# Head Injuries



## CobraIV (Dec 18, 2011)

I was reading somewhere for a fall victim who has cerebral spinal fluid leaking out there ears it mite not be a basilar skull fracture vs a severe head injury, but isnt a basilar skull fracture a severe head injury??? 


Also another "?" if an adult patient gets hit in the head and has an altered mental status how would you treat them if there refusing care?


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## DesertMedic66 (Dec 18, 2011)

As for the second question they are not able to refuse care if they have an altered mental status (per protocols)


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## mycrofft (Dec 18, 2011)

*Ok*

Any skull fracture is serious. Anything causing CSF to leak is extra serious. Basil (as in fractured at the base, where the spine attaches at the foramen magnum) skull fractures are particularly dangerous because they can be caused by a fall with no obvious impact on the head. 

Anytime the pt is confused or otherwise unable to render informed consent, they should be treated. If they resist, follow your protocols, but having law enforcement on hand helps. Be calm, be persuasive, stay nearby. As you can imagine, "going hands-on" as they say can lead to injury to you, and exacerbate the patient's injuries as well.

Good luck starting out on the EMS field.


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## Thriceknight (Dec 18, 2011)

mycrofft said:


> Any skull fracture is serious. Anything causing CSF to leak is extra serious. Basil (as in fractured at the base, where the spine attaches at the foramen magnum) skull fractures are particularly dangerous because they can be caused by a fall with no obvious impact on the head.
> 
> Anytime the pt is confused or otherwise unable to render informed consent, they should be treated. If they resist, follow your protocols, but having law enforcement on hand helps. Be calm, be persuasive, stay nearby. As you can imagine, "going hands-on" as they say can lead to injury to you, and exacerbate the patient's injuries as well.
> 
> Good luck starting out on the EMS field.



Totally what he said! ^^^^^^


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## mycrofft (Dec 18, 2011)

*Danged mac mini!*

"Basal", not "Basil".  And not "basilar" either.
Unless the pt is named Basil.


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## bigdogems (Dec 18, 2011)

If I find CSF coming out of the ear the exact cause isn't my first though. Getting my pt to a trauma center in the fastest (safest) way possible is.


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## mycrofft (Dec 18, 2011)

*In that case, C spine IS a real need.*

Common cause of this not commonly diagnosed trauma is landing hard on locked legs or an unbent spine, so cervical vertebrae ram into the base. Area of direct impact includes that governing vital signs and consciousness.
Had a guy who slid vertically down 16 stories. Broke both femurs, etc etc, and the 1st CV was mashed into the base of the skull, per the ER the next day I was on.


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## usafmedic45 (Dec 18, 2011)

> I was reading somewhere for a fall victim who has cerebral spinal fluid leaking out there ears it mite not be a basilar skull fracture vs a severe head injury, but isnt a basilar skull fracture a severe head injury???



I think you misunderstood what was written.  However, it is possible to have a skull fracture without related brain injuries.  That said, the main problem with a field diagnosis of CSF coming out of the ears is that not all that pours out of the ears is CSF.  Just as Battle's sign is a poor indicator of the presence or absence of basilar injuries (it takes up to several hours for it to appear in all but the most severe of injuries).  However, err on the side of caution and if you see what you suspect is CSF coming out of the ears, don't screw around and get the patient to the hospital. 



> Any skull fracture is serious.



At least so far as we are concerned in the field.



> Basil (as in fractured at the base, where the spine attaches at the foramen magnum) skull fractures are particularly dangerous because they can be caused by a fall with no obvious impact on the head.


They can also be caused without a fall.  The most common cause of basilar skull fractures are negative acceleration trauma, without or without an _obvious_ impact to the face or skull.  Simply put, the best example of this is the fatal injury to Dale Earnhardt.  He had a bruise over his left collarbone from where his chin impacted his chest.  This loaded his mandible and the force was transmitted to the temporomandibular joints which resulted in the skull fracture which killed him.  The force of his head (and the helmet) moving forward and back violently as it negatively accelerated at a rate different from that of his restrained thorax also likely put tension on the ligaments at the base of the skull (the alar, transverse, etc) which hold the atlanto-occipital joint together and further helped progress the fracture lines into the occipital bone.

I would also like to point out that not all basilar skull fractures involve the rear portion of the skull (the posterior cranial fossa to use the technical term).  This is a common misconception among non-physicians without a strong background in injury biomechanics.


