Many of the outdoor sports and the more extreme activities that we love, carry the risk of a head injury. Whether you are mountain biking, skiing, rock climbing, playing football in the park, or simply on a hike, there is potential for a head injury from a fall, crash, or whiplash from rapid head movement.

Traumatic brain injury (TBI) is an umbrella term physicians use that covers a wide range of injuries from a mild concussion, to internal bleeding inside the skull, and even a coma.

So how do we differentiate different types of traumatic brain injuries and when should we really be concerned?

Fainted girl helped by an old woman – Teenager trying to get back on her feet while receiving support from an elder

Concussions

Approximately 3.8 million concussions occur in the United States annually because of sport and recreation, with up to 50% of concussions going unreported. In the last ten years alone we’ve seen a 200% increase in emergency department visits for concussion, as our awareness in society overall has increased.

A concussion is defined as a mild traumatic brain injury that is caused by a direct blow or a transmitted force to the head (like from rapid acceleration, deceleration, or rotational movement). It causes impaired neurological function or brain damage that resolves on its own over hours, days, or weeks.

A concussion is clinically diagnosed from noticeable symptoms of the patient and based on the source of the initial head injury. Unfortunately, there is no way of capturing a concussion from a CT scan or MRI. Traditionally, it was thought that someone could not sustain a concussion if they did not lose consciousness, but we now know this to not be true and you can certainly have a concussion without losing consciousness.

What are the symptoms of a concussion?

Concussion symptoms can vary. The onset of concussions can be delayed and they can last for a variable amount of time from person to person.

Common symptoms of a concussion include:

Amnesia or loss of memory of what happened
Headache
Dizziness
Photophobia or sensitivity to light
Nausea, vomiting
Confusion
Mood swings or becoming very emotional

What happens to your brain during a concussion?

Before, it was thought that during the point of impact, the brain briefly lags behind as the head moves forward and then rapidly catches up, setting in motion an oscillation where the brain smashes into one side of the skull and then rebounds to the other (known as “coup-contrecoup” or French for “blow-counterblow”) damaging the outer surfaces of the brain.

Now, medical research suggests it’s more likely that the brain as a whole actually moves very little within the skull. Instead, the twisting and turning of the head can cause the brain tissue to stretch and transmit force down to the center of the brain. This theory that the inflammation and injury from the transmitted force affects the deeper tissues of the brain, is consistent with MRI scans in NFL players who have had persistent traumatic head injury.

Further research has shown that it is actually the stretching and compression of the deeper brain structures that disrupt these neural pathways, not the exterior of the brain, as was previously understood.

Symptoms of severe traumatic brain injury

Beyond a concussion, more severe traumatic brain injury includes significant changes in how the brain is functioning in regards to level of awareness, movement, and responsiveness.

Traumatic brain injury may be an indication of bleeding inside or around the brain. This can happen while the person is awake, so it is important to pay attention to the person’s behaviors. It’s worth noting one does not have to lose consciousness with this type of injury.

Serious symptoms of severe traumatic brain injury include:

Persistent confusion or agitation
Slurred speech
Weakness or numbness to part of the body
Loss of coordination
Blurred vision
Worsening headache
Persistent vomiting

four images of helmets in outdoor activities - white water rafting, skiing, rock climbing, and mountain biking

Helmet safety

When it comes to head injury prevention, as medical doctors, we cannot emphasize the importance of helmets enough. Helmets made out of bronze and leather were first used by Assyrian soldiers over 3,000 years ago. So keep in mind, real warriors wear helmets.

Today’s helmets are made of a hard plastic shell with foam on the inside which dissipates the energy of impact to reduce the force applied to your head.

Helmets in cycling have been shown to reduce the risk of severe traumatic brain injury by over 50% and reduce the risk of death by 44%. While helmets prevent lacerations, skull fractures and more severe head injuries, they were not traditionally protective against concussions.

