Symptoms of head trauma.

Initially, most patients with traumatic brain injury lose consciousness (usually within seconds to minutes), although some with minor trauma may have only obtundation or amnesia (amnesia is usually retrograde and lasts from seconds to hours). Young children may simply become hyperexcitable. Some patients may have seizures, often within the first hour or day. After these initial symptoms, some patients may be alert and lucid, while others may have levels of consciousness ranging from mild confusion to stupor or coma. The duration of unconsciousness and the severity of obtundation are proportional to the severity of the injury but are not specific. The Glasgow Coma Scale (GCS) is a rapid, reproducible scoring system used at the initial examination to determine the severity of traumatic brain injury. The GCS is based on the level of consciousness (as reflected by the ability to open the eyes) and the level of motor and speech responses. A score of 3 indicates a potentially fatal injury, especially if both pupils do not react to light and there is no oculovestibular response. The higher the score at initial examination, the higher the likelihood of complete recovery. It is generally accepted that the severity of traumatic brain injury is primarily determined by the GCS (scores from 14 to 15 - mild traumatic brain injury; 9-13 - moderate; scores from 3 to 8 - severe traumatic brain injury); however, the severity and prognosis can be determined more accurately if the GCS data and other factors are taken into account. The condition of some patients with initial signs of moderate traumatic brain injury, and in some with mild trauma, may worsen. For newborns and young children, the Modified Glasgow Coma Scale for newborns and young children is used.

Glasgow Coma Scale*

Estimated parameter	Reaction	Points
Opening the eyes	Spontaneously	4
	To the voice	3
	To a painful stimulus applied to the limbs or sternum	2
	No reaction	1
Speech response	Oriented, answers questions	5
	Disoriented, answers questions in a confused manner	4
	Unrelated set of words	3
	Inarticulate sounds	2
	No reaction	1
Motor reaction	Executes commands	6
	Appropriate movement to pain	5
	Withdrawal of a limb in response to pain (withdrawal, flexion)	4
	Flexion of the limb (decortication posture)	3
	Extension of the limb (decerebrate posture)	2
	No reaction	1

*A total score <8 points usually indicates coma.

Modified Glasgow Coma Scale for Newborns and Young Children

Estimated parameter	Newborns	Little children	Points*
Opening Eye	Spontaneously	Spontaneously	4
	To the voice	To the voice	3
	Only to pain stimulus	Only to pain stimulus	2
	No reaction	No reaction	1
Speech response	Cooing, babbling	Oriented, answers questions
	Easily induced crying	Confused speech	4
	Crying in response to pain	Unrelated set of words	3
	Groans in response to pain	Inarticulate sounds	2
	No reaction	No reaction	1
Motor response**	The movements are spontaneous and purposeful	Executes commands	6
	Withdrawal in response to touch	Localization of pain stimulus
	Pulling back in response to	Pulling back in response to	4
	Response to pain in the form of decorticate posture (pathological flexion)	Flexion response to pain	3
	Response to pain in the form of decerebrate posture (pathological extension)	Response to pain by extension	2
	No reaction	No reaction	1

"A total score of 12 points corresponds to severe head injury. With a total score of <8 points, intubation and artificial ventilation are indicated. With a total score of 6 points, intracranial pressure monitoring is indicated.

**If the patient is intubated, unconscious, and unable to speak yet, then the most important part of this scale is motor response, and this section must be carefully assessed.

Symptoms of an epidural hematoma typically develop within minutes to hours after the injury and include increasing headache, decreased consciousness, hemiparesis, and dilated pupils with loss of pupillary response to light. Some patients lose consciousness, with the subsequent development of the so-called lucid interval, after which neurological symptoms progress.

Marked elevation of intracranial pressure classically manifests as a combination of hypertension, bradycardia, and respiratory depression (Cushing's triad). Vomiting may occur, but is nonspecific. Severe diffuse brain damage or marked elevation of intracranial pressure may result in decortication and decorticate rigidity. Both signs make the prognosis unfavorable.

Herniation under the tentorium may cause coma, unilateral or bilateral pupillary dilation and/or pupillary insensitivity to light, hemiplegia (usually on the side opposite the dilated pupil), hypertension, bradycardia, and respiratory depression (shallow and irregular).

Basilar skull fractures may cause CSF leakage from the nose (rhinorrhea) and ears (otorrhea), blood in the tympanic cavity (hemotympanum) or in the internal auditory canal if the tympanic membrane is ruptured, ecchymosis in the postauricular region (Battle's sign), or periorbital ecchymosis (raccoon eyes). Loss of smell, vision, hearing, or facial nerve function may occur immediately or delayed. Other skull fractures may be palpable, especially through a soft tissue wound, as an indentation or step deformity. It should be remembered that step deformity may be simulated by blood under the aponeurosis.

Patients with chronic subdural hematomas may complain of headaches that increase during the day, abnormal (fluctuating) sleepiness or “head fuzzy” (which may mimic early dementia), and mild to moderate hemiparesis.