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Introduction to Emergency Medical Care 1

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1 Introduction to Emergency Medical Care 1
Advance Preparation Prepare anatomy models for demonstration. Research related multimedia links for illustration purposes. Reach out to local chapters of head injury/spinal injury foundations for educational resources. Invite a spinal injury patient to class. Prepare immobilization equipment for demonstration purposes. Invite assistant instructors and programmed patients to assist with psychomotor sessions.

2 OBJECTIVES 31.1 Define key terms introduced in this chapter. Slides 13–15, 17, 19, Describe the components and function of the nervous system and the anatomy of the head and spine. Slides 13– Describe types of injuries to the skull and brain. Slides 17–19, 22 continued

3 OBJECTIVES 31.4 Describe the general assessment and management of skull fractures and brain injuries. Slides 22– Describe specific concerns in the management of cranial injuries with impaled objects. Slide 21 continued

4 OBJECTIVES 31.6 Describe specific concerns in the management of injuries to the face and jaw. Slide Define nontraumatic brain injuries. Slide Explain the purpose and elements of the Glasgow Coma Scale. Slide 23 continued

5 OBJECTIVES 31.9 Discuss the assessment and management of open wounds to the neck. Slides 25– List types and mechanisms of spine injury. Slide Discuss the assessment and management of spine and spinal cord injury. Slides 29–31 continued

6 OBJECTIVES 31.12 Discuss issues in the immobilization of the head, neck, and spine, specifically for the following: applying a cervical collar; immobilizing a seated patient, including rapid extrication for high priority patients; applying a long backboard; rapid extrication from a child safety seat; immobilizing a standing patient; and immobilizing a patient wearing a helmet. Slides 34–39 continued

7 OBJECTIVES 31.13 Discuss issues in selective spine immobilization. Slides 28, 30–31

8 MULTIMEDIA Slide 32 Spinal Injuries Video Slide 40 KED Overview Video
These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

9 Understanding the anatomy of the nervous system, head, and spine
Understanding skull and brain injuries and emergency care for skull and brain injuries Understanding wounds to the neck and emergency care for neck wounds continued

10 Understanding spine injuries and emergency care for spine injuries
Understanding immobilization issues and how to immobilize various types of patients with a potential spine injury

11 Topics Nervous and Skeletal Systems Injuries to the Skull and Brain
Wounds to the Neck Injuries to the Spine Immobilization Issues Planning Your Time: Plan 145 minutes for this chapter. Nervous and Skeletal Systems (20 minutes) Injuries to the Skull and Brain (40 minutes) Wounds to the Neck (15 minutes) Injuries to the Spine (30 minutes) Immobilization Issues (40 minutes) Note: The total teaching time recommended is only a guideline.

12 Nervous and Skeletal Systems
Teaching Time: 20 minutes Teaching Tips: Use anatomical models and multimedia graphics to illustrate anatomy and physiology. Present anatomy in terms of protection. Describe how structures are protected and how trauma violates this protection.

13 Nervous System Controls thought, sensations, and motor functions
Central nervous system Brain, spinal cord Peripheral nervous system Vertebral nerves Cranial nerves Body’s motor and sensory nerves Point to Emphasize: The nervous system is divided into two subsystems: the central nervous system and the peripheral nervous system. Talking Points: The major components are the brain and the spinal cord. The skeletal system protects both; the skull protects the brain and the spine protects the spinal cord. Messages from the body to the brain are carried by sensory nerves, and messages from the brain to the muscles are carried by motor nerves. Motor nerves control voluntary movements. Autonomic nerves control involuntary movements. Discussion Topic: Describe the components of the nervous system. Discuss the function of the various components. Knowledge Application: Have students work in small groups. Assign each group a component of the nervous system. Ask the group to research and present on the function of its particular component.

