Point of Wounding: Head Injuries and TBI

Head InjuriesWith Traumatic Brain Injuries (TBI)

Head InjuriesWith Traumatic Brain Injuries (TBI)

Department of Combat Medic Training

C168W007

Terminal Learning ObjectiveTerminal Learning Objective

Given a casualty with a suspected head injury,

treat the head injuryIAW Prehospital Trauma Life Support

Chapters 8 and 21 and the Military Acute Concussion Evaluation (MACE)

Assessment Tool, the principles of Tactical Combat Casualty Care (TC3).

Enabling Learning Objective Enabling Learning Objective

Given a combat casualty with a suspected head injury and the MACE Assessment tool,

assess a casualty for a possible head injury

IAW Prehospital Trauma Life Support Chapter 8, the Military Acute Concussion evaluation

(MACE) Assessment Tool.

Assessment PriorityAssessment Priority

You have a casualty with a suspected head injury. What is assessment priority for the

casualty?

Hemorrhage Control

Airway

Breathing

Circulation

After life threatening injuries are identified and appropriately treated, obtain a baseline Glasgow

Coma Scale score.

This assessment priority never

changes

Glasgow Coma ScaleGlasgow Coma Scale

Eye Opening Best Verbal Response Best Motor Response

4 - Spontaneous Eye Opening

5 - Answers appropriately (Oriented)

6 - Follows Commands

3 - Eye Opens on Command

4 - Gives Confused Answers

5 - Localizes Painful Stimulus

2 - Eye Opens to Painful Stimulus

3 - Inappropriate Responses

4 - Withdrawals to Pain (Nonlocalizing Movement

to Pain)

1 - No Eye Opening 2 - Makes Unintelligible Noises

3 - Abnormal Flexion to Pain (Decorticate)

1 - Makes No Verbal Response

2 - Abnormal Extension to Pain (Decerebrate)

1 - Gives No Motor Response


What is the best score possible?15

What is the lowest score possible?3

If the casualty is intubated, (ETT, Combitube, King LT)

how is the GCS scored?Use only eye and motor scales and add a "T" to score.

PosturingPosturing

What type of posturing is illustrated?

Decorticate

Decerebrate

What does each type of posturing tell you about the type of injury

suffered?


Assess and reassess GCS (serial GCS assessments)

often during casualty assessment and transport.

Deterioration of more than 2 points is a significant finding. These casualties are at high risk for an

ongoing pathologic process.

Assessment of the HeadAssessment of the Head

Inspect and palpate for DCAP BLS and TIC

Inspect the mouth, nose and ears.

Assess the Pupils.

PupilsPupils

What can pupil

reaction tell us?

PupilsPupils

Difference >1.0 mm in size, sluggish or nonreactive pupils are abnormal.

Brainstem injury is probable if both pupils are dilated and do not react to light.

If pupils are dilated but react to light, injury is often reversible.

Dilated pupils that may or may not react to light may be caused by reasons other than a head injury

If the patient has a normal LOC, the dilated pupils are not due to head injury. Look for other causes.

Assessment of the NeckAssessment of the Neck

Suspect C-spine injuries for all non penetrating head, face and neck

wounds.

Spinal precautions should be initiated based on the tactical environment.

Assessment of the Extremities Assessment of the Extremities

The casualty has intact sensation/motor function if he can withdrawal or localize

pain to pinching of fingers and toes.

This also indicates normal or minimally impaired brain function.

Vital SignsVital Signs

Increased intracranial pressure causes Cushing's Triad.

What is Cushing’s Triad?

Increased blood pressure (hypertension).

Decrease in pulse rate (bradycardia).

Respiratory rate to increase, decrease and/or become irregular.

Check on your Learning…Check on your Learning…

Why is it important to take serial GCS assessments (An initial assessment and multiple reassessments) throughout your

casualty care?

To determine if there is a change in the casualty.

If a change is detected, the medic should be prepared for many issues that accompany a head injury.

Additionally, the casualty will need to be transported to a facility with specific capabilities.

Check on your Learning…Check on your Learning…

Upon your assessment of the casualty’s pupils you find they are dilated and do not react to light. What does this piece

of information tell you?

A brainstem injury is probable.

You are the MedicYou are the Medic

Your casualty opens her own eyes, does not understand who you are and what happened and can hold up two fingers

when you tell her to. What is her GCS?

Eyes – 4, Verbal – 4 and Motor – 6

Total GCS = 14


Upon reassessment, the same casualty slaps your hand away when you pinch the back of her arm. She will look at you only if you yell

to get her attention and is giving inappropriate responses. She will not show you two

fingers.

Eyes – 3, Verbal – 3 and Motor – 5

Total GCS = 11


What does the casualty’s serial GCS scores tell you?

The GCS has deteriorated more than 2 points.

The casualty’s has suffered a head injury and should be transported to a neurosurgical

facility.

Evacuate: Urgent Surgical

MACE AssessmentMACE Assessment

Military Acute Concussion Evaluation (MACE) Assessment

Where is a MACE assessment administered?In the combat theatre.

Not performed in the CUF or TFC phase.

Usually performed at BN aid station or higher.

MACE AssessmentMACE Assessment

Who should the MACE assessment be administered on?

Any casualties that report:

Being dazed, confused, “saw stars” or lost consciousness, even momentarily as a result of an

explosion/blast, fall, motor vehicle crash.

Any event involving abrupt head movement or a direct blow to the head.

Red Flags for immediate referral to MO and/or transport:

Unequal pupils

Deteriorating examination

Decreasing or loss of consciousness

RED FLAGS

MACE Assessment Demonstration

and Practical Exercise

Enabling Learning Objective 3Enabling Learning Objective 3

Given a combat casualty,

treat a casualty with a suspected head injury

IAW Prehospital Trauma Life Support Chapter 8 and 21.

