Page 51 - 2022 Ranger Medic Handbook

Head Trauma
Open head injury results from application of force with penetration of the skull. The most common agents are missiles
and blunt instruments. The lethality is proportional to the energy of the missile (which in turn is proportional to the
square of the velocity). Injuries caused by blunt instruments can cause open depressed skull fractures but are usually
of relatively low energy and cause only local injury to the brain. Nonetheless, these are serious wounds and have a high
potential for infection.
Closed head injury results from application of force to the head that does not involve penetration of the skull but may
involve scalp lacerations and facial fractures. The degree of injury to the brain is dependent on the energy transferred to SECTION 2
the brain as a result of the force applied to the head. Closed head injury most often results from falls and motor vehicle
accidents, even in an operational environment. Alteration of consciousness is the hallmark of brain injury and may be
mild or severe, immediate or delayed, brief or permanent. Delayed deterioration of consciousness may occur as a result
of hematoma formation within the skull or worsening swelling of the brain. The mechanism for this impairment of con-
sciousness is increasing intracranial pressure, with subsequent impairment of brain perfusion (blood flow).

Assessment & Management
Generally, with head injuries the primary damage is done and there is little that can be done to correct that dam-
age. The primary goal of head injury management is to identify or rule out intracerebral hemorrhage and then pre-
vent secondary injuries associated with hypoxia, hypotension, anemia, hyperthermia, and hypothermia. This equates
to aggressive bleeding control and airway management. Avoid hypoxia (any SpO 2 < 90%) and hypotension (any SBP
< 100), and react to the signs of brain edema, herniation, or seizures.
The hallmark of head injury is alteration of consciousness. This is best assessed using the Glasgow Coma Scale. Pupil-
lary function is also important to assess, and this can be done with any light source. In bright sunlight conditions, closing
the eye for 30 seconds and observing while quickly opening demonstrate pupillary reactivity. Regular reassessment, as
the tactical situation permits, is critical as a neurologic status may vary significantly over time.
Inspection: Vital signs should be assessed in any patient with a head injury and patency of the airway confirmed.
The head should be inspected for signs of open injury or skull fracture. Open injury will be accompanied by a defect,
and basal skull fracture may be associated with Battle’s sign (retroauricular ecchymosis) or raccoon eyes (periorbital
ecchymoses). Leakage of cerebrospinal fluid from the ears or nose may also be present. The pupils should be inspected
for equality and/or reactivity. Unequal or nonreactive pupils in an unconscious patient are ominous signs.
Auscultation: Auscultation is generally not helpful in the evaluation of the head injury itself, but in a patient with impaired
consciousness, a full exam, including auscultation of the lungs, should be performed.
Palpation: Palpation of the head may reveal an underlying closed depressed skull fracture (an “ashtray” feel). The
cervical, thoracic, and lumbar spine should be palpated to assess for tenderness or deformity, possibly indicating an
associated spinal injury.
MANAGEMENT: Treatment involves securing the airway, maintaining systolic blood pressure > 110, maintaining oxygen
saturation > 92% and < 100%, stabilizing the cervical spine (C-spine) if indicated, dressing any wound, and establishing
an intravenous line. Prevent seizures IAW Seizure Protocol and treat, if indicated, with hypertonic saline.
Extended Care
Key aspects of field management of severe TBI are the prevention of hypoxia and hypotension. Ensure early establishment
of a definitive airway, aggressively treat respiratory compromise, administer oxygen if available (to maintain saturation
> 92% and < 99%), and fluid resuscitate hypotension. DO NOT hyperventilate unless indicated for signs of herniation.
Controlled hyperventilation may be considered as a temporizing measure for evidence of increasing intracranial pres-
sure (ICP) and herniation (deteriorating mental status, unequal pupils, posturing). For impending herniation, ventilate
to achieve EtCO 2 of 25–30mmHg for 15–20 minutes. Otherwise, and without impending herniation, maintain EtCO 2 of
35-40mmHg. If EtCO 2 monitor is not available, ventilate at a rate of 20/min and a tidal volume of approximately 500mL.
Prevent seizures as per Seizure Protocol. Administer levetiracetam 1g IV to prevent seizure or 4g IV for seizure treatment.
Elevate the head 30 degrees. Prevent hypo/hyperthermia. Antibiotic prophylaxis for penetrating head trauma: ertapenem
1g IV/IO OR ceftriaxone 2g IV/IO. Ensure casualty is evacuated to a facility with a neuro surgeon available.

2022 RANGER MEDIC HANDBOOK 37