14 Anatomy of the Head Cranium Facial Bones (14) Mandible Maxillae
Nasal bones Malar (zygomatic) Talking Points: The cranium is the portion of the skull that houses the brain. It is made up of various bones completely encapsulating the brain and CSF. The face is made up of 14 different bones, most of which are fused and non-movable. Discussion Topic: Describe the anatomy of the skull. Explain how the skull’s structure protects the brain. Class Activity: Give students a blank diagram of the skull and have them label the major structures. Knowledge Application: Use a programmed patient or model. Demonstrate anatomy based on external landmarks.

15 Anatomy of the Spine Vertebrae Cervical (7) Thoracic (12) Lumbar (5)
Sacral (5) Coccyx (4) Talking Points: Vertebrae are irregularly shaped bones with a hollow space in the middle, which houses the spinal cord. They each have a spinous process that can be felt as bumps along the center of a person’s back. The sacral and coccygeal vertebrae are fused together to form the posterior portion of the pelvis. Discussion Topic: Describe the anatomy of the spinal column. Discuss how the spinal cord is protected. Class Activity: Using a skeleton anatomy model, have students label the regions of the spinal column. Knowledge Application: Line up students to form the five regions of the spinal column. Have each group discuss its role and its vulnerabilities. Critical Thinking: If the brain and spinal cord are so well protected, why are there so many injuries? How does human activity overcome these basic protective structures?

16 Injuries to the Skull and Brain
Teaching Time: 40 minutes Teaching Tips: Take care to differentiate the concept of open and closed head injuries from other open and closed wounds. This often can be confusing. Discuss the role of pressure. Describe how increasing pressure threatens the contents of a closed container. Relate this to the signs of herniation. Emphasize the need for reassessment in brain injuries. Require that students learn the Glascow Coma Scale. It is part of the language of health care. Make it a routine part of practice.

17 Injuries to the Skull and Brain
Scalp injuries Lots of blood vessels Profuse bleeding Skull injuries Open head injury Closed head injury Points to Emphasize: Scalp, skull, and brain are the different classifications of a head injury. These injuries can be further subdivided into concussions, contusions, lacerations, and hematomas. The skull is fractured in an open head injury. The skull is intact in a closed head injury. Talking Points: Scalp injuries should be treated like any other soft tissue injury and controlled via direct pressure then bandage. When the bones of the cranium are fractured and the overlying scalp is lacerated, it is considered an open head injury. If the scalp is lacerated but the cranial bones are intact, it is considered a closed head injury. Discussion Topics: Discuss the difference between a closed head injury and an open head injury. Describe the assessment findings associated with an open head injury.

18 Brain Injuries Traumatic Brain Injuries (TBI) Concussion Contusion
Coup Contrecoup Laceration Hematoma Subdural Hematoma Epidural Hematoma Intracerebral Hematoma Talking Points: Direct injuries to the brain occur in open head injuries, with the brain being lacerated, punctured, or bruised by the broken bones or foreign objects. Indirect injuries occur from shock of an impact on skull that is then transferred to the brain, including concussion and contusions. TBIs may be brief or long term with permanent damage to the brain. In a concussion, patients may not be aware there was an injury and there is usually no detectable damage to the brain. A contusion to the brain will often occur if the force is great enough to cause the brain to rupture blood vessels and then bounce off the opposite side of the skull. Coup is the bruising to the brain on the side of the blow. Contrecoup is the bruising to the opposite side of the brain from the rebound. Lacerations may be caused by the same forces that caused a contusion or from a direct penetration through the cranium. A hematoma is a collection of blood within tissue and is named for its location within the cranium. A subdural hematoma is a collection of blood between the brain and the dura; an epidural hematoma is a collection of blood between the dura and the skull; an intracerebral hematoma occurs when the blood pools within the brain. Knowledge Application: Use a programmed patient to simulate head injury scenarios. Have groups of students practice assessment and appropriate treatment.

