Injuries Related to Vehicular Accidents

8/2/2019 Injuries Related to Vehicular Accidents

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Injuries related to Vehicular accidents:

Whiplash

Sprains and Strains

Shoulder and Neck Pain

Headaches

Numbness

Dizziness & Vertigo

Lower Back Pain

Pain in Legs or Arms

Car Seat-belt Injury

Whiplash Overview

Whiplash is a nonmedical term used to describe neck pain following an injury to the soft tissues of your

neck (specifically ligaments, tendons, and muscles). It is caused by an abnormal motion or force applied

to your neck that causes movement beyond the neck's normal range of motion.

Whiplash happens in motor vehicle accidents, sporting activities, accidental falls, and assault.

The term whiplash was first used in 1928, and despite its replacement by synonyms (such as

acceleration flexion-extension neck injury and soft tissue cervical hyperextension injury), it continues to

be used to describe this common soft tissue neck injury. Your doctor may use the more specific terms

of cervical sprain, cervical strain, or hyperextension injury.

Whiplash Causes

The most frequent cause of whiplash is a car accident. The speed of the cars involved in the accident or

the amount of physical damage to the car may not relate to the intensity of neck injury; speeds as low as

15 miles per hour can produce enough energy to cause whiplash in occupants, whether or not they wear

seat belts.

Other common causes of whiplash include contact sport injuries and blows to the head from a falling

object or being assaulted.

Repetitive stress injuries or chronic strain involving the neck (such as using your neck to hold the

phone) are a common, non-acute causes.

Child abuse, particularly the shaking of a child, can also result in this injury as well as in more serious

injuries to the child's brain or spinal cord.

Whiplash Symptoms

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These signs and symptoms may occur immediately or minutes to hours after the initial injury; the sooner

after the injury that symptoms develop, the greater the chance of serious damage.

Neck pain

Neck swelling

Tenderness along the back of your neck

Muscle spasms (in the side or back of your neck)

Difficulty moving your neck around

Headache

Pain shooting from your neck into either shoulder or arm

When to Seek Medical Care

The best time to call your doctor is immediately after the injury. If the patient cannot determine whether an

emergency department visit is needed for the symptoms, then contact the doctor and ask for advice. If the

doctor is unavailable at the time of the injury, then call 911 for transport to the emergency department.

The risks associated with a possible neck injury are far too great to attempt to diagnose and self -treat.

See a doctor and have the patient's neck braced to keep the head from moving during transport.

Depending upon the severity of a car accident, emergency medical personnel may take the patient to an

emergency department immediately. In this case, a cervical collar will be placed around the patient's

neck, and the body will be strapped to a long, firm board to prevent any movements until a doctor sees

the patient.

With less severe car accidents, sports injuries, or other accidental injuries, emergency medical services

may or may not be involved in the patient's pre-hospital care. You should call 911 emergency medical

services if the patient develops any of the following symptoms shortly after the injury:

Neck pain

Pain in either or both arms

Shoulder pain

Headache

Dizziness

Weakness, tingling, or loss of function in the arms or legs

Exams and Tests





















Apply ice to the neck for 20 minutes at a time each hour for the first 24 hours while awake. Do not

apply ice directly to the skin. Place a towel between the ice and the neck. Continue to use ice therapy

until the pain stops. (After you see the doctor, follow his or her directions for ice therapy.)

Take acetaminophen for pain relief or ibuprofen for anti-inflammatory action. Avoid ibuprofen if you

have a past medical history of gastritis, duodenitis, peptic ulcer disease, reflux, or other stomach

problems

Medical Treatment

The doctor most likely will recommend a treatment plan including a mixture of the following:

Neck massage

Neck rest

Bed rest

Ice therapy

Heat therapy

Oral pain relievers and muscle relaxers

Immobilization of the neck with a soft cervical collar (only a minimal benefit if any at all)

Early range of motion exercises combined with heat therapystarting 72 hours after the injury to restore

flexibility

Avoidance of excessive neck strain for the next week and then increased activity as tolerated in thefollowing weeks

Sprains and Strains Overview

The body is meant to move. Muscles allow that movement to happen by contracting and making joints

flex, extend and rotate. Muscles attach on each side of the joint to bone by thick bands of fibrous tissue

called tendons. When a muscle contracts, it shortens and pulls on the tendon, which allows the joint to go

through a range of motion.

A strain occurs when the muscle tendon unit is stretched or torn. The most common reason is the

overuse and stretching of the muscle. The damage may occur in three areas:

The muscle itself may tear.

The area where the muscle and tendon blend can tear.

The tendon may tear partially or completely (rupture).

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Joints are stabilized by thick bands of tissue called ligaments which surround them. These ligaments

allow the joint to move only in specific directions. Some joints move in multiple planes; therefore, they

need more than one group of ligaments to hold the joint in proper alignment. The ligaments are anchored

to bone on each side of the joint. If a ligament is stretched or torn, the injury is called a sprain.

