These notes are for guidance only - hillwalkers are advised to attend a Mountain First Aid course [Search]. These notes are copyright © Ian Roy, 1992 and are reproduced here with permission from Boots Across Scotland. I have tried to stay as close as possible to the original text adding only where I thought appropriate.

Head Injuries on the Hill

Almost no head injury is so serious that it should be despaired of, nor so trivialthat it should be ignored. Less than 1% of head injuries need surgery, but if needed it is needed as soon as possible. Urgent evacuation in this instance is vital.

Causes of head injury:

  • Damage sustained during a fall.
  • Head struck by rock/ice fall or equipment.
  • Always wear protetcive headgear when climbing or there is a risk of rockfall.

There is no First Aid for actual brain injuries but a great deal can be done to prevent death or further injury which can be caused by:

  • Further rockfall or avalanche.
  • Blocked airway.
  • Neck injuries.
  • Serious blood loss.

INJURY from further ockfall can be prevented by:

  • Rescuers moving with caution.
  • Sheilding the casualty.
  • Moving the casualty to safety.

DEATH resulting from a Blocked Airway may be prevented by:

  • Sweeping fluid, vomit, etc out of the mount with fingers.
  • Turning the casualty onto their side, head downhill, allowing their tongue to fall forward and fluid in air passages to drain out of their mouth.
  • Holding jaw forward to keep tongue off back of throat.
  • Pulling head back slightly to maintain open airway.
  • Inserting plastic airway into the casualty's mouth over their tongue if this is needed by a deeply unconcious casualty. It should be inerted only if it slips easily into place - it should never be forced in. If the casualty gags then it is not needed. (Moisten plastic airway and insert hooked end up to roof of mouth thenrotate down into throat when in position.)
  • Keeping careful watch on casualty's breathing.
    Noisy breathing (snoring, gurgling, croaking) is a sign of an obstructed airway, not a head injury. Clear out the mouth again and re-adjust the head backwards. If breathing stops immediately begin blowing air into casualty's mouth or nose. Continue until breathing restarts.

REMEMBER: Many more people die as a result of an obstructed airwat than from a neck/head injury. Maintaining an open airway comes first - protecting a spinal injury takes second place.


About 15% of casualties with a serious head injury will also have a broken neck. Always suspect a neck injury especially if there is neck pain, stiffness or a lower level of consciousness. There is likely to be a fracture, dislocation or muscle/ligament damage.

Forget that old adage "never move a spinal injury for any reason". That bad advise could have fatal results. The golden rule to remember is: Avoid Unecessary Movement.

However, in some cases an unconscious casualty may die unless he is turned onto his side to releive obstructed breathing, maintain an open airway and allow fluid to drain from their mouth. Saving life is more important that the possible risk of spinal injury.

Risk of further neck injury can be lessened by:

  • Applying some kind of firm neck splint before moving.
  • First using onl "jaw thrust" to open the airway. Head tilt should be carried out if "jaw thust" is unsuccessful. The first 11° of head tilt should not affect the spine anyway.
  • Carefully log rolling an unconscious casualty onto his side using two or three helpers and keeping the casualty's head in the same relative position to their body during and after the movement.


Serious Blood Loss from a scalp wound is no indication of the severity of a head injury. Generally, bleeding can be stopped by applying pressure to a pad with the casualty sitting up (if conscious).


  • Even a small bump or bruise on the head may be a sign of a far more serious head injury.
  • Large, soft "boggy" swelling under the scalp may be a sign of a fractured skull.
  • Bruising around the eyes (Panda effect) or behind the ears may be a sign of a fractured skull.
  • Clear, colorless, oily fluid dripping or seeping from the casualty's ear may be a sign of a fracture at the base of their skull; this is a very serious injury. The fluid may also be straw coloured, or pink or even red if it is mixed with blood.Never attempt to stop this seepage by plugging the ear or nose but turn the casualty onto their injured side abd allow the seepage to drain into a pad.
  • Don't forget the possibility of serious blood loss from a wound in another part of the body that could be hidden from view by bulky clothing.


