EMT: Head Trauma

Head Injury: Assessment-Based Approach Primary Assessment

- Manual inline stabilization - Establish airway using a jaw-thrust - Ensure patent airway - Provide O2 to maintain an SpO2 of 95% or greater if breathing is adequate, or positive pressure ventilation with O2 if breathing is inadequate. - Assess mental status - Assess and record the patient's responsiveness in detail.

Scalp injuries

- The scalp may be contused, lacerated, abraded, or avulsed. - Scalp injuries bleed heavily because of the rich supply of blood vessels.

What is the emergency care for victim's of head trauma? Primary Assessment Care

1. Take spine precautions. 2. Maintain a patent airway, adequate breathing, and oxygenation. a. Use a jaw-thrust maneuver to open the airway. b. Remove foreign bodies from mouth; suction blood and mucus. c. Protect against aspiration by having suction available and by being prepared to roll the secured patient to clear the airway. 3. Establish and maintain adequate breathing. a. If breathing is adequate, administer oxygen to maintain an SpO2 of 95% or greater. b. If breathing is inadequate, administer positive pressure ventilation with supplemental oxygen at 10-12 ventilations per minute to ensure a SpO2 reading at 95% or greater. c. Consider controlled hyperventilation if signs of brain herniation are present.

What is the emergency care for victim's of head trauma? Assessment and Care Part II

4. Monitor the airway, breathing, pulse, and mental status for deterioration. 5. Control bleeding. a. Do not apply pressure to an open or depressed skull injury. b. Dress and bandage open head wounds. c. Do not attempt to stop the flow of blood or cerebrospinal fluid from the ears or nose; cover them loosely with a sterile gauze dressing. d. For other wounds, use gentle, continuous direct pressure with sterile gauze only as needed to control bleeding. e. Never try to remove a penetrating object; immobilize it in place and dress the wound. 6. Provide emergency care for seizures. 7. Transport immediately. E. Reassessment 1. Recheck the patient's airway and mental status. 2. Repeat the reassessment every 5 minutes.

Basilar skull fracture

A linear temporal fracture that extends downward and into the base of the skull, causes leakage of cerebrospinal fluid from the ears, nose, or mouth. Patient may develop ecchymosis around the eyes and behind the ears.

Concussion

A type of diffuse axonal injury. Due to acceleration and deceleration forces result in stretching and tearing of nerve fibers in the brain, disrupting neuronal transmission. A temporary loss of the brain's ability to function.

Brain Laceration

A type of traumatic brain injury that occurs when the tissue of the brain is mechanically cut or torn.

Cerebrum

Area of the brain responsible for all voluntary activities of the body

Flexion - decorticate posturing:

Arms across chest, legs extended indicates upper-level brain stem injury

Extension - decerebrate posturing:

Arms and legs extended, back sometimes arched. Indicates lower-level brain stem injury.

Epidural hematoma

Arterial or venous bleeding pools between the skull and the dura mater.

Secondary assessment of the ears and nose

Asses for leakage of blood or clear fluid; check for Battle's sign (purplish discoloration behind the ear).

Secondary assessment of the eyes

Asses pupils with a bright light for fixation or dilation; make sure the eyes track normally; check for dark discoloration around the eyes.

Secondary assessment: Motor/sensory assessment

Asses the patient's ability to move the fingers and toes; pinch the extremities and check the response.

Head Injury: Assessment-Based Approach Scene Size-up

Be alert for signs of head injury in a scene size-up. Unresponsiveness or altered mental status suggests the possibility of head injury. Never assume that mental status changes in a trauma victim are due to drug or alcohol intoxication.

subarachnoid hemorrhage

Bleeding into the subarachnoid space, where the cerebrospinal fluid circulates.

Brain contusion

Bruising and swelling of the surface of the brain without penetration

What are the results from swelling of brain tissue or bleeding within the skull?

Causes increased pressure inside the skull and decreased perfusion of the brain.

Secondary Assessment: Vital signs

Check and record every 5 minutes

Subdural hematoma

Collection of blood between the dura mater and the brain.

Diffuse axonal injury (DAI)

Diffuse brain injury that is caused by stretching, shearing, or tearing of nerve fibers with subsequent axonal damage.

cerebrospinal fluid

Fluid in the space between the meninges that acts as a shock absorber that protects the central nervous system.

Signs and Symptoms of a concussion

Headache and some temporary disturbance in brain function, altered mental status that progressively improves, momentary loss of consciousness, confusion, brief memory loss, irritability, combativeness, nausea and vomiting, and restlessness.

Secondary Assessment: Vital signs Respiration:

If definite signs of brain herniation exist, begin positive pressure ventilation at a rate of 20 ventilations per minute; if these signs are not present, ventilate at a rate of 10-12 ventilations per minute.

Secondary Assessment: Vital signs Pulse:

If fast, suspect hemorrhage or early onset of hypoxia; if slow, suspect pressure inside the skull or severe hypoxia.

Secondary Assessment: Vital signs Blood pressure:

If the systolic blood pressure is high or rising, suspect pressure inside the skull; if it is low or dropping, suspect blood loss that has led to shock.

Brain herniation

Increasing intracranial pressure related to the presence of large pocket of blood (hematoma) or swelling. Causes lower brain substances or structures to be pushed out of the foramen magnum.

Closed head injury

Injury in which the brain has been injured but the skin has not been broken and there is no obvious bleeding.

