Treat a Casualty with a Head Injury
It is most common for individuals working in hazardous environments to sustain soft tissue injuries to the head, face, and neck. On the battlefield, the structures that regulate the senses (eyes, ears, and nose) are extremely important for survival. The delicate structures, such as the eye, demand the health-care provider be diligent in the care of injured and damaged sensory organs. Also, when soft tissue injuries are present, underlying structures such as the cranium, brain, trachea, neck vessels, and cervical spine may also be damage.
(1) Bleeds freely when lacerated
(2) Can lead to significant blood loss due to prolonged bleeding
(3) Outermost part of the head
(1) Function - enclose and protect the brain tissue
(2) The bones of the anterior cranium connect to facial bones
(a) Mandible - lower jaw
(b) Maxillae - fused bones of upper jaw
(c) Zygomatic bones - cheekbones
(d) Nasal bone - provides some of the structure of the nose
(3) Foramen magnum is primary opening through which pressure can be released - base of the skull - opening from which the spinal cord exits
(1) Meninges - cover brain
(2) Brain hemisphears
(a) Cerebrum - higher functions
(b) Cerebellum - primitive functions
(c) Brain stem - vital body functions
(3) Cerebrospinal fluid
(a) Nutrient fluid that bathes the brain and spinal cord
(b) Constantly created within the ventricles of the brain
(c) Reabsorbed by arachnoid membrane which covers the brain and spinal cord
(d) Obstruction of spinal fluid flow will create an accumulation of spinal fluid within the brain which causes an increase in intracerebral pressure
NOTE: Airway, breathing, and circulation assessment and management must take a priority.
(1) General assessment
(2) Assess airway
(3) Assess breathing
(4) Assess circulation
(1) Look for obvious injuries
(a) Depressed or open skull fractures
(b) Lacerations
(c) All head injuries must be suspected of having cervical spine involvement and be managed accordingly
(2) Bleeding from ear or nose
(a) Clear fluid from ear or nose
(b) Swelling and/or discoloration behind the ear (Battle's sign)
(c) Swelling and/or discoloration around both eyes (raccoon eyes): may indicate basil skull fracture
(3) Pupils
(a) Brainstem injury is probable if both pupils are dilated and do not react to light: If pupils are dilated but react to light injury is often reversible
(b) Other causes of dilated pupils that may or may not react to light:
(i) Hypothermia
(ii) Anoxia
(iii) Lightning strike
(iv) Optic nerve injury
(v) Direct trauma to the eye
(vi) Drug effect
(c) Fixed/dilated pupils signify injury only in patients with decreased level of consciousness
(4) Extremities - Casualty has intact sensation/motor function if withdrawal or localized pain to pinching of fingers and toes occurs: Usually indicates there is or minimally impaired or normal brain function.
(5) Vital signs
(a) Can indicate changes in intracranial pressure
(b) Observe/record vital signs during secondary survey and each time you perform a reassessment
(c) Increasing intracranial pressure causes increased blood pressure, the reasons for this are:
(i) In closed head injury Intracranial pressure increases as a result of swelling of the brain due to trauma.
(ii) As the pressure increases on the brain cerebrovascular perfusion may be compromised.
(iii) The result of this is an autonomic response by the brain to increase perfusion and this results in an increased blood pressure
(d) Low blood pressure caused by a head-injury is usually a terminal event
(e) Pulse: a decrease in pulse rate is caused by an increase in intracranial pressure
(f) Respirations
(i) Increasing intracranial pressure causes respiratory rate to increase, decrease, and/or become irregular
(ii) Unusual respiratory patterns may reflect level of brain/brainstem injury
(iii) Prior to death, the casualty may develop a rapid, noisy respiratory pattern called central neurogenic hyperventilation
(iv) Not as useful an indicator as other vital signs in monitoring the course of head injury. Could also be affected by:
* Fear
* Hysteria
* Chronic illnesses
* Chest injuries
* Spinal cord injuries
(g) Assess neurologic status (See Glascow Coma Scale Handout)
(i) Utilize the Glascow Coma Scale (GCS)
(ii) Severe head injury: GCS is < 9
(iii) Moderate head injury: GCS is 9 to 12
(iv) Minor head injury: GCS is 13 to 15
(6) Reassess
(a) Record level of consciousness
(b) Record pupil size and reaction to light
(c) Record vital signs
(d) Decisions on casualty management are made based on changes in all parameters of the physical and neurological examination
(e) Baseline neurological status must be established. Future decisions on treatment depend on baseline evaluations.