Recent advances in helmet design have incorporated a slippery layer inside the helmet that allows helmet movement independent of the skull. This “MIPS” technology (which stands for ”Multi-directional Impact Protection System”) is built to absorb energy and redirect rotational forces from the brain, theoretically reducing the potential for concussions.

Follow these helmet safety tips:

Whatever outdoor sport you choose, make sure you know your limits and that you have the proper helmet for the correct activity. While any head protection is better than nothing, helmets are specifically designed for different activities.
If you happen to damage a helmet, be sure to replace it. They are not meant to be reused after a serious accident.
Lastly, when fitting a helmet, ensure it fits comfortably and is not too loose.

damaged red helmet, blue glove finger pointing to the damage, ambulance in the background

What to do when witnessing a head injury

With any injury or accident in the wilderness, scene safety is the first consideration. Make sure it’s safe for you to reach the injured person; there’s no use in putting your own safety at risk. Move everyone involved to a safe place where you can begin to assess the injured person for any head injuries with the following steps:

Check for consciousness. If the person is unconscious, check their breathing and pulse.
If they are alert, ask basic questions such as ‘Do you know where we are?’ or ‘What is your name?’
Evaluate for other body injuries.
- Stop any external bleeds with applied pressure.
- If you are concerned about a neck or spine injury, avoid moving the person and keep their head and neck stabilized until you can seek help. GOES can walk you through these steps with step-by-step visual guides.
If the person is alert and aware, then continue to monitor their symptoms for any traumatic brain injury.
- Remember, concussion symptoms can take time to develop, so pay close attention to any behavioral changes.
- In rare cases, the injury may cause an epidural hematoma which is an area of bleeding outside of the brain. This can cause an initial “lucid period” where the person seems okay at first, but their mental state rapidly declines as the bleeding worsens. If you notice behavior changes, this warrants immediate medical attention and evacuation.

Special risk populations and further considerations

People who take blood thinners are at a 7 -10 times greater risk of bleeding around and inside the brain from even a minor head injury. As always, medical history is important information. Before taking a trip, be sure you know if anyone in your group is on any blood thinner medications.
People older than 65 years of age are at greater risk of bleeding after head injury due to age-related changes including more fragile bridging veins and brain volume loss. Have a low threshold to seek medical care for these populations.
Children also may be more difficult to assess because they aren’t able to describe their symptoms as clearly as an adult.

When to get a CT scan in children

Research has shown that in children a CT scan of the head should be considered in the following situations after a head injury:

Confusion, agitation, or other altered level of consciousness
Loss of consciousness
Source of injury: bike accident without a helmet, falls from 3 ft or higher, head struck by a high impact object, thrown from a vehicle, etc.
Persistent vomiting
Severe headache
For children younger than 2: large area of swelling of the scalp somewhere other than the forehead or not acting normally.

MRI CT scans of the human brain

Is it ok for a person with a head injury to go to sleep?

Yes, they can go to sleep, but what is more important is if they can be woken up!

It is an old wive’s tale to not let a person sleep after a head injury. However, the most important thing is to monitor a person’s mental status and symptoms. If someone develops more severe symptoms (such as confusion, vomiting, seizures, erratic behavior, or excessive drowsiness) or if they cannot be woken, then you need to seek out medical attention immediately.

Know when to evacuate

Suffering a mild head injury does not always require having to end your trip early or seeking immediate medical care. GOES is here to empower people to know what to do in specific scenarios.

If you feel comfortable knowing the person’s risk profile and monitoring their symptoms, then allow them to rest. Avoid additional strenuous activity and be sure that they are drinking plenty of water. Knowing our limits, practicing prevention and safety, and recognizing mild and severe head injury symptoms will ensure we all can get back home safely.

Every scenario could be different during a head injury. GOES Health’s first aid guide can calmly walk you through an emergency situation and help you determine when to evacuate. Download GOES Health to learn and explore more.

Head injuries in the outdoors: Signs, symptoms, and what to do in the moment