Download TRAUMA SERIES: HEAD TRAUMA Jassin M. Jouria, MD Dr. Jassin

TRAUMA SERIES:
HEAD TRAUMA
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical
author. He graduated from Ross University School of Medicine and has completed his
clinical clerkship training in various teaching hospitals throughout New York, including
King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria
has passed all USMLE medical board exams, and has served as a test prep tutor and
instructor for Kaplan. He has developed several medical courses and curricula for a
variety of educational institutions. Dr. Jouria has also served on multiple levels in the
academic field including faculty member and Department Chair. Dr. Jouria continues to
serves as a Subject Matter Expert for several continuing education organizations covering
multiple basic medical sciences. He has also developed several continuing medical
education courses covering various topics in clinical medicine. Recently, Dr. Jouria has
been contracted by the University of Miami/Jackson Memorial Hospital’s Department of
Surgery to develop an e-module training series for trauma patient management. Dr. Jouria
is currently authoring an academic textbook on Human Anatomy & Physiology.
ABSTRACT
Head trauma can range from minor bumps that cause slight discomfort to a serious
injury that result in permanent disability or impairment, or even death. Head trauma is a
serious matter that affects people of all ages. Sports, auto accidents, and physical
abuse are some of the leading causes of head trauma, but while the cause may be
obvious, the effects are not always readily seen. In fact, sometimes head trauma may
manifest over a period of days, weeks, or even years. For this reason, it’s important to
closely monitor any incidence of head trauma and adjust treatment according to
changing symptoms.
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Continuing Nursing Education Course Director & Planners
William A. Cook, PhD,
NurseCe4Less.com Director
Doug Lawrence, MS, Nurse Ce4Less.com Webmaster Course Planner
Susan DePasquale, CGRN, MSN, Nurse Ce4Less.com Lead Nurse Planner
Accreditation Statement
This activity has been planned and implemented in accordance with the policies of
NurseCe4Less.com and the continuing nursing education requirements of the American Nurses
Credentialing Center's Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 12 hours. Nurses may only claim credit commensurate
with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in
clinical education for all continuing nursing educational (CNE) activities. All authors and course
planners participating in the planning or implementation of a CNE activity are expected to
disclose to course participants any relevant conflict of interest that may arise.
Statement of Need
Continuing education that enhances the knowledge of nurses in all aspects of head
trauma is expected to improve patient quality of care. Nurses with advanced knowledge
to manage head trauma in the emergency/neuroscience settings are essential in the
aim to reduce patient mortality and morbidity and improve recovery outcomes.
Course Purpose
This course will provide advanced learning for nurses interested in the management of the
individual with head trauma.
Learning Objectives
Differentiate between open and closed head injuries.
Describe the difference between diffuse and focal injuries.
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Identify the three types of head injuries.
Explain the contrecoup effect.
Understand the types of hematomas that are common with head injuries.
Explain the concussion grading scale.
Describe the effects of dementia pugilistica.
List common effects and outcomes of head injuries.
Explain a lucid interval.
Understand the potential timeline for a brain injury.
Describe the common symptoms of a patient with a head injury.
List diagnostic tools for head injuries.
Identify the most appropriate type of CT for diagnosing a brain injury.
Explain first aid and common analgesics for treating a head injury.
Identify strategies for controlling cranial pressure.
Describe the effects of shaken baby syndrome.
Explain the link between Alzheimer’s and head injuries.
Target Audience
Advanced Practice Nurses, Nurses and Healthcare Professionals in all settings
Course Author & Director Disclosures
Jassin M. Jouria, MD has no disclosures
William S. Cook, PhD has no disclosures
Doug Lawrence, MS has no disclosures
Susan DePasquale, CGRN, MSN has no disclosures
Acknowledgement of Commercial Support:
There is no commercial support for this course.
Activity Review Information:
This course has been peer reviewed by Susan DePasquale, CGRN, MSN. Review Date:
October 5, 2013
Release Date: October 15, 2013
Termination Date: October 15, 2016
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INTRODUCTION
Head trauma is one of the most common injuries sustained during a trauma situation.
In fact, approximately fifty percent of individuals who experience trauma show signs of a
head injury (1). Head trauma can range from minor bumps that cause slight discomfort
to a serious injury that results in permanent disability or impairment, or even death.
Head trauma is a serious matter that affects people of all ages. Sports, auto accidents,
and physical abuse are some of the leading causes of head trauma, but while the cause
may be obvious, the effects are not always readily seen (2). In fact, sometimes head
trauma may manifest over a period of days, weeks, or even years. For this reason, it’s
important to closely monitor any incidence of head trauma and adjust treatment
according to changing symptoms.
Health care providers must be familiar with the different causes and types of head injury
to adequately treat trauma patients. In many instances, head injury will accompany
other trauma-induced injuries. Therefore, all trauma patients must be evaluated for
head injuries, even if no signs are present. Many head injuries will not produce
immediate symptoms, even if significant damage has occurred(3). A patient should be
evaluated using standard guidelines and diagnostic imaging, if appropriate(4). When a
head injury is detected, treatment should begin immediately to avoid further
complications.
Overview
Head trauma involves any trauma to the scalp, skull or brain and may include an
alteration in consciousness, even if it is brief. Patients who experience head trauma will
have a range of symptoms depending on the type of injury, the force, the location and
the severity of the injury. In some patients, the injury will be mild and will resolve over a
short period of time. However, in other patients, the trauma will produce severe injuries
that will have long-term effects.
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The most common causes of head trauma include:

Motor vehicle accidents

Firearm-related injuries

Falls

Assaults

Sports-related injuries

Recreational accidents (5)
ANATOMY AND PHYSIOLOGY OF THE BRAIN
The head is a complex region comprised of various components, all of which can be
injured during head trauma situations. The components of the head and brain include:
Nervous System
The brain is part of the nervous system and operates in conjunction with other parts of
the body to provide operative functions (6). The nervous system is comprised of two
regions:

Central Nervous System (CNS)

Peripheral Nervous System (PNS)
The central nervous system houses the brain and spinal cord, while the peripheral
nervous system is comprised of spinal nerves and cranial nerves (7). The spinal nerves
branch from the spinal cord outward and the cranial nerves branch from the brain
outward. The peripheral nervous system also houses the autonomic nervous system
(6). The autonomic nervous system controls various functions including:

Breathing

Digestion

Heart rate

Secretion of hormones (8)
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Scalp
The scalp is the soft tissue that covers the entire area of the skull. It is comprised of five
layers:

Skin

Connective tissue

Epicranial aponeurosis

Loose areolar tissue

Pericranium (7)
The first three layers of the scalp are joined together to form one unit, but the unit is
able to move freely along the loose areolar tissue that covers the pericranium. The
pericranium adheres to the calvaria (6).
Skull
The skull provides protection for the brain. It consists of two distinct regions:
Cranial Bones:

Foramen Magnum

Frontal

Temporal

Occipital

Parietal
Facial Bones:

Lacrimel bone

Inferior nasal conchae

Vomer

Nasal bone

Malar

Maxilla bone

Mandible bone (8)
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A dense white fibrous membrane called the periosteum, which is very vascular, covers
the skull bone. The periosteum provides nutrition to the bone cells through branches
that it sends into the bone. These nutrients are necessary for brain growth and repair.
At the base of the skull is the foramen magnum, which is an opening in the occipital
bone through which the spinal cord passes (9).
Meninges
The region between the brain and the skull is called the meninges. This area is
comprised of three layers of tissue. The tissue covers the brain and the spinal cord and
provides protection to both areas. The three layers of the meninges are:

Dura mater

Arachnoid

Pia mater (7)
The dura mater is the outermost layer of the meninges, and the pia mater is the
innermost layer. The dura mater contains two layers of membrane. The outer layer is
called the periosteum and the inner layer is the dura. The dura lines the inside of the
entire skull. It helps protect and secure the brain by creating small folds and
compartments. The folds of the dura are called the falx and the tentorium. The right and
left sides of the brain are separated by the falx. The upper and lower parts of the brain
are separated by the tentorium (8).
The arachnoid layer of the meninges is thin and delicate and contains a number of
blood vessels. It covers the entire surface of the brain. The space between the dura
and arachnoid membranes is referred to as the subdural space (10).
The pia mater is the layer of the meninges that is located closest to the surface of the
brain. The pia mater is comprised of a number of blood vessels that branch far into the
brain. The pia covers the entire surface of the brain and follows the folds of the brain.
The major arteries supply blood to the brain. The area between the arachnoid and the
pia is referred to as the subarachnoid space, which contains cerebrospinal fluid (11).
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Cranial Vault (brain)
The cranial vault is the region of the head that houses the cerebrum, cerebellum, and
brainstem (6). The cranial vault is comprised of the following components:

Brain tissue (80%)

Cerebral Spinal Fluid (CSF) (10%)

Blood (within blood vessels) (10%) (12)
The following table provides descriptions of each area of the cranial vault:
Region
Cerebrum
Description
The cerebrum is the largest part of the brain and is composed of right and left
hemispheres. It performs higher functions like interpreting touch, vision and
hearing, as well as speech, reasoning, emotions, learning, and fine control of
movement.
The surface of the cerebrum has a folded appearance called the cortex. The
cortex contains about 70% of the 100 billion nerve cells. The nerve cell bodies
color the cortex grey-brown giving it its name – gray matter (Fig. 4). Beneath
the cortex are long connecting fibers between neurons, called axons, which
make up the white matter.
The folding of the cortex increases the brain’s surface area allowing more
neurons to fit inside the skull and enabling higher functions. Each fold is called
a gyrus, and each groove between folds is called a sulcus. There are names for
the folds and grooves that help define specific brain regions.
Cerebellum
The cerebellum is located under the cerebrum. Its function is to
coordinate muscle movements, maintain posture, and balance
Brainstem
The brainstem includes the midbrain, pons, and medulla. It acts as a
relay center connecting the cerebrum and cerebellum to the spinal cord.
It performs many automatic functions such as breathing, heart rate, body
temperature, wake and sleep cycles, digestion, sneezing, coughing,
vomiting, and swallowing. Ten of the twelve cranial nerves originate in
the brainstem.
(7)
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Hemispheres:
The brain is divided into two hemispheres, the right hemisphere and the left
hemisphere, which are joined by the corpus callosum fibers. These fibers are
responsible for delivering messages to each hemisphere. The right hemisphere
controls the left side of the body and the left hemisphere controls the right side of the
body (13).
The left hemisphere controls the following functions:

Speech

Comprehension

Arithmetic

Writing
The right hemisphere controls the following functions:

Creativity

Spatial ability

Artistic skills

Musical skills (8)
Injury to the cranial vault commonly produces an increase in intracranial pressure.
Ultimately, according to the Monroe-Kellie Doctrine, when the volume of any of the three
cranial components increases, the volume of one or both of the others must decrease or
the intracranial pressure will rise (14). Intracranial volume typically increases when the
patient experiences a cerebral edema, and intracranial mass, or an increase in blood or
cerebral spinal fluid (15).
Lobes
The right and left hemispheres are further divided into lobes by fissures. Each
hemisphere contains four lobes:

Frontal

Temporal

Parietal

Occipital (16)
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Each of the lobes is divided into areas that control specific functions. However, while
the lobes are divided, they do not function independently. The complexity of the cranial
cavity requires consistent relationships between the various lobes as well as between
the left and right hemispheres (6). The following table provides information on the
different functions of each lobe:
Lobe
Function
Frontal
The frontal lobes are the largest of the four lobes responsible for many different functions.
Lobes
These include motor skills such as voluntary movement, speech, intellectual and behavioral
functions. The areas that produce movement in parts of the body are found in the primary
motor cortex or precentral gyrus. The prefrontal cortex plays an important part in memory,
intelligence, concentration, temper and personality.
The premotor cortex is a region found beside the primary motor cortex. It guides eye and
head movements and a person’s sense of orientation. Broca's area, important in language
production, is found in the frontal lobe, usually on the left side.
Occipital
These lobes are located at the back of the brain and enable humans to receive and process
Lobes
visual information. They influence how humans process colors and shapes. The occipital
lobe on the right interprets visual signals from the left visual space, while the left occipital
lobe performs the same function for the right visual space.
Parietal
These lobes interpret simultaneously, signals received from other areas of the brain such as
Lobes
vision, hearing, motor, sensory and memory. A person’s memory and the new sensory
information received, give meaning to objects.
Temporal
These lobes are located on each side of the brain at about ear level, and can be divided into
Lobes
two parts. One part is on the bottom (ventral) of each hemisphere, and the other part is on
the side (lateral) of each hemisphere. An area on the right side is involved in visual memory
and helps humans recognize objects and peoples' faces. An area on the left side is involved
in verbal memory and helps humans remember and understand language. The rear of the
temporal lobe enables humans to interpret other people’s emotions and reactions.
(8)
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Vascular System
Regular and consistent blood flow is crucial to the maintenance of brain activity.
Approximately 20% of the cardiac output of blood is used for arterial blood flow (6). The
brain is responsible for the regulation of blood flow over various blood pressure ranges
using vasodilation or vasoconstriction of the arteries (15). Blood is supplied to the brain
by two primary arteries, as outlined below:
Carotid Arteries:
These arteries are responsible for providing circulation to the anterior region of the
brain. The anterior region of the brain includes the frontal, temporal, partial, and
occipital lobes. The carotid arteries supply the brain with approximately 80% of the
blood flow.
Vertebral Arteries:
The vertebral arteries are responsible for the posterior circulation of the brain. These
arteries join together and form the basilar artery. The vertebral arteries provide
approximately 20% of the blood flow to the brain (17). While the anterior and posterior
circulation function independent of each other, they often communicate with each other
using communicating arteries that come together to form the Circle of Willis (10). The
Circle of Willis responds to decreased arterial flow by establishing a protective
mechanism. It shunts blood from the anterior to posterior regions of the brain, or vice
versa. This protective measure helps delay the deteriorating neurological signs and
symptoms that are often present in individuals with head trauma (7).
The following table provides an overview of the different (anterior and posterior) arterial
regions and functions:
Anterior Circulation
Anterior Cerebral Artery
Supplies most medial portions of frontal lobe and superior medial parietal
(ACA)
lobes
Anterior Communicating
Connects the anterior cerebral arteries at their closest juncture
Artery (AcomA)
Internal Carotid Artery
Ascends through the base of the skull to give rise to the anterior and
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(ICA)
middle cerebral arteries, and connects with the posterior half of the circle
of Willis via the posterior communicating artery
Middle Cerebral Artery
Trifurcates off the ICA and supplies the lateral aspects of the temporal,
(MCA)
frontal and parietal lobes
Posterior Circulation
Posterior Communicating
Connects to the anterior circle of Willis with the posterior cerebral artery of
Artery (PcomA)
vertebral-basilar circulation posteriorly
Posterior Cerebral Artery
Supplies the occipital lobe and the inferior portion of the temporal lobe. A
(PCA)
branch supplies the choroid plexus
Basilar Artery (BA)
Formed by the junction of the two vertebral arteries, it terminates as a
bifurcation into the posterior and cerebral arteries supplying the brainstem
Vertebral Artery (VA)
The vertebrals emerge from the posterior base of the skull
(Foramen Magnum) and merge to form the basilar artery supplying the
brainstem
(6)
Cranial Nerves
The brain includes twelve cranial nerves that control specific bodily functions (18). The
following is a list of the cranial nerves and the functions that they control:

Olfactory: Smell

Optic: Visual fields and ability to see

Oculomotor: Eye movements; eyelid opening

Trochlear: Eye movements

Trigeminal: Facial sensation

Abducens: Eye movements

Facial: Eyelid closing; facial expression; taste sensation

Auditory/vestibular: Hearing; sense of balance

Glossopharyngeal: Taste sensation; swallowing

Vagus: Swallowing; taste sensation
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
Accessory: Control of neck and shoulder muscles

Hypoglossal: Tongue movement (19)
Hypothalamus
The hypothalamus is directly responsible for sending messages to the pituitary gland
(7). The structure itself is very small, but it contains a number of nerve connections that
make communication between he hypothalamus and the pituitary gland possible (2).
The hypothalamus receives information from the autonomic nervous system and is
responsible for the following functions:

Eating

Sexual behavior

Sleeping

Body temperature regulation

Emotions

Hormone secretion

Movement (6)
Brain Stem
The brainstem is the part of the brain that connects the brain to the spinal cord. It is
located in front of the cerebellum (15). The brainstem is comprised of three
components:

Midbrain – responsible for ocular motion

Pons – responsible for coordinating eye and facial movements, facial sensations,
hearing, and balance

Medulla Oblongata – controls breathing, blood pressure, heart rhythms, and
swallowing (8)
The pons and the brainstem transmit messages from the cortex to the spinal cord and
are responsible for maintaining the basic life functions (20). If this area of the brainstem
is damaged or destroyed, it can cause brain death in the patient (21). Humans require
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these basic functions to survive and if transmission is interrupted, survival is not
possible (12).
The midbrain, pons, medulla and part of the thalamus contain the reticular activating
system. This system is responsible for controlling wakefulness as well as attentiveness
and the regulation of sleep patterns (6).
The brainstem contains ten of the twelve cranial nerves that control the following:

Hearing

Eye movement

Facial sensations

Taste

Swallowing

Movements of the face, neck, shoulder and tongue muscles (8)
Brain Cells
The two types of cells contained within the brain are the neurons and glial cells. They
are sometimes referred to as the neuroglia and glia. There are approximately 50%
more glial cells than neurons (22). The primary job of the neuron is to send and
receive nerve impulses and signals (23). The glial cells are responsible for the
following:

Provide nutrition

Provide support

Maintain homeostasis

Form myelin

Facilitate signal transmission in the nervous system (6)
Cerebrospinal Fluid (CSF)
Cerebrospinal fluid is a clear, watery substance that surrounds the brain and the spinal
cord. It provides a cushion that helps protect the brain and spinal cord from injury (19).
The fluid constantly circulates throughout the various channels around and within the
spinal cord and brain. It is absorbed and replenished on a continuous basis (8).
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The fluid is produced within the ventricles, which are hollow channels within the brain
(24). The chorois plexus is the ventricle structure that is responsible for the majority of
cerebrospinal fluid. Typically, the amount of CSF that is produced is balanced with the
amount that is absorbed (7).
Ventricles
There are four cavities that comprise the ventricular system. The four cavities are
referred to as ventricles (25). They are connected by a series of holes that are referred
to as foramen, as well as tubes (7). The cerebral hemisphere contains two ventricles
referred to as the lateral ventricles. Their job is to communicate with the third ventricle
using a separate opening that is called the Foramen of Munro (26).
The third ventricle serves as the center of the brain, with walls comprised of the
thalamus and the hypothalamus (6). The Aqueduct of Sylvius is a long tube that
connects the third ventricle to the fourth ventricle (2).
Other parts of the brain
Limbic System:
The limbic system includes the hypothalamus, the thalamus, the amygdala, and the
hippocampus. All of these components are involved in hormone and emotional
regulation (12).
Pineal Gland:
The pineal gland is attached to the posterior region of the third ventricle. There is no
concrete understanding of the exact role of the pineal gland. However, there is some
indication that it plays a role in sexual maturation (8).
Pituitary Gland:
The pituitary gland is located at the base of the brain within the region known as the
pituitary fossa or sella turcica. This area is located behind the nose (6). The pituitary
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gland controls the secretion of hormones and is responsible for the control and
coordination of the following activities:

Growth and development

The function of various body organs (i.e. kidneys, breasts and uterus)

The function of other glands (i.e. thyroid, gonads, and adrenal glands) (23)
Due to the fact that the pituitary gland is responsible for controlling hormone secretion, it
is often referred to as the “Master Gland.” (12)
Thalamus:
The thalamus is comprised of the basal ganglia as well as four components:

Hypothalamus

Epythalamus

Ventral thalamus

Dorsal thalamus (15)
The thalamus is responsible for transmitting all information to and from the cortex. The
primary information that is transmitted by the thalamus includes:

