Crisis Medicine and Head Injuries
Head injuries can be soft tissue injuries (brain, scalp, blood vessels) or bony injuries (skull, facial bones). Damage can be caused by direct impact, such as a laceration in the scalp or a fracture of the skull (also called the “cranium”). It can also be caused by the rebound of the brain against the inside walls of the cranium; this may cause tearing of the blood vessels in the brain, which can result in a hemorrhage. Accumulation of blood in the cranium increases the pressure inside the brain (the “intracranial pressure”), which can be life-threatening. Anyone with a traumatic injury to the head must always be observed closely.
The brain requires blood and oxygen to function normally. An injury which causes bleeding or swelling inside the skull will increase the intracranial pressure. This causes the heart to work harder to get blood and oxygen into the brain. Without adequate circulation, brain function ceases. Pressure that is high enough could actually cause a portion of the brain to push downward through the base of the skull. In a collapse situation, this will almost invariably lead to death.
How Bad are Head Injuries?
Most head injuries result in only a laceration to the scalp and a swelling at the site of impact. Cuts on the scalp or face will tend to bleed, as there are many small blood vessels that travel through this area. This bleeding, although significant, is rarely a sign of internal damage. There are a number of signs and symptoms, however, that will identify those patients that are more seriously affected. They are:
1. Loss of Consciousness
2. Convulsions (Seizures)
3. Worsening Headache
4. Nausea and Vomiting
5. Bruising (around eyes and ears)
6. Bleeding from Ears and Nose
8. One Pupil More Dilated than the Other
9. Indentation of the Skull
A person with trauma to the head may be knocked unconsciousness for a period of time or may remain completely alert. If consciousness is not lost, the patient may experience a headache and may require treatment to superficial injuries. See the section in this handbook on soft tissue wounds. After a period of observation, it is most likely not serious unless one of the signs and symptoms from the above list are noted.
Loss of consciousness for a very brief time (say, 2 minutes or so) will merit close observation for the next 48 hours. A head injury of this type is called a “concussion”. This patient will usually awaken somewhat “foggy”, and may be unclear as to how the injury occurred or the events shortly before. It will be important to be certain that the patient has regained normal motor function. Even so, rest is prescribed for the remainder of the day, so they may be closely watched. When your patient is asleep, it will be appropriate to awaken them every 2-3 hours, to make sure that they are easily aroused and have developed none of the danger signals listed above. In most cases, a concussion causes no permanent damage unless there are multiple episodes of head trauma over time, as in the case of some boxers or other athletes.
If the period of unconsciousness is over 10 minutes in length, you must suspect the possibility of significant injury. Vital signs such as pulse, respiration rate, and blood pressure should be monitored closely. The patient’s head should be immobilized, and attention should be given to the neck and spine, in case they are also damaged. Verify that the airway is clear, and remove any possible obstructions. In a collapse, this person is in a life-threatening situation that will have few curative options if consciousness is not regained.
Other signs of a significant injury to this area are the appearance of bruising behind the ears or around the eyes (the “raccoon” sign) despite the impact not occurring in that area. This could indicate a fracture with internal bleeding. Bleeding from the ear itself or nose without trauma to those areas is another indication. The fluid may also be clear, and may represent spinal fluid leakage. Again, these signs are indicative of a skull fracture and could be life-threatening. In addition, pressure from intracranial bleeding may compress nerves that lead to the pupils. In this case, you will notice that your unconscious patient has one pupil more dilated than the other.
Observation is the key when dealing with head injuries. Follow your patient closely, and they’ll have the best chance to recover.