Head Injury
Created by George Encinosa
CE Broker Number 20-300417
Objectives
At the completion of this packet the learner will:
1. Discuss knowledge of the Anatomy and Physiology of the nervous system
2. Verbalize of the sympathetic and parasympathic nervious system
3. Compare the difference between an open and a close head injury.
4. Verbalize the different types of brain injuries
5. List the three types of intra-cranial bleeding.
Anatomy and Physiology of the Nervous System
The Central nervous system consist of the Brain and spinal cord. This Includes skull and spinal
column. Different parts of the brain control different functions. The Cerebrum controls most
voluntary motor function and conscious thought. The Cerebellum coordinates body movements,
and the Brain stem controls functions necessary for life, including cardiac and respiratory
systems. The skull is covered by layer of muscle fascia, above which is the scalp. While the
spinal canal is surrounded by a thick layer of skin and muscles. The CNS is further protected by
the meninges consisting of an outer layer called the dura mater and an inner layers are the
arachnoid and pia mater. The arachniod and pia are much thinner than the dura mater and
contain blood vessels. Cerebral spinal fluid fills the space between the meninges and acts as a
shock absorber. When an injury penetrates these layers, CSF may leak from the nose, ears, or an
open skull fracture.
Sensory nerves carry information from the body to the brain. Motor nerves carry information
from the brain to the body, connecting nerves link sensory nerves to motor nerves.
The nervous system controls the body’s activities. Voluntary activities are under conscious
control (somatic) while involuntary activities are not under conscious control (autonomic).
The Sympathetic nervous system or sometime referred to as the fight or flight response secrete
a chemical call Norepinephrine. Norepinephrine is a positive inotropic and positive
chronotropic on the heart with vasoconstriction and bronchial dilation properties. Some
common responses are dilated pupils, increased pulse rate, or rising blood pressure.
Parasympathetic system is the complete opposite effects of sympathetic. The parasympathetic
nervous secretes acetylcholine
The skull has two layers of bone that protect the brain, the cranium and the face.
The spinal column is the body’s central supporting structure. It is made up of vertebrae which
are divided into the cervical, thoracic, lumbar, sacral, and coccygeal. Vertebrae. Vertebrae are
connected by ligaments and separated cushions, called intervertebral disks.
Injury to the vertebrae can cause paralysis if the spinal cord has been damage or compressed.
Head Injuries
All head injuries can be potentially serious. Face and scalp have unusually rich blood supplies
and even small lacerations can quickly lead to significant blood loss. Scalp lacerations are
usually the result of direct blows to the head; they often indicate deeper, more serious injuries.
A fracture of the skull is an indication of a significant force applied to the head. The fracture
may be open or closed. A conclusion that a fracture is present if:
a. The patient’s head appears deformed.
b. There is a visible crack in the skull within a scalp laceration.
c. Ecchymosis develops under the eyes (raccoon eyes).
d. Ecchymosis appears behind one ear over the mastoid process (Battle’s sign).
A Brain injuries can be classified into three main category, a concussion, a contusion and
Intracranial bleeding.
A concussion is a temporary loss or alteration of part or all of brain function without actual
physical damage to the brain. A concussion may result in unconsciousness the inability to
breathe for short periods of time.
A concussion could result in confusion or amnesia. The amnesia can fall under to category
Retrograde amnesia: Patient is able to remember everything but the events leading up to
the injury.
Anterograde amnesia: Patient cannot remember events after the injury.
This condition usually lasts only a short time.
A contusion is a bruise to the brain which can occur when the skull is struck. It involves physical
injury to the brain tissue. There will be bleeding and swelling from injured blood vessels. The
bleeding will cause an increase intracranial pressure within the skull.
Intracranial bleeding is caused by a laceration or rupture of a blood vessel inside the brain
or in the meninges, in one of three areas:
i. Subdural hematoma: Beneath the dura but outside the brain
ii. Intracerebral hematoma: Within the substance of the brain tissue itself
iii. Epidural hematoma: Outside the dura and under the skull
Intracranial bleeding can develop rapidly, usually due to arterial injury, as in an epidural
hematoma or It can develop very slowly, as may be seen with a subdural hematoma
Expanding hematoma results in compression of the brain tissue, can cause progressive loss
of brain function.
Cerebral edema is a common complication of any head injury and one of the most serious
It is aggravated by low oxygen levels in the blood and improved by adequate perfusion.
