5-7. GENERAL ASSESSMENT OF HEAD TRAUMA

Approximately 40 percent of serious trauma victims have central nervous system injuries. This group has a death rate twice as high (35 percent versus 17 percent) as that of victims without central nervous system injuries. Estimations are that head injuries account for 25 percent of all trauma deaths and up to one-half of all motor vehicle fatalities. The head-injured victim will rarely be cooperative and is often under the influence of alcohol. When evaluating a patient with a head injury, always assume that the patient also has a spinal cord injury.

a. Respiration. A head injury produces several types of abnormal respiratory patterns. Possible abnormalities include:

(1) A slowed respiratory rate caused by an acute rise in intracranial pressure.

(2) A rapid respiratory rate can be caused if the intracranial pressure continues to rise.

(3) Respirations may be noisy.

(4) Kussmaul and Cheyne-Stokes patterns are often caused by the metabolic causes of coma.

b. Blood Pressure. Over a period of time, note any changes in the patient's blood pressure. The rise or fall of blood pressure can indicate changes in the patient's condition or further injury.

(1) Rising blood pressure. Generally, blood pressure rises if intracranial pressure rises. The systolic blood pressure in particular will rise. The effect is a widening of pulse pressure (pulse pressure = systolic blood pressure minus diastolic blood pressure). Therefore, if the patient's blood pressure rises without any medical explanation, he may experience a rise in intracranial pressure.

(2) Falling blood pressure. If the patient's blood pressure is falling, he may have an injury which has not been discovered and treated. The skull is a very small box which is almost full of brain. Therefore, there is very little room in the skull for blood. If the patient is in hypovolemic shock (shock produced by reduction of blood volume, possible cause is hemorrhage), he is probably bleeding somewhere other than the head. Look for a source of major hemorrhage somewhere else in the body.

c. Pulse. A change in pulse rate (either increasing or decreasing) may indicate a serious problem. Note the following conditions:

(1) A slowing pulse will usually accompany the rise in blood pressure observed in a patient with rising intracranial pressure. A continued rise in intracranial pressure can produce tachycardia (abnormally fast heart beat), causing death.

a rapidly expanding hematoma.

d. General Examination. A general examination should include the following: (1) Check the scalp or skull for lacerations or fractures.

(2) Fluid from the ears and nose should be checked for the presence of spinal fluid. Soak up a small amount of drainage from the ears or nose with a 4 x 4 gauze square. Cerebral spinal fluid will form a ring around the blood.

(3) Any trauma above the clavicle (collarbone) should suggest cervical spine injury.

(4) Consider that the patient may have cervical spine injury and immobilize his head and neck if:

(a) The mechanism of injury suggests violent action to the spine.

(b) The patient has a severe head injury.

(c) Injury to the patient resulted in:

1 Loss of consciousness.

2 Markedly altered level of consciousness.

3 Display of specific signs of neurological deficit (motor or sensory).

e. Special Considerations. Be aware that:

(1) Drugs and alcohol will frequently change the level of consciousness and cloud significant signs and symptoms of the trauma patient.

(2) Altered respiratory patterns may be caused by other injuries and by uncorrected hypovolemia (markedly diminished blood volume).

(3) Metabolic abnormalities can alter respiratory function.

(4) Blood pressure elevation may be caused by pain, anxiety, or preexisting hypertension.

(5) Only at the terminal stages of head injury does the patient exhibit hypotension as the result of head injury itself.

(6) Assume a patient with low blood pressure is hemorrhaging elsewhere and treat for shock.

(7) Repeat examinations at intervals and record accurately. Look for trends and changes such as:

(a) Significant rise in blood pressure.

(b) Slower pulse occurring late in the cycle.

f. Neurological Examination. A neurological examination is performed to assess the patient's condition at the time he is being examined.

(1) AVPU for initial assessment. The letters AVPU stand for methods of assessing a patient's responsiveness or unresponsiveness. The patient will be checked for alertness, verbal responsiveness, pain responsiveness, and, finally, unresponsiveness.

(a) Alertness to stimuli.

(b) Responds to verbal stimulus.

(c) Responds to painful stimulus.

(d) Unresponsive to stimuli.

(2) Glasgow coma scale for secondary assessment. Patient responses in these areas are checked:

(a) Eye opening.

(b) Verbal response.

(c) Motor response.

(3) Evaluation of pupils for equality/reaction to light. Check the patient's eyes for normal or abnormal reactions as follows:

(a) Normal reactions include:

1 When exposed to light, the pupils constrict.

2 When light is shined into one pupil, the other pupil also constricts.

(b) Abnormal reactions include: 1 Pupils are fixed and pinpoint.

2 Drooping upper eyelid when eyes are open (ptosis).

3 One pupil dilated and fixed.

4 Both pupils dilated and fixed.