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Signs and symptoms

Head injury

  • Altered mental status.
  • Poor PMS.
  • Lack of consensual reflex indicates increased pressure in the brain.
  • Unequal or fixed pupils.
  • Irregular breathing pattern.
  • Raccoon sign (dark around the eye) is a delayed sign of skull fracture.
  • Battle's sign (dark behind the ear) is a late sign of basilar skull fracture.
  • Cushing's reflex (increasing systolic blood pressure, decreasing heart rate, changes in breathing pattern) is a sign of severe head injury.
  • Flexion or extension.
  • Amnesia.

Spinal injury

  • Numbness and loss of sensation.
  • Paralysis.
  • Pain that may be independent of movement.
  • Loss of bowel or bladder control.
  • Priapism.
  • Impaired breathing.
  • Drop in blood pressure with flushed skin from neurogenic shock.


  • Spinal immobilization if injury to the spine is suspected (leave helmet and shoulder pads on for football players as removing them could cause spinal movement).
  • Manage injuries that compromise the airway.
  • Oxygen administration to perfuse the brain.
  • PPV if breathing is inadequate.
  • Control bleeding.
  • For severe head injuries: hyperventilation at a rate of 20 breaths per minute. Signs for severe head injury include unequal pupils, increased systolic pressure, irregular or absent breathing, Cushing's reflex, absent PMS, seizures, flexion or extension.
  • Assess for PMS.
    • Pulse: radial for upper extremities and pedal for lower extremities.
    • Motor:
      • Flex arms tests the function of C6 vertebrae.
      • Extending the arms (and wrists) tests for C7.
      • Spreading fingers apart tests for T1.
      • Pushing down with the feet into a tip-toe position tests for S1 and S2.
      • Pulling up with the feet tests for L5.
    • Sensation: test for both touch and pain and let the patient locate the source of the touch or pain.

Trauma and mechanisms

  • Scalp injuries: the scalp is highly vascular, and can bleed very heavily. Also, bleeding can occur under the skin, giving the appearance and feel of deformities.
  • Skull injuries: the thinnest portion of the skull is the temporal region, which is prone to fracture. Basilar skull fracture when the base of the skull fractures.
  • Brain injuries
    • Hypoperfusion to the brain.
    • Contusions and lacerations.
    • Closed and open head injuries.
    • Diffuse axonal injury: shearing, tearing, and stretching of nerve fibers.
  • CSF leakage can be confirmed by a glucose content analysis. CSF contains glucose, while tears and nasal secretions do not.
  • Concussion: injury resulting from the stretching, tearing and shearing of brain tissue. Can cause amnesia, confusion, and altered mental status. May lead to contusions.
  • Contusion: bruising and swelling of the brain tissue.
  • Coup-contrecoup injury: contusion caused by rapid acceleration or deceleration, such as in a car crash, where the brain bounces back and forth against the skull.
  • Subdural hematoma: venous bleeding between the dura mater and the arachnoid layer of the brain.
  • Epidural hematoma: bleeding between the skull and dura. Often associated skull fracture. Usually bleeding is severe, and can drastically increase intracranial pressure.
  • Spinal injuries
    • Flexion: excessive curvature forward.
    • Extension: excessive curvature backward.
    • Compression: injury from compressing.
    • Distraction: injury from pulling.
    • Rotation: injury from rotating.
    • Lateral bending: excessive curvature sideward.
    • Penetration: injury from penetration.
  • Inury to the C3 and C5 verbebrae can cause respiratory failure.
  • Priapism: a persistent erection, a classical sign of cervical spine injury.


  • Consensual reflex: light shone in one eye stimulates both eyes to constrict.
  • Diplopia: double vision.
  • Retrograde amnesia: forgetting things before the incident.
  • Anterograde amnesia: forgetting things after the incident.