by cavedoc55 » Sep 11, 2010 9:24 pm
Gee, Do I even weigh in?
Yeah, sure, why not....
IMHO,
There is absolutely no utility in trying to keep a patient with a traumatic brain injury awake.
If a person has suffered an injury severe enough to result in unconsciousness, efforts to keep them awake will NOT alter their course.
The fear of allowing them to sleep falls into the category of "old wives tale." The image of slapping the poor injured person and shouting "Stay with me! Stay with me!" makes great drama for TV, but in fact makes little clinical sense.
The only utility in assessing the patient's level of consciousness is to monitor their course: if a patient with a head injury is initially awake and alert and subsequently cannot be awakened, that would indicate a decline in the patient's condition. BUT, keeping the patient awake will NOT alter his course or positively affect his outcome. It will make the bystanders/rescuers feel better, but it will not help the patient at all. In fact, if the patient is sleeping/unconscious, he/she is arguably more comfortable and the brain will require less energy...hence the idea of inducing barbiturate coma in brain-injured patients to facilitate their recovery.
Furthermore, within the context of cave rescue [isn't that what we're talking about?] where rescue and time to arrival to definitive care may take hours or days, then how long are you going to keep the patient awake? I have visions of rescuers taking shifts staying awake to slap around the poor sleep deprived patient to prevent him/her from sleeping because of some fear of allowing the patient to sleep [BTW, please don't do that]. He/she has to sleep sooner or later.
I cannot count the times people have arrived in the ED with well meaning by-standers or family saying, "We wouldn't let him go to sleep!" It's all one can do to smile {inwardly} and resist blurting out something to regret later.
Bottom line: allow the poor sucker to sleep: he/she will be more comfortable and their brain will require less energy. If there will a prolonged time between injury and definitive care [like, say, in a cave rescue scenario], it makes sense toperiodically awaken the patient to assess their level of consciousness. How often? It depends. Why awaken the patient every 5 minutes to assess their LOC if you can't do anything about it?
Having said all that, I agree with the other statements made in this thread: patients with a traumatic brain injury should be evaluated by a competent physician as soon as practical. The old movie image of the hero being rendered unconscious by a blow to the head, then awakening and returning to the fight is an absolute falsehood and has caused more harm to the treatment of TBI than....Saturday morning cartoons.
These are my opinions, and mine alone, arrived at after practicing medicine for 30 years [the last 20 in Emergency Medicine] and after consultation with Neurologists and Neurosurgeons [who might know of what they speak].
Stephen Mosberg, M.D., DABFM
Every situation and individual is different and must be evaluated on its own: No treatment should be started or carried out based solely on this or any other protocol. No medication, treatment, or medical device should be administered or applied without complete training in, and a thorough understanding of, the uses, limitations and possible complications of said treatment or device. The opinions expressed herein are solely those of the author and do not represent the views, opinions, treatment protocols or standards of any other individual, group of individuals, medical group or organization, hospital, other organization, the NSS or any Section thereof or any of its other Internal Organizations.
So there!