A head injury is any sort of trauma to the brain, scalp or skull. Head injuries are a major cause of mortality and disability in adults. Each year about 1.5 million Americans sustain a head injury, with an estimated 3% of death rate.

Types of Head Injury

Head injuries can be broken up into two main types: closed and penetrating.

Closed Head Injury

A closed head injury is any trauma the head receives, that does not go through the skull. Injuries can range from minor injuries to devastating, life-threatening major injuries with lifelong physical, cognitive, or psychological impairment.

Closed head injuries are the main cause of mortality in infants under the age of 4 and the leading cause for both physical disability and cognitive impairment in young people.

They can cause fractures in the skull, as well as considerable harm to the brain. It can be in the form of a bruise, a concussion, or can cause an intracranial hemorrhage.

Treatment depends on the injury and its severity. There are different types of treatment options to those who have sustained a closed head injury such as cognitive rehabilitation, patient education and pharmacotherapy. Mild injuries do not need treatment.

Penetrating Head Injury

A penetrating head injury occurs when an incident causes a foreign object to lodge in or pass through the head. Care plans for this type are two-phased. You need to monitor ICP and blood pressure and stabilize the head and spine — along with any other monitoring necessitated in a closed head injury.

In addition, you’ll need to remove the penetrating object and debride and irrigate the wound. If the foreign item is near a main vascular structure, you should proceed with an angiogram to assess the risk of vascular injury before removing it. Then, debride and irrigate to help prevent infection. Penetrating head injuries are incredibly susceptible to infections since the objects typically carry germs and filth, so proper wound care is essential.

Levels of Severity in Head Injuries

Mild Head Injury

Mild head injuries are further broken down into low or moderate-risk. Most mild head injuries are treated as low-risk initially. However, if symptoms progress in severity or duration, it becomes a moderate-risk mild head injury and requires different care.

Low-Risk Mild Head Injury

Common side effects for low-risk mild head injuries are nausea, headaches and dizziness. These patients generally won’t need any imaging and can be released after minimal observation if they have someone at home who can routinely monitor them. Send them home with a detailed plan of care and signs to watch for.

Concussions are the most common cause of mild head injury symptoms, so it’s important to assess your patient accordingly. You’ll rate the severity of the concussion from a level I to a level V.

• Level I: minor confusion, but no change to memory.
• Level II: anterograde amnesia for less than five minutes and confusion.
• Level III: previous level’s symptoms plus retrograde amnesia and loss of consciousness for less than five minutes.
• Level IV: loss of consciousness is between five and 10 minutes.
• Level V: loss of consciousness is longer than 10 minutes.

Moderate-Risk Mild Head Injury

Patients experiencing extreme or extended nausea, headache and dizziness or loss of consciousness, anterograde amnesia or signs of intoxication should be upgraded to a moderate-risk head injury. These require imaging, such as a CT scan and at least eight hours of observation. Before you can sign off for their release, they need a clear scan, have a negative blood alcohol test and pass through the observation hours without issue.

For most mild head injuries, symptoms get better after a week or two. If the condition is still persistent after two months but with no new or worsening symptoms, your patient may have post-concussion syndrome (PCS). The continuation of symptoms can make it very difficult for them to go about their daily lives. After a concussion, patients have a 5-30% chance of developing PCS. While this condition can be quite debilitating, you can give reassurance that symptoms generally will fade over time. 

Moderate to Severe Head Injury

Moderate to severe head injuries are characterized by a GCS score of 12 or lower. Patients with a more serious head injury might have similar symptoms to a minor head injury but may also experience:

• Severe or worsening nausea, emesis or headache.
• Dilated pupils.
• Slurred speech.
• Weakness or numbness in the arms or legs.
• Not waking from sleep.
• Loss of coordination.
• Mood changes or irritability.

The priority with a head injury of this type is to prevent further injury or secondary damage. You may need to stabilize the head and spine. You should also monitor blood pressure, ICP and blood and oxygen flow to the brain. Work first to control all of these factors to stabilize the patient as much as possible. During this process, assess the patient for other bodily injuries and damage since a head injury rarely happens in a vacuum.

Head Injury Assessment

Speedy assessment is essential for all head injuries. Without immediate attention, the situation can worsen rapidly. Assessment with questioning, Glasgow Coma Scale (GCS) and imaging should be the first steps with any head trauma.

Questions to Ask

Begin your evaluation by asking a series of basic questions to determine the background. You may need to ask emergency personnel or a family member if the patient is unconscious or was unconscious at the time of the injury. Take notes and ask any necessary follow-ups until you feel confident in your next steps. Some questions to ask might include:

• What were you doing when the incident occurred?
• Where was the head injured?
• Are there any other injuries?
• Did you lose consciousness? If so, for how long?
• What level is your pain?
• Are you experiencing any other symptoms?

Glasgow Coma Scale

The GCS is the most common method for assessing acute brain injuries. You’ll test the patient’s eye opening, verbal response and motor response, ending with a score between three and 15. These totals reflect the current severity of the head injury.

• Mild: score of 13-15.
• Moderate: score of 9-12.
• Severe: score of 8 or less.

Perform these routinely to track progress or regression. You’ll likely already have at least one reference score to compare your assessment with.

Tests and Monitoring

In some cases, further imaging and monitoring might be necessary. Your traditional options for imaging with a head injury are CT or MRI. You may also need to set up an intracranial pressure (ICP) monitor to track tissue swelling and to help prevent further brain damage.

Head Injury Treatment

After a diagnosis is established, proceed with the proper treatment plan based on the severity of the injury. Treatment for mild head injury is minimal — short-term observation and OTC pain killers with follow-up if symptoms worsen. However, most moderate to severe closed head injuries and penetrating head injuries will need further care.

Medication

Prescription medication can help patients with a variety of symptoms.

• Anti Convulsants: to prevent seizures.
• Muscle Relaxants: to reduce muscle spasms.
• Anti Coagulants: to prevent blood clots.
• Coma-Inducing Drugs: to reduce strain on oxygen flow to the brain.
• Diuretics: to reduce ICP by lowering the amount of fluid.
• Anti-Depressants and Anti-Anxiety Medication: to stabilize mood and decrease feelings of panic.

Surgery

Often surgery is necessary with moderate to severe closed head injuries or a penetrating head injury. Possibilities you might encounter include:

• Removing hematomas.
• Debridement of dead or damaged tissue.
• Repairing skull fractures.
• Relieving pressure in the skull.
• Stopping a brain bleed.

Rehabilitation

Once the patient has come through initial treatment, most of those with moderate to severe closed head injuries or a penetrating head injury will need some form of rehabilitation services. They may need referrals or extended care from a:

• Physical Therapist.
• Speech Therapist.
• Occupational Therapist.
• Counselor.
• Neuropsychologist.
• Physiatrist.
• Social Worker.
• Traumatic Brain Injury or Rehabilitation Nurse.

In Summary

Upon initial examination, collect all pertinent information and assess the patient’s GCS score. A 13-15 indicates a mild head injury. Keep for short-term observation and send home with care instructions. A score of 12 or below implies a moderate to severe head injury and will need imaging and monitoring. The most critical aspect of treatment in these instances is preventing further injury and secondary damage.

Bibliography

Adnan, Cabral, Kufera, Haron, Haase, Lottenberg, et al. (2019). Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas. National Library of Medicine.

Discharge Instructions for Concussion. Saint Luke’s.

Gaines, Kathleen. (2022). Understanding and Interpreting the Glasgow Coma Scale. Full Beaker, Inc.

What is Post-Concussion Syndrome (PCS)? Concussion Legacy Foundation.

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