Head Injury Evaluation and Treatment (part 1 of 2)

Every adventurer, out-of-the-way traveler, and sailor needs to know about head injury assessment and treatment. Head injuries here refer to any trauma to the scalp, brain, or skull. Like other fractures, they are initially classified as either open or closed.

Basic anatomy:

  • From the outside inward we encounter 1) the scalp 2) skull 3) meninges which is the sheath like covering of the brain and includes the outer a) dura b) arachnoid c) pia layers 4) the brain. See diagram.

Head injuries commonly encountered includes:

  • Scalp laceration
  • Concussion and/or traumatic brain injury (TBI) (the brain is violently accelerated or decelerated in the skull; with TBI the brain gets small areas of swelling or bleeding and loss of consciousness typically lasts greater than 6 hours). Concussion, by definition is loss of consciousness or memory changes lasting less than 6 hours.
  • Skull fracture (opened or closed)
  • Epi-dural bleed (between the skull and meninges): may or may not have an immediate loss of consciousness. Can occur sometime later after a normal period.
  • Sub-dural bleed (between the meninges and brain): function may be normal initially or there may be paralysis on one side of the body.
  • Brain contusion (bruise) or laceration
  • Brain herniation (due to extreme injury or bleeding of the brain, increasing pressure Altering consciousness

Field Evaluation:

Symptoms that constitute an emergency. Seek help immediately if possible.

  • Progressively worsening headache
  • Severe pain in the neck or base of the skull
  • Repeated vomiting
  • Can hardly be awakened
  • Worsening changes in consciousness, confusion, disorientation
  • Any numbness or weakness of the face, arm, leg.
  • Dark circles around the eyes called raccoon eyes.
  • Swelling or discoloration behind the ears
  • Clear fluid coming from the nose
  • Bleeding from the ears
  • Pupil sizes are unequal
  • High blood pressure, slowing of the heart rate, slow or irregular breathing occurring simultaneously (called Cushing’s triad)

Many head injuries are accompanied with neck trauma. Take precautions-see neck injuries.


The current standard for severe head injury evaluation is the Glasgow Coma Scale:

Glasgow Coma Scale

Area                                                    Response                                                                              Points

Eyes          Open Spontaneously                                                                                                          4

Open to verbal commands                                                                                                3

Open in response to pain (squeeze nailbed, or knuckle chest)                                  2

No eye-opening or response                                                                                              1


Verbal      Oriented (is aware of location, day, what happened)                                                  5

Disoriented but able to answer questions                                                                      4

Inappropriate answers to questions, but words understandable                              3

Incomprehensible speech                                                                                                  2

None                                                                                                                                        1


Motor      Obeys commands (moving arm, touching nose, etc.)                                                    6

Withdraws from pain to nailbed or pinching skin                                                         5

Grimaces to pin prick of foot                                                                                              4

Responds to pain only by flexing limbs (decorticate posturing)                                 3

Responds to pain with rigid extension of body (decerebrate posturing)                   2

No response                                                                                                                            1


Scores of 14 or 15 indicate mild traumatic brain injury (TBI); 9 to 13 moderate TBI; 3-8 severe TBI

Often TBI with scores of 14-15 can rest and be observed closely if medical facilities are unavailable. Have a plan should things worsen.

Continued with Part 2


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