heart is beating and the amount of fluid in the body. Blood pressure is monitored by another catheter placed in an artery (called an Arterial Line or A Line), usually placed in the wrist or foot.
The arterial line is used so that the doctors and nurses can tell what the blood pressure is at all times. It is likely the patient will be hooked up to a heart monitor, and will have EKG electrodes taped to the chest to monitor the heart rate rhythm. The patient may need medications to keep the heart beating normally. The patient usually is not alert enough to eat, and so he may be getting nutrients through a feeding tube.
Other IVs may also be run through pumps, so there may be several around the bed. Since the stomach may produce too much gastric juice, there may be a tube that goes into the stomach called a nasogastric, or NG, tube. This tube may be hooked up to a suction bottle to remove these gastric juices.
From the Brain Injury Association of Kentucky. Reprinted with permission. Third-party publishing restricted. www.biak.us.