Head Injuries Overview There are an estimated 1.7 million traumatic brain injuries (TBI) each year. More than 230,000 victims require hospitalization and survive. About 52,000 people die annually from TBIs.
Common causes include traffic accidents, falls, accidents at work, home, or during sports activities, or physical assault. Half of all TBIs are caused by motor vehicle accidents.96 The skull protects the delicate brain inside.
The brain is surrounded by cerebrospinal fluid (CSF), which cushions it from the light bumps and bounces of everyday activities.
The fluid, however, may not be able to absorb the force of a hard blow to the head or a sudden stop. The result can be brain injury from a severe concussion or from tearing of nerve fibers or blood vessels around the brain (closed head injury). An external object, such as a bullet or a nail, can also damage the brain (penetrating head injury).
Head injuries can be classified as external, involving the scalp, or internal, involving the skull, blood vessels or brain itself. Skull fractures may be obvious with open wounds, or assumed because of how the injury occurred, or pain in the affected area. A serious brain injury can be life threatening. Providing immediate first aid can save a victim’s life.
Assume that any person with a head injury also has a neck injury. When caring for a victim with a suspected head injury, stabilize the head and neck together to prevent further injury. Do not continue the injury assessment. Monitor response, breathing, circulation and appearance. Treat the victim in the position found. All head injuries should be evaluated by a physician. External.
Head Injuries: Most falls or blows to the head result in external injuries. Scalp lacerations (small or large wounds to the scalp or face) bleed profusely because the scalp is well supplied with blood vessels. Treat a scalp laceration by controlling bleeding and providing appropriate wound care.
The person should be seen by a physician for a large or deep laceration, or if there are any signs or symptoms of brain injury. A hematoma, or “goose egg,” is a large swelling on the scalp after a blow. It is caused by the scalp’s veins leaking blood into the tissue just beneath the skin. The hematoma may last for several days or even weeks. Apply an ice pack wrapped in a moist cloth to the area for 20 minutes, and observe for any signs of brain injury.
A “black eye,” or bruising around the eye, is the result of bleeding around the eye and under the skin. Most black eyes are not serious and can be treated by gently 89 applying an ice pack wrapped in a moist cloth up to 20 minutes. Avoid any pressure on the eye itself. Since bruising around the eyes can be a sign of brain injury or even skull fracture, other symptoms of head injury must be evaluated carefully.
If there is bleeding within the eye, it can result in permanent damage to vision. Seek emergency medical care if there is bleeding in the eye or from the nose, vision problems, or other signs of head injury. Trauma to the nose is usually caused by blunt injury. Consider the mechanism of injury and a possible brain or cervical spine injury. Cervical spine immobilization may be necessary. Control bleeding as necessary.
Apply an ice pack wrapped in a moist cloth to reduce swelling. Consider a facial fracture if there is irregularity in the contours of the facial bones, pain on palpation, or diplopia (double vision). Seek emergency medical care to determine if the victim has sustained a fracture. Be observant for possible brain or cervical spine injury. Cervical spine immobilization may be necessary. Control bleeding as needed.
Apply an ice pack wrapped in a moist cloth to reduce swelling. With any external head injury, it is important to observe carefully for signs of internal head injury. If the victim shows any changes in mental ability, behavior or physical skills, or has a headache or vomiting, seek emergency medical care immediately.
Internal Head Injuries: Any head injury that causes a period of unconsciousness indicates at least a concussion, and maybe even a more severe injury. A concussion is defined as a bruise to the brain, and may or may not include a temporary loss of consciousness or amnesia of the period surrounding the injury.
The person with a concussion will sometimes repeat the same question to the rescuer over and over again. A concussion is caused by a violent jolt (e.g. whiplash, roller coaster) or blow to the head (e.g. a fall with the head striking an object, or a moving object striking the head).
A concussion is usually not life threatening, but can have serious effects. The signs and symptoms may appear gradually and can last for weeks. Early symptoms may be overlooked by the victim, family and friends. There could be bleeding in or around the brain, or swelling of brain tissue. Although a person who has had a concussion will usually make a full recovery, it is important to watch closely for signs and symptoms of further brain injury (see below).
A physician should evaluate anyone who has suffered a loss of consciousness or received a significant head injury. The physician may ask you to wake the person during the night to make sure there are no further signs of a brain injury. If the person displays signs or symptoms of brain injury, it is a medical emergency.
Activate EMS (call 9-1-1). A subdural hematoma is a collection of blood on the surface of the brain, just below the dura mater (outer covering of the brain). Those at most risk for a subdural hematoma are victims of a head injury, the very young or very old, chronic alcohol abusers, and persons taking anticoagulant medication (blood thinners).
