1. Injuries to the Head and Spine
Chapter 29
Injuries to the Head and Spine

2. Case History
You respond to a 60-year-old man who fell while riding a motorcycle without a helmet. He has a contusion on the left side of his forehead and fluid leaking from his nose, mouth, and ears. He is verbally combative but cannot move his upper and lower extremities.

3. Central and Peripheral Nervous System

4. Brain

5. Layers of the Brain

6. Blood Supply to the Brain

7. Skeletal System Provides structure and support Protects vital organs
Allows movement, in conjunction with muscles

8. Skull

9. Base of the Skull

10. Nerve Cells and Pressure
Nerve cells are very sensitive to pressure.
When pressure is applied to nerve cells, function becomes compromised.
Determinants of injury from pressure:
The amount of pressure applied on nerve
The period of time over which it is applied

11. Mechanism of Injury – Compression Forces

12. Mechanism of Injury – Hyperflexion

13. Mechanism of Injury – Hyperextension

14. Lateral Bending Distraction Pulling apart of the spine
Example: Hanging

15. High Index of Suspicion for Spinal Injury
Motor vehicle crashes
Pedestrian vs. vehicle collisions
Falls
Blunt trauma

16. High Index of Suspicion for Spinal Injury
Penetrating trauma to head, neck, or torso
Motorcycle crashes
Hangings
Diving accidents
Unconscious trauma victims

17. Spinal Injuries – Signs and Symptoms
Tenderness in the area of injury
Pain associated with moving
Do not ask the patient to move to try to elicit a pain response.
Do not move the patient to test for a pain response.
Tell the patient not to move while you are asking questions.
Normal function does not rule out spinal injury.

18. Spinal Injuries – Signs and Symptoms
Pain independent of movement or palpation
Along spinal column
Lower legs
May be intermittent
Obvious deformity of the spine on palpation
Soft tissue injuries associated with trauma
From head and neck to cervical spine
Shoulders, back, or abdomen (thoracic, lumbar region)
Lower extremities (lumbar, sacral region)

19. Motor and Sensory Function – Upper Extremities

20. Motor and Sensory Function – Lower Extremities

21. Loss of Sensation and Function Below Level of Injury
Loss of sensation and paralysis
C4: clavicles
T4: nipple line
T10: navel
L1: groin
Level of injury – respiratory paralysis
Above C3, complete paralysis/respiratory arrest
Below C5, intercostals and abdominals, diaphragmatic breathing only
Upper or lower extremities
Incontinence

22. Assessment of Spine-Injured Responsive Patient
Mechanism of injury
Questions to ask
Does your neck or back hurt?
What happened?
Where does it hurt?
Can you move your hands and feet?
Can you feel me touching your fingers?
Can you feel me touching your toes?

23. Assessment of Spine-Injured Unresponsive Patient
Mechanism of injury
Initial assessment
Inspect for
Contusions
Deformities
Lacerations
Punctures/penetrations
Swelling

24. Assessment of Spine-Injured Unresponsive Patient
Palpate for areas of tenderness or deformity.
Obtain information from others.
Mechanism of injury
Mental status

25. Complications Inadequate breathing effort Paralysis
Prepare for positive-pressure ventilation.
Maintain manual inline stabilization.
Paralysis

26. Emergency Medical Care
Body substance isolation
Determined by presenting problem
Goggles
Gloves
Mask
Gown

27. Critically Injured Patient
Perform a rapid extrication.
Bring body into alignment.
Transfer to long board without short spine board.
Transport immediately.

28. Injuries to the Head – Structural
Specific sections of the brain are injured.
Brain lacerations
Brain contusions
Blockage of vessels (stroke)
Injuries can be traumatic or nontraumatic.

29. Structural Injuries – Signs and Symptoms
Result in localized findings (unilateral)
Unequal pupils
One-sided paralysis
One-sided sensory loss

30. Metabolic Injuries Interruption of energy needed for cell life
Poisoning
Hypoxia
Low blood sugar

31. Metabolic Injuries – Signs and Symptoms
Symmetrical findings
General signs of CNS dysfunction

32. Structural vs. Metabolic Findings

33. Secondary Complications of Brain Injury
Hypoxia
Hypotension
Hypoglycemia
Infections
Increased intracranial pressure

34. Significance of Secondary Complications
Occur with direct brain injury
Aggravate brain function
Management is important to overall care.
Treatment prevents further injury to the brain.

35. Injuries to the Brain and Skull
Most common cause of traumatic death
May be immediate
May occur over time
Rapid recognition and management is key.
Access to surgical intervention is critical.
Immobilization, airway, and ventilation
Key to prehospital care

36. Injuries to the Brain and Skull
Scalp
Skull fracture
Concussion
Increased intracranial pressure
Epidural hematoma
Subdural hematoma

37. Related Nontraumatic Conditions
Clots or hemorrhage
Nontraumatic brain injuries
Can be a cause of altered mental status
Signs and symptoms parallel those of traumatic injuries
No evidence of trauma
Lack of mechanism of injury

38. Skull Injury – Signs and Symptoms
Mechanism of trauma
Scalp injuries
Contusions
Lacerations
Hematomas
Deformity to the skull

39. Skull Injury – Signs and Symptoms
Blood or fluid leakage from the ears or nose
Bruising around the eyes
Bruising behind the ears (mastoid process)

40. Concussion Transient loss of consciousness or neurologic function
Many degrees of injury
Least severe
Momentary loss of function immediately after injury
Short period of confusion

