3Nervous SystemNervous System – provides overall control of thought, sensation, and the voluntary and involuntary motor functions of the body. The major components of the nervous system are the brain and the spinal cord.Central Nervous System – consists of the brain and spinal cordPeripheral Nervous System – the nerves that enter and exit the spinal cord between the vertebrae and the twelve pairs of cranial nerves that travel between the brain and organs without passing through the spinal cord, and all of the body’s other motor and sensory nervesAutonomic Nervous System – controls involuntary functions such as heartbeat, breathing, control of the diameter of your vessels, control of the round sphincter muscles closing your bladder and bowel and digestion
4Nervous SystemBrain – controlling organ of the body and the center of consciousness; occupies the entire space within the cranium, and each type of brain cell has a specific function and certain parts of the brain perform certain functionsSpinal Cord – consist of long tracts of nerves that join the brain with all body organs and parts, and protected by the spinal columnNerves – sensory nerves send information to the brain on what the different parts of the body are doing relative to their surroundings while the motor nerves carry messages from the brain and result in stimulation of a muscle or organ*** Prior to traveling down the spinal cord, they cross over the opposite side of the body, which means that the nerves originating from the right side of the brain, control the left side of the body and vice versa ***
5Functions of the Central Nervous System AutomaticReflexConsciousVoluntary control of musclesInvoluntary control of muscles
6Skull and Facial BonesCranium - the portion of the skull that encloses the brain (formed by the forehead, top , back and upper sides of the skull). The cranial floor is the inferior wall of the brain case. The bones are fused together.Facial Bones – 14 irregularly shaped bones that form the face, which are fused into immovable joints except the mandible
7Skull and Facial Bones CRANIUM FACE Orbit Nasal bones Zygomatic Skull (houses and protects the brain; consists of the cranium and the face)Cranium (houses and protects the brain)CRANIUM(Surrounds the eyes)OrbitNasal bonesZygomatic(cheek bones)(Provides some structure of nose)Maxilla(fused bones of theUpper jaw)FACEMandible(lower jaw bone)
8Contents of the Skull Bone Dura mater Arachnoid Pia mater Epidural space (potential)Subarachnoid spaceSubdural spaceIntracerebralArachnoidDura materSkullPia mater
9Spinal Column(made up of 33 vertebrae, which are the separate bones of the spinal column)
10Corresponding Anatomy Spinal ColumnDivisionCorresponding AnatomyNumber of VertebraeCervicalNeck7ThoracicThorax, ribs, upper back12LumbarLower back5SacralBack wall of pelvisCoccyxTailbone4
11Spinal ColumnSpinous Process – the bony bump on a vertebra – you can feel this on a person’s backSpinal Cord – travels through the hollow portion of the each vertebraCerebral Spinal Fluid – the fluid that surrounds the brain and spinal cord
13Spinal Injury Considerations Thoracic spine is usually not injured due to the sternum and spinePelvic-sacral spine attachment helps to protect the sacrum in the same wayCervical and lumbar are more injury prone due to no other support by bony structures
14Mechanisms of Spinal Injury CompressionFallsDiving accidentsMotor vehicle accidentsExcessive Flexion, Extension, and RotationLateral Bending
15Mechanisms of Spinal Injury DistractionPulling apart of the spineHangings
16Mechanisms of Spinal Injury Maintain a high index of suspicionMotor Vehicles crashesPedestrian – vehicles collisionsFallsBlunt TraumaPenetrating trauma to the head, neck and torsoMotorcycle crashesHangingsDiving accidentsUnconscious trauma victims
19Signs & Symptoms of Spinal Injuries Ability to walk, move extremities or feel sensation; or lack of pain or numbness to spinal column does not rule out the possibility of spinal column or cord damage. DO NOT check for ROMTenderness in the area of injuryPain associated with
20Signs & Symptoms of Spinal Injuries Pain independent of movement or palpation (do not intentionally check for this)Along spinal columnLower legsMay be intermittentObvious deformity of the spine upon palpation – rare sign in the field
