Article from July, 2012

head_trauma

Many of us on departing on expeditions think about protecting our head and eyes from the elements and insects but besides allergies for those afflicted, little thought is directed to what else can cause problems in that area. Two potentially exquisite sources of pain and suffering, eyes and teeth, have been covered in previous columns. But other than colds and flu, what other problems above the shoulders may affect the traveler and interrupt the mission?

One problem we all have experienced that comes to mind (pun intended) is headache. Prominent Wilderness Medicine Society and EC member Dr. Bill Forgey, FN ’75, states that headache is not uncommon but was not a significant reason for terminating a trip in his study of 280 long-distance Appalachian Trail hikers. The most common type of headache is caused by tension or fatigue and is relieved just like back home with rest and your choice of moderate pain reliever. Certainly familiar to many explorers are headaches following alcohol overindulgence where personalized home concoctions offer partial relief but this topic is beyond the scope of this discussion. Migraines are usually well known to the sufferer but may be precipitated by stress, high altitude, lack of sleep, and certain foods encountered on an expedition that are typically avoided in daily life. Patients who have migraines often have their specific medications but narcotics may be needed. Atypically severe headaches could signify meningitis (classically with fever and stiff neck) or other severe health problems such as uncontrolled high blood pressure, intracranial hemorrhage, tumor, or infection. It is highly unlikely that you will run into this in the field though meningitis is endemic to some areas and hemorrhage could occur after head trauma.

At the other end of the spectrum from the common headache is injury sustained from trauma. Traumatic brain injury (TBI) accounts for about 250,000 hospitalizations and 60,000 deaths each year in the US and about 80,000 victims left with permanent neurological damage. The majority of civilian TBI is caused by blunt trauma from motor vehicle accidents or falls and though penetrating trauma is less common, it is far more lethal. Alcohol contributes to about 40% of severe head injuries.

TBI can be either focal or diffuse and coexist. Focal injuries usually result from a blow to the head and location, extent, and progression determine morbidity and mortality. Diffuse injuries are secondary to shearing forces or lack of oxygen. Skull fractures imply a strong force has been applied to the head and are associated with other head injuries. One should suspect a skull fracture if there is leakage of clear fluid from ears or nose, bruising is noted around the eyes (raccoon-like) or behind the ears, pupils are unequal and poorly reactive, or there is blood in the eardrum.

Skull fractures are often accompanied by hemorrhage on the outer surface or within the brain. In these cases, it is common to have loss of consciousness followed by a period of lucidity but then mental deterioration. This is the reason head injury victims need to be monitored regularly even if they appear improved.

So what do you do if someone sustains a head injury? It is important to determine whether the victim lost consciousness. A person struck on the head who remained conscious rarely has a serious TBI. The first step when encountering such a victim is to determine if they are conscious and respond appropriately to questions about name, date, and location. Do not move the victim and do stabilize the neck because neck fractures are the most common serious injuries associated with head trauma. If not properly responsive, make sure that the airway is open, breathing is adequate, and check for a pulse – the ABCs of assessment – Airway, Breathing, Circulation.

• Make sure that you maintain the airway and frequently evaluate the patient because the airway in a dazed or unconscious patient can obstruct with blood, the tongue, or vomit.
• Examine the scalp gently for lacerations or deformities that might suggest a skull fracture. Scalp wounds can bleed profusely because of many blood vessels which do not contract like in other dermal areas. Direct firm pressure on the scalp will slow the bleeding until you can bandage the wound.
• Examine the eyes to see if pupils are equal in size and react to a light source equally. Eyes that are unequal or poorly reactive to light suggest a skull fracture.
• Try to determine from the victim or witnesses how the injury occurred if not evident. Information about the accident may help determine the extent of injuries.
• Gently palpate along the cervical (neck) spine for deformities.
• Examine the rest of the body for injuries. Trauma often involves multiple organs or structures.
• Determine any medical history including medications that the victim takes. A person on aspirin or anticoagulants like Coumadin is a greater risk for serious bleeding.
• Arrange for immediate evacuation for any serious head injury. If you have to transport the victim, make sure you stabilize the neck.

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This article was published in The Explorers Journal

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