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ation, such as name and birth date. These questions also help determine the presence of
amnesia, with which an individual does not remember events that occurred shortly before
(retrograde amnesia) or after (anterograde amnesia) the accident. Amnesia is an indirect
sign of an injury to the hippocampus or surrounding cortices in the brain.
The level of consciousness can be quantified with scientific grading scales, such as the
GlasgowComaScale(GCS)orthesimplifiedAVPU(Alert,Verbalstimuli,Painfulstimuli,
Unresponsive) method ( Table 8-1 ) . Although the assessment and calculation of the GCS
maybefairlysophisticatedandcumbersomefornonmedicalprofessionals,itspracticaluse
is of crucial importance for assessing the severity of brain injury and communicating the
information to a rescue team. Any person with amnesia or lack of normal level of con-
sciousness (GCS of 14 points or less; lack of A in AVPU method) is at risk of having sus-
tainedasignificantbraininjurythatmaybecomeworseovertimeandshould,therefore,be
evacuated at the earliest possible moment.
Headache, Nausea, and Vomiting
Othersignsofasignificantbraininjuryincludethepresenceofsevereheadache,nausea,
and vomiting. Appearance of these symptoms and signs some time after the head injury
areindicative ofincreasedintracranial pressureresultingfromswellingorbleedingandthe
need for urgent evacuation.
Scalp Injuries and Skull Fractures
The assessment of head-injured individuals includes inspection and palpation of the
scalp and skull to detect external wounds or a skull fracture. Scalp wounds may be a sig-
nificant, albeit often underestimated, external bleeding source because the scalp contains
numerous blood vessels that may bleed profusely, even after minor injuries. On the other
hand,theexcellent vascular supplyrendersthescalplesssusceptible toinfection following
contaminated wounds.
Skull fractures are often surprisingly difficult to diagnose. Nonfatal fractures may occur
with relatively little brain injury and no detectable external deformity. In contrast, many
fatal brain injuries occur without an associated skull fracture. The main risk of skull frac-
tures is not the depression of bone into the brain, which is a rare occurrence, but the asso-
ciated rupture of arterial vessels outside the dura, which results in an epidural hematoma,
bleeding between the brain and skull. An epidural hematoma is associated with a dismal
prognosis. The affected individuals usually have a lucid interval between the initial trauma
and subsequent deterioration and are a paradigm of head-injured individuals who talk and
die. Therefore, the identification of a skull fracture, either by direct palpation or visualiza-
tion or by indirect means, is of crucial importance for identifying head-injured individuals
at risk of death.
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