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Chapter 4
TRAUMATIC BRAIN INJURY
Recommendations are considered Category 1B by the WMS Panel of Expert Reviewers.
I. GENERAL INFORMATION
Anyone with a blow to the head or face, whether blunt or penetrating, risks developing
increased intracranial pressure (ICP) or intracranial hemorrhage (ICH). Because
definitive management of increasing ICP or ICH is not possible in the wilderness,
prevention of head injuries should rank high among priorities. Prevention involves
attention to safety and includes wearing an adequate helmet, approved for the specific
activity being undertaken. It must fit the user and be held in place with a non-stretching
chinstrap. The use of even a properly fitted helmet does not preclude the possibility of a
serious head injury, but it does reduce the risk. Chinstraps should not obstruct venous
blood flow as this may cause increased ICP.
II. GUIDELINES FOR ASSESSMENT
Some individuals after a blow to the head or face are low-risk and not in need of
immediate evacuation. These patients have had relatively minor injuries. They do not lose
consciousness or lose consciousness for only a brief period of time. They have no history
of a bleeding disorder or the use of medications that might increase the risk of bleeding.
Monitor patients in this category for 24 hours and awaken every 2 hours for assessment.
Watch for: 1) alterations in mental status, including personality changes, lethargy,
drowsiness, disorientation, unusual irritability, persistent retrograde amnesia, and
combativeness; 2) persistent nausea and vomiting; 3) change in visual acuity; and 4)
alterations in coordination and/or speech. If these signs or symptoms of increasing ICP
appear, then an evacuation should be initiated.
Urgent evacuation is recommended for all patients who have received a blow to
the head or face that results in loss of consciousness for more than a brief period of time
or who have significant signs or symptoms of increasing ICP, or a depressed or basilar
skull fracture. These signs and symptoms include 1) debilitating headache, 2) alterations
in mental status (see above), 3) persistent nausea and vomiting, 4) ) raccoon eyes
(periorbital ecchymosis), 5) Battle's sign (ecchymosis behind and below the ears), 6) loss
of coordination, 7) loss of visual acuity, 8) appearance of clear fluid (possibly cerebral
spinal fluid) from the nose and/or ears, 9) seizures, 10) relapse into unconsciousness, and
11) the inability to retain new memory.
III. GUIDELINES FOR TREATMENT
If there is an obvious head injury consider the possibility of a cervical spine injury (see
Spinal Injury Management). Specific measures to implement during evacuation include
the critical importance of establishing and maintaining an airway in all unconscious
patients. Airway management, without specific adjuncts, can usually be accomplished by
keeping the patient in a stable (preferably left-side) position, which also helps alleviate
the possibility of aspirating vomitus, a common threat with head-injured patients.
Alternatively, with consideration for possible spinal injury, place the patient with his/her