Sprains and Strains Causes

Sprains and strains occur when the body is put under stress. In these situations, muscles and joints are

forced to perform movements for which they are not prepared or designed to perform. An injury can occur

from a single stressful incident, or it may gradually arise after many repetitions of a motion.

Sprains and Strains Symptoms

The first symptom of a sprain or strain injury is pain. Other symptoms, such as swelling and spasm, can

take time (from minutes to hours) to develop.

Pain is always a symptom that indicates that there is something wrong with the body. It is the message

to the brain that warns that a muscle or joint should be protected from further harm. In work, exercise,or sport, the pain may come on after a specific incident or it may gradually progress after many

repetitions of a motion.

Swelling almost always occurs with injury, but it may take from minutes to hours to be noticed. Any

time fibers of a ligament, muscle, or tendon are damaged, some bleeding occurs. The bleeding (such

as bruising on the surface of the skin) may take time to be noticed.

Because of pain and swelling, the body starts to favor the injured part. This may cause the muscles

that surround the injured area to go into spasm. Hard knots of muscle might be felt near the site of the

injury.

The combination of pain, swelling, and spasm causes the body to further protect the injured part,

which results in difficulty with use. Limping is a good example of the body trying to protect an injured

leg.

Sprains and Strains Treatment

Self-Care at Home

Initial treatment for sprains and strains should occur as soon as possible. Remember RICE!

Rest the injured part. Pain is the body's signal to not move an injury.

Ice the injury. This will limit the swelling and help with the spasm.

Compress the injured area. This again, limits the swelling. Be careful not to apply a wrap so tightly that

it might act as a tourniquet and cut off the blood supply.

Elevate the injured part. This lets gravity help reduce the swelling by allowing fluid and blood to drain

downhill to the heart.










































Over-the-counter pain medication is an option. Acetaminophen (Tylenol) is helpful for pain, but ibuprofen

(Motrin, Advil) or naproxen (Aleve) might be better because these medications relieve both pain and

inflammation. Remember to follow the guidelines on the bottle for appropriate dose of the medicine,

especially for children and teens. Underlying medical conditions or use of other prescription medicines

may limit the use of over the counter pain medications.

Medical Treatment

Sprains and strains can usually be treated with home therapy using the RICE interventions. However, if

the injury is more severe, your care provider may suggest splinting or casting to rest the injured joint. In

some cases, operations are required to fix complete tears of muscles or tendons to allow complete return

of function and to allow those muscles to do their job of moving the body. Significant tears of ligaments

that stabilize joints also may need repair, but again, most are treated with short-term immobilization and

early return to activity. Sometimes, resting the injury requires some help. Slings for arm injuries or

crutches for leg injuries can be used, in addition to a variety of removable splints to protect the injured

area from further damage and movement. Resting also helps relieve some of the muscle spasm

associated with the injury.

Occasionally, if the injury is especially severe, the physician may want to use a nonremovable splint

made of plaster or fiberglass. Although the splint may look like a cast, it doesn't have plaster or

fiberglass completely encircling the injured area. Instead, by only going partially around an injury, there

is some room to allow for swelling that may occur during the next few days.

Surgery

If the need for an operation is considered, an orthopedic (or bone) specialist is likely to become

involved. Many times these decisions are made over a period of a few days and not immediately,

unless there is concern about the stability of a joint or damage to an artery or nerve.

Shoulder and Neck Pain Overview

Your neck and shoulders contain muscles, bones, nerves, arteries, and veins, as well as many

ligaments and other supporting structures. Many conditions can cause pain in the neck and

shoulder area. Some are life-threatening (such as heart attack and major trauma), and others are

not so dangerous (such as simple strains or contusions).

Shoulder and Neck Pain Causes

The most common cause of shoulder pain and neck pain is injury to the soft tissues, including the

muscles, tendons, and ligaments within these structures. This can occur from whiplash or other injury

to these areas. Degenerative arthritis of the spine in the neck (cervical spine) can pinch nerves that

can cause both neck pain and shoulder pain. Degenerative disc disease in the neck (cervical

spondylosis) can cause local neck pain or radiating pain from disc herniation, causing pinching of

nerves (cervical radiculopathy). Abnormal conditions involving the spinal cord, heart, lungs, and someabdominal organs also can cause neck and shoulder pain. Here are some examples:

Broken collarbone: Falling on your outstretched arm can cause your collarbone to break. This is

particularly common when cyclers fall off of their bicycles.

Bursitis: A bursa is a sac over the joints to provide a cushion to the joints and muscles. These bursae

can become swollen, stiff, and painful after injuries.

Heart attacks: Although the problem is the heart, heart attacks can cause shoulder or neck pain,

known as "referred" pain.




































































































Broken shoulder blade: An injury to the shoulder blade usually is associated with relatively forceful

trauma.

Rotator cuff injuries: The rotator cuff is a group of tendons that support the shoulder. These tendons

can be injured during lifting, when playing sports with a lot of throwing, or after repetitive use over a

long time. This can lead to pain with motion of the shoulder due to shoulder impingement syndrome

and eventually to a chronic loss of range of motion of the shoulder (frozen shoulder).Shoulder or A-C separation: The collarbone (clavicle) and shoulder blade (scapula) are connected by

ligaments. With trauma to the shoulder, these ligaments can be stretched or torn.