19 Intracranial Pressure
Talking Points: There is limited room for expansion inside the skull. When a hematoma expands, it places pressure on the brain, compressing it. Since the skull is solid, the brain is forced to the only open space, the foramen magnum. When the intracranial pressure increases, the blood pressure must increase to pump blood into and perfuse the brain. As the brain and brain stem become severely compressed into the foramen magnum and downward, herniation can occur creating posturing. Discussion Topic: Describe the signs and symptoms of rising intracranial pressure. How would you recognize herniation? Knowledge Application: Present assessment and vital sign trends. Ask students to recognize increasing ICP. What further changes should an EMT anticipate? Critical Thinking: How might the signs of rising intracranial pressure mimic the effects of alcohol intoxication? How might an EMT differentiate the two?

20 Think About It Does my patient have a serious or potentially serious head injury? Should the patient be transported to a trauma center? Do my patient’s complaint and MOI indicate spinal stabilization? Is immobilization warranted?

21 Injuries to the Head and Face
Cranial injuries with impaled objects Stabilize object in place Injuries to the face and jaw Primary concern: Airway When possible, position to allow for drainage from mouth Point to Emphasize: The release of cerebrospinal fluid and the presence of “Battle’s sign”  and “raccoon eyes” can indicate an open head injury.  

22 Nontraumatic Brain Injuries
Many signs of brain injury may be caused by an internal brain event (hemorrhage, blood clot) Signs are the same as for traumatic injury, except no evidence of trauma and no MOI. Class Activity: Describe signs and symptoms of a head injury. Ask the class to decide if it is open or closed. Discuss treatment strategies.

23 Glasgow Coma Scale (GCS)
May use GCS in addition to AVPU for ongoing neurological assessment Considerations for use of GCS Eye opening Verbal response Motor response Do not spend extra time at the scene calculating GCS Point to Emphasize: Constant reassessment of the brain-injured patient is essential. Mental status can deteriorate rapidly, and primary treatments such as airway management may become necessary. Talking Points: Eye opening: Spontaneous means the patient opens eyes without you doing anything. If the eyes are closed and you say, “Open your eyes,” this is response to verbal stimuli. If patient’s eyes remain closed, apply an accepted painful stimuli. Verbal response: Oriented: patient is aware of who he is, where he is, and day of week. Confused: patient cannot answer the previous questions, but can speak in phrases or sentences. Inappropriate words: patient says or shouts a word or several words that do not fit situation or question. Incomprehensible sounds: patient responds with mumbling, moans, or groans. No verbal response: patient does not respond to repeated verbal or physical stimulation. Motor Response: Obeys command: patient is able to follow instruction and carry out request. Localizes pain: patient does not follow commands but attempts to move your hand when applying painful stimulation. Withdraws: patient responds to painful stimuli by making some meaningful movement but not to pull your hand away. Posturing: patient stiffens with arms and legs extended and has an internal rotation of the shoulder and forearm. No motor response: patient makes no motion or grimace to painful stimuli. Knowledge Application: Describe a variety of brain-injured patients and have students assign a GCS score.

24 Wounds to the Neck Teaching Time: 15 minutes
Teaching Tips: Use multimedia graphics to illustrate neck anatomy. Relate the discussion about air emboli to prior discussions about sucking chest wounds. The principles of occlusive dressings are the same. Emphasize the potential for spinal injury in the presence of neck trauma.

25 Wounds to the Neck Large, major vessels close to surface create the potential for serious bleeding Pressure in large vein is lower than atmospheric pressure Great possibility of air embolus being sucked through Treatment: stop bleeding, prevent air embolism Points to Emphasize: Because large arteries and veins lie close to the surface of the neck, the potential for serious bleeding from an open wound is great. Since the pressure in a large vein is likely to be lower than atmospheric pressure, the risk of an air embolus is great. Discussion Topic: Describe the risks of trauma to the neck. Discuss the two major life threats associated with neck wounds. Knowledge Application: Present different types of occlusive dressings. Have students practice application of an occlusive dressing to a neck wound.

