Point of Wounding: Head Injuries and TBI

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  • 1.  
  • 2. Head Injuries With Traumatic Brain Injuries (TBI)
    • Department of Combat Medic Training
    • C168W007
  • 3. Terminal Learning Objective
    • Given a casualty with a suspected head injury,
    • treat the head injury
    • IAW Prehospital Trauma Life Support Chapters 8 and 21 and the Military Acute Concussion Evaluation (MACE) Assessment Tool, the principles of Tactical Combat Casualty Care (TC3).
  • 4. Enabling Learning Objective
    • Given a combat casualty with a suspected head injury and the MACE Assessment tool,
    • assess a casualty for a possible head injury
    • IAW Prehospital Trauma Life Support Chapter 8, the Military Acute Concussion evaluation (MACE) Assessment Tool.
  • 5. Assessment Priority
    • You have a casualty with a suspected head injury. What is assessment priority for the casualty?
    • Hemorrhage Control
    • Airway
    • Breathing
    • Circulation
    • After life threatening injuries are identified and appropriately treated, obtain a baseline Glasgow Coma Scale score.
    This assessment priority never changes
  • 6. Glasgow Coma Scale Eye Opening Best Verbal Response Best Motor Response 4 - Spontaneous Eye Opening 5 - Answers appropriately (Oriented) 6 - Follows Commands 3 - Eye Opens on Command 4 - Gives Confused Answers 5 - Localizes Painful Stimulus 2 - Eye Opens to Painful Stimulus 3 - Inappropriate Responses 4 - Withdrawals to Pain (Nonlocalizing Movement to Pain) 1 - No Eye Opening 2 - Makes Unintelligible Noises 3 - Abnormal Flexion to Pain (Decorticate) 1 - Makes No Verbal Response 2 - Abnormal Extension to Pain (Decerebrate) 1 - Gives No Motor Response
  • 7. Glasgow Coma Scale
    • What is the best score possible?
    • 15
    • What is the lowest score possible?
    • 3
    • If the casualty is intubated,
    • (ETT, Combitube, King LT)
    • how is the GCS scored?
    • Use only eye and motor scales and add a "T" to score.
  • 8. Posturing What type of posturing is illustrated? Decorticate Decerebrate What does each type of posturing tell you about the type of injury suffered?
  • 9. Glasgow Coma Scale
    • Assess and reassess GCS
    • (serial GCS assessments)
    • often during casualty assessment and transport.
    • Deterioration of more than 2 points is a significant finding. These casualties are at high risk for an ongoing pathologic process.
  • 10. Assessment of the Head
    • Inspect and palpate for DCAP BLS and TIC
    • Inspect the mouth, nose and ears.
    • Assess the Pupils.
  • 11. Pupils
    • What can pupil reaction tell us?
  • 12. Pupils
    • Difference >1.0 mm in size, sluggish or nonreactive pupils are abnormal.
    • Brainstem injury is probable if both pupils are dilated and do not react to light.
    • If pupils are dilated but react to light, injury is often reversible.  
    • Dilated pupils that may or may not react to light may be caused by reasons other than a head injury
    • If the patient has a normal LOC, the dilated pupils are not due to head injury. Look for other causes.
  • 13. Assessment of the Neck
    • Suspect C-spine injuries for all non penetrating head, face and neck wounds.
    • Spinal precautions should be initiated based on the tactical environment.
  • 14. Assessment of the Extremities
    • The casualty has intact sensation/motor function if he can withdrawal or localize pain to pinching of fingers and toes.
    • This also indicates normal or minimally impaired brain function.
  • 15. Vital Signs
    • Increased intracranial pressure causes Cushing's Triad.
    • What is Cushing’s Triad?
    • Increased blood pressure (hypertension).
    • Decrease in pulse rate (bradycardia).
    • Respiratory rate to increase, decrease and/or become irregular.
  • 16. Check on your Learning…
    • Why is it important to take serial GCS assessments (An initial assessment and multiple reassessments) throughout your casualty care?
    • To determine if there is a change in the casualty.
    • If a change is detected, the medic should be prepared for many issues that accompany a head injury. Additionally, the casualty will need to be transported to a facility with specific capabilities.