Whiplash injury: Injury to the ligamentous and muscular structures of the neck and shoulder can be

caused by sudden acceleration or deceleration, as in a car accident. This can also cause muscle

spasms in the neck and shoulder areas.

Tendonitis: The tendons connect the muscles to the bones. With strain, the tendons can become

swollen and cause pain. This is also referred to as tendinitis.

Gallbladder disease: This can cause a pain referred to the right shoulder.

Any cause of inflammation under the diaphragm can also cause referred pain in the shoulder.

Shoulder and Neck Pain Symptoms and Signs

Pain: All pain seems sharp, but pain can also be described as dull, burning, crampy, shocklike, or

stabbing. Pain can lead to a stiff neck or shoulder and loss of range of motion. Headache may result.

The character of each symptom is important to your doctor because the particular features can be

clues to the cause of your pain.

Weakness: Weakness can be due to severe pain from muscle or bone movement. The nerves that

supply the muscles, however, also could be injured. It is important to distinguish true weakness

(muscle or nerve damage) from inability or reluctance to move because of pain or inflammation.

Numbness: If the nerves are pinched, bruised, or cut, you may not be able to feel things normally. This

may cause a burning or tingling sensation, a loss of sensation, or an altered sensation similar to

having your arm "fall asleep."

Coolness: A cool arm or hand suggests that the arteries, veins, or both have been injured or blocked.This may mean that not enough blood is getting into the arm.

Color changes: A blue or white tinge to the skin of your arm or shoulder is another sign that the

arteries or veins could have been injured. Redness can indicate infection or inflammation. Rashes may

be noted as well. Bruising may be evident.

Swelling: This may be generalized to the whole arm or may be localized over the involved structures (a

fracture area or an inflamed bursa, for example). Muscle spasms or tightness may simulate actual

swelling. Dislocation or deformity may cause a swollen appearance or, paradoxically, a sunken area.

Deformity: A deformity may be present if you have a fracture or a dislocation. Certain ligament tears

can cause an abnormal positioning of the bony structures.


If pain or other symptoms start to worsen, call your doctor or immediately go to a hospital emergency

department.

For milder cases, basic home-care measures (see below) are adequate until your doctor can see you.

In many cases, simple injuries, such as strains and bruises, heal themselves and do not require an

office visit.





































For persisting pain in the shoulder or neck, an evaluation by a health-care professional is appropriate.

If you have severe or worsening pain, weakness, numbness, coolness, deformity, or color changes,

you should go to a hospital emergency department immediately.

If you develop a high fever (temperature >102.5 F), severe headache, chest pain, shortness of breath,

dizziness, nausea, or sweatiness, or if you develop the sudden onset of numbness or weakness,

particularly on one side of the body, call 911 for emergency services to go to the nearest emergencydepartment by ambulance.

Shoulder and Neck Pain Treatment

Self-Care at Home

Minor injuries that have only slight pain can be treated at home. If the source of the pain and the cause of

the pain are not known, or if symptoms suggest you might have a more serious condition, you should

contact your doctor while initiating basic care measures.

Rest: Use the injured area as little as possible for the first two to three days, then slowly begin to

exercise the injured area. This speeds recovery.

Ice: Place the ice in a plastic bag, wrap the bag with a towel, and then apply to the injured area for 15-

20 minutes every hour. Directly applying ice can damage the skin.

Elevation: Elevation of the injured area above your heart helps the swelling go down. This reduces

your pain. Use pillows to prop yourself up.

Pain control: Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can help control swelling and pain.

Heat: Do not apply heat in the first week after an injury because it can increase the swelling in the

injured area and worsen your pain.

Medical Treatment

A treatment plan will be developed after a complete history and physical examination (and any tests, ifindicated). Treatment options vary for each condition. Clearly, a simple strain is treated far differently than

a heart attack.

If you have a minor sprain or strain, then you can expect a combination of the following treatments:

o Pain medications: It may take several days to settle the pain down using acetaminophen (Tylenol)

with or without an anti-inflammatory medicine such as ibuprofen (Advil or Motrin) or naproxen

(Aleve). Stronger narcotic-containing medicines are usually not necessary, but your doctor may

provide these for the first few days.

o Immobilization: This may be accomplished possibly using a splint, cast, or sling. It is very important

to follow your doctor's instructions regarding the use of these devices, particularly when it is

advised to discontinue the use and begin moving the area.o Instructions: It's best to rest and elevate the injured area. Continued use of the injured area may not

necessarily make the injury worse, but it can prolong the symptoms. In most cases, limited use is

acceptable within normal ranges of motion and without weight or strain.

o Hospital stay: If you are more severely injured, you may need to be admitted to the hospital for

further testing or may be referred to an orthopedist (bone and joint specialist) for care.