Pain sensation

Attention

Alertness (8)
TYPES OF HEAD TRAUMA
The injuries sustained during head trauma are complex as they are impacted by a
number of factors, including the type of trauma, the amount of force, the region, and the
region injured. Since the head and brain involve a number of different structures that
operate both independent of and with each other, injuries can range from mild to
severe. Injuries can affect more than one area of the brain, which can cause complex
injuries.
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Head injuries are caused when an object strikes the head and transfers force to the
brain tissue. The type of trauma is either blunt or penetrating. Blunt trauma produces a
closed head injury, while penetrating trauma produces an open injury (27). When an
individual experiences blunt trauma one of the following types of force will occur:

Deceleration

Acceleration

Acceleration-deceleration

Rotational

Deformation (28)
The following is an explanation of the different injuries that can occur as a result of the
forces listed above:
Deceleration forces occur when the head hits an immovable object such
as the forehead hitting the windshield. This causes the skull to decelerate
rapidly. The brain moves slower than the skull causing the brain tissue to
collide with skull. As the brain moves over the bony prominences, it can
stretch, shear or tear the tissue. Acceleration injuries can occur when an
object hits the head and the skull and the brain are set in motion.
Acceleration-deceleration forces occur due to the rapid changes in velocity
of the brain within the cranial vault. Rotational forces occur from the
twisting of the head usually after impact. The degree of injury depends
upon the speed and direction the brain is rotated. Rotational forces affect
white matter tissue of the brain. The most common areas affected include
the corpus collosum and the brain stem. Deformation forces occur when
the velocity of the impact changes the shape of the skull and compresses
the brain tissue. The brain tissue is cushioned within the cranial vault by
cerebrospinal fluid, one of the protective mechanisms of the brain. Direct
injury to the brain tissue can occur as contusions, lacerations, necrosis
and hematomas with coup and contrecoup injuries. Coup injuries occur at
the site of impact and the contrecoup injury occurs at the opposite side or
at the rebound site of impact. Bi-polar injuries may occur from front to
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back or side to side. Quadra-polar injuries involve all sides of the brain—
front, back, and each side. The most common area of impact of a coup
injury is the occipital lobe and the contrecoup injury is the frontal lobe (29).
When a patient experiences a penetrating injury, the object causing the injury breaks
through the scalp and skull and penetrates the brain. Typically, the penetrating object
will cause tissue lacerations, contusions and hemorrhages, along with a range of
secondary injuries (30). The injury will range in severity depending on a number of
factors including size, shape, speed and location of entry. Gunshot wounds and stab
wounds are especially problematic and both have a high incidence of mortality (11).
There are two classifications of head trauma:

Primary – This type of injury occurs as a direct result of the trauma

Secondary – These injuries often develop over a period of time (typically
between several hours and five days) (27)
Initial treatment will focus on repairing any primary injuries, while later treatment will
transition to minimizing potential secondary injuries (31). When an individual
experiences a head trauma, he or she will often incur both primary and secondary
injuries (23).
The following table provides information on both types of injury:
Injury Type
Description
Primary
Primary injuries are a result of acceleration-deceleration and rotational forces occurring
Injuries
at the time of impact. These cause coup (initial impact site) and contrecoup (rebound
site of impact) injuries. The forces exerted on the brain tissue may result in shearing,
tensile or compressive stresses. They can lead to ruptured blood vessels causing
hemorrhage, hematomas, and/or contusions. Injuries include lacerations, bone
fractures, contusions, hematomas and diffuse axonal injuries.
Secondary
Secondary injuries occur after the initial traumatic injury and are a consequence of the
Injuries
primary injury. A pathological cascade occurs due to the biochemical changes in cellular
structure. These changes lead to cell death and further secondary injuries such as
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hypoxia, hypotension, hypercarbia, hyperexcitation, cerebral edema, pathologic changes
associated with increased intracranial pressure, late bleeding and expanding intracranial
lesions.
(29)
Open vs. Closed Injuries
Head injuries can be either open or closed. With a closed injury, the patient
experiences trauma in the absence of skull penetration (5). With an open injury, the
patient’s skull is penetrated (2).
Open and closed head injuries cause different symptoms and must be treated
differently. The following information provides the distinctions between the two types of
injuries.
Signs and Symptoms of Closed Injury:

Altered or decreasing mental status—the best indicator of a brain injury

Irregular breathing pattern

Obvious signs of a mechanism of injury—contusions, lacerations, or hematomas
to the scalp or deformity to the skull

Blood or cerebrospinal fluid leaking from the ears or nose

Bruising around the eyes (raccoon eyes)

Bruising behind the ears, or mastoid process (Battle’s sign)

Loss of movement or sensation

Nausea and/or vomiting; vomiting may be forceful or repeated

Unequal pupil size (dilated) that does not react to light (fixed) with altered mental
status

Possible seizures

Unresponsiveness (32)
Signs and Symptoms of Open Injury:

Obvious results of the mechanism of injury—contusions, lacerations, or
hematomas to the scalp

Deformity to the skull or obvious penetrating injury
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
A soft area or depression detected during palpation

Brain tissue exposed through an open wound

Bleeding from an open bone injury (33)
Diffuse vs. Focal Injuries
Brain injuries are either diffuse or focal. In diffuse injuries, the damage occurs
throughout various areas of the brain. The damage is microscopic and widespread and
it often occurs as the result of force that is exerted on the brain tissues (34). The force
causes damage to the axons, which are the parts of the brain that communicate with
each other and initiate nerve cell responses (35). Focal brain injuries are confined to
one specific region of the brain. They cause localized damage and are easily
identifiable (36).
Types of Diffuse Injuries:

Concussion

Brain edema.

Diffuse axonal injury (27)
Types of Focal Injuries:

contusion

intracranial hematoma

extradural hematoma

subdural hematoma

intracerebral hematoma (ICH )

subarachnoid hemorrhage (SAH )

intraventricular hemorrhage (IVH ) (37)
COMMON CATEGORIES OF HEAD INJURIES
Head trauma can produce a wide range of injuries, depending on the type of force, the
object, the site of impact and the level of penetration. While a patient may experience a
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variety of injuries, there are some injuries that are more common than others. These
include scalp wounds, skull fractures, and traumatic brain injury.
Scalp Wounds
Scalp wounds are very common in head trauma situations and can range in severity
from very mild to severe (38). The scalp is the primary layer of the cranial region and is
often injured in instances of head trauma. In most cases, scalp injuries occur when
there is a skull or brain injury. However, in some instances, a scalp injury can occur
independent of any other brain injury (30). While most scalp wounds are not severe,
they can be alarming as the scalp is very vascular and prone to excessive bleeding (6).
In some situations, bleeding may be present between the layers of the scalp (10).
While such bleeding does not require extensive treatment, it is necessary to conduct a
thorough assessment of the patient’s injuries to determine the extent of damage (36). It
is especially important to palpitate the patent’s scalp to determine if there is a fracture in
conjunction with the wound (39). Once an assessment has been completed, the wound
should be cleaned thoroughly to prevent infection (31).
The following is a list of common scalp wounds:

Bruises

Laceration

Avulsion

Hematoma (15)
Skull Fractures
One of the most common severe injuries is the skull fracture. Although skulls serve as
the first line of defense in protecting the brain, they are actually quite prone to injury.
There are two distinct types of skull fracture:

Depressed Skull Fracture - This type of fracture is caused by pieces of the
broken skull pressing into the brain tissue

Penetrating Skull Fracture - This type of skull fracture is caused by something
piercing the skull (e.g. bullet, knife, etc.). The object produces a distinct injury to
the brain tissue which is localized (40).
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Skull fractures rarely occur in a patient unless he or she experiences a significant force,
as the skull is extremely hard (41). The skull is comprised of three layers. The inner
and outer layers are quite hard, and the middle layer is comprised of a spongy material
that is prone to injury (7). There are a number of different types of fractures depending
on the location of the injury, the type of force and the severity of the injury.
Linear Skull Fracture
It is very common for patients to experience linear fractures. However, the fractures
often require little to no treatment (42). Linear fractures are most common in instances
where a force spreads over a wide area (41). When the bone fractures, it may lacerate
the arteries located in the region which often results in an intracranial bleed (42). In
most instances, a linear fracture will heal on its own within a period of two or three
months (40). However, in some rare instances, a linear fracture may progress into a
growing fracture. This complication typically develops over a number of months and will
cause the bone to erode (43). In addition, the fracture line will widen, thereby producing
a leptomeningeal cyst.
In these instances, the patient will require surgical treatment to remove the cyst (41).
The patient may also require dural repair and cranioplasty (40). In some instances, the
linear fracture may cause a separation of the cranial suture. These separations are
called diastatic fractures. When a patient experiences a diastatic fracture, he or she will
require continuous monitoring to ensure that there is no extradural bleeding present
(44).
Depressed Skull Fracture
Depressed skull fractures occur when a patient has experienced a significant amount of
force against the head (45). Depressed fractures are more serious and severe than
linear fractures (46). Depressed fractures occur when the force causes a downward
displacement of the skull bones. This displacement can range in severity from a slight
depression to a complete displacement of the outer hard bone layer, which will move
under the inner hard bone and cause direct pressure to the brain tissue (41).
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Depressed skull fractures are most common in instances of open scalp wounds (38).
However, the skull will still have an intact dural membrane (28). When a patient
experiences a complex depressed skull fracture, he or she will present with a laceration
of the dura membrane. These lacerations are caused by bony skull fragments (38). In
some complex depressed skull fractures, a patient may experience complications. The
most common complications include hemorrhage and laceration of the brain tissue (47).
When a patient presents with a depressed skull fracture, he or she may require surgical
care to repair the damage and control bleeding (32). In many instances, the patient will
also require irrigation and debridement, dural repair, elevation, and bone fragment
placement (48).
Basilar Skull Fracture
It is more common for a patient to experience fractures in the cranial region than at the
base of the skull. However, in some instances, a patient will experience a basilar skull
fracture. These fractures occur after the patient experiences a severe blow to the head
(49). A basilar fracture is a break that occurs along one of the following regions:

basilar portion of the occipital bones

orbital plate of the frontal bones

cribriform plate of the ethmoid, sphenoid, and petrous or squamous portions of
the temporal bones (50)
It is difficult to diagnose a basilar fracture using a standard X-Ray. Instead, practitioners
must rely on a standard clinical assessment to identify symptoms of the fracture (51).
The presentation and clinical findings will depend on the specific location of the fracture.
During a clinical examination, the provider will assess the patient’s symptoms to identify
the location and type of basilar fracture. The following is a list of the signs and
symptoms specific to each type:

Anterior Fossa: rhinorrhea (discharge from nose), raccoon eyes (periorbital
ecchymosis), anosmia (loss ofsmell), oculomotor palsies

Middle Fossa: hemotympanum (blood in the middle ear), otorrhea, vertigo,
Battle’s sign (mastoid ecchymosis), unilateral hearing loss
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
Posterior Fossa: hypotension, tachycardia, alteration in respirations due to
compression of the brainstem (49)
Basilar skull fractures rarely cause complications and they do not require extensive
treatment and repair. Most fractures only require an observation for 24 – 48 hours (41).
However, in some rare instances, the patient may experience a complication in the form
of a cerebral spinal fluid leak (CSF). As the result of a skull fracture, a patient may
experience tears in the membranes that cover the brain. These tears can result in leaks
of cerebral spinal fluid (19).
When a patient experiences a tear between the dura and the arachnoid membrane,
which is referred to as a CSF fistula, cerebral spinal fluid will often leak out of the
subarachnoid space into the subdural space. This type of leaking is referred to as a
subdural hygromea (24). In some instances, cerebrospinal fluid may leak out of the
nose and ears (52). When a patient has tears that cause CSF to leak from the brain
cavity, they are at an increased risk of developing infections such as meningitis, which
is caused by air and bacteria entering the cavity (24). Patients are also at risk of
developing pneumocephalus from air entering the intracranial cavity and becoming
trapped in the subarachnoid space (24).
If there is a chance of a CSF leak, the patient must be monitored and assessed for
leaks on a continuous basis, over a period of several days. CSF assessment should
begin at the time of admission and continue throughout the duration of the patient’s
treatment, especially as the patient increases mobility (31). CSF leaks are more
common when patients begin moving around and can change positions or move from
the bed to a chair (24). In most instances, CSF leaks will resolve on their own and will
not require any intervention or treatment (36).
The presence of a CSF leak can be identified through an assessment of the patient’s
symptoms. In a conscious patient, the nurse will work with the patient to identify any of
the following symptoms:

a salty or sweet taste in the patient’s mouth
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
post-nasal drip

coughing or clearing of throat

visible drainage from ear or nose (19)
When a patient experiences a CSF leak, the fluid should be able to flow freely. The flow
should not be blocked using any artificial means. When the CSF is blocked, the patient
is at risk of developing an increase in intracranial pressure, as well as an infection (53).
Patients who experience a CSF leak are at an increased risk of developing meningitis.
While meningitis is a rare complication in instances of a CSF leak, it is still important to
understand the risk and identify any present symptoms. Meningitis is an infection of the
meninges. Meningitis will occur when a CSF leak is present in a tear in the meninges
(54).
It is important to treat patients with a CSF leak immediately. In some instances,
patients will be treated with antibiotics. However, some situations will not warrant the
use of antibiotics (24). The patient should refrain from the following activities if a CSF
leak is present:

Drinking with a straw

Drinking hot fluids

Blowing his or her nose

Using the incentive spirometer (19)
The above activities pose the risk of creating a vacuum, which will increase pressure in
the cranial area and may result in the introduction of bacteria or viruses into the cranial
region (24).
Cranial Nerve Injuries
Patients will often experience cranial nerve injuries as the result of skull fractures,
especially when the fracture occurs at the base of the skull (18). These cranial nerve
injuries often result in compressive cranial neuropathies. The brainstem contains twelve
cranial nerves, with nine of them projecting out toward the head and face. Therefore,
cranial nerve damage often results in partial paralysis of facial muscles (19).
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Facial Fractures
Facial fractures are common in trauma situations such as motor vehicle accidents,
assault, domestic violence, and sports injuries (55). They are often grouped together
with head trauma as they occur in conjunction with injuries sustained during trauma to
the head. Facial fractures are broken into three categories base on their location: Le
Fort I, Le Fort II, and Le Fort III. Le Fort injuries are common in situations that involve a
significant level of impact and extensive force. The force that causes a Le Fort fracture
is often so significant that it will also cause damage to the spinal cord and skull, as well
as cause neurological damage (56).
The following is a description of the three different types of Le Forte fractures:
Le Fort I Fracture
This fracture is the most common type and occurs along the maxilla bone. The
patient presents with gross malocclusion, intra-oral ecchymosis and possibly
epistaxis.
Le Fort II Fracture – Mid-face separation
This fracture occurs between the malar bone and the maxilla bone and across
the nasal bone from one side to the other. It also involves the orbit and ethmoid
bones. It is considered an extension of a Le Forte I fracture. The patient presents
with a dishpan face, wrinkled bridge of the nose, severe epistaxis and edema
along the fracture lines. There may or may not be a CSF leak.
Le Fort III Fracture – Craniofacial disruption
This fracture involves the malar and the nasal bone. The patient presents with
malocclusion, facial edema, free-floating maxilla, a CSF leak, and severe
epistaxis. The airway can be severely compromised in these patients and an
alternative airway (tracheostomy) is highly recommended (55).
When patients experience a facial fracture, they have an increased risk of being unable
to maintain their airway. This is especially common in patients who are unconscious
(57). Patients with facial fractures have an increased risk of heavy bleeding. The
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highest risk occurs in patients with Le Fort II and Le Fort III fractures. This is due to the
proximity to the internal maxillary artery. It is common for this artery to tear and bleed
into the ethmoid or the maxillary sinuses (42). Bleeding will need to be minimized using
nasal packing for approximately 24 – 48 hours. However, the packing should not
remain in place for longer than 48 hours, as the patient is at risk of developing necrosis
of the nasal mucous membranes (2). There is also a chance that the patient will
develop an infection (47).
Patients with facial fractures should be assessed immediately for neurological
impairment, as it is imperative that the damage be minimized (36). The patient should
also be assessed for cranial nerve function to identify any motor or sensory dysfunction.
To determine if there is damage, the CN V-trigeminal and CN VII-facial nerves should
be evaluated (58). Continuous monitoring of the patient’s responses enables
practitioners to identify any complications that may arise. For example, if a patient
produces excessive salivation, it may be a sign of a parotid duct gland tear (59).
Therefore, any changes should be identified and documented.
Patients with facial fractures are typically treated surgically (39). In most instances, the
patient will undergo a plating of the bones, which will often involve wiring the jaw shut.
When this occurs, the patient will require feeding either through a feeding tube or with a
straw. Since the patient cannot eat solid foods, the liquid diet must be high in protein to
provide adequate nourishment. A feeding tube will only be used if the patient is unable
to swallow effectively (55).
Traumatic Brain Injury (TBI)
Traumatic Brain Injury (TBI) is one of the most common trauma related injuries, and is
the most severe form of head trauma. According to the Center for Disease Control,
approximately 1.7 million traumatic brain injuries occur each year (60). Many of these
injuries occur along with other injuries. While traumatic brain injury is considered one
type of head trauma, it is sometimes used to refer to most head injuries that a patient
experiences. In fact, some providers use the term traumatic brain injury
interchangeably with head trauma. Therefore, many of the symptoms and
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complications included in the traumatic brain injury section overlap with those found in
other sections of this course. However, for the purpose of this section, we use
Traumatic Brain Injury to refer to one specific type of head trauma.
Traumatic brain injury is commonly referred to as either TBI, acquired brain injury, or
head injury (37). It is caused by a sudden trauma to the head that causes damage to
the brain. Depending on how the trauma occurs, the resulting damage may be focal, or
it can be diffuse (31). Traumatic brain injury can result from either a closed head injury
or from a penetrating head injury (60).
Traumatic brain injury is the direct result of a blow to the head. However, not all forces
to the head cause traumatic brain injury. Depending on a number of factors, such as
the level of impact and the type of object, the severity of the injury may range from nonexistent to severe (54). In instances where the force actually causes some level of
trauma, the injury will range from mild to severe (60). Mild injuries typically cause a
minor, or brief, change in mental status. Mild injuries may result in a temporary loss of
consciousness, but there will be no long term adverse affects (61). Severe injuries can
result in full, extended loss of consciousness. They may also cause short or long-term
amnesia (62). Throughout all levels of injury, TBI produces a range of functional and
sensory changes. These changes impact the patient’s movement, thinking, sensation,
language, and emotions (60).
Many of the symptoms of traumatic brain injury develop over time and may not appear
for a number of days or weeks. In some rare cases, the symptoms may not appear for
months (27). Many patients with mild traumatic brain injury will recover within a number
of weeks or months, although some symptoms may persist for longer (31). In patients
who experience moderate to severe traumatic brain injury, the recovery time is greater.
In fact, many moderate to severe TBI patients never fully recover (52). Many TBI
symptoms are life long complications. According to the Center for Disease Control,
approximately 5.3 million Americans are living with a TBI-related disability (60).
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A majority of traumatic brain injuries cases (approximately half) occur as the result of
transportation accidents, which includes automobiles, motorcycles, bicycles, and
pedestrian accidents. These accidents are the major cause of TBI in people under age
75 (37). For those 75 and older, falls cause the majority of TBIs (63). Approximately
20% of TBIs are due to violence, such as firearm assaults and child abuse, and about
3% are due to sports injuries (27).
The cause of the TBI plays a role in determining the patient’s outcome. For example,
approximately 91% of firearm TBIs (two-thirds of which may be suicidal in intent) result
in death, while only 11% of TBIs from falls result in death (27). Civilians and military
personnel in combat zones are also at increased risk for TBIs. The leading causes of
such TBI are bullets, fragments, and blast; falls; motor vehicle-traffic crashes; and
assaults. Blasts are a leading cause of TBI for active-duty military personnel in war
zones (40).
Traumatic brain injuries can cause a number of complications that may occur during the
onset of the injury, as well as after the injury has been treated and resolved. In some
instances, these complications may be mild and easily treatable and manageable. In
other instances, these complications can pose a significant threat to the individual.
Some complications can be life threatening, while others may cause long term disability
(27).
A traumatic brain injury can cause some significant initial complications within the
following categories:

Arousal

Consciousness

Awareness

Alertness

Responsiveness (54)
The above conditions are complications that are specific to traumatic brain injury.
However, there are also conditions that can occur immediately after a traumatic brain
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injury that are not specific to TBI, but that occur as a direct result of the injury. These
complications increase in prevalence in direct correlation to the severity of the injury.
Complications of TBI are outlined and further elaborated on below:

Immediate seizures

Hydrocephalus or posttraumatic ventricular enlargement

CSF leaks

Infections

Vascular injuries

Cranial nerve injuries

Pain

Bed sores

Multiple organ system failure in unconscious patients (47)
Seizures
It is common for approximately for patients with TBI to experience seizures. In fact,
25% of patients with brain contusions or hematomas will experience seizures, while
approximately 50% of patients with penetrating head injuries will experience seizures
(64). In these patients, seizures typically occur within the first 24 hours of the injury
(65). While some patients who experience immediate seizures will have an increased
risk of developing seizures that occur within hours or days of the injury, there is no risk
of the patient developing posttraumatic epilepsy. Typically, patients who experience
immediate or early seizures are treated with anticonvulsants if the seizures are
persistent and recurring (64).
Hydrocephalus and Posttraumatic Ventricular Enlargement
Hydrocephalus or posttraumatic ventricular enlargement is a condition that is caused by
the accumulation of cerebrospinal fluid in the brain. This excess fluid causes dilation of
the cerebral ventricles and an increase in intracranial pressure (ICP) (53). This
condition is common during the acute stage of traumatic brain injury, but it can also
occur during later stages (37). It is most common within the first year of the injury (66).
It is characterized by worsening neurologic outcome, behavioral changes, incontinence,
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axtaxia, and impaired consciousness (67). This condition typically develops as a result
of meningitis, subarachnoid hemorrhage, intracranial hematoma, or various other
injuries that have the potential to produce pressure (52). Typical treatment involves
shunting and draining the fluid (31).
Infections
Individuals with traumatic brain injury are prone to a number of infections that can occur
within the intracranial cavity. Depending on the type of injury, infections can occur in a
variety of locations in the brain, including the dura, below the dura, below the arachnoid,
and within the space of the brain (37). The majority of infections will develop within a
few weeks of the trauma. They can result from penetrating injuries or from skull
fractures. Patients are typically treated with antibiotics. However, surgery may
occasionally be used to remove sections of the infected tissue (52).
Vascular Injuries
Traumatic brain injury patients are especially prone to vascular injuries due to the
damage caused to the head and/or brain. While damage to small blood vessels rarely
has a significant impact on the patient, damage to the large blood vessels can result in
severe complications. For instance, damage to a major artery may result in a stroke
due to bleeding from the artery or as a result of the formation of a clot (66).
Common types of vascular injuries include:

Hemorrhagic stroke – bleeding directly from the artery

Ischemic stroke – blocked blood flow to the brain

Thrombus or thrombosis – the formation of a clot at the site of the injury

Vasospasm – an exaggerated, persistent contraction of the walls of the blood
vessel

Aneurysms – blood filled sacs caused by stretching of an artery of blood vessel
(51)
Patients with the above conditions may experience headaches, vomiting, partial
paralysis (often on one side of the body) and semi-consciousness. These symptoms
often appear several days after the injury (37). Depending on the specific complication,
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different treatments will be used. For example, anticoagulants are often used to treat
ischemic strokes. However, surgery is typically used to treat hemorrhagic strokes (52).
The conditions included above occur immediately following the onset of a traumatic
brain injury. Therefore, they are often identified and treated during the initial stage of
injury (31). In addition to injuries that occur during the initial stage of injury, there are
other complications that will develop over time and that will typically last throughout the
individual’s lifetime, or at least for a significant period of time (54). These complications
are considered TBI related disabilities.
TBI related disabilities vary depending on the location of the injury, the severity of the
injury and the age and general health of the patient. The most common types of TBI
related disabilities affect the following areas:

cognition (thinking, memory, and reasoning)

sensory processing (sight, hearing, touch, taste, and smell)

communication (expression and understanding)

behavior or mental health (depression, anxiety, personality changes, aggression,
acting out, and social inappropriateness) (53)
It is quite common for TBI patients to develop a range of symptoms and complications
as a result of the injury. In fact, approximately 40% of all TBI patients develop post
concussion syndrome (PCS), which is defined simply as a collection of symptoms,
within days or weeks of suffering an injury (68). PCS is common in all TBI patients, not
just those who have experienced a concussion or loss of consciousness. In fact, a
number of patients who are being treated for mild TBI are diagnosed with PCS (69).
The following symptoms are common in patients with PCS:

Headache

Dizziness

Vertigo (a sensation of spinning around or of objects spinning around the patient)

Memory problems

Trouble concentrating

Sleeping problems
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
Restlessness

Irritability

Apathy

Depression

Anxiety (34)
These symptoms may last for a few weeks after the head injury. Typical treatment
involves the use of medicines and therapy to reduce the impact of the symptoms and
help the patient cope (70).
Cognitive Impairments
It is common for patients with traumatic brain injury to experience cognitive disabilities,
especially if they have lost consciousness. In many patients, the impairments include a
loss of higher level mental skills (71). Of the different cognitive impairments, memory
loss is the most common, with patients experiencing the loss of specific memories and
the inability to form or store new memories. In some instances, patients may develop
posttraumatic amnesia. There are two types of posttraumatic amnesia:

Anterograde – impaired memory of events that happened after the TBI

Retrograde – impaired memory of events that happened before the TBI (58)
It is common for patients with cognitive impairments to become confused easily or to
have problems with distraction. These patients will typically experience difficulty
concentrating and focusing their attention. Some patients may also experience
problems with higher level functions, which includes planning, organizing, abstract
reasoning, problem solving, and making judgments (71). Patients experience the
greatest recovery during the first six months, after which the recovery becomes more
gradual. Cognitive impairments are more common in patients with moderate or severe
TBI (52).
Sensory Problems
Sensory impairments are common in TBI patients. The most common form of sensory
impairment is with vision. It is common for TBI patients to experience difficulty
registering what they are seeing or recognizing various objects (67). TBI patients are
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also prone to problems with hand eye coordination. Due to these impairments, TBI
patients often experience difficulty maneuvering through spaces and often bump into
objects or drop them (90). Sensory impairments produce a general instability in TBI
patients. As a result, many TBI patients are unable to operate a motor vehicle or
complex machinery (67). Many of these sensory issues cannot be treated and remain
with the patient indefinitely. However, in some instances, optometric vision therapy has
produced good results in patients with oculomotor dysfunctions (72).
While vision impairments are the most common form of sensory impairment in TBI
patients, some patients will also develop problems with hearing, smell, taste, or touch.
These impairments are the result of damage to the areas of the brain that controls these
senses. These conditions are difficult to treat (67).
Language and Communication Problems
Many TBI patients experience language and communication problems. Some patients
only experience difficulties with subtle aspects of communication, such as body
language and emotional, nonverbal signals (73). However, others will actually
experience difficulty understanding and producing spoken and written language. This
type of impairment is called aphasia(74). The following is a list of the different forms of
aphasia:

Broca’s Aphasia (nonfluent/motor) – difficulty recalling words and/or speaking in
complete sentences. Characterized by broken phrases and frequent pauses.
Patients often experience extreme frustration.

Wernicke’s Aphasia (fluent/sensory) – Patients display little meaning in their
speech, but typically speaks in complete sentences and use correct grammar.
Characterized by the use of flowing gibberish and sentences that include
nonessential and invented words. Patients are often unaware that they are not
making sense and express frustration when others do not understand them.

Global Aphasia – extensive damage to the portions of the brain responsible for
language. Characterized by severe communication disabilities (73).
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In some instances, TBI patients may experience difficulties with spoken language as a
result of damage to the section of the brain that controls the speech muscles. This
disorder is called dysarthria, and it affects patients differently than other impairments.
With dysarthria, the patient is able to understand and think of appropriate
words/language. However, the patient is unable to speak the words because of
damage to the speech muscles (93). Therefore, speech may be slurred and garbled.
Some patients experience difficulty with intonation or inflection. This is called prosodic
dysfunction (75).
Emotional and Behavioral Problems
Many TBI patients experience emotional and behavioral difficulties, which are often
classified as general psychiatric issues (76). It is common for a TBI patient to exhibit
personality changes and behavioral issues. The following is a list of the common
psychiatric problems experienced by TBI patients:

Depression

Apathy

Anxiety

Irritability

Anger

Paranoia

Confusion

Frustration

Agitation

Insomnia or other sleep problems

Posttraumatic Stress Disorder (PTSD)

Mood swings (77)
Typically, behavioral problems include the following:

aggression and violence

impulsivity

disinhibition
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
acting out

noncompliance

social inappropriateness

emotional outbursts

childish behavior

impaired self-control

impaired self-awareness

inability to take responsibility or accept criticism

egocentrism

inappropriate sexual activity

alcohol or drug abuse/addiction (78)
In some instances, the personality issues may be severe enough to warrant a diagnosis
of borderline personality disorder (79).
Other TBI patients may experience developmental stagnation. When this occurs, the
patient fails to mature emotionally, socially, or psychologically after the trauma (78).
This is especially problematic for children and young adults who suffer from a TBI.
Typical treatment for the various emotional and behavioral problems includes
medication and both occupational therapy and psychotherapy (31).
Coup and Contrecoup Effect
In some instances, the patient will experience a coup or contrecoup injury to the head.
These terms are used to identify a range of head injuries, but they are most commonly
used in instances of cerebral contusions (80). The two terms are used to identify the
specific injury pattern and the location of the damage.
The following is a description of the different types of injury:
Coup Injury
Damage to the brain at the point of initial impact or blow.
Contra Coup Injury
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Damage to the brain on the side opposite the side that received the initial impact or
blow.
Coup- Contrecoup Injury
Damage to the brain on both sides- the side that received the initial impact or blow and
the side opposite the initial impact. This occurs when the force of the initial blow is great
enough to cause brain damage at the site of initial impact between the skull and brain
and is also great enough to cause the brain to move in the opposite direction and hit the
opposite side of the skull, causing damage at that site. (81)
OUTCOMES AND EFFECTS OF INJURIES
Head trauma can impact the brain and other parts of the body in a number of ways.
Depending on the type, severity and location of the injury, the patient will experience a
range of outcomes and effects. Patients will not experience every one of the outcomes
listed below, but they may experience one or more. It is important to understand the
potential outcomes and effects of head injuries so that any damage can be minimized
and/or prevented.
Contusion
A contusion is defined as bruising of the brain, and it is caused by bleeding and edema
within the brain tissue (82). A contusion is a secondary injury, as it is caused by a
primary injury that swells, bleeds and results in increased intracranial pressure (15).
Contusions can occur in instances of blunt and penetrating trauma. In some patients,
the contusion will appear at the site of impact. In other patients, the conusion will
appear on the opposite side of the injury (80). It is most common for patients to
experience a contusion in the frontal or temporal lobes (47). Contusions can vary in
shape and size, and will often produce different signs and symptoms. In many
instances, contusions will produce some or all of the following symptoms:

Change in level of consciousness

Seizures

Disorientation
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
Headache

Vomiting

Increased intracranial pressure

Deterioration of neurological status (83)
Contusions are diagnosed using a CT or MRI, either of which can identify small
amounts of bleeding within the edema (84). Once bleeding has been identified, the
patient will require a follow up scan twenty four hours later to determine if there has
been an increase in the amount of blood or to see if the edema has developed around
the bleeding (82). The following treatments are often used for contusions:

Supportive therapy

Hyperventilation (when intubated)

Osmotic diuretics

Barbituates

Management of intracranial pressure

Surgery (last resort if other treatment options are not successful) (83)
Contusions to the lobe
The following table shows the effects of a contusion on the different lobes:
Frontal lobes

(Blood Supply:
Lateral – MCA
Left – cognition, right voluntary motor function, expressive
aphasia

Middle – ACA)
Right – short-term memory, alteration in emotional control,
motivation, inhibition; moral ethical and social value disruption;
and left voluntary motor function
Parietal lobes

(Blood Supply:
Lateral – MCA
Left – right sensory deficits, alteration in ability to understand
written word

Middle – ACA)
Right – visual disturbances left sensory deficits, spatial
confusion, and alteration in ability to process emotions and
behavior
Temporal Lobes

Left – receptive aphasia, alteration in interpretive area (causes
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(Blood Supply: MCA)
difficulty in learning and re-learning)

Right – unprovoked and abrupt aggression, and alteration in
hearing, taste and smell
Occipital Lobes

reading comprehension, and conjugate deviation of eyes/head
(Blood Supply: PCA)
Cerebellar Lobes

(Blood Supply: PCA and BA)
Brainstem
(Blood Supply: VA and BA)
visual problems including recognition of objects, alteration in
problems including equilibrium, spatial, and locomotion, and
altered posture

temperature regulation (hypo or hyperthermia), altered
autonomic nervous system responses, thalamic syndrome
(hyperthermia, tachycardia, posturing, tachypnea), involuntary
motor function, may have pupillary dilation (CN III – indication
of herniation) or pin point pupils (indication of hemorrhage in
the pons), altered eye movements, respiratory alterations,
uncontrolled vomiting, and altered swallowing abilities (CN IX)
(29)
Hematoma
A hematoma is the result of damage to one of the major blood vessels in the head.
There are three types of hematomas that affect the brain:

Epidural Hematoma – this type of hematoma is identified by the bleeding that
occurs between the skull and the dura.

Subdural Hematoma – In this type of hematoma, the blood is confined between
the dura and the arachnoid membrane.

Intracerebral Hematoma – this type of hematoma is characterized by bleeding
that occurs within the brain itself (60).
Epidural Hematomas
Epidural hematomas are collections of blood that are commonly located in the temporal
area of the brain (85). An epidural hematoma is typically caused by a laceration of the
middle meningeal artery, and it will often expand rapidly and cause shifting in the medial
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brain tissue (86). When this occurs, surgical intervention will be required immediately
(86).
If the hematoma does not receive immediate treatment, it can result in brain death (87).
Patients who experience an epidural hematoma will experience an initial period of
lucidity, which will be followed by rapid neurological deterioration (85).
The symptoms of an epidural hematoma include:

Ipsilateral (same side) pupil dilation (due to direct lateral pressure on
cranial nerve III from shifting brain tissue)

Change in the level of consciousness

Posturing

Contralateral limb weakness

Hemiparesis

Hemiplegia (47)
Subdural Hematoma
Subdural hematomas occur in the region below the dura and often venous, originating
from the bilateral bridging veins (88). Subdural hematomas are most common in the
following types of accidents:

Falls

Motor vehicle crashes

Assaults

Violent shaking (87)
Subdural hematomas are divided into two classifications based upon the timing of the
appearance of symptoms:

Acute: 24 – 48 hours after trauma

Subacute: 2 days to 2 weeks after trauma

Chronic: 2 weeks to 3 months after trauma (30)
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A subdural hematoma will be identifiable on a CT scan. It will appear as a crescent
shaped hematoma that will spread along the inner table of the skull (45). Once the
hematoma is identified, it will require treatment. Standard treatment includes an
elimination of the clot and minimization of bleeding (89). It is standard protocol to keep
the patient in a completely flat position for at least twenty four hours so that the brain
tissue is able to reexpand (65).
Intracerebral Hematomas
An intracerebral hematoma occurs within the cerebral tissue and can occur with minimal
blood. In fact, a patient can experience an intracerebral hematoma with as little as 5
cc’s of blood in the cerebral tissue (90). Intracerebral hematomas occur most frequently
with depressed skull fractures, penetrating injuries, and acceleration-deceleration
injuries (91). In some instances, intracerebral hematomas may occur when the patient
experiences bleeding in the necrotic brain tissue (92). Patients will often experience a
sudden deterioration of their neurological status (90). Depending on the severity, size
and location of the hematoma, the patient may require medical and surgical
interventions (86).
Hemorrhage
A patient will often experience a brain hemorrhage when the fragile blood vessels within
the skull rupture (15). The type of bleeding will be classified based upon the location.
The layers of the meninges are used as a guide to determine the type of bleeding (85).
The type of brain bleed depends on how and where the meningeal layers capture the
blood and how it is distributed.
Epidural Hemorrhage
An epidural hemorrhage is the least common type of hemorrhage and typically occurs in
less than one percent of intracranial hemorrhage cases (42). This type of hemorrhage
is typically the result of a laceration in the middle meningeal artery (30). When epidural
bleeding occurs from a venous source, the bleeding will be quite slow. However, when
the bleeding is from an artery, it will progress much faster (83).
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Epidural hemorrhages are quite dangerous and can often be life threatening (87).
When a patient experiences an epidural hemorrhage, he or she will typically follow one
of two patterns of injury. Approximately fifty percent of patients with an epidural
hemorrhage will experience a brief loss of consciousness immediately following the
injury, but they will regain consciousness shortly after (23). When the patient regains
consciousness, he or she will be asymptomatic. However, the patient will often develop
symptoms within the hours following the return to consciousness (77).
Typical symptoms include:

Headache

Nausea

Vomiting

Lethargy

Confusion

Altered mentation

Unconsciousness (5)
The lucid interval stage of injury can last anywhere from two minutes to sixteen hours,
with the average duration being 2 – 6 hours (93). Approximately half of the patients with
an epidural hemorrhage will lose consciousness and never regain it. Of these,
approximately 15 – 20% will die (94).
Subarachnoid Hemorrhage
A subarachnoid hemorrhage occurs when the cerebral blood vessels are stretched or
torn during injury (95). Since there is a small amount of CSF present in this region, it
can be difficult to differentiate between the two on a CT scan (96). Therefore, it is more
plausible and reliable to use the patient’s clinical presentation and relevant brain injury
as guides when assessing and identifying a subarachnoid hemorrhage (97).
Subarachnoid hemorrhages can cause extensive neurological deterioration and other
secondary injuries, including but not limited to:

Focal ischemia

Localized cerebral edema
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
Vasospasm

Thrombosis of blood vessels

Traumatic aneurysm (95)
Typically, patients who experience a subarachnoid hemorrhage will often show signs of
neurological deterioration, intracranial hypertension, and meningeal irritation (26).
There is no standard protocol used to treat patients. In fact, there is some controversy
surrounding the best method to treat a subarachnoid hemorrhage (88). Some patients
may be treated using calcium channel blockers, but this method of treatment is not
widely used. Other providers will take a “wait and see” stance (47).
Cerebral Hemorrhage
A cerebral hemorrhage is defined as any bleeding that occurs within the actual matter of
the brain. It is most common in the frontal and temporal lobes and occurs most often as
the result of penetrating trauma (85). However, some patients may experience a
cerebral hemorrhage after sustaining an acceleration-deceleration injury. This occurs
when the force causes tears within the blood vessels within the brain (83).
In instances of cerebral hemorrhage, a patient will experience symptoms that are similar
to those found in other head injuries. However, specific symptoms will vary depending
on the location and severity of the injury and the bleeding. A patient may not
experience symptoms immediately, but once symptoms do appear, the patient will often
progress rapidly from asymptomatic to unconscious (90).
Extradural Hemorrhage
An extradural hemorrhage is bleeding that occurs in the region between the inside of
the skull and the dura (47). The most common cause of an extradural hemorrhage is a
skull fracture, especially in children and adolescents (41). In fact, extradural
hemorrhages are most common in younger individuals due to fact that the membrane
covering the brain is loosely attached to the skull, unlike the covering in adults, which is
more firmly attached (98).
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Extradural hemorrhages often occur as the result of a ruptured blood vessel, most
commonly an artery. The blood released by the artery will flow into the spaces between
the dura matter and the skull (86). The blood typically flows rapidly and quickly collects,
thereby causing pressure on the brain, which leads to an increase in the pressure inside
the head (intracranial pressure) (53). When the hemorrhage progresses to this stage,
the patient will require intervention to relieve the pressure. If the pressure is not
relieved, the patient may experience additional brain damage (25).
Diffuse Axonal Injury
This injury, also known as shearing, is caused by contrecoup and is characterized by
damage to neurons and the subsequent loss of connections among them. Once this
occurs, there is the potential for the breakdown of communication among all neurons in
the brain (52). Diffuse axonal injury (DAI) is common with primary head injuries and is
typically caused by acceleration-deceleration and rotational forces (35). DAI causes a
disruption to the neuronal transmission and occurs as a result of stretching and
shearing of the neurons (99).
Diffuse Axonal Injury is identified using an MRI, but may also appear on a CT scan (4).
A patient will show a variety of symptoms depending on the type and severity of diffuse
axonal injury. DAI is classified using severity as the scaling agent and is diagnosed
after a patient presents with a prolonged coma lasting longer than six hours (100). The
following is the classification information or diffuse axonal injury:

Mild DAI: Coma lasting 6-24 hours, mild to moderate memory impairment, and
mild to moderate disabilities

Moderate DAI: Coma lasting > 24 hours, followed by confusion and long-lasting
amnesia. Withdrawal to purposeful movements, and mild to severe memory,
behavioral, cognitive, and intellectual deficits

Severe DAI: Deep prolonged coma lasting months with flexion and extension
posturing. Dysautonomia can occur. Deficits are noted in cognition, memory,
speech sensorimotor function and personality (101)
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Concussion
A concussion is the most common and most mild form of traumatic brain injury. The
Center for Disease Control defines a concussion as:
“a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the
head that can change the way your brain normally works. Concussions can also
occur from a fall or a blow to the body that causes the head and brain to move
quickly back and forth (68).”
However, the term is commonly used to identify a mild injury to the head or brain.
Concussions can range in severity and some require extensive medical treatment. If
untreated, some concussions can cause more significant problems (60).
Most individuals will recover fully from a concussion over a short period of time.
However, some individuals require more recovery time. For these individuals, recovery
can take a number of days, weeks or even months (61). In addition, some individuals
may experience severe symptoms as a result of a concussion that indicate that the
patient is at risk of developing long term complications (66). It is important that
providers recognize the different symptoms of concussions so that they are able to
differentiate between common symptoms and those that indicate a more significant
problem. Typical concussion symptoms are identified using four categories, as below:

Thinking/Remembering

Physical

Emotional/Mood

Sleep (69)
Using the categories listed above, the following table provides an overview of standard
concussion symptoms:
Thinking/
Physical
Emotional/Mood
Sleep
Remembering
Difficulty thinking
Headache; Fuzzy or
clearly
blurry vision
Feeling slowed down
Nausea or vomiting
Irritability
Sleeping more than
usual
Sadness
Sleep less than usual
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(early on); Dizziness
Difficulty concentrating
Sensitivity to noise or
More emotional
Trouble falling asleep
light; Balance problems
Difficultyremembering
Feeling tired, having no
new information
energy
Nervousness or anxiety
(68)
The symptoms listed above are common concussion symptoms. However, there are
some symptoms that are considered a red flag to providers and warrant immediate
attention. According to the Center for Disease Control, the following warning signs
should be taken seriously and should be treated immediately:
Danger Signs in Adults

Headache that gets worse and does not go away.

Weakness, numbness or decreased coordination.

Repeated vomiting or nausea

Slurred speech.
Emergency treatment should be sought immediately if the patient shows any of the
following signs:

Looks very drowsy or cannot be awakened.

Has one pupil (the black part in the middle of the eye) larger than the other.

Has convulsions or seizures.

Cannot recognize people or places.

Is getting more and more confused, restless, or agitated.

Has unusual behavior.

Loses consciousness (a brief loss of consciousness should be taken seriously
and the person should be carefully monitored).
Danger Signs in Children

Any of the danger signs for adults listed above.

Will not stop crying and cannot be consoled.
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
Will not nurse or eat (68)
Grading scale
Throughout the years, a number of classification and grading systems have been
developed to assess the type and severity of a concussion. The individual care
provider, based on the situation and the patient’s needs, determined which grading
system was used. There are over sixteen concussion-grading scales. However the
most widely used scales are the Contu Grading System, the Colorado Medical Society
Guidelines, and the American Academy of Neurology Guidelines. The following is a list
of the most common concussion grading scales:
American Academy of Neurology Concussion Severity - March 1997 Practice Parameter:
Dr. Phalin used this system in his doctoral study of different models for detecting recovery in sports
concussions:
Grade 1:

Transient Confusion

No Loss of Consciousness

Concussion Symptoms < 15 Minutes
Grade 2:

Transient Confusion

No Loss of Consciousness

Concussion Symptoms > 15 Minutes
Grade 3:

Any Loss of Consciousness, Brief or Prolonged
AAN Guidelines suggest observation for the following features of concussion:

Vacant stare (befuddled facial expression)

Delayed verbal and motor responses (slow to answer questions or follow instructions)

Confusion and inability to focus attention (easily distracted and unable to follow through with
normal activities)

Disorientation (walking in the wrong direction, unaware of time, date. and place)

Slurred or incoherent speech (making disjointed or incomprehensible statements)
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
Gross observable incoordination (stumbling, inability to walk tandem/straight line)

Emotions out of proportion to circumstances (distraught, crying for no apparent reason)

Memory deficits (exhibited by the athlete repeatedly asking the same question that has already
been answered, or inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes)

Any period of loss of consciousness (paralytic coma, unresponsiveness to arousal.
AAN Guidelines Suggest Monitoring for "Early" and "Late" Symptoms of Concussion Early Symptoms:

Headache

Dizziness or vertigo

Lack of awareness of surroundings

Nausea or vomiting
Late Symptoms (days to weeks):

Persistent low grade headache

Light-headedness

Poor attention and concentration

Memory dysfunction

Easy fatigability

Irritability and low frustration tolerance

Intolerance of bright lights or difficulty focusing vision

Intolerance of loud noises, sometimes ringing in the ears

Anxiety and/or depressed mood

Sleep disturbance
Concussion Severity: R.C. Cantu, 1991
Contu's system is often used in research involving sports concussions.
Grade 1:
No Loss of Consciousness AND Post Traumatic Amnesia < 30 Minutes
Grade 2:
Loss of Consciousness < 5 Minutes OR Post Traumatic Amnesia of 30 Minutes to 24 Hours
Grade 3:
Loss of Consciousness > 5 Minutes OR Post Traumatic Amnesia > 24 Hours
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In 2001 Cantu's system was updated and included additional symptoms:
Grade 1:
No Loss of Consciousness and Post-Traumatic Amnesia < 30 minutes, and post-concussion symptoms
15-30 min.
Grade 2:
Loss of Consciousness < 1 minute or post-traumatic amnesia 30 min.- 24 hrs.
Grade 3:
Loss of Consciousness > 1 minute, Post-traumatic amnesia > 24hrs, or signs and symptoms < 1 week.
Ruff Concussion Grades
Type I :

altered mental state or transient loss of consciousness (LOC)

1-60 seconds of post-traumatic amnesia (PTA)

one or more neurological symptoms
Type II:

definite LOC with time unknown or < 5 minutes

60 seconds to 12 hours of post-traumatic amnesia (PTA)

one or more neurological symptoms
Type III:

5 - 30 minutes of LOC

more than 12 hours of PTA

one or more neurological symptoms
American College of Sports Medicine Guidelines
Grade I:
None or transient retrograde amnesia, None to slight mental confusion, No loss of coordination,
Transient dizziness, Rapid recovery
Grade II:
Retrograde amnesia; memory may return slight to moderate mental confusion, Moderate dizziness,
Transient tinnitus, Slow recovery
Grade III:
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Sustained retrograde amnesia; anterograde is possible with intracranial hemorrhage, Severe mental
confusion, Obvious motor impairment, Prolonged tinnitus, Delayed recovery
Colorado Medical Society Concussion Rating Guidelines
Grade I:
No loss of consciousness, Transient confusion, No amnesia
Grade II:
No loss of consciousness, Transient confusion, Amnesia
Grade III:
Loss of consciousness
Zurich Group
Grade I:
Simple, Injury resolves over 7 – 10 days
Grade II:
Complex, Persistent symptoms, Specific, Specific sequelea, Prolonged loss of consciousness ( more
than 1 minute), Or prolonged cognitive function impairment
(102)
There has been a great deal of controversy surrounding the different grading scales and
their usefulness over the years. Much of the controversy has focused on the
inconsistency in the grading scales (103). Depending on the scale used, a patient may
have a class 2 concussion or a class 3 concussion. Therefore, recent concussion
assessment guidelines have eliminated the used of classification systems in favor of a
symptom-based approach to concussion assessment and identification (104). Rather
than rate the concussion, practitioners are now encouraged to use basic symptom
identification and objective assessment to determine whether or not a patient has a
concussion (105).
Dementia pugilistica
Some patients who experience repeat head trauma will develop dementia pugilistica.
However, it typically takes a number of years and many repeat episodes of head trauma
to appear (22). It is especially common after a patient experiences numerous
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concussions. These concussions can cause permanent brain damage, which will
impact the long term condition of the patient’s mental facilities (106). The condition is
especially common in boxers and other athletes who experience repeat head trauma
(22). Dementia pugilistica is permanent and cannot be cured. However, progression of
the cognitive degeneration can be minimized through the use of medication and therapy
(59).
The symptoms of dementia pugilistica will vary and often present as a range of mental
and physical symptoms. The following is a list of the most common symptoms of
dementia pugilistica:

inhibited ability to process written or spoken language

inability to concentrate on tasks

difficulty remembering events

psychotic episodes

mood swings

unpredictable behavior changes

hand tremors

speaking difficulties

loss of motor movement coordination (61)
Coma
A coma is defined as a deep state of unconsciousness (102). A patient who
experiences a coma is alive, but loses the ability to move or respond to the environment
and external stimulation (47). Most comas last an average of two to four weeks, but
some patients can remain in a coma for an extended period of time. The duration of a
coma and the extent of recovery will vary depending on the cause, severity and location
of the damage (107). Some patients will recover completely from a coma, while others
will experience long term physical, mental, intellectual and emotional problems (102). A
patient who remains in a coma for an extended period of time (months or years) is at an
increased risk of developing an infection such as pneumonia, which can be life
threatening (108).
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During a coma, a patient is completely unconscious and cannot be aroused. The patient
is also unresponsive and unaware of his or her surroundings (102). Patients will not
respond to external stimuli and do not experience sleep-wake cycles (109). A coma is
typically the result of severe trauma to the brain, and is most common with injuries to
the cerebral hemispheres of the upper brain and the lower brain or brainstem (107). In
most instances, a coma will only last for a few days or a few weeks. However, in some
extreme situations, a patient may progress to a vegetative state (110).
When a patient appears to be in a coma, the trauma team will first stabilize the patient
and assess the vital signs and basic neurological signs. After the vital signs and basic
neurologic functions are assessed, the emergency medical provider will assess the
patient’s level of consciousness and neurologic functioning (109). This assessment is
done using the Glasgow Coma Scale, which is a standardized, 15 point test that
measures neurologic functioning using three assessments: eye opening, best verbal
response, and best motor response. A patient will be determined to be in a coma if he
of she meets the criteria on the coma scale (60).
The Center for Disease Control guidelines for the Glasgow Coma Scale are as follows:
Eye Opening Response

Spontaneous; open with blinking at baseline - 4 points

To verbal stimuli, command, speech - 3 points

To pain only (not applied to face) - 2 points

No response - 1 point
Verbal Response

Oriented - 5 points

Confused conversation, but able to answer questions - 4 points

Inappropriate words - 3 points

Incomprehensible speech - 2 points

No response - 1 point
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Motor Response

Obeys commands for movement - 6 points

Purposeful movement to painful stimulus - 5 points

Withdraws in response to pain - 4 points

Flexion in response to pain (decorticate posturing) - 3 points

Extension response in response to pain (decerebrate posturing) - 2 points

No response - 1 point
Categorization:
Coma

No eye opening, no ability to follow commands, no word verbalizations (3 - 8)
Head Injury Classification:

Severe Head Injury----GCS score of 8 or less

Moderate Head Injury----GCS score of 9 to 12

Mild Head Injury----GCS score of 13 to 15
Disclaimer: Based on motor responsiveness, verbal performance, and eye opening
to appropriate stimuli, the Glasgow Coma Scale was designed and should be used
to assess the depth and duration coma and impaired consciousness. This scale
helps to gauge the impact of a wide variety of conditions such as acute brain
damage due to traumatic and/or vascular injuries or infections, metabolic disorders
(e.g., hepatic or renal failure, hypoglycemia, diabetic ketosis), etc. (110)
The coma is one form of altered consciousness that occurs during head trauma. If the
trauma is severe enough, patients may experience one of the other types of altered
consciousness. These altered states of consciousness are often considered different
types of comas, even though they have different symptoms, and are explained below.
Stupor:
When a patient experiences a stupor, he or she is often unresponsive but is able to be
aroused, if only briefly, by a strong stimulus (52).
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Vegetative State:
When a patient is in a vegetative state, he or she is completely unaware of the
surroundings. However, unlike with a coma, patients in a vegetative state continue to
have a sleep-wake cycle. In addition, patients may experience periods of alertness
(31). Patients in a vegetative state will often open their eyes and show other signs of
movement and function, which may include groaning and some reflex responses (52).
In many instances, a vegetative state is the result of trauma to the cerebral
hemispheres with the absence of injury to the lower brain and brainstem (111).
Most patients will only remain in a vegetative state for a few weeks, but some may
progress to a persistent vegetative state, which is defined as longer than thirty days
(52). Once a patient has been in a vegetative state for a year, the chances of recovery
are extremely low (54).
Locked-In Syndrome:
With Locked-In Syndrome, the patient is unable to move or communicate normally as
the result of paralysis of the body. However, the patient is fully aware and awake (60).
Locked-In Syndrome is caused by damage to areas in the lower brain and brainstem,
but not by damage to the upper brain (47). Typically, patients use movements and eye
blinking to communicate. Ultimately, most patients do not gain their motor control back
once they are in a locked-in state (52).
Brain Death:
Brain death is a newer diagnosis that has occurred due to the development of assistive
devices that artificially maintain blood flow and breathing (52). Brain death is defined as
a lack of measurable brain function. This is typically caused by injuries to the cerebral
hemispheres and brainstem (54). There is also a loss of integrated activity within
specific areas of the brain (52). This condition is irreversible. If a patient does not
remain on assistive devices, he or she will experience immediate cardiac arrest and will
stop breathing (2).
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The various unconscious states listed above are easy to diagnose as the result of
advancements in imaging and other technologies. Using these new technologies,
practitioners can identify the area of the brain affected and diagnose the patient based
on the level of activity present in different regions of the brain (31). Most commonly,
doctors use CT and MRI to identify the affected areas of the brain. However, other
diagnostic imaging tools such as cerebral angiography, electroencephalography (EEG),
transcranial Doppler, ultrasound, and single photon emission computed tomography
(SPECT) may be used (112).
Death
The most severe outcome of head trauma is death. While some patients may
experience brain death (see: Traumatic Brain Injury section), others will fully succumb to
injuries sustained during a head trauma situation. Death is most common in patients
who experience moderate to severe trauma (113).
The 2011 CDC Surveillance Report on Traumatic Brain Injury provides the following
information regarding head injury related deaths:
2011 CDC Surveillance Report
Head Injury Related Deaths
During 1997--2007, an annual average of 53,014 deaths (18.4 per 100,000 population; range: 17.8-19.3) among U.S. residents were associated with TBIs. During this period, death rates decreased 8.2%,
from 19.3 to 17.8 per 100,000 population (p = 0.001). TBI-related death rates decreased significantly
among persons aged 0--44 years and increased significantly among those aged ≥75 years. The rate of
TBI deaths was three times higher among males (28.8 per 100,000 population) than among females
(9.1). Among males, rates were highest among non-Hispanic American Indian/Alaska Natives (41.3 per
100,000 population) and lowest among Hispanics (22.7). Firearm- (34.8%), motor vehicle-- (31.4%),
and fall-related TBIs (16.7%) were the leading causes of TBI-related death. Firearm-related death rates
were highest among persons aged 15--34 years (8.5 per 100,000 population) and ≥75 years (10.5).
Motor vehicle--related death rates were highest among those aged 15--24 years (11.9 per 100,000
population). Fall-related death rates were highest among adults aged ≥75 years (29.8 per 100,000
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population). Overall, the rates for all causes except falls decreased.
(1)
Head injury related death is most common in patients who experience trauma from
firearms, motor vehicles, and falls (34). This is due to the severity and type of injury
caused by these mechanisms. While these are the primary causes of head injury
related death, any head injury can be life threatening depending on the type and
location.
TIMELINE FOLLOWING INJURY
Immediate
In the period immediately following head trauma, the patient will experience a range of
symptoms and conditions. The specific symptoms will depend on the type of injury, the
damage incurred, and the location of the injury. Many patients will lose consciousness,
at least briefly (93). Some patients may also show signs of confusion (114). The period
immediately following a head injury is crucial for the identification and treatment of any
conditions (36).
Lucid interval
A lucid interval is the period of consciousness that occurs between the initial period of
unconsciousness and a subsequent period of unconsciousness (93). A patient only
experiences a lucid interval if he or she becomes unconscious again immediately
following the period of consciousness (115). This occurs when blood builds on the
brain, producing significant pressure on the brain tissue. If a patient does not receive
immediate treatment, he or she is at an increased risk of death (116).
Later in life
Many individuals who experience mild head injuries will recover completely within a few
weeks of the trauma and will not experience long term complications (47). However,
patients who experience moderate to severe forms of traumatic brain injury will often
experience long term problems associated with the injury (13).
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The following is a list of the more common long-term problems associated with head
injuries.
Parkinson’s Disease
In some patients, Parkinson’s disease may develop years after TBI as a result of
damage to the basal ganglia. Symptoms of Parkinson’s disease include:

tremor or trembling

rigidity or stiffness

slow movement (bradykinesia)

inability to move (akinesia)

shuffling walk

stooped posture (117)
Parkinson’s Disease is a rare complication of TBI, but it can occur. Other movement
disorders that may develop after TBI include tremor, ataxia (uncoordinated muscle
movements), and myoclonus (shock-like contractions of muscles) (118).
Alzheimer’s Disease
Alzheimer’s disease (AD) is defined as a progressive, neurodegenerative disease
characterized by dementia, memory loss, and deteriorating cognitive abilities. According
to recent research, there is an association between head injury in early adulthood and
the development of AD later in life. The risk of developing AD later in life is increased in
direct correlation to the severity of the head injury (119).
Chronic Traumatic Encephalopathy and ALS
There is evidence that TBI contributes to the incidence of nerve degenerative diseases
such as amyotrophic lateral sclerosis (ALS) and chronic traumatic encephalopathy
(CTE). In fact, there is pathological evidence that there is a direct correlation between
repeated blows to the head and the long-term development of these diseases (120).
Posttraumatic Dementia
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Posttraumatic dementia is characterized by symptoms of both dementia and
Parkinson’s and is caused by a single, severe TBI that results in a coma (78).
Long Term Treatment for Head Trauma
Many individuals experience long term complications and disabilities as the result of
head trauma (121). Therefore, long-term treatment is often needed beyond the
emergency treatment that is provided initially. Initial treatment for patients with
moderate to severe traumatic brain injury is focused on stabilizing the patient and is
often done within the emergency department or intensive care unit (31). Once the
patient is stabilized, further treatment may be required depending on the type and
severity of the injury.
Most long-term treatment involves rehabilitation, as the goal is to have the patient
regain the appropriate neurologic functions. This component of treatment is often
conducted in a subacute unit of the hospital or in an independent rehabilitation center
(52). In addition, some long term treatment will be conducted through outpatient
services (31). Treatment at this stage is diverse and is tailored to the specific recovery
needs of the patient.
Most long term treatment includes physical therapy, occupational therapy, speech and
language therapy, psychiatric care, psychological services, social support and life skill
development, and physiatry (92). The specific rehabilitative program will utilize the
services of experts in the above areas to develop a comprehensive program that
addresses the specific treatment needs of the program. Initial treatment will most likely
be extensive, with longer term treatment being less frequent (122). As the patient
regains the appropriate skills, treatment will be reevaluated and modified to continue to
meet the needs of the patient (79).
The goal of long-term treatment is to bring the patient to a level of functioning that
enables him or her to live independently and integrate with society. When patients
experience a long term or permanent disability as the result of a head injury, the
rehabilitation team will provide treatment and therapy that focuses on adapting to the
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disability and developing new skills that will enable the patient to function within the
constraints of the disability (121).
Long-term rehabilitation will typically be conducted in a variety of settings, including
hospital outpatient programs, inpatient rehabilitation centers, day treatment programs,
hospital outpatient programs and independent living centers. The specific setting will be
determined based on the rehabilitation needs of the patient and the specific services
available in the geographic area (71).
SYMPTOMS
An individual will experience a variety of symptoms as the result of a head injury. Each
patient will experience symptoms differently, and symptoms will vary depending on the
type and severity of the injury. The following are the most common symptoms of mild
and moderate/severe head injuries.
Mild head injury:

Raised, swollen area from a bump or a bruise

Small, superficial (shallow) cut in the scalp

Headache

Sensitivity to noise and light

Irritability

Confusion

Lightheadedness and/or dizziness

Problems with balance

Nausea

Problems with memory and/or concentration

Change in sleep patterns

Blurred vision

"Tired"eyes

Ringing in the ears (tinnitus)

Alteration in taste
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
Fatigue/lethargy
Moderate to severe head injury (requires immediate medical attention) - symptoms may
include any of the above plus:

Loss of consciousness

Severe headache that does not go away

Repeated nausea and vomiting

Loss of short-term memory, such as difficulty remembering the events that led
right up to and through the traumatic event

Slurred speech

Difficulty with walking

Weakness in one side or area of the body

Sweating

Pale skin color

Seizures or convulsions

Behavior changes including irritability

Blood or clear fluid draining from the ears or nose

One pupil (dark area in the center of the eye) looks larger than the other eye

Deep cut or laceration in the scalp

Open wound in the head

Foreign object penetrating the head

Coma (a state of unconsciousness from which a person cannot be awakened;
responds only minimally, if at all, to stimuli; and exhibits no voluntary activities)

Vegetative state (a condition of brain damage in which a person has lost his
thinking abilities and awareness of his surroundings, but retains some basic
functions such as breathing and blood circulation)

Locked-in syndrome (a neurological condition in which a person is conscious and
can think and reason, but cannot speak or move) (11)
The above is a list of general symptoms of mild to severe head injuries. The following
section will provide more detailed information on each of the most common symptoms.
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Bleeding
Bleeding is common with head injuries. With penetrating head injuries, bleeding can
occur externally or internally (59). Internal bleeding is most common in the brain tissue
or between the cranial layers (47). In blunt trauma injuries, bleeding typically occurs
internally, although there may be minimal bleeding at the site of impact (28). Bleeding
is not always apparent when it is internal. Therefore, it is important to utilize radiologic
imaging to identify any internal areas of bleeding (4).
Bruising
Bruising is common in instances of blunt head trauma (38). Most patients will
experience external bruising at the site of impact (15). External bruises can range in
severity and appearance, depending on the amount of force used and the area of the
head that is bruised. Some patients will experience internal bruising, otherwise known
as contusions (82).
A contusion is defined as bruising of the brain, and it is caused by bleeding and edema
within the brain tissue (83). It is a secondary injury, as it is caused by a primary injury
that swells, bleeds and results in increased intracranial pressure (15). Contusions can
occur in instances of blunt and penetrating trauma (28). In some patients, the contusion
will appear at the site of impact as a coup injury. In other patients, the contusion will
appear on the opposite side of the injury as a contrecoup injury (80). It is most common
for patients to experience a contusion in the frontal or temporal lobes (37).
Neurological deficits
Many patients will experience cognitive deficits as a result of head trauma. The specific
deficits will vary depending on the location and severity of the injury. The following is a
list of the most common cognitive deficits experienced by head trauma patients:

Arousal or over-stimulation

Attention and filtering issues

Information coding and retrieval (memory) issues

Learning, both using old information and acquiring new information

Problem solving

Higher-level thinking skills also known as “executive skills” (67)
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Some of the cognitive deficits listed above will be short-term problems and will be
eliminated over time with the aid of therapy and rehabilitation services (122). However,
other cognitive deficits will persist long term and may not ever resolve themselves (59).
In some instances, persistent cognitive deficits can be minimized or eliminated through
the use of more intensive rehabilitation services (123).
Cognitive deficits have a direct correlation with neurobehavioral problems (71).
Therefore, it is important to discuss the two together. Neurobehavioral problems are
directly related to specific components of head trauma. Depending on the injury, the
patient may experience neurobehavioral problems that cause changes in behavior and
attitudes.
The following is a list of the common neurobehavioral problems experienced by head
trauma patients:

Reduced inhibitions and judgment

Difficulty with self-regulation or self-control

Impulse control

Over-arousal

Frustration tolerance

Problems in perception

Overreaction to situations

Anger without provocation

Socially inappropriate behaviors (124)
Treatment for neurobehavioral problems includes therapy, medication, and behavior
modification (77).
Some patients will experience neuromotor problems. These are also a direct result of
specific head injuries and will vary depending on the type and location of injury.
Neuromotor problems affect the patient’s physical movement and ability to control the
body (125). The following is a list of the most common neuromotor problems:
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
Initiating or starting a movement

Maintaining muscle control

Sustaining a movement

Executing a complex movement, such as walking (61)
If a patient experiences neuromotor problems, he or she will be treated using specific
therapies and strategies that will help improve motor functions and regain skills (105).
Amnesia
Patients who sustain head injuries may experience some degree of amnesia. Amnesia
is defined as a loss of memory for any period of time (126). Amnesia is broken into two
categories, depending on the way that it presents itself.
Retrograde Amnesia
The patient loses memories of events that occurred prior to the injury. Some patients
may only lose a few seconds or a minute of memory (114). In these instances, the
patient may remember part of the accident, but not the entire accident. Other patients
may experience the loss of a longer duration of time, up to days or years (127).
In some instances, patients may not remember the accident at all, or even the year prior
to the accident (59). Most patients will recover their memories as the damage heals.
However, there is no standard time period or pattern that the return of memories will
follow (126).
Anterior Amnesia
Patients who experience anterior grade amnesia will lose memories of the events that
occurred following the injury. In these instances, the will continue to lose new
memories, while still retaining memories of events that occurred prior to the injury (127).
Changes in Pupil Shape and Size
Different complications of head trauma can cause changes in the shape and size of the
pupil. Therefore, a standard examination should include an assessment of the patient’s
pupils. Any changes should be noted and used to determine the extent of injury. The
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following table provides information on the areas of the pupil that may experience
changes:
Area of Change
Description
Pupil Size and Equality
Pupil size is reported as the width or diameter of each pupil in millimeters. A
standardized pupil gauge should be used to report the pupil size in
millimeters. The use of this gauge aids in decreasing subjectivity, particularly
when serial assessments are performed. The normal diameter of the pupil is
between 2 and 5 mm, with the average pupil measuring 3.5 mm. Although
both pupils should be equal in size, a 1-mm discrepancy is considered a
normal deviation. This condition is known as anisocoria and is present in
15% to 17% of the population without any known clinical significance. Pupil
size should be assessed both before and after the pupil responds to direct
light.
Pupil Shape
Pupil shape is reported as round, irregular, or oval. The normal shape of the
pupil is round. An irregular-shaped pupil may be the result of
ophthalmological procedures such as cataract surgery or lens implants, and
this should be noted on the initial assessment and confirmed with the patient
or family. A pupil that is oval in shape may indicate the early compression of
cranial nerve III due to increased intracranial pressure (ICP), and thus should
be addressed immediately. If an oval pupil is detected, measures should be
taken to decrease ICP. As ICP is reduced, the oval-shaped pupil should
resolve. However, if ICP continues to rise or is not treated, the oval-shaped
pupil will become further dilated and will eventually become nonreactive to
light.
Pupil Reactivity
Pupil reactivity is reported as the response or reflex of each pupil to direct
light. Shining a low-beam flashlight inward from the outer canthus of each
eye assesses reactivity. Each eye should be checked separately. The light
should not shine directly into the pupil because the glare or reflection may
obscure visualization. The reaction that each pupil has to the light stimulus
should be recorded. The speed of pupillary reactivity is recorded as brisk,
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sluggish, or nonreactive. Normally, pupils should constrict briskly in response
to light. A sluggish or slow pupillary response may indicate increased ICP,
and nonreactive pupils are often associated with severe increases in ICP
and/or severe brain damage.
A complete pupillary reactivity examination also includes assessment of the
consensual pupillary response and accommodation. The consensual
pupillary response is the constriction that normally occurs in a pupil when
light is shown into the opposite eye.6 Because of this response, the trauma
nurse should wait for several seconds before assessing pupillary light reflex
in the second eye, as that pupil may be temporarily constricted.
Accommodation is the constriction of pupils that occurs when a conscious
patient is focusing on a close object. Pupils should normally constrict
bilaterally when an object is held within 4 to 6 inches of a patient's nose.
General Pupil
When performing pupillary examinations in patients with TBI, trauma nurses
Abnormalities
may detect abnormalities, such as an irregular pupil size, shape, or a
sluggish or nonreactive pupil. When an abnormality is detected, the trauma
nurse should first identify whether the abnormality was present on the
previous pupillary examination. If an abnormal pupil is present on the initial
pupillary examination, it should be clearly documented, and a physician
should be immediately notified. Immediate notification of a physician should
occur with changes in pupillary response. Comparing the current
examination with the previous to provide time-oriented data for the physician
is wise but should never delay immediate physician notification.
General Indications
A complete neurologic examination should be performed and any changes in
the patient's condition should be noted and reported to a physician. An
abnormal pupil in a patient with TBI is often indicative of increasing ICP due
to progression of the hematoma/hemorrhage or cerebral edema. However,
the trauma nurse should be aware of other clinical factors that may cause an
abnormal pupil response. Table 2 highlights abnormal pupils that may be
seen in TBI patients and identifies both physiologic and clinical factors
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contributing to the abnormalities. Regardless of the cause of an abnormal
pupil, the trauma nurse should always notify a physician immediately when
an abnormal pupil is detected. A CT scan and continuous ICP monitoring will
aid in definitively identifying the cause of the abnormal pupil.
(128)
Stiff neck
Within the twenty-four hours following a head injury, a patient may experience a stiff
neck. This is often indicative of a more serious complication and should be monitored
closely (36).
Severe headache
It is common for a patient to experience a headache immediately after experiencing a
blow to the head. Most patients will experience headaches within the first few weeks
following a head injury (129). However, most headaches should stop within four weeks
of the injury (130). Headaches are not cause for concern as long as they do not get
worse over time (36). Headaches are classified using three distinct categories:

Mild: A mild headache improves or goes away completely with home treatment,
medication, or rest. It may return when the medication wears off.

Moderate: A moderate headache improves with home treatment, medication, or
rest, but it never completely goes away. The patient is always aware that the
headache is present.

Severe: A severe headache is incapacitating. Home treatment, medication, and
rest do not relieve this headache (130).
If a patient experiences a continuous headache that gets worse over time, it should be
taken into consideration. These headaches are often indicative of swelling and/or
bleeding on the brain, or within the areas surrounding the brain (131). In some
instances, the blood and swelling will occur between the brain and the covering of the
brain. The bleeding may occur rapidly, or it may slowly develop (130). Some patients
will display symptoms within minutes of hours of the injury, while other patients will not
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experience symptoms until weeks after the injury (132). If a patient reports a new and
persistent headache that does not develop immediately following the injury, he or she
may have a blood clot. Along with the headache, the patient may experience confusion
and sleepiness (59).
While most headaches are not cause for alarm, any headache that is persistent and
accompanies by other symptoms (e.g. drowsiness and personality changes) is
concerning and must be assessed immediately. This type of headache is often
indicative of an increase in pressure around the brain, which can be life threatening if
left untreated (133).
Physical Deficits
Many patients will experience physical deficits as a result of head trauma. The most
common physical deficits and correlating symptoms felt after head trauma include:

Hearing loss

Tinnitus (ringing or buzzing in the ears)

Headaches

Seizures

Dizziness

Nausea/Vomiting

Blurred vision

Decreased smell or taste

Reduced strength and coordination in the body, arms, and legs (21)
Vomiting/Nausea
Vomiting and nausea are common symptoms in instances of head trauma and can
occur with mild to severe trauma. When a patient experiences vomiting or nausea, it is
important to make sure he or she is comfortable and that there is no chance of
asphyxiation (134).
Loss of Consciousness
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It is common for head trauma patients to experience loss of consciousness immediately
following a head injury. Some patients will only lose consciousness for a few seconds,
while others may remain unconscious for hours or days (135). Loss of consciousness
can affect the patient even after he or she awakens. The following is a list of the most
common side effects a patient will experience after a loss of consciousness:

Drowsiness

Confusion

Restlessness

Agitation upon waking

Vomiting

Seizures

Impaired balance

Lack of coordination

Impaired ability to think

Inability to control emotions

Difficulty moving

Inability to feel things

Difficulty with speech

Loss of vision

Hearing impairment

Memory impairment or loss (115)
DIAGNOSIS
Assessment and treatment of head trauma should begin as soon as possible.
Therefore, emergency personnel are often the first individuals who assess and treat the
injury (52). Typically, treatment begins as soon as emergency responders arrive on the
scene or as soon as an individual arrives at the emergency room. Initial brain damage
that is caused by trauma cannot be reversed. So, initial treatment involves stabilizing
the patient and administering treatment that will prevent further damage (31).
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The key components of the trauma assessment are as follows:
1. ABC’s:
Assess the airway with stabilization of the cervical spine, breathing, circulation,
heart rate and blood pressure before the neurological exam.
2. Examination of the Skull:
Assess for periorbital and postauricular ecchymosis, cerebrospinal fluid otorrhea
and rhinorrhea, hemotympanum, penetrating injury or depressed fracture, and
lacerations.
3. History:
Gather information related to the mechanism of injury and care prior to
hospitalization.
4. Neurological Exam:
Cerebral function
Assess the level of consciousness, mental
status, awareness, arousal, cognitive function,
and behavior.
Cranial Nerve and pupillary examination
This reflects brainstem function. Assess the
pupils, eye movements,
cough reflex, corneal reflex and gag reflex.
Motor and cerebellar function
Assess strength, movement, gait, and posture.
Each extremity must be assessed separately. It
is important to document the degree and type of
stimulus applied to elicit the motor activity.
Central stimuli include sternal rub, trapezius
pinch and/or supraorbital pressure. Abnormal
findings include abnormal posturing, flaccidity,
and focal motor movements.
Sensory examination
Assess tactile and pain sensations.
Reflex examination
Assess superficial and deep tendon reflexes.
Glasgow Coma
This is a valuable component of the
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Scale
neurological exam because it is nationally and
internationally recognized. It is only one part of
the neurological exam.
Severe Head Injury: GCS # 8 or a decrease in 2
points or more after admission.
Moderate Head Injury: GCS 9-12
Mild Head Injury: GCS 13-15
(29)
Due to the diverse causes of head trauma and the differing needs of patients, initial
contact with the patient involves an assessment of the cause of the injury and a
screening to determine the extent of the injuries (31). This is important, as the
mechanism of injury will determine the type of treatment needed. For example, blast
trauma related head trauma is more complex than other forms of head trauma (136).
Due to the complexity of blast related head injury, the assessment and treatment can be
difficult to administer and determine. Therefore, in combat, it is more common to
evaluate all service members who have been exposed to a blast and identify those that
present symptoms of head injury (136). However, in civilian instances of head trauma,
it is more common to assess each patient individually based on the symptoms present
as non blast related causes of head trauma tend to be less complicated (31).
Prior to conducting a full assessment of an individual who is suspected of having a
traumatic brain injury, the primary concern is ensuring that the patient is stabilized and
that any further injury is prevented. During the initial stage of contact, medical
personnel are primarily concerned with ensuring that the patient has a proper supply of
oxygen to the brain and the rest of the body (48). Another priority is to maintain an
adequate blood flow while controlling blood pressure. This will help stabilize the patient
while minimizing further damage to the brain (31).
Once a patient is stabilized, medical personnel will assess the patient and determine the
extent of the injury. Primary assessment includes measuring vital signs and reflexes, as
well as administering a thorough neurological exam. The initial exam includes checking
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the patient’s temperature, blood pressure, pulse, breathing rate, pupil size and response
to light (26). After the vital signs and basic neurologic functions are assessed, the
emergency medical provider will assess the patient’s level of consciousness and
neurologic functioning. This assessment is done using the Glasgow Coma Scale, which
is a standardized, 15 point test that measures neurologic functioning using three
assessments: eye opening, best verbal response, and best motor response. These
measures are used to determine the severity of the brain injury (137).
In addition to the CDC guidelines for the Glasgow Coma Scale (GCS) discussed earlier
on this study, there are modified versions of the GCS that are age specific and help in
the assessment of individuals unable to cooperate with all three types of responses in
the GCS; for example, intubated patients or those encumbered by a host of medical
equipment. This is briefly elaborated on below, and for further understanding the learner
is directed to the following helpful webiste: Brainline.org (2013) @
http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html.
The Glasgow Coma Scale (GCS) provides a reliable, objective way to record an
individual’s level of consciousness; and, is an assessment tool that physicians and
nurses use for the initial and ongoing assessment of a head trauma victim. The GCS
has been studied and there is empirical evidence to support its value in trauma case
outcomes. For nurses functioning in a children’s hospital or pediatric unit, the following
modified pediatric GCS or PCGS may be used, outlined below:
Eye Opening (E)
• 4 = spontaneous
• 3 = to voice
• 2 = to pain
• 1 = none
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Verbal Response (V)
• 5 = smiles, oriented to sounds, follows objects, interacts
• 4 = cries but consolable, inappropriate interactions
• 3 = inconsistently inconsolable, moaning
• 2 = inconsolable, agitated
• 1 = none
• Motor Response (M)
• 6 = moves spontaneously or purposefully
• 5 = withdraws from touch
• 4 = withdraws to pain
• 3 = decorticate posture (an abnormal posture that can include rigidity, clenched
fists, legs held straight out, and arms bent inward toward the body with the
wrists and fingers bend and held on the chest)
• 2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held
straight out, toes pointed downward, head and neck arched backwards)
• 1 = none
The GCS scoring levels for children are the same as for adults to assess level of
consciousness and to further determine the degree of brain injury; using the same
severity scale, i.e. 3 - 8 is the most severe, 9 - 12 is a moderate injury and 13 - 15
suggests the child has a mild traumatic brain injury. For moderate and severe injuries in
children there is often significant long-term impairments the same as in adults.
After the Glasgow Coma Scale is administered, further testing is conducted to
determine the level of damage and the severity of the injury. Imaging tests are used to
assist with the diagnosis of the patient as well as make a determination about the
prognosis of the patient (31). Skull and neck x rays are used to check for bone
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fractures and spinal instability in patients with mild to moderate injuries (138). In
patients with mild head trauma, a diffusion tensor imaging is sometimes used. This
device can reliably detect and track brain abnormalities and is sensitive enough to be
used on patients with mild injury (61). In some cases, a magnetoencephalography may
be used to obtain further information regarding a mild case of head trauma (97).
Additional diagnostic imaging is used in cases of moderate to severe head trauma. In
these instances, patients will be assessed using a computed tomography (CT) scan.
This scan creates cross sectional x ray images of the head and brain and is used to
identify any bone fractures that might be present in the skull. The CT scan also
indicates if there is the presence of hemorrhage, hematomas, contusions, brain tissue
swelling, and tumors (139).
Once the initial assessment is complete, additional imaging may be conducted. In
these instances a magnetic resonance imaging (MRI) is often used to determine if there
is additional damage beyond the scope of the initial assessment. The MRI is used to
determine if there have been any subtle changes in the brain tissue and are used when
more detail is needed than standard x rays can provide (20). MRI’s are not used during
the initial emergency assessment as they require a significant amount of time and are
not always available during the initial assessment (9). However, an MRI is an important
diagnostic tool and should be used when appropriate and available.
Examination
When a patient presents with head trauma, he or she will undergo a complete
examination, with the purpose of assessing the trauma and identifying specific injuries.
While the examination will vary depending on the patient’s needs, there are standard
examination methods that are typically used during the initial examination.
Regardless of the type of injury (blunt or penetrating, open or closed) the initial
examination will be conducted as soon as possible and will often occur in conjunction
with resuscitation (140). It is important to conduct the initial assessment as soon as
possible to identify any life threatening injuries and minimize any additional damage.
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Early identification of an complications will reduce the likelihood of the patient
developing secondary injuries (70).
While it is important to manage any damage caused by an open head wound, it should
not interfere with the initial stabilization of the patient. Therefore, the initial stage of the
patient examination will include assessing and managing the airway, breathing,
circulation, and related components (36). Once that is complete, the emergency
provider will begin the primary survey. The primary examination will focus on identifying
any complications or secondary injuries (106). The following guidelines are provided for
the primary and secondary examination of the patient:
Primary Examination
As part of the primary survey, the pupillary size and reactions are noted and the conscious state is
assessed. Disturbances of consciousness may follow focal damage to the reticular formation, which
extends from the rostral midbrain to the caudal medulla. It receives input from all sensory pathways and
projects widely to the cerebral cortex and limbic system. Focal cortical lesions do not affect
consciousness, but coma may result from general depression of the cerebral cortex.
Using purely descriptive methods to assess conscious state is problematic. One observer’s “somnolent”
is another’s “drowsy”. When is a person stuporous and when are they obtunded? What is semiconscious and when does a clouded conscious state become coma? Consciousness is a continuum
and the Glasgow Coma Scale (GCS) is used as a measure (albeit crude) of level of consciousness.
Secondary Examination
Once the primary survey is complete, the secondary survey should include a more thorough
neurological examination, starting with a reassessment of the Glasgow Coma Scale, and an
examination of the head, face and neck. The head and face should be examined for lacerations and
fractures. Scalp lacerations can be palpated with a gloved finger. If there is an underlying depressed
fracture, surgery will be required. Profuse bleeding may occur from a scalp laceration and this can be
controlled with a pressure dressing or by a few temporary full-thickness sutures.
The nose and ears are inspected for leaks of cerebrospinal fluid (CSF). This is usually mixed with blood
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and results in a thinner discharge that will separate on blotting paper. If this is not available, the
separation can also be observed on a sheet or pillowcase. If there is CSF rhinorrhea or otorrhoea, a
basal skull fracture is present (regardless of whether it can be seen on radiographs).
Bilateral periorbital hematomas (raccoon eyes) and subconjunctival hemorrhages where the posterior
margin cannot be seen are both indicators of anterior fossa fracture. Haemotympanum or bruising over
the mastoid (Battle’s sign) suggests a middle fossa fracture. Battle’s sign usually takes several hours to
develop. The nose, mid face and orbits should also be palpated for fractures that may require treatment
later. When the patient is log-rolled, the back of the head and cervical spine should also be examined.
The neurological examination will be limited because of the lack of cooperation of the patient, but it
should still be possible at least to determine if there are lateralizing signs such as a hemiparesis or a
third cranial nerve palsy
Higher functions are assessed first. Most often this will be limited to level of consciousness and, in
particular, the “voice” component of the GCS. In a relatively cooperative patient with a focal injury it may
be possible to assess language further, but in the early period after a head injury it will be difficult to
differentiate dysphasia from confusion.
Memory becomes important later and the period of post-traumatic amnesia is used as an indicator of
injury severity.
Cranial nerves
Many of the cranial nerves can be assessed even in the unconscious patient.
I (olfactory): Assessment obviously requires cooperation, but this nerve should be examined when
possible, as it is the most commonly affected cranial nerve after head injury and is often ignored.
Anosmia may seem trivial but it has significant effects beyond enjoyment of food and wine. Anosmic
patients will not be able to smell smoke from a fire or leaking gas, both of which may potentially put
them at risk.
II (optic): The pupillary reactions to light depend on the integrity of the optic and oculomotor nerves, as
well as their connections. Normally both pupils should constrict when light is shone in either eye or
when the patient looks at a near object (accommodation reflex). A pupil that responds to direct light
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implies that the ipsilateral optic and oculomotor nerves are intact. If it responds to direct light, but not
consensually, this implies damage to the contralateral optic nerve. A pupil reacting only consensually
suggests ipsilateral optic nerve damage. An oculomotor nerve injury will produce an ipsilateral dilated
pupil, which does not respond directly or consensually, but the contralateral pupil will constrict when
light is shone in either eye. One must remain aware that the commonest cause of a dilated pupil after
head injury is traumatic mydriasis due to local ocular trauma. This should be suspected if the dilated
pupil was present right from the time of injury and there is local trauma to the globe or orbit.
During examination of the eyes the fundi are assessed. One would not expect to see papilledema in the
early hours after a head injury, and funduscopy is done more for the purpose of assessing the integrity
of the eye itself (checking for retinal detachment or hemorrhage, vitreous hemorrhage, corneal
laceration, etc.). Contact lenses should be looked for and removed. Visual fields can be checked by
confrontation in a cooperative patient or by menace in an uncooperative patient. They are not clinically
assessable in the unconscious patient.
III, IV and VI (oculomotor, trochlear and abducens): The pupils are assessed as above. Ptosis (III) is
difficult to assess in patients who are unconscious. Ocular movements can be observed and any
dysconjugate movements noted. If the patient is cooperative this is easy. An alert but uncooperative
patient can be made to look at objects quite readily by placing them in their field of vision. This also
applies to children. Oculocephalic reflexes test the third, fourth and sixth cranial nerves and their
connections. Movement of the head from side to side or up and down will be accompanied by
movement of the eyes in the opposite direction, resulting in a constant point of fixation.
The term “doll’s eyes” is often used to describe oculocephalic reflexes but this frequently leads to
confusion. Whether doll’s eyes are normal or abnormal depends on the sophistication of the doll. One
with eyes painted on would describe the abnormal and one with eyes free to rotate would better
approximate the normal situation. It is preferable to avoid the term altogether and describe
oculocephalic reflexes as being normal or abnormal. It is not usually recommended to test
oculocephalic reflexes in a head-injured patient owing to the high risk of associated cervical spinal
injury. If it is important to know if these reflexes are intact (e.g., in assessing brain death), caloric testing
is usually undertaken.
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V (trigeminal): The motor component of the trigeminal nerve can be tested in a cooperative patient, but
the sensory part can be assessed even in the unconscious. Painful stimuli applied to the supraorbital
nerve should usually produce a response and the corneal reflex tests trigeminal function as well as
facial nerve function.
VII (facial): Facial movements are readily assessed in the cooperative patient, but can also be observed
when painful stimuli are applied and as part of the corneal reflex. Facial nerve palsies are often seen
with middle fossa fractures and this nerve should be assessed early in any patient with CSF otorrhoea
or Battle’s sign. Taste is not usually tested. Patients often complain of loss of taste after a head injury
but this is usually due to anosmia.
VIII (acoustic): This is hard to test clinically in the unconscious patient. An alert but uncooperative
patient can be observed for reaction to sudden noises. Assessment in the unconscious usually requires
brainstem auditory evoked potential monitoring. This nerve is also often injured in middle fossa
fractures.
IX (glossopharyngeal), X (vagus): There is usually little more to do than observe swallowing and test the
gag reflex, either directly or by moving an endotracheal tube.
XI (accessory): Sternomastoid and trapezius function can be tested, but it is unusual for the accessory
nerve to be injured intracranially.
XII (hypoglossal): A hypoglossal nerve injury will force the protruded tongue to the ipsilateral side. Over
time the ipsilateral side of the tongue becomes wasted.
Motor function
The sophistication of motor testing depends on the level of cooperation of the patient. At the least, it is
possible to detect asymmetry in movement or responses to pain as described above in assessing the
GCS. Reflexes are often brisk but may be absent with associated spinal cord injury (spinal shock).
Plantar reflexes will usually be extensor after a significant head injury. Priapism and loss of anal tone
are other indicators of spinal cord injury that should be sought.
Sensory function
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The same applies as for motor function. If there is a response to pain, this can be compared in different
areas. This is important when a spinal cord injury is suspected and one is attempting to determine at
what level. Sometimes there can be movement of limbs through local spinal cord reflexes; hence, when
assessing a patient for brain death, it is mandatory that the painful stimulus is applied to a cranial nerve
distribution.
(140)
In many instances, the examination will include radiologic imaging. The following
tables, provided by the American College of radiology, give specific recommendations
for the different radiologic procedures that are used in head trauma situations.
Major Recommendations
Clinical Condition: Head Trauma (ACR Appropriateness Criteria®)
Variant 1:
Minor or mild acute closed head injury (GCS ≥13), without risk factors or neurologic deficit.
Radiologic Procedure
Rating
CT head without contrast
7
MRI head without contrast
4
MRA head and neck without
3
Comments
RRL*
Known to have low yield.
O
Rarely indicated with mild trauma.
O
contrast
MRA head and neck without
3
O
and with contrast
CT head without and with
3
contrast
CTA head and neck with
3
Rarely indicated with mild trauma.
contrast
MRI head without and with
2
O
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contrast
CT head with contrast
1
X-ray head
1
FDG-PET/CT head
1
US transcranial with Doppler
1
Arteriography cervicocerebral
1
Tc-99m HMPAO SPECT head
1
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9
*Relative
Usually appropriate
Radiation
Level
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2:
Minor or mild acute closed head injury, focal neurologic deficit and/or risk factors.
Radiologic Procedure
Rating
Comments
RRL*
CT head without contrast
9
MRI head without contrast
6
For problem solving.
O
MRA head and neck without
5
If vascular injury is suspected. For
O
contrast
MRA head and neck without
problem solving.
5
and with contrast
If vascular injury is suspected. For
O
problem solving. See statement regarding
contrast in the text below under
"Anticipated Exceptions."
CTA head and neck with
contrast
5
If vascular injury is suspected. For
problem solving.
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MRI head without and with
3
O
contrast
CT head without and with
2
contrast
CT head with contrast
1
Tc-99m HMPAO SPECT head
1
FDG-PET/CT head
1
US transcranial with Doppler
1
X-ray head
1
Arteriography cervicocerebral
1
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9
*Relative
Usually appropriate
Radiation
Level
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Moderate or severe acute closed head injury.
Radiologic Procedure
Rating
Comments
RRL*
CT head without contrast
9
MRI head without contrast
6
O
MRA head and neck without
5
O
contrast
MRA head and neck without
5
and with contrast
CTA head and neck with
See statement regarding contrast in the
O
text below under "Anticipated Exceptions."
5
contrast
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CT head without and with
2
contrast
MRI head without and with
2
O
contrast
X-ray head
2
CT head with contrast
1
US transcranial with Doppler
1
FDG-PET/CT head
1
Arteriography cervicocerebral
1
Tc-99m HMPAO SPECT head
1
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9
*Relative
Usually appropriate
Radiation
Level
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Mild or moderate acute closed head injury, child <2 years old.
Radiologic Procedure
Rating
CT head without contrast
9
MRI head without contrast
7
Comments
Diffusion weighted imaging especially
RRL*
O
helpful for nonaccidental trauma.
MRI head without and with
4
contrast
Potentially useful in suspected
O
nonaccidental trauma. See statement
regarding contrast in the text below
under "Anticipated Exceptions."
MRA head and neck without
4
If vascular abnormality suspected.
O
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contrast
MRA head and neck without
4
and with contrast
If vascular abnormality is suspected.
O
See statement regarding contrast in the
text below under "Anticipated
Exceptions."
CTA head and neck with
4
If vascular abnormality is suspected.
2
Appropriate as part of skeletal survey in
contrast
X-ray head
suspected nonaccidental trauma. May
be appropriate when screening for
patients suspected of having penetrating
head trauma or foreign bodies.
CT head without and with
2
contrast
CT head with contrast
1
FDG-PET/CT head
1
Tc-99m HMPAO SPECT head
1
US transcranial with Doppler
1
Arteriography cervicocerebral
1
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9
*Relative
Usually appropriate
Radiation
Level
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Subacute or chronic closed head injury with cognitive and/or neurologic deficit(s).
Radiologic Procedure
Rating
Comments
RRL*
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MRI head without contrast
8
O
CT head without contrast
6
Tc-99m HMPAO SPECT head
4
For selected cases.
FDG-PET/CT head
4
For selected cases.
MRA head and neck without
4
For selected cases.
O
4
For selected cases. See statement
O
contrast
MRA head and neck without
and with contrast
regarding contrast in the text below under
"Anticipated Exceptions."
CTA head and neck with
4
For selected cases.
contrast
MRI head without and with
3
O
contrast
CT head without and with
2
contrast
CT head with contrast
2
X-ray head
2
MRI functional (fMRI) head
2
O
US transcranial with Doppler
1
O
Arteriography cervicocerebral
1
without contrast
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9
*Relative
Usually appropriate
Radiation
Level
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
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Variant 6: Closed head injury, rule out carotid or vertebral artery dissection.
Radiologic Procedure
CTA head and neck with
Rating
Comments
RRL*
8
contrast
MRA head and neck without
8
Add T1 neck images.
O
8
Add T1 neck images. See statement
O
contrast
MRA head and neck without
and with contrast
regarding contrast in the text below under
"Anticipated Exceptions."
MRI head without contrast
8
Include diffusion-weighted images.
CT head without contrast
8
CT head without and with
6
Consider perfusion.
Arteriography cervicocerebral
6
For problem solving.
MRI head without and with
6
See statement regarding contrast in the
O
contrast
contrast
O
text below under "Anticipated
Exceptions."
CT head with contrast
4
X-ray head
2
Tc-99m HMPAO SPECT head
1
US transcranial with Doppler
1
FDG-PET/CT head
1
Consider perfusion.
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9
*Relative
Usually appropriate
Radiation
Level
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Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 7: Penetrating injury, stable, neurologically intact.
Radiologic Procedure
Rating
CT head without contrast
9
CTA head and neck with
7
Comments
RRL*
contrast
MRA head and neck without
6
If there is no MRI contraindication.
O
6
If there is no MRI contraindication. See
O
contrast
MRA head and neck without
and with contrast
statement regarding contrast in the text
below under "Anticipated Exceptions."
Arteriography cervicocerebral
5
If vascular injury is suspected.
MRI head without contrast
5
If there is no MRI contraindication.
CT head without and with
4
Consider perfusion.
4
If there is no MRI contraindication. See
O
contrast
MRI head without and with
contrast
O
statement regarding contrast in the text
below under "Anticipated Exceptions."
X-ray head
4
CT head with contrast
2
US transcranial with Doppler
1
Tc-99m HMPAO SPECT head
1
FDG-PET/CT head
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate;
O
*Relative
Radiation
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Level
7,8,9 Usually appropriate
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 8: Skull fracture.
Radiologic Procedure
Rating
CT head without contrast
9
CTA head and neck with
7
Comments
RRL*
If vascular injury is suspected.
contrast
MRI head without contrast
6
X-ray head
5
For selected cases.
MRI head without and with
4
Useful if infection suspected. See
contrast
O
O
statement regarding contrast in the text
below under "Anticipated Exceptions."
CT head without and with
4
contrast
MRA head and neck without
4
O
contrast
MRA head and neck without
4
and with contrast
See statement regarding contrast in the
O
text below under "Anticipated Exceptions."
CT head with contrast
2
US transcranial with Doppler
1
Tc-99m HMPAO SPECT head
1
Arteriography cervicocerebral
1
O
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FDG-PET/CT head
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9
*Relative
Usually appropriate
Radiation
Level
(141)
The tables above lists the guidelines and recommendations for all forms of radiologic
imaging used in head trauma situations. However, the two most commonly used
diagnostic assessments are the Non-contrast CT and the MRI (112).
Non-contrast CT
Computed tomography (CT scan) is a diagnostic imaging procedure that produces
horizontal, or axial, images of the body. These images are often called “slices.” (45)
The CT scan uses a combination of X Ray imaging and computer technology to obtain
the images in a noninvasive format (142). A CT scan is an important diagnostic tool as
it is able to provide detailed images of different parts of the body. It is especially useful
in obtaining images of the bones, muscles, fat and organs (143).
CT scans are used more frequently than standard X Rays because the images are
more detailed (139). Standard X Rays use a single beam of energy that is aimed at the
specific body part being analyzed. The image is captured on a plate that is placed
behind the body, once the beam of light passes through the various body parts (skin,
bone, muscle, and tissue) (4). X Rays are limited in their ability to provide detailed
imaging, as they cannot capture images of internal organs and other structures of the
body. Therefore, a CT scan is often the primary assessment used. A CT scan uses a
moving X Ray beam to capture the images. The beam circles around the body, thereby
capturing a number of different views of the same body part (142). The information is
transmitted to a computer, which then interprets the data and creates a two dimensional
form. The form is displayed on a monitor, which is then reviewed by the radiologist
(144).
CT scans are conducted in two ways, as described below:
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Contrast CT
Patients ingest a substance orally, or receive an injection intravenously. The contrast
solution enables the radiologist to view the specific body part or region more clearly
(45).
Non-Contrast CT
The CT scan is conducted without the use of any solution. In instances of head trauma,
the patient will undergo a non contrast CT scan (145).
CT scans are especially useful in instances of head trauma as they provide detailed
images of the brain structure and brain tissue. CT scans can help the treating physician
identify any underlying injuries or infections of the brain, especially when other
examinations of images are inconclusive (143). The scan is often used to identify the
following complications of head trauma:

Intracranial bleeding

Structural anomalies

Infections

Clots (96)
The following are the CDC Guidelines for using a CT scan with patients with mild
traumatic brain injury. The guidelines provide recommendations for determining which
patients with a known or suspected mild brain injury requires a head CT and which may
be safely discharged.
CDC Brain Injury Guidelines for Adults: Fact Sheet

A noncontrast head CT is indicated in head trauma patients with loss of consciousness or
posttraumatic amnesia in presence of specific symptoms.

A noncontrast head CT should be considered for head trauma patients with no loss of
consciousness or posttraumatic amnesia in presence of specific symptoms.

Even without a loss of consciousness or amnesia, a patient could still have an intracranial
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injury. Identifying those patients at risk is key.

A patient with an isolated mild TBI and a negative CT is at minimal risk for developing an
intracranial lesion and may be safely discharged.