(1) Signs and symptoms
(a) Obvious object that has passed through an external cheek
(b) Bleeding into the mouth and throat
(c) Blood in the mouth and throat may induce nausea and vomiting
(2) Special considerations
(a) Ensure an open airway
(b) Ensure airway is free of obstructions (i.e., broken teeth/dentures or oral cavity bleeding)
(c) If necessary, examine the external cheek and the inside of the mouth to determine if the object passed through the cheek wall.
(d) If you see an impaled object in the cheek but cannot see both ends, stabilize the object in place. Do not try to remove it as long as the airway is intact.
(3) Treatment and transport considerations
(a) Immobilize the head and neck
(b) If the airway is open, leave the object in place and stabilize it. DO NOT TWIST THE OBJECT.
(c) Pack the inside of the cheek with rolled gauze, leaving 3 to 4 inches exposed, and dress the external wound
(d) Suction as needed
(e) Full spinal immobilization
(f) Transport in lateral recumbent position with head of spine board elevated to allow for drainage
(g) Give oxygen via the nasal cannula
(h) Monitor vital signs and airway every 3-5 minutes for any changes
(1) Signs and symptoms
(a) Abrasions, lacerations, and punctures
(b) Avulsions
(c) Difficulty breathing through nares
(d) Epistaxis
(2) Special considerations
(a) Other injuries may be present
(b) Ensure airway is patent. Even though the mouth may be clear, blood and mucus released from nasal injuries can flow into the throat causing an obstruction. Expect vomiting and be prepared to suction.
(c) Treatment and transport considerations
(i) Abrasions, lacerations, and punctures - Control bleeding, apply a sterile dressing, then, bandage in place.
(ii) Avulsion - Return the attached flaps to the normal position. Apply a pressure dressing and bandage. Fully avulsed flaps of skin and avulsed portions of external nose should be kept cool and transported with the patient.
(iii) Foreign objects - DO NOT pull free or probe. Transport without disturbing the object.
(iv) Fully immobilize the spine if signs of C-Spine or head injury is present.
(v) Monitor vital signs, airway, and LOC every 3-5 minutes. Transport the patient in a sitting position if no signs/symptoms of a head/spinal injury are present.
(vi) Nosebleeds (epistaxis)
* For a patient with no signs or symptoms of skull fracture or spinal injury, place the patient in a slightly forward, seated position to allow for drainage, or lay the patient back with the head slightly elevated, or turn the head to one side.
* For an unconscious patient or if signs and symptoms of spinal injury are present, fully immobilize the patient on a long spine board. Elevate the board 6 inches and turn it to the side to facilitate drainage.
* You or the patient may pinch the nostrils to control bleeding. Apply pressure for at least 5 minutes and do not pack the nostrils.
CAUTION: If there is clear fluid or a mix of blood and clear fluid draining from the nose or the ears, the patient may have a skull fracture. Do not pinch the nostrils or attempt to stop the drainage flow.
(1) Signs and symptoms
(a) Lacerated lip or gum
(b) Lacerated or avulsed tongue
(c) Dislodged teeth
(2) Special considerations
(a) Airway obstruction - look for foreign objects i.e. blood, teeth, vomit, mucus, etc.
(b) Remove any dislodged teeth and dental appliances
(i) With a gloved hand, remove loose dentures and any parts of broken dentures
(ii) Transport any dental appliance and broken teeth with the patient. Place the tooth in a container of normal saline or milk. Do not rub the tooth.
(c) Ensure an open airway
(d) Lacerated lip or gum - Control bleeding by placing a rolled or folded dressing between the lip and the gum leaving a dressing “tail" exposed. For profuse bleeding, position the patient to allow for drainage. Monitor the patient and dressing closely. ONLY IF THE PATIENT IS FULLY ALERT.
(e) Lacerated or avulsed tongue - DO NOT pack the mouth with dressings. Position the patient for drainage. For a fully avulsed tongue, save and wrap the part, keep it cool, and transport it with the patient.
(f) Avulsed lip - Control bleeding with a pressure dressing and position for drainage. Do not bandage across the mouth. Save, wrap, label, and transport any fully avulsed tissues keeping the part cool.
