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Clinical practice guidelines. Nursing interventions in adult care with severe head injury


How to cite this article:
López-Morales AB, Calderón-Dimas C, Rodríguez-Benítez G, López-Castillo R, García-Sandoval A. Guía de práctica clínica. Intervenciones de enfermería en la atención del adulto con traumatismo craneoencefálico grave. Rev Enferm Inst Mex Seguro Soc. 2015;23(1):43-49.

Clinical practice guidelines. Nursing interventions in adult care with severe head injury

Ana Belém López-Morales,1 Cristóbal Calderón-Dimas,2 Gabriela Rodríguez-Benítez,3 Rocío López-Castillo,3 Amalia García-Sandoval4

1Coordinación Técnica de Excelencia Clínica, Coordinación de Unidades Médicas de Alta Especialidad, Distrito Federal.

2Dirección de Enfermería, Hospital de Traumatología y Ortopedia 21, Monterrey, Nuevo León.

3Dirección de Enfermería, Hospital de Traumatología y Ortopedia Lomas Verdes, Estado de México.

4Servicio de Urgencias, Hospital de Traumatología “Dr. Victorio de la Fuente Narváez”, Distrito Federal.

Instituto Mexicano del Seguro Social, México.

Correspondence: Ana Belem López-Morales

Email: ana.lopezm@imss.gob.mx

Received: January 30th 2013

Judged: December 12th 2013

Accepted: November 17th 2014


Introduction: At first world countries head injury is one of the main dead causes between 15-24 years; after this age incidence reaches between 60-65 years, Head injury can potentially disrupt the life of the individual, their family, society and the health care system.

Objective: To provide recommendations based on the best available evidence with the intention of standardizing actions in the care of the adult with a severe head injury.

Methodology: Clinical questions were formulated. A sequence that is standardized for the pursuit of clinical practice guidelines in English or Spanish language, starting from the key words: severe traumatic, brain injury, nursing, complications and interventions were established. In addition, Data bases as: Cochrane Library Plus, AHRQ, SING, GIB and Fisterra were consulted. The majority of the recommendations were taken from selected clinical guidelines. The information is expressed in levels of evidence (E) and grade of recommendation (R), in accordance with the characteristics of the design and type of study of the publications.

Conclusions: It is possible to give timely and efficient specialized nursing care to patients with severe head injury. Neurointensive care nursing staff has an important role in the maintenance of cerebral self-regulation.

Keywords: Aged; Craniocerebral trauma; Nursing services.


Head trauma is a common pathology in industrialized countries and is one of the leading causes of death among people aged 15 to 24; after this age, the incidence decreases, only to rise again between ages 60 and 65. The highest incidence occurs in males, and the most common cause is automotive accident.1

Severe head injury threatens life and causes considerable physical and psychological disorders, and moreover could potentially alter or limit the individual's life completely; this disorder affects the patient, their family, society, and the healthcare system by its serious consequences and costs of acute and long-term care.

Historically, the management of severe head injury has gone through several stages, one of which was conventional neurosurgical operation, in which patients were treated outside the intensive care units, without using any neurological monitoring technique.

Since the seventies, these patients have been cared for in intensive care units; at this same moment the clinical practice of intracranial pressure monitoring was introduced, and, later, other monitoring and evaluation techniques.2 Nurses in intensive neurological areas play a key role in maintaining cerebral autoregulation, since they continuously provide care and report changes that may occur in a patient in critical condition.  

This leads to the development of a clinical practice guideline based on the best evidence, to standardize and provide nurses with solid rules that support the daily practice of nursing care in the management of patients with severe head injury, as well as serving as a basis for decision-making.

This guide is aimed at heads of nursing, intensive care nurses, general nurses, nursing assistants, health personnel in training, and service interns attending to women and men over age 16 diagnosed with severe head trauma, regardless of mechanism injury, admitted to the emergency unit, intensive care unit, or neurosurgical service.

