Brain Injuries and Fatigue

Do Patients with a Head Injury have to Stay Awake?

Question

Do patients with head injury have to stay awake?

Bystanders and lay rescuers at accidents are greatly concerned with keeping patients with a head injury awake after an accident. They're worried the patient may have a concussion. The belief is that if allowed to fall asleep, the patient will die. Is it necessary to keep patients with head injury from slipping into unconsciousness?

Answer

No. Waking head injury patients every hour or so was the standard assessment tool many years ago, but treatment has changed with technology like CT and MRI scanners.

Even today, however, it's easy to see how waking head injury patients (not necessarily keeping them awake) seems to be their ticket to survival.

Glasgow Coma Scale (or Score)

One low-tech tool that we still use to assess head injury patients is called the Glasgow Coma Scale (GCS), which measures the brain's ability to function. The measurements take into account the patient's best responses to directions, touch and his surroundings. They include how the patient responds to voice and pain. In an unconscious patient, assessing the severity of a potential head injury means having to wake him up. In fact, how easy it is to wake him up is part of the Glasgow Coma Scale.

The scale is probably the worst scoring system in emergency medicine (follow along and you'll see why). The three measurements are eyes, verbal and motor.

Eyes measures what causes a patient's eyes to open. This is the "how easy is it to wake them" measurement.

A fully alert patient has her eyes open all the time. She gets four points. If you have to say something to get her to open her eyes, we say she is responsive to verbal stimulus (not to be confused with the verbal measurement--now you're beginning to see why this is a silly scoring system) and she gets three points.

Having to rub your knuckles into her sternum to get her to open her eyes means she's responsive to painful stimulus and earns two points. For doing absolutely nothing--not even opening her eyes--she gets a point. I don't know why; probably just because kids get participation trophies in soccer today.

Verbal measures how your patient responds to questions. If he answers questions appropriately and can chat, he is said to be oriented and gets five points. Not able to answer questions appropriately means he's confused or disoriented and gets four points. If he's using words, but they don't make sense, he earns three points for trying. If he's mumbling incoherently, he is awarded two points for making sound. Just lying there? A point.

Motor is the measurement of a patient's movement. If he can follow commands (blink when you ask or squeeze your hands), he is awarded six points. If he doesn't do what you tell him, you have to hurt him (a little, don't go crazy). People respond to painful stimulus in a predictable way.

Rub your knuckles into his sternum (breastbone). If he grabs your hands or pushes them away, that's five points and it's called localizing. Trying to pull away from you is called withdrawing and is worth four points. Flexor posturing (hands make fists and toes point away from the head) gets three points. Extensor posturing (fingers are straight and toes point toward the head) is two points. Remember, both types of posturing only count if they happen because you caused pain. Again, if the patient just lies there, give him a point.

The GCS is calculated by adding all three measurements together. The most a patient can get is 15 points. That's a perfect score. An unresponsive patient, to which any respectable scoring system wouldn't give any points, gets a score of 3 points. Absurd, but it is what it is. The GCS has been around for a very long time.

CT Scans

Until CT scanners became so readily available, people suspected of having sustained concussions were sent home from the ER with family members who'd been instructed to wake the patients every hour or so. If the family was unable to wake the patient, they were instructed to call 911 or bring him back to the ER.

Now that concussion patients can be scanned to rule out the possibility of a more serious brain injury, doctors no longer need to tell family members to wake the patients. Each case is different, and some doctors will still tell family members to wake patients once or twice overnight, but it's generally not needed.

In no case was keeping a head injury patient awake ever the treatment of choice. If a patient lapses into unconsciousness, there's really nothing we can do outside of a proper hospital to keep her awake. If you are unable to wake a patient suspected of having a head injury, call 911 or take her to the emergency department immediately.

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