Chapter 30

30: Head and Spine Injuries

Cognitive Objectives

(1 of 5)

5-4.1

State the components of the nervous system.

5-4.2

List the functions of the central nervous system.

5-4.3

Define the structure of the skeletal system as it relates to the nervous system.

5-4.4

Relate mechanism of injury to potential injuries of the head and spine.

5-4.5

Describe the implications of not properly caring for potential spine injuries.

5-4.6

State the signs and symptoms of a potential spine injury.

Cognitive Objectives

(2 of 5)

5-4.7

Describe the method of determining if a responsive patient may have a spine injury.

5-4.8

Relate the airway emergency medical care techniques to the patient with a suspected spine injury.

5-4.9

Describe how to stabilize the cervical spine.

5-4.10 Discuss indications for sizing and using a cervical spine immobilization device. 5-4.11 Establish the relationship between airway management and the patient with head and spine injuries.

Cognitive Objectives

(3 of 5)

5-4.12

Describe a method for sizing a cervical spine immobilization device.

5-4.13

Describe how to log roll a patient with a suspected spine injury.

5-4.14

Describe how to secure a patient to a long spine board.

5-4.15

List instances when a short spine board should be used.

5-4.16

Describe how to immobilize a patient using a short spine board.

Cognitive Objectives

(4 of 5)

5-4.17

Describe the indications for the use of rapid extrication.

5-4.18

List the steps in performing rapid extrication.

5-4.19

State the circumstance when a helmet should be left on the patient.

5-4.20

Discuss the circumstances when a helmet should be removed.

5-4.21

Identify different types of helmets.

5-4.22

Describe the unique characteristics of sports helmets.

Cognitive Objectives

(5 of 5)

5-4.23

Explain the preferred methods to remove a helmet.

5-4.24

Discuss alternative methods for removal of a helmet.

5-4.25

Describe how the patient’s head is stabilized to remove the helmet.

5-4.26

Differentiate how the head is stabilized with a helmet compared to without a helmet.

Affective Objectives

(1 of 2)

5-4.27

Explain the rationale for immobilization of the entire spine when a cervical spine injury is suspected.

5-4.28

Explain the rationale for utilizing immobilization methods apart from the straps on the cots.

5-4.29

Explain the rationale for utilizing a short spine immobilization device when moving a patient from the sitting to the supine position.

Affective Objectives

(2 of 2)

5-4.30

Explain the rationale for utilizing rapid extrication approaches only when they indeed will make the difference between life and death.

5-4.31

Defend the reasons for leaving a helmet in place for transport of a patient.

5-4.32

Defend the reasons for removal of a helmet prior to transport of a patient.

Psychomotor Objectives

(1 of 3)

5-4.33

Demonstrate opening the airway in a patient with a suspected spinal cord injury.

5-4.34

Demonstrate evaluating a responsive patient with a suspected spinal cord injury.

5-4.35

Demonstrate stabilization of the cervical spine.

5-4.36

Demonstrate the four-person log roll for a patient with a suspected spinal cord injury.

5-4.37

Demonstrate how to log roll a patient with a suspected spinal cord injury using two people.

Psychomotor Objectives

(2 of 3)

5-4.38

Demonstrate securing a patient to a long spine board.

5-4.39

Demonstrate using the short board immobilization technique.

5-4.40

Demonstrate the procedure for rapid extrication.

5-4.41

Demonstrate preferred methods for stabilization of a helmet.

5-4.42

Demonstrate helmet removal techniques.

Psychomotor Objectives

(3 of 3)

5-4.43

Demonstrate alternative methods for stabilization of a helmet.

5-4.44

Demonstrate completing a prehospital care report for patients with head and spinal injuries.

Anatomy and Physiology of the Nervous System

Central Nervous System

Sensory and Connecting Nerves • The connecting nerves in the spinal cord form a reflex arc. • If a sensory nerve in this arc detects an irritating stimulus, it will bypass the brain and send a direct message to a motor nerve.

How the Nervous System Works • The nervous system controls virtually all of our body activities including reflex, voluntary and involuntary activities • Voluntary activities are action that we consciously perform (ie, passing a dish) • Involuntary activities are actions that are not under our control (ie, body functions) • Body functions are controlled by the autonomic nervous system

Autonomic Nervous System • Two components • Sympathetic nervous system – Reacts to stress with a flight or fright response. – Some common responses are dilated pupils, increased pulse rate, or rising BP. • Parasympathetic nervous system – Causes the opposite effect of the sympathetic nervous system

Spinal Column

Anatomy and Physiology of the Skeletal System • • • •

Two layers of bone protect the brain. Skull is divided into cranium and face. Injury to the vertebrae can cause paralysis. Vertebrae are connected by intervertebral disks.

