Head injury

---

Facilitator:
Medics:
Patients:
Cop:
Time: 20 mins; 1400-1420
Actual time:
Learning Objectives:
Materials: Baton, roller gauze, 4x4s.

---

Dramatic opening

Trainer starts to talk when "cop" comes from other room and hits trainer on head.¹

Traumatic Brain Injury

² Bleeding from the scalp is difficult to staunch, but it is capillary bleeding and not life-threatening. The big concern after head injury is whether there was a Traumatic Brain Injury (TBI). We can't diagnose TBI but we can recognize red flags and get help.

MOI for TBI

Bump, blow, or jolt to the head -- or penetrating head injury -- that disrupts normal function of brain.

• Forceful blow to resting head.

• Head strikes unyielding object (i.e. ground).

• Jolt ("rotational acceleration-deceleration") torques or twists brain.

• Repetitive impact -- multiple low impact-traumas before brain has time to recover (boxing, police baton, drunken fall from standing position).³

Assessment and red flags

When someone may have sustained a head injury, begin with ABCs and then assess severity of the injury.

• Observe for MOI and behavioral/affective change.

• Ask about events, fainting, nausea/vomiting, bladder incontinence.

Suspect potential mild TBI

• MOI: No major trauma.

• Chief complaint: "I just got whacked, but I'm fine."

• Exam: No bleeding, deformity, bruising, or swelling.

• Vitals: Alert and oriented, no altered mental status or personality changes.

• History: Did not pass out even for a moment, did not vomit, did not lose control of bladder. Remembers events; no nausea or dizziness.

• Plan: Be nice, educate about avoidance of repetitive impact, educate about self-assessment for delayed red flags; let go.

Suspect mild/moderate TBI

No two mTBI are alike in MOI and signs/symptoms.

• MOI: Forceful bump, blow, or jolt to head or body that resulted in rapid movement of head or brain.

• Exam: Bleeding, bruising, or swelling -- but no deformity.

• Vitals: Immediate or delayed change in physical, cognitive, emotional, or sleeping patterns -- but no major deficiencies/impairments.

• History: Passed out and recovered, nausea, vomiting, dizziness, or bladder incontinence -- transient not persistent.

• Plan: Educate patient and friend about self-assessment; encourage follow-up with qualified provider (911 call or walk-in); educate about avoidance of repetitive impact, educate about self-assessment for delayed red flags. Don't send home without buddy. If no buddy/any other concern: 911.

Severe head injury

• MOI: Major trauma (bike collision, motorcycle collision, close-range projectile round to the head, gunshot wound to head).

• Exam: Deformity.

• Vitals: Altered mental status (combative, asking same question over and over, saying same thing over and over, very bewildered or agitated), lowered LOR.

• Plan: 911, hold C-spine, control scene, elevate bleeding severe head injury (upright, not laying down: "If it's red, raise the head"), expect super-combativeness.

Alcohol confuses assessment

Many head injuries involve alcohol. Maybe the patient's friend can help sort out if this is his "normal drunk" or if he seems different. If you're pretty confident it's the alcohol, educate friends to observe for delayed red flags and call for back-up.⁴

First aid

Once you have recognized and responded to red flags, head injury care is mostly palliative and education.

For minor scalp lacerations, irrigate the wound, apply pressure with a 4x4, dress with a roller gauze (do not wrap under chin), and refer to emergency department for stitches/staple wound closure and follow-up evaluation.

Aftercare

After a head injury, the person should always get further medical care. Often action clinics provide follow-up care to the walking wounded, who face-planted off a park-bench and were brought in by their friends, who want to go back to the action for the day.

Minor head injury

• Consider leaving the action.

• Try not to injure the head again; multiple head injuries can cause fatal brain injury.

• If you suffer second head injury, seek immediate medical attention.

• If you check out OK, go home and return to action only after a full week of no further symptoms and a follow-up with your healthcare worker.

More serious head injury

After hospital assessment, have a responsible person stay with you to watch for the development of serious symptoms. The first 24 hours after injury are critical, although serious after-effects can appear up to 6 months after the injury.⁵

Rest in bed the first 24 hours. Your friend should wake you every 2 hours for the first 24 hours. If he notices any of these signs, seek immediate further medical attention:

• Can't be awakened or aroused.

• Vomiting.

• Unable to move arms & legs equally well on both sides.

• Blood or fluid drips from ears or nose.

• Temperature above 100F.

• Cannot breathe well or breathe in a funny pattern.

• Stiff neck.

• Pupils unequal size or shape.

• Convulsions.

• Noticeable restlessness, confusion, or disorientation.

• Persistent headache.

Don't take any non-prescribed medicine, including aspirin, for at least the first 24 hours. Your friend should wake you every 4 hours the second day and every 8 hours the third day after the injury.