This article was one of a series of first aid articles aimed at the ski tourer.

Head Injuries

Head injuries are an important cause of death and disability following an accident, minor head injuries are also very common, and although not life threatening can lead to quite prolonged symptoms. The first aider needs to decide firstly how serious the injury is, and then how to manage the situation.

There is very little actual first aid on scene that can be done without specialist medical knowledge and equipment. Prevention of further damage - which includes ensuring good oxygenation and protecting the neck is a priority. Being able to describe the cause and development of the head injury is very valuable when medical contact is made and may well make a difference in the eventual outcome for the victim.

Assessment

Degree of trauma - obviously the further the fall the greater the likelihood of a serious head injury. Any fall over 4ft is definitely significant, 'bodies' found on the ground at the bottom of slopes should be presumed to have fallen the full distance. Every patient who has a head injury should also be assumed to have a neck injury (see below).

Loss of consciousness - this is not a very reliable indicator of brain injury, but if the casualty has lost consciousness for more than 1 minute after the accident, the injury becomes more serious. (See assessment of consciousness). People are often temporarily 'stunned' or dazed for a few seconds even with a trivial injury. The casualty may have loss of memory for events before, during and after the accident - this also indicates a more serious injury, and also makes the patient in the field more difficult to handle as he may not remember where he is, who to call or where he's going.

Assessment of Consciousness

It is important to avoid vague terms, for example - light stupor, drowsiness, semi-conscious etc as they have no real definitive meaning. It is relevant to the first aider to know exactly how conscious/unconscious the casualty is, and to be able to report this back as it is important later for further management. The casualty's response to verbal and/or painful stimulus is used to score the coma (It is not essential to remember this in detail but if you grasp the basic principles than this is very helpful.) The patients response in three areas is recorded - verbal response, eye movement and general movement.

Start by trying to get the patient to respond to your voice, if there seems to be no reaction rub the casualty's breast bone to cause some discomfort and see if there is any response. Then 'score' the patient according to system shown in the table below.

Scoring for the Assessment of Consciousness
The Glasgow Coma Score

1 Verbal Response
Orientated and Converses	5
Disorientated and converses	4
Inappropriate Words	3
Incomprehensible DSounds	2
No Response	1
2 Eye Opening
Spontaneously	4
To verbal command	3
To pain	2
No response	1
3 Best Movement
Obeys commands	6
Localises pain	5 (Victim can point to site of pain)
Withdraws	4 (Limbs move away from pain)
Flexion to pain	3 (similar to a 'jerk' reaction)
Extension to pain	2 (movement of any type in response to pain other than above)
No response	1

A fully conscious patient will score 15/15 a score of 8 or under is unconscious, 3 is the minimum and is very worrying. A score less than 14/15 should be declared a major head injury and treated accordingly.

Orientation

If alert, the casualty should be if they know who they are, where they are, date and time. If they can reply accurately to all of these the chances of a significant problem are unlikely.

Complications

There are several reasons to be careful with patients with head injury. Firstly one needs to keep a look out for complications, particularly those which can be treated if medical help is available. The main complications are internal bleeding into the brain (this is indicated by the patient either remaining unconscious or by becoming less conscious i.e. the coma score gets less, fitting (ie epileptic fits), and brain damage due to lack of oxygen. This last complication may be due to other injuries (eg chest injury) causing blood loss or difficulty breathing. Proper positioning of the casualty (the recovery position - lying on their side) will help prevent blockage of the airway by the tongue, vomit or other debris which by stopping good breathing leads to lack of oxygen.

Symptoms

Common symptoms are:

Headache	this is likely to occur with any head injury. It becomes more significant if it is so severe that simple painkillers do not relieve it, or it is made worse by lying down. A headache waking someone from sleep should be brought to medical attention immediately.
Vomiting	People often vomit once after a bump to the head (particularly children) persistent vomiting is a sign of brain irritation and needs to be checked.
Other symptoms	such as drowsiness or double vision, etc may appear.

Management

Major head injury

ie a patient who has fallen a significant distance, and/or lost consciousness (score 8 or less) for more than 1 minute and or scores 13 or less when assessed. Lie the patient in the recovery position (NB Care of the neck) Clear any clothes/ obstructions from the airway and seek help as soon as possible.

Minor head injury

the patient will be alert but may be disorientated, will probably have a headache and may vomit. It is safe to give a painkiller such as paracetamol. The casualty should then be taken to medical help as soon as possible. Trivial head injury - common sense will usually indicate the patient who's head injury is insignificant ie minor degree of injury, mild headache and no disturbance of orientation - should be safe to carry on after a short period of rest.

Neck Injury

Any patient with a serious head injury almost certainly has a neck injury. If conscious level is diminished make sure the neck is protected by moving it as little as possible. Improvise a collar using scarves or socks wrapped round some clothing to make a roll and move the patient as little as possible, and keep the head in line with the body.

Concussion

This is a vague term, but even after a minor head injury patients may complain of some of the following:
  - Headache (often worse in the evening)
  - Nausea (but no vomiting)
  - Lack of concentration,
  - Volatile mood changes and irritability, These can last for some weeks and should be checked by a doctor.

author: Dr Rosemary J Mortons
publish date: May 1998

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