Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Section II: Critical Body Systems

that happened, there is no significant brain injury. Injuries to the face and scalp without a change in brain function do not carry the anticipated problem of increased ICP. Post concussive Syndrome Following a blow to the head, some patients experience symptoms including mild headache, photophobia, nausea, sleep disturbance, and dizziness developing a day or so after the injury. Some become depressed, angry, or tearful. This can develop with or without the field diagnosis of TBI. This post concussive syndrome can last anywhere from hours to weeks, but 3 – 5 days is typical. Mental status remains near normal, but their discomfort alone may be a good enough rea- son to put the patient ashore or end a backcountry adventure early.

High Risk TBI Wilderness Perspective

General Principles

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• S/sx of increased ICP • Persistent abnormal mental status • History of previous brain injury • Skull fracture • High risk mechanism • Anticoagulant medication

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Low Risk

High Risk

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Sometimes, even more ominous signs like anterograde amnesia or loss of distant memory can quickly improve. Anterograde amnesia is the term for the inability to retain new memory and is a form of altered mental status. The patient may literally forget what has been happening from minute to minute as you talk to him. With loss of distant memory, the patient may not recall where he lives, how he came to be where he is now, or even his age. In the absence of other red flags, improvement to normal mental status relieves the immediate emergency, but early evacuation to medical care is still advised.

Post Concussive Syndrome • Can occur without measurable brain injury • May develop quickly or > 24 hours after injury

General Principles

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• Normal mental status with: - mild to moderate headache - blurred vision, photophobia - disrupted sleep pattern - nausea, loss of appetite - dizziness • Does not indicate elevated ICP • Symptomatic treatment as needed • Non-urgent medical follow-up

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Field treatment is symptomatic; medicate for headache, allow for rest as possible, and avoid activities that require a lot of concentration. Generally, nonurgent medical follow-up is ade- quate. However, progressive worsening or the appearance of new symptoms, such as persistent vomiting, should motivate urgent evacuation. Stroke A sudden change in brain function without a history of trauma or intoxication should make you think of stroke. It may be as subtle as a little numbness in one hand or arm or a slight facial droop, or as dramatic as complete paralysis of one

This helmet damage indicates a high-energy impact and an increased potential for brain swelling and increased intracranial pressure. Finally, being able to diagnose a TBI means that you can also determine when the patient does not have a TBI. There may be an ugly scalp lac- eration or a broken nose, but if the patient has normal mental status and remembers everything