Symptoms can take weeks or even months to develop, and may worsen as the hematoma gradually increases pressure on the brain. About 15% of head trauma victims develop a subdural hematoma. Many subdural hematomas are so small they don’t cause any symptoms or need surgical removal.
More serious cases may result in permanent brain damage or even death. The person may need a neurosurgeon to perform a craniotomy (opening a section of skull to evacuate the hematoma) or drill a burr hole through the skull to drain the trapped blood and relieve the pressure on the brain. If someone has symptoms of a brain injury, activate EMS (call 9-1-1).
An epidural hematoma, or extradural hemorrhage, occurs when there is bleeding between the dura mater and the inner skull. It happens more commonly in young people, because the dura mater is not as firmly attached to the skull. Usually a severe head injury causes a rupture of a blood vessel, which bleeds into the space between the dura mater and the skull. A hematoma (collection of blood) develops, pressing on the brain, increasing the pressure within the skull (intracranial pressure), and causing further injury to the brain. A skull fracture is a crack or break in the skull (the bony covering of the brain).
It can affect the brain directly by damaging brain tissue, or indirectly by resulting in the formation of subdural or epidural hematomas, which increase pressure on the brain. Common causes include motor vehicle accidents, falls, physical assault, and sports injuries. Symptoms may be similar to those of other head injuries.
Certain symptoms may indicate a basilar skull fracture (fracture at the base of the skull): bloody drainage from the nose or ear immediately after the injury, raccoon’s eyes (bruises around the eyes), and Battle’s sign (bruising behind the ears) seen several days after the skull fracture.
Signs and Symptoms of Head Injury: Head trauma (bleeding, bruising, localized swelling, soft spots or indentations) Constant or recurrent headache Raccoon’s eyes (swelling and bruising under the eyes) Bruising behind the ears seen several days after a basilar skull fracture (Battle’s sign) Confusion, amnesia, repetitive questions, slowed mental processing Slurred speech Nausea and repeated vomiting Difficulty with movement or sensation; loss of balance Blurred or double vision; unusual eye movements Unequal pupils Bleeding from the nose, ears, eyes, mouth Seizures Loss of consciousness Ringing in the ears (tinnitus) Abnormal breathing Dizziness Drowsiness, fatigue Neck pain or stiffness Loss of bowel or bladder control Difficulty swallowing Change in sleeping pattern (sleeping much longer or insomnia) Change in behavior or mood (irritability, sadness, anxiety, listlessness)
Treatment: 1. Assess response, breathing, circulation and appearance. 2. Activate EMS system (call 9-1-1). 3. Immobilize cervical spine (neck) with your hands. 4. Control bleeding (do not apply direct pressure to a suspected skull fracture, as this may increase pressure to the skull). 5. Monitor mental status. 6. Apply an ice pack wrapped in a moist cloth to the bruised area to control swelling. Do not apply pressure. 7. If the person vomits, roll to the side to clear the airway, keeping the head and neck stabilized. 8. Be prepared to report to EMS personnel the mechanism of injury, how long a victim was unresponsive, initial and on-going assessments, person’s prior and current mental status, and any past history of head injuries. 9. Do not move the victim unless it is absolutely necessary. 10. Do not remove a penetrating object. 11. Do not leave the person alone. Shaken Baby Syndrome Shaken baby syndrome is a form of child abuse with severe consequences.
When an infant or toddler is shaken, the brain bounces back and forth inside the skull, causing brain bruising, swelling, and possible brain damage or death. The child is usually younger than 2 years old, but it may be seen in children up to 5 years old. Injury can occur with as little as 5 seconds of shaking. Prevent Falls: Falls are the leading cause of traumatic brain injury (TBI). People age 75 and older have the highest incidence of injury and death from fall-related TBI.
It’s important to: Reduce the risk for falls. Recognize a TBI after a fall. Get medical help immediately.
Tips to Prevent Head Injury: Always wear a helmet when: Riding a bike, motorcycle, all-terrain vehicle or snowmobile Playing a contact sport such as football, boxing or ice hockey Using roller skates, in-line skates or skateboards Skiing or snow boarding Batting or running bases in softball or baseball Riding a horse Select the right helmet. Make sure helmets fit properly (see manufacturers’ guidelines). Consider newer and more advanced helmet designs which may provide better protection. Inspect equipment annually for signs of wear and tear. Follow manufacturers’ and state athletic associations’ testing guidelines. Bike helmets should be worn directly on the top of the head, covering the top of the forehead. They should not be tipped forward or back.
