Head injuries can range from minor to life-threatening and require prompt recognition and treatment. Signs and symptoms may include altered mental status, visible head damage, unequal or nonreactive pupils, nausea, vomiting, personality changes, paralysis, seizures, and abnormal vital signs. Proper care involves managing the airway, providing oxygen, rapid trauma assessment, monitoring for deterioration, and preparing for transport to a trauma center.

3. Emergency Medical Technician
24 - Head Injuries
© 2014
• Head injuries can be
extremely serious, and
often are not obvious
• Injuries can cause
permanent disability or
death
• Recognizing and
properly treating head
injuries can help
improve the outcome
for patients
3

4. Emergency Medical Technician
24 – Head Injuries
© 2014
1. Head Injuries
2. Care for Head Injuries

6. Emergency Medical Technician
24 - Head Injuries
© 2014
• Commonly caused by:
– Vehicular incidents
– Falls
– Sports
– Violence
– Workplace accidents
• Familiarization with
injury types can help
you:
– Identify critical
patients
– Make appropriate
transport decisions
6

7. Emergency Medical Technician
24 - Head Injuries
© 2014
• The structures of the
central nervous system:
– Brain
– Spinal cord
• CNS coordinates body
system functions:
– Respiratory systems
– Circulatory systems
• The central nervous
system can suffer
severe consequences
during an injury to the
head or spine
7

8. Emergency Medical Technician
24 - Head Injuries
© 2014
• Even no obvious injury to
the head, consider the
potential, especially in
regards to the MOI
• Be aware that some
injuries to the brain are
not evident until days or
even weeks later
• Obtain a thorough history
especially if the patient is
experiencing symptoms
that are common
indicators of a head
injury
8

9. Emergency Medical Technician
24 - Head Injuries
© 2014
• Injuries to the head can
include trauma to the:
– Face
– Scalp
– Skull
– Brain
• Secondary or
concurrent injuries may
also involve the neck
9

10. Emergency Medical Technician
24 - Head Injuries
© 2014
• Injuries to the face can
cause blood, other
fluids, teeth and bone
to obstruct the airway
10

11. Emergency Medical Technician
24 - Head Injuries
© 2014
• Scalp injuries may bleed
profusely:
– Large number of blood
vessels in the scalp
• The skin may remain
intact, but the
membrane between the
skin and the skull can
tear:
– Profuse bleeding
causes blood to pool
under the scalp
11

12. Emergency Medical Technician
24 - Head Injuries
© 2014
• Be aware that there
could be possible skull
damage beneath a scalp
injury
• Skull injuries include
injuries on both the
cranium and the face
12

13. Emergency Medical Technician
24 - Head Injuries
© 2014
• Injuries to the head are
classified as:
– Open
– Closed
• An open head injury:
• Bones of the cranium
may be fractured
• Scalp may be lacerated
• Significant bleeding
and damage to the
skull or brain may be
visible
13

14. Emergency Medical Technician
24 - Head Injuries
© 2014
• Closed head injuries:
– The cranium will be
intact even if the scalp
is lacerated
• The skull may NOT be
damaged or cracked:
– However the brain can
still suffer a severe
injury caused by force
14

15. Emergency Medical Technician
24 - Head Injuries
© 2014
• The injury may present
with:
– Deformity
– Swelling
– Depression of the skull
bones
15

16. Emergency Medical Technician
24 - Head Injuries
© 2014
• Brain injuries can cause
swelling or bleeding
inside the skull:
– This can result in
increased pressure
inside the skull and
decreased perfusion in
the brain
• Some brain injuries,
called diffuse axonal
injuries:
– Can cause the nerve
fibers to be sheared,
torn or stretched
16

17. Emergency Medical Technician
24 - Head Injuries
© 2014
• These injuries interfere
with the transmission of
nerve impulses and occurs
in about half of all severe
in head traumas
17

18. Emergency Medical Technician
24 - Head Injuries
© 2014
• When injuries are
serious enough to
disrupt the normal
functioning of the brain,
traumatic brain injury
(TBI) can result
• This injury can cause:
– Temporary
– Permanent brain
damage
18

19. Emergency Medical Technician
24 - Head Injuries
© 2014
• TBI is the leading cause
of injury, death and
disability
• Can result from:
– Direct injury
– Indirect injury
– Secondary injury
19

20. Emergency Medical Technician
24 - Head Injuries
© 2014
• Direct injuries to the
brain can be caused by
broken bones or
penetrating foreign
objects
• Types of injuries
include:
– Lacerations
– Punctures
– Bruising
20

