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Assessing
and Treating Head Injuries
By
Steve Schotz, EMT,
NMBP
and National Ski Patrol Outdoor Emergency Care Instructor
Although they
look gruesome, superficial cuts to the scalp without underlying
skull or brain injury are relatively benign injuries. However,
head wounds should be treated with care. In rare cases, especially
when there are other sources of blood loss, severe bleeding can
cause hypovolemic shock. Skull fractures and brain injuries are
cause for much greater concern.
This paper
examines three major topics: Lacerations of the Scalp, Skull
Fractures and Brain Injuries. The third topic is examined in depth
Topic 1:
Lacerations of the Scalp
Treat
lacerations by applying direct pressure with your gloved hand
using a dry, sterile dressing. If the skin is avulsed (torn
into a flap which remains connected) flush the area clean with
water, fold the flap back down, and apply pressure with a
dressing. Secure dressings to the head with roller gauze. If
dressings become saturated with blood, do not remove them, but add
more dressings on top. If you suspect an underlying skull
fracture, apply very gentle pressure, being careful not to
compress the fracture or push bone fragments into the brain. There
are several
different types of soft tissue injuries.
Topic 2: Skull
Fractures
Fractures may
be open, if the skin above the fracture is broken allowing
access to the bone, or closed, if the overlying skin is
intact. Suspect a fracture if there is point tenderness
(pain) when you palpate (press) the skull or face bones or
if there is substantial swelling or skull deformity. Raccoon
eyes (bruising around the eyes) and Battle's Sign
(bruising behind the ear) suggest a fracture to the base of the
skull, but these usually develop some time after the initial
injury. Clear fluid from the nose or ear may be cerebrospinal
fluid leakage and indicates a skull fracture.
Topic 3: Brain
Injuries
A
concussion occurs when head trauma causes a temporary change
in brain function without perceptible physical damage to the
brain. Concussions can involve minor changes (e.g. seeing stars)
or serious changes (loss of consciousness) in brain function.
A
contusion is the bruising of brain tissue and is more serious.
The skull is essentially a sealed compartment. Because of
associated swelling and bleeding, increased pressure and
distortion of the brain tissue can result in serious and
life-threatening symptoms.
Intracranial
hemorrhage refers to bleeding from vessels within the brain or
its covering. If your patient is deteriorating rapidly and showing
poor neurological signs, suspect intracranial bleeding. It is very
important to assess patients with suspected brain injury for their
Level of Responsiveness (LOR). LOR is measured using the AVPU
scale, which refers to the patient's ability to remain awake and
responsive.
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Level of Responsiveness
Scale
Alert: patient is
awake and responsive without any prompting or stimulation
Verbal: patient requires verbal prompting to stay
responsive ("Hey!")
Pain: patient requires painful stimulation to stay
responsive (e.g. pinching an earlobe)
Unresponsive: patient does not respond at all.
Also assess the patient's orientation
- the awareness of his/her name, location, date/time, and
circumstances. Each of these is called a sphere, and the patient
can be oriented in 0, 1, 2, 3, or 4 spheres. When you report to
the ambulance crew, specifically state the status of each sphere
(oriented or not) and what the course of the LOR has been (e.g.
responsive only to pain)
Indications of Traumatic
Brain Injury
- Obvious damage to
helmet or head (fractures, bleeding, bruising, deformities
etc.)
- Clear or blood-tinged
fluid from the nose or ears
- Pupils of different
size or that don't respond to changes in light
- Loss of memory
- Reduction in
orientation or level of responsiveness (e.g. confused,
"spacey," disoriented)
- Increased blood
pressure, irregular respirations, and lowered pulse
- Changes in sensation in
or ability to move the extremities
- Dizziness
- Repetitive speech
- Convulsions
- Nausea and vomiting
- Poor coordination
Steps for Treating a
Brain Injury
- As with any injury,
first assess and immediately provide care for any problems
with airway, breathing, and circulation (ABC's):
- Keep the airway
open
- Provide
supplemental high-flow oxygen if available
- Control any serious
external bleeding
- Rescue breathing or
CPR if indicated
- Helmet
removal: Safe
helmet removal requires proper instruction and practice. A
helmet needs to be removed only if it:
- Impedes assessment
or treatment of ABC's
- Prevents proper
immobilization of the spine
- Is loose and
prevents the head from being stabilized or secured to a
backboard
- Conduct a rapid body
survey and locate other significant injuries. A significant
head injury is likely to have an associated spinal injury,
so take spinal precautions beginning with your initial
assessment. See "Handling Suspected Spinal
Injuries." Head injury patients require a cervical
collar and a backboard. Minimize movement.
- Call for immediate
evacuation
- Do not give anything to
the patient by mouth.
- Monitor vital signs and
level of responsiveness every 15 minutes for stable patients
and every 5 for unstable patients.
- All head injuries
should be evaluated by a physician. Serious symptoms can
develop over the following 48-72 hours.
- Because patients can
lose consciousness, obtain information regarding identity,
emergency contacts, allergies, medical problems and
medications taken and last time they ate and drank while
waiting for evacuation.
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