I
Detailed Lesson Plan
Chapter 31
Head Trauma
90–100 minutes
|Chapter 31 objectives can be found in an accompanying folder. |
|These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. |
|Minutes |Content Outline |Master Teaching Notes |
| |Introduction |Case Study Discussion |
|5 |During this lesson, students will learn about assessment and care for a patient suffering from a head injury. |What type of injury would present with a delayed onset of |
| |Case Study |signs and symptoms such as this? |
| |Present Dispatch and Upon Arrival information from the chapter. |What are your immediate concerns for this patient? |
| |Discuss with students how they would proceed. | |
| |Anatomy of the Skull and Brain—The Skull |Teaching Tip |
|5 |Contains and protects the brain and upper portion of the spinal cord |Pass around an anatomical model of the skull to illustrate the|
| |Cranial skull |basilar skull—a set of structures that is often difficult for |
| |Made of plates of large, flat bones |students to visualize. |
| |Bones are fused together to form a helmet-like covering. | |
| |Facial bones | |
| |14 irregularly shaped bones | |
| |Cheek, nose, and jaw bones | |
| |Basilar skull (floor of the skull) | |
| |Many separate pieces of bone | |
| |Weakest part of the skull | |
| |Spinal cord, nerves, and blood vessels perforate these bones | |
| |Many bony ridges that can cause injury to brain | |
| |Anatomy of the Skull and Brain—The Brain |Discussion Questions |
|10 |Cerebrospinal fluid |How can you describe the location of intracranial bleeding |
| |Dense, serous substance surrounding brain |with respect to the meninges? |
| |Protects brain and spinal cord against impact |Why is swelling or bleeding within the brain quickly life |
| |Clear and colorless |threatening? |
| |Circulates through skull and spinal column |What are the functions of the brain stem? |
| |Is reabsorbed by circulatory system | |
| |Combats infection and cleanses brain and spinal cord | |
| |Leakage through nose and ears is classic sign of basilar skull fracture |Knowledge Application |
| |The meninges (layers of tissue surrounding the brain) |Given a description of the location of bleeding within the |
| |Dura mater |cranium, students should be able to describe it using the |
| |Outermost layer |correct terminology. |
| |Double layer of tough, fibrous tissue |Given a description of a region of the brain, students should |
| |Arachnoid |be able to describe the major functions of that area. |
| |Between dura mater and pia mater | |
| |Separated from pia mater by subarachnoid space (lattice of fibrous, spongy tissue) |Class Activity |
| |Pia mater |Assign groups of students to research and present the anatomy |
| |Beneath arachnoid |and physiology of different parts of the brain. |
| |In contact with brain | |
| |Bleeding in the brain | |
| |Epidural bleeding | |
| |Occurs between dura mater and skull | |
| |Usually involves brain’s outermost arteries | |
| |May have no permanent consequences if treated early | |
| |Subdural bleeding | |
| |Occurs beneath dura | |
| |Usually venous | |
| |Subarachnoid hemorrhage | |
| |Occurs between arachnoid membrane and surface of brain | |
| |Can be fatal within minutes | |
| |Parts of the brain | |
| |Cerebrum | |
| |Comprises three-fourths of brain’s volume | |
| |Divided into right and left hemispheres | |
| |Each hemisphere divided into four lobes | |
| |Frontal lobe (anterior) | |
| |Parietal lobe (middle) | |
| |Occipital lobe (posterior) | |
| |Temporal lobe (side) | |
| |Responsible for most conscious and sensory functions, emotions, and personality | |
| |Not attached to inside of skull | |
| |Cerebellum (“little brain”) | |
| |Found underneath cerebrum | |
| |Controls muscle movement and coordination | |
| |Predicts when to stop movement | |
| |Coordinates reflexes that maintain posture and equilibrium | |
| |Brain stem | |
| |Most primitive and best-protected part of brain | |
| |Tethered to skull by nerves and vessels | |
| |Controls most automatic functions of the body (cardiac, respiratory, vasomotor or blood pressure, and so on) | |
| |Made up of pons, midbrain, and medulla or medulla oblongata | |
| |Medulla physically connects the brain to the spinal cord. | |
| |All messages between brain and spinal cord pass through the medulla. | |
| |Head Injury—Scalp Injuries | |
|5 |The scalp may be contused, lacerated, abraded, or avulsed. | |
| |Scalp injuries bleed heavily because of the rich supply of blood vessels. | |
| |Underlying fascia (fibrous membrane) may be torn while the skin stays intact. | |
| |Ruptured or depressed fascia can feel, on palpation, like a depressed skull fracture. | |
| |If blood fills area between depressed skull fracture and scalp, skull will feel normal during palpation. | |
| |Head Injury—Skull Injuries |Discussion Questions |
