Head Trauma Treatment & Management

Updated: Jan 09, 2015 Author: Craig R

Ainsworth, MD; Chief Editor: John
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What is a head injury?

A head injury is any sort of injury to your brain, skull, or scalp. This can range from a mild
bump or bruise to a traumatic brain injury. Common head injuries include concussions, skull
fractures, and scalp wounds. The consequences and treatments vary greatly, depending on
what caused your head injury and how severe it is.

Head injuries may be either closed or open. A closed head injury is any injury that doesn’t
break your skull. An open, or penetrating, head injury is one in which something breaks your
skull and enters your brain.

It can be hard to assess how serious a head injury is just by looking. Some minor head
injuries bleed a lot, while some major injuries don’t bleed at all. It’s important to treat all
head injuries seriously and get them assessed by a doctor.

CAUSES
What causes a head injury?
In general, head injuries can be divided into two categories based on what causes them. They
can either be head injuries due to blows to the head or head injuries due to shaking.

Head injuries caused by shaking are most common in infants and small children, but they
can occur any time you experience violent shaking.

Head injuries caused by a blow to the head are usually associated with:

 motor vehicle accidents

 falls
 physical assaults
 sports-related accidents

In most cases, your skull will protect your brain from serious harm. However, injuries severe
enough to cause head injury can also be associated with injuries to the spine.

TYPES

What are the major types of head

injuries?
Hematoma

A hematoma is a collection, or clotting, of blood outside the blood vessels. It can be very
serious if a hematoma occurs in the brain. The clotting can cause pressure to build inside
your skull, which can cause you to lose consciousness or result in permanent brain damage.

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Hemorrhage

A hemorrhage is uncontrolled bleeding. There can be bleeding in the space around your
brain, which is a subarachnoid hemorrhage, or bleeding within your brain tissue, which is
an intracerebral hemorrhage.

Subarachnoid bleeds often cause headaches and vomiting. The severity of intracerebral
hemorrhages depends on how much bleeding there is, but over time any amount of blood can
cause pressure to build.

Concussion

A concussion is a brain injury that occurs when your brain bounces against the hard walls of
your skull. Generally speaking, the loss of function associated with concussions is
temporary. However, repeated concussions can eventually lead to permanent damage.

Edema

Any brain injury can lead to edema, or swelling. Many injuries cause swelling of the
surrounding tissues, but it’s more serious when it occurs in your brain. Your skull can’t
stretch to accommodate the swelling, which leads to a buildup of pressure in your brain. This
can cause your brain to press against your skull.

Skull fracture

Unlike most bones in your body, your skull doesn’t have bone marrow. This makes the skull
very strong and difficult to break. A broken skull is unable to absorb the impact of a blow,
making it more likely that there will also be damage to your brain. Learn more about skull
fractures.

Diffuse axonal injury

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A diffuse axonal injury, or sheer injury, is an injury to the brain that doesn’t cause bleeding
but does damage your brain cells. The damage to the brain cells results in them not being
able to function and can also result in swelling, causing more damage. Though it isn’t as
outwardly visible as other forms of brain injury, diffuse axonal injury is one of the most
dangerous types of head injuries and can lead to permanent brain damage and even death.

SYMPTOMS

What are the symptoms of a head

injury?
Your head has more blood vessels than any other part of your body, so bleeding on the
surface of your brain or within your brain is a serious concern in head injuries. However, not
all head injuries cause bleeding.

It’s important to be aware of other symptoms to watch out for. Many symptoms of serious
brain injury won’t appear right away. You should always continue to monitor your
symptoms for several days after you injure your head.

Common symptoms of a minor head injury include:

 a headache
 lightheadedness
 a spinning sensation
 mild confusion
 nausea
 temporary ringing in the ears

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The symptoms of a severe head injury include many of the symptoms of minor head injuries.
They can also include:

 a loss of consciousness
 seizures
 vomiting
 balance or coordination problems
 serious disorientation
 an inability to focus the eyes
 abnormal eye movements
 a loss of muscle control
 a persistent or worsening headache
 memory loss
 changes in mood
 leaking of clear fluid from the ear or the nose

GETTING HELP

When does a head injury require medical

attention?
Head injuries shouldn’t be taken lightly. See your doctor right away if you think you have
the symptoms of a serious head injury.

