Brain injury

Head injury or, more specifically, traumatic brain injury (TBI), is a major cause of death and
disability in multiple-trauma patients worldwide. Traumatic brain injury is a serious condition
caused by an external force impacting the head, leading to damage to the brain.
As an emergency care provider, promptly recognizing and transporting head injuries, especially
those above the clavicle, can significantly improve patient outcomes by ensuring timely
intervention for potential TBI and cervical spine injuries.
Traumatic brain injury (TBI)
 A major cause of death and disability
 CNS injury present in 40% of multiple traumas
 TBI is the cause of 25% of trauma fatalities
 Prevention remains the most effective treatment

Pathophysiology of Head Trauma

Head injuries are either open or closed, depending on whether or not the Dura mater is
breached. Brain injury processes can also be divided into two components: primary and
secondary.

1. Primary brain injury

Results from immediate mechanical force and is best prevented through safety measures like
seat belts, helmets, and firearms education. Injuries can occur from external forces or brain
movement within the skull, causing damage at the impact site injuries may occur to the brain
in the area of original impact (coup) or the opposite side (contracoup).
 2. Secondary brain injury

Results from hypoxia and decreased brain perfusion. It can be prevented with good
prehospital care. Swelling from the primary injury increases intracranial pressure, reducing
cerebral blood flow and causing further damage. Maintaining normal CO2 levels (35-45
mmHg) is crucial, as both hyperventilation and hypoventilation can worsen brain injury.
Prophylactic hyperventilation is no longer recommended.

Head Injuries
 The head consists of the face, scalp, skull, and brain.
 Each of these components can sustain serious injuries.
 In young children, the head is the heaviest part of the body.
 This makes children more prone to head injuries from falls or deceleration trauma.

1. Facial Injuries
 Facial wounds can range from minor to potentially fatal due to airway compromise or
hemorrhagic shock.
 Most bleeding can be controlled by direct pressure, but life-threatening hemorrhage from
the nose or pharynx can be difficult to manage prehospital.
 Nasal fractures are common and rarely cause severe hemorrhage.
 Facial and jaw fractures pose a risk of airway compromise due to swelling and bleeding.
 Eye injuries, while not life-threatening, can be disabling and should be treated with gentle
irrigation and an eye shield, avoiding pressure on the globe.

Common signs and symptoms of facial injuries in a prehospital setting:

 Visible Deformities: Uneven or deformed facial bones.

 Swelling and Bruising: Around the eyes, nose, or jaw.
 Bleeding: From open wounds, nose, or mouth.
 Pain: Especially when moving the jaw or facial muscles.
 Difficulty Breathing: Due to swelling or bleeding obstructing the airway.
 Vision Problems: Blurred or double vision, difficulty moving the eyes.
 Numbness: Changes in sensation over the face.
 Displaced Jaw or Nose: Misalignment of the upper and lower jaw.
  Difficulty Swallowing: Due to swelling or injury

Management
1. Airway Management:
 Ensure the airway is clear and unobstructed.
 Be prepared to perform advanced airway techniques if necessary, such as
intubation.
2. Bleeding Control:
 Apply direct pressure to control bleeding.
 Use gauze or bandages to cover wounds and maintain pressure.
3. Stabilization:
 Immobilize the cervical spine if there is any suspicion of spinal injury.
 Stabilize any obvious fractures using appropriate splints or bandages.
4. Eye Protection:
 For eye injuries, gently irrigate with normal saline if chemicals are involved.
 Apply an eye shield and avoid any pressure on the globe, especially if an open
globe injury is suspected.
5. Monitoring and Support:
 Continuously monitor vital signs and oxygen saturation.
 Provide oxygen therapy if needed.
6. Positioning:
 Elevate the head of the stretcher to reduce swelling and facilitate breathing.
7. Pain Management:
 Administer analgesics as appropriate to manage pain and discomfort.
8. Transport:
 Transport the patient to the nearest appropriate medical facility for further
evaluation and treatment

