Treatment of Head Injury

Part three of a three part series

In our last two installments we looked at the way heads get injured and the various ways the brain tends to bleed. In this, our last installment in the head injury series, let’s take a look at basic treatment and management of the head injury patient.

There are a lot of variables that need to be considered when managing a head injury patient in the prehospital environment. Your treatment will be guided by considerations like the mechanism and severity of the head injury, other associated injuries, the patients mental status and their basic stability. 

These are some guidelines when sizing up and prioritizing your care.

Airway Management:

Head trauma management begins with the airway. The brain is sensitive to hypoxia and a poorly managed airway can turn a significant but recoverable head injury into a devastating head injury. Our brain injured patients can present some unique airway challenges. Seizures and posturing can produce trismus and spinal precautions prohibit proper tilting of the head.

In these cases, oral and nasal airway adjuncts are helpful in ensuring proper ventilation while keeping the head midline and neutral. If the Glasgow is less than eight, consider an advanced airway like a king tube, combi-tube or ET tube. All of these should be protected from the possibility of a clenched jaw with some sort of bite block type protection.

Continue Reading…

Rapid Diagnosis: Pinpoint Pupils

Abnormally constricted or “pinpoint” pupils are a great finding for our rapid diagnosis series. There are many things that can cause the pupil to abnormally dilate. Very few things will make the pupil abnormally constrict. Constricted pupils are a doorway to a very short list of ailments and with a bit of background you should be able to hang your hat on one fairly quick.

How do we assess for “pinpoint” pupils?

Recall that the pupil should be mid-range and reactive under normal lighting conditions. When subjected to bright light, the pupil will constricted to reduce the volume of light entering the iris. In darkness the pupil will dilate to allow as much ambient light in as possible. Pupils smaller than 2mm in diameter under normal lighting conditions can be considered “pinpoint”. Any pupil that responds to changes in lighting conditions with 1mm of movement or less can be considered minimally reactive or nonreactive.

To assess for pinpoint pupils we need to subject the pupil to darkness by asking the patient to close their eyes or covering the patients eye. When we return the light source to the pupil we expect the pupil to be larger and rapidly return to its original size. If the pupils remain <2mm in diameter through the changing light conditions we have a “pinpoint pupils” finding. The fancy medical term for this phenomenon is abnormal miosis.

If the patient has bilateral pinpoint pupils consider the following possible etiologies:

Continue Reading…