  • 17. Check on your Learning…
    • Upon your assessment of the casualty’s pupils you find they are dilated and do not react to light. What does this piece of information tell you?
    • A brainstem injury is probable.
  • 18. You are the Medic
    • Your casualty opens her own eyes, does not understand who you are and what happened and can hold up two fingers when you tell her to. What is her GCS?
    • Eyes – 4, Verbal – 4 and Motor – 6
    • Total GCS = 14
  • 19. You are the Medic
    • Upon reassessment, the same casualty slaps your hand away when you pinch the back of her arm. She will look at you only if you yell to get her attention and is giving inappropriate responses. She will not show you two fingers.
    • Eyes – 3, Verbal – 3 and Motor – 5
    • Total GCS = 11
  • 20. You are the Medic
    • What does the casualty’s serial GCS scores tell you?
    • The GCS has deteriorated more than 2 points.
    • The casualty’s has suffered a head injury and should be transported to a neurosurgical facility.
    • Evacuate: Urgent Surgical
  • 21. MACE Assessment
    • Military Acute Concussion Evaluation (MACE) Assessment
    • Where is a MACE assessment administered?
    • In the combat theatre.
    • Not performed in the CUF or TFC phase.
    • Usually performed at BN aid station or higher.
  • 22. MACE Assessment
    • Who should the MACE assessment be administered on?
    • Any casualties that report:
    • Being dazed, confused, “saw stars” or lost consciousness, even momentarily as a result of an explosion/blast, fall, motor vehicle crash.
    • Any event involving abrupt head movement or a direct blow to the head.
  • 23.
    • Red Flags for immediate referral to MO and/or transport:
    • Unequal pupils
    • Deteriorating examination
    • Decreasing or loss of consciousness
  • 24.
    • MACE Assessment
    • Demonstration
    • and
    • Practical Exercise
  • 25.  
  • 26.  
  • 27.  
  • 28. Enabling Learning Objective 3
    • Given a combat casualty,
    • treat a casualty with a suspected head injury
    • IAW Prehospital Trauma Life Support Chapter 8 and 21.
  • 29. Scalp Wounds
  • 30. Skull Fractures
  • 31. Skull Fractures
  • 32. Skull Fractures
  • 33. Facial Injuries
  • 34. TBI
    • Traumatic Brain Injury
    • An injury to the brain resulting from an external force and/or acceleration/deceleration mechanism from an event.
    • Brain trauma can cause a broad range of physical, cognitive emotional and social problems.
  • 35. TBI
    • What are the signs and symptoms of a TBI?
    • AMS, headache, nausea, vomiting, dizziness/balance problems, fatigue, insomnia, sleep disturbances, drowsiness, sensitivity to light and noise, blurred vision, difficulty remembering and/or difficulty concentrating.
    • Post concussion symptoms
    • Decreased memory and attention/concentration, slower thinking, irritability, depression, impaired vision, mood swings, balance problems, headaches, and nausea.
  • 36. Levels of TBI
    • Mild
    • GCS = 14 to 15
    • 80% of head injuries
    • Usually full
    • recovery within
    • weeks.
    Moderate GCS = 9 to13 10% of head injuries Most are admitted /observed due to potential for deterioration. Severe GCS = < 9 10% of head injuries Mortality approx. 40% Most occur in 48 hrs Long-term disability is common.
  • 37. Concussion
    • Trauma to the head with variable period of **unconsciousness or confusion and then a return to normal consciousness
    • **Not required to make a possible diagnosis of concussion.
  • 38. Concussion
    • Signs and Symptoms
    • Vacant Stare Disoriented
    • Delayed verbal response
    • Confused and inability to focus attention
    • Slurred or incoherent speech
    • Lack of coordination (stumbling, dizzy)
    • Inappropriate emotions to the circumstances
    • Short-term memory deficits
    • (casualty repeats the same questions)
    • Inability to memorize and recall
  • 39. Intracranial Hematoma
  • 40. Intracranial Hematoma
    • Headache - Visual Changes - Confusion
    • Personality Changes --- Decreased Pulse
    • Slurred speech or Dysarthria (difficulty speaking)
    • Changes in LOC - Possible Coma
    • Increased blood pressure (hypertension).