Special consideration
 Nose bleeding
1. Stay Calm: Keep the person calm and seated.
2. Lean Forward: Have them lean slightly forward to avoid swallowing blood.
3. Pinch the Nose: Pinch the soft part of the nose (just below the bony bridge) for 10-15
minutes.
4. Breathe Through the Mouth: Encourage breathing through the mouth while pinching the
nose.
5. Apply Ice: Place an ice pack on the bridge of the nose to constrict blood vessels.
6. Avoid Nose Blowing: Advice against blowing the nose for several hours after the
bleeding stops.
7. Nasal packing with vasoconstrictor

Figure -- Pinch the Nose for nose bleeding management

 Penetrating Eye Injury
Sign and Symptoms
 Object stuck in the eye
 Painful red eye or a reported feeling of something in eye
 GGG Problems with vision
 Abnormally shaped pupil
 Clear liquid draining from the eye
 Signs of trauma around the eye
Prehospital Management
 Do not push on the eye
 Do not remove objects penetrating the eye
 Elevate the head of the bed and place a patch over both eyes
 Urgent transfer to hospital where ophthalmology service is available
2. Scalp wound
  Scalp wounds bleed heavily due to the high vascularity and inelastic tissue, which
prevents normal vasospasm.
 This can lead to prolonged bleeding and significant blood loss.
 While shock from scalp wounds is rare in adults, children are at higher risk due to
their smaller blood volume.

Key signs and symptoms of a scalp wound in a prehospital setting:

 Visible Bleeding: Often heavy and brisk due to the scalp’s high vascularity.
 Swelling and Bruising: Around the wound site.
 Pain: Localized to the area of injury.
 Possible Skull Fracture: Look for deformities or irregularities in the skull.
 Neurological Symptoms: Such as confusion, dizziness, or loss of consciousness,
indicating potential brain injury.
 Shock: Particularly in children, due to significant blood loss.

Management

 Control Bleeding: Apply direct pressure with sterile gauze. If bleeding is severe,
use a hemostatic dressing.
 Irrigate the Wound: Clean the wound with saline or clean water to remove debris
and reduce infection risk.
 Assess for Serious Injuries: Check for signs of skull fractures or brain injury, such
as altered consciousness or neurological deficits1.
 Protect the Wound: Cover with a sterile dressing. Avoid adhesive bandages
directly on the scalp.
 Monitor for Shock: Keep an eye on vital signs and be prepared to manage shock,
especially in children.
 Transport Promptly: Ensure rapid transport to a medical facility for further
evaluation and treatment.

3. Skull Injuries
A skull injury involves any damage to the bones of the skull, often resulting from trauma.
These injuries can range from minor fractures to severe, life-threatening conditions.

Types of Skull Injuries

 Linear Fractures: Simple breaks in the bone without displacement.

 Depressed Fractures: Bone fragments are pushed inward, potentially damaging
the brain.
 Basilar Fractures: Breaks at the base of the skull, often involving the temporal
bone.
 Compound Fractures: Open fractures where the bone breaks through the skin.

Signs and Symptoms

 Visible Deformity: Irregularities or depressions in the skull.

 Bleeding: From the wound, ears, nose, or mouth.

 Bruising: Around the eyes (raccoon eyes) or behind the ears (Battle’s sign).

 Neurological Symptoms: Confusion, loss of consciousness, seizures, or focal

neurological deficits.

 CSF Leakage: Clear fluid draining from the nose or ears, indicating a possible
basilar fracture.

Management
  Initial Assessment: Conduct a primary survey (ABCs - Airway, Breathing, and
Circulation) and stabilize the cervical spine.

 Control Bleeding: Apply direct pressure to external wounds with sterile gauze.
Avoid excessive pressure if a skull fracture is suspected.

 Protect the Airway: Ensure the airway is clear and consider advanced airway
management if necessary.

