Head Trauma: First Response Essentials
(warning: this article contains graphic images)
According to the latest AIHW National Hospital Morbidity Database (2020-2021), traumatic brain injury leads to over 23,500 hospitalisations in Australia each year. These life-altering events can occur anywhere - from busy city streets to remote outback locations - and the first minutes of recognition and care can profoundly impact recovery outcomes. Whether you're a professional first responder or someone committed to emergency preparedness, understanding how to manage head trauma effectively is a critical capability to have in your skill bank.
Head injuries present unique challenges. While the initial trauma - what medical professionals call the "primary injury" - happens in an instant, it's the prevention of "secondary injury" that first responders can influence. This secondary damage occurs in the minutes and hours following the initial trauma, and with proper knowledge and quick action, its effects can be minimised.
This guide builds on the Rescue Trauma & Casualty Care (RTACC) Manual in conjunction with the latest ANZCOR guidelines to provide practical, evidence-based approaches to head trauma management. You'll learn to recognize critical signs and symptoms, and master the essential interventions that can make a significant difference in patient outcomes.
Let’s dive in, TacMed Nation!
Understanding Head Trauma
Head trauma, also known as traumatic brain injury (TBI), occurs when an external force damages the brain. These life-threatening injuries are commonly caused by direct impact to the head or face, acceleration/deceleration forces, or penetrating injuries. Rapid recognition and early management significantly influence patient outcomes.
In head trauma cases, there are two distinct phases of injury, which RTACC identifies as primary and secondary injury.
Primary Injury:
- Occurs at the moment of impact
- Results in immediate damage to brain tissue
- Examples include skull fractures, brain contusions, and torn blood vessels
- Cannot be reversed by first responders, but proper care can prevent further complications
Secondary Injury:
- Complications that develop after the initial trauma
- Can occur minutes to hours after the primary injury
- Examples include obstructed airway, lack of oxygen to the brain, low blood pressure/shock, brain swelling, seizures, and declining consciousness
- Can be prevented or minimized through adequate prehospital care
Understanding these two phases of injury helps first responders focus on preventing further damage through proper assessment and early intervention.
Initial Assessment
When approaching a casualty with suspected head trauma, detecting changes in their level of consciousness is essential - this can indicate the severity of any injury to the brain. Using the AVPU scale, responders can quickly assess the extent of injury and monitor for any improvement or deterioration in the casualty's condition.
The AVPU Scale For Head Trauma Assessment
A = Alert
- Casualty is fully awake
- Oriented to surroundings
- Responds to verbal communication
- Attempt to keep the patient talking to monitor their condition
When you approach a patient and say "Hello, I'm here to help," an alert patient will orient towards your voice, make eye contact, and engage in conversation. They demonstrate awareness of their surroundings and respond appropriately to questions. These behaviours represent the highest level of consciousness and an “A” on the AVPU scale.
V = Response to Voice
- Casualty responds when spoken to
- May be confused or disoriented
- Requires verbal stimulation to respond
- Attempt to keep the patient awake and talking to continually reassess their condition
A patient who responds to voice may not immediately react when you enter their space, but when you speak to them, they show some response. This might be opening their eyes, turning towards you, or making sounds, though they may seem confused or drowsy. This represents "V" on the AVPU scale.
P = Responds to Pain (Time Critical)
- Only responds to painful stimuli
- Requires immediate medical intervention
- Urgent transport is needed
If there's no response to voice, we check for a response to Pain. This involves applying a stimulus like a trapezius squeeze. The patient might move, groan, or try to pull away from the painful stimulus, but they won't open their eyes or speak to you. This represents "P" on the AVPU scale - the patient needs urgent medical care.
U = Unresponsive (Time Critical)
- No response to voice or pain
- Highest priority for medical care
- Immediate transport required
An Unresponsive patient shows no response at all - not to your voice, not to painful stimuli. They remain completely unresponsive to any stimulus. This "U" on the scale represents the lowest level of consciousness and is the most time-critical situation, requiring immediate medical intervention.
