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)
Motor Response
6—Obeys commands (patient does simple things as asked)
5—Localizes to pain (purposeful movements toward changing painful stimuli (e.g., hand crosses midline and gets above clavicle when supraorbital pressure applied)
4—Withdraws from pain (pulls part of body away when pinched; normal flexion)
3—Flexion in response to pain (decorticate response)
2—Extension to pain (decerebrate response: adduction, internal rotation of shoulder, pronation of forearm)
High Risk for Traumatic Brain Injury: Immediate Evacuation
Skull Fracture
Signs and Symptoms
2. Deformity, step-off, or crepitus on palpation of the scalp
3. Blood or clear fluid draining from the ears or nose without direct trauma to those areas
4. Ecchymosis around the eyes (raccoon eyes) or behind the ears (Battle’s sign)
5. In a patient with a skull fracture, observe for seizures, unequal or nonreactive pupils, weakness, or altered level of consciousness from an underlying brain injury (quantify with GCS or SMS).
Prolonged Unconsciousness
Treatment
1. Immediate evacuation to a medical center is mandatory.
2. During transport, maintain cervical spine precautions and keep the patient’s head uphill on sloping terrain. On a flat surface, elevate the head of the litter 30 degrees.
3. Be prepared to logroll the patient if the patient vomits.
4. Continually monitor the airway for signs of obstruction and decreasing respiratory rate.
Moderate Risk for Traumatic Brain Injury: Brief Loss of Consciousness or Change in Consciousness at Time of Injury
Signs and Symptoms
1. Short-term unconsciousness, in which the patient wakes up after 1 or 2 minutes and gradually regains normal mental status and physical abilities, indicating concussion (which may be initially assessed using the Sport Concussion Assessment Tool 3 [SCAT3] evaluation; see Appendix C)
2. Confusion or amnesia for the event and repetitive questioning by the patient even in the absence of history of loss of consciousness
Treatment
1. Be aware that the safest strategy is to evacuate the patient to a medical center for evaluation and observation.
2. Interrupt the patient’s normal sleep every 2 hours briefly to see that the condition has not deteriorated and he or she can be easily aroused.
3. If a patient is increasingly lethargic, confused, or combative or does not behave normally, and if these signs are present in isolation and the evacuation can be completed in less than 12 hours, evacuation should proceed. If evacuation is impossible or will require longer than 12 hours, the patient should be closely observed for 4 to 6 hours. If the examination improves to normality during the observation period, it is reasonable to continue observation.
Low Risk for Traumatic Brain Injury: May be Observed and Does Not Require Immediate Evacuation
Treatment
1. Inspect the scalp for evidence of lacerations, which generally bleed copiously, and apply pressure as needed.
2. If the patient appears normal (can answer questions appropriately, including name, location, and date; walks normally; appears to have coordinated movements; and has normal muscle strength), no immediate evacuation is required.
3. If the patient develops any signs or symptoms of brain injury (Box 14-1), evacuate the patient immediately.
4. For a child who has had a head injury, then begins to vomit, refuses to eat, becomes drowsy, appears apathetic, or in any other way seems abnormal, evacuate him or her to a medical facility as soon as possible.
5. Close observation of these patients includes awakening the patient from sleep every 2 hours and avoidance of strenuous activity for at least 24 hours. The following signs indicate that more advanced medical care is necessary: (1) inability to awaken the patient; (2) severe or worsening headaches; (3) somnolence or confusion; (4) restlessness, unsteadiness, or seizures; (5) difficulties with vision; (6) vomiting, fever, or stiff neck; (7) urinary or bowel incontinence; and (8) weakness or numbness involving any part of the body.
6. Generally one should not return to an environment in which concussion is a risk (e.g., contact sports) until symptoms have been absent for 7 days.
7. The SCAT3 is a standardized method of evaluating injured persons 13 years of age and older for concussion. Use the Child-SCAT3 for children ages 5 to 12 years. Compared to a baseline SCAT3, the test can be used to indicate the possible presence of a concussion (see Appendix C).
Scalp Lacerations
Treatment
1. Apply direct pressure to the wound with your gloved hand. It might be necessary to hold pressure for up to 30 minutes.
2. If you are faced with a bleeding scalp laceration and the patient has a healthy head of hair, tie the wound closed using the patient’s own hair (see Chapter 20). This should not be expected to control the bleeding but will approximate the edges of the wound.
Scalp Bandaging
Scalp wounds often require a dressing placed over hair, making adhesion difficult. The dressing can be secured with a triangular bandage in a method that allows for considerable tension should pressure be necessary to stop bleeding (see Fig. 20-7).
