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Head Injuries and Facial Trauma
Questions and Answers
1
What is the anatomy of the brain and pathophysiology of injury?
Familiarity with the anatomy leads to an understanding of the pathophysiology of traumatic brain injury. The skull is a hard area with a fixed volume. Contact of the brain against the bone of the skull can cause primary injury. The fixed volume of the skull allows for little room for any type of expansion either due to bleeding or cerebral edema. Expanding volume in the skull leads to pressure on the brain and vascular structures, compromising blood flow. Treatment is geared to reducing this pressure on the brain. When the pressure within this fixed compartment becomes too great, the brain is forced downward through the skull base, and this is called herniation. Herniation of the brain compromises the regulation of heart rate and blood pressure and is typically a lethal event.
2
When I get on scene and see a patient with a potential head injury, what are the most important first steps to take?
The initial approach to any trauma patient should still focus on A irway, B reathing, and C irculation. Assess whether the patient has a patent airway, if they are breathing, and if they have adequate perfusion. Remember that patients can exsanguinate from scalp wounds. The scalp is very well perfused and bleeds profusely. Hemorrhage control is critical.
3
How do I objectively assess a patient’s mental status?
Practitioners still use the Glasgow Coma Scale (GCS) to attempt a standardized method of communication regarding mental status. The 10th edition of the Advanced Trauma Life Support Student Course Manual reflects the revised GCS, which allows for an area that cannot be assessed. Remember that a low GCS score may have other etiologies, such as acute intoxication, medication overdoses, and a low GCS does not always imply a severe brain injury.
| Eye opening (E) | Spontaneous | 4 |
| To Sound | 3 | |
| To pressure | 2 | |
| None | 1 | |
| Not testable | NT | |
| Verbal response (V) | Oriented | 5 |
| Confused | 4 | |
| Words | 3 | |
| Sounds | 2 | |
| None | 1 | |
| Not testable | NT | |
| Best motor response (M) | Obeys commands | 6 |
| Localizing | 5 | |
| Normal flexion | 4 | |
| Abnormal flexion | 3 | |
| Extension | 2 | |
| None | 1 | |
| Not testable | NT |
*Normal flexion—withdrawal to pain in the original GCS.
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