Low Back Pain Overview






























































Picture of a herniated lumbar disc, a common cause of sciatica

o Spondylosis occurs as intervertebral discs lose moisture and volume with age, which decreases the

disc height. Even minor trauma under these circumstances can cause inflammation and nerve root

impingement, which can produce classic sciatica without disc rupture.

o Spinal disc degeneration coupled with disease in joints of the low back can lead to spinal-canal

narrowing (spinal stenosis). These changes in the disc and the joints produce symptoms and can















be seen on an X-ray. A person with spinal stenosis may have pain radiating down both lower

extremities while standing for a long time or walking even short distances.

o

Cauda equina syndrome is a medical emergency whereby the spinal cord is directly compressed.Disc material expands into the spinal canal, which compresses the nerves. A person would

experience pain, possible loss of sensation, and bowel or bladder dysfunction. This could include

inability to control urination causing incontinence or the inability to begin urination.

Musculoskeletal pain syndromes that produce low back pain include myofascial pain syndromes

and fibromyalgia.

o Myofascial pain is characterized by pain and tenderness over localized areas (trigger points), loss

of range of motion in the involved muscle groups, and pain radiating in a characteristic distribution

but restricted to a peripheral nerve. Relief of pain is often reported when the involved muscle group

is stretched.

o Fibromyalgia results in widespread pain and tenderness throughout the body. Generalized

stiffness, fatigue, and muscle aches are reported.

Infections of the bones (osteomyelitis) of the spine are an uncommon cause of low back pain.

Noninfectious inflammation of the spine (spondylitis) can cause stiffness and pain in the spine that is

particularly worse in the morning. Ankylosing spondylitis typically begins in adolescents and young

adults.

Tumors, possibly cancerous, can be a source of skeletal pain.

Inflammation of nerves from the spine can occur with infection of the nerves with the herpes zoster

virus that causes shingles. This can occur in the thoracic area to cause upper back pain or in the

lumbar area to cause low back pain.


































As can be seen from the extensive, but not all inclusive, list of possible causes of low back pain, it is

important to have a thorough medical evaluation to guide possible diagnostic tests.

Low Back Pain Symptoms

Pain in the lumbosacral area (lower part of the back) is the primary symptom of low back pain.

The pain may radiate down the front, side, or back of your leg, or it may be confined to the low back.

The pain may become worse with activity.

Occasionally, the pain may be worse at night or with prolonged sitting such as on a long car trip.

You may have numbness or weakness in the part of the leg that receives its nerve supply from a

compressed nerve.

o This can cause an inability to plantar flex the foot. This means you would be unable to stand on

your toes or bring your foot downward. This occurs when the first sacral nerve is compressed or

injured.

o Another example would be the inability to raise your big toe upward. This results when the

fifth lumbar nerve is compromised.


The Agency for Healthcare Research and Quality has identified 11 red flags that doctors look for when

evaluating a person with back pain. The focus of these red flags is to detect fractures (broken bones),

infections, or tumors of the spine. Presence of any of the following red flags associated with low back pain

should prompt a visit to your doctor as soon as possible for complete evaluation.

Recent significant trauma such as a fall from a height, motor vehicle accident, or similar incident

Recent mild trauma in those older than 50 years of age: A fall down a few steps or slipping and landing

on the buttocks may be considered mild trauma.











History of prolonged steroid use: People with asthma, COPD, and rheumatic disorders, for example,

may be given this type of medication.

Anyone with a history of osteoporosis: An elderly woman with a history of a hip fracture, for example,

would be considered high risk.

Any person older than 70 years of age: There is an increased incidence ofcancer, infections, and

abdominal causes of the pain.

Prior history of cancer

History of a recent infection

Temperature over 100 F

IV drug use: Such behavior markedly increases risk of an infectious cause.

Low back pain worse at rest: This is thought to be associated with an infectious or malignant cause of

pain but can also occur with ankylosing spondylitis.

Unexplained weight loss

The presence of any of the above would justify a visit to a hospital's emergency department, particularly if

your family doctor is unable to evaluate you within the next 24 hours.

The presence of any acute nerve dysfunction should also prompt an immediate visit. These would

include the inability to walk or inability to raise or lower your foot at the ankle. Also included would be

the inability to raise the big toe upward or walk on your heels or stand on your toes. These might































indicate an acute nerve injury or compression. Under certain circumstances, this may be an acute

neurosurgical emergency.

Loss of bowel or bladder control, including difficulty starting or stopping a stream of urine orincontinence, can be a sign of an acute emergency and requires urgent evaluation in an emergency

department.

If you cannot manage the pain using the medicine you are currently prescribed, this may be an

indication for a reevaluation or to go to an emergency department if your doctor is not available.

Generally, this problem is best addressed with the doctor writing the prescription who is overseeing

your care.

Low Back Pain Exams and Tests

Medical history

Because many different conditions may cause back pain, a thorough medical history will be performed

as part of the examination. Some of the questions you are asked may not seem pertinent to you but

are very important to your doctor in determining the source of your pain.

Your doctor will first ask you many questions regarding the onset of the pain. (Were you lifting a heavy

object and felt an immediate pain? Did the pain come on gradually?) He or she will want to know what

makes the pain better or worse. The doctor will ask you questions referring to the red flag symptoms.