21. Emergency Medical Technician
24 - Head Injuries
© 2014
• Indirect injuries involve
an impact shock to the
skull that is transferred
to the brain
• These injuries include:
– Concussions
– Contusions
21

22. Emergency Medical Technician
24 - Head Injuries
© 2014
• A concussion is caused
either by a blow to the
head or a transfer of
force to the brain, this
can occurs without a
direct blow:
– It usually does not
include any detectable
damage to the brain
22

23. Emergency Medical Technician
24 - Head Injuries
© 2014
• Concussions are
commonly caused by:
– Sports Activities
– Vehicle-related
incidents
– Falls
23

24. Emergency Medical Technician
24 - Head Injuries
© 2014
• According to the National Institutes of
Health, concussive brain injuries
account for the vast majority of brain
injuries
• Concussions are classified as:
– Minor
– Mild
– Severe
24

25. Emergency Medical Technician
24 - Head Injuries
© 2014
• A minor concussion
does not cause a loss of
consciousness but may
cause:
– Transient confusion
– Disorientation
• A mild concussion may
result in a brief loss of
consciousness followed
by a headache
25

26. Emergency Medical Technician
24 - Head Injuries
© 2014
A severe concussion can
cause:
– A longer period of
unconsciousness
– Abnormal vital signs
– Memory loss
26

27. Emergency Medical Technician
24 - Head Injuries
© 2014
• If loss of consciousness
occurs from a
concussion, it always
occurs immediately after
impact:
– Any delay in the loss of
consciousness
indicates that some
other injury is involved
27

28. Emergency Medical Technician
24 - Head Injuries
© 2014
• Concussions can also
present with:
– Confusion
– Irritability
– Nausea
– Inability to answer
questions or follow
commands
• Typically, the altered
mental status
associated with a
concussion will steadily
improve
28

29. Emergency Medical Technician
24 - Head Injuries
© 2014
• A contusion, or brain
bruise, can occur in
both open or closed
head injuries
• Contusions are caused
when the force of a
blow causes the brain
to hit the inside of the
skull
29

30. Emergency Medical Technician
24 - Head Injuries
© 2014
• An injury that occurs
when a violent motion
or impact brings the
head to a sudden stop:
– The brain slams into
the skull and causes
injury at the point of
contact
30

31. Emergency Medical Technician
24 - Head Injuries
© 2014
• Then the brain
rebounds into the
opposite side of the
skull, causing further
injury:
– This ruptures blood
vessels either on the
surface of the brain or
deep inside
31

32. Emergency Medical Technician
24 - Head Injuries
© 2014
• A secondary brain injury is
caused when internal
systems affect the brain,
such as:
– A lack of oxygen
– A build-up of carbon
dioxide
– A change in blood
pressure
• This can cause progressive
deterioration of the
patient’s physical and
mental status
32

33. Emergency Medical Technician
24 - Head Injuries
© 2014
• Examples of secondary
injuries include:
– Hematomas, in which a
collection of blood puts
pressure on the brain
– Swelling in the brain
also increases the
intracranial pressure
further
33

34. Emergency Medical Technician
24 - Head Injuries
© 2014
• As the condition
worsens, the pressure
compresses the vessels
in the brain, limiting
cerebral flow
• Downward pressure on
the brainstem results in
abnormal vital signs
34

35. Emergency Medical Technician
24 - Head Injuries
© 2014
• Common signs and
symptoms include:
– Altered mental status
– Visible damage to the
head
– Unequal or unreactive
pupils
35

36. Emergency Medical Technician
24 - Head Injuries
© 2014
• Nausea and vomiting
• Personality change
• Paralysis or disability
on one or both sides of
the body
• Seizures:
– During which the
patient may or may not
lose consciousness
36

37. Emergency Medical Technician
24 - Head Injuries
© 2014
• Altered mental status
can range from
disorientation to
unresponsiveness
• AMS is the most
important sign in any
head injury:
– Especially if it does not
improve or the
patient’s conditions
continues to
deteriorate
37

38. Emergency Medical Technician
24 - Head Injuries
© 2014
• Damage to the head can
include:
– Laceration
– A depression injury
– Presence of bone
fragments
• Pain, tenderness or
swelling may also be
present
38

39. Emergency Medical Technician
24 - Head Injuries
© 2014
• Vision may be:
– Blurred
– Diplopia “double
vision”:
 In one or both eyes
• Pupils may be:
– Unreactive
– Unequal:
 This can indicate
damage to the globe,
eye muscle, optic nerve
or brainstem
39