 Monitor Neurological Status: Regularly assess the patient’s level of consciousness

using the Glasgow Coma Scale (GCS).

 Immobilize the Patient: Use a cervical collar and backboard to prevent further
injury.

 Administer Oxygen: Provide supplemental oxygen to maintain adequate

oxygenation.

 Prevent Hypotension: Establish IV access and administer fluids to maintain blood

pressure.

 Rapid Transport: Expedite transport to a trauma center for definitive care.

Special Considerations
 Avoid Nasal Intubation: In cases of suspected basilar skull fractures, avoid nasal
intubation due to the risk of further injury.

 Pain Management: Administer analgesics cautiously, avoiding medications that

may mask neurological symptoms.

4. Brain Injuries

Brain injuries and related vascular injuries vary in severity. They range from minor to
life-threatening conditions. Let’s explore these injuries, starting with the least severe and
moving towards the most critical.

4.1 Concussion
 A concussion is a mild traumatic brain injury (TBI) caused by a blow to the head or a
sudden jolt that shakes the brain inside the skull. It temporarily affects brain function.

 No structural injury to brain

 Level of consciousness may be affected
 May cause retrograde short-term amnesia
Signs and Symptoms
 Headache: Often the most common symptom.
 Confusion: Difficulty thinking clearly or concentrating.
 Dizziness: Feeling unsteady or lightheaded.
 Nausea and Vomiting: Common after the injury.
 Memory Loss: Difficulty remembering events before or after the injury.
 Sensitivity to Light and Noise: Increased sensitivity to stimuli.
 Fatigue: Feeling unusually tired or lethargic.

Prehospital Management
 Initial Assessment: Conduct a primary survey (ABCs - Airway, Breathing, and
Circulation) and stabilize the cervical spine if necessary.
 Monitor Consciousness: Regularly assess the patient’s level of consciousness
using the Glasgow Coma Scale (GCS).
 Prevent Further Injury: Ensure the patient avoids activities that could lead to
another head injury.
 Provide Comfort: Keep the patient calm and comfortable. Administer analgesics
if needed, avoiding medications that may mask symptoms.
 Educate the Patient: Inform the patient and their caregivers about the signs of
worsening symptoms, such as increasing headache, repeated vomiting, or
confusion.
 Transport: If symptoms are severe or worsening, transport the patient to a
medical facility for further evaluation.

4.2 Cerebral contusion

A cerebral contusion is a type of traumatic brain injury (TBI) where the brain tissue is bruised,
leading to bleeding and swelling within the brain. This injury often results from a direct blow to
the head.

Signs and Symptoms

 Altered Consciousness: Ranging from confusion to loss of consciousness.

 Neurological Deficits: Weakness, numbness, or difficulty speaking.
 Headache: Severe and persistent.
 Nausea and Vomiting: Common after the injury.
 Seizures: May occur immediately or be delayed.
 Behavioral Changes: Agitation or lethargy.

Prehospital Management

 Initial Assessment: Conduct a primary survey (ABCs - Airway, Breathing, Circulation)

and stabilize the cervical spine.
 Airway Management: Ensure the airway is clear. Consider advanced airway
management if necessary.
 Oxygenation: Provide supplemental oxygen to maintain adequate oxygenation.
 Monitor Vital Signs: Regularly check blood pressure, heart rate, and respiratory rate.
 Neurological Assessment: Use the Glasgow Coma Scale (GCS) to assess the level of
consciousness.
 Prevent Secondary Injury: Avoid hypotension and hypoxia, which can worsen brain
injury.
 Control Seizures: Administer anticonvulsants if seizures occur.
 Rapid Transport: Expedite transport to a trauma center or specialized facility.

Special Considerations

 Avoid Nasal Intubation: In cases of suspected basilar skull fractures.

 Pain Management: Administer analgesics cautiously, avoiding medications that may
mask neurological symptoms.

