Closed Head Injuries

  1. Incidence
    1. Morbidity
    2. Mortality
  2. Anatomy and Physiology of the Brain and Spine
    1. Spine
      1. Spinous process
      2. Cervical
      3. Thoracic
      4. Lumbar
      5. Spinal Fluid
    2. Spinal Cord
    3. Brain
      1. Skull
      2. Meninges
        1. Dura mater
        2. Arachnoid mater
        3. Pia mater
      3. Gray matter – composed of nerve cells
      4. White matter – covered nerve pathways that conduct messages of the brain
      5. Brain stem – center for involuntary functions, temperature regulation, respiratory and heart rate, nerve function transmissions
      6. Cerebrum – main part of brain, divided into two hemispheres, with four lobes
      7. Cerebellum – center for equilibrium and coordination
      8. Meninges – coverings of the brain
      9. Cerebral spinal fluid
    4. Types of Skull Fractures
      1. Basal
      2. Compressed
      3. Open
      4. Linear
    5. Types of Brain injuries
      1. Concussion – temporary disruption to brain without injury due to closed trauma
      2. Contusion – bruise of brain matter, may be diffuse or localized to one area
      3. Cerebral laceration
      4. Space occupying lesions
        1. Epidural bleed – typically arterial with high emergent risk
        2. Subdural – typically venous, may be acute or chronic
      5. Penetrating wounds
  3. General Assessment Considerations for Brain Trauma Patients
    1. Airway and Ventilation
      1. Maintain airway
      2. Assess for adequate ventilation
    2. Mechanism of Injury
      1. Consider the potential for blunt head trauma based on mechanism of injury
      2. Assess the need to remove the helmet with proper spinal considerations if airway compromise or bleeding under the helmet is present
    3. Spinal Immobilization
      1. In patients with head injuries with altered mental status
      2. Mechanism of injury that suggests the possibility of trauma to the spine
    4. Respiratory Status -- brain injuries can cause irregular breathing patterns due to injuries affecting the brain stem
    5. Complete a Neurological Exam
      1. Appearance and behavior
        1. Alert
        2. Responds to verbal stimuli
        3. Responds to painful stimuli
        4. Unresponsive
      2. Observe posture and motor behavior – appropriate movement
      3. Facial expression
      4. Speech and language
      5. Thoughts and perceptions
        1. Logical
        2. Ability to make decisions
      6. Memory and attention
        1. Assess orientation
          1. person
          2. place
          3. time
          4. purpose
        2. Knowledge of recent events
      7. Pupils
        1. Equal
        2. React to light
      8. Vital signs
        1. Blood pressure
          1. systolic pressure increase
          2. hypotension is associated with poorer outcomes in head injured patients
        2. Pulse rate – may be slower than normal if severe head injury
    6. Management Considerations With Brain Trauma
      1. Maintain airway throughout care
      2. Administer oxygen by non-rebreather mask – maintain oxygen saturation >90 percent at all times
  4. Nasopharyngeal airways should not be used
  5. Assist ventilation if indicated – avoid hyperventilation; except in specific circumstances
  6. Transport Considerations
    1. Head trauma patients with impaired airway or ventilation, open wounds, abnormal vital signs, or who do not respond to painful stimuli may need rapid extrication
    2. Head trauma patients must be transported to appropriate trauma centers
    3. Head trauma patients may deteriorate rapidly and may need air medical transport
    4. Adequate airway, ventilation, and oxygenation are critical to the outcome of head trauma patients
    5. Head trauma patients frequently vomit – keep suction available
    6. Head trauma patient frequently have seizures
  7. Refer to Brain Injury Foundation Guidelines
  8. Age-Related Variations for Pediatric and Geriatric Assessment and Management of Brain Injury
    1. Pediatric
    2. Geriatric
  9. Neurological examination considerations
    1. Movement of extremities
      1. absent or weak
      2. note level of impairment
    2. Respiratory ability
      1. chest wall movement
      2. abdominal Excursion
    3. Sensation
      1. present throughout body
      2. absent – note the specific level of impairment
      3. altered sensation distal to injury – jingling, numbness, “electric shocks”
    4. Pain and tenderness present at site
    5. Vital signs
      1. Hypotension may be present with cervical or high thoracic spine injuries;
      2. Heart rate may be slow or fail to increase in response to hypotension
    6. Other signs or symptoms associated with spinal cord trauma
      1. priapism
      2. inability to maintain body temperature
      3. loss of bowel or bladder control
  10. History for patient with suspected spinal trauma
  11. Describe the types of closed head injuries and the location of the injury

Content Creator: Carli Wymore
CAPCE Course Number: 20-EMTP-F3-2211
Total CE Hours: 1
Level: Advanced
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.