Head Injury
General Treatment
1. Because potential problems include airway compromise from obstruction caused by the tongue, vomit, blood, or broken teeth, make a quick inspection of the patient’s mouth as part of the primary survey.
2. Logroll the patient to clear the mouth without jeopardizing the spine (Fig. 14-1). Be aware that head trauma may be accompanied by spine injury.
3. Primary survey of the head-injured patient involves rapid assessment of level of consciousness using the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive).
4. Secondary survey includes a more detailed neurologic examination, including pupillary examination (Table 14-1), Glasgow Coma Scale (GCS) or Simplified Motor Score (SMS), and a more detailed neurologic examination.
Table 14-1
Interpretation of Pupillary Findings in Head-Injured Patients
| PUPIL SIZE | LIGHT RESPONSE | INTERPRETATION |
| Unilaterally dilated | Sluggish or fixed | Third nerve compression secondary to tentorial herniation |
| Bilaterally dilated | Sluggish or fixed | Inadequate brain perfusion; bilateral third nerve palsy |
| Unilaterally dilated or equal | Cross-reactive (Marcus Gunn) | Optic nerve injury |
| Bilaterally constricted | Difficult to determine; pontine lesion | Opiates |
| Bilaterally constricted | Preserved | Injured sympathetic pathway |
Glasgow Coma Scale
The GCS (see Appendix B) is the most widely used method of defining a patient’s level of consciousness and obviates use of ambiguous terminology such as lethargic, stuporous, and obtunded. The GCS is a neurologic scale that aims to give a reliable, objective way of recording the state of consciousness of a person for initial and continuing assessment. A patient is assessed against the criteria of the scale, and the resulting points give the GCS score (see later). The patient’s best motor, verbal, and eye-opening responses determine the GCS score. A patient who is able to follow commands, is fully oriented, and has spontaneous eye-opening scores a GCS of 15; a patient with no motor response, eye opening, or verbal response to pain scores a GCS of 3. Patients with a GCS score of 8 or less are considered being in “coma.” Head-injury severity is generally categorized into three levels on the basis of the GCS score after initial resuscitation. A “mild” GCS score is 13 to 15; “moderate” GCS score is 9 to 12; and “severe” GCS score is 3 to 8. Any patient with a GCS score less than 15 who has sustained a head injury should be evacuated as soon as possible. A declining GCS score suggests increasing intracranial pressure or other cause of worsening traumatic brain injury.
Elements of the Glasgow Coma Scale Explained
4—Eye(s) opening spontaneously
3—Eye(s) opening to speech (not to be confused with awaking of a sleeping person; such patients receive a score of 4, not 3)
2—Eye(s) opening in response to pain (patient responds to pressure on his or her fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used)
Verbal Response
5—Oriented (patient responds coherently and appropriately to questions such as the patient’s name and age, where he or she is located and the reason; the year, month, etc.)
4—Confused (patient responds to questions coherently, but there is some disorientation and confusion)
3—Inappropriate words (random or exclamatory articulated speech, but no conversational exchange)