4.3 Intracranial Hemorrhage in Trauma:

Intracranial hemorrhage (ICH) refers to bleeding within the skull, often resulting from traumatic
injury. This bleeding can occur in various locations, including within the brain tissue
(intracerebral), between the brain and its outer coverings (subdural or epidural), or in the spaces
around the brain (subarachnoid). It is a life-threatening condition requiring immediate medical
attention.

Signs and Symptoms

 Severe Headache: Often sudden and intense.

 Altered Consciousness: Ranging from confusion to coma.
 Neurological Deficits: Weakness, numbness, difficulty speaking, or vision problems.
 Nausea and Vomiting: Common in acute phases.
 Seizures: May occur immediately or be delayed.
 Pupil Changes: Unequal pupil size or non-reactive pupils.
 High Blood Pressure: Often present in cases of Intracerebral hemorrhage.

Prehospital Management

 Initial Assessment: Conduct a primary survey (ABCs - Airway, Breathing, and

Circulation) and stabilize the cervical spine if trauma is suspected3.
 Airway Management: Ensure the airway is clear. Consider advanced airway
management if necessary3.
 Oxygenation: Provide supplemental oxygen to maintain adequate oxygenation.
 Monitor Vital Signs: Regularly check blood pressure, heart rate, and respiratory rate.
 Neurological Assessment: Use the Glasgow Coma Scale (GCS) to assess the level of
consciousness.
 Prevent Secondary Injury: Avoid hypotension and hypoxia, which can worsen brain
injury1.
 Control Seizures: Administer anticonvulsants if seizures occur.
 Rapid Transport: Expedite transport to a trauma center or specialized facility.

Special Considerations

 Avoid Nasal Intubation: In cases of suspected basilar skull fractures.

  Pain Management: Administer analgesics cautiously, avoiding medications that may
mask neurological symptoms3.

Head Trauma Assessment

Rapid trauma survey
Head
The initial assessment of a patient with head trauma aims to identify life-threatening conditions
and prioritize care. Key points include:

 Determine Brain Injury: Quickly assess if the patient has a brain injury and monitor for
deterioration.
 Urgency Based on Symptoms: Patients with a history of loss of consciousness followed
by a lucid period (possible epidural hematoma) need urgent transport compared to those
who are alert after a knockout (possible concussion).
 Record Observations: Document all observations without interrupting patient care, as
this helps in detecting clinical deterioration.
 Assume Cervical Spine Injury: Treat all patients with trauma above the clavicle and
altered LOC as having a cervical spine injury until proven otherwise. Use spinal motion
restriction along with airway and breathing management.
 Neurologic Exam: Initially limited to LOC and obvious paralysis. Use the AVPU method
(Alert, Verbal, Pain, Unresponsive) for quick assessment.
 Airway Management: Critical to prevent obstruction from the tongue, blood, vomit, or
other secretions. Suction should be readily available.

 Rapid trauma survey

Head Examination:
 Check the scalp for lacerations, depressed, or open skull fractures.
  Gently feel for unstable areas of the skull.
 Apply direct pressure to control scalp bleeding; use hemostatic gauze if needed.
 Signs of basilar skull fracture include bleeding from the ear/nose, clear fluid from the
nose/ear, Battle’s sign (swelling/discoloration behind the ear), and raccoon eyes
(discoloration around both eyes).

Pupils
 Assess pupil reaction to light.
 Non-reactive, dilated pupils indicate a possible brainstem injury (poor prognosis).
 Dilated but reactive pupils suggest a potentially reversible injury; urgent transport is
necessary.
 rapid trauma survey for patients with abnormal LOC:
 Head Examination:
 Check the scalp for lacerations, depressed, or open skull fractures.
 Gently feel for unstable areas of the skull.
 Apply direct pressure to control scalp bleeding; use hemostatic gauze if needed.
 Signs of basilar skull fracture include bleeding from the ear/nose, clear fluid from the
nose/ear, Battle’s sign (swelling/discoloration behind the ear), and raccoon eyes
(discoloration around both eyes).
 Pupils:
 Assess pupil reaction to light.
 Non-reactive, dilated pupils indicate a possible brainstem injury (poor prognosis).
 Dilated but reactive pupils suggest a potentially reversible injury; urgent transport is
necessary.