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## mycrofft (Dec 18, 2011)

*Ah, thanks. Never taught aught except the "posterior cranial fossa".*

So a good strong punch to the jaw could also initiate a basal skull fx? Wonder how many minor ones of those go either undiagnosed or belatedly diagnosed?

WIKI says it can also be in the ethmoid and sphenoid bones; basically anything above the mandible and not in the globular cranium? And yes it can also be spelled "basilar". (Sorry, Rathbone).

A neighbor's adult daughter with cerebral palsy pitched forwards out of her wheelchair and broke her nose, was released from the hospital that afternoon, and was found dead in bed the next morning with battle signs. Sounds like....


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## mycrofft (Dec 18, 2011)

*We've all missed the gist of the OP though, right?*

 Restated, is there any injury, presumably cranial, that could produce CSF without a skull fracture?

I'd say not very likely. Maybe a penetration to the spinal column, but how much fluid would you see?

Sidebar: took care of a fellow who shed CSF on the tarmac street where later I took a running course. The blood washed away right off, but there was a darkening of the asphalt which lasted a month later that autumn; I'm guessing the CSF.


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## Underoath87 (Dec 24, 2011)

mycrofft said:


> *Restated, is there any injury, presumably cranial, that could produce CSF without a skull fracture?*
> 
> I'd say not very likely. Maybe a penetration to the spinal column, but how much fluid would you see?
> 
> Sidebar: took care of a fellow who shed CSF on the tarmac street where later I took a running course. The blood washed away right off, but there was a darkening of the asphalt which lasted a month later that autumn; I'm guessing the CSF.



Puncture or rupture of the eardrum.


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## Dwindlin (Dec 25, 2011)

Underoath87 said:


> Puncture or rupture of the eardrum.



There is no CSF in the middle ear. You would have to rupture no only the tympanic membrane but also the round or oval window. Even then that fluid isn't CSF.


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## RocketMedic (Dec 26, 2011)

That being said, OP, there's no good way to judge the current or (especially) the _eventual_ degree of insult to the brain, even in an ER. If you have a plausible mechanism of injury, a complaint, or *especially* altered mentation, you should suspect a potential injury. 

TBI does not always manifest immediately. Personally, I was bounced across the interior of an MRAP by an IED and hit a stretcher pole with my helmet. Aside from a sore neck, ringing ears, and a bruised shoulder, I was fine- at the time. But two days later, I was nauseous and dizzy for no good reason, and it took a day to resolve, and it hasn't come back since. According to our PA, I received a decent concussion and didn't even realize it.

In any prehospital context, a skull fracture, regardless of etimology, should be considered a very strong indicator of brain injury and transported to an appropriate facility. A mandibular fracture or soft-tissue injury to the face is less of a threat, but it still needs to be considered.


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## Melclin (Dec 26, 2011)

CobraIV said:


> I was reading somewhere for a fall victim who has cerebral spinal fluid leaking out there ears it mite not be a basilar skull fracture vs a severe head injury, but isnt a basilar skull fracture a severe head injury???
> 
> 
> Also another "?" if an adult patient gets hit in the head and has an altered mental status how would you treat them if there refusing care?



I think the issue here is traumatic brain injury VS skull fracture. As, of course, you would be aware, the brain and the skull are two different things and it is entirely possible to have one of either without the other. 

A spot of googling should do the trick old boy.


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## mycrofft (Dec 26, 2011)

*Parsing to field usefulness:*

If anything is coming out of the ears, treat for cervical, cranial and intra-cranial injury, support vitals, get to hospital. ("Intra" might also include "trans" if the fx has communicated to ears, nasopharynx, sinus. Your airway selection and placement protocols may be affected).
Also, potentially you could see CSF behind an intact tympanum. Otoscopes are OK tools once you learn what you are looking at.

Used to hear EMT trainers going on about "how to tell if that's CSF", but it does not pragmatically affect field treatment beyond the steps I listed above.  

A darn good CLINICAL/SURGICAL article:
http://www.utmb.edu/otoref/grnds/CSF-leaks-050112/CSF-leaks-050112.htm

And the territory:







For ear leaks, see  TEMPORAL bone. You can see as USAF noted above how trauma to the mandible can transmit to the temporal bone. Norman Maclean in his story "The Ranger, the Cook, and a Hole in the Sky", graphically describes the subjective sensation of such an injury; the story is in his collection, "A River Runs Through It."


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