In particular, you should always call 911 or go to an emergency room if you experience loss
of consciousness, confusion, or disorientation. Even if you don’t go to the ER immediately
after the accident, you should seek help if you still have symptoms after a day or two.
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In the case of a potentially serious head injury, you should always call 911. Motion can
sometimes make a head injury worse, and emergency medical personnel are trained to move
injured people carefully without causing more damage.

DIAGNOSIS

How is a head injury diagnosed?

One of the first ways your doctor will assess your head injury is with the Glasgow Coma
Scale (GCS). The GCS is a 15-point test that assesses your mental status. A high GCS score
indicates a less severe injury.

Your doctor will need to know the circumstances of your injury. Often, if you’ve had a head
injury, you won’t remember the details of the accident. If it’s possible, you should bring
someone with you who witnessed the accident. It will be important for your doctor to
determine if you lost consciousness and for how long if you did.

Your doctor will also examine you to look for signs of trauma, including bruising and
swelling. You’re also likely to get a neurological examination, in which your doctor will
evaluate your nerve function by assessing your muscle control and strength, eye movement,
and sensation, among other things.

Imaging tests are commonly used to diagnose head injuries. A CT scan will help your doctor
look for fractures, evidence of bleeding and clotting, brain swelling, and any other structural
damage. CT scans are fast and accurate, so they’re typically the first type of imaging you
will receive. You may also receive an MRI scan, which can offer a more detailed view of the
brain. An MRI scan will usually only be ordered once you’re in stable condition.

TREATMENTS

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How is a head injury treated?
The treatment for head injuries depends on both the type and the severity of the injury.

With minor head injuries, there are often no symptoms other than pain at the site of the
injury. In these cases, you may be told to take acetaminophen (Tylenol) for the pain. You
shouldn’t take nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil)
or aspirin(Bufferin), because they can make any bleeding worse. If you have an open cut,
your doctor may use sutures or staples to close it. They’ll then cover it with a bandage.

Even if your injury seems minor, you should still watch your condition to make sure it
doesn’t get worse. It isn’t true that you shouldn’t go to sleep after you have injured your
head, but you should be woken up every two hours or so to check for any new symptoms.
You should go back to the doctor if you develop any new or worsening symptoms.

You may need to be hospitalized if you have a serious head injury. The treatment you
receive at the hospital will depend on your diagnosis.

The treatment for severe head injuries can include:

Medication

If you’ve had a severe brain injury, you may be given antiseizure medication. You’re at risk
for seizures in the week following your accident.

You may be given diuretics if your injury has caused a buildup of pressure in your brain.
Diuretics cause you to excrete more fluids. This can help to relieve some of the pressure.

If your injury is very serious, you may be given medication to put you in an induced coma.
This may be an appropriate treatment if your blood vessels are damaged. When you’re in a
coma, your brain doesn’t need as much oxygen and nutrients as it normally does.

Surgery
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It may be necessary to do emergency surgery to prevent further damage to your brain. For
example, your doctors may need to operate to remove a hematoma, repair your skull, or
release some of the pressure in your skull.

Rehabilitation

If you’ve had a serious brain injury, you’ll most likely need rehabilitation to regain full brain
function. The type of rehabilitation you get will depend on what functionality you’ve lost as
a result of your injury. People who’ve had a brain injury will often need help regaining
mobility and speech.

OUTLOOK

What is to be expected in the long term?

The outlook depends on the severity of your injury. Most people who’ve had minor head
injuries experience no lasting consequences. People who’ve had serious head injuries may
face permanent changes in their personality or physical and cognitive abilities. Severe head
injuries in childhood can be particularly concerning, as it’s generally thought developing
brains are susceptible to injuries. There is ongoing research studying this issue.

Your healthcare team will work with you to ensure that you have as full of a recovery as
possible.