Extremity
  Test sensation and motor function: In extremities, especially in patients with decreased
LOC. Withdrawal or localization to pain indicates grossly intact sensation and motor
function.
 Decorticate posturing: Arms flexed, legs extended; indicates deep cerebral hemispheric
injury.
 Decerebrate posturing: Arms and legs extended; indicates upper brainstem injury and is
more severe, often signifying cerebral herniation.
 Flaccid paralysis: Usually denotes spinal cord injury.

Figure ---- A. Decorticate and, B. decerebrate posturing

Neurologic Exam
 Neurologic Exam: Familiarity with the Glasgow Coma Scale (GCS) is essential for
applying the revised trauma score and other field triage scoring systems.
 GCS Score: Simple, easy to use, and has good prognostic value. A GCS score of 8 or less
in a patient with traumatic brain injury (TBI) is considered severe12.
 Initial GCS Score: Serves as the baseline and should be recorded.
 Early GCS Assessment: May not reflect head injury severity due to systemic causes (e.g.,
hypoxia, hypotension, hypoglycemia, alcohol).
 Corrected Evaluation: After addressing systemic factors, the GCS score more accurately
represents brain damage severity.
 Record Each Part: Note the score for each GCS component, not just the total score.
 Motor Component: Recent studies suggest the motor component of the GCS is as
effective as the complete GCS.
Vital sign
 Vital Signs: Should be obtained by another team member during the exam and are crucial
for monitoring head trauma patients.
 Indicators of Increased ICP: Vital signs can indicate changes in intracranial pressure
(ICP).
 Respiration: Increasing ICP can cause respiratory rate changes and irregular patterns,
reflecting brain or brainstem injury. Central neurogenic hyperventilation may occur just
before death.
 Other Factors Affecting Respiration: Fear, emotional disorders, chest injuries, hypoxia,
spinal cord injuries, and diabetes can also affect respiration, making it less reliable as an
indicator compared to other vital signs.
 Pulse: Increasing ICP causes a decreased pulse rate as a late sign of Cushing’s response.
Tachycardia may indicate shock or pain.
 Blood Pressure: Increasing ICP leads to increased blood pressure and widened pulse
pressure. Hypotension in head injury patients is usually due to hemorrhagic shock, not
TBI. Hypotension significantly increases mortality in brain injury patients.
 Management: Maintain systolic blood pressure at 100–110 mmHg in adults with severe
head injury (GCS ≤ 8). For children, maintain blood pressure within the normal range for
their age. The goal is to keep cerebral perfusion pressure (CPP) above 60 mmHg.
 Secondary Survey
 Secondary Survey: For suspected TBI patients with altered mental status, this survey is
done during transport or not at all if the transport is short.
 Reassessment Exam: Record LOC, pupil size and reaction to light, GCS score, and any
changes in focal weakness or paralysis. This, along with vital signs, helps monitor the
patient’s condition and guide management decisions.
 It is extremely important to make a rapid assessment and then transport the patient to a facility
capable of managing TBI. Appropriate triage of the patient to facilities capable of managing TBI
can have a significant impact on the outcome of the patient.

Spinal injury
Spinal cord injuries, though rare, require careful management by emergency care providers to
prevent further damage.

The process involves evaluating the patient, providing appropriate treatment, and ensuring safe
transportation to the hospital.

Spinal motion restriction (SMR) techniques are used to minimize spine movement and prevent
additional injury. Over the past decade, the approach to SMR has shifted from focusing solely on
the mechanism of injury to considering the patient’s condition and the injury mechanism. This
structured assessment helps in treating, packaging, and transporting patients with potential spinal
cord injuries effectively.