Every climber's fear is that a head injury may have caused brain damage. A casualty with a really bad head injury and severe brain damage is likely to get worse and die. If the injury is not so bad the casualty is likely to improve.

The brain is a delicate, spongy tissue protected by the skull and a colourless, oily liquid in which it floats.

The most common injury, concussion, is simply the result of the brain being swirled about in this fluid.

The brain is well supplied with blood by many small blood vessels which can be torn. Blood escaping from these cannot escape and causes pressure against the brain with seriois, and somtimes fatal, results. Bruising and swelling can also cause pressure.

A fractured skull may result in a peice of broken bone being pushed into the brain causing pressure and bleeding and a scalp wound at the fracture site may allow infection into the brain.

Types of Brain Injury

  • CONCUSSION - Shaken, not damaged.
  • LOCAL DAMAGE - Bruised, torn or bleeding in one specific part of the brain.
  • CLOT COMPRESSION - Swelling or bleeding causing pressure against the brain.
  • DIFFUSE INJURY - severe, massive, widespread injury causing immediate deep unconsciousness with the risk of an obstructed airway.


The brain has been shaken but it has not been damaged, causing only a breif spell of confusion or unconsciousness. The casualty may feel sick or be unable to remember what happened.

If there is no unconsciousness after the fall or blow it is reasonable to assume that there is no serious injury to the head.

If the unconsciousness lasted no more than two or three minutes then the casualty may appear normal and feel able to get up and walk. In these circumstances you should check:

  • HIS MEMORY: Asking simple questions, adding single digit numbers.
  • HIS VISION: Eliminate blurred or double vision.
  • CO-ORDINATION: Get the casualty to touch the end of their nose with their finger, starting with an outstretched arm and with their eyes closed.
  • HIS BALANCE: Ensure they can walk in a straight line.
The casualty should be escorted of the hill by at least two helpers. He should NEVER be allowed to go off alone in case of later collapse.


Warning signs will be present that should alert you to the possibility of brain damage. These should be actively looked for and noted:

  • Confused.
  • Dizzy.
  • Feeling sick.
  • Slurred speech.
  • Impaired vision.
  • Headache.
  • Drowsy.
  • Heavy breathing.
  • Fluid seeping from ear/nose.
  • High temperature.
  • Twitching.
  • Fitting.
  • Weakness or paralysis down one side of the body.

Danger signs that the casualty's conditions is worsening:

  • Deepening unconsciousness.
  • Pupils are different sizes, become dilated or are slow to respond to light.
  • Slowing pulse rate.


Send for help immediately, giving accurate details of the casualty's location, their injuries and condition. Try to treat their other serious injuries and protect them from hypothermia. Maintain an open airway and monitor their breathing.

Vital Help you can give the emergency services is to take a written onte of the casualty's changing condition every 15 minutes stating the time the measurements were recorded. Record:

  1. Their Level of Consciousness. Either
    • Alert - aware of events and speaking normally.
    • Speech confused or slurred - only answering questions.
    • Obeying simple commands (eg Look at me. Squeeze hand.)
    • Responds to pain. (Pinch cheeck/Rub eyebrow.)
    • Unresponsive - no response to any of the above.
  2. Pupils: look at both pupils simultaneously and compare them - draw what you see (small/large/different sizes).
  3. Take Pulse Rate: How many times does their heart beat per minute. Feel at throut or listen to their chest.

There may sometimes be a temporary improvement in the casualty's level of consciousness, even a period of apparent full reovery (called a lucid interval) - this is warning of clot compression.

An accurate record showing changes in condition with the times noted and sent with the casualty will be of tremendous help once they reach hospital.

These notes are for guidance only.
Hillwalkers and climbers are strongly advised to attend a (Mountain) First Aid Course.
© Ian Roy, 1992.