Ensure that the airway is open and that adequate ventilations and high-flow oxygen are
given. Do not wait for cyanosis or other obvious signs of hypoxia.
It is not uncommon for the patient with a head injury to have a convulsion or seizure.
Another effect of cerebral edema and increased intracranial pressure (Cushing’s reflex)
Which is an increased blood pressure, a decreased pulse rate, and irregular respirations
Signs and symptoms to look for in a head injury include
1. Lacerations, contusions, or hematomas to the scalp
2. Soft area or depression upon palpation
3. Visible fractures or deformities of the skull
4. Ecchymosis about the eyes (raccoon eyes) or behind the ear over the mastoid process
(Battle’s sign)
5. Clear or pink CSF leakage from a scalp wound, the nose, or ear
6. Failure of the pupils to respond to light
7. Unequal pupil size
8. Loss of sensation and/or motor function
9. A period of unconsciousness
10. Amnesia
11. Seizures
12. Numbness or tingling in the extremities
13. Irregular respirations
14. Dizziness
15. Visual complaints
16. Combative or other abnormal behavior
17. Nausea or vomiting
Glasgow coma scale
A Glasgow scale is a good indicator of a possible head injury and the severity of the injury. GCS
is broken down into three section, eye response, verbal response and motor response. Every time
a patient response in a particular category they receive a number all three number are add up to
give you the Glasgow scale. This GLS will give you an indication of the severity of the injury or
neurological status.
A Glasgow of 15 is considered normal as the number decreases the severity of the neurological
deficit become higher. The lowest number possible on the scale is a 3. Someone with a Glasgow
scale of 8 is to be considered to have a substantial injury.
To perform a Glasgow start with the eyes
Eye Opening Response
4=Spontaneous : at this point, with no stimulation the patient’s eyes open
3=To voice: the patient eyes are closed and a request to open your eyes should be complied with.
2=To pain: If verbal stimulation is unsuccessful in eliciting eye opening, the standard painful
stimulus is applied. Document if eyes are closed due to swelling or facial injuries, etc.
1=None: no eye opening.
Best Verbal Response
5=Orientated: After the patient is aroused, he is asked who he is , where he is and what the year
and month are. If accurate answers are obtained, this is recorded as oriented.
4=Confused: Although the patient is unable to give correct answer to previous questions, he is
capable of producing complete phrases, sentences, and even conversational exchange.
3=Inappropriate words: The patient speaks or exclaims only a word or two. Such a response is
unusually obtained only by physical stimulation rather than a verbal stimulus, although
occasionally a patient will shout obscenities or call relatives names for no apparent reasons
2=Incomprehensible word: The patient response consists of groans, moans, or indistinct
mumbling and does not contain any intelligible words.
1=No verbal response: Prolonged and, if necessary, repeated stimulation does not produce any
phonation.
Best Motor Response
6=Obeys command: This requires an ability to comprehend instructions, usually given in some
form of verbal commands but sometimes by gestures and writing. The patient is required to
perform the specific movements requested.
5=Localizes Pain: If the patient does not obey commands, a painful stimulus may be applied as
firm pressure to the sternum or nail bed for 5 seconds.
Reaches to and / or tries to remove source of pain
4=Withdrawals: After painful stimulus:
• Elbow flexes
• Rapid movement
• No muscle stiffness
• Arm is drawn away from the torso
3=Flexion Response: After painful stimulus:
• Slow movement
• Accompanied by stiffness
• Forearm and head held against the body
• Limbs assume hemiplegic position
2=Extension Response: After painful stimulation:
• Leg and arm extend
• Accompanied by stiffness
• Internal rotation of shoulder and forearm
1=None: no motor response.
Assessment of Head and Spine Injuries
Suspect a spinal injury with the following significant mechanisms of injury:
1. Motor vehicle crashes
2. Pedestrian-motor vehicle collisions
3. Falls
4. Blunt trauma
5. Penetrating trauma to the head, neck, or torso
6. Motorcycle crashes
7. Hangings
8. Diving accidents
9. Recreational accidents
.
