Traumatic brain injuries (TBIs) usually occur from a sudden blow to the head or other physical event. It is one of the most common causes of disability and death in adults. TBI’s a broad term that encompasses many types of damage that can impact the brain. If it effects one area of the brain, it is termed a “focal” injury. If it spans over several areas, it is called a “diffuse” injury. Severity can range from a mild concussion to a life-threatening situation involving fracture of the skull.
Fortunately, most head injuries aren’t lethal and cause only superficial damage, such as 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). It’s important for the off-grid medic to recognize when trauma to the skull causes damage that can lead to a bad outcome.
Concussions are the most common type of TBI. A concussion is associated with a variety of symptoms that are often immediately apparent. Although the effects vary from one individual to the next: You might expect a loss of consciousness, but in the majority of cases, the victim may remain completely alert. Headache is actually the most commonly seen symptom and may occur on-and-off for days afterwards.
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
Let’s say a person has been knocked unconscious by a blow to the head. In most cases, they will regain consciousness in less than 2 minutes. You can expect them to be “foggy,” move clumsily, be slow to answer questions, and behave inappropriately (put me in, coach!). They may not even remember the events immediately prior that led to the injury. In sports, an injured player may not remember their position, the score, or who their opponent is.
A standardized assessment of concussion test can be performed in suspect cases. This test evaluates orientation, immediate memory, concentration and delayed memory. Test questions include:
- Stating the date, month, year, day of the week.
- Memorizing a list of words, then repeating them.
- Repeating a sequence of numbers backwards.
- Saying the months of the year backwards.
Of course, 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 other injuries and determine that the patient has regained normal motor function. Make sure they can move all their extremities with normal range of motion, coordination, and strength.
A period of “relative rest” is prescribed for the next 48 hours. The patient should avoid strenuous activity or perform duties that require serious mental effort (including video games). The patient does not have be kept awake nor has to remain in a dark room, as suggested by some. There are those who no longer believe it is necessary to wake the patient if they’re asleep as long as they’re breathing normally, but many still recommend awakening them every two or three hours the first night, to make certain 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.
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. This is because the brain “bounces” against the hard 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 as the brain rebounds, known as a “contrecoup” injury.
Illustration by Patrick J. Lynch, medical illustrator (http://patricklynch.net)
OPEN AND CLOSED BRAIN INJURIES
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.
Why? The brain requires blood and oxygen to function normally. An injury which causes bleeding or swelling inside the skull will result in pressure. This pressure makes it harder for the heart to get blood and oxygen into the brain. If bleeding, an accumulation, known as a “hematoma,” could occur within the brain tissue itself, or between the layers of matter covering the brain.
Without adequate circulation and oxygenation, 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.
SIGNS AND SYMPTOMS OF SEVERE TBI
A severe traumatic brain injury occurs when bleeding into tissue causes a lack of oxygen or the brain’s nerve fibers (axons) tear as it “ricochets” inside the bony skull.
There are a number of signs and symptoms which might help the off-grid medic identify those patients that have a serious TBI. They include:
- Prolonged loss of consciousness
- 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, significant injury is suspected. In these cases, verify that the airway is clear and breathing is regular. 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 stabilizing the neck and spine, in case they are also damaged.
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 did not occur 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 or light yellow; 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.
CONSEQUENCES OF SEVERE TBI
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.
Look for these signs using the acronym “B.E.F.A.S.T.”:
Balance: Patient experiences sudden loss of balance.
Eyes: Partial or total vision loss.
Face: Smiling yields an uneven appearance.
Arm: One arm is weaker than the other when testing strength.
Speech: The patient may slur words or be unable to talk
Time: In normal times, getting the patient to advanced care immediately is of paramount importance.
A stroke is usually heralded by a sudden severe headache. In the aftermath, whatever functions are associated with the part of the brain affected will be lost or impaired, as described above.
Strokes may also occur due to reasons other than trauma, 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. Statistically, more than 80 percent of strokes are caused by a blood clot, so blood thinners like warfarin or even aspirin might help. The problem is, these medicines would worsen the minority of strokes caused by hemorrhage; it may be difficult to tell which is which without advanced testing.
In these circumstances, the medic should keep the victim on bed rest for a time; In the long run, they may recover partial function. If they do, most improvement will happen in the first few days. Having said that, each brain injury and rate of recovery is unique. In younger people, miraculous results have been documented. In these cases, it’s thought that other areas of the brain make up the deficit caused by damaged tissue. The brain might learn to reroute information and function around lost areas. The end result is, however, difficult to predict and may not be apparent for quite some time.
The many other possible long-term effects of serious traumatic brain injuries are wide-ranging and seriously impact a person’s quality of life. They include:
- Shortened attention span
- Memory deficits
- Loss of problem-solving ability
- Paralysis or weakness
- Spasticity (tightening and shortening of the muscles)
- Poor balance and loss of coordination
- Tremors or seizures
- Problems swallowing
- Changes in vision, hearing, and other senses
- Loss of body awareness (position, movements, etc.)
- Difficulty communicating orally or in writing
- Difficulty understanding the written word
- Difficulty in performing common activities of daily living, like eating, bathing, paying bills, etc.
- Loss of the ability to drive a car or perform other learned skills
- Difficulties understanding and responding normally to social interaction
- Changes in sleep patterns and eating habits
- Loss of bowel and bladder control
- Personality changes (anxiety, depression, irritability, aggression, etc) or engaging in inappropriate behavior
President Theodore Roosevelt once said, “Do what you can, with what you have, where you are.” Trauma to the head may have negligible consequences, or it may be life-threatening and leave the victim with long-term deficits. In some circumstances, there may be little that you, the medic, can do in a long-term survival situation; it’s a hard reality in hard times.
Joe Alton, MD
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