26 Treatment: Open Neck Wound
Ensure open airway Place gloved hand over wound Apply occlusive dressing Apply pressure to stop bleeding Bandage dressing in place Immobilize spine if MOI suggests cervical injury Point to Emphasize: Occlusive dressings should be applied to open neck wounds to prevent air emboli. Talking Points: Dressing should be thick material that won’t be sucked into wound. Seal dressing on all sides. When applying pressure, do not compress both carotid arteries at once. When bandaging dressing, take care not to restrict the airway or the arteries and veins of the neck. Discussion Topics: Discuss why an occlusive dressing should be applied to a neck wound. Describe the treatment priorities for treating a patient with a serious neck wound. Knowledge Application: Use moulage (especially moulage blood) and a programmed patient to present neck wound scenarios. Have groups of students practice assessment and treatment. Critical Thinking: What types of injuries to airway structures could a serious neck wound present? What effect on the movement of air could these types of injuries have?

27 Injuries to the Spine Teaching Time: 30 minutes
Teaching Tips: Use an anatomical model or skeleton to demonstrate in-line neutral position. Discuss how moving one part of the spinal column affects other parts. Use multimedia graphics to illustrate different mechanisms of injury. Discuss the potential for particular spinal injuries in each. Use a programmed patient or model to demonstrate proper assessment of the spinal column. Teach a thorough neurological examination. Teach providers to pick up the subtle nerve deficit.

28 Injuries to the Spine Assume possible cervical-spine injury if MOI exerts great force on upper body or if soft-tissue damage to head, face, or neck Spinal cord is a relay between most of body and brain for sending messages Neurogenic shock: form of shock resulting from nerve paralysis; causes uncontrolled dilation of blood vessels Points to Emphasize: Injuries to the spine must be considered whenever there is serious trauma to any part of the body. The spine is injured most often by compression or excessive flexion, by extension, or rotation from falls, by diving injuries, and by motor-vehicle collisions. Talking Points: The cervical and lumbar spine are susceptible to injury because they are not supported by other bony structures. The adult skull weighs more than 17 pounds and rests on a very small area of the cervical spine. Motor-vehicle collisions produce a violent whiplash injury because of the speed and sudden deceleration. A fall can also create enough force to fracture or dislocate vertebrae. Assume that any fall three times the patient’s height will also be accompanied by a spine injury. Diving accidents, when the diver impacts the board or side or bottom of the pool, can cause the head to be forced beyond it’s normal limits of motion causing cervical vertebrae to be fractured or dislocated. A dermatome is an area of the body surface that is innervated by a single spinal nerve. Discussion Topics: Discuss the forces that can cause spinal injuries. Describe different mechanisms of injury and relate them to actual injuries. Explain why some areas of the spine are more vulnerable to injury than others. Define neurogenic shock. Discuss the pathophysiology of hypoperfusion in this type of shock.

29 Assessment: Spinal Injury
Paralysis of extremities Pain without movement Pain with movement Tenderness anywhere along spine Impaired breathing Deformity Priapism Loss of bowel or bladder control Point to Emphasize: Injury to the spine can interrupt nervous system control of body functions. Talking Points: Paralysis of extremities: probably most reliable sign of spinal cord injury in conscious patients. Pain without movement: pain not always constant and may occur anywhere from top of head to buttocks. Pain in leg is common for certain types of injury to lower spine. Other painful injuries can mask this symptom of spinal injury. Pain with movement: patient normally tries to lie perfectly still to prevent pain. Do not ask patient to move just to determine if it will cause pain. However, if the patient complains of pain in the neck or back experienced with voluntary movements, including spinal pain with movement in apparently uninjured shoulders and legs, this is a good indicator of possible spinal injury. Tenderness anywhere along spine: Gentle palpation of the injury site, when accessible, may reveal point tenderness. Discussion Topic: Describe the signs and symptoms of a spinal cord injury. Class Activity: Have students assess the spine of the student sitting next to them. Discuss normal findings and compare them to the signs of injury.

