Australasian Emergency Nursing Journal (2013) 16, 127—135

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RESEARCH PAPER

Thai emergency nurses’ management of

patients with severe traumatic brain injury:
Comparison of knowledge and clinical
management with best available evidence
Jintana Damkliang, MNS (Adult Nursing), RN a,b,∗
Julie Considine, RN, PhD, FACN c,d,1
Bridie Kent, PhD, BSc (Hons), RN e,2

a
School of Nursing and Midwifery, Deakin University, Australia
b
Faculty of Nursing, Prince of Songkla University, Thailand
c
Eastern Health — Deakin University Nursing & Midwifery Research Centre, Australia
d
Centre for Quality and Patient Safety Research, Australia
e
University of Plymouth, UK

Received 11 June 2013 ; received in revised form 23 September 2013; accepted 23 September 2013

KEYWORDS Summary
Background: In Thailand, the rate of TBI-related hospitalisation is increasing, however, little is
Brain injury;
known about the evidence-based management of severe TBI in the developing world. The aim
Emergency nursing;
of this study was to explore Thai emergency nurses’ management of patients with severe TBI.
Trauma;
Methods: An exploratory descriptive mixed method design was used to conduct this two stage
Neurotrauma;
study: survey methods were used to examine emergency nurses’ knowledge regarding manage-
Evidence-based
ment of patients with severe TBI (Stage 1) and observational methods were used to examine
practice;
emergency nurses’ clinical management of patients with severe TBI (Stage 2). The study setting
Thailand
was the emergency department (ED) at a regional hospital in Southern Thailand.
Results: 34 nurses participated in Stage 1 (response rate 91.9%) and the number of correct
responses ranged from 33.3% to 95.2%. In Stage 2, a total of 160 points of measurement were
observed in 20 patients with severe TBI over 40 h. In this study there were five major areas
identified for the improvement of care of patients with severe TBI: (i) end-tidal carbon dioxide

∗ Corresponding author at: c/- School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, Victoria 3125, Australia.

Tel.: +61 3 9244 6127.

E-mail addresses: jdamklia@deakin.edu.au (J. Damkliang), julie.considine@deakin.edu.au (J. Considine), brigid.kent@plymouth.ac.uk
(B. Kent).
1 Address: c/- School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, Victoria 3125, Australia.
2 Address: School of Nursing and Midwifery, Drake Circus, Plymouth PL4 8AA, UK.

1574-6267/$ — see front matter © 2013 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.aenj.2013.09.001
128 J. Damkliang et al.

(ETCO2 ) monitoring and targets; (ii) use of analgesia and sedation; (iii) patient positioning; (iv)
frequency of nursing assessment; and (v) dose of Mannitol diuretic.
Conclusions: There is variation in Thai nurses’ knowledge and care practices for patients with
severe TBI. To increase consistency of evidence-based TBI care in the Thai context, a knowledge
translation intervention that is ecologically valid, appropriate to the Thai healthcare context and
acceptable to the multidisciplinary care team is needed.
© 2013 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