Time is critical in head trauma. Your initial AVPU assessment guides the urgency and level of care needed - from monitoring an alert patient to immediate intervention for those unresponsive. Let's examine the essential steps in managing these injuries effectively.
Immediate Management Priorities
When managing head trauma patients, rapid assessment should lead to decisive action. Any loss of consciousness, even momentarily, requires immediate medical attention via ambulance. As ANZCOR advises, "if there has been a loss of consciousness or altered consciousness at any time, no matter how brief."
For time-critical head trauma patients (‘P’ and ‘U’ on the AVPU scale), first responders should focus on these key interventions:
Airway Management
Your priority is maintaining an open airway. As ANZCOR states: "protect the neck whilst maintaining a clear airway." Remember - all head injuries should be treated as having a potential neck injury until cleared by a medical professional. So, how do we do that?
- If the patient is conscious, reassure them and help them to remain still.
- Unconscious patients should be moved carefully, with little twisting.
- Gently move the head into a neutral position.
- Try jaw thrust manoeuvre to open the airway first, before tilting the head.
Bleeding Control
Managing external bleeding is a critical priority. As ANZCOR states, "If bleeding is severe or life-threatening, controlling the bleeding takes priority over airway and breathing interventions." For head injuries, pay particular attention to scalp wounds, which can bleed profusely due to the head's rich blood supply.
Bleeding Control Steps:
- Use personal protective equipment if available
- Apply direct pressure to the wound site and hold the pressure until medical help arrives.
- If there is also severe, life-threatening bleeding on a limb, do not hesitate to apply an approved arterial tourniquet. Place it high and tight on the injured limb, following the manufacturer's guidelines.
- If the patient isn’t already, have them lay down to avoid any further damage from collapsing.
Here at TacMed Australia, we are passionate about bleeding control. Expand your knowledge with these related articles from the TacMed Australia Learning Centre:
- Life-Saving Decisions: Your Guide to Bleeding Control Equipment
- Wound Packing 101: A Critical Skill for First Responders
Cardiopulmonary Resuscitation.
The criteria for starting resuscitation are clear: when a person is both unresponsive and not breathing normally, first responders must begin CPR. If an emergency defibrillator is available, it should be applied as soon as possible. As ANZCOR notes, "The time to defibrillation is a key factor that influences survival," with approximately 10% reduction in survival for every minute defibrillation is delayed.
An Automated External Defibrillator (AED) should only be used on someone who is unresponsive and not breathing normally. Continue CPR until the AED is turned on and pads are attached, then follow the AED's voice prompts. Remember that CPR alone cannot save someone in cardiac arrest due to Ventricular Fibrillation - early defibrillation is essential.
Patient Transport
All head injury patients should be assessed by a healthcare professional - even those who appear to have only minor injuries. ANZCOR advises all patients with suspected head trauma "should be assessed by a health care professional before continuing with sport or other activity."
For time-critical patients, rapid transport is essential. The current RTACC reports that current standards aim to have all head trauma casualties in hospital for CT scan within one hour of injury. This allows early detection of serious injuries and prompt treatment of any complications.
Remember:
- Patients who have experienced any loss of consciousness, even briefly, need urgent hospital assessment
- A patient's condition can deteriorate rapidly, even hours after a seemingly minor head injury
- Early medical intervention gives the best chance of positive outcomes
- Always call an ambulance if you're unsure about the severity of a head injury
Special Considerations
While managing head trauma patients, several specific situations require additional attention:
Cervical Spine Protection
As described in the Immediate Management Priorities section of this article, all head trauma patients should be treated as having a potential neck injury until proven otherwise. Keep the patient as still as possible and maintain spinal alignment during any necessary movement. If they're conscious, encourage them to remain still and avoid turning their head.
