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Assessing and Treating Head Injuries

Although they look gruesome, superficial cuts to the scalp without underlying skull or brain injury are relatively benign injuries. However, head wounds should be treated with care. In rare cases, especially when there are other sources of blood loss, severe bleeding can cause hypovolemic shock. Skull fractures and brain injuries are cause for much greater concern.

This paper examines three major topics: Lacerations of the Scalp, Skull Fractures and Brain Injuries. The third topic is examined in depth

Topic 1: Lacerations of the Scalp

Treat lacerations by applying direct pressure with your gloved hand using a dry, sterile dressing. If the skin is avulsed (torn into a flap which remains connected) flush the area clean with water, fold the flap back down, and apply pressure with a dressing. Secure dressings to the head with roller gauze. If dressings become saturated with blood, do not remove them, but add more dressings on top. If you suspect an underlying skull fracture, apply very gentle pressure, being careful not to compress the fracture or push bone fragments into the brain. There are several different types of soft tissue injuries.

Topic 2: Skull Fractures

Fractures may be open, if the skin above the fracture is broken allowing access to the bone, or closed, if the overlying skin is intact. Suspect a fracture if there is point tenderness (pain) when you palpate (press) the skull or face bones or if there is substantial swelling or skull deformity. Raccoon eyes (bruising around the eyes) and Battle's Sign (bruising behind the ear) suggest a fracture to the base of the skull, but these usually develop some time after the initial injury. Clear fluid from the nose or ear may be cerebrospinal fluid leakage and indicates a skull fracture.

Topic 3: Brain Injuries

A concussion occurs when head trauma causes a temporary change in brain function without perceptible physical damage to the brain. Concussions can involve minor changes (e.g. seeing stars) or serious changes (loss of consciousness) in brain function.

A contusion is the bruising of brain tissue and is more serious. The skull is essentially a sealed compartment. Because of associated swelling and bleeding, increased pressure and distortion of the brain tissue can result in serious and life-threatening symptoms.

Intracranial hemorrhage refers to bleeding from vessels within the brain or its covering. If your patient is deteriorating rapidly and showing poor neurological signs, suspect intracranial bleeding. It is very important to assess patients with suspected brain injury for their Level of Responsiveness (LOR). LOR is measured using the AVPU scale, which refers to the patient's ability to remain awake and responsive.

Level of Responsiveness Scale

Alert: patient is awake and responsive without any prompting or stimulation
Verbal: patient requires verbal prompting to stay responsive ("Hey!")
Pain: patient requires painful stimulation to stay responsive (e.g. pinching an earlobe)
Unresponsive: patient does not respond at all.

Also assess the patient's orientation - the awareness of his/her name, location, date/time, and circumstances. Each of these is called a sphere, and the patient can be oriented in 0, 1, 2, 3, or 4 spheres. When you report to the ambulance crew, specifically state the status of each sphere (oriented or not) and what the course of the LOR has been (e.g. responsive only to pain).

Indications of Traumatic Brain Injury

  • Obvious damage to helmet or head (fractures, bleeding, bruising, deformities etc.)
  • Clear or blood-tinged fluid from the nose or ears
  • Pupils of different size or that don't respond to changes in light
  • Loss of memory
  • Reduction in orientation or level of responsiveness (e.g. confused, "spacey," disoriented)
  • Increased blood pressure, irregular respirations, and lowered pulse
  • Changes in sensation in or ability to move the extremities
  • Dizziness
  • Repetitive speech
  • Convulsions
  • Nausea and vomiting
  • Poor coordination

Steps for Treating a Brain Injury


  1. As with any injury, first assess and immediately provide care for any problems with airway, breathing, and circulation (ABC's):
    1. Keep the airway open
    2. Provide supplemental high-flow oxygen if available
    3. Control any serious external bleeding
    4. Rescue breathing or CPR if indicated


  2. Helmet removal: Safe helmet removal requires proper instruction and practice. A helmet needs to be removed only if it:
    • Impedes assessment or treatment of ABC's
    • Prevents proper immobilization of the spine
    • Is loose and prevents the head from being stabilized or secured to a backboard


  3. Conduct a rapid body survey and locate other significant injuries. A significant head injury is likely to have an associated spinal injury, so take spinal precautions beginning with your initial assessment. See "Handling Suspected Spinal Injuries." Head injury patients require a cervical collar and a backboard. Minimize movement.


  4. Call for immediate evacuation


  5. Do not give anything to the patient by mouth.


  6. Monitor vital signs and level of responsiveness every 15 minutes for stable patients and every 5 for unstable patients.


  7. All head injuries should be evaluated by a physician. Serious symptoms can develop over the following 48-72 hours.


  8. Because patients can lose consciousness, obtain information regarding identity, emergency contacts, allergies, medical problems and medications taken and last time they ate and drank while waiting for evacuation.

is an Emergency Medical Technician and an Outdoor Emergency Care instructor for the National Ski Patrol. He welcomes your questions on first aid practices.