Head injuries can be soft tissue injuries (brain, scalp, blood vessels) or bony injuries (skull, facial bones), so I’ve placed this section between soft tissue and orthopedic problems.

Causes of Head Injuries

Damage is usually caused by direct impact, such as a laceration in the scalp or a fracture of the part of the skull that contains the brain (also called the “cranium”). An “open” head injury means that the skull has been penetrated, possibly exposing the brain tissue;  if the skull is not fractured, it is referred to as a “closed” injury.

Damage can also be caused by the rebound of the brain against the inside walls of the skull; this may cause tearing of the blood vessels in the brain, which can result in a hemorrhage. There may be no obvious penetrating wound in this case; the original trauma may even have occurred at a site other than the head. An example of this would be the violent shaking of an infant or a serious case of “whiplash”

How Should a Traumatic Injury to the Head be Treated?

Anyone with a traumatic injury to the head must always be observed closely, as symptoms from bleeding or swelling may take time to develop. 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 from 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 called a “herniation”. Without modern critical care, this will almost invariably lead to death.

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 it may be significant, does not have to signify internal damage; treat as with any other minor wound. There are a number of signs and symptoms, however, which might identify those patients that are more seriously affected.  They include:

• Loss of Consciousness
• Convulsions (Seizures)
• Worsening Headache
• Nausea and Vomiting
• Bruising (around eyes and ears)
• Bleeding from Ears and Nose
• Confusion/Apathy/Drowsiness
• One Pupil More Dilated than the Other
• 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 could require treatment for superficial injuries. After a period of observation, a head injury without loss of consciousness is most likely not serious unless one of the other 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.  In other words, make sure they can move all their extremities with normal range and strength. 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 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 direct trauma to those areas is another indication.  The fluid may also be clear, and may represent spinal fluid leakage. 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.

A stroke, (also known as a cerebrovascular accident or CVA), is damage to the brain caused by lack of blood supply.  This could occur in a head injury due to a blockage of blood 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. Whatever functions are associated with the part of the brain affected will be lost or impaired. This might include the inability to speak, blindness, or loss of normal comprehension.  Symptoms, such as paralysis or weakness, are often on one side of the body and/or 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.  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.

Dr. Bones