30 Treatment: Spinal Injury
Provide manual in-line stabilization Assess ABC’s Rapidly assess head and neck; apply rigid cervical collar Rapidly assess for sensory and motor function Knowledge Applications: Have students work in small groups. Assign each group a specific mechanism of spinal injury. Have groups research and present on the pathophysiology of their mechanism. Use specific examples. Assign each student a specific sign or symptom of spinal injury. Have the student research and present the pathophysiology that makes his sign or symptom occur. continued

31 Treatment: Spinal Injury
Apply appropriate spinal immobilization device Reassess sensory and motor function Point to Emphasize: In-line immobilization is a key component in the treatment of a spinal injury. Knowledge Application: Use programmed patients to simulate spinal injuries. Have teams of students practice assessment and treatment. Critical Thinking: Does nerve impingement always mean “no feeling”? What are other signs of disruption to the nervous pathway?

32 Spinal Injuries Video Video Clip Spinal Injuries What signs and symptoms might you see in a patient with a cervical injury? How do you measure a cervical collar? Describe how to apply a cervical collar to a patient. Why is manual stabilization of the cervical spine necessary after you apply a cervical collar? Click here to view a video on the subject of treating cervical injuries. Back to Directory

33 Immobilization Issues
Teaching Time: 40 minutes Teaching Tips: Use an anatomical model spine in conjunction with immobilization equipment to demonstrate the procedure for maintaining in-line stabilization. Demonstrate different immobilization devices such as collars, vest-style extrication devices, and backboards. Have appropriate equipment and assistant instructor help on hand to run efficient psychomotor sessions. Use a vehicle to describe the challenges of moving a potential spinal injury patient.

34 Applying a Cervical Collar
Always maintain manual stabilization Use in conjunction with a long backboard Point to Emphasize: Cervical spine immobilization devices are designed to limit flexion, extension, and lateral movement when combined with an immobilization device. Discussion Topic: Describe in-line neutral position. How can you best achieve this in your patient? Describe the steps for measuring and applying a cervical collar. Class Activity: Have students measure the student next to them for a cervical collar. Knowledge Activity: Demonstrate the function of a variety of immobilization equipment such as collars, backboards, and other immobilization devices. Knowledge Application: Using a manikin or programmed patient, practice measuring and applying cervical collars.

35 Immobilizing a Seated Patient
Low priority: Use a short board or vest-immobilization device High priority: Maintain manual stabilization while moving patient Point to Emphasize: High-priority seated patients may be extricated using a rapid extrication technique. Low-priority seated patients will require the application of a short board or vest-style extrication device. Discussion Topic: Describe the technique for immobilizing a seated patient, including the use of rapid extrication and a short board or vest-style extrication device. Knowledge Application: Use an automobile and a programmed patient. Have groups of students practice extrication techniques.

36 Applying a Long Backboard
Log roll patient Pad voids between board and head/torso Secure head last If pregnant, tilt board to left after immobilizing Point to Emphasize: To immobilize a patient using a long board, EMTs should position the patient using a log roll. They should pad void spaces and should secure the patient at the thighs, pelvis, and upper chest, securing the head last. Knowledge Application: Use a programmed patient to simulate spinal injury scenarios. Have teams of students practice immobilization techniques.

37 Standing Patient Rapid takedown
Requires three providers, cervical collar, and long backboard Point to Emphasize: Use a rapid takedown technique to transfer a standing patient to a long backboard. Discussion Topic: Describe the steps for properly transferring your patient to a long backboard. Consider both the log roll and the rapid takedown techniques.