He or she will ask if you have had the pain before. Your doctor will ask about recent illnesses and

associated symptoms such as coughs,fevers, urinary difficulties, or stomach illnesses. In females, the

doctor will want to know about vaginal bleeding, cramping, or discharge. Pain from the pelvis, in thesecases, is frequently felt in the back.

Physical examination

To ensure a thorough examination, you will be asked to put on a gown. The doctor will watch for signs

of nerve damage while you walk on your heels, toes, and soles of the feet. Reflexes are usually tested

using a reflex hammer. This is done at the knee and behind the ankle. As you lie flat on your back, one

leg at a time is elevated, both with and without the assistance of the doctor. This is done to test the

nerves, muscle strength, and assess the presence of tension on the sciatic nerve. Sensation is usually

tested using a pin, paper clip, broken tongue depressor, or other sharp object to assess any loss of

sensation in your legs.

Depending on what the doctor suspects is wrong with you, the doctor may perform an abdominal

examination, a pelvic examination, or a rectal examination. These exams look for diseases that can

cause pain referred to your back. The lowest nerves in your spinal cord serve the sensory area and

muscles of the rectum, and damage to these nerves can result in inability to control urination and

defecation. Thus, a rectal examination is essential to make sure that you do not have nerve damage in

this area of your body.

Imaging


















tone. Very few experts recommend more than a 48-hour period of decreased activity or bed rest. In

other words, get up and get moving to the extent you can.

Medical Treatment

Initial treatment of low back pain is based on the assumption that the pain in about 90% of people will goaway on its own in about a month. Many different treatment options are available. Some of them have

been proven to work while others are of more questionable use. You should discuss all remedies you

tried with your health-care provider.

Home care is recommended for the initial treatment of low back pain. Bed rest remains of unproven

value, and most experts recommend no more than two days of bed rest or decreased activity. Some

people with sciatica may benefit from two to fours days of rest. Application of local ice and heat provide

relief for some people and should be tried.Acetaminophen and ibuprofen are useful for controlling pain.

Many studies have called into question the usefulness of our present treatment of back pain. For any

given person, it is not known if a particular therapy will provide benefit until it is tried. Your doctor may

try treatments known to be helpful in the past.

Low Back Pain Medications

Medication treatment options depend on the precise diagnosis of the low back pain. Your doctor will

decide which medication, if any, is best for you based on your medical history, allergies, and other

medications you may be taking.

Nonsteroidal anti-inflammatory medications (NSAIDs) are the mainstay of medical treatment for the

relief of back pain. Ibuprofen, naproxen, ketoprofen, and many others are available. No

particular NSAIDhas been shown to be more effective for the control of pain than another. However,

your doctor may switch you from one NSAID to another to find one that works best for you.

COX-2 inhibitors, such as celecoxib(Celebrex), are more selective members of NSAIDs. Although

increased cost can be a negative factor, the incidence of costly and potentially fatal bleeding in the

gastrointestinal tract is clearly less with COX-2 inhibitors than with traditional NSAIDs. Long-term

safety (possible increased risk for heart attack or stroke) is currently being evaluated for COX-2

inhibitors and NSAIDs.

Acetaminophen is considered effective for treating acute pain as well. NSAIDs do have a number of

potential side effects, including gastric irritation and kidney damage, with long-term use.

Muscle relaxants: Muscle spasm is not universally accepted as a cause of back pain, and most

relaxants have no effect on muscle spasm. Muscle relaxants may be more effective than a placebo






































(sugar pill) in treating back pain, but none has been shown to be superior to NSAIDs. No additional

benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone.

Muscle relaxants cause drowsiness in up to 30% of people taking them. Their use is not routinely

recommended.

Opioid analgesics: These drugs are considered an option for pain control in acute back pain. The use

of these medications is associated with serious side effects, including dependence, sedation,

decreased reaction time, nausea, and clouded judgment. One of the most troublesome side effects

isconstipation. This occurs in a large percentage of people taking this type of medication for more than

a few days. A few studies support their short-term use for temporary pain relief. Their use, however,

does not speed recovery.

Steroids: Oral steroids can be of benefit in treating acute sciatica. Steroid injections into the epidural

space have not been found to decrease duration of symptoms or improve function and are not

currently recommended for the treatment of acute back pain without sciatica. Benefit in chronic

pain with sciatica remains controversial. Injections into the posterior joint spaces, the facets, may be

beneficial for people with pain associated with sciatica. Trigger point injections have not been proven

helpful in acute back pain. Trigger point injections with a steroid and a local anesthetic may be helpful

in chronic back pain. Their use remains controversial.

Low Back Pain Surgery

Surgery is seldom considered for acute back pain unless sciatica or the cauda equina syndrome is

present. Surgery is considered useful for people with certain progressive nerve problems caused by

herniated discs.

Head Injury Overview

Traumatic head injuries are a major cause of death, and disability but it might be best to refer to the

damage done as traumatic brain injury.

