5-6. SPECIFIC TYPES OF HEAD INJURY

a. Scalp Wounds. The scalp has many blood vessels, a number of which are close to the surface. A scalp laceration, therefore, may bleed profusely even though a major blood vessel has not been cut. Initially, even a minor laceration may bleed a great deal. Normally, blood in the scalp clots rapidly, and blood flow can be controlled easily. If necessary, bleeding can usually be controlled by direct pressure; that is, by compressing the scalp between the fingertips and the skull. It is important to control bleeding in both adults and children, but it is especially important in children because they have a smaller volume of blood.

b. Skull Injuries. The skull is composed of the cranium and the face. Skull fractures are commonly fractures to the cranium rather than the face.

(1) Signs/symptoms of skull injuries. The most obvious signs of a skull fracture are visible bone fragments and bits of brain tissue. The possibility of a skull fracture exists when any of the following less obvious signs/symptoms are present:

(a) Following an injury, the patient may be either unconscious or have an altered level of consciousness.

(b) The patient has sustained an injury that has caused a deep laceration or severe bruises to the scalp or forehead.

(c) There is severe pain or swelling at the site of a patient's head injury.

(d) There is a deformity of the patient's skull; for example, a depression in the cranium, a large swelling, or anything that looks unusual about the cranium's shape.

(e) The patient has a bruise or swelling behind the ear (Battle's sign - discoloration behind the ear caused by a fracture in the base of the skull). This sign may appear hours to days after the injury.

(f) The pupils of the patient's eyes are unequal in size.

(g) Tissue around or under both eyes of the patient are discolored ("black eye(s)" or "raccoon eyes"). This discoloration may appear hours after the injury.

(2) Treatment for skull fracture.

(a) Follow these general procedures:

1 Assure/maintain an open airway.

2 Resuscitate, if necessary.

3 Keep the patient at rest; do not let him move around.

4 Control bleeding.

5 Monitor the patient's vital signs.

6 Dress and bandage any open wounds.

7 Try to keep a conscious patient alert by talking to him. Ask him questions to force him to concentrate.

(b) Remember:

1 DO NOT put pressure on an obvious skull fracture.

2 DO NOT try to remove penetrating objects. Leave them in place and transport the patient.

(c) If the patient has no hematoma, infection, or cerebral spinal fluid leak, a skull fracture presents no danger at this time.

c. Concussion. A concussion is a mild state of stupor or temporary unconsciousness caused by a blow to the head. In this condition, there is no laceration or bleeding in the brain. There is no significant injury to the brain itself.

(1) Signs/symptoms of concussion. Signs and symptoms of a concussion occur immediately. Included are the following:

(a) Knowledge that the patient has received a blow to the head, has had a temporary loss of consciousness, and memory loss are indications of a concussion.

(b) The most important indication of concussion is memory loss for the exact moment of injury. This is a sign of brain dysfunction. The patient may never remember the exact moment of injury. His brain had not had time to record the moment in his memory. Sometimes, the patient cannot remember events just preceding the moment of injury, a condition called retrograde. Or, a patient may not be able to remember events that happened just after the moment of injury, this condition being called antigrade. Short time memory loss may cause a patient to ask questions repeatedly about the moments surrounding his injury.

(c) The patient may become combative.

(d) Not all patients who have a concussion lose consciousness. But those who do may regain consciousness anywhere from a few minutes to an hour. If the loss of consciousness was only momentary, often neither the patient nor witnesses are sure whether or not the patient lost consciousness.

(2) Treatment for concussion. There is no specific treatment for a concussion. If the patient is not being detained for observation, a responsible adult should be told to check on the patient hourly. The adult should be told the signs/symptoms that would indicate that the patient needs further medical help. Usually, within 24 to 48 hours, the symptoms of concussion begin to subside.

d. Cerebral Contusion. A focal brain injury is an injury in which there is dysfunction of a particular region, system, or side of the brain. The most common type of focal brain injury is a cerebral contusion. This type of contusion is a bruise in the brain that consists of a superficial focus of brain hemorrhage, necrosis, and/or laceration.

(1) Types of cerebral contusions. Included are the following:

(a) Coup contusion. This type of contusion occurs in the part of the brain that is directly under the focus of an impact.

(b) Contrecoup contusion. This contusion occurs in areas of the brain that are remote from the focus of impact.

1 Blows to the back of the head commonly cause this type of contusion. A contrecoup contusion can, however, be caused by a blow to any part of the head.

2 There is scientific disagreement on exactly how a contrecoup contusion occurs. One theory is that the impact of something on the skull accelerates or decelerates the brain within the cranial cavity. The result is that the brain collides with the inner surface of the skull and becomes bruised.

(2) Treatment. Patients with cerebral contusion require hospitalization for observation.

e. Intracranial Hematoma. Intracranial hematoma (within the cranium, a swelling that contains blood) is a rare injury, but important because this injury is the most common cause of preventable death following a head injury. Two classifications of traumatic intracranial hematomas are acute epidural hematomas and acute subdural hematomas.

(1) Acute epidural hematoma. This type of hematoma is an accumulation of blood between the dura (the thick, dense, fibrous layer which covers and protects the brain and the spinal cord) and the inner surface of the skull. The cause of an acute epidural hematoma is either a tear in a meningeal artery within the dura or an impact injury to a dural venous sinus. Since the bleeding is arterial, pressure builds rapidly and death can occur quickly. But, the prognosis for recovery is good if the patient is diagnosed correctly and treated early. Signs and symptoms of acute epidural hematoma include the following:

(a) A history of head trauma.

(b) Initial loss of consciousness.

(c) Next, a period of consciousness and coherence.

(d) Patient lapses back into unconsciousness.

(e) Patient develops paralysis on the opposite side of the injury with dilated/fixed pupils of the eye on the same side as the injury.

(f) If not treated, paralysis is followed by death.

NOTE: The time when the patient is lucid and relatively alert is the period between the recovery from the primary brain injury (usually a concussion) and the onset of signs/symptoms of brain distortion/displacement by the hematoma. When you know that a person has had a blow to the head and you see this lucid period between periods of unconsciousness, suspect the presence of an acute epidural hematoma.

(2) Acute subdural hematoma. An acute subdural hematoma is caused by a high velocity impact. This type of hematoma comes from venous bleeding located between the dura and the brain. The impact damages the underlying brain tissue. Signs/symptoms include:

NOTE: If surgery is performed less than 4 hours after the injury, the recovery rate for a patient with intracranial hematoma is about 90 percent. If surgery is performed more than 4 hours after the injury, the recovery rate is about 30 percent. Even a patient with acute intracranial hematoma has a better chance of recovery with early operative treatment.

GENERAL NOTE: Generally, patients with head trauma injury should be hyperventilated to get as much oxygen to the cells as possible and to lower intracranial pressure (pressure within the skull).