Thai government has introduced initiatives to reduce the

What is known severity and the impact of RTAs, the rate of TBI-related hos-
pitalisation is still increasing. According to the Bureau of
Increasing rates of severe TBI is a continuing challenge Policy and Strategy [BOPS] reports, the number of patients
for Thai healthcare providers, particularly for emer- with intracranial injury rose dramatically in every region of
gency department clinicians. Current evidence-based Thailand from 70,134 cases in 2007 (110 per 100,000 popula-
guidelines for the initial management of severe TBI tion) to 82,993 cases in 2010 (130 per 100,000 population).9
are predominantly from Western countries with well- The increasing number of TBIs in Thailand means that the
developed trauma care systems and facilities. management of severe TBI is a continuing challenge for Thai
healthcare providers, particularly for emergency depart-
ment (ED) clinicians providing initial care for patients with
What this paper adds
severe TBI.
Evidence-based guidelines for the initial management of
There is variation in Thai nurses’ knowledge and care severe TBI have been established in many countries. In the
practices for patients with severe TBI. Some elements US, for example, the Brain Trauma Foundation (BTF) has
of variation in clinical practice may place patients at guidelines for severe TBI both in pre-hospital and in-hospital
risk of harm. The results of this study provide a platform care.2,10 Similar guidelines have been published in Australia,
for targeted evidence-based interventions to improve the UK and New Zealand.11—14 The majority of the guide-
care of patients with severe TBI in the Thai ED setting. lines recommend immediate resuscitation of the patient
and prevention of secondary insult.2,10—14 The recommen-
dations from these guidelines are summarised through the
maintenance of airway and cervical spine protection, oxy-
Introduction genation and ventilation, circulation, and disability as shown
in Table 1.
Severe traumatic brain injury (TBI) is defined by a Glas- However, these guidelines are targeted at countries
gow Coma Scale (GCS) score of 8 or less.1,2 Severe TBI where the patients with severe TBI are managed within well-
is a major cause of death and disability worldwide. The developed trauma care systems and facilities.2,10—12,14 Little
incidence of severe TBI varies greatly in different parts is known about the evidence-based management of severe
of the world. In the United States, the annual rate of TBI in the developing world, where facilities and resources
TBI-associated deaths is estimated to be 18 per 100,000 are limited, and the incidence and management of TBI is
population.3 In Europe, the average mortality rate follow- poorly understood.
ing TBI is approximately 15 per 100,000 population.4 In
Australia, the incidence of severe TBI was 12 per 100,000 Aim
residents,5 and the mortality rate following TBI-related hos-
pitalisations was 4.6 per cent.6 In Asia, the mortality rate The aim of this study was to explore Thai emergency nurses’
per 100,000 population varies from 20 in India to 38 in management of patients with severe traumatic brain injury.
Taiwan.4 The specific research questions were:
In Thailand, there is little information available for
nationwide TBI epidemiology, except for a few isolated stud- (i) How does Thai emergency nurses’ knowledge regarding
ies in individual settings. In southern Thailand, a study of management of patients with severe traumatic brain
1000 patients with a head injury was conducted in four hos- injury compare with best available evidence?
pitals, including a university hospital and three community (ii) How does Thai emergency nurses’ clinical management
hospitals.7 Of these, 3.4% of head injured patients were of patients with severe traumatic brain injury compare
identified as suffering from a severe TBI. Road traffic acci- with best available evidence?
dents (RTAs) accounted for approximately 60% of all cases of
head injury, and most were motorcycle accidents. Helmets
used in motorcycle related head injury were reported in
Methods
13.2%.7 In 2007, a study of 28 Thai regional and tertiary hos-
pitals indicated that approximately 4852 people died from Design
RTAs, and 62,934 RTA victims were seriously injured.8 Almost
30% of RTA cases studied sustained isolated head injuries, An exploratory descriptive mixed method design was
and approximately 17% had multiple injuries. Although the used to examine Thai emergency nurses’ knowledge and
Thai emergency nurses’ management of patients 129