The clinical questions that it sought to answer were:

  • What are the nursing interventions performed in the initial management of adult patients with severe head injury?
  • What are the nursing interventions necessary to improve brain tissue perfusion in adult patients with severe head injury?
  • What are the nursing interventions necessary to maintain intracranial adaptive capacity in adult patients with severe head injury?
  • What is the participation of nursing in the care of patients with sedation?
  • What are the nursing interventions to prevent complications secondary to severe head injury?

To develop the guide, questions were formulated structured with the acronym PICO (patient or population, intervention, comparison, and outcomes), aimed at identifying nursing interventions, as well as diagnostic labels indicated in the nursing care plan. A standardized sequence was established to search for nursing clinical practice guidelines in the following databases: National Guideline Clearinghouse, Scottish Intercollegiate Guidelines Network, and National Institute for Health and Clinical Excellence. For the remaining bibliographical material, in addition to the above, Cochrane Library Plus and Artemis were used. The working group selected clinical practice guidelines with the following criteria: English and Spanish languages, evidence-based medicine methodology, consistency and clarity in the recommendations, recently published, and freely available. Under these criteria three guides were selected to fit and adapt. Also, systematic and narrative reviews were used as part of the information search.

In cases in which there was controversy on the information reported in the studies, differences were discussed in consensus, and the format of reasoned judgment was used for making recommendations.
The results are expressed in levels of evidence (E) and degree of recommendation (R), according to the classification systems used in the original guidelines; for information not contained in those, the modified Shekelle system was used.


The National Head Injury Foundation defines traumatic brain injury as "damage to the brain, of a non-degenerative nature, caused by an external force, which can result in decreased or altered state of consciousness, resulting in a deterioration of cognitive and physical performance capabilities." Severe head injury is the direct injury of skull, brain, or meningeal structures that occurs as a result of an abrupt exchange of mechanical energy caused by an external physical agent that causes functional impairment in patients.

According to the Glasgow Coma Scale, a score of 13-15 indicates mild head injury or concussion; 12-9, moderate head injury; and 8 to 3, severe trauma.

For all types of head trauma, treatment should initiate with adequate resuscitation of the patient, according to the protocol for advanced trauma life support, preferably at the scene of the accident. Resuscitation should be followed by the implementation of necessary measures to prevent secondary brain injury.

Interventions in initial management (Annex 1)


Initial management in patients with head injury must be backed by the principles of advanced trauma life support (ATLS) (E-4).3 An adult patient with a head injury should initially be assessed and managed in accordance with the principles and standard practice embodied in the ATLS. (R-D)3

Attention to the airway is an essential aspect in the critical patient (E-IV).4 It is important to verify airway patency, to aspirate secretions that can obstruct it, and to place a stent to keep the airway patent, ensuring an adequate supply of oxygen and hypercapnia prevention. (R-D)4

Endotracheal intubation is the technique of choice for the definitive isolation of the airway (R-D).4 It is necessary to ensure an adequate supply of oxygen to maintain oxygen saturation greater than 95% and to avoid possible complications. (R-D)4 In adult males an 8.5 caliber french endotracheal tube is advisable, and in females 8 french; in adolescents a 7 or 8 caliber french tube is suitable (good practice).


Episodes of hypoxia in patients with severe head injury increases the risk of death by 50% (E-1).5 Therefore, it is vital to maintain normal ventilation (PCO2 between 35 and 40 mm Hg), especially in the first hours of brain injury. (R-A)5

To improve venous return through the jugular veins and lung function, it is recommended to keep the patient hemodynamically stable at midline with an inclination of 30 degrees, and to prevent rotation and flexion and extension of the neck. (R-A)5


An episode of hypotension doubles the risk of death of a patient. (E-1)5

Hypotension negatively influences the prognosis of the patient, especially when head injury is severe or when cerebral autoregulation is lost, a compensatory mechanism that maintains adequate blood flow (E-III).6 The risk of secondary cerebral ischemia is prevented by maintaining systolic pressures above 90 mm Hg by fluid challenge. (R-C)6

