Head injury

Concussion

Concussion is a form of traumatic brain injury (TBI) that can range in severity. If a person struck in the head has lost consciousness, they have suffered at least a concussion. However, a person does not need to have gone unconscious to have suffered a concussion. The working definition of a concussion is an immediate and temporary impairment of brain function, sometimes accompanied by a brief period of amnesia after a blow to the head. The following signs and symptoms are commonly associated with a concussion: unaware of what happened; confusion; cannot recognize people or surroundings; loss of memory (not typically including, however, one’s name and location); loss of consciousness; headache or sensation of pressure in the head; dizziness; balance problems; nausea; vomiting; feeling “foggy,” “dazed,” or “stunned”; visual problems (e.g., seeing stars or flashing lights, or seeing double); hearing problems (e.g., ringing in the ears); irritability or emotional (mood) changes; inappropriate behavior; slowness or fatigue; inability to follow directions or slow to answer questions; easily distracted or poor concentration; glassy-eyed or vacant staring; slurred speech; seizure. With regard to the latter, a single brief seizure immediately following a concussion is not always an ominous sign, but in a wilderness situation should prompt an evacuation for evaluation by a physician. Headache, dizziness, and difficulty concentrating (persistent postconcussive symptoms) might persist for weeks after a concussion, so the victim should not be in a position, such as lead climber, to put others at risk. Evolving evidence shows that it might take a concussion a month or more to heal, even after the victim is free of noticeable symptoms. During the healing period, they might be at risk for a much more severe injury (“second impact syndrome”) with a similar inciting force. Necessary supervised nonaggressive physical activity can be undertaken if there are no persistent symptoms, but the presumption should be that a symptom-free month is necessary before someone can be “cleared” for vigorous physical activity. With regard to high altitude, one should probably wait for at least 60 days after resolution of all symptoms. If someone is symptomatic with a concussion, they should not sleep above an altitude of 9843 feet (3000 meters).

When a traumatic injury to the brain occurs, if any of the following are present, proceed with extreme caution and seek medical attention: loss of consciousness, abnormal behavior, severe mechanism of injury (e.g., fall from a height), Glasgow Coma Scale score below 15 (see page 75), large soft collection of blood (hematoma) within the scalp, or possibility of a skull fracture.

Treatment principles for head injuries

• 1.

  Protect the airway (see page 18) and cervical spine (see page 33). Make a quick inspection of the mouth to identify anything that needs to be cleaned out, such as blood, vomit, or broken teeth. Consider positioning the victim on their side in the recovery position (see page 22).

• 2.

  If the victim wakes up after a brief loss of consciousness and quickly regains their normal mental status and physical abilities, they have probably suffered a minor injury (so long as there is no relapse into unconsciousness or persistent lethargy, nausea or vomiting, or severe headache). The victim with any loss of consciousness in the wilderness should be evacuated for further medical evaluation. If the victim is far from help, they should undertake no vigorous activity and be kept under close observation for at least 24 hours. It is commonly taught that after someone has sustained a head injury with loss of consciousness (implying a concussion), they should be kept awake. It is also taught that if the victim falls asleep, they should be awakened regularly, presumably to demonstrate that they can be awakened and have not worsened or lapsed into a coma. However, be aware that sleeping in and of itself has no influence on the progression of the head injury. Furthermore, some persons who have suffered a concussion (or worse) become sleepy. If they fall asleep, they will not worsen because they fell asleep. If they worsen, it is part of the progression of the head injury, not related in any way to sleep. You cannot keep someone awake forever because they need sleep in order to rest. So, if you’re in a situation in which you are assessing someone who has suffered a head injury to determine their neurologic status, you need to set reasonable intervals at which to perform the examinations. There is no magic number, but if you’re concerned that someone is worsening, reassessing at least once every 2 hours seems reasonable. Signs of worsening following a blow to the head include increasing nausea and vomiting, blurred vision, increasing headache, and any change in mental status (e.g., declining alertness, ability to converse, or ability to follow commands; increasing confusion; or decreasing level of consciousness). If someone seems more sleepy (drowsy) than usual after a head injury, particularly if they are a child, perhaps difficult to assess and compounded with exhaustion, it’s better to be safe than sorry by bringing that person to medical attention as soon as possible.

