Head injuries are common across all age groups, but particularly in young children, sportspeople, and older adults. They can range from being minor (requiring rest and pain relief) to severe (becoming unresponsive and requiring medical care). A concussion can develop to be one common type of severe head injury. It can be difficult to identify a concussion because there are many signs and symptoms which vary and are not always immediately apparent. In addition, some people do not recognise or admit to experiencing symptoms of a concussion. This can lead to a delay in proper treatment or accessing medical care unnecessarily.
Guidelines
Good practice points
- Any person suspected of sustaining a head trauma (a forceful bump, blow or jolt to the head or body that results in the rapid movement of the head and brain), along with any of the signs of a concussion, must be presumed to have a severe head injury or concussion.
- Following a head trauma, the following signs may indicate a concussion. The person:
> becomes unresponsive, even for just a few seconds
> starts behaving differently (they become aggressive, have slurred speech or a loss of balance, for example)
> they vomit more than once. - Any person with a severe head injury or concussion must stop any activity and access medical care to evaluate and manage their condition.
- Emergency medical care should be accessed immediately following a blow to the head if the person:
> becomes unresponsive, even for just a few seconds
> has an altered mental status (e.g., they become aggressive, have slurred speech, have a seizure; children may have an abnormal attitude or be very quiet and stop playing)
> has a motor or sensory deficit of one or more limbs (e.g., tingling in a limb, or balance or coordination problems)
> has a severe headache for more than two hours despite taking pain relief
> has impaired vision (e.g., sensitivity to light, blurred or double vision)
> has blood or a clear fluid coming out of their nose, ear or mouth
> vomits more than once
> is unresponsive with abnormal breathing. - If the person has a mild headache, a bump on their head, or feels nauseous following a blow to the head, they may rest and continue to be observed for any change to their symptoms or behaviour requiring medical care.
- If the person shows none of these signs following a blow to the head, they may carry on with their day but should be observed in case any of the above signs develop over the next 24 hours.
- In instances of head injury, a Spinal injury should also be considered.
Chain of survival behaviours
Prevent and prepare
- Promote and practise safe behaviours, such as wearing a seatbelt and using a headrest when travelling by car or wearing a helmet when travelling by motorcycle, bicycle or horse.
- Consider athletic body protection (i.e. helmets, face masks) when participating in contact sports. Sports coaches should be aware of the risks, and players should discontinue their involvement in sports if a head or spine injury is suspected.
- Junior sports should consider at what age the introduction of tackling is appropriate and should endeavour to teach correct techniques (Harmon et al., 2019).
- Remove trip hazards from places of work and home, particularly where there are small children, elderly people, or people with disabilities to reduce the chance of trips and falls.
- Never dive into shallow water, or water with an obstructed view or high flow (e.g. rivers) and take particular care when diving in the dark.
- Learn how to recognise the signs of a concussion.
Early recognition
The person has a forceful bump, blow or jolt to the head or body that results in the rapid movement of the head and brain. This could include incidents such as a fall, a road traffic accident or an explosion.
Mild head injury
- A bump on their head.
- A mild headache.
- Feels nauseous.
If the person has a mild headache or feels nauseous following a blow to the head, they may rest and continue to be observed for any change to their symptoms or behaviour requiring medical care.
Severe head injury (or concussion)
- Becomes unresponsive, even for just a few seconds.
- Has an altered mental status (e.g., they become aggressive, have slurred speech, have a seizure; children may have an abnormal attitude or be very quiet and stop playing).
- Has a motor or sensory deficit of one or more limbs (e.g., tingling in a limb, or balance or coordination problems).
- Has a severe headache for more than two hours despite taking pain relief.
- Has impaired vision (e.g., sensitivity to light, blurred or double vision).
- Has blood or a clear fluid coming out of their nose, ear or mouth.
- Vomits more than once.
- Is unresponsive with abnormal breathing.
Other signs could also indicate a head injury and the signs may present differently in people. The main thing to look for is a change in the person. The signs of a severe head injury can happen immediately or can develop over several hours or days.
The possibility of a spinal injury should always be considered in the case of a forceful impact or fall.
First aid steps
- Remove the person from their activity and ask them to rest.
- Monitor the person according to the signs of a concussion and for changes in their level of response and breathing.
- If the head injury is severe:
a. Access EMS.
b. Reassure the person and encourage them to keep their head and neck as still as possible. If the person is lying down, you may also use your hands or knees to keep their head as still as possible.
c. Monitor the person’s level of response and breathing until EMS arrives.
