The good news in the world of head trauma and brain injury is that we’re seeing a lot more folks putting on helmets before they go out and do 
potentially dangerous, head crushing stuff. The good/bad news is that we’re encountering more patients who are wearing helmets and need to be placed in full spinal immobilization. This brings up a controversial decision. Should we remove the helmet or leave it in place?
The leave it or remove it controversy has been around for as long as I’ve been in EMS and, like most controversies that remain unresolved for years, there are merits to both options. In these instances, it’s easy to create blanket rules and then follow them mindlessly.
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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.
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Part two of a three part series
In our last post (part one) we introduced the subject of head injuries with an overview of trauma patterns
typically found in head injury patients. Today let’s talk about bleeding inside the skull or intracranial hemorrhage.
Brain hemorrhage occurs when blood vessels inside the skull rupture. There are some non-traumatic causes as well. Ruptured aneurysms and hemorrhagic strokes would be a few examples of non-traumatic intracranial hemorrhages.
We classify bleeding in the skull by location, using the layers of the meninges as a guide. You may recall from EMT class that the meninges are fluid coated membranes that surround and protect the brain and spinal cord. They also encapsulate and limit the ways that blood can move inside the skull. How the brain bleeds is entirely dependant on which meningeal layers capture and contain the blood.
Do you remember those meningeal layers? Lets do a quick review in case you’ve forgotten, courtesy of our friends at ADAM education:
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Part one of a three part series.
It seems that after the tragic deaths of both Natasha Richardson and Billy Mays, head injuries have been 
getting a lot of play time in the media. Richardson died of an epidural bleed after a helmetless fall on skis. Mays was found to have an enlarged heart, but the minor head injury he received the night before his death launched speculation that he had died from intracranial bleeding as well.
Both of these incidents bring to light an important element of head injury response and evaluation. Patients with critical, life threatening brain injuries don’t always present as sick. Often they report feeling just fine. The emergency responder needs to approach head injuries with a high index of suspicion.
Today were going to begin a three part series on head injuries. In part one we’ll take a look at the different ways the skull and brain get injured. In part two we’ll talk about how the brain bleeds and how that can change the patients presentation. In part three we’ll look at treatment considerations for the head injured patient.
Let’s do a quick review of what’s inside your head:
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Big biker dude strained against the double layers on tape across his forehead and it occurred to me that the act of c-spine seemed pointless if the patient insisted on fighting violently against the tape and straps. Three firefighters were still holding big biker dude (BBD) down and the firefighter closest to his head was yelling, “calm down. … CALM DOWN!” This wasn’t working, but I understood. Sometimes the urge is irrisistible. For his part, big biker yelled back in disorganized consonants and vowels, “uaaaaghhh”.
BBD had laid his Harley down just before an intersection at the corner of our district. Medic units from three
different providers would be responding to the intersection to establish who’s patient he really was. This was often a recipe for conflict, but not tonight. The second medic on scene was happy to assist me with setting up IV’s and the third drove by without stopping. From his position in the road, BBD clearly wasn’t in my response area, none-the-less, big biker dude was all mine.
Maybe it was all the leather, or perhaps it was the Harley, or the time of night, but I assume from their demeanor that most folks on scene thought that big biker dude was really drunk or really mean or both. In reality he was neither. Big biker dude had a closed head injury and he was in his combative phase. Combative closed head injuries can be easily mistaken for aggressive patients by emergency responders and, if we’re not careful, the confusion can lead to incidents like this one and profoundly inappropriate care.
So what makes closed head injury patients fight us?
I found surprisingly little information addressing this specific question. While there is plenty of information to be found regarding the debate over how to treat these challenging patients, exactly why they fight is left unexamined. The reasons for combativeness are primarily theoretical. They are likely a combination of the following:
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