|7 |Linear skull fracture |What is a basilar skull fracture? |
| |Resembles a line |What are the signs and symptoms of a basilar skull fracture? |
| |No gross deformity | |
| |Can be diagnosed only through a radiograph | |
| |Depressed skull fracture | |
| |Occurs when bone ends are pushed inward toward the brain | |
| |Depression can typically be palpated. | |
| |May pose harm if bone ends damage brain tissue | |
| |Closed skull fracture—No open wound to scalp | |
| |Open skull fracture | |
| |Open wound to scalp | |
| |Bacteria and other contaminants may infect brain through open wound | |
| |Cerebrospinal fluid may leak from open wound | |
| |Basilar skull fracture | |
| |Often begins as linear temporal fracture that extends downward and into the base of the skull | |
| |Often causes leakage of cerebrospinal fluid from ears, nose, or mouth | |
| |Patient often develops ecchymosis (bruise-type discoloration) around eyes and behind ears after several hours. | |
| |Head Injury—Brain Injuries |Teaching Tip |
|8 |Injury to the skull can cause swelling of brain tissue or bleeding within the skull. |Take time to explain how increased intracranial pressure |
| |Both conditions can cause increased pressure inside skull and decreased perfusion of the brain. |affects cerebral blood flow. |
| |Effects of pressure inside skull and decreased perfusion | |
| |Inadequate delivery of oxygen and glucose to brain tissues |Critical Thinking Discussion |
| |Inadequate removal of carbon dioxide and other waste from brain tissues |What happens to perfusion of the brain when brain tissue |
| | |swells? |
| | | |
| | | |
| |Head Injury—Pathophysiology of Traumatic Brain Injury |Discussion Questions |
|25 |Closed head injury |How do intracranial hematomas develop? |
| |Scalp may be lacerated, but skull remains intact; no opening to the brain. |What conditions can lead to secondary brain injury? |
| |Brain injury may still be extensive. | |
| |Open head injury | |
| |Involves break in skull and break in scalp |Weblinks |
| |Involves direct local damage to tissue |Go to and click on the mykit link for |
| |Can also result in brain damage from infection, laceration, or puncture |Prehospital Emergency Care, 9th edition to access web |
| |Diffused axonal injury (DAI) |resources on traumatic brain injuries. |
| |Results from shearing, tearing, or stretching of nerve fibers | |
| |Interferes with communication and transmission of nerve impulses throughout the brain | |
| |Most common in auto crashes and pedestrians struck by autos | |
| |Categorized as mild (concussion), moderate, or severe (involves brain stem) | |
| |Concussion (temporary loss of brain’s ability to function) | |
| |Normally causes headache and some temporary disturbance in brain function | |
| |Presents with an altered mental status that progressively improves | |
| |Loss of consciousness will only occur immediately after impact. | |
| |Signs include confusion, brief memory loss, irritability, combativeness, nausea and vomiting, and restlessness. | |
| |Contusion (bruising and swelling of brain tissue) | |
| |Can accompany concussion | |
| |Causes bleeding into surrounding tissues | |
| |May cause increased intracranial pressure | |
| |Coup/contrecoup injury—Damage at and directly opposite the point of impact | |
| |Acceleration/deceleration injury—Head comes to a sudden stop but brain continues to move, resulting in bruising to | |
| |brain. | |
| |Signs and symptoms | |
| |All signs and symptoms of a concussion | |
| |Decreasing mental status or unresponsiveness | |
| |Paralysis | |
| |Unequal pupils | |
| |Alteration of vital signs | |
| |Profound personality changes | |
| |Subdural hematoma (collection of blood between dura mater and brain) | |
| |Due to low-pressure venous bleeding from veins torn during impact | |
| |Commonly associated with cerebral contusion | |
| |Formation of hematoma may cause pressure on the brain, resulting in cerebral injury. | |
| |Acute hematoma—Signs and symptoms begin almost immediately upon impact. | |
| |Occult hematoma—Signs and symptoms do not appear for days or weeks after impact. | |
| |Most common type of severe head injury; accounts for 33 percent of all severe head injuries | |
| |Those especially vulnerable to subdural hematoma | |
| |Anyone over the age of 60 | |
| |Anyone whose blood clots abnormally slowly (hemophiliacs, alcoholics, patients taking anticoagulant drugs) | |
| |Signs and symptoms | |
| |Weakness or paralysis on one side of the body | |
| |Deterioration in level of responsiveness | |
| |Vomiting | |
| |Dilation of one pupil | |
| |Abnormal respirations or apnea | |
| |Possible increasing systolic blood pressure | |
| |Decreasing pulse rate | |
| |Headache | |
| |Seizures | |
| |Confusion | |
| |Personality change (chronic subdural hematoma) | |
| |Epidural hematoma | |