40. Emergency Medical Technician
24 - Head Injuries
© 2014
• The patient may have
repeated forceful,
projectile vomiting,
sometimes without
premonitory nausea
40

41. Emergency Medical Technician
24 - Head Injuries
© 2014
• Injury can cause
changes to personality
and range from
irritability to
combativeness to
irrational behavior
41

42. Emergency Medical Technician
24 - Head Injuries
© 2014
• Paralysis or disability
can range from
diminished to
completely absent
motor or sensory
function
42

43. Emergency Medical Technician
24 - Head Injuries
© 2014
• Expect to see irregular
breathing patterns and
increased blood
pressure with a
decreased pulse:
– Cushing reflex
43

44. Emergency Medical Technician
24 - Head Injuries
© 2014
Blood or cerebral spinal
fluid may drain from the
ears or nose:
– Basilar skull fracture
44

45. Emergency Medical Technician
24 - Head Injuries
© 2014
• Patient may exhibit
nonpurposeful
responses to painful
stimuli
– Decorticate or flexion
posturing
– Decerebrate or
extension posturing
45

46. Emergency Medical Technician
24 - Head Injuries
© 2014
• Decorticate or flexion
posturing:
– Arms and wrists curl at
the upper chest
– The legs and feet
extend with the toes
curled inward
46

47. Emergency Medical Technician
24 - Head Injuries
© 2014
• Decerebrate posturing:
– The arms extend along
the sides
– Shoulders rotated
inward
– The wrists flexed
– The legs extended
47

48. Emergency Medical Technician
24 - Head Injuries
© 2014
• These postures indicate
progressive
disconnection of the
upper brain from the
brainstem The
prognosis not good:
– Assessment and care is
critical and time
sensitive
48

49. Emergency Medical Technician
24 – Head Injuries
© 2014

50. Emergency Medical Technician
24 - Head Injuries
© 2014
• Manage a head injury
patient as you would
any trauma patient
• Perform your
assessment based on
the mechanism of injury
involved
50

51. Emergency Medical Technician
24 - Head Injuries
© 2014
• Assume the presence of
a possible cervical spine
injury if:
– Soft tissue damage to
the head, face or neck
– If the MOI has exerted
significant force on the
upper body
• Immediately provide
and maintain in-line
manual stabilization
51

52. Emergency Medical Technician
24 - Head Injuries
© 2014
• Assess and manage the
ABCs
– Use the jaw-thrust
maneuver if it is
necessary to manage
the airway
• Determine the level of
responsiveness using:
• AVPU scale
• Glasgow Coma Scale
52

53. Emergency Medical Technician
24 - Head Injuries
© 2014
• If the patient is
unconscious and has no
gag reflex:
– Use oropharyngeal
airway
 Take care not to
hyperextend the neck
during insertion
53

54. Emergency Medical Technician
24 - Head Injuries
© 2014
• Administer high-flow
oxygen
• Provide ventilatory
assistance if breathing
is inadequate
• Have suction ready:
– Patients can be prone
to vomiting
• Call for ALS intercept or
prepare to transport:
– Follow protocols
54

55. Emergency Medical Technician
24 - Head Injuries
© 2014
• Perform a rapid trauma
assessment
• Assess for DCAP-BTLS
• Use extreme care when
assessing the patient’s
head
55

56. Emergency Medical Technician
24 - Head Injuries
© 2014
• Palpate gently for
deformities and
depressions
– Presence of a
depression may be
masked by swelling or
the pooling of blood
• Open wounds should
not be probed
• Leave all bone
fragments or other
objects in place
56

57. Emergency Medical Technician
24 - Head Injuries
© 2014
• If present in an open skull fracture or
depressed or deformed cranial injury:
– Attempt to control bleeding without applying
direct pressure
– Applying pressure could cause further
damage
• Gently dress and bandage open wounds
57

58. Emergency Medical Technician
24 - Head Injuries
© 2014
• Assess the eyes for
deviations from normal
pupil reaction
• Check the pupils and
note their size, using a
light source
• Check for if pupils react
simultaneously and
equally when the light
is shined in only one
eye at a time
58

59. Emergency Medical Technician
24 - Head Injuries
© 2014
Indications of serious
head, brain or brain stem
injury, or increased
pressure on the brain
include:
– Pupils that are slow to
respond
– Extremely constricted
unequal in size
– Fixed and dilated
59