Discuss discharge instructions with patients and give them a discharge instruction sheet to take
home and share with their family and/or caregiver. Be sure to:
o Alert patients to look for post concussive symptoms (physical, cognitive, emotional, and
sleep) since onset of symptoms may not occur until days after the initial injury.
o Instruct patients on what to expect, what to watch for, and when it is important to return
immediately to the emergency department.
o Emphasize that getting plenty of rest and sleep is very important after a concussion, as
it helps the brain to heal. Patients should gradually return to their usual routine only
after they start to feel better.
(146)
The CDC also provides leveled recommendations for determining which patients in the
emergency department should undergo a non-contrast CT scan; which are included
below:
CDC Brain Injury Guidelines for Adults: Fact Sheet
Level A recommendations:
A noncontrast head CT is indicated in head trauma patients with loss of consciousness or
posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age > 60
years old, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma
above the clavicle, posttraumatic seizure, GCS score < 15, focal neurologic deficit, or coagulopathy.
Level B recommendations:
A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or
posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, ≥ 65 years old,
physical signs of a basilar skull fracture, GCS score < 15, coagulopathy, or a dangerous mechanism of
injury.*
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* Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall
from a height of > 3 feet or 5 steps.
Level C recommendations: None specified.
(146)
MRI
Magnetic Resonance Imaging (MRI) is a radiologic scan produces images of various
body structures using a combination of magnetism, radio waves and computer
technology. The MRI is conducted using a large circular magnet that surrounds a
scanner tube (147). Images are obtained after placing the patient on a movable
surface, and then inserting him or her into the magnetic tube.
Once the patient is in the MRI tube, a strong magnetic field is created. This magnetic
field aligns the protons of the hydrogen atoms. Once the hydrogen atoms are aligned,
they are exposed to a beam of radio waves. The radio waves impact the protons within
the body, causing them to spin, thereby producing a faint signal, which is easily
detected by the MRI receiver. The information obtained by the scanner is sent to a
computer, where it is processed to produce an image (142).
An MRI utilizes high resolution technology, which allows it to produce highly detailed
images that will show changes in many of the structures in the body (148). In some
instances, additional agents will be used to enhance the accuracy of the images. It is
most common to use contrast agents such as gadolinium (20). Due to the MRI’s high
level of sensitivity, it is able to detect many brain injuries that are undetectable using
other methods (9). In fact, an MRI is often used to identify asymptomatic brain damage
in patients who appear to be normal (148).
While an MRI and CT scan both use the slicing technique for obtaining images, the
process is different for each. The MRI uses a magnetic field while the CT scan uses Xrays (96). As a result, the MRI provides more detailed images than a CT scan and is
able to detect damage that is as small as 1 – 2 mm; a CT scan cannot detect damage
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this small (142). The CT scan is more appropriate for identifying fresh blood in and
around the cranial region (149). However, an MRI better detects old blood that has
been hemorrhaged into the cranial cavities (9). Whether or not to use an MRI will
depend on the type, cause and location of the head injury.
Other Diagnostic Imaging Procedures
While the CT scan and the MRI are the most widely used forms of diagnostic imaging
for head trauma, there are a number of other procedures that are being used more
frequently as the technology is developing and as the diagnostic needs of the patient
and the provider are changing. The following table provides a list of the more
commonly used alternate forms of diagnostic imaging.
Diagnostic Procedure
Description
SUSCEPTIBILITY WEIGHTED IMAGING (SWI)
This is a software program that enables an MRI to
MRI
more accurately show tiny hemorrhages known as
micro hemorrhages. These small white dots
actually show up on the MRI because of the iron
content left behind after blood has been in an area
through injury. These tiny capillaries in the brain
are torn and the small amounts of blood can be
seen on SWI-MR. In persons fifty or older, there
are white dots, which can often be from aging. In
the younger person, or in an older person, where
these abnormalities are clustered at the grey-white
junction (where the grey matter meets the white
matter) these are generally traumatically caused. If
a patient is undergoing a MRI after a trauma,
especially a trauma involving a high-speed collision
or a fall from a height, the provider should
prescribe an SWI MRI so that these abnormalities
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can be detected. There can be as many as several
hundred of these small injuries throughout the
brain, but they are an objective unarguable type of
evidence for brain injury and are exceedingly
helpful in any brain injury litigation. They can also
identify the areas of the brain that have been
shaken and can aid in rehabilitative strategies.
DIFFUSION TENSOR IMAGING (DTI)
Diffusion Tensor Imaging is a type of MRI that uses
special software to view parts of the brain a normal
MRI cannot. The interesting premise of this new
technology is that it measures the movement of
water molecules in relation to the white track fibers
of the white matter of the brain. If the fibers are
healthy and untorn, then the water molecules will
show parallel movement along those tracks as they
slide along them. Torn or missing white matter fiber
will allow perpendicular movement of the water
molecules.
This new technology allows for visualization of
natural damage to the white matter. It is a very
impressive technology and will be impressive to
jurors and others involved in TBI litigation. Most
radiology groups do not have this software and it
tends to be available only in larger tertiary or
teaching-hospital centers. DTI will be especially
helpful in cases involving high velocity change
injury, such as high-speed car accidents, falls from
a height, and other accidents in which the injury is
suspected to be Diffused Axonal Injury (DAI).
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MRA (MAGNETIC RESONANCE
MRA, or magnetic resonance angiography, is a
ANGIOGRAPHY)
means of visualizing the carotid and vertebral
arterial systems in the neck and brain without
having to inject contrast into the bloodstream. The
resolution is not as good as with conventional
arteriography, but the patient is spared the risks of
catheterization and allergic reactions to the dye. (In
conventional arteriography, a catheter is threaded
from the femoral artery in the groin backward up
the aorta into a carotid or vertebral artery in the
neck, and then dye is injected up the catheter. As
the dye flows into the brain, x-rays are taken of the
cerebral vasculature.)
EEG (ELECTROENCEPHALOGRAM)
Monitors the brain's electrical activity by means of
wires attached to the patient's scalp. These wires
act like an antenna to record the brain's electrical
activity. Normally, the resting brain emits signals at
a frequency of 8 to 13 cycles per second (cps),
called alpha activity, which is best seen in the
occipital regions. Anything faster than 8-13cps is
called beta activity. Slower rhythms include theta
activity (6-7 cps) and delta activity (3-5 cps).
Theta and delta activity occur in the normal brain
as the patient descends into sleep. If the patient is
awake, any slowing of electrical activity in a focal
area of the brain may indicate a lesion there.
Similarly, widespread slowing indicates a
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widespread disturbance of brain function, often
due to a blood borne insult like low blood sugar,
drug intoxication, liver failure, etc. "Spiking" (sharp
waves of electrical activity) discharges indicate an
irritable area of cerebral cortex. If allowed to
spread, the spikes can produce a seizure.
It is not uncommon for an EEG to be normal
between seizures in patients with bonafide
seizures. During a seizure, however, the EEG is
almost invariably abnormal. Conversely, 15% of
the population shows mild abnormalities on EEG,
representing old head trauma, old strokes,
migraine, viral infections, and most of the time for
unknown reasons.
QUANTITATIVE EEG (QEEG, BEAM, BRAIN
This test is performed in a way similar to EEG.
MAPPING)
Brain wave activity varies throughout the day
depending on the state of alertness. Each area of
the brain normally spends a characteristic amount
of time in alpha, beta, theta, and delta activity.
Brain mapping computers are now capable of
creating a map of the brain's electrical activity
depicting how long each area of the brain spends
in each of the basic rhythms. By comparing the
patient's map with that of a control population, it is
possible to localize areas of focal slowing of
electrical activity. Alone, a QEEG is insufficient to
diagnose brain damage but in conjunction with
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other neurologic tests, QEEG can be confirmatory.
PET SCAN (POSITRON EMISSION
PET scanning (positron emission tomography) is
TOMOGRAPHY)
based on the fact that the brain uses glucose for
energy. By labeling a glucose molecule with a
radioactive "tag," and then inhaling radioactive
glucose and placing the patient's head under a
large geiger counter, one can identify abnormal
areas of the brain that are underutilizing glucose.
Because cyclotrons are needed to generate the
radioactive gas, PET scanning is not widely
available.
SPECT SCAN (SINGLE PHOTON EMISSION
SPECT scanning (single photon emission
COMPUTED TOMOGRAPHY)
computed tomography) is similar to PET scanning
in that a radioactive chemical is administered
intravenously to the patient, but the radioactive
chemical remains in the bloodstream and does not
enter the brain. As a result, the SPECT scan maps
the brain's vascular supply. Because damaged
brain tissue normally shuts down its own blood
supply, focal vascular defects on a SPECT scan
are circumstantial evidence of brain damage. The
advantage of a SPECT scan over a PET scan is its
ready availability and relatively cheap cost. Recent
studies have demonstrated abnormal SPECT
scans after head trauma when the CAT and MRI
were normal, suggesting that the SPECT scan is
more sensitive to brain injury then either CT or MRI
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scans. Because the radioactive chemicals used in
SPECT and PET scans are carried to all parts of
the body by vascular tree, SPECT scans and PET
scans are used judiciously in patients of
reproductive age.
EVOKED POTENTIALS
Evoked studies take advantage of the fact that
each time a sensory system of the body -- vision,
hearing, touch -- is stimulated, an electrical signal
is generated in the brain. These electrical signals
can be detected with electrical wires on the scalp.
Thus, visual evoked recordings (VER) are
recorded over the occipital lobes; brainstem
auditory evoked recordings (BAER) over the
temporal lobes; and somatosensory potentials
(SSEP) over the parietal lobes.
LUMBAR PUNCTURE
A lumbar puncture (spinal tap - not the band) is
used to analyze cerebrospinal fluid. An analysis of
the fluid can help tell physicians, for example, if
there is any bleeding in the brain and spinal cord
areas.
MAGNETIC RESONANCE SPECTROSCOPY
This is an exciting new tool, used in conjunction
(MRS)
with MRI that detects the intra-cellular relationship
of brain metabolites. Studies show that in an
injured brain, the relationship between the amount
of certain compounds in the brain changes in
predictable ways, which can be picked up, non-
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invasively, by MRS. While MRS is in its early
stages, it holds great promise in the
"objectivication" of brain injury. This data can and
should be captured on MRI within six weeks of
injury.
(142)
TREATMENT
The initial assessment and diagnostic imaging is used to determine the level of severity
of the injury and to determine any specific complications. Once this information is
obtained, and the patient is stabilized, medical personnel can begin to treat the specific
injuries. Treatment is individualized based on the specific injuries and the severity of
the damage.
In some instances, a patient with head trauma may require initial surgical interventions.
These surgical interventions are conducted immediately following the initial assessment
and treatment stage, as they are used as immediate treatment to minimize some of the
initial complications that are most threatening to the success of the patient (37). When
a patient requires an initial surgical intervention, he or she is typically admitted to the
intensive care unit for further treatment and monitoring. Initial surgical interventions are
used to remove or repair hematomas and contusions (52).
In many instances, a patient will experience swelling in the brain. When this occurs,
fluids accumulate within the brain and pressure begins to build. This causes additional
swelling and disruptions to the fluid balance (60). With other injuries, swelling and fluid
accumulation is normal and poses little risk. However, when this occurs within the
brain, it can be extremely dangerous. The skull limits the space for expansion, so the
brain is unable to expand. Therefore, the accumulation of fluid causes unnecessary
pressure on the brain, which is known as intracranial pressure (ICP) (14).
When a patient presents with swelling in the brain, it is necessary to monitor the
swelling to ensure that it does not cause additional damage. This is accomplished
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using a probe or catheter (52). The instrument is inserted into the skull and is placed at
the subarachnoid level to ensure accurate measurements. Once the instrument is
properly placed, it is connected to a monitor that displays information regarding the
patient’s ICP. This information is closely monitored so that action can be taken if the
ICP reaches an alarming level (31). If this occurs, the patient may have to undergo a
ventriculostomy. This procedure is used to drain cerebrospinal fluid as a way to reduce
pressure on the brain (32). In some instances, pharmacological agents may be used to
decrease ICP. These drugs include mannitol and barbituates (52).
While the above information provides an overview of the different types of treatment a
patient may receive, it is important to note that the treatment for head injury will differ
depending on the severity and type of injury. A patient will require different care for a
penetrating head injury than a blunt head injury. In addition, a mild head injury will be
treated differently than a severe head injury. It is important to understand the treatment
goals for each type of injury.
Mild Head Injury
When a patient experiences a mild head injury, he or she will require minimal treatment.
Most mild head injuries will resolve on their own and will not progress in severity (146).
However, there is a chance that the head injury can progress to a more serious injury
(61). During the initial assessment, the risk level of the head injury will be assessed and
it will be categorized as either low risk or moderate risk (21).
Low Risk injuries typically include the following symptoms:

Headaches

Dizziness

Nausea (3)
Patients who display symptoms of low risk injuries will not require extensive treatment.
They rarely require the level of assessment that moderate or high risk patients require,
and it is not common to utilize radiologic imaging to evaluate the injury (150). In most
instances, patients will be released and will require monitoring at home until the window
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for developing additional injuries has passed (151). When the patient is released, he or
she should be given thorough instructions for monitoring the injury at home.
The home caregiver should wake the patient every two hours to provide a thorough
assessment. Caregivers should watch for the following symptoms in the patient:

Severe headaches

Persistent nausea

Vomiting

Seizures

Confusion

Unusual behavior

Watery discharge from the nose or ear (76)
Moderate Risk injuries typically include the following symptoms:

Persistent emesis

Severe headache

Anterograde amnesia

Loss of consciousness

Signs of intoxication (152)
When a patient shows signs of a moderate risk head injury, he or she must be assessed
using a CT scan. Once the CT scan findings are reviewed, the patient is eligible for
release, assuming the findings were clear. However, patients must be observed for at
least eight hours prior to being released (70).
Patients who have moderate to severe brain injuries will require treatment beyond an
initial observation and release. Treatment will depend on the type, location and severity
of the injury. However, in most instances, treatment will follow an initial standard set of
procedures before being tailored to the specific needs of the patient. This section will
include information on the general guidelines for initial patient treatment.
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The University of Orlando provides the following overview of the standard protocol for
the treatment of moderate to severe head trauma:
The first priority in trauma resuscitation of the head-injured patient is the
prevention of hypoxia and hypotension. All head-injured patients are
treated as if they have a cervical spine injury (until clinically proven
otherwise) by opening the airway with the jaw thrust maneuver. If the GCS
is less than or equal to 8 or if the patient is hypoventilating, intubation may
be required to secure the airway. The next step is to hyperoxygenate the
patient with 100% oxygen. Hyperventilation is no longer recommended
unless the patient begins to rapidly deteriorate. Rather, normocapnea or
mild hypocapnea (PaCO2 30 – 35 mm Hg is used to prevent severe
vasoconstriction and cerebral ischemia. Circulation should be maintained
with use of normal saline, and then inotropes (Dopamine, Neosynephrine)
if severe hypotension is present. In the past IV fluids were restricted to
prevent brain swelling, but evidence-based medicine shows that early post
injury hypotension (MAP ≤ 90 mm Hg) greatly increases morbidity and
mortality due to secondary brain insult resulting from poor perfusion. Once
the patient is hemodynamically stable, a non-crystalloid solution is infused
to maintain the patient’s normal volume. A solution of D5W is not indicated
as it can freely cross the blood brain barrier and enter into the brain tissue.
After the initial resuscitation has been successfully completed, the goal of
management is to prevent and control complications of secondary head
injuries especially intracranial hypertension, cerebral hypoxia and
ischemia. Treatments are utilized in an attempt to control intracranial
hypertension (ICP > 15 mm Hg) and to enhance cerebral perfusion (CPP
> 70 mmHg). (29)
First Aid
The first step in treating head trauma is to provide the patient with initial, comprehensive
first aid. The specific treatments provided will depend on the patient’s condition.
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However in all instances, the provider will work to treat any damage while reducing the
likelihood of any additional damage (129).
Avoid direct pressure to skull injuries
It is important to avoid putting direct pressure on any part of the patient’s skulls during
the initial examination or stabilization procedures. Many head injuries will become
worse if pressure is applied. In some instances, the application of pressure will result in
an increase in bleeding and potential life threatening complications (18).
ABC (Airway, breathing, circulation)
Patient stabilization is the primary objective when a patient is admitted with head
trauma. The emergency team will begin working to stabilize the patient immediately,
while assessing the patient and identifying any additional injuries. Once the patient is
stabilized, more focused treatment will be administered (23).
Head trauma patient stabilization includes three primary components:
1. Airway
2. Breathing
3. Circulation
When a patient presents with head trauma, the emergency team will immediately begin
working on the three components listed above. It is important to note that these three
components of stabilization serve as both assessments and treatment. The three areas
are assessed for immediate damage, and any necessary treatment is administered (23).
As soon as the patient arrives in the emergency department, he or she will receive a
rapid primary survey to assess and identify any immediate problems (153). The first
area to receive treatment is the airway. If a patient requires intubation, it is initiated
immediately. Typically, nasotrachael or endotracheal intubation is used with abdominal
trauma patients. Once an airway has been established, patients who require breathing
assistance will receive the appropriate treatment (154).
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The next stage in patient care involves the circulatory system. An initial assessment of
the circulatory system is conducted to determine if the patient has experienced a
circulatory collapse (44). This can be caused by hypovolemia from hemorrhage.
Immediate treatment is necessary to prevent further blood loss and assist with patient
resuscitation (33).
While the airway, breathing and circulation are the primary areas of focus for the
assessment and treatment of head trauma patients, providers have begun using the
ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach instead. The
goal remains the same, but this approach provides a more thorough assessment of the
patient (149). The ABCDE approach expands the original treatment protocol to provide
more in-depth assessment and treatment of the abdominal trauma patient. Therefore,
this section includes detailed information about the ABCDE approach. Since the
airway, breathing, and circulatory assessments and treatment are part of the ABCDE
approach, they are discussed more fully in this section.
ABCDE Approach
This approach can be used in any type of clinical emergency to assess the patient and
determine the necessary treatment needs (46). Using the ABCDE approach is highly
recommended by most medical professionals as it is considered an effective means of
improving patient outcomes through the early identification and treatment of life
threatening injuries and complications (155). The ABCDE approach is best used by
skilled professionals in an acute setting, as it requires a basic understanding and
common knowledge of early identification and treatment (149).
If a team is providing the treatment, it is important that all team members understand
and employ the ABCDE approach to ensure consistent assessment and consistent
identification and treatment (155). Emergency personnel and treatment team members
should receive adequate training in the ABCDE approach prior to working with trauma
patients.
The goals of the ABCDE approach include the following:

to provide life-saving treatment
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
to break down complex clinical situations into more manageable parts