The restoration of blood volume can be achieved with the use of short thick-caliber catheters (14-16 french) in two peripheral veins, preferably of the upper extremities; one should avoid using veins that cross the injured sites (R-A).5 The recommendation is to use isotonic salt solutions (R-A)5 until achieving acceptable pressure numbers (mean arterial pressure not less than 80 mm Hg) and recovering normal pulses (R-A).5 In order to monitor the patient, placement of a pulse oximeter or capnograph is indicated. (R-C)7

Neurological deficit

All changes of consciousness are potentially lethal emergencies until the vital functions are stabilized. (E-IV)8

The management of patients with head injury should be guided by clinical assessment and protocols based on the Glasgow Coma Scale to assess three types of responses: verbal, eye, and motor (E-3).3 To optimize the utility of the scale, serial measurements must be performed at different intervals and when clinical conditions change. (R-C)9

Anisocoria greater than 2 mm with unilateral mydriasis is indicative of compromise of the third cranial nerve (E-III),10 so pupillary examination should be done to find two components: symmetry and light response (R-C),10 as well as continued examination of the cranial nerves.


To facilitate examination and comprehensive assessment, including the area of the back (E-IV),4 the patient should be completely undressed. It is advisable to cut clothing, for greater visibility of body structures. (R-D)4

Patient assessment should be done by qualified personnel, both medical and nursing, who during the first six hours must frequently perform full assessments (R-D)3 and include the following observations: pupil size and reactivity, limb movement, respiratory rate and oxygen saturation, heart rate, blood pressure, temperature (E-3),3 and examination of the cranial nerves (good practice).

Interventions to improve brain tissue perfusion (Annex 1)

Changes in cerebral and spinal blood flow can damage neurological function and adversely affect the development of patients with traumatic brain injury (E-IV),11 so oxygen supply for cerebral protection (R-D)11 is recommended using mask with reservoir bag at 15 L/min (good practice). 

Cerebral blood flow is regulated by cerebral metabolic rate and is affected by average blood pressure and intracranial pressure. (E-IV)11

Monitoring of local cerebral tissue oxygenation and local metabolites are recent measures for patients with severe head injury and may be useful to identify cerebral ischemia and to evaluate treatment (E-III).12 Using a catheter is recommended to assess perfusion pressure and cerebral oxygenation, which requires handling by trained personnel. (R-C)13

Interventions to maintain intracranial adaptive capacity (Annex 1)

The frequency with which intracranial hypertension is identified in severe trauma is 53-63% with abnormal computerized tomography and 13% with normal. (E-III)12

Increased intracranial pressure can move in the brain towards areas with lower pressure and thus generate herniation syndrome; the most common types of this are uncal, transtentorial, and infratentorial (E-III).13 Increased intracranial pressure is the main intracranial cause of secondary brain injury after severe head injury, and it is related to mortality and unfavorable outcomes (E-IV).14 Measures to reduce it include decompressive craniectomy, which decreases it in 85% of cases (R-D),14 the use of osmotic diuretics such as mannitol and hypertonic saline (R-D),6 due its initial rheological effect with increased cerebral blood flow and oxygen transport and a later and lasting osmotic effect (R-D),14 as well as the classic intraventricular drainage, which immediately improves brain adaptation (R-D).14 It is also recommended not to cause hyperventilation to reduce intracranial pressure (R-2)15 and to raise the headboard of the bed 30 degrees. (R-2)15

Maintaining normothermia can avoid increased intracranial pressure. (R-2)15

Participation in care of the sedated patient

The aim of sedation and analgesia in the critically ill patient should be blocking the inflammatory response, which ensures an optimum level of comfort, reduces the stress response, and facilitates adaptation to mechanical ventilation. (E-IV)16

Once analgesia is assured, sedation is especially relevant in the comprehensive treatment of critically ill ventilated patients (E-IV).16 Monitoring of both is one of the cornerstones for an appropriate strategy and for avoiding associated complications. (E-IV)17 

The establishment of a sedation protocol in a critical care unit should be agreed upon by the medical staff and adapted to the available infrastructure and resources (E-IV),17 and prolonged sedation (over 72 hours) should be agreed upon with nursing staff. The protocol should include periodic goals of sedation, appropriate monitoring with scales, and an algorithm of titration and withdrawal (R-D).17 We recommend using validated scales for pain control and sedation. (R-D)17

