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Patient Care

Head to Head

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Attack One receives a midafternoon call for a child injured in a bicycle accident. “Oh, no, not another one,” a crew member groans. “We just had a bike accident on our last shift.”

The crew recalls the shift before. Middle of the afternoon, they arrived on a residential street to find a child lying motionless in the road. The car had been moving quickly, based on the skid marks. As they walked up, they saw heavy damage to the bike but noticed a bike helmet still in place on the child. As they arrived at the boy’s head, he opened his eyes, then moved his arms and legs and spoke some magical words:

“What happened? Can I get up?”

The child moved around, popped up to a sitting position before the EMTs could even reach for him, and looked around for his house. Concern melted away as the child asked questions and told the crew only his abrasions hurt, and he hated to see his bicycle so beaten up. The crew removed his helmet as they immobilized him, noting cracks in the side of the headgear. An equally relieved mother arrived at the scene and reported the child always wore his helmet as he cruised the quiet neighborhood. The child had several abrasions and a possible fracture of his wrist, but smiled as he was loaded into the ambulance. The police sergeant had the helmet photographed to use in future teaching.

But this is the next shift, and the Attack One crew pulls up on a quieter residential street. There are not so many bystanders, and no car sits at the far end of a set of skid marks. This child lies motionless against a curb, his bike behind him. The police officer at his head appears very concerned, and as they move toward the boy, they find no helmet.

“Someone in the apartments here called when they saw this child lose control of his bike and strike his head on the curb,” the officer reports. “I was right down the street, and he hasn’t moved since I got here.”

The child is on his right side, and the officer holds his neck in a stable position. There’s blood on the ground underneath the right side of the boy’s head, and during assessment the paramedic finds a large lump and laceration just above the right ear. No one knows who the child is, but he appears around 8 years of age. His extremities and face are not injured; it appears his head took the direct impact against the tall curb on the side of the road.

The EMTs take control of the head and neck while the paramedic does the assessment. The child is on a very warm asphalt surface, so they roll a blanket underneath him as he’s lifted onto a long backboard, maintaining spinal motion restriction. As the crew begins to apply straps and head pads, the child starts to retch. The paramedic asks everyone to take hold of the child and roll the board and child to the right side. As they do the child forcefully vomits a large amount. The Attack One crew and police officer stabilize the child throughout, and when he finishes the paramedic sweeps his mouth, then directs the rescuers to quickly strap the child to the board in a way that they can roll him again if needed.

“With that type of vomiting, this child has a severe head injury and likely has pressure building in his brain,” the medic says. “We’ll need to move him quickly to the trauma center. We can’t wait for parents.” He turns to the police officer. “Will you please advise any parents when they arrive that we’re taking the child immediately to the children’s hospital? We’ll let the hospital know we had to leave before we had a name.”

The immobilized child is rapidly placed on the stretcher, with a crew member maintaining a constant vigil for more vomiting. The stretcher is loaded into the ambulance, and the crew attempts to obtain the first set of vital signs. The boy starts to retch and vomits again. Once more the crew rolls him to the right. As he finishes vomiting he begins to tremble and then slips into a generalized seizure.

The paramedic delivers crisp orders: “Keep him rolled to the right so he doesn’t aspirate. Place an oxygen mask with 10 liters above his face but not strapped on. Get the pediatric bag-valve mask and airway kit ready for me. I’m going to give him some seizure medicine in his nose, and then we’ll intubate him. Get the intraosseous kit out and an IV setup ready, and we’ll do that last if we have time.”

All hands are working as they keep the backboard rolled, obtain the vital signs, deliver oxygen to improve saturation and assist giving a dose of IN midazolam through a device that produces a fine mist of it. Before administering it, the paramedic examines the nose and makes sure there’s no blood or other material in it, and no drainage from either ear. Within about two minutes the child stops seizing. A secondary evaluation follows, and the boy’s clothing is removed while he is kept warm. No injuries are noted except the one to his head.

“How far are we from the hospital?” the paramedic asks. “About 5–7 more minutes,” the driver reports.