to serve as an assessment and treatment algorithm

to establish common situational awareness among all treatment providers

to buy time to establish a final diagnosis and treatment. (155)
The ABCDE approach is promoted as an effective tool for diagnosing and treating
critically ill or injured patients and is widely used in emergency care setting. The
ABCDE approach is most often used by emergency technicians, critical care specialists,
and traumatologists (44). Using the ABCDE approach in conjunction with other
emergency treatment protocol has proven to increase the patient survival rate and
decrease the long term impact of the injuries (33).
The ABCDE approach can be used with all patients, regardless of age or medical
status. Regardless of the cause, the clinical signs of various critical conditions are
similar. Therefore, the ABCDE approach can be used to identify clinical issues even if
the cause is unknown. In fact, it is not necessary for emergency personnel to know the
underlying cause of the conditions when initiating ABCDE (149). Ultimately, the ABCDE
approach should be used in any situation in which a critical injury is present, as it is a
useful tool for determining the presence of critical conditions, especially when those
conditions are not immediately apparent or identifiable (44).
The ABCDE approach provides efficiency in the identification and treatment of the
patient as the initial assessment and the treatment are performed in conjunction with
each other (155). In situation where the cause is not apparent, immediate treatment
may be necessary for any life threating injuries or conditions. In these instances,
treatment will be initiated prior to making a definitive diagnosis. The ABCDE approach
provides a means for initiating treatment without knowing the exact diagnosis (149).
The ABCDE approach follows a standard process that follows the words indicated by
the ABCDE. First, life-threatening airway problems are assessed and treated; second,
life threatening breathing problems are assessed and treated, etc. This approach
enables the treatment team to quickly identify issues and treat them accordingly. The
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ABCDE approach also helps determine which services are needed and what level of
assistance is required.
In many emergency situations, additional care may be needed from other emergency
responders, specialists, and other hospital departments. This identification helps
increase the speed and efficiency of treatment, thereby improving the outcome. Using
the ABCDE approach helps to quickly determine the level of assistance required and
the specific departments that are needed for treatment and assistance (156).
The ABCDE assessment should be conducted as soon as possible to begin the
treatment process (44). In addition, the assessment should be repeated in regular
intervals until the patient is stable as a means of determining the effectiveness of
various treatments (39). If a patient shows signs of deterioration, additional treatment
may be needed. The patient should be reassessed after each treatment or intervention
to assess the outcome (156).
The following is the description and recommendation for using the ABCDE approach
with patients in a trauma scenario:
A – Airway: is the airway patent?
If the patient responds in a normal voice, then the airway is patent. Airway obstruction can be partial or
complete. Signs of a partially obstructed airway include a changed voice, noisy breathing (e.g., stridor),
and an increased breathing effort. With a completely obstructed airway, there is no respiration despite
great effort (i.e., paradox respiration, or “see-saw” sign). A reduced level of consciousness is a common
cause of airway obstruction, partial or complete. A common sign of partial airway obstruction in the
unconscious state is snoring.
Untreated airway obstruction can rapidly lead to cardiac arrest. All health care professionals, regardless
of the setting, can assess the airway as described and use a head-tilt and chin-lift maneuver to open the
airway. With the proper equipment, suction of the airways to remove obstructions, for example, blood or
vomit, is recommended. If possible, foreign bodies causing airway obstruction should be removed. In
the event of a complete airway obstruction, treatment should be given according to current guidelines.
In brief, to conscious patients give five back blows alternating with five abdominal thrusts until the
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obstruction is relieved. If the victim becomes unconscious, call for help and start cardiopulmonary
resuscitation according to guidelines.
Importantly, high-flow oxygen should be provided to all critically ill persons as soon as possible.
B – Breathing: is the breathing sufficient?
In all settings, it is possible to determine the respiratory rate, inspect movements of the thoracic wall for
symmetry and use of auxiliary respiratory muscles, and percuss the chest for unilateral dullness or
resonance. Cyanosis, distended neck veins, and lateralization of the trachea can be identified. If a
stethoscope is available, lung auscultation should be performed and, if possible, a pulse oximeter
should be applied.
Tension pneumothorax must be relieved immediately by inserting a cannula where the second
intercostal space crosses the midclavicular line (needle thoracocentesis). Bronchospasm should be
treated with inhalations.
If breathing is insufficient, assisted ventilation must be performed by giving rescue breaths with or
without a barrier device. Trained personnel should use a bag mask if available.
C – Circulation: is the circulation sufficient?
The capillary refill time and pulse rate can be assessed in any setting. Inspection of the skin gives clues
to circulatory problems. Color changes, sweating, and a decreased level of consciousness are signs of
decreased perfusion. If a stethoscope is available, heart auscultation should be performed.
Electrocardiography monitoring and blood pressure measurements should also be performed as soon
as possible. Hypotension is an important adverse clinical sign. The effects of hypovolemia can be
alleviated by placing the patient in the supine position and elevating the patient’s legs. An intravenous
access should be obtained as soon as possible and saline should be infused.
D – Disability: Assess the level of consciousness
The level of consciousness can be rapidly assessed using the AVPU method, where the patient is
graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U). Alternatively, the
Glasgow Coma Score can be used. Limb movements should be inspected to evaluate potential signs of
lateralization.
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The best immediate treatment for patients with a primary cerebral condition is stabilization of the airway,
breathing, and circulation. In particular, when the patient is only pain responsive or unresponsive,
airway patency must be ensured, by placing the patient in the recovery position, and summoning
personnel qualified to secure the airway. Ultimately, intubation may be required.
Pupillary light reflexes should be evaluated and blood glucose measured. A decreased level of
consciousness due to low blood glucose can be corrected quickly with oral or infused glucose.
E – Exposure: any clues to explain the patient’s condition?
Signs of trauma, bleeding, skin reactions (rashes), needle marks, etc, must be observed. Bearing the
dignity of the patient in mind, clothing should be removed to allow a thorough physical examination to
be performed. Body temperature can be estimated by feeling the skin or using a thermometer when
available.
(155)
The following table provides information regarding the ABCDE method and specific
treatments for each category:
Assessment
Treatment
A–
Voice
Head tilt and chin lift
Airways
Breath sounds
Oxygen (15 l min−1) Suction
B–
Respiratory rate (12–20 min−1)
Seat comfortably
Breathing
Chest wall movements
Rescue breaths
Chest percussion
Inhaled medications
Lung auscultation
Bag-mask ventilation
Pulse oximetry (97%–100%)
Decompress tension pneumothorax
Skin color, sweating
Stop bleeding
C–
Circulation Capillary refill time (<2 s)
Elevate legs
Palpate pulse rate (60–100 min−1)
Intravenous access
Heart auscultation
Infuse saline
Blood pressure (systolic 100–140 mmHg)
Electrocardiography monitoring
D–
Level of consciousness – AVPU
Treat Airway, Breathing, and Circulation
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Disability
• Alert
problems
• Voice responsive
Recovery position
• Pain responsive
Glucose for hypoglycemia
• Unresponsive
Limb movements
Pupillary light reflexes
Blood glucose
E–
Expose skin
Exposure
Temperature
Treat suspected cause
(157)
Cover wounds
During the initial treatment stage, it is important to properly cover any wounds that are
exposed. Covering wounds prevents the patient from losing additional blood and it
helps reduce the likelihood of infection (15). Wounds should be covered using sterile
dressing and should not interfere with the remainder of the treatment process (122).
Management
Management of a patient with a head injury will differ depending on severity. To ensure
consistency with patient care, a standard set of guidelines for the management of head
injuries was developed. These guidelines provide minimal care recommendations for
the patient. The table below provides general interventions for patients with head
injuries (158):
Multidisciplinary A coordinated, multidisciplinary healthcare team should be established at the time of
care team
the patient’s admission and implemented for the duration of hospitalization. It should
include one or more physicians (such as trauma surgeons, intensivists, and
neurosurgeons), nurses, respiratory therapists, pharmacists, nutritionists, physical
therapists, occupational therapists, speech language pathologists, physiatrists, case
managers, social workers, and clergy. The patient’s family should be involved as well.
Blood pressure
Expect an arterial catheter to be inserted, to monitor blood pressure and allow
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and volume
frequent blood sampling. During the acute post-injury phase, BTF guidelines state that
management
hypotension should be avoided; if it occurs, the patient’s volume status should be
evaluated first and hypotension should be corrected rapidly. A urinary catheter is
inserted to assess adequacy of renal perfusion. The kidney requires 20% to 25% of
cardiac output; commonly, it’s the first organ to show the effects of impaired perfusion
or intravascular volume. The care team should establish multiple I.V. access sites.
Usually, at least one of these sites is for a central venous catheter (CVC), which
allows fluid and drug administration as well as central venous pressure monitoring to
assess volume status. If volume status is inadequate, the patient should receive
additional I.V. fluids. For persistent hypotension, continuous infusion of a vasoactive
drug (such as dopamine or norepinephrine) should begin once adequate intravascular
volume is restored. As the patient’s volume and blood pressure status stabilize and
intracranial hypertension resolves, the need for aggressive volume management and
vasoactive drugs decreases; gradually, these interventions are eliminated. To
minimize the risk of bloodstream infection, invasive vascular devices (such as a CVC
and an arterial line) should be removed as soon as the patient stabilizes.
Brain and
Low peripheral oxygen saturation values or low arterial blood oxygen values (as
tissue
shown by arterial blood gas testing) should be avoided. Maintaining adequate brain
oxygenation
tissue oxygenation seems to improve patient outcomes. However, systemic oxygen
levels don’t always accurately represent the brain’s oxygen level; to assess this level
directly, a special catheter may be inserted into the brain or jugular vein. If such a
device is used, oxygen administration can be adjusted accordingly. Also, many TBI
patients require prolonged mechanical ventilation and may benefit from a
tracheotomy. A tracheotomy helps reduce the risk of ventilator-associated pneumonia
(VAP), as do suctioning of secretions above the tracheotomy cuff, maintaining the
head of the bed at 30 degrees, and performing good oral care every 4 hours.
Ventilation
The patient’s arterial carbon dioxide (CO2) value should be maintained in the lownormal range. A very low CO2 level can contribute to vasoconstriction, which in turn
may decrease cerebral blood flow. As intracranial hypertension resolves, the CO2
level can be allowed to return to the normal range. Nursing care includes continual
monitoring for hypoventilation (as shown by diminished breath sounds and
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somnolence increased from baseline) and assisted secretion removal.
Osmotherapy
Osmotherapy aims to increase the osmolality of the intravascular space, which in turn
helps mobilize excess fluid from brain tissue. If ICP increases, mannitol (an osmotic
diuretic) may be given to decrease cerebral edema, transiently increase intravascular
volume, and improve cerebral blood flow. Hypertonic saline solution (saline
concentrations of 3% to 24%) may be used to promote osmotic mobilization of water
across the blood-brain barrier.
ICP monitoring
To aid rapid identification of increased ICP, a monitoring device may be inserted
through a small hole drilled into the skull. Parenchymal, epidural, subdural, and
subarachnoid monitoring devices can be used. In some cases, an extraventricular
drain (ventriculostomy) may be placed. When caring for a patient with any of these
devices, follow aseptic standards scrupulously. Evaluate CSF characteristics
(including cloudiness and volume changes) to help detect infection early. Perform
routine care for the insertion site. Also, minimize entry into the drainage system and
maintain such safety precautions as restricting changes in head-of-bed elevation and
securing the extraventricular drain to prevent dislodgment.
CPP monitoring
Cerebral perfusion pressure (CPP) should be maintained at an appropriate level by
optimizing volume status, as with I.V. fluids, osmotherapy, and vasoactive drugs. A
brain tissue oxygen monitor may be used to help determine which CPP and ICP levels
the patient tolerates best.
Anesthetic,
Short-acting anesthetic and sedative- analgesic agents, such as propofol and fentanyl,
sedative, and
typically are given. When dosages are decreased, the patient can be awakened
analgesic
quickly, permitting nonpharmacologically tainted assessment of neurologic status. Use
agents
caution, though, when explaining such “wake-up” assessment to family members;
inform them that the patient doesn’t actually wake up and return to a pre-injury
condition. As the patient improves, dosages are reduced gradually. The patient must
be monitored for pain; if needed, enterally administered analgesia should be
considered to manage pain without causing significant neurologic status changes.
Pentobarbital may be given to control increased ICP in patients who don’t respond to
first-line therapies. Called pentobarbital coma, this approach minimizes the brain’s
electrical activity for several days. The exact mechanism of pentobarbital coma isn’t
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known.
Temperature
The damaged brain is more susceptible to increased temperature, so the patient
management
should be kept normothermic (typically at 95° to 98.6° F [35° to 37° C]) to reduce
brain metabolism and promote anti- inflammatory effects. Cooled water or saline
solution circulated through external body wraps or special intravascular cooling
catheters can be used to maintain the desired temperature. Although ice packs may
be used, they are labor intensive and may lead to inconsistent cooling. Once
intracranial hypertension resolves, the patient’s temperature can be allowed to
normalize.
Venous
TBI patients are at increased risk for venous thromboembolism (VTE). In some cases,
thromboembolis antiembolic stockings or pneumatic compression devices may be used. Once the risk
m prophylaxis
of hemorrhage passes, low molecular- weight heparin may be given. Also, inferior
venal caval filters may be placed transvenously. Screening duplex ultrasound studies
of the legs may be done to help identify VTE.
Seizure
TBI may increase the risk of nonepileptic seizures in a small number of patients.
prophylaxis
Seizures that immediately follow the injury or arise during the early post-injury phase
presumably are a reaction to the initial trauma; those arising more than 2 weeks after
injury are thought to stem from permanent changes in brain structure. Although the
seizure risk is low, seizures increase metabolic activity and oxygen demands, which
may further compromise the damaged brain. Routine seizure prophylaxis later than 1
week after a TBI isn’t recommended. However, if needed, phenytoin or valproate can
be given.
Steroids
The BTF doesn’t recommend giving steroids because these drugs haven’t been
shown to decrease ICP or improve outcomes.
Nutrition
Initially, a nasogastric or orogastric tube is inserted to decompress the stomach and
reduce the aspiration risk. (Typically, the nasal route is avoided as it can obstruct
sinus drainage, leading to sinusitis or VAP.) TBI patients have increased metabolic
demands, so parenteral or enteral nutrition should begin as soon as tolerated.
Nutritional target goals should be met by day 7. A small-bore feeding tube may be
placed into the small intestine or a percutaneous gastrostomy tube may be used to
deliver nutrition and decrease the aspiration risk.
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Positioning
In patients with increased ICP, frequent turning and repositioning may not be possible.
As ordered, keep the head of the bed elevated at least 30 degrees with the patient’s
neck in neutral alignment, to promote venous drainage of the brain and reduce brain
swelling. This position also decreases the risk of aspiration and VAP. A patient with
impaired oxygenation and ventilation may be placed on a kinetic therapy bed or may
be positioned prone. During patient turning and repositioning, take measures to
prevent skin breakdown.
SHAKEN BABY SYNDROME
Shaken Baby Syndrome (aka Shaken Impact Syndrome) is a head injury that typically
occurs as the result of abuse toward a child (159). In most instances, shaken baby
syndrome is a direct result of an individual (parent or caregiver) shaking an infant
severely due to anger or frustration. It is especially common in situations when an
infant will not stop crying (160).
Shaken baby syndrome occurs due to the physical composition of the infant. Infant’s
neck muscles are quite weak, making them unstable under the weight of the infant’s
head. When an individual shakes an infant back and forth, the head moves back and
forth without full support of the neck. This causes damage to the brain, which can be
fatal (160). When an infant is shaken violently, the following may occur:

Subdural hematoma is a collection of blood between the surface of the brain and
the dura (the tough, fibrous outer membrane surrounding the brain.) This occurs
when the veins that bridge from the brain to the dura are stretched beyond their
elasticity, causing tears and bleeding.

Subarachnoid hemorrhage is bleeding between the arachnoid (web-like
membrane surrounding the brain filled with spinal fluid) and the brain.

Direct trauma to the brain substance itself when the brain strikes the inner
surfaces of the skull.

Shearing off or breakage of nerve cell branches (axons) in the cortex and deeper
structures of the brain caused by violent motion to the brain.
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
Further irreversible damage to the brain substance from the lack of oxygen if the
child stops breathing during shaking.

Further damage to the brain cells when injured nerve cells release chemicals
which add to oxygen deprivation(161)n to the brain.
Other injuries related to this abuse include:

Retinal hemorrhages ranging from a few scattered hemorrhages to extensive
hemorrhages involving multiple layers of the retina.

Skull fractures resulting from impact when the baby is thrown against a hard or
soft surface.

Fractures to other bones, including the ribs, collarbone, and limbs; bruising to the
face, head and entire body. (162)
Shaken baby syndrome is most common in infants under the age of two. However, the
majority of cases involve infants under the age of one, with most instances occurring in
infants between the ages of three to eight months (159). While shaken baby syndrome
is most common in infants under the age of two, it can occur in children up to the age of
four, although it is quite rare (163). According to the National Center on Shaken Baby
Syndrome, there are approximately 600 – 1400 cases of shaken baby syndrome each
year. Shaken baby syndrome is the leading cause of death and disability in infants and
children (159).
Few infants will show external signs when they have sustained head injury as the result
of shaken baby syndrome (160). In most instances, the injuries will not appear
immediately, as caregivers and providers will disregard many of the symptoms as being
due to general fussiness or a virus of some sort (163). Once a patient shows signs of
head injury, the brain has swelled as a secondary response to the trauma (162). In
some instances, the symptoms will appear immediately following the injury. However,
many patients will not show signs until approximately 4 – 6 hours after the injury (160).
The following signs and symptoms may be present with shaken baby syndrome:

Altered level of consciousness
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
Drowsiness accompanied by irritability

Coma

Convulsions or seizures

Dilated pupils that do not respond to light

Decreased appetite

Vomiting

Posture in which the head is bent back and the back arched

Breathing problems and irregularities

Abnormally slow and shallow respiration

Cardiac arrest

Death

Physical findings upon medical examination

Retinal hemorrhages

Closed head injury bleeding (subdural, epidural, subarachnoid, subgaleal)

Lacerations

Contusions

Concussions

Bruises to the face, scalp, arms, abdomen, or back

Soft tissue swelling which may indicate a fracture to the skull or other bones

Abdominal injuries

Chest injuries

Abnormally low blood pressure

Tense fontanel (soft spot) (162)
When an infant or child shows any of the symptoms above, it is crucial to conduct a
thorough assessment to determine the level of damage (if any) that is present. The
following is a list of the suggested assessments that should be administered in the case
of shaken baby syndrome:

Complete patient history

Optic fundus exam for retinal hemorrhages
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
Computed tomography scan (CT or CAT scan) of the head and abdomen

Magnetic resonance imaging (MRI) in select cases

Lumbar puncture with precautions

Skeletal survey

Nuclear scan

Drug screening

Routine blood samples (161)
When a patient experiences shaken baby syndrome, the prognosis is poor. Most cases
of shaken baby syndrome are fatal, and those that are not will often result in severe
neurological deficits (163). Shaken baby syndrome will most likely be fatal if the patient
experiences any of the following:

Uncontrollable increased intracranial pressure from cerebral edema

Bleeding within the brain

Tears in the brain tissue (161)
When shaken baby syndrome is not fatal, the child may experience the following longterm complications or disabilities:

Cerebral palsy

Paralysis

Vision loss or blindness

Mental retardation

Epilepsy

Seizures (162)
HEAD INJURY AND THE LINK TO ALZHEIMER’S DISEASE
Alzheimer’s disease (AD) is defined as a progressive, neurodegenerative disease
characterized by dementia, memory loss, and deteriorating cognitive abilities. According
to recent research, there is an association between head injury in early adulthood and
the development of AD later in life. The risk of developing AD later in life is increased in
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direct correlation to the severity of the head injury (119). The following is an excerpt
obtained from an informative website, The Human Brain, which provides a variety of
helpful resources for health care teams as well as victims of TBI and AD alike (@
http://www.fi.edu/learn/brain/head.html):
The link between head injury and the risk of Alzheimer's disease (AD) is
indicated by data from the MIRAGE study (Multi-Institutional Research in
Alzheimer Genetic Epidemiology). Patients with AD were nearly ten times more
likely to have a history of head injury that resulted in loss of consciousness. The
study suggests that "head injury with loss of consciousness and, to a lesser
extent, head injury without loss of consciousness, increased the risk of AD.
Research led by Dr. Douglas H. Smith at the University of Pennsylvania supports
previous epidemiological links between a single episode of brain trauma and the
development of AD later in life.
A study conducted by researchers at Duke University and the National Institute on
Aging focused on injured World War II veterans, and this research group linked serious
head injury in early adulthood with Alzheimer’s disease in later life. Although there is the
suggestion of a higher risk of later life dementia following a severe head injury, there is
no clear direct (cause-effect) correlation between head injury and AD reported by
reseachers in the field of dementia and AD as yet. Nonetheless, it is believed that the
research indicates a strong association between early life head trauma and the
occurrence of AD in later life, which needs to be studied further.
SUMMARY
Head trauma is one of the most common injuries sustained during a trauma situation.
In fact, approximately fifty percent of individuals who experience trauma show signs of a
head injury. Head trauma can range from minor bumps that cause slight discomfort to a
serious injury that results in permanent disability or impairment, or even death. Head
trauma is a serious matter that affects people of all ages. Sports, auto accidents, and
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physical abuse are some of the leading causes of head trauma, but while the cause
may be obvious, the effects are not always readily seen. In fact, sometimes head
trauma may manifest over a period of days, weeks, or even years. For this reason, it’s
important to closely monitor any incidence of head trauma and adjust treatment
according to changing symptoms.
Health care providers must be familiar with the different causes and types of head injury
to adequately treat trauma patients. In many instances, head injury will accompany
other trauma-induced injuries. Therefore, all trauma patients must be evaluated for
head injuries, even if no signs are present. Many head injuries will not produce
immediate symptoms, even if significant damage has occurred. A patient should be
evaluated using standard guidelines and diagnostic imaging, if appropriate. When a
head injury is detected, treatment should begin immediately to avoid further
complications. The goal of head trauma care is detection, treatment, and prevention of
long-term problems. Many of the effects of head trauma can be reduced or prevented
with proper treatment and management.
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