Interventions to prevent secondary complications (Annex 1)

Risk of posttraumatic epilepsy

Post-traumatic epilepsy occurs in about 5% of patients admitted to hospital with closed head trauma, and 15% of those suffering severe head injury. (E-IV)4

Three main factors are associated with late epilepsy: early seizures (occurring in the first week), intracranial hematoma, and depressed skull fracture. (E-IV)4

A basic principle is that if an injured neuron is provided an optimal environment in which to recover, this can restore normal function (E-IV),4 which is why early and timely administration of neuroprotectors is important (R-D).4 It is not recommended to combine neuroprotectors with other drugs (good practice).

For their part, the administration of antiepileptic drugs decreases the incidence of early posttraumatic seizures (R-2);15 when they are extended, surveillance and control are important. (R-D)4 Electroencephalogram can identify patients at risk for post-traumatic seizures. (R-3)15

Pneumonia risk associated with mechanical ventilation

Pneumonia related to mechanical ventilation in patients with acute brain injury, both medical and traumatic, reaches 40-50% (E-IV);18 it is the second most common in-hospital complication and ranks first in intensive care services; 80% of episodes occurs in patients with artificial airway. (E-IV)19

Ventilator-associated pneumonia is the most common cause of death among hospital-acquired infections in the intensive care unit, especially if it is caused by Pseudomonas aeruginosa and Staphylococcus aureus. (E-IV)19

Providing oral care is an effective strategy to reduce this (R-C);20 the use of endotracheal tube with a light for the aspiration of subglottic secretions in patients with mechanical ventilation greater than 72 hours has also proven useful. (R-D)19

For prevention of early pneumonia, oropharyngeal decontamination and aspiration of subglottic secretions are recommended; to prevent late pneumonia, prophylactic antibiotic therapy should not be maintained beyond 24 hours. (R-D)19

The aspiration of the airways should be done taking into account the response of each patient (good practice).

Risk of impaired skin integrity

A comprehensive assessment of the state of health of people at risk of developing pressure ulcers is necessary (E-3),21 preferably with a scale such as Braden, with predictive ability superior to that of clinical judgment (E-2b).21 It is recommended to assess risk whenever there are changes in the general condition of the patient. (R-C)21

Skin inspection should be done daily and systematically with extra care given to the sacrum, ischial tuberosity, malleolus, calcaneus, and occipital region to detect erythema, edema, and induration (E-4).21 As a precaution it is advisable never to ignore redness over bony prominences (R-C)21 and not to massage the skin covering these areas. (R-B)21

It is essential to monitor wound drainage and exudate, to protect the skin with barrier products such as polyurethane film or zinc paste (R-C),21 and to keep the skin clean and dry to avoid friction; the use of warm water and mild soap is recommended. (R-C)21

Changes in posture minimize the effect of pressure causing pressure ulcers (E-2b).21 In patients with impaired mobility, it is necessary to do passive motion exercises, postural changes (R-D)21 every two or three hours following a determined rotation (R-B),21 and to use cushions to relieve pressure on the trochanters, ankles, and heels. (R-C)21

Risk of infection

The adult with severe brain injury is at high risk of infection due to multiple invasive procedures that they are exposed to (E-IV).22 Performing the procedures with appropriate aseptic and antiseptic practice reduces risks (R-D)22 and monitoring color, smell, and consistency of secretions and excretions can give warning about infection (good practice).


Currently, nursing staff has many resources for the care of the patient with severe head injury, allowing them to provide timely and efficient specialized care that is paramount in maintaining cerebral autoregulation.