Table 1 Summary of evidence-based recommendations for Table 2 Summary of levels of EMS providers in Thailand.
the initial management of severe TBI.
Level of EMS Training Skills
Airway and C-spine • Early intubation provider
protection10,11,13
Advanced life Emergency nurse Advanced CPR
• Maintain cervical spine stabilisation
support (Bachelor prepared) including advanced
• Open and clear airway using Jaw
(ALS) or emergency airway management
Thrust
physician (ETT), assisted
Oxygenation and • Monitor oxygenation continuously, ventilation,
ventilation2,10,13 keep SaO2 > 90% intravenous
• Monitor ventilation using cannulation and
capnography, keep ETCO2 medication
35—40 mmHg administration
Circulation2,10,13 • Administer isotonic solution Intermediate 110 h and trained by Basic CPR including
• Monitor blood pressure, keep life support National Institute applied
SBP > 90 mmHg (ILS) for Emergency oropharyngeal
Medicine airway, bag-valve
Disability2,10—14 • The GCS should be measured prior mask ventilation,
to administering sedatives or chest compression,
paralytic agents, or after these drugs intravenous
have been metabolised cannulation and
• Pupils should be measured after the medication
patient has been resuscitated and administration
stabilised Basic life 3—5 days and Basic CPR including
• Administer a small dose of support trained by applied
sedatives and analgesics (BLS) provincial oropharyngeal
• Keep head and neck in neutral emergency medical airway, bag-valve
alignment services unit mask ventilation,
• Keep head of bed at 30◦ (unless chest compression
contraindicated) First 1—2 days and First aid including
• Ensure using appropriate size of responder trained by bleeding control,
cervical collar (FR) provincial splinting, and
• Splinting of limb fractures emergency medical transferring
• Urinary catheterisation services unit
• Early computerised tomography
(CT) brain imaging

and initial emergency department care is provided. There

are 4 levels of EMS provider training and skills in Thailand15
management of patients with severe TBI. This study was
and these levels are presented in Table 2.
conducted in two stages. In Stage 1, survey methods were
The ED at the study site uses a three category triage
used to examine emergency nurses’ knowledge regarding
scale; emergent, urgent, and non-urgent. The majority of
management of patients with severe TBI. In Stage 2, obser-
adult patients with severe TBI are triaged as ‘emergent’
vational methods were used to examine emergency nurses’
and received into one of two adult resuscitation bays. The
clinical management of patients with severe TBI.
adult resuscitation bays have capacity to continuously mon-
itor oxygen saturation, cardiac rhythm, heart rate, and
Setting blood pressure (non-invasive). Each resuscitation bay has
one ParaPac® transport ventilator. One end-tidal carbon
The study was conducted in the ED at a regional hospital dioxide (ETCO2 ) monitor is available for the whole ED. Within
in Southern Thailand. The ED manages over 54,000 atten- the ED, there is also a paediatric resuscitation bay, three
dances per year; of these approximately 300 patients (ED general monitored cubicles, and nine unmonitored obser-
statistics 2012, unpublished) have severe TBI defined as GCS vation bays. Most patients with severe TBI are transferred
of 8 or less.1,2 Although there are guidelines for severe TBI from ED to CT and then to the intensive care unit (ICU) or
management, as discussed, they are mostly derived from trauma ward. Occasionally, patients are transferred from ED
countries with well-developed trauma systems and although to CT and then back to ED before going to operating room or
available in Thai ED settings, there was no evidence of guide- ICU but this is not the normal practice. The average length
line use at the study site at the time of this study. In addition, of ED stay at the study site for patients with severe TBI is
most recommendations in the guidelines used in Thailand approximately 2 h.
focus on physician care and there are no specific nurs- Usual staffing is nine nurses and four Emergency Physi-
ing management recommendations for patients with severe cians on both morning and evening shift, and seven nurses
TBI. In order to describe the context of emergency care in and three Emergency Physicians overnight. All ED nurses
Thailand, a summary of emergency medical services (EMS) working in the study site are Registered Nurses who have
130 J. Damkliang et al.