Seizures
Head trauma patients may experience seizures. If a seizure occurs:
- Ensure the area around them is clear of hazards
- Protect their head from injury
- Time the seizure if possible
- Never attempt to restrain them or put anything in their mouth
- Once the seizure stops, place them in the recovery position while protecting their spine
Combative Patients
Head trauma can cause confusion and agitation. When dealing with combative patients:
- Ensure your own safety first
- Speak calmly and clearly
- Minimise the number of people around the patient
- Remember that combativeness may be a sign of serious brain injury
- Never attempt to physically restrain them unless necessary for immediate safety
Environmental Considerations
Australia's climate and geography always presents unique challenges in prehospital care:
- In hot conditions, keep your casualty cool and out of the sun to prevent overheating and further complications.
- In remote locations, initiate transport early rather than monitoring and risking the onset of deterioration.
- Consider helicopter evacuation for remote and austere incidents
Extended Assessment
While initial assessment using AVPU gives us critical information about a patient's condition, there are two additional neurological assessments that provide valuable insights: the Glasgow Coma Scale (GCS) and Pupil Response.
Glasgow Coma Scale
This internationally recognized scale has been used clinically for over 40 years. It evaluates three key aspects:
- Eye opening (scored out of 4)
- Verbal response (scored out of 5)
- Best motor response (scored out of 6)
The scores are added together, to establish the following results:
· 15/15 indicates fully conscious
· Less than 12/15 typically requires close airway monitoring
· Below 8/15 indicate the need for urgent advanced airway management.
· 3/15 indicates totally unresponsive.
Figure 6.2: Glasgow COMA Scale from the RTACC Manual
Pupil Assessment
Regular pupil checks provide crucial information about brain function. In normal conditions, pupils should be equal in size and both pupils should constrict promptly when a light is shone in either eye.
Key Changes to Watch For:
- Both pupils dilated and unresponsive - may indicate serious head injury, drugs or death
- Both pupils dilated but react to light – fear, excitement
- Both pupils pin-point small - may indicate other medical conditions requiring assessment
- Single pupil enlarged and not responding - time-critical sign of potential brain injury
- Unequal pupils - may indicate disruption of nerve pathways in the head
To properly assess pupils:
- Reduce ambient light if possible
- Compare both pupils - they should be equal in size
- Document pupil size (pin-point, mid-size, or dilated)
- Ask conscious patients to focus on a distant object
- Using a pen torch:
- Shine the light from cheek to first eye for 3-4 seconds
- Watch for pupil constriction
- Move light back to cheek and watch for dilation
- While lighting the first eye again, observe the second eye's response
- Repeat the entire process on the second eye
- Regularly reassess if consciousness level changes
Note: for unconscious patients, support your hand on their forehead while carefully lifting their eyelids to assess pupil response.
Head trauma requires immediate action. While the initial injury has already occurred, quick recognition and proper care can prevent the devastating effects of secondary injury. The AVPU scale provides rapid patient assessment, guiding your immediate interventions and transport decisions.
From professional first responders to prepared community members, the message is clear: all head injuries require medical assessment, no matter how minor they may appear. However, if you are first on scene and awaiting patient transportation, there are basic life saving measures and assessment tools that you can do at the time of injury that can significantly improve your patient’s outcome.
Remember, TacMed Nation: Stay current with your first response capabilities, regularly review ANZCOR First Aid guidelines and keep your Trauma Kit stocked and well maintained. Head injuries can occur anywhere, at any time - your knowledge and preparedness could save a life.
Stay safe,
Team TacMed.
Note: Always follow current ANZCOR guidelines and seek immediate emergency medical care in any trauma situation. This information supplements but does not replace proper first aid training.
References:
AIHW (2021a) [Australian Institute of Health and Welfare]. Health service use for patients with traumatic brain injury, Canberra: AIHW, Australian Government.
RTACC Manual (2022) The ATACC Group Ltd. Chapter 6: Head Trauma and Other Serious Injuries p92-97
ANZCOR Guideline 9.1.4. Head Injury
ANZCOR Guidelines – Basic Life Support