(f) Transport the patient in a sitting position unless signs of spinal/head injury are present
(1) Scalp wounds
(a) Do NOT underestimate blood loss from a scalp wound
(b) Control with direct pressure
(2) Skull injuries
(a) Linear nondisplaced fractures, compound fractures, or depressed fractures
(b) In adults with large contusion or darkened swelling of scalp, suspect underlying skull fracture
(i) Placing direct pressure upon an obvious depresses or compound skull fracture should be AVOIDED
(ii) Leave penetrating object in the skull in place and immediately transport to the MTF
(iii) For a gunshot wound to the head, unless there is a clear entrance and exit wound to the head, assume the bullet may have ricocheted and be lodged in the neck near the spinal cord
(1) Concussion
(a) Implication that there is no significant injury to the brain
(b) Trauma to the head with a variable period of unconsciousness or confusion and then a return to normal consciousness
(c) Amnesia from the injury may occur
(d) Short-term memory may be affected and there may be:
(i) Dizziness
(ii) Headache
(iii) Ringing in the ears
(iv) Nausea
(2) Cerebral contusion
(a) Bruised brain tissue
(b) History of prolonged unconsciousness or serious alteration in state of consciousness
(i) Profound confusion
(ii) Persistent amnesia
(iii) Vomiting
(iv) Abnormal behavior
(c) Brain swelling may be severe and rapid
(d) Casualty may appear to have suffered a cerebrovascular accident (stroke) or have focal neurological signs
(e) Casualty may have personality changes dependent on location of cerebral contusion
(f) Injured casualties with an altered level of consciousness should be hyperventilated and transported rapidly to a trauma center
(3) Intracranial hemorrhage
(a) Three major types-epidural hematoma, subdural hematoma, and intracranial hematoma
(b) Signs and symptoms include:
(i) Headache
(ii) Visual changes
(iii) Personality changes
(iv) Slurring of speech
(v) Confusion
(vi) Changes in level of consciousness and coma
(4) Special considerations
(a) Suspect brain or C-spine injuries for all head, face, and neck wounds
(b) Check mouth carefully for broken teeth/blood
(c) Do NOT attempt to clean the surface of a scalp wound. To do so may cause additional bleeding.
(d) Do NOT remove impaled objects; stabilize in place
(e) Gently palpate for depressions
(f) Do NOT apply a pressure dressing
(5) Treatment and transport considerations
(a) Ensure an open and clear airway
(b) Protect for possible neck/spinal injuries
(i) Do not lift or attempt to wrap the head of a casualty who is lying down if there are signs of a spinal injury
(ii) Neck movement worsens the injury of the casualty with a spinal injury
(c) Control bleeding by gentle pressure
(i) If brain tissue is exposed or cranial/facial fracture suspected, do not apply pressure
(ii) Use only enough pressure to stop the flow of blood
(iii) Underlying fractures may be present
(d) Manage IV fluids, as indicated
(i) Administer normal saline or .45 % normal saline only overload
(ii) Restrict to minimal fluid infusion to avoid overload
(e) Assess for shock:
(i) Administer fluids as needed to support circulation if hypovolemic shock is the cause
(f) Apply a dressing/bandage being careful not to compromise the airway
(g) If brain tissue is exposed, apply a sterile dressing. Local protocol will dictate whether to apply a moist or dry sterile dressing
(h) Administer a high flow of oxygen
(i) Reassess neurologic status and vital signs
(i) Increase in severity of headache
(ii) Increase pupil size
(iii) Progressive weakness on one side
(j) Stabilize impaled object
(k) Support with suction of secretions as needed if available
(l) Administer wound care. Evaluate last tetanus immunization for update, if appropriate
(m) Administer pain control as needed
(n) Full spinal immobilization
(o) Transport in head raised position by elevating the top of the litter or spine board 6 inches. If a facial wound is present, tilt the spine board towards the side of the injury to allow for drainage.
(p) Raise head of bed 30 degrees
To provide your casualty with the highest chance of recovery, you must know the anatomy of the head and central nervous system. The most important point in management of the head injured casualty is rapid assessment, treatment of decreased level of consciousness by hyperventilation and adequate airway management, rapid transport to the appropriate echelon of care, and frequent reassessment. Also remember that spinal injury is usually associated with head injuries. You must immobilize the spine to prevent harm and paralysis.