Reprinted from Off Belay, by kind permission of its Editor


INJURIES to the skull and its contents are one of the most difficult first aid problems. The first rule is unquestionably to seek the aid of competent medical care. However, if the injury occurred in a remote mountain area, several hours or days may pass before the victim can receive proper attention. During this interval of time, the first aider must do his or her part.

Head injuries in mountaineering situations are invariably the result of a fall or being struck by a falling object. Several factors will influence the severity of the injury—the distance of the fall, whether it was a direct or "broken" fall, whether the head hit first, the size of the falling object. The external appearance of the injury may vary; there may be no sign at all, or severe damage and bleeding. And it will be a rare situation when a head injury is the only consequence of an accident.

Of course, the danger of incurring a head injury can be reduced by proper equipment, specifically a rock helmet. It is well estab¬lished that a properly designed helmet reduces or eliminates head injuries except in the case of very large falling objects, or very severe impacts. However, many climbers choose not to use helmets. Hopefully, the choice is made with full understanding and acceptance of the hazards involved.

What Happens Inside?

External and superficial injuries about the head are no different from injuries elsewhere, and are handled in much, the same fashion. What makes a head injury different and many times more serious is what's inside—the brain. The brain is the essence of human life because it controls all other bodily and emotional imictions. Unfortunately, despite its importance, the brain is not able to repair itself. Damage is permanent and, if extensive fatal.

In typical mountaineering accidents, a head injury may cause immediate damage to the brain or may precipitate a physiological response which will cause damage if untreated. The first type of situation is obvious, though often not easy to recognize with certainty. The impact has been so severe, that the life controlling pot lion of the brain has been destroyed. If there is even the slightest doubt, the situation should be considered as non-fatal, and the appropriate first aid performed.

If the initial damage is not immediately overwhelming, it may still have serious consequences. It may inactivate important bodily functions such as respiration, which will require immediate first aid. But the most insidious aspect of a head injury is the pro¬gressive build up of pressure within the skull, which can damage brain tissues unaffected by initial injury and ultimately cause death.

This pressure can originate in two ways. The impact can rupture blood vessels within the skull which bleed into the tissues or into the space between the skull and the' lining (dura) around the brain. Or the impact can cause simple swelling (cerebral edema). It is not important to be1 able to distinguish between cerebral edema and intracranial haemorrhage. However, it is important to understand how the brain will react. A severe blow to the head will always produce bleeding and/or swelling of the brain, just as an injury will produce bruising or swelling in other parts of the body. Everyone is aware of how an injured ankle becomes too large for the shoe. In much the1 same way, an injured brain becomes too large for its container, the skull. If not allowed to expand, the swollen foot becomes painful and can sustain perma¬nent damage from the pressure and impaired circulation, but this is eased when the shoe is removed. When the brain is crowded the effects vary from a headache and dizziness to death because the pressure cannot be relieved. In severe cases, only surgery can prevent severe damage or death.1

The rate of pressure build up is important in determining the final outcome of the injury. If the bleeding or swelling produces only a slow steady build up of pressure, the visible rate of dete-rioration will be slow and the prognosis good. If bleeding and swelling are extensive, the victim will deteriorate rapidly with reduced chances for survival.

First Things First

Most head injuries involve some scalp damage and brief un¬consciousness. As in any accident, the first considerations are insuring a "patent" or open airway, controlling bleeding, and treating for shock.2

Loosen restrictive clothing and search the mouth for broken teeth and foreign objects. Airway obstruction from a lax, mislocated tongue is common in an unconscious victim. Initiate mouth-to-mouth resuscitation if the victim is not breathing. Con¬current chest and head injuries constitute a particularly unfavour¬able combination, because a lack of Oxygen caused by breathing distress can complicate brain injury. Insuring the victim is breathing adequately is a prime consideration of the initial first aid responses.

Most often, bleeding is from the rich supply of relatively small, superficial vessels in the scalp, and can be controlled by direct pressure with an adequate head dressing. Sustained arterial bleeding requires a knowledge of "pressure points", described in many first aid texts.

Treat for shock as in other injuries with a few exceptions. Do not lower the victim's head. Do not give Mm any type of pain medication. Do not give him any liquids. Otherwise, keep him warm and comfortable, splint broken bones, etc. However, shock is a rare complication of head injury alone. Most often, signs of shock point to other injuries such as fractures of long bones, facial bones, abdominal, or chest injuries.

With immediate, life threatening emergencies tended to, examine the victim for obvious fractures about the eyes and ears. Blood seeping from the ear canal indicates a fracture of the base of the skull. However, be sure the blood came from the ear canal and not an external wound. Always cleanse the ear and watch for fresh seepage.

And What Next ?

In the event of internal head injuries it is important to realize that you can do very little in the way of direct first aid. How¬ever, regular observations of the victim's condition must be made and recorded. Without this information, the attending physician will not be able to determine whether the victim is improving or deteriorating and at what rate changes are taking place. The pros¬pect of recovery from severe head injury depends on the speed with which appropriate treatment is instituted, and this in turn depends on early diagnosis.

The members of the climbing party can provide information invaluable for later treatment. An accurate description of the accident may help the attending physician in locating fractures or explaining signs that develop long after the injury.

The first question asked by the attending physician will be is the victim better, worse or the same? In other words, what was the victim like earlier. Hence it is of paramount importance to obtain a comprehensive "base-line" as soon after the accident as possible. It is equally important that these initial observa¬tions be recorded in concise terms that are fully intelligible to those who later must decide what treament is indicated.