The purpose of the head, including the skull and face, is to protect the brain against injury. In addition to

the bony protection, the brain is covered in tough fibrous layers called meninges and bathed in fluid that

may provide a little shock absorption.

When an injury occurs, loss of brain function can occur even without visible damage to the head. Force

applied to the head may cause the brain to be directly injured or shaken, bouncing against the inner wall

of the skull. The trauma can potentially cause bleeding in the spaces surrounding the brain, bruise the

brain tissue, or damage the nerve connections within the brain.

Caring for the victim with a head injury begins with making certain that the ABCs of resuscitation are

addressed (airway, breathing, circulation). Many individuals with head injuries are multiple trauma victims

and the care of their brain may take place at the same time other injuries are stabilized and treated.



























Skull Fracture

The skull is made up of many bones that form a solid container for the brain. The face is the front part of

the head and also helps protect the brain from injury. Depending upon the location of the fracture, there

may or may not be a relationship between a fractured skull and underlying brain injury. Of note, a

fracture, break, and crack all mean the same thing, that the integrity of the bone has been compromised.

One term does not presume a more severe injury than the others. Fractures of the skull are described

based on their location, the appearance of the fracture, and whether the bone has been pushed in.

Location is important because some skull bones are thinner and more fragile than others. For example,

the temporal bone above the ear is relatively thin and can be more easily broken than the occipital bone

at the back of the skull. The middle meningeal artery is located in a groove within the temporal bone. It is

susceptible to damage and bleeding if the fracture crosses that groove.

Basilar skull fractures occur because of blunt trauma and describe a break in the bones at the base

of the skull. These are often associated with bleeding around the eyes (raccoon eyes) or behind the

ears (Battle's sign). The fracture line may extend into the sinuses of the face and allow bacteria from

the nose and mouth to come into contact with the brain, causing a potential infection.

In infants and young children, whose skull bones have not yet fused together, a skull fracture may

cause a diastasis fracture, in which the bone junctions (called suture lines) widen.

Fractures can be linear (literally a line in the bone) or stellate (a starburst like pattern) and the pattern

of the break is associated with the type of force applied to the skull.

Penetrating skull fractures describe injuries caused by an object entering the brain. This includes

gunshot and stab wounds, and impaled objects to the head.

A depressed skull fracture occurs when a piece of skull is pushed toward the inside of the skull

(think of pressing in on a ping pong ball). Depending upon circumstances, surgery may be required toelevate the depressed fragment.

It is important to know whether the fracture is open or closed (this describes the condition of the skin

overlying the broken bone). An open fracture occurs when the skin is torn or lacerated over the

fracture site. This increases the risk of infection, especially with a depressed skull fracture in which

brain tissue is exposed. In a closed fracture, the skin is not damaged and continues to protect the

underlying fracture from contamination from the outside world.

Intracranial Bleeding

Intracranial (intra=within + cranium=skull) describes any bleeding within the skull. Intracerebralbleeding describes bleeding within the brain itself. More specific descriptions are used based upon

where the blood is located.

Bleeding in the skull may or may not be associated with a skull fracture. An intact skull is no guarantee

that there is not underlying bleeding, or hemorrhage, in the brain or its surrounding spaces. For that

reason, plain X-rays of the skull are not routinely performed.







Epidural, subdural, and subarachnoid bleeding are terms that describe bleeding in the spaces between

the meninges, the fibrous layered coverings of the brain. Sometimes, the terms hemorrhage (bleeding)

and hematoma (blood clot) are interchanged. Because the skull is a solid box, any blood that

accumulates within the skull can increase the pressure within it and compress the brain. Moreover,

blood is irritating and can cause edema or swelling as excess fluid leaks from the surrounding blood

vessels. This is no different than the swelling that can occur surrounding a bruise on an arm or leg. The only difference is that there is no room within the skull to accommodate that swelling.

Subdural Hematoma

When force is applied to the head, bridging veins that cross through the subdural space (sub=beneath

+dura= one of the meninges that line the brain) can tear and bleed. The resultant blood clot increases

pressure on the brain tissue. Subdural hematomas can occur at the site of trauma, or may occur on

the opposite side of the injury (contracoup: contra=opposite + coup=hit) when the brain accelerates

toward the opposite side of the skull and crushes or bounces against the opposite side.

Chronic subdural hematoma may occur in patients who have had atrophy (shrinkage) of their brain

tissue. These include the elderly and chronic alcoholics. The subdural space increases and the

bridging veins get stretched as they cross a much wider distance. Minor or unnoticed injuries can lead

to some bleeding, but because there is enough space in the skull to accommodate the blood, there

may be minimal initial symptoms. Asymptomatic (producing no symptoms) chronic subdural

hematomas may be left to resolve on their own; however, it may require attention if the individual's

mental status changes or further bleeding occurs.

Depending upon the neurologic status of the affected individual, surgery may be required.

Epidural Hematoma

Thee dura is one of the meninges or lining membranes that covers the brain. It attaches at the suturelines where the bones come together. If the head trauma is epidural (epi=outside +dura) the blood is

trapped in a small area and cause a hematoma or blood clot to form. Pressure can increase quickly

within the epidural space, pushing the clot up against the brain and causing significant damage.