Open head injury

Injury to the head often caused by a penetrating object in which there may be bleeding and exposed brain tissue.

Depressed skull fracture

Inward indentation of the skull with possible pressure on brain

Cushing's reflex (triad)

Irregular, decreased respirations (caused by impaired brainstem function) Bradycardia. Systolic hypertension (widening pulse pressure)

What is the Glasgow Coma Scale?

It is a measure of the patient's eye opening, verbal response, and motor response to different stimuli.

Closed skull fracture

No open wound to the scalp

Open skull fracture

Open wound to the scalp and cerebrospinal fluid may leak from the open wound

Unresponsive

Patient exhibits no response to verbal or painful stimuli.

Nonpurposeful response

Patient reacts inappropriately to pain.

Purposeful Response

Patient tries to remove/move away from pain.

How should the EMT document the patient's responsiveness?

Record your observations of mental status accurately, noting the types of stimuli administered and the patient's responses.

Linear skull fracture

Resembles a line without gross deformity

Secondary brain injury

Results from a complex cascade of pathophysiologic processes following the primary brain injury

Primary brain injury

Results from trauma to the brain that occurs at the time of insult from direct impact, acceleration/deceleration, or penetrating wound.

What happens to perfusion of the brain when brain tissue swells?

Results inadequate delivery of oxygen and glucose to brain tissues and inadequate removal of carbon dioxide and other waste from brain tissues.

Secondary Assessment: Cushing's reflex (Triad):

Systolic blood pressure increases, heart rate decreases; respiratory pattern may also change and become irregular.

Brainstem

The oldest part and central core of the brain, beginning where the spinal cord swells as it enters the skull; the brainstem is responsible for automatic survival functions

Pia Mater (gentle mother)

This is the meninges layer (meningeal membrane) that is thin, innermost layer?

Secondary assessment of the head

Using extreme care, palpate for deformities, depressions, lacerations, and penetrating objects

Traumatic Brain Injury (TBI)

a blow to the head or a penetrating head injury that damages the brain

Signs and Symptoms of a brain contusion

a. All signs and symptoms of a concussion b. Decreasing mental status or unresponsiveness c. Paralysis d. Unequal pupils e. Alteration of vital signs f. Profound personality changes

What are the signs and symptoms of head injury? Part I

a. Altered mental status, disorientation to unresponsiveness that does not improve, or gets worse b. Irregular breathing pattern (severe) c. Cushing's reflex (increasing blood pressure and decreasing pulse) (severe) d. Obvious signs of injury—contusions, lacerations, hematomas to the scalp; deformity of the skull e. Visible damage to the skull f. Pain, tenderness, or swelling at the injury site g. Blood or cerebrospinal fluid from the ears or nose h. Discoloration around the eyes in the absence of trauma to the eyes (very late) i. Absent motor or sensory function

Signs and symptoms of brain herniation

a. Dilated or sluggish pupil on one side b. Weakness or paralysis c. Severe alteration in consciousness d. Abnormal posturing (decorticate or decerebrate) e. Abnormal ventilation pattern f. Cushing's reflex

Conditions that worsen secondary brain injury include:

a. Hypoxia b. Hypercarbia c. Hypoglycemia d. Hyperglycemia e. Hyperthermia f. Hypotension

Signs and Symptoms of an epidural hematoma

a. Loss of responsiveness; responsiveness returns (lucid interval), but then rapidly deteriorates b. Decreasing mental status c. Severe headache d. Fixed and dilated pupils e. Seizures f. Increasing systolic blood pressure and decreasing heart rate g. Vomiting h. Apnea or abnormal breathing pattern i. Systolic hypertension and bradycardia j. Posturing (withdrawal or flexion)

Emergency care of a patient with a traumatic brain injury includes:

a. Patency of the airway b. Adequate ventilation c. Adequate oxygenation d. Maintain a systolic blood pressure greater than 90 mmHg e. Promote a normal body core temperature f. Ensure a normal blood glucose level

Signs and symptoms of a subdural hematoma

a. Weakness or paralysis on one side of the body b. Deterioration in level of responsiveness c. Vomiting d. Dilation of one pupil e. Abnormal respirations or apnea f. Possible increasing systolic blood pressure g. Decreasing pulse rate h. Headache i. Seizures j. Confusion k. Personality change (chronic subdural hematoma)

Secondary Assessment History: What questions should be asked?

a. When and how did the incident occur? b. What is the patient's chief complaint? c. Have symptoms changed since the incident? d. Did the patient lose consciousness at any time? e. Was he moved after the incident? f. Is there any history of previous blows to the head? Can you provide any details?

subdural bleeding

bleeding outside brain that may occur slowly with signs/symptoms developing over hours or days. Usually venous.

epidural bleeding

bleeding outside the dura and under the skull

What are the signs and symptoms of head injury? Part II

j. Nausea and/or vomiting k. Unequal pupil size with altered mental status l. Diplopia (double vision) m. Possible seizures n. Nonpurposeful response to painful stimuli o. Retrograde amnesia (no memory of what led up to incident) p. Anterograde amnesia (no memory of what happened after incident)

Arachnoid mater

middle layer of the meninges

Cerebellum ("little brain")

the "little brain" at the rear of the brainstem; functions include processing sensory input and coordinating movement output and balance

Dura mater

thick, outermost layer of the meninges surrounding and protecting the brain and spinal cord

meninges

three layers of connective tissue in which the brain and spinal cord are wrapped