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NOTE
Many bumps or knocks to the head do not cause a concussion or other severe head injury. Where the person has had a blow to the head, but the signs are not present or are mild, help the person to rest and then to carry on with their day. However, they should be observed as a concussion can develop over several hours or days.
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Access help
- Observe the person for signs of concussion and access help if these are present.
Recovery
- In many cases, rest from activity is the most effective initial treatment. However, injuries to the head are difficult to confirm and difficult to manage in out-of-hospital settings.
- Signs and symptoms of a head injury should have been resolved before returning to activities with associated risks (e.g. some work activities, driving or operating machinery or contact sports).
- Be aware that normal cognitive function may take time to be fully restored and that there may be residual learning and behavioural challenges in the short term (Harmon et al., 2019).
Education considerations
Context considerations
- Minor head injuries are a common occurrence and usually do not result in serious injury. Where learning first aid is within the context of a workplace or school or is for people who are involved with sport or driving, seek to understand the risks and risk behaviours that could lead to head injuries and frame education around them.
Learner considerations
- Consider how different learners or local translation during facilitation may change the meaning of certain recognition signs (such as headache, dizziness, nausea, vomiting, confusion, amnesia, tingling, mood change, behaviour change, fogginess etc). Discuss terminology with learners to help them to understand how to distinguish between a mild and severe head injury (Halter, awaiting publication, 2020).
Facilitation tips
- Use scenarios to help learners understand how serious or not the head injury is. Note that in some cultures, medical care is sought for any head injury, but that first aid providers can learn how to recognise a head injury, and many head injuries are minor and will not need professional attention (Kulnik, 2019; Halter et al., 2020).
- Consider differences in management and recognition, including how different people might have different levels of ability to respond to questions about how they are feeling, or what they can remember. For example, a small child or a person with dementia might struggle to answer a question with or without a head injury, so in such cases observation of behaviour change by someone who knows the person will be particularly important.
Facilitation tools
- It might be helpful for learners to understand the signs of a concussion in these three groups:
> What the person feels: such as headache for more than two hours despite taking pain relief, nausea, drowsiness, dizziness, sensitivity to light or noise, double or blurry vision.
> Signs that can be recognised by someone who knows the person: such as a change in how they walk or talk, confusion, a change in their mood or behaviour (becoming anxious or aggressive).
> Signs that could be recognised by someone who does not know the person, such as becoming unresponsive, having a seizure, or vomiting more than once. - Use simple traffic light illustrations to help learners understand when a head injury might need urgent medical attention.
- Create contextually relevant scenarios to reinforce learning (e.g. sport-focused role play examples for schools and sports club contexts, road traffic collisions using chairs and tables to represent cars) (Kureckova, 2017). Videos of these scenarios can also be very effective.
- Practise asking questions and taking a basic history of the person to help with the identification of relevant signs and symptoms. (See General approach.)
Learning connections
- In incidents that cause a head injury, a Spinal injury should also be considered.
- A person with a head injury may become unresponsive.
- A Seizure may result from a blow to the head.
- A bruise may form on the head to which an icepack could be applied.
Scientific foundation
Systematic reviews
In 2015, the International Liaison Committee on Resuscitation (ILCOR) reviewed the published evidence on the recognition of concussion by first aid providers (Singletary, 2015). They identified very low-certainty evidence from one observational study with 19,708 people that compared the use of a simplified motor score and the Glasgow Coma Scale (GCS) score. There was no significant difference between both scores concerning the likelihood of differentiating between a minor head injury and a more serious concussion (brain injury), the need for advanced neurosurgical intervention and emergency tracheal intubation. A head injury without a concussion is a brain injury, but it can be challenging to differentiate between the two. No evidence was found with regards to the critical outcome of the difference in time to recognise a deteriorating person, as well as other important outcomes such as surviving 30 days with a good neurological outcome or the likelihood of a poor neurological outcome.
ILCOR acknowledged the role that a simple scoring system could play. However, since these tools require a two-stage assessment (before concussion and post-concussion), this assessment is not recommended for first aid providers. A recent scoping review explored the need for updating this systematic review, but no recent studies on a single-stage assessment system could be identified.