Most important are signs of deterioration caused by increased intracranial (inside the skull) pressure. These are a lowering of the' level of responsiveness, slowing of the pulse rate, rising of the blood pressure, a slowing of the respiration rate, and the appearance of neurological abnormalities. These features represent changes in the victim's condition and can be recognized only if recorded evaluation was made previously. Conversely improve¬ment can be confirmed clearly and confidently only if the victim ' is more responsive, there are no signs of deterioration, and that .my neurological abnormalities recognized earlier have lessened or disappeared.

In the record of observations, it is important to make a dis¬tinction between two commonly misunderstood terms—sign and symptom. A sign is what the observer sees in the victim, what you as the first aider can actually determine by examination, such as swelling, clumsiness, rapid breathing. A symptom on the other hand is what the victim tells the observer, such things as pain, dizziness, blurred vision. Your record of the victim's condition should clearly indicate whether you are reporting a sign or symptom. Since the terms are easily confused, it is probably best not to use them at all. Instead indicate clearly whether you are recording what the victim said or what you observed.

Observations which should be made and recorded fall into three categories, (1) level of responsiveness, (2) vital functions, and (3) abnormal neurological signs.

Level of Responsiveness

Is the victim rational and correctly oriented, or is he confused and disoriented? Is he alert or drowsy, rousable or unrousable? Is he rousable to his name being called? To being shaken? To being uncomfortably stimulated (tickling of underarms or soles of feet)? If he responds is it verbally, by co-ordinated move¬ments or by unco-ordinated, inaccurate attempts to fiind the sti¬mulation and stop it ? Is he unresponsive even to normally pain¬ful stimuli?

If the answers to these questions are recorded carefully at the outset, they will give a clear picture of any change in the level of responsiveness to the physician who sees the victim later, information needed to decide whether the victim is better, worse, or the same. However, avoid vague adjectives such as "semi- stuporous". Instead give a brief description of what the victim is capable or incapable of doing. Later observations of the level of responsiveness consists simply of determining whether the victim responds differently than at the previous examination.

Vital Functions

The pulse rate, respiration rate, and blood pressure are the important vital signs ; all but the last can be observed in the field. But if the pulse or heart beat is adequately described, some infor-mation about the blood pressure may be inferred. A progressive slowing of the pulse with a "bounding" or drum-like quality is an indication of increased blood pressure. A light and "thready" pulse is an indication of low blood pressure.

In head injuries, lower blood pressure occurs very late in the course of the victim's condition, and indicates that pressure is being exerted on the brain stem which controls all vital functions. A slowing of respiration is also a late sign of brain stem com¬pression.

Abnormal Neurological Signs

Pupil response is the most important sign in this category, although it can be somewhat ambiguous. The muscles that con¬trol the iris, the coloured part of the eye, are in turn controlled by structures within the brain which are very sensitive to increase in pressure. If a blood vessel on one side of the brain is bleeding, the increase in pressure on that side will invariably affect the pupil on the same side.

Pupil response if observed regularly can be an extremely important sign in the progress of the victim's condition. After breathing is assured and bleeding stopped, shade the victim's eyes and allow the pupils to dilate. Then direct a light at each pupil and observe their response. The important observations to make are these. Are the pupils equal? Do they both react to light? If not, in what way are they abnormal or different from each other? Be sure to indicate which eye you're observing, right or left, since later both may be affected.

Pupils are usually normally reactive immediately after the injury, unless of course there has been direct damage to the eyes or the sight mechanism itself. The important change which may occur is the pupil on the side of the injury begins to dilate and becomes less and less reactive' to light. By the time it is widely dilated and fixed, the other pupil will usually have started to behave in the same way. If both pupils become dilated and fixed, the brain probably has suffered irreparable damage, often precluding any sort of useful recovery even if the cause of the increasing internal pressure is controlled.

Other abnormal neurological signs to look for are muscle weak¬ness, paralysis, muscle spasms or convulsions, speech difficulty, vomiting, and loss of bladder or bowel control.

Extent of Observations

After the initial post-accident record, the observations should be repeated each half hour for twelve hours, and longer if full consciousness is not restored. During this period, the evacuation should be arranged, since time is an important factor in the final outcome.

The usual picture Of a severe head injury victim an hour or two after the accident is a conscious or partially conscious indi¬vidual, flushed face, rapid shallow breathing, bounding pulse around 40 to 50 beats per minute, with slowly reactive, often unequal pupils. If this type of deterioration is observed, evacua¬tion to medical assistance must be accomplished with the greatest haste.


  1. Head injuries were also discussed in "Improvised First Aid for Mountaineering Injuries" by Otto Trott, M.D. in OFF BELAY No. 1.
  2. Author's note : Many first aid references place control of bleeding ahead of breathing in the initial first aid response. However, I have personally parti¬cipated in the initial treatment of more than one hundred and fifty cardiac arrests in hospitals where it is standard procedure to attend to resuscitation first, no matter what other complications are present.

It is true that extensive, uncontrolled bleeding may result in fatal shock or death through loss of blood. However, the penalty for not breathing is equally severe. Failure to breathe for 3 to 5 minutes can cause residual brain damage. A more severe consequence is an irreversible acidosis (chemical change in the blood caused by a build up of carbon dioxide) and death.

Mechanical resuscitation of an unconscious victim wlll prevent this fatal shift in blood chemistry as long as the heart is still beating.

While there may be situations where extreme bleeding must be given prior ity. the recommen ded initial response is to insure the victim is breathing. The la test re vision of the American Red Cross Advanced First Aid Manual (page 21) now recommends this approach also.—B.F.


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