60. Emergency Medical Technician
24 - Head Injuries
© 2014
• CSF protects the brain
from impact
• Look for leakage of
blood or cerebrospinal
fluid, or CSF at ears and
nose:
– Leakage of the fluid is
a classic sign of skull
fracture or release of
intracranial pressure
• Allow CSF to flow freely
• Apply a loose dressing
to absorb it
60

61. Emergency Medical Technician
24 - Head Injuries
© 2014
• Obtain baseline vital
signs and document the
results so trending can
be observed
• Deterioration in vital
signs is not uncommon
with head injuries
• Vital signs can also vary
greatly depending on
the severity and kind of
head injury
61

62. Emergency Medical Technician
24 - Head Injuries
© 2014
• A pulse that is fast or
increasing:
– Could indicate
hemorrhage or early
hypoxia
• A pulse that is slow or
decreasing:
– Can indicate pressure
inside the skull or
severe hypoxia
62

63. Emergency Medical Technician
24 - Head Injuries
© 2014
• Monitor respirations for
rate, depth and pattern:
– Irregular breathing
pattern if the injury is
severe is common with
severe injury
– Follow protocols
regarding
hyperventilation
63

64. Emergency Medical Technician
24 - Head Injuries
© 2014
• With blood pressure, note
whether the systolic
pressure is high or rising:
– This can also indicate
pressure inside the skull
• A low or dropping systolic
pressure may indicate:
– Blood or fluid loss:
 The need for fluid
administration under
these circumstances
requires ALS intercept
• When time allows, perform
a detailed assessment for
other injuries you may have
missed
64

65. Emergency Medical Technician
24 - Head Injuries
© 2014
• Provide appropriate
care for shock:
– Even if signs are not
immediately present
– Patients should remain
in the supine position
• Continue to monitor the
patient for:
– Changes vital signs
– Neurologic changes
– Pupil size and
reactivity
65

66. Emergency Medical Technician
24 - Head Injuries
© 2014
• Direct patient to
remain still
• Provide manual in-line
stabilization of the head
and neck
– This is extremely
important for
protecting against
further injury and
paralysis
66

67. Emergency Medical Technician
24 - Head Injuries
© 2014
• Check for orientation to
person, place and time
• During treatment,
continue to observe the
patient for any
deterioration in the level
of consciousness:
– A decreasing mental
status is the most
important sign to look
for with a patient that
has sustained a head
injury
• A decrease in mental
status requires
immediate transport
67

68. Emergency Medical Technician
24 - Head Injuries
© 2014
• Perform a rapid trauma
assessment
• After assessing the
head and neck, apply a
cervical collar or per
protocols
68

69. Emergency Medical Technician
24 - Head Injuries
© 2014
• Patient’s who have
suffered a head injury
may not detect or
respond to pain in an
injured area:
– This can make it
difficult to detect all
injuries or the severity
69

70. Emergency Medical Technician
24 - Head Injuries
© 2014
• Immobilize per protocols
• Depending on the
circumstances or
seriousness of the injury:
– You may obtain baseline
vitals on scene
– While en route
• Provide appropriate care
for shock
• Administer high-flow
oxygen
• Prepare for sudden
vomiting
70

71. Emergency Medical Technician
24 - Head Injuries
© 2014
• Obtain detailed patient
history
• Try to determine whether
the patient lost
consciousness
• Obtain any other details
about the event:
• Such as how long the period
of unconsciousness lasted
• When it occurred in relation
to the injury
• If the patient was moved
after the incident
• If there is previous history
of head injury
71

72. Emergency Medical Technician
24 - Head Injuries
© 2014
• Reassess vital signs and level
of responsiveness every 5
minutes
• Check pupillary response and
note any lack of function:
– Any changes can alert you to
possible complications
• Continue to ask questions:
– Can help to distract the
patient from their pain
– Will alert you to any changes
in mental status
• Keep the patient calm and
provide reassurance during
transport
72

73. Emergency Medical Technician
24 - Head Injuries
© 2014
• Progressive confusion
or the presence of
aphasia, which is the
impairment of the
power to use or
comprehend words, are
serious findings and
should be documented
73

74. Emergency Medical Technician
24 – Head Injuries
© 2014

75. Emergency Medical Technician
24 - Head Injuries
© 2014
• Head Injuries
• Care for Head Injuries

76. Emergency Medical Technician
24 - Head Injuries
© 2014
• Trauma to the head or brain is a
serious injury
• You must be able to identify the
presence of serious head injury and
act quickly and confidently to
provide emergency care