undertaken a four year Bachelor of Nursing degree. Nurses (2) Airway management and c-spine protection: use of
working in the ED have also undertaken an additional four jaw thrust or airway adjuncts, nursing management
months of postgraduate education specifically related to during endotracheal intubation (manual in-line sta-
emergency nursing. On any given shift in the ED, there are bilisation, medication administration), confirmation of
usually one to two postgraduate prepared nurses and six to correct endotracheal tube (ETT) placement, appropri-
eight Registered Nurses. ately sized and applied cervical collar.
(3) Oxygenation and ventilation: oxygen saturation moni-
Participants toring, ETCO2 monitoring, respiratory rate monitoring.
(4) Circulation and fluid balance: use of intravenous fluids,
All 37 emergency nurses (both Registered Nurses and post- heart rate and ECG monitoring, blood pressure monitor-
graduate prepared nurses) were invited to participate in the ing.
study through a face-to-face invitation at nursing staff meet- (5) Disability: nursing assessment of GCS score and pupil
ings. In Stage 1, emergency nurses were asked to complete size and reactivity.
the knowledge questionnaire. In Stage 2, the emergency (6) Disability: maintenance of cerebral venous outflow
nurse who was caring for the patient with severe TBI was through positioning; maintaining head in neutral align-
asked allow nonparticipant observation of patient care, and ment and elevating head of bed 30 degrees.
verbal consent was obtained before commencing the obser- (7) Management of pain, agitation, and irritability: use of
vation. Participation in Stage 1 and Stage 2 was voluntary. sedation, splinting of fractures, urinary catheterisation,
use of analgesics, monitoring for signs of agitation.
(8) CT scan and ED discharge: results, patient’s condi-
Tool development tion immediately before transfer, personnel involved in
transfer.
Stage 1
In Stage 1, a questionnaire was used to test nurses’
The observation tool was developed based on the lit-
knowledge regarding management of severe TBI. In the
erature review and related to the key elements of the
absence of pre-existing published tools, the questionnaire
management of patients with severe TBI. The tool was pilot
was developed by the researchers specifically for this study.
tested prior to being used in the study. All observation data
The questionnaire enabled collection of demographic data
were collected by a single researcher (JD).
(nurses’ age, highest level of nursing education, years of ED
experience, specific training in trauma care) and required
nurses to complete 21 multiple choice questions (MCQs). Data collection
The MCQs were developed based on a literature review
related to current research evidence for emergency nurs- Stage 1
ing management of a patient with severe TBI. The key A paper based survey was distributed to emergency nurses
areas examined by the MCQs were: airway management at regular staff meetings. Some nurses completed the sur-
and cervical spine protection (Q1—4), ventilation manage- vey at the meeting and others returned the survey to the
ment (Q5—9), circulation management (Q10—11), patient researcher via a drop box or directly. The survey took
reassessment (Q12), positioning (Q13), intracranial pres- approximately 15 min to complete. For the nurses who took
sure monitoring (Q14—15), Mannitol management (Q16—18), the survey away, the researcher made it clear that they were
management of pain and irritability (Q19—20) and diagnostic not to use text books or other resources to assist with the
imaging (Q21). One point was given for each correct answer, MCQs.
resulting in a total possible score of 21.
Content and face validity was established by expert panel
Stage 2
review. Three specialists in ED medicine, a neurosurgeon, an
The data were collected using nonparticipant observation
Advanced Trauma Life Support (ATLS) certified anaesthetist,
where the researcher observed the situation without inten-
and an ED physician, evaluated the items for relevance
tionally influencing the activities and behaviours under
and accuracy. The alpha coefficient was employed as the
a study.17 The observation commenced when the patient
index of content validity, using a 4-point rating scale, from
arrived in ED and continued through phases of resuscitation,
non-relevant (1point) to very relevant (4 point).13 The over-
observation/monitoring, and treatment until the patients
all alpha coefficient was 0.97, indicating higher agreement
were transferred to other departments. Each observation
between the experts.
ranged from 35 min to 3 h and 15 min depending on patients’
condition and ED length of stay. Observation took place over
Stage 2 a seven week period and over various times of the day and
A structured observation tool developed by the researchers days of the week.
was used in Stage 2 of the study to examine eight major
areas clinical management of patients with severe TBI:
Ethical considerations
(1) Demographics and injury severity: patient age and gen-
der, source of referral to ED, details of extra-cranial The study was approved by the Human Research and Ethics
injuries, injury severity score (ISS) (ISS more than 15 Committee (HREC) at Deakin University and the Research
indicates major trauma),16 ED length of stay and ED Committee at the study site. All nurses gave written
discharge destination. informed consent. Patient consent was waived by HREC.
Thai emergency nurses’ management of patients 131

Table 3 Results of knowledge scoring by 21 items (n = 34).

