After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?
A. Give him a barbiturate.
B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
D. Elevate the head of his bed.
Correct Answer: C. Perform a lumbar puncture.
The client’s history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn’t be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. A head computed tomogram (CT) should be obtained before performing a lumbar puncture if there is a concern for increased intracranial pressure. Signs and symptoms of possible increased intracranial pressure include altered mental status, focal neurological deficits, new-onset seizure, papilledema, immunocompromised state, malignancy, history of focal CNS disease (stroke, focal infection, tumor), concern for mass CNS lesion and age greater than 60 years old.
Option A: After a head injury, barbiturates may be given to prevent seizures. Phenobarbital has extensive use as an antiepileptic drug in the neonatal and pediatric population. It is the most cost-effective drug treatment for epilepsy in adults in low resource countries. Intravenous barbiturates have been used for neurosurgery due to the reduction in cerebral metabolic rate of oxygen consumption.
Option B: Mechanical ventilation may be required if breathing deteriorates. The clinical presentation of increased intracranial pressure can easily be mistaken for other issues, such as intoxication, stroke, infection, or postictal state. It requires a high index of suspicion, particularly in milder cases. In more severe cases, close neurological monitoring and consultation with neurology and neurosurgery are important.
Option D: Elevating the head of the bed may be used to reduce ICP. Elevate the head of the bed to greater than 30 degrees. Keep the neck midline to facilitate venous drainage from the head. Nursing care must pay close attention to changes in neurologic status, any change in vitals such as an increasingly erratic heart rate, development of bradycardia, accurate and equal intake and output when having diuresis, and maintenance of proper blood pressure.
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