Initial assessment
General impression
a. Ask the patient:
i. What happened?
ii. Where does it hurt?
iii. Does your neck or back hurt?
iv. Can you move your hands and feet?
v. Did you hit your head?
b. Confused or slurred speech, repetitive questioning, or amnesia are good indicators of a
head injury.
c. If patient is unresponsive, ask family/bystanders when the patient lost consciousness.
d. Stabilize the spine in all cases unless the patient is crystal clear on what happened and it
is a non-significant MOI.
Airway and breathing
a. Use the jaw-thrust maneuver to open the airway.
b. Vomiting may occur in patients with a head injury. Suction immediately.
c. Move the patient as little as possible. Once the c-collar is applied, do not remove it.
d. Breathing difficulty may occur. If breathing is too fast or shallow, provide positive
pressure ventilations.
Circulation
a. A pulse that is too slow can indicate a serious condition.
b. Assess and treat for shock.
Transport decision
a. If patient has problems with ABCs, provide rapid transport.
Focused history and physical exam
The absence of pain does not rule out a potential spinal injury. Do not ask patients with possible
spinal injuries to move their neck. Rapid physical exam for significant trauma exam must be
quick and decisive. Decreased level of consciousness is the most reliable sign of a head injury.
People with head injuries have irregular respirations. Look for blood or CSF leaking from the
ears, nose, or mouth and for bruising around the eyes and behind the ears. Evaluate the pupils.
Unequal pupil size often signals a problem. Do not probe scalp lacerations. Do not remove an
impaled object from an open head injury.
Focused physical exam for a non-significant trauma warrants the provider to watch for a change
in the level of consciousness. Use the Glasgow Coma Scale. Any pain, tenderness, weakness,
numbness, and tingling could be signs of spinal injury. Patients with severe spinal injury may
lose sensation or become paralyzed below the suspected level of injury. They may become
incontinent.
Obtain baseline vital signs, a complete set of baseline vital signs is essential. Without a set of
baseline vital you will not be able to monitor the progression of the injury.
Assess pupil size and reactivity to light. If injury has occurred on one side of the brain, just one
pupil will dilate. Continue to monitor the pupils for changes.
Do a SAMPLE history .Gather as much history as possible while preparing for transport.
Interventions of a head injury include:
a. Control bleeding.
b. Using a dry, sterile dressing, fold torn skin flaps back down onto the skin bed before
applying pressure.
c. If you suspect a skull fracture, do not apply excessive pressure; this may push bone
fragments into the brain.
d. If the dressing becomes soaked, place a second dressing over it.
e. Once bleeding has been controlled, secure it with a soft self-adhering roller bandage.
f. Monitor and treat for shock.
g. Protect airway from vomiting.
h. Provide immediate transport.
i. Document vital signs every 5 minutes for unstable patients and every 15 minutes for
stable patients.
Emergency Medical Care of Spinal Injuries
Management of the spinal injury is very important, if not handled properly you can further there
injury and can cause permanent paralysis. Here are the steps you can take to properly manage
this type of injury
A. Initial steps
1. Follow BSI precautions.
2. Maintain the airway.
3. Assess respirations.
4. Give oxygen.
B. Managing the airway
1. If the airway is obstructed, perform the jaw-thrust maneuver.
2. Do not use the head tilt-chin lift maneuver.
3. Once the airway is open, hold the head in a neutral, in-line position until it can be fully
immobilized.
4. Consider inserting an oro-pharyngeal airway.
5. Give oxygen to any patient who is having trouble breathing.
C. Stabilization of the cervical spine
1. Begin manual in-line stabilization by holding the head firmly with both hands.
2. Kneel behind the patient, and place hands around the base of the skull on either side.
3. Support the lower jaw with index and long fingers while supporting the head with palms.
4. Gently lift the head until the patient’s eyes are looking straight ahead and the head and
torso are in line (eyes-forward position).
a. Align the nose with the navel.
b. Never twist, flex, or extend the head or neck excessively.
5. Manually maintain this position as airway is established.
a. Have the partner place a rigid cervical collar around the neck to provide more stability.
b. Do not remove hands from the patient’s head until the patient is properly secured to a
backboard and the head is immobilized.
c. Patient must remained immobilized until he or she is examined at the hospital.
6. Once the patient is immobilized, assess the pulse, motor function, and sensation in all
extremities.
7. An improperly fitting collar will do more harm than good.
a. If a properly sized collar is not available, place a rolled towel around the head and tape
it to the backboard while immobilizing the patient on the board.
b. Maintain manual support until the patient is fully secured to a backboard.
