HEAD AND NECK INJURIES - Medicine for Mountaineering and Other Wilderness Activities - page 103

ofthescalpthatproduceswellingandbleeding.Occasionally,signstypicalofafractureare
presentontheoppositesideoftheheadfromthepointofimpact.Inthislocation,pain,ten-
derness, swelling, and discoloration are indicative of a fracture. This injury, the so-called
contre-coup fracture, is produced by the coincidence of forces created by an impact on the
opposite side of the skull.
A sign of a fracture of the base of the skull (basilar skull fracture) is drainage from the
ears or nose of cerebrospinal fluid or blood. Any bleeding from the ears or nose in indi-
vidualswithheadtraumamustbeconsideredasignofabasilarfracture,untilprovenother-
wise. Additional indirect signs of a skull fracture are bruises behind the ear (battle sign) or
around the eyes (raccoon eyes). In contrast to these subtle findings, larger depressed skull
fracturesorfracturesaccompaniedbyobviousdeformity,aswellasopenfractures,areeasy
to diagnose but are usually associated with a lethal outcome. The presence of any direct or
indirect signs of a skull fracture mandates immediate evacuation to a trauma center.
Pupils
Thepupilsaretheonlyexternal“window”tothebrain.Undernormalconditions,pupils
are similar in size and react to light by constricting in a coordinated, symmetric fashion.
Any discrepancy in pupil size or symmetry or the presence of asymmetric or absent light
reactions is a sign of potentially severe brain injury. (Many individuals with such signs
are unconscious.) Pupil reaction is tested by quickly changing light exposure from dark to
bright, either with a flashlight or by manually covering and uncovering one eye. With a
normal consensual reaction, the opposite, untested pupil reacts identically to the illumin-
ated pupil. Any abnormality in pupil size, symmetry, or reaction time, or absence of pupil
reaction or consensual reaction, mandate immediate evacuation.
Rarely, a person may clarify the presence of differing pupil sizes as a known precondi-
tion. However, when in doubt, the lack of pupil symmetry has to be considered a sign of
brain injury until proven otherwise.
Associated Head Injuries
Aside from a compromised airway, which is considered a “killing injury” in head
trauma, significant associated injuries include the following:
Injuries to the chest (hypoxia, blood loss)
Injuries to the abdomen and pelvis (blood loss)
Long bone fractures (blood loss, stress, and pain)
Spine injuries (neurological impairment, neurogenic shock)
These injuries may significantly aggravate the extent of a head injury due to secondary
insults related to a diminished supply of blood and oxygen to the brain. An isolated trau-
maticbraininjuryneverresultsinshockorhypotension( Chapter3:Life-ThreateningProb-
lems ) . The rare occurrence of neurogenic shock is exclusively associated with injuries to