Head Injuries • Scalp lacerations • Skull fractures • Brain injuries • Medical conditions • Complications of head injuries

Scalp Lacerations • Scalp has a rich blood supply. • There may be more serious, deeper injuries.

Skull Fracture • Indicates significant force • Signs – Obvious deformity – Visible crack in the skull – Raccoon eyes – Battle’s sign

Concussion (1 of 2) • Brain injury • Temporary loss or alteration in brain function • May result in unconsciousness, confusion, or amnesia

Concussion (2 of 2) • Brain can sustain bruise when skull is struck. • There will be bleeding and swelling. • Bleeding will increase the pressure within the skull.

Intracranial Bleeding • Laceration or rupture of blood vessel in brain – Subdural – Intracerebral – Epidural

Other Brain Injuries • Brain injuries are not always caused by trauma. • Medical conditions may cause spontaneous bleeding in the brain. • Signs and symptoms of nontraumatic injuries are the same as those of traumatic injuries. – There is no mechanism of injury.

Complications of Head Injury • • • •

Cerebral edema Convulsions and seizures Vomiting Leakage of cerebrospinal fluid

Signs and Symptoms (1 of 3) • Lacerations, contusions, hematomas to scalp • Soft areas or depression upon palpation • Visible skull fractures or deformities • Ecchymosis around eyes and behind the ear • Clear or pink CSF leakage

Signs and Symptoms (2 of 3) • Failure of pupils to respond to light • Unequal pupils • Loss of sensation and/or motor function • Period of unconsciousness • Amnesia • Seizures

Signs and Symptoms (3 of 3) • • • • • •

Numbness or tingling in the extremities Irregular respirations Dizziness Visual complaints Combative or abnormal behavior Nausea or vomiting

Spine Injuries • Compression injuries occur from a fall. • Motor vehicle crashes or other types of trauma can overextend, flex, or rotate the spine. • Distraction: When spine is pulled along its length; causes injuries. – Hangings are an example.

Significant Mechanisms of Injury • • • • • • • •

Motor vehicle crashes Pedestrian-motor vehicle collisions Falls Blunt or penetrating trauma Motorcycle crashes Hangings Driving accidents Recreational accidents

• Your unit is on standby at the All American College during a gymnastic tournament. • A bystander comes to you and states a 19-year-old female gymnast has fallen head first from a balance beam. • You find the patient prone on a rubber mat awake and breathing normal. No threats to life are observed. You are the provider

• What is the mechanism of injury? • What injuries do you suspect? • What is the next step in the assessment process? You are the provider continued

Scene Size-up

• Observe scene for hazards; take BSI precautions. • Anticipate problems with ABCs. • Pay attention for changes in level of consciousness. • Call for ALS backup as soon as possible when serious MOI is present. • Look for a deformed helmet or deformed windshield.

• You manually stabilize the spine and log roll the patient. • You assess the ABCs and place the patient on oxygen via nonrebreathing mask. • She said she felt pain in her neck right away and has tingling in her arms and legs. You begin a rapid trauma assessment. You are the provider continued (1 of 2)

• Why did you do a rapid trauma assessment? • What steps comes next? You are the provider continued (2 of 2)

Initial Assessment

• Ask the patient: – What happened? – Where does it hurt? – Does your neck or back hurt? – Can you move your hands and feet? – Did you hit your head? • Confused or slurred speech, repetitive questioning, or amnesia indicate head injury. • Ask when patient lost consciousness. • Stabilize the spine.

ABCs • Use jaw-thrust maneuver to open airway. • Vomiting may occur. Suction immediately. • Move patient as little as possible. Do not remove c-collar. • Consider providing positive pressure ventilations. • A pulse that is too slow can indicate a serious condition. • Assess and treat for shock.

Transport Decision • If patient has problems with ABCs, provide rapid transport.

• You check for an absence of a distal pulse. Pulse is normal. Bleeding is not noted. • You determine that this patient is a low-priority transport. You are the provider continued (1 of 3)

• What do you need to be sure to ask during the SAMPLE history? • Describe the rest of your emergency care. You are the provider continued (2 of 3)

• You quickly inspect and palpate the chest for DCAP-BTLS. This was unremarkable. • You start the patient on high-flow oxygen. • You apply a cervical collar and immobilize her to a long board. • The patient could vomit. Be ready to reposition the long board and suction. You are the provider continued (3 of 3)

Focused History and Physical Exam

• The absence of pain does not rule out a potential spinal injury. • Do not ask patients with possible spinal injuries to move their neck.

Rapid Physical Exam for Significant Trauma (1 of 2) • Quickly use DCAP-BTLS. • Decreased level of consciousness is the most reliable sign of head injury. • Expect irregular respirations. • Look for blood or CSF leaking from ears, nose, or mouth.

Rapid Physical Exam for Significant Trauma (2 of 2) • Look for bruising around eyes, behind ears. • Evaluate pupils. • Do not probe scalp lacerations. Do not remove an impaled object.