While individuals who sustain small epidural hematomas may be observed, most require surgery.

Patients have improved survival and brain function recovery if the operation to remove the hematoma

and relieve pressure on the brain occurs before they have lost consciousness and become comatose.

An epidural hematoma may often occur with trauma to the temporal bone located on the side of the

head above the ear. Aside from the fact that the temporal bone is thinner than the other skull bones

(frontal, parietal, occipital), it is also the location of the middle meningeal artery that runs just beneath

the bone. Fracture of the temporal bone is associated with tearing of this artery and may lead to an

epidural hematoma.

Subarachnoid Hemorrhage

In a subarachnoid hemorrhage, blood accumulates in the space beneath the inner arachnoid layer of

the meninges. The injury is often associated with an intracerebral bleed (see below). This is also the

space where cerebral spinal fluid (CSF) flows and affected individuals can develop















severe headache,nausea, vomiting, and a stiff neck because the blood causes significant irritation to

this meningeal layer. It is the same response that can be seen in patients who have a leaking cerebral

aneurysm or meningitis. Treatment is often observation and controlling the symptoms.

Intraparenchymal Hemorrhage/Intracerebral Hemorrhage/Cerebral Contusion

These terms describe bleeding within the brain tissue itself and can be considered a bruise to the brain

tissue.

Aside from the direct damage to the brain tissue that was injured, swelling or edema is the major

complication of an intracerebral bleed.

Surgery is not often considered except in situations in which the pressure within the skull increases to

the point at which part of the bone is temporarily removed to allow the brain to expand. When and if

the brain swelling resolves, another operation replaces the piece of skull that was removed.

Diffuse Axonal Injury or Shear Injury

A potentially devastating brain injury occurs when the brain injury occurs to the axons, the part of the

neurons or brain cell that allows those cells to send messages to each other. Because of the damage

of electrical flow between cells, the affected individual often appears comatose with no evidence of

bleeding within the brain. The mechanism of injury is usually acceleration-deceleration, and the nerve

endings that connect the brain cells rip apart.

Treatment is supportive, meaning that there is no surgery or other treatment presently available. The

patient's basic needs are met hoping that the brain will recover on its own. Most don't.

Concussions may be potentially considered a milder form of this type of injury.

Picture of the areas of the brain subject to injury


























Picture of an epidural, subdural, and intracerebral hematomas



Head Injury Causes

Traumatic head injury affects more than 1.7million people in the United States each year including almost

a half million children; 52,000 people die.

Adults suffer head injuries most frequently due to falls, motor vehicle crashes, colliding or being struck by

an object, and assaults. Falls and being struck are the most common causes of head injury in children.

National traumatic brain injury estimates from the CDC



Head Injury Symptoms

It is important to remember that a head injury can have different symptoms and signs, ranging from a

patient experiencing no initial symptoms to coma.

A high index of suspicion that a head injury may exist is important, depending upon the mechanism of

injury and the initial symptoms displayed by the patient. Being unconscious, even for a short period of

time is not normal. Prolonged confusion, seizures, and multiple episodes of vomiting should be signs that

prompt medical attention is needed.

In some situations, concussion-type symptoms can be missed. Patients may experience difficulty

concentrating, increased mood swings, lethargy or aggression, and altered sleep habits among other

symptoms. Medical evaluation is always wise even well after the injury has occured.

Head Injury in Infants and Young Children

Infants often visit health care practitioner because of a head injury. Toddlers tend to fall as they learn to

walk, and falls remain the number one cause of head injury in children. While guidelines exist regarding

the evaluation of head injury victims, they tend to be applied to those older than 2 years of age.

A minor head injury in an infant is described by the American Academy of Pediatrics as the following: a

history or physical signs of blunt trauma to the scalp, skull, or brain in an infant or child who is alert or

awakens to voice or light touch.

Infants are usually unable to complain about headache or other symptoms. Therefore, basic guidelines as

to when to seek medical care can include the following:

Altered mental status. The child is not acting or behaving normally for that child.

Vomiting

Scalp abnormalities including lacerations and swelling that may be associated with skull fracture

Forehead contusions tend to be less worrisome than occipital (back of the head) contusions

Seizure


















Often a careful physical examination is all that is needed to assess the infant's risk for intracranial

hemorrhage, but some testing may be considered.

CT scan may be indicated based upon the health care practitioner's assessment of the child. Plain skull

X-rays may be considered to look for a fracture, as a screening tool to decide about the need for a CT

scan.

Usually, if the health care practitioner finds no evidence for concern, the infant can be discharged home

for observation. While parents may choose to, there is no need to keep the infant awake or waken them

should they fall asleep.

Head Injury Guidelines and Assessment: Glasgow Coma Scale

The Glasgow Coma Scale was developed to provide a simple way for health care practitioners of different

skill levels and training to quickly assess a patient's mental status and depth of coma based upon

observations of eye opening, speech, and movement. Patients in the deepest level of coma:

do not respond with any body movement to pain,

do not have any speech, and

do not open their eyes.