Areas of knowledge Participants selecting the correct response

n %

Airway management and cervical spine protection

Q1: securing the airway with ETT 33 97.1
Q2: performing a jaw-thrust to open airway 27 79.4
Q3: use of auscultation and capnography to confirm ETT placement 30 88.2
Q4: apply an appropriate size and proper application of a cervical collar 21 61.8
after intubation
Ventilation management
Q5: target SpO2 /PaO2 31 91.2
Q6: target end-tidal CO2 (ETCO2 ) 9 26.5
Q7: target ETCO2 if hyperventilated is used as a temporising measure for 17 50.0
cerebral herniation
Q8: results of hypocarbia in severe TBI 18 52.9
Q9: results of hypercarbia in severe TBI 20 58.8
Circulation management
Q10: appropriate solution for resuscitation 32 94.1
Q11: target of blood pressure 27 79.4
Patient reassessment
Q12: reassessment with airway, breathing, and circulation 25 73.5
Positioning
Q13: maintain head and neck in neutral position 24 70.6
Intracranial pressure monitoring
Q14: action if the patient developed a fixed and dilated pupil (s) 24 70.6
Q15: signs of IICP in brain stem 18 52.9
Mannitol management
Q16: standard dose of Manitol 16 47.1
Q17: condition that should be avoided during administration of Mannitol 29 85.3
Q18: purpose of Mannitol 33 97.1
Management of pain and irritability
Q19: nursing interventions that would be appropriate in preventing 15 44.1
complications following a severe TBI
Q20: use of sedatives and analgesics in a severe TBI 9 26.5
Diagnostic imaging
Q21: purpose of CT brain imaging 33 97.1

Data analysis 32.4% of participants (n = 11) had undertaken specific train-

ing in trauma care.
Study data were analysed using IBM SPSS 21.0. Descriptive The number of correct responses ranged from 33.3% to
statistics were used to summarise the study findings. When 95.2% (Mdn = 71.4%, IQR = 57.1—80.9%). The areas with the
study data were not normally distributed, medians (Mdn) highest number of correct responses were related to secur-
and interquartile ranges (IQR) are presented. In Stage 1 of ing the airway with endotracheal intubation, purpose of
the study, absent responses were coded as incorrect and Mannitol, and purpose of CT brain imaging. For each of
scored as zero. these questions, 97.1% (33/34) participants had the cor-
rect response. The areas with the lowest number of correct
responses were related to target end-tidal carbon dioxide
Results (ETCO2) levels (26.5%, n = 9), use of sedatives and anal-
gesics in a patient with severe TBI (26.5%, n = 9), and nursing
Stage 1 interventions that would be appropriate in preventing com-
plications following a severe TBI (44.1%, n = 15) (Table 3).
Of the 37 nurses approached to participate in Stage 1 of the
study, 34 nurses returned surveys giving a response rate of
91.9%. The median age of study participants was 32 years Stage 2
(IQR = 26—36) and 73.5% were female. The majority of par-
ticipants were Bachelor prepared (88.2%, n = 30) and 11.8% A total of 160 points of measurement were observed in 20
held Master’s degrees (n = 4). Participants had a median of patients with severe TBI over 40 h. Of the 20 patients with a
4 years of emergency nursing experience (IQR = 1—8) and severe TBI observed, 18 were males and 2 were females. All
132 J. Damkliang et al.

Table 4 Nursing management of patients with severe TBI (n = 20).