Focused Physical Exam for Nonsignificant Trauma • Watch for change in level of consciousness. • Use Glasgow Coma Scale. • Pain, tenderness, weakness, numbness, and tingling are signs of spinal injury. • May lose sensation or become paralyzed • May become incontinent

Baseline Vital Signs/ SAMPLE History • Complete set of baseline vital signs is essential. • Assess pupil size and reactivity to light; continue to monitor. • Gather as much history as possible while preparing for transport.

Interventions (1 of 2) • Control bleeding. • Fold torn skin flaps back down onto the skin bed. • Do not apply excessive pressure. • If dressing becomes soaked, place a second dressing over it.

Interventions (2 of 2) • Once bleeding has been controlled, secure with a soft self-adhering roller bandage. • Monitor and treat for shock. • Protect airway from vomiting. • Provide immediate transport.

Detailed Physical Exam

• Perform if time permits. • Can help identify subtle or covert injuries

Ongoing Assessment

• Focus on reassessing ABCs, interventions, vital signs. • Communication and documentation – Hospital may prepare better with info from your assessment. – Document changes in level of consciousness. – Include history. – Document vital signs every 5 minutes if unstable, every 15 minutes if stable.

Emergency Medical Care of Spinal Injuries • Follow BSI precautions. • Manage the airway. – Perform the jaw-thrust maneuver to open the airway. – Consider inserting an oropharyngeal airway. – Administer oxygen. • Stabilize the cervical spine.

Stabilization of the Cervical Spine (1 of 3) • Hold head firmly with both hands. • Support the lower jaw. • Move to eyes-forward position.

Stabilization of the Cervical Spine (2 of 3) • Support head while partner places cervical collar. • Maintain the position until patient is secured to a backboard.

Stabilization of the Cervical Spine (3 of 3) • Do not force the head into a neutral, in-line position if: – Muscles spasm – Pain increases – Numbness, tingling, or weakness develop – There is a compromised airway or breathing problems.

Emergency Medical Care of Head Injuries • Establish an adequate airway. • Control bleeding and provide adequate circulation. • Assess the patient’s baseline level of consciousness.

Managing the Airway • • • • • • •

Establish an adequate airway. Use the jaw-thrust maneuver. Maintain head in neutral, in-line position. Place cervical collar. Suction. Provide high-flow oxygen. Continue to assist ventilations and administer oxygen.

Circulation • • • • •

Begin CPR if patient is in cardiac arrest. Blood loss aggravates hypoxia. Shock can occur. Transport immediately to trauma center. If patient becomes nauseated or vomits, place on left side.

Preparation for Transport: Supine Patients (1 of 2) • Maintain in-line stabilization. • Have the other team members position the immobilization device. • Log roll patient.

Preparation for Transport: Supine Patients (2 of 2) • Secure patient to backboard. • Reassess pulse, motor, and sensory function in each extremity and continue to do so periodically.

Preparation for Transport: Sitting Patients (1 of 2) • • • •

Maintain manual in-line stabilization. Apply a cervical collar. Place a short board behind patient. Position device around patient.

Preparation for Transport: Sitting Patients (2 of 2) • Turn patient and lower to long backboard. • Secure short and long backboards together. • Reassess the pulse, motor function, and sensation.

Preparation for Transport: Standing Patients • Stabilize the head and neck and apply a cervical collar. • Position board behind patient. • Carefully lower the patient to the ground.

Applying a Cervical Collar (1 of 2) • One EMT-B provides continuous manual in-line support of the head. • Measure the proper size collar.

Applying a Cervical Collar (2 of 2) • Place the chin support snuggly under the chin. • Wrap the collar around the neck. • Ensure that the collar fits.

Backboards • Short backboards – Used on patients found in a sitting position • Long backboards – Provide full-body immobilization

Helmet Removal (1 of 4) • Is the airway clear and is the patient breathing adequately? • Can airway be maintained and ventilations assisted with helmet in place? • How well does the helmet fit? • Can the patient move within the helmet? • Can the spine be immobilized in a neutral position with the helmet on?

Helmet Removal (2 of 4) • A helmet that fits well prevents the head from moving and should be left on, as long as: – There are no impending airway or breathing problems. – It does not interfere with assessment and treatment of the airway. – You can properly immobilize the spine.

Helmet Removal (3 of 4) • Open the face shield. • Prevent head movement. • Partner places hands. • Gently slip helmet off halfway.

Helmet Removal (4 of 4) • Partner slides hands from occiput to back of head. • Remove helmet. • Stabilize spine. • Apply cervical collar. • Pad as needed.

Pediatric Needs (1 of 2) • Immobilize a child in the car seat, if possible.

Pediatric Needs (2 of 2) • Children may need extra padding to maintain immobilization. • Children may need extra padding under the shoulders.