  1. Cabrera-Rayo A, Martinez-Olazo O, Ibarra-Guillén A, Morales-Salas R, Laguna-Hernández G, Sánchez-Pompa M. Traumatismo craneoencefálico severo. Rev Asoc Mex Med Crit Ter Int. 2009;23(2):94-101. [Cited 2012 Oct 9]. Available from: http://www.medigraphic.com/pdfs/medcri/ti-2009/ti092g.pdf
  2. López HJ, Varela-Hernández A, Soler-Morejón C, Vega-Basulto S, Lacerda-Gallardo Á. Estado actual del manejo del traumatismo craneoencefálico grave en los hospitales de atención al adulto en Cuba. Rev. Cub Med Int Emerg. 2004;3(4)11-23. [Cited 2012 Oct 9]. Available from: http://bvs.sld.cu/revistas/mie/vol3_4_04/mie03404.htm
  3. Scottish Intercollegiate Guidelines Network (SING). Early management of patients with a head injury. A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network; 2009. [Cited 2012 Oct 9]. Available from: http://www.sign.ac.uk/pdf/sign110.pdf
  4. Comité de Trauma del Colegio Americano de Cirujanos. Programa Avanzado de Apoyo Vital en Trauma para médicos. Séptima edición. Comité de Trauma del Colegio Americano de Cirujanos; 2010. [Cited 2012 Oct 9]. Available from: http://www.cleaedu.com/portal/2013-01-29-01-30-58/2013-02-12-23-44-10/libros/category/2-medicina-general?download=20:atls-apoyo-vital-en-trauma
  5. Ministerio de Salud (MINSAL). Guía clínica. Atención de urgencia del traumatismo craneoencefálico. Series Guías Clínicas Minsal No. 49. Santiago, Chile: Minsal; 2007. [Cited 2012 Oct 9]. Available from: http://almacen-gpc.dynalias.org/publico/TCE%20en%20fase%20aguda%20Chile%202007.pdf
  6. Cam-Páucar JL. Manejo inicial del paciente con trauma craneoencefálico e hipertensión endocraneana aguda. Acta Med Per. 2011;28(1):38-45. [Cited 2012 Oct 9]. Available from: http://www.scielo.org.pe/pdf/amp/v28n1/a07v28n1.pdf
  7. Gómez-Martínez V, Ayuso-Baptista F, Jiménez-Moral G, Chacón-Manzano MC. Recomendaciones de buena práctica clínica: atención inicial al paciente poli traumatizado. SEMERGEN. 2008;34(7):354-63. [Cited 2012 Oct 9]. Available from: http://zl.elsevier.es/es/revista/semergen-medicina-familia-40/recomendaciones-buena-practica-clinica-atencion-inicial-al-13127193-formacion-continuada-2008
  8. González-Martínez JF, Gómez-Moreno SM, Castelbón JF. Alteraciones del nivel de conciencia. Coma. En: Carlavilla-Martínez AB, Castelbón-Fernández FJ, García-Sánchez JI, Gracia-Lorenzo V, Ibero-Esparza, Lalueza-Blanco A, et al., editors. Manual de diagnóstico y terapéutica médica. Sexta edición. MSD: Madrid. 2007. p. 983-96.
  9. Millán-Guerrero R, Isais-Millán S, Hernández-Moreno J, Mendoza-Lóez I, Trujillo-Hernández B, Ibarra-Barrientos R. Características clínicas de pacientes con trauma craneal. Rev Med Inst Mex Seguro Soc. 2010;48(4):427-30. [Cited 2012 Oct 9]. Available from: http://revistamedica.imss.gob.mx/index.php?option=com_multicategories&view=article&id=796:caracteristicas-clinicas-de-pacientes-con-trauma-craneal&catid=149:practica-clinico-quirurgica&Itemid=605
  10. Quiroga A, Ávila J, Badillo G, Cleves O, Garavito M, Huertas L, et al. Intervenciones de enfermería en trauma craneoencefálico en urgencias. Repert Med Cir. 2009;18:223-30. [Cited 2012 Oct 9]. Available from: http://pesquisa.bvsalud.org/enfermagem/resource/pt/lil-552231
  11. Niño-De Mejía C. Protección cerebral. Rev Mex Anestesiol. 2010 33(1):S189-95. [Cited 2012 Oct 9]. Available from: http://www.medigraphic.com/pdfs/rma/cma-2010/cmas101au.pdf