Article resources

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Medically reviewed by Seunggu Han, MD onAugust 29, 2017 — Written by Lauren Reed-
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Medical Therapy
The treatment of head injury may be divided into the treatment of closed head
injury and the treatment of penetrating head injury. While significant overlap exists
between the treatments of these 2 types of injury, some important differences are
discussed. Closed head injury treatment is divided further into the treatment of mild,
moderate, and severe head injuries.
Mild head injury
Most head injuries are mild head injuries. Most people presenting with mild head
injuries will not have any progression of their head injury; however, a small
percentage of mild head injuries progress to more serious injuries. Mild head injuries
may be separated into low-risk and moderate-risk groups. Patients with mild-to-
moderate headaches, dizziness, and nausea are considered to have low-risk
injuries. Many of these patients require only minimal observation after they are
assessed carefully, and many do not require radiographic evaluation. These
patients may be discharged if a reliable individual can monitor them. Patients on
anticoagulation therapy should have radiographic imaging performed even if they
have had minimal head trauma as they can progress from a mild head injury to a
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catastrophic injury because their ability to coagulate blood has been medically
inhibited.
Patients who are discharged after mild head injury should be given an instruction
sheet for head injury care. The sheet should explain that the person with the head
injury should be awakened every 2 hours and assessed neurologically. Caregivers
should be instructed to seek medical attention if patients develop severe
headaches, persistent nausea and vomiting, seizures, confusion or unusual
behavior, or watery discharge from either the nose or the ear.
Patients with mild head injuries typically have concussions. A concussion is defined
as physiologic injury to the brain without any evidence of structural alteration.
Concussions are graded on a scale of I-V. A grade I concussion is one in which a
person is confused temporarily but does not display any memory changes. In a
grade II concussion, brief disorientation and anterograde amnesia of less than 5
minutes' duration are present. In a grade III concussion, retrograde amnesia and
loss of consciousness for less than 5 minutes are present, in addition to the 2
criteria for a grade II concussion. Grade IV and grade V concussions are similar to a
grade III, except that in a grade IV concussion, the duration of loss of consciousness
is 5-10 minutes, and in a grade V concussion, the loss of consciousness is longer
than 10 minutes.
As many as 30% of patients who experience a concussion develop postconcussive
syndrome (PCS). PCS consists of a persistence of any combination of the following
after a head injury: headache, nausea, emesis, memory loss, dizziness, diplopia,
blurred vision, emotional lability, or sleep disturbances. Fixed neurologic deficits are
not part of PCS, and any patient with a fixed deficit requires careful evaluation. PCS
usually lasts 2-4 months. Typically, the symptoms peak 4-6 weeks following the
injury. On occasion, the symptoms of PCS last for a year or longer. Approximately
20% of adults with PCS will not have returned to full-time work 1 year after the initial
injury, and some are disabled permanently by PCS. PCS tends to be more severe in
children than in adults. When PCS is severe or persistent, a multidisciplinary
approach to treatment may be necessary. This includes social services, mental
health services, occupational therapy, and pharmaceutical therapy.
After a mild head injury, those displaying persistent emesis, severe headache,
anterograde amnesia, loss of consciousness, or signs of intoxication by drugs or
alcohol are considered to have a moderate-risk head injury. These patients should
be evaluated with a head CT scan. Patients with moderate-risk mild head injuries
can be discharged if their CT scan findings reveal no pathology, their intoxication is
cleared, and they have been observed for at least 8 hours.
Moderate and severe head injury
The treatment of moderate and severe head injuries begins with initial
cardiopulmonary stabilization by ATLS guidelines. The initial resuscitation of a
patient with a head injury is of critical importance to prevent hypoxia and
hypotension. In the Traumatic Coma Data Bank study, patients with head injury who
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presented to the hospital with hypotension had twice the mortality rate of patients
who did not present with hypotension. The combination of hypoxia and hypotension
resulted in a mortality rate 2.5 times greater than if neither of these factors was
present. Of note, recent studies have demonstrated that hyperoxia in severe head
injury patients who have been intubated can also be deleterious. Hyperoxia with a
PaO2> 300 mm Hg in ventilated TBI patients was associated with higher in-hospital
case fatality. [8]

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Head Trauma Treatment & Management Updated: Jan 09, 2015 Author: Craig R Ainsworth, MD;
Chief Editor: John Geibel, MD, DSc, MSc, AGAF

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