• 3.

  Confusion or amnesia for the event that caused the blackout is not uncommon and not necessarily serious, so long as the confusion does not persist for more than 30 to 45 minutes. Because a serious brain injury might not become immediately apparent, the wilderness traveler who has been knocked out should not venture farther from civilization for 24 hours. If headache or nausea persists beyond 2 to 3 hours, the victim should begin to make their way (assisted by rescuers) to medical care. If the injury is minor and evacuation is not undertaken, advance the victim’s activity as follows: no physical activity and complete rest until without symptoms; next, light walking without any heavy lifting or resistance activity; next, mild exercise with slight resistance; finally, full activity. Don’t progress beyond one “level” each 24-hour period. It might be helpful to not only avoid physical exertion for the first day, but also to avoid mental exertion.

• 4.

  If the victim wakes up and is at first completely normal, only to become drowsy, disoriented, or to lapse back into unconsciousness (typically, after 30 to 60 minutes of normal behavior), they should be evacuated and rushed to a hospital. This might indicate bleeding from an artery inside the skull, causing an expanding blood clot (epidural hematoma) that compresses the brain. Frequently, the unconscious victim with an epidural hematoma will be noted to have one pupil significantly larger than the other ( Fig. 55 ).

  

• 5.

  If the victim awakens but has a severe headache, bleeding from the ears or nose with no obvious external injury to those organs, clear fluid draining from the ear or nose, unequal-sized or poorly reactive (don’t constrict promptly on exposure to bright light) pupils, weakness, bruising behind the ears or under the eyes, vomiting, or persistent drowsiness, they might have a skull fracture. Such signs mandate immediate evacuation to a medical facility.

• 6.

  In a wilderness setting, if the victim suffers a seizure (see page 80) after a head injury, no matter how brief, they should be transported to a medical facility for further evaluation.

• 7.

  If the victim is weak in an arm or leg, is disoriented, or has a fluctuating level of consciousness (normal 1 minute, drowsy the next), they might have suffered a significant brain injury and should be immediately rushed to a medical facility.

• 8.

  Because there is a high incidence of associated neck injuries, any person with a serious head injury should have their cervical spine stabilized (see page 88). Head injuries often cause vomiting. Therefore, be prepared to turn the victim on their side so that they don’t choke (see page 22). A victim may need to be evacuated in the side (recovery) position.

Neurological Assessment Scales. Frequent and regular assessment of the patient’s neurological status should be carefully tracked; GCS (Glasgow Coma Scale) is commonly used in the hospital setting, but there are other available scales as well. GCS was developed as a scoring system not for acute care in the field, but rather for repeated bedside assessment of persons with changing states of consciousness and to measure duration of coma in an intensive care unit setting. So, it might not be reliable, in part because it is subjective (relative to the examiner’s ability to apply it) and difficult to remember. Research suggests that simply determining that a patient cannot follow verbal commands is equivalent to a GCS score of 13 or less for the purpose of determining important injury outcomes.

Glasgow Coma Scale (GCS) This scale was introduced for medical professionals as a method to follow the progress of a brain-injured victim in an intensive care unit setting. However, because it is the most commonly used scale, you should be familiar with it and prepared to report your findings.

Persons with a GCS score of 15 can deteriorate even if they have suffered apparently minor head injuries. Warning signs for persons who might have a serious problem include increasing headache; persistent vomiting; restlessness; increased confusion or sleepiness; observed decrease in GCS score; uncontrolled urination or bowel movement; clear or blood-tinged fluid coming from an ear or the nose without an injury to these areas; raccoon eyes or Battle’s sign (see page 91); a convulsion; weakness or numbness of a body part; and a focal blow to the side of the head. So, if a person appears normal, but has suffered any one of these, they are perhaps at a greater risk for having a serious brain injury. This person therefore should be watched very closely. If you are far from medical attention, you should make plans for a prompt evacuation.