Scalp WoundsScalp Wounds

Skull FracturesSkull Fractures



Facial InjuriesFacial Injuries

TBITBI

Traumatic Brain Injury

An injury to the brain resulting from an external force and/or acceleration/deceleration mechanism from

an event.

Brain trauma can cause a broad range of physical, cognitive emotional and social problems.

TBITBI

What are the signs and symptoms of a TBI?AMS, headache, nausea, vomiting, dizziness/balance

problems, fatigue, insomnia, sleep disturbances, drowsiness, sensitivity to light and noise, blurred

vision, difficulty remembering and/or difficulty concentrating.

Post concussion symptoms Decreased memory and attention/concentration,

slower thinking, irritability, depression, impaired vision, mood swings, balance problems, headaches,

and nausea.

Levels of TBILevels of TBI

Mild

GCS = 14 to 15

80% of head injuries

Usually full recovery within

weeks.

Moderate

GCS = 9 to13


Most are admitted /observed due to potential for

deterioration.

Severe

GCS = < 9


Mortality approx. 40%

Most occur in 48 hrsLong-term disability

is common.

ConcussionConcussion

Trauma to the head with variable period of **unconsciousness or confusion and then a

return to normal consciousness**Not required to make a possible diagnosis of

concussion.

ConcussionConcussion

Signs and SymptomsVacant Stare Disoriented

Delayed verbal response

Confused and inability to focus attention

Slurred or incoherent speech

Lack of coordination (stumbling, dizzy)

Inappropriate emotions to the circumstances

Short-term memory deficits (casualty repeats the same questions)

Inability to memorize and recall

Intracranial HematomaIntracranial Hematoma

Intracranial HematomaIntracranial Hematoma

Headache - Visual Changes - Confusion

Personality Changes --- Decreased Pulse

Slurred speech or Dysarthria (difficulty speaking)

Changes in LOC - Possible Coma

Increased blood pressure (hypertension).

Lucid Interval - Pupil Changes - Nausea & Vomiting

*Hemiparesis (weakness on one side of the body)

*Hemiplegia (paralysis on one side of the body)

*On the side of the body opposite of the trauma impact

Check on Your Learning…Check on Your Learning…

Your casualty has suffered a head injury and had an initial GCS of 11. First reassessment the score is 9 and on second the score is 6. What do you know about the level of TBI the

casualty is demonstrating?

This is a severe TBI.

Accounts for 10% of head injuries suffered.

He has a 40% chance of dying in the next 48 hours. Long-term disability for this casualty is very

probable.


The casualty suffered blunt trauma to the face and asks you if he is missing a tooth because

his teeth feel weird. What would type of injury do you suspect?

A mandible fracture.

Treat a Casualty with a Suspected Head Injury

Treat a Casualty with a Suspected Head Injury

Special Considerations

Suspect brain or C-spine injuries for all head, face and neck wounds. (MOI)

Do not clean a scalp wound. (Additional bleeding occurs.)

Do not remove impaled objects; stabilize in place.

Gently palpate for depressions.

Facial trauma CAN be associated with AMS and severe trauma to the brain.

TreatmentTreatment

The first step with any combat casualty is?Control any life threatening hemorrhage.

If the tactical situation allows, what is the next step?

Take Spinal Precautions (Hold C-Spine).

TreatmentTreatment

AirwayBe prepared to suction.

BreathingProvide normal tidal volume and rate when

assisting with ventilation. Do NOT hyperventilate.

TreatmentTreatment

CirculationDo not apply pressure dressings to open or depressed

skull fractures.For soft tissue injuries, control bleeding with pressure

on the edges of the wound.

For complex scalp wounds several gauze pads held in place by an elastic roller bandage creates an

effective pressure dressing.

Hemostatic gauze may be effective in controlling bleeding.

TreatmentTreatment

CirculationThe combo of hypoxia and hypotension

is associated with a mortality rate of about

75%75%Follow fluid resuscitation protocols.

Due to morphine's effect, it is NOT recommended for individuals with a suspected brain injury.

TreatmentTreatment

TransportTransport in a supine position.

Although elevating the head (reverse Trendelenburg)

may decrease intracranial pressure, cerebral profusion may be jeopardized especially

when the head is elevated greater than 30 degrees.

If a facial wound is present, tilt the casualty towards the side of the injury to allow for drainage


Should you hyperventilate a casualty with a head injury?

No. Hyperventilation has been shown to worsen the outcome of head injury casualties.

How should you transport a casualty with a head injury?

Supine


How should a casualty suffering from shock, due to a head injury, be managed?

Gain vascular access and follow fluid resuscitation

algorithm.

NOTE: Do NOT delay transport in an effort to gain vascular

access. Transport ASAP.


What is the “definitive MTF” for a casualty suffering from a head injury? Under what priority should the casualty be evacuated?

One that has neurosurgical capability.

The casualty should be considered Urgent Surgical. When possible, the fact the casualty is urgent

surgical due to a neurological issue can be relayed.

SummarySummary

What do you expect the vital signs of a casualty with a head injury and increasing intracranial

pressure to do?Increased blood pressure (hypertension)

Decrease in pulse rate (bradycardia),

Respiratory rate increases, decreases, or becomes irregular.

What is this combination called?Cushing's Triad (Cushing's Phenomenon).

SummarySummary

What signs and symptoms do you expect to see from

a casualty that has suffered a head injury?

Why?

Questions?

Education

Point of Wounding: Head Injuries and TBI