What practices are appropriate during inpatient observation and at subsequent discharge of head injured patients not admitted to specialist neurosurgical or intensive care?

7.1 Clinical Observation and Recording

Careful, repeated observation forms a major part of the care of patients admitted to a general (i.e. non neurosurgical) ward according to the criteria described in section 6.1. The aim is to detect promptly patients who deteriorate neurologically who may need referral to a neurosurgical unit, and to confirm satisfactory recovery and to enable discharge in the majority of patients. The process of admission to a hospital ward requires good verbal and written communication and record-keeping.

Accident and Emergency medical and nursing staff should communicate details of the mechanism and type of injury and a maintain a chart of the neurological progress since arrival in A&E.

Nursing staff should carry out a neurological assessment on arrival in the ward and compare it with that obtained in A&E. Any discrepancy between these assessments, suggesting deterioration, or other concerns about the patient's condition should be discussed immediately with the relevant medical staff.

Children <3 years old who have sustained a head injury are particularly difficult to evaluate and clinicians should have a low threshold of suspicion for early consultation with a Specialist Paediatric Surgical Unit.

Children requiring admission should be admitted under the care of a paediatrician or paediatric surgeon with experience in the care of children with a head injury and should be observed in a children's ward.

The Glasgow Coma Scale (GCS) is used widely to make neurological observations, and in trained hands is a good discriminative measure of conscious level (see section 2.1). It works best as a monitoring tool if each subscale (eye opening, verbal, and best motor response) rather than a total score is used as a separate predictor. Using only one type of flexor response in the motor component improves the consistency of recording the best motor response. Despite the apparent simplicity and clarity of the GCS, it is open to misinterpretation and misapplication leading to confusion,¹²⁹ especially when only the total score is reported.¹³⁰ High levels of consistency can be achieved, if training in the use of the scale is provided and reinforced.²⁸ Evidence level III and IV

Wards for the observations of head injured patients should be suitably staffed by experienced doctors and nurses to provide the necessary close observation and prompt action if deterioration occurs. ¹¹⁹, ¹³¹, ¹³²

All medical and nursing staff involved in the care of head injured patients should be trained in the use and recording of the Glasgow Coma Scale.

Other features monitored should be pupil size and reactivity, limb movements, respiratory rate, heart rate, blood pressure and temperature.

Observations should be recorded on a chart, of a design common to Scottish hospitals, a copy of which must go with the patient throughout the different departments during the patient's hospital stay. .

An example observation recording chart is included as Annex 2.

7.2 Frequency of Observations

How often observations should be made has not been rigorously studied, but should relate to the estimated risk of clinically influential findings. The risk of rapid deterioration is higher during the first six hours and diminishes as the time since injury increases.⁵⁷, ⁹⁶, ⁹⁵, ¹³³ Evidence level III

The guideline development group recommends that the factors to be considered include:

• the history of post traumatic amnesia
• the time lapse since injury
• the pattern of previous findings in GCS
• the findings on skull x-ray or CT scan
• other risk factors, e.g. warfarin therapy.

Head injured patients, who warrant admission, should have neurological observations carried out at least in the following frequency starting after initial assessment in A&E. 1/2 hourly for 2 hours 1 hourly for 4 hours 2 hourly for 6 hours 4 hourly thereafter until fit for discharge

IIt is necessary for medical staff to know the patient's condition on admission and to review progress. Medical staff should assess the patient on admission to the ward and should re-assess the patient at least once within the next 24 hours. Assessment should include examination for the GCS, neck movement, limb power, pupil reactions, other cranial nerves and signs of basal skull fracture.

7.3 Frequency of Reappraisal

Head injured patients can develop a wide range of secondary complications, both intracranial and extracranial.¹³⁴ The occurrence of such complications may be indicated clinically either if a patient fails to improve at the expected rate or, if there is evidence of clinical worsening. In either circumstance the patient should be reappraised by a member of the medical staff in order to confirm the clinical features, to consider how they may be explained and to arrange for appropriate investigations and intervention.¹⁰¹ Evidence levels III and IV

Although neurological changes direct attention to the possibility of intracranial complication, more often the cause is an extracranial complication and the priority is to ensure that the airway is clear, oxygenation adequate, etc.¹⁷ The effects of alcohol or other drugs may be a factor in persisting impairment of consciousness¹¹⁹, ¹²² but these effects are usually short-lasting (less than four hours) and the role of estimation of alcohol level is controversial.⁹⁴ Sequelae of alcohol withdrawal can also contribute to neurological impairment. Evidence levels III and IV

Any of the following examples of neurological deterioration should prompt urgent reappraisal by a doctor: the development of agitation or abnormal behaviour a sustained decrease in conscious level of at least one point in the motor or verbal response or two points in the eye opening response of the GCS the development of severe or increasing headache or persisting vomiting new or evolving neurological symptoms or signs, such as pupil inequality or asymmetry of limb or facial movement

If reappraisal confirms a neurological deterioration, many factors need to be evaluated but the first step is to ensure the airway is clear, and that oxygenation and circulation are adequate.

Clinical signs of shock in a head injured patient should be assumed, until proven otherwise, to be due to hypovolaemia caused by associated injuries.

Whilst an intoxicating agent may confuse the clinical picture, the assumption that deterioration or failure to improve is due to drugs or alcohol must be resisted.

If systemic causes of deterioration such as hypoxia, fluid and electrolyte imbalance, or hypoglycaemia can be excluded, then resuscitation should continue, according to ATLS principles while anaesthetic help and neurosurgical advice are sought (see section 8).

7.4 Discharge after Observation

Every patient needs a discharge plan. After inpatient observation, the need for home observation is less, and asking the family to wake the patient at intervals is usually not appropriate.¹²⁵, ¹³⁵ Evidence level IV

Whenever possible, relatives should be involved in the patient's ongoing care and written advice should be given, modified from that given when a patient is discharged from A&E without admission (see section 6.2.1 and Annex 6). A careful assessment should be made of previous health and home circumstances, particularly in the elderly, who may have an associated illness or be taking medication which may have contributed to a fall, and a referral to the care for the elderly service may reduce the future risk of injury.¹²⁰ Evidence level III

Written discharge information should be given to the patient or a relative prior to leaving the ward and they should demonstrate an understanding of the information given.

Before discharge from the ward a patient with a head injury must be assessed by an experienced doctor, who must establish that all the following criteria have been met: (a) Consciousness has recovered fully and is sustained at the pre-injury state. (b) The patient is eating normally and not vomiting. (c) Neurological symptoms/signs have either resolved, or are minor and resolving or are amenable to simple advice/treatment, (e.g. headache relieved by simple analgesia, or momentary positional vertigo due to vestibular disturbance). (d) The patient is either mobile and self caring or returning to a safe environment with suitable social support. (e) The results of imaging and other investigations have been reviewed and no further investigation is required. (f) Extracranial injury has been excluded or treated.

An immediate discharge document should be sent to the patient's general practitioner, in advance of the more detailed discharge letter (see section 9).

(See the SIGN report on the immediate discharge document, which is under review in 2000.¹³⁶)