Observational areas Yes No N/A

n (%) n (%)

Airway management
• Jaw thrust 7 (100%) 0 13
• Oropharyngeal airway 20 (100%) 0 0
• Prepare capnography 0 20 (100%)
• Confirm ETT placement — auscultation 20 (100%) 0 0
• Confirm ETT placement — ETCO2 0 20 (100%) 0
Cervical spine protection
• Manual in-line stabilisation during intubation 7 (100%) 0 13
• Appropriate size cervical collar 19 (95%) 1 (5%) 0
• Cervical collar correctly fitted 17 (85%) 3 (15%) 0
Oxygenation and ventilation
• Continuous SpO2 monitoring 20 (100%) 0 0
• Continuous ETCO2 monitoring 0 20 (100%) 0
• Regular observation of respiratory rate 5 (25%) 15 (75%) 0
Circulation and fluid balance
• Continuous heart rate monitoring 9 (45%) 11 (55%) 0
• Continuous ECG monitoring 9 (45%) 11 (55%) 0
• Blood pressure monitoring at least every 15 min 11 (55%) 9 (45%) 0
Disability
• Nursing assessment of GCS and pupil size 20 (100%) 0 0
• Maintain head in neutral alignment 17 (85%) 3 (15%) 0
• Head of bed elevated 30 degrees 1 (6.3%) 15 (93.7%) 4
• Administration of sedation prior to intubation 5 (100%) 0 15
• Limb fractures splinted 0 1 (100%) 19
• Urinary catheterisation 20 (100%) 0 0
• Analgesics administered 0 20 (100%) 0
• Observation for signs of agitation/coughing 8 (88.9%) 1 (11.1%) 11

patients had been involved in motorcycle accidents. Most cases, the nursing response to hypoxaemia included repor-
were referred from a smaller community hospital (n = 15) ting to the Emergency Physician (n = 3), checking placement
approximately 15—100 kilometres from the study site and of the pulse oximeter probe (n = 3), checking ETT cuff (n = 1),
transferred by ambulance but five patients were brought and ETT suction (n = 3). The frequency of respiratory rate
directly from the accident site to the ED. The GCS on ED monitoring was variable and ranged from 5 min to 30 min:
arrival ranged from 3 to 8: the median GCS was 5 and 30% of respiratory rates were recorded as ‘ET’ in 60% of patients
patients had GCS of 3. The median injury severity score was (n = 12) indicating that the patient was intubated with an
32 (IQR = 26—39). An ISS score more than 15 indicates major ETT in situ.
trauma.16 Intravenous normal saline (0.9%) was administered to all
The application of jaw thrust was observed in 100% patients however two patients received packed red cells
of patients however hyperextension of patient’s head was and 25% received colloid solution (Voluven® ). The median
observed in three patients. Five patients were intubated volume of intravenous fluids administered during ED care
in the ED and fifteen patients were already intubated at was 900 mls (IQR = 525—3675). Continuous monitoring of
the transferring community hospital, however, two of these pulse rate occurred in all patients however only 45% of
patients needed re-intubation in the ED. A cervical col- patients had continuous ECG monitoring. All patients had
lar was applied in all patients, however there were three non-invasive blood pressure monitoring however the fre-
patients in whom the cervical collar was not properly applied quency of blood pressure monitoring ranged from 5 min to
(collar too small, loose application, and collar applied back- 2 h. Five patients had observed episodes of hypotension (sys-
to-front). The most common method of confirming ETT tolic blood pressure < 90 mmHg). The nursing responses in
placement was chest auscultation and ETCO2 was not used all five patients included insertion of large bore cannulae,
to confirm ETT placement in any patients. IV fluid administration, reporting to the ED physician, and
SpO2 was continuously monitored in all patients but no keeping head of bed in flat position.
patient had continuous ETCO2 monitoring. The median SpO2 The GCS and pupil size were assessed every 5—10 min to
was 99% (IQR = 96—100) however SpO2 values ranged from 0% every 2 h. Abnormality of GCS and pupil size and reactiv-
(in patients who had cardiac arrest on ED arrival) to 100%. ity was found in all 20 patients. As discussed previously, the
There were three patients who had an observed episode median GCS was 5 and 30% of patients had GCS of 3. Bilat-
of hypoxaemia defined as SpO2 less than 90%. In these eral fixed dilated pupils were presented in 30% of patients
Thai emergency nurses’ management of patients 133

