A head injury ranges from a mild concussion to bleeding inside the skull that compresses the brain. Prehospital and emergency care aim to prevent secondary brain injury by avoiding low oxygen, low blood pressure and hyperventilation.
Key symptoms
- Headache, dizziness, nausea or vomiting
- Confusion, no memory of the event or loss of consciousness
- Drowsiness or worsening alertness
- Seizure
- Blurred vision, weakness or trouble speaking
What you find on exam
- Glasgow Coma Scale, repeated over time
- Pupil size and reaction to light
- Scalp wounds, skull deformity, raccoon eyes, bruising behind the ear, fluid from the nose or ears
- Neurological exam: limb strength, speech and coordination
- Cervical spine assessment, since neck injury often comes with head injury
Tests
- Glucose check
- Noncontrast CT of the head, guided by the Canadian CT Head Rule
- Coagulation tests if the patient takes blood thinners
- Capnography with a target of 35 to 45 mmHg in ventilated patients
Treatment basics
- Keep oxygen saturation at 94 percent or higher and avoid systolic pressure below 110 mmHg
- Avoid hyperventilation unless there are signs of brain herniation
- Raise the head of the bed 30 degrees; spinal motion restriction if indicated
- Reverse anticoagulation for bleeding inside the skull
- Neurosurgery for expanding bleeds; for concussion, rest then a gradual return to activity
Red flags
- GCS dropping by 2 points or more
- One pupil dilated and not reacting
- Repeated vomiting, seizure or worsening headache
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Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; NREMT psychomotor skill sheets (EMT and Paramedic); NCCPA PANCE Content Blueprint. Written by Making Synapses. Making Synapses is not affiliated with these organizations.