8. Do not force the head into a neutral, in-line position if any of the following develop:
a. Muscle spasms in the neck
b. Increased pain
c. Numbness, tingling, or weakness
d. Compromised airway or ventilation
9. In these situations, immobilize the patient in the position in which the patient was found.
Emergency Medical Care of Head Injuries
Patients with head injuries often have injuries to the cervical spine. Protect and stabilize the
cervical spine at all times. Avoid moving the neck.
Treat the patient with a head injury according to three general principles:
1. Establish an adequate airway.
2. Control bleeding and provide adequate circulation to maintain cerebral perfusion.
3. Assess the patient’s baseline level of consciousness and continuously monitor it.
Assess and treat other injuries. Be prepared for convulsions and other changes in the patient’s
condition. Transport the patient promptly and with extreme care.
Managing the airway
1. Establish an adequate airway.
2. If a patient has an airway obstruction, perform the jaw-thrust maneuver to open the airway.
3. Once the airway is open, maintain the head in a neutral, in-line position until it can be fully
immobilized with a cervical collar.
4. Remove any foreign bodies, secretions, or vomitus from the airway.
5. Make sure a suctioning unit is available.
6. Once the airway has been cleared, check ventilation.
7. Give high-flow oxygen to any patient who is having trouble breathing.
a. Reduces hypoxia and possible cerebral edema
b. Do not wait until the patient becomes cyanotic.
8. Continue to assist ventilations and administer oxygen until the patient reaches the hospital.
Circulation
1. Begin CPR if the patient is in cardiac arrest.
2. Active blood loss aggravates hypoxia by reducing the available number of oxygen-
carrying red blood cells.
3. With a head injury, shock is usually due to hypovolemia caused by bleeding from other
injuries.
a. Transport such patients immediately to a trauma center.
b. Maintain the airway while:
i. Protecting the cervical spine
ii. Ensuring adequate ventilation
iii. Administering 100% oxygen
iv. Controlling obvious sites of bleeding with direct pressure
v. Placing the patient supine on a backboard
vi. Keeping the patient warm
4. If a patient becomes nauseated or begins to vomit, place him or her on the left side to
prevent aspiration.
a. Be sure to maintain the head in the in-line neutral position with the cervical collar in
place.
b. Also have a suctioning unit available.
Preparation for Transport
Certain consideration and preparation must be made to transport a spinal injury safely to the
hospital with increasing the likelihood of furthering the injury. Here are some steps you can take
when transporting a spinal injury patient.
Supine patients
1. A patient who is supine can be effectively immobilized by being secured to a long
backboard.
2. The four-person log roll is the ideal procedure for moving a patient from the ground to a
long backboard.
3. Steps in immobilizing a supine patient to a long backboard include:
a. Maintain in-line stabilization.
b. Assess pulse, motor, and sensory function in all extremities.
c. Apply a cervical collar.
d. The other team members should position the immobilization device (backboard) and
place their hands on the far side of the patient.
e. On command, rescuers log roll the patient toward themselves.
i. One rescuer quickly examines the back while the patient is log rolled on the side, then
slides the backboard behind and under the patient.
ii. The team then rolls the patient back onto the backboard.
f. Ensure that the patient is centered on the backboard.
g. Secure the upper torso first.
h. Secure the pelvis and upper legs next.
i. Begin to immobilize the patient’s head to the backboard by positioning a commercial
immobilization device or rolled towels.
j. Secure the head by taping the head-immobilization device or towels across the forehead.
k. Check and readjust all straps as needed.
l. Reassess pulse, motor, and sensory function in all extremities and continue to do so
periodically.
Sitting patients
Some patients with a possible spinal injury will be in a sitting position. Use a short backboard or
other spinal extrication device to immobilize the spine. The short board is then secured to the
long board. Exceptions to this rule are situations in which there is not time to first secure the
patient to the short board, including:
a. You or the patient are in danger.
b. You need to gain immediate access to other patients.
c. The patient’s injuries justify urgent removal.
d. In these situations, lower the patient directly onto a long backboard, using the rapid
extrication technique.