Those in lighter comas may offer some response, to the point they may even seem awake, yet meet the

criteria of coma because they do not respond to their environment.


Call 911 or activate your local emergency response service should any person sustain a significant

head injury. This includes all persons with loss of consciousness who do not immediately waken andreturn to normal as well as those who show signs of weakness or numbness on one side of their body,

complain of difficulty speaking, or have vision loss. These are the same symptoms as a person having

a stroke.

Mechanism of injury is also an important consideration. Persons in a motor vehicle collision or who

have fallen from a height should be kept still with their neck protected, in case there is an associated

spinal cord injury.

Other symptoms that should prompt seeking medical care include confusion, loss of short-term

memory, and repeatedvomiting.

A less specific symptom but one that can also be used with children is to decide whether the person is

acting like his or herself. This is a subtle and non specific way of evaluating an injured person, but if

there is concern that they are not acting "normal", medical care should be accessed.

Persons with head injuries who are impaired because of alcohol or drugs should be brought for

medical attention and evaluation.















Those who are taking prescription blood thinning medications such as warfarin(Coumadin), dabigatran

etexilate (Pradaxa), enoxaparin (Lovenox), and heparinshould seek medical care for all head injuries,

even if it is very minor.

Head Injury Diagnosis

The physical examination and the history of the exact details of the injury are the first steps in caring for a

patient with head injury. The patient's past medical history and medication usage will also be important

factors in deciding the next steps. Plain skull X-rays are rarely done for the evaluation of head injury. It is

more important to assess brain function than to look at the bones that surround the brain. Plain X-ray

films may be considered in infants to look for a fracture, depending upon the clinical situation.

Computerized tomography (CT) scan of the head allows the brain to be imaged and examined for

bleeding and swelling in the brain. It can also evaluate bony injuries to the skull and look for bleeding in

the sinuses of the face associated with basilar skull fractures. CT does not assess brain function, and

patients suffering axonal shear injury may be comatose with a normal CT scan of the head.

Numerous guidelines exist to give direction as to when a CT should be completed in patients who presentawake after sustaining a minor head injury.

The Ottawa CT head rules apply to patients age 2 to 65.

High Risk

Glasgow Coma Scale less than 15, two hours after injury

Suspect open or depressed skull fracture

Sign of basilar skull fracture

Vomiting more than once

Older than 65 years of age

Medium Risk

Amnesia before impact greater than 30 minutes

Dangerous mechanism of injury

Head Injury Treatment

Head Injury Self-Care at Home

Many people who hit their heads do not need to seek medical attention. People often hit their heads on a

cupboard or trip and fall on a soft surface, get up and dust themselves off and are otherwise well.

Occasionally, a bump can occur underneath the skin of the scalp or forehead. This 'goose egg' is a

hematoma on the outside of the skull and is not necessarily related to any potential bleeding that can















affect the brain. Treatment is the same as any other bruise or contusion and includes ice, and over-the-

counter pain medication.

Car accidents can cause many different injuries, to virtually any part of your body, depending on the circumstances ofthe crash and the severity of the impact. But if you take a closer look at the range of insurance claims and personal

injury lawsuits related to auto accidents, you'll see that certain injuries crop up more than others. This

article discusses the most common car accident injuries.

Brain and Head Injuries - In an injury after, an accident, one of the most common injuries suffered by drivers and

passengers is a closed head injury, which can range from a mild concussion to a traumatic brain injury (TBI). Even

when there is no physical sign of trauma (i.e. cuts or bruises), the brain is at risk of being jostled inside the

skull because of the impact of a car crash, so that bruising and other injuries can result.

Neck Injuries - Another common form of injury from a car accident is neck injuries, which can occur in more mild

forms such as whiplash and neck strain, to more serious injuries like cervical radiculopathy and disc injury.

Back Injuries - The impact of a car accident and the resulting torque on the bodies of drivers and passengers can

cause back injuries such as a sprain, strain, fracture, disc injury, thoracic spine injury, lumbar radiculopathy, and

lumbar spine injury. Like neck injuries, sometimes the symptoms of even the most serious back injuries can take

some time to show up after an accident, and just as often a back injury can cause longlasting pain and discomfort.

Face Injuries - In a car accident, injuries to the face can be caused by almost anything -- including a steering wheel,

dashboard, airbag, windshield, side window, car seats or shattered glass. These injuries range in severity

from scrapes and bruises, to laceration and fractures, even Temporomandibular disorders of the jaw (TMJ) and

serious dental injuries.

Psychological Injuries - Injuries caused by car accidents aren't limited to the physical. Especially after serious caraccidents involving severe injuries and even loss of life, drivers and passengers may suffer short or long-term

psychological injuries such as emotional distress, and may even develop conditions that closely resemble post

traumatic stress disorder (PTSD).

http://www.all-about-car-accidents.com/topics/after-car-accident-first-steps-take.html




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Injuries Related to Vehicular Accidents