Head Injuries Require Quick, Skilled Care

by Food and Drug Administration (FDA)

American deaths from head injury since 1977 exceed the total of war dead from all U.S. battles, including the Revolutionary War. Yearly, head injury creates 5,000 cases of seizure disorders, leaves up to 90,000 victims permanently disabled, puts 2,000 humans into a vegetative existence, and claims as many as 100,000 lives, including 10 of every 100,000 children.

And, in the 15 seconds it took to read those statistics, another head injury occurred.

Most likely it was a young man, for his risk is more than twice that of a woman. Most likely it was from a motor vehicle accident, for mishaps involving cars, motorcycles and other vehicles account for half of all head injuries.

The annual tally of head injuries is conservatively estimated to be over 2 million, with 500,000 requiring hospital admission.

Emergency!

In a 1986 report published by the National Head Injury Foundation (a nonprofit advocacy group), Thomas Kay, Ph.D., of New York University Medical Center defines moderate to severe head trauma as clearly serious, often life-threatening, with obvious disability and need for specialized treatment. In other words, an emergency.

"Head trauma? We put a neck collar on. We always suspect spinal injury," says Burton Conway, emergency medical technician on weekends in rural Virginia and medical physicist during the week at the Food and Drug Administration's Center for Devices and Radiological Health (CDRH).

It's a good idea for anyone to learn first-aid, including cardiopulmonary resuscitation. The American Heart Association and the Red Cross offer classes.

To someone at the scene of an accident involving a potentially serious head injury, particularly if that person is untrained, Conway cautions:

Never risk spinal injury by moving the head-injured victim unless there's immediate danger, such as a fire.

Never stem the flow of fluid from the nose or ears, which may be from the brain, as this can inflict damaging pressure on the brain.

Never remove an object penetrating the skull, as this can cause massive bleeding.

"Get professional help right away," he says.

Emergency protocols vary from state to state. In the unique state-wide Maryland Emergency Medical System, a 911 call reaches a "central alarm" communications center, one per county, that can dispatch ambulances from local fire departments and request a "medevac" helicopter. Maryland has eight helicopter bases and 11 trauma centers. Ambulances are staffed by emergency medical technicians, cardiac rescue technicians, or emergency medical technician paramedics, depending on the need. The helicopters carry paramedics able to provide the highest level of pre-hospital care.

Ameen Ramzy, M.D., who directs emergency medical services for Maryland, says the technicians arriving at the scene quickly assess injuries, determine where the patient should go, and begin radio communications with the receiving center. They start an intravenous line, administer fluids in case of shock, and may also apply medical anti-shock trousers to temporarily increase blood pressure.

"The emphasis," Ramzy says, "is rapid assessment, rapid evacuation, establishing and maintaining an airway — with a tube down the throat, if needed — and administering oxygen."

He stresses that severely injured patients should reach definitive care, not just the closest hospital, within an hour from injury — an interval some call the "golden hour."

The Trauma Center

"A young man we received today was injured in a car crash — an unbelted passenger," says Walker Robinson, M.D., acting chief of the University of Maryland's neurotrauma unit in Baltimore. "He's unconscious, unresponsive, and has rapid pulse. He's not moving his arms or legs and is gasping for breath. We've got shock, maybe from bleeding, problems with the chest, and a broken neck."

The first person who sees him, says Robinson, is a traumatologist, a surgeon experienced in treating accident injuries, who leads the trauma team in looking at the patient "to try to determine which bit and piece isn't working right."

Quickly, they measure vital signs such as heartbeat and blood pressure and place electrodes on the skin to attach lines to cardiac and other monitors. They set up life-support measures such as mechanical breathing (ventilation) and blood replacement to reduce the risk of imminent death. Seeing the young man has head injury, they consult the unit's neurosurgeon: Robinson.

A thorough physical examination follows. Systematic testing of reflexes determines the patient's level of consciousness — "the most important factor in evaluating a head-injured patient," says Robinson.

The computed axial tomography (CAT or CT) scan is the gold standard diagnostic radiological procedure (see also "What About Skull X-Rays?" on page 13) for head injury because it depicts the critical soft tissue of the brain so well.

(CT scans produce mathematically computed cross-sectional images of the brain's soft tissue. CT uses an x-ray tube but provides much more information than ordinary x-rays. CDRH regulates the instruments as medical devices and as radiological equipment. For more on imaging techniques, see "A Primer on Medical Imaging, Parts I and II" in the April and May 1989 issues of FDA Consumer.)

Robinson looks to CT scans and other diagnostic tests to explain why the brain isn't working right. There may be a blood clot (hematoma) or a depressed fracture pushing on the brain, which requires surgery. Quite commonly, he says, "we don't find anything to operate on but see evidence of damage, such as contusion, or bruise, on the brain."

About the Author

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FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.