3. Steps in immobilizing a patient found in a sitting position include:
a. Stabilize the head and then maintain manual in-line stabilization until the patient is
secured to the long backboard.
b. Assess pulse, motor, and sensory function in each extremity.
c. Apply a cervical collar.
d. Insert a short spine immobilization device between the patient’s upper back and the
seat back.
e. Open the board’s side flaps (if present), and position them around the patient’s torso
and snug to the armpits.
f. Secure the upper torso straps first.
g. Position and fasten both groin loops.
h. Pad any space between the patient’s head and the board as necessary.
i. Secure the forehead strap.
j. Place the long backboard next to the patient’s buttocks.
k. Turn the patient parallel to the long board, and slowly lower him or her onto it.
l. Lift the patient (without rotating him or her), and slip the long board under the short
board.
m. Secure the short and long boards together.
n. Reassess the pulse, motor, and sensation in all four extremities.
Standing patients
1. The EMT-B may arrive at a scene to find a patient standing or wandering around after an
accident or injury.
2. If underlying head, neck, or spinal injuries are suspected, immobilize the patient to a long
backboard before proceeding to assess him or her.
3. Steps in immobilizing a patient found in a standing position include:
a. Establish manual, in-line stabilization, apply a cervical collar, and instruct the patient
to remain still.
b. Position the backboard upright directly behind the patient.
c. Two EMT-Bs stand on either side of the patient and the third is directly behind the
patient, maintaining immobilization.
d. The two EMT-Bs grasp the handholds at shoulder level or slightly above by reaching
under the patient’s arms while standing at either side.
e. Prepare to lower the patient to the ground.
f. Carefully lower the patient as a unit under the direction of the EMT-B at the head. That
EMT-B will have to make sure that the patient’s head stays against the board and
carefully rotate his or her hands as the patient is being lowered in order to maintain in-
line stabilization.
Immobilization devices
1. Assume the presence of spinal injury in all patients who have sustained head injuries.
2. Use manual in-line immobilization or a cervical collar and long spine board.
Cervical collars
1. Cervical collars provide preliminary, partial support.
2. One should be applied to every patient who has a possible spinal injury.
3. Keep in mind that cervical collars do not fully immobilize the cervical spine.
4. Maintain manual support until the patient is completely secured to a spinal immobilization
device.
5. To be effective, a rigid cervical collar must be the correct size for the patient.
a. The collar should rest on the shoulder girdle.
b. It must provide firm support under both sides of the mandible, without obstructing the
airway.
6. Application of a cervical collar
a. One EMT-B provides continuous manual in-line support of the head while the other
prepares the collar.
b. Measure the proper collar size.
i. An improperly sized immobilization device has potential for further injury.
ii. If the correct size is not available, use a rolled towel; tape it to the backboard around
the patient’s head, and provide continuous manual support.
c. Begin by placing the chin support snugly underneath the chin.
d. Maintaining head and neutral neck alignment, wrap the collar around the neck and
secure the collar to the far side of the chin support.
e. Ensure that the collar fits properly and recheck that the patient is in a neutral, in-line
position. Maintain in-line stabilization until the patient is completely secured to the
board.
Short backboards
1. Most common are the vest-type device and the rigid short board.
2. They are designed to stabilize and immobilize the head, neck, and torso.
3. Use a short backboard to immobilize noncritical patients who are found in a sitting
position and have possible spinal injuries.
Long backboards
1. Several types of long board immobilization devices provide full body spinal
immobilization.
2. Long backboards are used to immobilize patients found in any position.
Pediatric needs
1. If infants and children who have been in motor vehicle crashes are found still in their car
seats:
a. Immobilize the child in the car seat, if possible.
b. Apply a cervical collar, ensuring it is properly sized.
2. If a properly fitting collar is not available, use a rolled towel and tape it to the car seat.
a. Pad the sides of the car seat to prevent lateral movement.
b. Place additional padding in any spaces between the patient and the car seat.
3. If the child is not in a car seat:
a. Use an appropriately sized immobilization device.
b. Small children may require additional padding to maintain the in-line neutral position.
c. Pad, as needed, to avoid excessive neck flexion.
Click here to start exam
References
Heegaard WG, Biros MH. Head. In: Marx J. Rosen’s Emergency Medicine: Concepts and
Clinical Practice. 7th ed. St. Louis, Mo: Mosby; 2009:chap. 38.
Atabaki SM. Pediatric head injury. Pediatr Rev. 2007;28(6):215-224.
Evan Fusco, MD, Consulting Staff, Department of Emergency Medicine, St John's Regional Health Center.
2009