They should be snug, but comfortable. Make sure the chinstrap is attached, and the helmet does not move side-to-side or front-to-back. Most helmets can be customized for fit with the removable pads that are included. Parents and sports coaches should be well educated in the signs and symptoms of a concussion. Coaches must know when to remove players from a game or practice, and parents must be alert to signs of head injury, since many epidural and subdural hematomas are slow to form.
Avoid participating in sports activities until cleared by a physician or trained healthcare professional after a previous concussion with unconsciousness. Studies have indicated that a person who has had a prior concussion has an increased risk of serious brain injury and even death in subsequent brain injuries.
Always wear a seat belt in a motor vehicle, and place infants and small children in appropriate child car seats. Keep firearms unloaded and locked away securely. Firearms are involved in 10% of all TBIs, but 44% of TBI-related deaths.
Prevent falls in the home. a. Install child safety gates at the top and bottom of stairs. b. Install handrails on stairways. c. Use non-slip mats in tubs and showers. d. Install grab bars next to the toilet and in the tub or shower. e. When reaching for high objects, use a step stool, preferably with a grab bar. f. Install window guards to protect young children from falling out of windows. Make sure your child’s playground surface is made of a shock-absorbent material. Do not dive into water if the depth is unknown. Wear a hard hat when indicated at work. For more information: Brain Injury Association of America (BIAA) (800) 444-6443 www.biausa.org
Neck and Spine Injuries Overview The spinal cord is a group of nerve tracts extending along the back, originating in the brain and ending in the spinal nerves that go to the various parts of the body. It is protected by the vertebral column, a series of bones (vertebrae) that extends from the base of the skull to the tailbone. All the information going from the brain to the limbs (e.g. movement) and from the limbs to the brain (e.g. sensation) travel through the spinal cord. The spinal cord can be damaged by a contusion (bruising), compression (pressure), or laceration (tearing or severing nerve fibers).
When a traumatic event damages the cells within the spinal cord, it can result in loss of movement, sensation, and other activities such as breathing and bladder control. An injury at a specific level of the spinal cord may cause partial or complete loss of motor function (voluntary movement) and sensation below the level of the injury.
Although the spinal nerves still exit the spinal cord between each vertebra and go to a particular muscle or organ (e.g. bladder, diaphragm), there is no longer communication (messages being sent or received) with the brain. An injury to the neck is especially devastating. The neck contains the airway, major blood vessels, and spinal cord tracts which innervate the respiratory muscles and all four limbs.
The result of a spinal cord injury at the neck (cervical spine) can be quadriplegia (paralysis of both arms and legs), inability to breathe without a mechanical ventilator due to paralysis of the diaphragm, and loss of bowel and bladder control. A high enough injury can result in immediate death. A spinal cord injury at the chest level (thoracic) or lower back (lumbar) can result in paraplegia (paralysis of the legs and lower part of the body).
Between 12,000 – 20,000 people suffer spinal cord injuries (SCI) annually in the US; up to 50% will die. Males sustain 80% of SCI. More than half of all victims are 15 to 35 years old. High-risk incidents include motor vehicle accidents (46%), severe blunt trauma and penetration injuries (16%), diving and sports injuries (12%), falls (22%), lightning strikes, head injuries, and any incident in which the victim is unresponsive for an unknown reason.
Use of a seat belt and airbag can reduce the risk of injury by 80%. Alcohol is involved in 25% of SCI. If the victim of a traumatic injury sustains a vertebral fracture, the spinal cord may still be intact. The initial care of a victim with a spinal injury may affect the rest of his or her life. Improper handling of the victim can result in permanent paralysis or even death.
If there is a chance of spinal injury, assume there is one. If a victim has a head injury, assume there is also a neck injury. 116 Do not move a victim of a severe injury unless: 1. You need to open or maintain an airway or perform CPR. If the person vomits, carefully log roll him or her to the side, supporting the head, neck and back to prevent twisting. 2. There is imminent danger. Move the victim using a drag or pull; keep the head and spine completely supported and aligned. Improper movement of an injured person can cause severe spinal cord injury.
Signs and Symptoms: Head, neck or back injury or pain Unresponsive trauma victim Numbness or tingling in extremities Weakness or paralysis in extremities Loss of bowel or bladder control Difficulty breathing Treatment:
1. Assess response, breathing, circulation and appearance. 2. Activate EMS (Call 9-1-1). 3. Maintain cervical spinal immobilization. a. Use the palms of your hands to support the head in the position found. b. Maintain an open airway. 4. Reassure the person; keep him or her calm and still. 5. DO NOT move the victim except for airway management, CPR or imminent danger. a. Move long axis (drag, pull). b. Maintain a neutral position of the neck.