| |Arterial or venous bleeding pools between skull and dura | |
| |Bleeding is rapid, profuse, and severe and expands rapidly in a small space. | |
| |Rare; accounts for two percent of all severe head injuries | |
| |Extreme emergency | |
| |Most commonly results from low-velocity impact or from deceleration injury | |
| |Usually associated with a skull fracture, especially in temporal region | |
| |Signs and symptoms |Discussion Question |
| |Loss of responsiveness; responsiveness returns (lucid interval) then rapidly deteriorates (occurs in only 20 |What are the similarities and differences between subdural and|
| |percent of cases) |epidural hematomas? |
| |Decreasing mental status (more common than above) | |
| |Severe headache | |
| |Fixed and dilated pupils | |
| |Seizures | |
| |Increasing systolic blood pressure and decreasing heart rate | |
| |Vomiting | |
| |Apnea or abnormal breathing pattern | |
| |Systolic hypertension and bradycardia (Cushing’s reflex) | |
| |Posturing (withdrawal or flexion) | |
| |Needs immediate surgical repair; prognosis is generally good. | |
| |Laceration | |
| |Often occurs when an object penetrates the skull | |
| |Permanent injury; almost always results in bleeding | |
| |Can cause massive disruption of nervous system | |
| |Brain herniation (compression of the brain) |Critical Thinking Discussion |
| |Hematoma puts pressure on the brain, resulting in compression and pushing of brain downward and through foramen |What is the explanation for Cushing’s reflex? |
| |magnum (opening in base of skull) | |
| |Compression of brain stem destroys vital functions (heartbeat, respiration, blood pressure). | |
| |Signs and symptoms | |
| |One dilated or sluggish pupil | |
| |Weakness or paralysis |Discussion Question |
| |Severe alteration in consciousness |What are indications of herniation? |
| |Abnormal posturing (nonpurposeful movement) | |
| |Abnormal ventilation pattern | |
| |Systolic hypertension and bradycardia (Cushing’s reflex) | |
| |May consider controlled hyperventilation | |
| |IX. Head Injury—Assessment-Based Approach: Head Injury |Knowledge Application |
|25 |Scene size-up |Given a variety of scenarios, students should be able to |
| |Always be alert for signs of head injury in a scene size-up. |identify and properly manage patients with head injuries. |
| |Unresponsiveness or altered mental status should always suggest the possibility of head injury. | |
| |Never assume that mental status changes in a trauma victim are due to drug or alcohol intoxication. |Critical Thinking Discussion |
| |Primary assessment |How can EMTs’ actions help minimize secondary brain injury? |
| |First step is manual in-line stabilization of the spine. | |
| |Establish an airway using a jaw-thrust maneuver. |Video Clip |
| |Maintain airway and provide oxygen by nonrebreather mask. |Go to and click on the mykit link for |
| |Assess patient’s mental status and keep in mind that it may change. |Prehospital Emergency Care, 9th edition to access a video on |
| |Assess and record patient’s responsiveness accurately and in detail. |applying a cervical collar. |
| |Purposeful response—Patient tries to remove/move away from pain. | |
| |Nonpurposeful response—Patient reacts inappropriately to pain. |Discussion Question |
| |Flexion (decorticate) posturing (arms across chest, legs extended) indicates upper-level brain stem injury. |What are flexion and extension posturing? |
| |Extension (decerebrate) posturing (arms and legs extended, back sometimes arched) indicates lower-level brain stem | |
| |injury. | |
| |Unresponsive—Patient exhibits no response at all to verbal or painful stimuli. | |
| |Secondary assessment | |
| |Physical exam | |
| |Head—Using extreme care, palpate for deformities, depressions, lacerations, or penetrating objects. | |
| |Eyes—Check pupils with a bright light for fixation or dilation; make sure eyes track normally; check for dark | |
| |discoloration around eyes. | |
| |Ears and nose—Check for leakage of blood or clear fluid; check for Battle’s sign (purplish discoloration behind | |
| |ear). | |
| |Motor/sensory assessment—Check patient’s ability to move fingers and toes; pinch extremities and check response. | |
| |Baseline vital signs—Check and record every five minutes. | |
| |Pulse—If fast, suspect hemorrhage or early onset of hypoxia; if slow, suspect pressure inside skull or severe | |
| |hypoxia. | |
| |Respiration—If definite signs of brain herniation exist, begin positive pressure ventilation at a rate of 20 | |
| |ventilations per minute; if these signs are not present, ventilate at a rate of 10–12 per minute. | |
| |History—Ask patient or bystanders: | |
| |When and how did the incident occur? | |
| |What is the patient’s chief complaint? | |
| |Have symptoms changed since the incident? | |
| |Did the patient lose consciousness at any time? | |