41. Concussion – More Severe
Brain contusion
Vision loss
Paralysis
Sensory deficits

42. Signs of Increased Intracranial Pressure
Conscious patients
Headaches
Nausea
Vomiting (sometimes projectile)
Alterations in consciousness may occur
Sleepy
Responds to verbal stimuli
Responds to painful stimuli
Unresponsive

43. Signs of Increased Intracranial Pressure in Children
Drowsiness, nausea, vomiting
Even after minor head injury
Worsening may be due to
Hypoxia
Hypotension
Other causes

44. Eye and Motor Findings Unilaterally dilated pupil
May not constrict with light
Eyelid may droop
Unilateral weakness, paralysis, sensory loss, or a combination may be seen.
As pressure increases, motor and sensory findings may affect both sides.
With further deterioration, abnormal postures or positions may be seen.
Eventual flaccidity

45. Abnormal Posturing

46. Respirations
Abnormal respiratory patterns

47. Pulse and Blood Pressure
Late sign of increased intracranial pressure
Pulse slows.
Blood pressure increases.

48. Epidural Hematoma
Requires rapid recognition and early surgical intervention
Usually presents with short period of unconsciousness after blunt trauma to head, followed by lucid interval, then decrease in LOC
Blown pupil on side of injury
Weakness and sensory impairment on opposite side of body
Abnormal respiratory pattern
Abnormal posturing
Possible high blood pressure and slow pulse
If left untreated, death occurs.

49. Epidural Hematoma

50. Subdural Hematoma

51. Brain Injury – Signs and Symptoms
Altered or decreasing mental status
Confusion, disorientation, or repetitive questioning
Best indicator of a brain injury
Unresponsive
Irregular breathing pattern
Consideration of mechanism of injury
Deformity of windshield
Deformity of helmet

52. Brain Injury – Signs and Symptoms
Contusions, lacerations, hematomas to scalp
Deformity to skull
Blood or fluid leakage from ears and nose
Bruising around eyes
Bruising behind ears (mastoid process)
Neurologic disability
Nausea and/or vomiting
Unequal pupil size with altered mental status
Seizure activity may be seen

53. Open Head Injury – Signs and Symptoms
Bruising around eyes
Bruising behind ears (mastoid process)
Nausea and/or vomiting
Brain injury
Possible signs and symptoms of a closed head injury

54. Glasgow Coma Scale Objective assessment of mental status
Three parameters
Eye opening
Verbal response
Motor ability

55. Eye Opening Scores 4 – Open spontaneously (no stimuli)
3 – Open to verbal stimuli
2 – Open to painful stimuli
1 – Do not open

56. Verbal Response Scores 5 – Alert and oriented
4 – Confused (attention can be maintained)
3 – Inappropriate (attention cannot be maintained)
2 – Incomprehensible sounds
1 – No response

57. Motor Ability Scores 6 – Obeys verbal commands
5 – Localized to pain (reaches to source of pain)
4 – Withdraws (rolls or moves from pain)
3 – Flexion (flexes arms to pain)
2 – Extension (extends arms to pain)
1 – No response to pain

58. Emergency Medical Care
Use personal protection measures.
Suspect spinal injury; immobilize spine.
Maintain airway/artificial ventilation/oxygenation.
Perform initial assessment.
Immobilization spine.
Complete detailed physical examination en route.

59. Emergency Medical Care
Monitor
Airway, breathing, pulse, and mental status
Control bleeding.
Do not apply pressure to open or depressed skull
Dress and bandage open wound.

60. Emergency Medical Care
Nontraumatic injury
Place patient on the left side.
Be prepared for changes in patient’s condition.
Transport immediately.

61. Cervical Spine Immobilization Devices – Indications
Any suspected injury to the spine, based on
Mechanism of injury
History
Signs and symptoms
Used in conjunction with short and long backboards.

62. Cervical Spine Immobilization Devices – Precaution
Cervical immobilization devices alone do not provide adequate inline immobilization. Maintain manual immobilization until the head is secured to the board.

63. Long Backboards
Several different types of long board immobilization devices exist.
Provide stabilization and immobilization to the head, neck and torso, pelvis, and extremities.
Use to immobilize patients found in a lying, standing, or sitting position
Use in conjunction with short backboards.

64. Rapid Extrication Unsafe scene Unstable patient condition
Patient blocking access to a seriously injured patient
Based on
Time
Patient condition
Not the EMT’s preference

65. Rapid Extrication Apply C-collar before move. Perform smoothly.
Coordination from lead person is key.
Secure to long spine board after removal.

66. Helmet Removal – Special Assessment Needs
Ability to gain access to airway and breathing
Fit of the helmet
May prevent proper spinal immobilization
Patient movement within the helmet

67. Indications for Leaving Helmet in Place
Fit of helmet is good with little or no movement of head.
Helmet does not impede airway or cause breathing problems.
Removal would cause further injury to the patient.
Proper spinal immobilization could be performed with helmet in place.
Helmet does not interfere with the ability to assess and reassess airway and breathing.

68. Indications for Helmet Removal
Inability to assess and/or reassess airway and breathing
Restriction of adequate airway or breathing management
Improperly fitted helmet
Inability to perform proper spinal immobilization because of helmet
Cardiac arrest

69. Types of Helmets Sports Motorcycle Typically open anteriorly
Easier access to airway
Motorcycle
Full face guard
Shield
Other

70. General Rules – Helmet Removal
Technique depends on type of helmet.
Remove patient’s eyeglasses before removing the helmet.

71. Infants and Children
Require same attention to spinal immobilization as adults
Pad spine boards from the shoulders to the heels
Accounts for larger head in proportion to rest of body
If C-collar does not fit properly, use rolled towel and tape.
Transport in car seat if assessment, treatment, and immobilization can be accomplished.