(n = 6), and 20% of patients (n = 4) had unilateral dilated stimulus that can increase intracranial pressure.11 Increased
pupils. Patients’ head and neck were maintained in neutral intracranial pressure decreases cerebral perfusion pressure
alignment in 17 cases, using an appropriate sized cervical and places the patient at risk of secondary brain injury.18
collar. Only one patient had the head of bed elevated to 30 Adequate analgesia is critical in the prevention of elevated
degrees, and rest of patients were in the supine position for intracranial pressure in patients with severe TBI, so titrated
the whole ED episode of care. Four patients were given seda- intravenous opioids are recommended for patients with
tives (Diazepam 10 mg) before intubation, six patients were severe TBI.11,21 Possible barriers to adequate pain manage-
given sedatives for agitation, and only one patient received ment in the ED could be staff attitudes, knowledge deficits,
Profofol® before intubation and when agitated. There was and misconceptions about the need of effective pain man-
one patient observed to have a wrist fracture that was not agement in patient with severe TBI, particularly when they
splinted. Urinary catheterisation occurred in all patients. are intubated so cannot verbalise pain. Some nurses may
No patient received analgesics during care in the ED. ED believe that giving any analgesics to patients with severe
management is summarised in Table 4. TBI may eliminate the ability to perform neurological assess-
The median ED length of stay was 95 min (IQR = 60—140). ment and this misconception requires further investigation.
Two patients died in the ED; they both had open skull frac- A major barrier to effective pain relief for patients with
tures with exposed brain tissue (ISS were 53 and 40). Twelve severe TBI is that in the Thai context, nurses cannot give
patients were transferred from ED to the trauma ward, five analgesics without prescription from the physician, which is
patients were transferred from ED to the operating room, the case in most countries. However, advocacy is an impor-
and only one patient was transferred to ICU. tant part element of the ED nursing role, and in patients with
severe TBI, this is important given that they cannot commu-
nicate their pain status and untreated pain can cause further
Discussion increases in intracranial pressure. There is an urgent need
for further education and agreement from the multidisci-
In this study there were five major areas identified for plinary team regarding analgesic administration in patients
the improvement of care of patients with severe TBI. with severe TBI.
First, end-tidal carbon dioxide (ETCO2 ) was not observed Third, only one patient was observed to have the head
to be used in any patient and multiple choice questions of bed elevated to 30 degrees and nurses’ responses to mul-
regarding ETCO2 monitoring were poorly answered. It is tiple choice questions regarding patients positioning were
clearly recommended that all patients with ETT intuba- variable. Appropriate patient positioning is a basic nursing
tion should have ETCO2 monitoring10 to ensure correct tube responsibility and for patients with severe TBI, elevation
placement and to monitor ETCO2 levels. Capnography is an of the head of the bed to 30 degrees is recommended
important element of care for patients with severe trau- to decrease intracranial pressure by facilitating cerebral
matic brain injury10 as patients should be maintained in venous outflow.18,19,23 For every 10 degrees of head eleva-
a state of normocapnia (ETCO2 < 35—40 mmHg). Hyperven- tion, it is reported that the mean intracranial pressure drops
tilation (ETCO2 < 35 mmHg) should be avoided10 as it may by 1 mmHg.23 It is therefore recommended that patients
cause vasoconstriction leading to cerebral ischaemia.18—20 with severe TBI should be nursed in an approximately 30
Detection of the development of hypercapnia is also impor- degrees head-up position, if other injuries allow.18,19,23 Pos-
tant as hypercapnia is known to cause cerebral vasodilation, sible explanations for this finding may be that nurses did
increase intracranial pressure, decrease cerebral perfusion not know the importance of elevation of the head of the
pressure and place the patient at risk of secondary brain bed to 30 degrees in patients with severe TBI. Also, it was
injury.18,21,22 One possible explanation for this finding was observed that some patients arrived in the ED on a spinal
that there was only one capnography monitor for the whole board and the board was not removed until the patient
ED (that has three resuscitation bays) so equipment avail- was transferred to other departments. Not only does pro-
ability is an issue. Further, the capnograph was stored in longed time on a spinal board increase the risk of pressure
a corner of the resuscitation room rather than at the bed injury,24 it also made it impossible to elevate head of bed
side, further limiting immediate availably. Anecdotal evi- to 30 degrees. Another explanation for nurses not elevating
dence suggests that nurses knew capnography was available the head of the bed was the presence of hypotension. In
but they did not know how to use the equipment in terms this study, five patients had observed episodes of hypoten-
of how to connect it to the endotracheal tube and/or how sion (systolic blood pressure less than 90 mmHg), so keeping
to interpret the ETCO2 value. In addition, nurses may have the head of bed in a flat position was reasonable in these
limited knowledge of the importance of ETCO2 monitoring patients.
and using ETCO2 values to guide management of patients Fourth, it was observed that the frequency of nursing
with severe TBI. assessment of vital signs and neurological status was vari-
Second, it was observed that no patient with severe TBI able. The frequency of respiratory rate monitoring ranged
received any analgesics during care in the ED and multiple from 5 min to 30 min which suggest frequent measurement of
choice questions regarding use of analgesics and sedatives respiratory rate, however, respiratory rates were recorded
in severe TBI were poorly answered. This finding is particu- as ‘ET’ in 60% of patients so it is impossible to know the
larly concerning given that 13 patients studied had multiple patient’s adequacy of ventilation. Adequacy of ventilation
injuries in addition to their severe TBI and therefore could is important information in patients with severe TBI as
be expected to have significant pain. As recommended in hypoventilation causes hypercapnia that increases cerebral
the NICE guidelines, pain in the patients with severe TBI vasodilation and intracranial pressure.18—20 The frequency
should be managed effectively because pain is a noxious of blood pressure monitoring ranged from 5 min to 2 h as did
134 J. Damkliang et al.