| |Was he moved after the incident? | |
| |Is there any history of previous blows to the head? Can you provide any details? | |
| |Signs and symptoms | |
| |Altered mental status, from disorientation to unresponsiveness that doesn’t improve, or that gets worse | |
| |Irregular breathing pattern (severe) | |
| |Cushing’s reflex (increasing blood pressure and decreasing pulse) (severe) | |
| |Obvious signs of injury—Contusions, lacerations, hematomas to scalp; deformity to skull | |
| |Visible damage to skull |Discussion Question |
| |Pain, tenderness, or swelling at injury site |What are some general signs and symptoms of brain injury? |
| |Blood or cerebrospinal fluid from ears or nose | |
| |Discoloration around eyes in absence of trauma to eyes (very late) | |
| |Absent motor or sensory function | |
| |Nausea and/or vomiting | |
| |Unequal pupil size with altered mental status | |
| |Diplopia (double vision) | |
| |Possible seizures | |
| |Nonpurposeful response to painful stimuli | |
| |Retrograde amnesia (no memory of what led up to incident) | |
| |Anterograde amnesia (no memory of what happened after incident) | |
| |Emergency medical care | |
| |Take Standard Precautions. | |
| |Take manual in-line spine stabilization. | |
| |Maintain a patient airway, adequate breathing, and oxygenation. | |
| |Use a jaw-thrust to open airway. | |
| |Remove any foreign bodies from the mouth; suction blood and mucus. | |
| |Protect against aspiration by having suction available and by being prepared to roll secured patient to clear | |
| |airway. | |
| |If breathing is adequate, administer oxygen by nonrebreather mask at 15 lpm. | |
| |If breathing is inadequate, administer positive pressure ventilation with supplemental oxygen at 10–12 per minute | |
| |with SpO2 reading at 95 percent or greater. | |
| |Consider controlled hyperventilation if signs of brain herniation are present. | |
| |Monitor airway, breathing, pulse, and mental status for deterioration. | |
| |Control bleeding. | |
| |Do not apply pressure to open or depressed skull injury. | |
| |Dress and bandage open head wounds. | |
| |Do not attempt to stop flow of blood or cerebrospinal fluid from ears or nose; cover loosely with sterile gauze | |
| |dressing. | |
| |For other wounds, use gentle, continuous direct pressure with sterile gauze only as needed to control bleeding. | |
| |Never try to remove a penetrating object; immobilize in place and dress wound. | |
| |Provide emergency care for seizures. | |
| |Transport immediately. | |
| |Reassessment | |
| |Recheck patient’s airway and mental status. | |
| |Repeat reassessment every five minutes. | |
| |Head Injury—Summary: Assessment and Care |Class Activity |
|5 |Review possible assessment findings and emergency care for head injuries. |Give students 20 to 30 minutes to review the lecture and their|
| |Review Figures 31-18 and 31-19. |textbooks. Divide the class into two teams. Read aloud the In |
| | |Review questions from the text. The team to ring its bell |
| | |first gets an opportunity to answer. If the students on the |
| | |team are correct, they get a point. If they are incorrect, the|
| | |other team gets an opportunity to answer. |
| |XI. Follow-Up |Case Study Follow-Up Discussion |
|10 |Answer student questions. |Based on Mike’s presentation, what type of injury do you |
| |Case Study Follow-Up |suspect? |
| |Review the case study from the beginning of the chapter. |What factors do you believe made a difference in Mike’s good |
| |Remind students of some of the answers that were given to the discussion questions. |outcome? |
| |Ask students if they would respond the same way after discussing the chapter material. Follow up with questions to | |
| |determine why students would or would not change their answers. |Class Activity |
| |Follow-Up Assignments |Alternatively, assign each question to a group of students and|
| |Review Chapter 31 Summary. |give them several minutes to generate answers to present to |
| |Complete Chapter 31 In Review questions. |the rest of the class for discussion. |
| |Complete Chapter 31 Critical Thinking. | |
| |Assessments |Teaching Tips |
| |Handouts |Answers to In Review and Critical Thinking questions are in |
| |Chapter 31 quiz |the appendix to the Instructor’s Wraparound Edition. Advise |
| | |students to review the questions again as they study the |
| | |chapter. |
| | |The Instructor’s Resource Package contains handouts that |
| | |assess student learning and reinforce important information in|
| | |each chapter. This can be found under mykit at |
| | |. |
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MASTER TEACHING NOTES
• Case Study Discussion
• Teaching Tips
• Discussion Questions
• Class Activities
• Media Links
• Knowledge Application
• Critical Thinking Discussion
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