List Archives

Sun Dec 17 01:18:01 GMT 2006

Navin,
Without knowing the full clinical details it can be 
difficult to make suggestions, but here goes.
You need to consider possible causes of his irritability;
Fear, pain, hpoxia, cerebral hypoperfusion from 
hypovolaemia, cerebral irritation from intracranial 
pathology, intoxication, etc,etc,
however given that you state he has a visible head injury 
you have to assume that this is the cause of his 
irritation until proven otherwise.
In order to properly assess and manage this patient you 
will need to have "control" of him.  Assemble a team of at 
least 6 people (one for each limb, one for the head and 
one to obtain IV access and give medications).  Attempt to 
constantly verbally explain and reassure the patient as to 
what is occuring although this is likely to be unhelpful 
if irritability due to head injury.  Make sure your team 
understands what they have to do and how, and then 
physically restrain the patient, obtain IV access and give 
sedation.  In nearly all head injuried patients to 
maintain adequate "control" of both patient and airway and 
to ensure adequate cerebral oxygenation whilst performing 
examination, investigation (i.e. CT head) and management 
(i.e. control of external haemorrhage, correction of 
hypotension etc) the patient will need to be intubated at 
this point.  This requires an appropriate rapid sequence 
induction technique that won't drop cerebral perfusion 
pressure or conversally, cause significant rises in ICP 
with laryngoscopy.  There will be many different opinions 
in this trauma group as to how to do this, but it will 
depend on the drugs you have available and the familiarity 
with those drugs by the staff using them and performing 
the intubation.  Last time I looked the Trauma.org website 
had a nice guide to RSI and pros and cons of various meds 
that could be considered.
Once airway is protected, depending on presence or absence 
of other injuries, he can have a CT scan of his head to 
exclude a surgically correctable cause of his 
irritability.
This is a not infrequent problem in Emergency Departments 
I work in, particularly on Friday/Saturday evenings.
Hope this is helpful,
Cheers,
Stefan

Dr Stefan Mazur
Emergency Physician/Retrieval Fellow
Adelaide
Australia

On Fri, 15 Dec 2006 13:03:57 +0000 (GMT)
  navin goyal <drnavingoyal at yahoo.co.in> wrote:
> Dear Mail Subscribers,
> 
> Had anyone  came  accross  a highly  irritable  Head 
> Injury  Patient in the trauma resuscitation room with 
>visble injury over the head . The patient does not allow 
>you to take a IV access and using IV sedative is distant 
>thing . And anything you do , you want to do as earlt as 
>possible as you see a bleeding wound in the scalp .How 
> did  you go about  this  patient.
> 
> Thank You 
> 
> Dr. Navin Goyal
> Trauma Fellow
> LTM Govt Hospital and medical College,
> Sion , Mumbai.
> INDIA.
> 
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Highly Irritable Head Injury Patient