38 Patient Found Wearing a Helmet
When to leave helmet in place Fits snugly, allowing no movement Absolutely no impending airway or breathing issues Removal would cause further injury Proper spinal immobilization can be done with helmet in place Point to Emphasize: Carefully judge the need to remove a helmet. When necessary, assure that appropriate resources are available. continued

39 Patient Found Wearing a Helmet
When to remove helmet Interferes with ability to assess and manage airway Improperly fitted Interferes with immobilization Cardiac arrest Critical Thinking: What are the negative effects of spinal immobilization? Should there be a cost benefit analysis?

40 KED Overview Video Video Clip KED Overview Discuss when it is appropriate to use a KED. Why should you explain to your patient what you are going to do? Explain the steps needed to apply a KED. Why should you place a patient on a long backboard after using the KED? Click here to view a video on the use of a vest-style extrication device. Back to Directory

41 Chapter Review

42 Chapter Review The two main divisions of the nervous system are the central nervous system and the peripheral nervous system. Maintain a high index of suspicion for head or spine injury whenever there is a relevant mechanism of injury. continued

43 Chapter Review Provide cervical spine stabilization before beginning any other patient care when head or spine injury is suspected. Altered mental status is an early and important indicator of head injury. Monitor and document your patient’s mental status throughout the call. continued

44 Chapter Review A traumatic brain injury is any injury that disrupts function of the brain and may include anything from a slight concussion to a severe hematoma. Always secure the torso to the backboard before the head.

45 Remember The key components of the nervous system are the brain and the spinal cord. These organs regulate thought, sensations, and motor functions. The skull, vertebrae, and cerebrospinal fluid efficiently protect the brain and spinal cord. continued

46 Remember In a closed head injury, the skull remains intact. This is dangerous, for the skull is a closed container with little room for bleeding or swelling. Neck wounds are at risk for massive bleeding and air entry, causing emboli. continued

47 Remember The spine is injured most often by compression or excessive flexion, by extension, or rotation from falls, by diving injuries, and by motor-vehicle collisions. These injuries can interrupt nervous system control of body functions. continued

48 Remember In-line immobilization of 33 spinal bones is the essential component of spinal injury immobilization. Specific procedures apply to different immobilization and extrication situations. EMTs should be proficient in handling the basics of these procedures.

49 Questions to Consider Does my patient have a mechanism of injury that would indicate the need for spinal immobilization? Do my patient’s potential head or spine injuries require prompt transport to a trauma center? Talking Points: Have students review the types of MOI that suggest spinal injury. Remind students of the importance of identifying increasing intracranial pressure in their judgment of whether a patient should be promptly transported.

50 Critical Thinking You are treating a patient with a head injury. He has an altered mental status and a significant MOI to the head. Your partner thinks you should hyperventilate. When should you hyperventilate? What are the signs and symptoms that would indicate this is necessary? Talking Points: In some EMS systems, if the patient shows signs of increased intracranial pressure (such as decreased mental status associated with dilated pupils or sluggish pupil reaction, abnormal respiration patterns, increased systolic blood pressure, and a decreased pulse rate), EMTs are instructed to ventilate the patient with supplemental oxygen at the rate of approximately 20 breaths per minute. This slight hyperventilation will help reduce brain tissue swelling by lowering carbon dioxide levels and raising oxygen levels. The procedure is not without risk however. Too much ventilation can decrease blood flow to the brain. It is reserved for patients with critical head injuries, where the benefit is felt to outweigh the risk. Hyperventilating a breathing patient with a bag-valve mask and oral airway is extremely difficult to do and runs a serious risk of inflating the stomach and causing aspiration of stomach contents. Hyperventilation is not a routine part of the management for all head injury patients—only those who are believed to have increasing intracranial pressure.

51 Please visit Resource Central on www. bradybooks
Please visit Resource Central on to view additional resources for this text. Please visit our web site at and click on the mykit links to access content for this text. Under Instructor Resources, you will find curriculum information, lesson plans, PowerPoint slides, TestGen, and an electronic version of this instructor’s edition. Under Student Resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.

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