  12. Cruz-Santos J, Cuenca-Dardón JF. Manejo perioperatorio del paciente con traumatismo craneoencefálico. Rev Mex Anestesiol 2008;31(2):108-15. [Cited 2012 Oct 9]. Available from: http://www.medigraphic.com/pdfs/rma/cma-2008/cma082g.pdf
  13. Vargas-Rodríguez IC. Repercusión de las intervenciones de enfermería sobre la presión de perfusión cerebral en pacientes con lesiones cerebrales, Monografía para optar al título de especialista en Cuidado al Adulto en Estado Crítico de Salud, Universidad de Antoquia, Medellín, 2005.
  14. Alted-López E, Bermejo-Aznárez S, Chico-Fernández M. Actualizaciones en el manejo del traumatismo craneoencefálico grave. Med Intensiva. 2009;33(1):16-30. [Cited 2012 Oct 9]. Available from: http://scielo.isciii.es/scielo.php?pid=S0210-56912009000100003&script=sci_arttext
  15. American Association of Neuroscience Nurses. (AANN) Nursing management of adults with severe traumatic brain injury. AANN Clinical Practice Guideline Series. Glenview, IL: American Association Neuroscience Nurses; 2008. p. 20. [Cited 2012 Oct 9]. Available from: http://www.aann.org/pdf/cpg/aanntraumaticbraininjury.pdf
  16. Chamorro C, Martínez-Melgar JL, Barrientos R; Grupo de Trabajo de Analgesia y Sedacion de la SEMICYUC. Monitorización de la sedación. Med Intensiva. 2008;32 Suppl 1:45-52. [Cited 2012 Oct 9]. Disponible en  http://www.medintensiva.org/es/pdf/13116126/S300/
  17. Estébanez-Montiel M, Alonso-Fernández MA, Sandiumenge A, Jiménez-Martín MJ; Grupo de Trabajo de Analgesia y Sedación de la SEMICYUC. Sedación prolongada en unidades de cuidados intensivos. Med Intensiva 2008;32(1):19-30. Available from: http://www.medintensiva.org/es/pdf/13116123/S300/
  18. Belda FJ, Aguilar G, Soro M, Maruenda A. Manejo ventilatorio del paciente con traumatismo craneoencefálico grave. Rev Esp Anestesiol Reanim. 2004;51:143-50. [Cited 2012 Oct 9]. Available from: http://files.sld.cu/anestesiologia/files/2011/12/manejo-ventilatorio-tce143-150.pdf
  19. Díaz E, Lorente L, Valles J, Rello J. Neumonía asociada a la ventilación mecánica. Med Intensiva. 2010;34(5):318-24. [Cited 2012 Oct 9]. Available from: http://scielo.isciii.es/scielo.php?pid=S0210-56912010000500005&script=sci_arttext
  20. NSW Health/Intensive Care Coordination and Monitorin Unit. Consensus-based Clinical Guideline for the Provision of Oral Care for the Critically Ill Adult. NSWHealth Statewide Guidelines for Intensive Care. New South Wales, Australia. NSW Health/Intensive Care Coordination and Monitorin Unit; 2010. [Cited 2012 Oct 9]. Available from: http://intensivecare.hsnet.nsw.gov.au/current/files/8%20%20Final%20oral%20guideline%20December%205_1.pdf
  21. Governs de les illes Balears. Prevención y tratamiento de las úlceras por presión. España, Illes Balears: Conselleria de Salut i Consum; 2007. [Cited 2012 Oct 9]. Available from: http://www.caib.es/govern/archivo.do?id=148743
  22. Palomar M, Rodríguez P, Nieto M, Sancho S. Prevención de la Infección nosocomial en pacientes críticos. Med Intensiva. 2010;34(8):523-33. [Cited 2012 Oct 9]. Available from: http://scielo.isciii.es/scielo.php?pid=S0210-56912010000800005 &script=sci_arttext

Annex 1. Critical path for diagnosis and treatment for the patient with severe traumatic brain injury.3-5

Conflict of Interest Statement

The authors declared that there is no personal or institutional conflict of interest of a professional, financial, or commercial nature, during the planning, execution, writing of this article. 

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