Risk & Rescue
Head injury in the field: what to watch for over the next hours
The dangerous head injuries are not always the ones that look bad at the time. Some deteriorate over hours, which is why observation matters as much as the initial assessment.
Head injuries in the outdoors range from a knock that produces a headache to a life-threatening bleed inside the skull. The difficulty is that these can look similar in the first minutes, and the serious ones sometimes appear fine initially and worsen later.
What follows is general guidance, not a substitute for training or for medical advice — anyone spending serious time in remote terrain should take a wilderness first aid course.
Immediate priorities
Assume a neck injury with any significant head impact. Any mechanism that hits the head hard enough to cause concern can injure the cervical spine, and the two travel together. Keep the head and neck still and aligned, and do not move the casualty unless there is an immediate danger.
Check the basics: are they responsive, are they breathing, is there major bleeding. Scalp wounds bleed dramatically and look alarming; direct pressure controls them and the appearance is not a guide to severity.
Note the time. Everything that follows is about change over time, and you need a baseline.
Establishing a baseline
Record what you find, in writing if you can, because memory is unreliable and a handover to a rescue team is far more useful with times attached.
Level of responsiveness: are they fully alert, do they respond to your voice, only to pain, or not at all. Are they oriented — do they know who they are, where they are, roughly what time it is, and what happened.
Pupils: are they equal in size and do they react to light. Unequal pupils are a significant finding.
Was there loss of consciousness, and for how long. Any memory gap for events before or after the impact.
Then repeat the same checks every fifteen minutes or so, and write down the results with times.
The signs that mean evacuate now
Any of these, at any point, means this is a serious emergency requiring urgent professional care:
Deteriorating level of consciousness — someone who was alert becoming drowsy, confused or unresponsive. This is the most important single sign.
A worsening headache, particularly one described as severe.
Repeated vomiting.
Seizure.
Unequal or unreactive pupils.
Clear or blood-stained fluid from the nose or ears.
Weakness, numbness or loss of coordination on one side.
Slurred speech, or increasing confusion and agitation.
Any loss of consciousness lasting more than a very brief moment.
The lucid interval is the pattern that catches people out: an injured person who seems fine for a period and then deteriorates. That is why observation continues even when someone appears to have recovered.
Concussion, which is common and still serious
A concussion can occur without loss of consciousness. Typical signs: headache, dizziness, nausea, sensitivity to light or noise, feeling slowed down or foggy, difficulty concentrating, unusual emotional responses, and memory gaps.
Someone concussed should not continue the activity. Not the same day, not "once they feel better". Judgement, balance and reaction time are impaired, which in climbing, paddling or steep terrain is dangerous in itself. A second impact before recovery is significantly more damaging than the first.
Recovery from concussion should be managed with medical advice, with a graded return to activity. The urge to push through is strong and it is wrong.
While you wait or move
Keep them still, warm and insulated from the ground. Do not give food or drink if there is any chance they will need an anaesthetic or if their consciousness is impaired.
Do not give painkillers that affect bleeding without medical advice. Keep talking to them — it is both reassuring and a continuous assessment.
If they are unresponsive but breathing and you have no reason to suspect a spinal injury, the recovery position protects the airway. Where spinal injury is likely and you must protect the airway, keep the head aligned and use a jaw thrust technique. These are exactly the manoeuvres that are far easier having been taught them once.
The default
When in doubt, evacuate. Head injuries are the category where cautious over-reaction costs an aborted trip and under-reaction costs far more, and the assessment tools available in the field are limited.
A helmet is the prevention. It does not eliminate the risk, but the difference between helmeted and unhelmeted head injuries in climbing, skiing and paddling is stark, and it is one of the few pieces of protective equipment whose benefit is not seriously disputed.
