Traumatic brain injuries: Continuing dilemmas in the pre-hospital care arena

An emergency call was received by Ambulance Control in response to an adult female following a suspected, although unwitnessed fall from a horse. The rider was found by fellow equestrians crawling around a field in an agitated and confused state, with little available information regarding the events proceeding the suspected fall. From the limited history available, it appeared more likely than not, that the patient had suffered a cerebral insult either prior to, or during a fall from her horse. On arrival of the pre-hospital helicopter emergency medical services (HEMS) team consisting of two critical care paramedics (CCP) and a HEMS doctor; the patient was found agitated, combative, mumbling incoherently and unable to comprehend simple commands from the medical team.

Immediate manual inline immobilisation was initiated to prevent further secondary injuries from a possible undiagnosed c-spine fracture, while a primary survey was undertaken. This survey provides a rapid basic clinical assessment to ascertain immediate threats to life, but proved extremely difficult to undertake due to the agitated behaviour displayed by the patient. The primary survey revealed that there was no catastrophic haemorrhage; the patient maintained a patent airway; was tachypnoeic, and appeared well perfused; with a palpable radial pulse. Although, a significantly impaired level of consciousness was observed, which immediately raised suspicions of a potential moderate to severe traumatic brain injury (TBI). However, with no significant damage to the rider’s helmet and in the absence of any visible external injuries to the face, head or scalp to indicate a TBI, the extent of agitation at this stage appeared inconsistent. This inconsistency prompted the medical team to consider other potential diagnoses for the patient’s behaviour, such as a primary cerebral event associated with pre-existing cerebral pathology, hypoxic brain injury, hypoglycaemia, alcohol consumption and/ or drug abuse.