Most head injuries cause superficial damage and are not life-threatening. Indeed, most head injuries amount to only a laceration of the scalp, a black eye, or a painful bump. These wounds, however, can hide damage inside the cranium, the part of the skull that contains the brain. Injuries that affect the brain are called traumatic brain injuries (TBIs). It’s important for the medic to recognize when trauma to the skull has caused damage that is more than superficial.
Concussions are the most common type of TBI. A concussion is associated with a variety of symptoms that are often immediately apparent. The presentation differs from one individual to the next. Although you might expect a loss of consciousness, the victim may remain completely alert. Headache is actually the most commonly seen symptom. Other symptoms include:
• Loss of motor coordination
• Blurred or double vision
• Slurred speech
• Ringing in the ear (also called “tinnitus”)
• Difficulty focusing on tasks at hand
A person with trauma to the head may be knocked unconsciousness for a period of time. In most cases, they will “wake up” in less than 2 minutes. You can expect them to be “foggy” and behave inappropriately (put me in, coach!). They may not remember the events immediately prior to the injury.
Loss of consciousness is a serious concern. If the victim is “out” less than two minutes, the patient will merit close observation for the next 48 hours. You should examine for evidence of superficial injuries and determine that the patient has regained normal motor function. Make sure they can move all their extremities with normal range and strength.
Rest is prescribed for the remainder of the day. When your patient goes to bed, it will be appropriate to awaken them every two or three hours, to make sure that they are easily aroused. In most cases, a concussion causes no permanent damage unless there are multiple episodes of head trauma over time, as in the case of boxers or other athletes in contact sports.
It should be noted that a physical strike to the head is not necessary to suffer a concussion. A particularly jarring football tackle or the violent shaking of an infant can cause a concussion or worse traumatic brain injury. This is because the brain “bounces” against the walls of the cranium. When injury occurs at the site of a blow to the head, it’s called a “coup” injury. Just as often, it can occur on the opposite site of the head, known as a “contrecoup” injury.
In many cases, evidence of direct trauma to the skull is visible. An “open” head injury means that the skull has been penetrated with possible exposure of the brain tissue. If the skull is not fractured, it is referred to as a “closed” injury. An indentation of the skull is clear evidence of a fracture and the outlook may be grim, due to the likelihood of bleeding or swelling in the brain. A closed injury may still become life-threatening for the same reasons.
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. Blood accumulation (known as a “hematoma”) could occur within the brain tissue itself, or between the layers of tissue covering 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. This is known as a “brain herniation” and, without modern medical care, will almost invariably lead to death.
There are a number of signs and symptoms which might identify those patients that have a serious TBI. They include:
• Prolonged loss of consciousness
• Convulsions (Seizures)
• Worsening headache over time
• Nausea and vomiting
• Bruising (around eyes and ears)
• Bleeding from ears and nose
• Worsening confusion/Apathy/Drowsiness
• One pupil more dilated than the other
• Indentation of the skull
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 breathing is regular. 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 traumatic brain injury are the appearance of bruising behind the ears (Battle’s sign) or around the eyes (raccoon sign). This indicates internal bleeding in the cranium, despite the impact not occurring in those areas. Bleeding from the ear itself or nose without direct trauma to those areas is another indication. The fluid that drains out may be clear; this may represent spinal fluid leakage.
In addition, intracranial bleeding may cause pressure that compresses nerves that lead to the pupils. In this case, you will notice that your unconscious patient has one pupil more dilated than the other.
A severe consequence of bleeding in the brain is a stroke, (also known as a cerebrovascular accident or CVA). It represents damage to the brain caused by lack of blood supply. This could occur in a head injury due to a blockage of blood flow to a portion of the brain. This blockage could be due to a clot, a hemorrhage, or anything else that compromises the circulation in the area. Another possibility is a defect in a blood vessel known as an “aneurysm” which could rupture even in the absence of a traumatic event.
Whatever functions are associated with the part of the brain affected will be lost or impaired. These patients often present with an inability to speak, partial or complete blindness, and paralysis or weakness of one side of the body and face. The stroke is usually heralded by a sudden severe headache.
Strokes may also occur due to other reasons as well, such as uncontrolled high blood pressure. Although it may not be difficult to diagnose a major CVA in an austere setting, few options will exist for treating it. Blood thinners might help a stroke caused by a clot, but worsen a stroke caused by hemorrhage. It could be difficult to tell which is which without advanced testing.
Keep the victim on bed rest; sometimes, they may recover partial function after a period of time. If they do, most improvement will happen in the first few days.
Trauma to the head may have negligible consequences, or it could have life-threatening consequences. In some circumstances, there may be little that you, the medic, can do in a long-term survival situation.
Joe Alton, MD
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