    • Lucid Interval - Pupil Changes - Nausea & Vomiting
    • *Hemiparesis (weakness on one side of the body)
    • *Hemiplegia (paralysis on one side of the body)
    • *On the side of the body opposite of the trauma impact
  • 41. Check on Your Learning…
    • Your casualty has suffered a head injury and had an initial GCS of 11. First reassessment the score is 9 and on second the score is 6. What do you know about the level of TBI the casualty is demonstrating?
    • This is a severe TBI.
    • Accounts for 10% of head injuries suffered.
    • He has a 40% chance of dying in the next 48 hours. Long-term disability for this casualty is very probable.
  • 42. Check on Your Learning…
    • The casualty suffered blunt trauma to the face and asks you if he is missing a tooth because his teeth feel weird.
    • What would type of injury do you suspect?
    • A mandible fracture.
  • 43. Treat a Casualty with a Suspected Head Injury
    • Special Considerations
    • Suspect brain or C-spine injuries for all head, face and neck wounds. (MOI)
    • Do not clean a scalp wound . (Additional bleeding occurs.)
    • Do not remove impaled objects; stabilize in place.
    • Gently palpate for depressions.
    • Facial trauma CAN be associated with AMS and severe trauma to the brain.
  • 44. Treatment
    • The first step with any combat casualty is?
    • Control any life threatening hemorrhage.
    • If the tactical situation allows, what is the next step?
    • Take Spinal Precautions (Hold C-Spine).
  • 45.  
  • 46. Treatment
    • Airway
    • Be prepared to suction.
    • Breathing
    • Provide normal tidal volume and rate when assisting with ventilation.
    • Do NOT hyperventilate.
  • 47. Treatment
    • Circulation
    • Do not apply pressure dressings to open or depressed skull fractures.
    • For soft tissue injuries, control bleeding with pressure on the edges of the wound.
    • For complex scalp wounds several gauze pads held in place by an elastic roller bandage creates an effective pressure dressing.
    • Hemostatic gauze may be effective in controlling bleeding.
  • 48. Treatment
    • Circulation
    • The combo of hypoxia and hypotension
    • is associated with a mortality rate of about
    • 75%
    • Follow fluid resuscitation protocols.
    • Due to morphine's effect, it is NOT recommended for individuals with a suspected brain injury .
  • 49. Treatment
    • Transport
    • Transport in a supine position.
    • Although elevating the head (reverse Trendelenburg)
    • may decrease intracranial pressure,
    • cerebral profusion may be jeopardized especially when the head is elevated greater than 30 degrees.
    • If a facial wound is present, tilt the casualty towards the side of the injury to allow for drainage
  • 50. Check on Your Learning…
    • Should you hyperventilate a casualty with a head injury?
    • No. Hyperventilation has been shown to worsen the outcome of head injury casualties.
    • How should you transport a casualty with a head injury?
    • Supine
  • 51. Check on Your Learning…
    • How should a casualty suffering from shock, due to a head injury, be managed?
    • Gain vascular access and follow fluid resuscitation
    • algorithm.
    • NOTE:
    • Do NOT delay transport in an effort to gain vascular access. Transport ASAP.
  • 52. Check on Your Learning…
    • What is the “definitive MTF” for a casualty suffering from a head injury? Under what priority should the casualty be evacuated?
    • One that has neurosurgical capability.
    • The casualty should be considered Urgent Surgical. When possible, the fact the casualty is urgent surgical due to a neurological issue can be relayed.
  • 53. Summary
    • What do you expect the vital signs of a casualty with a head injury and increasing intracranial pressure to do?
    • Increased blood pressure (hypertension)
    • Decrease in pulse rate (bradycardia),
    • Respiratory rate increases, decreases, or becomes irregular.
    • What is this combination called?
    • Cushing's Triad (Cushing's Phenomenon).
  • 54. Summary
    • What signs and symptoms do you expect to see from a casualty that has suffered a head injury?
    • Why?
  • 55.
    • Questions?