assessment of GCS and pupil size. Intervals of 2 h between TBI in the Thai ED setting. In order to implement this
assessment of blood pressure is concerning given the direct evidence-base in the Thai context, education and a knowl-
relationship between blood pressure, intracranial pressure edge translation intervention that is ecologically valid,
and cerebral perfusion pressure20,21 and the importance of appropriate to the Thai healthcare context (particularly ED
early detection and treatment of hypotension in preventing resources) and acceptable to the multidisciplinary care team
secondary brain injury.20 A number of guidelines for care will be major considerations.
of patients with head injury2,11 recommend assessment of
vital signs, GCS and pupils half-hourly. There are a number
of possible explanations for the variability in time between Provenance and conflict of interest
nursing assessments. Staffing is challenging at the study site
with only nine nurses for fifteen care areas including three Professor Julie Considine is a Deputy Editor of Australian
resuscitation bays so nurses are always balancing compet- Emergency Nursing Journal but has not been involved in the
ing priorities and one to one nursing care of patients with review process for this paper. This paper was not commis-
severe TBI is not always possible. Almost 80% of nurses were sioned.
correct in the response to the knowledge questionnaire item
related to target blood pressure but their knowledge related
to regular assessment and the importance of limiting blood Funding
pressure fluctuations requires further investigation. Percep-
tions of injury severity and ED length of stay may also be This study is an unfunded PhD study. Ms Damkliang is sup-
factors in decisions related to frequency of nursing assess- ported by a scholarship from Faculty of Nursing, Prince of
ment. For example, there were three patients observed who Songkla University, Thailand.
were transferred from community hospitals with stable vital
signs, had no sign of agitation: these patients were assessed
twice, on ED arrival and before transferred to other depart-
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