The medic then addresses the crew: “He’s breathing on his own, and with his oxygen level at an acceptable point on the pulse oximeter, we’re not going to intubate right now. He’s not going to be a quick IV start, so I’m not going to try. We need to apply the end-tidal carbon dioxide monitor to make sure he’s breathing at a correct rate. Keep the board elevated a little and off to the right side. I’m calling the hospital and asking them to be prepared to manage his airway. We’ll support his breathing for the few minutes until we get there.”

The crew applies a nasal cannula to the child, which measures carbon dioxide levels through a port on the side that’s connected to their monitor device. The first readings show an EtCO2 level of 37 mmHg.

“That’s where we want him for the head injury, so we don’t need to assist ventilations,” the medic says. “Keep the oxygen flowing around his face to maintain oxygenation. We’ll try to keep his oxygen level over 95% and his carbon dioxide between 35–40 mmHg. If he vomits or seizes again, we’ll have to modify what we’re doing.”

But the remaining miles to the children’s hospital pass quickly, and the patient has no further events.

Hospital Management

The trauma team is in the ED resuscitation area, and there’s a quick transfer onto the ED cart. They keep the child’s head slightly elevated, with a 30-degree tilt to the right. The paramedic gives the report to the hospital team leaders. The staff switches the boy to the hospital monitors, and the trauma leader sets the same target values for oxygen and carbon dioxide. The nursing staff surveys for an intravenous site but can’t find one quickly, so they place an intraosseous line in the boy’s left leg.

The team finds no other wounds on the child, but assessment of the skull indicates a likely fracture in the very dangerous area just above the right ear. The emergency physician tells the team the child will need an airway in place before he can have a CT scan and will need to be started on seizure-prevention medications. The team performs a rapid-sequence intubation, using medicines to reduce the impact of the procedure on the child and the risk of further seizures. The medicines are given into the IO line, and within a minute the child has an endotracheal tube inserted. A tube is then placed from his mouth into his stomach to completely empty his stomach. Then they take him to the CT scanner.

The boy’s parents have not arrived at the hospital yet, so the Attack One crew contacts the dispatcher to see if they’ve been identified at the scene. The dispatcher reports there’s still no parental presence and neighbors aren’t sure of the child’s name. The crew advises the hospital, and the child will be treated with an alias until he can be identified.

The crew has a big cleanup to do, so they’re still present when the results of the CT scan come back. The child has a very bad brain injury and bleeding in the right side of his head, where his skull is fractured. He will go directly to the operating room.

The boy has a very difficult hospital course and is not able to communicate or care for himself when he leaves the hospital for a longer-term rehabilitation facility.

Case Discussion

The prehospital emergency care of a child with a head injury will focus on proper immobilization, maintenance of the airway, adequate oxygenation, prevention of shock and poor perfusion of the brain, and reducing the risk of complications. The injury to the brain cannot be reversed by prehospital care, but secondary injury can be prevented, and the possibility of a great outcome is enhanced by good perfusion, oxygenation and attention to the details of patient packaging.

The child in this case had two common complications of head injuries, vomiting and seizing. Many children will vomit, and that risk increases when there is rising pressure inside the skull. EMTs must be on constant alert for vomiting and quickly clear the airway and prevent aspiration of vomited gastric content into the airway and lungs. A rapid and easy method for protecting the airway from aspiration is correct immobilization of the child, then using that immobilization method to roll the child to the side. Suction alone cannot capture all the content coming up from the stomach, so a vomiting child is better protected by techniques that allow gravity to help.

The occurrence of seizures is also a common complication of severe head injury. The prevention or early control of seizures is another way to improve the ultimate outcome of a head-injured patient. The administration of intranasal midazolam, which delivers the antiepileptic medication directly to the blood and cerebrospinal fluid via the nasal mucosa, is safe and effective. There are atomization devices to administer medications quickly, particularly in pediatric patients, before an intravenous line can be established.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. He spent 32 years as a firefighter and EMT. Contact him at jaugustine@emp.com.

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