Non-systematic reviews
The Scientific Advisory Council of American Red Cross (2015) stresses that first aid providers must recognise that no two minor traumatic brain injuries, also known as concussions, are identical in either the cause or symptoms. First aid providers therefore may have difficulty recognising them. The diagnosis of a minor traumatic brain injury should involve the assessment of a range of domains including, but not limited to the person’s symptoms, behaviour, balance and coordination, sleeping patterns, cognition and analytical abilities and response to physical exertion. Each assessment tool should contribute additional information regarding the status of the injured person by independently evaluating different aspects of cerebral functioning.
While many assessment tools are commonly used, individual variations in test scores and the necessity of a baseline assessment make it difficult for first aid providers to use these tools and interpret the results.
To help recognise a concussion, first aid providers should look for two signs. First, the person with a minor traumatic brain injury usually experiences a forceful bump, blow, or jolt to the head or body that results in a rapid movement of the head and brain. Second, first aid providers should look for any change in the person’s physical, cognitive, emotional or sleep patterns. Note that these symptoms may not appear immediately and that some people do not recognise or admit that they are having problems, particularly athletes in the middle of a match.
A concussion may be subtle and difficult to diagnose. Any person who has sustained trauma to the head, and experiences any of the symptoms identified here should be removed from activity and referred to a qualified healthcare professional, experienced in evaluating and managing a concussion.
Education papers
Many of the clinical papers relating to head injuries focus on the effectiveness of diagnostic checklists which are designed for use by healthcare professionals. We did not find any checklists in the literature that would be suitable for first aid providers. However, one paper qualitatively explored the factors which affect the confidence and willingness of a first aid provider to act in a head injury situation. These included:
- Knowing the person with the head injury – this is relevant because a change in behaviour, attitude, speech or response level are indicators of a head injury.
- Being in a familiar setting with someone else nearby to consult.
- Witnessing the accident.
Authors concluded that education which helped learners to think through scenarios to build their confidence to recognise whether a head injury was serious or not, rather than just calling for help, was important (Kulnik et al., 2019). Linked to this paper is a study awaiting publication which explores how different words describing signs and symptoms are understood by people. Most respondents from the qualitative part of the study reported low levels of confidence in knowing the signs and symptoms of head injury, and there was a variety of understanding of terminology (such as consciousness versus being knocked out) that affected the action that someone might take. This again demonstrates a need to provide clearer guidance to first aid providers on how to recognise a serious head injury (Halter et al., 2020).
References
Systematic reviews
Singletary, E.M., Zideman, D.A., De Buck, E.D., Chang, W.T., Jensen, J.L., Swain, J.M., … & Yang, H.J. (2015). Part 9: First Aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation, 132(16 Suppl 1), S269-311.
DOI: 10.1161/CIR.0000000000000278
Zideman, D.A, Singletary, E.M., De Buck, E., Chang, W.T., Jensen, J.L., Swain, J.M., … & Yang, H.J. (2015). Part 9: First aid: 2015 International consensus on first aid science with treatment recommendations. Resuscitation, 95. e225-e261.
DOI: 10.1016/j.resuscitation.2015.07.047
Non-systematic reviews
MacPherson, B. D., Markenson D., (2015). Mild traumatic brain injury (concussion) scientific review. American Red Cross Scientific Advisory Council.
Education references
Halter et al. (2020). Exploring laypersons’ understanding of indications for when emergency services might be needed for head injury: a mixed-methods study [unpublished manuscript]. Awaiting publication.
Harmon, K. G., Clugston, J. R., Dec, K., Hainline, B., Herring, S., Kane, S. F., … & Putukian, M. (2019). American Medical Society for Sports Medicine position statement on concussion in sport. British journal of sports medicine, 53(4), 213-225. Available from:
https://www.uslacrosse.org/sites/default/files/public/documents/safety/AMSSM-ConcussionStatement-2019.pdf
Kulnik, S. T., Halter, M., Hilton, A., Baron, A., Garner, S., Jarman, H., … & Oliver, E. (2019). Confidence and willingness among laypersons in the UK to act in a head injury situation: a qualitative focus group study. British Medical Journal, 9(11). Available from:
https://bmjopen.bmj.com/content/9/11/e033531.abstract
Kureckova, V., Gabrhel, V., Zamecnik, P., Rezac, P., Zaoral, A., & Hobl, J. (2017). First aid as an important traffic safety factor–evaluation of the experience-based training. European transport research review, 9(1), 5.
DOI: 10.1007/s12544-016-0218-4
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