21Signs & Symptoms of Spinal Injuries Soft tissue injuries associated with traumaHead, neck and cervical spineShoulders, back or abdomen – thoracic/lumbarLower extremities – lumbar/sacralNumbness, weakness or tingling in the extremities – paralysis is probably the most reliable sign of spinal cord injury in conscious patients – check for PMS
22Signs & Symptoms of Spinal Injuries Loss of sensation or paralysis below the suspected level of injuryLoss of sensation or paralysis in the upper or lower extremitiesIncontinencePriapismPosturing
23Signs & Symptoms of Spinal Injuries Impaired breathing – if little or no movement of the chest, the patient is breathing with the diaphragm alone; reversal of normal breathing patterns with the rib cage collapsing on inspiration and rising on expiration; “C–3, –4, –5 keep the diaphragm alive”Severe spinal shock – neurogenic shock can be caused by the failure of the nervous system to control the diameter of the blood vessels
24Assessing Spinal Injury Questions to ask:What happened?Where does it hurt?Does your neck or back hurt?Continued…
25Assessing Spinal Injury Responsive PatientMOIQuestions 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?
26test for a painful response. DO NOT ask the patientto move to try to elicita painful response. Donot move the patient totest for a painful response.
27Assessing Spinal Injury Inspect for DCAP-BTLSAssess quality of strength of extremitiesHand gripGently push feet against handsAssess distal pulses
32Assessing Spinal Injury Unresponsive PatientMOIInitial assessmentInspect for:ContusionsDeformitiesLacerationsPunctures/PenetrationsSwellingPalpate for areas of deformity and tendernessObtain information from others at the scene to determine information relevant to mechanism of injury or patient mental status prior to the EMT-B’s arrival
33Complications of Spinal Injury Patients with head and spine injuries may be unable to maintain their own airway and breathes on their own. Airway management is essential with every patient. Such patients require cervical spine precautions. Consider:Loss of consciousnessForeign materialsSwellingUnstable bone fracturesParalysisWaist down = paraplegicNeck down = quadriplegic
34Treating Spinal Injury Take BSI precautions.Establish and maintain in-linePlace the head in a neutral (eyes looking forward) position unless the patient complains of pain or the head is not easily moved into positionMaintain constant manual in-line immobilization until the patient is properly secured to a backboard with the head immobilized
35Treating Spinal Injury Perform initial assessmentWhenever possible, airway control must be done with in-line immobilization, using the jaw-thrust maneuverWhenever possible, artificial ventilation must be done with in-line immobilization, using the jaw-thrust maneuverAssess PMS in all extremities.Assess the cervical region and neck
36Treating Spinal Injury Apply a rigid, cervical immobilization device.Properly size the cervical immobilization device. If it doesn't fit use a rolled towel and tape to the board and have rescuer hold the head manually.An improperly fit immobilization device will do more harm than good. A collar that is too large will hyperextend the neck, a collar that is too small could cause flexion, and a collar that is too loose could allow for lateral movement. A collar that is too tight could interfere with the patient’s airway.
37Treating Spinal Injury If found in a lying position, immobilize the patient to a long spine boardMove the patient onto the device by log-rolling him/her(1) One EMT-Basic must maintain in-line immobilization of the head and spine.(2) EMT-Basic at the head directs the movement of the patient.(3) One to three other EMT-Basics control the movement of the rest of the body.(4) Quickly assess posterior body if not already done in focused history and physical exam.(5) Position the long spine board under the patient.
38Treating Spinal Injury Patient found lying on back continued…(6) Place patient onto the board at the command of the EMT-Basic holding in-line immobilization using a slide, proper lift, log roll or scoop stretcher so as to limit movement to the minimum amount possible. Which method to use must be decided based upon the situation, scene and available resources.(7) Pad the void under the shoulders of the infant and child to establish a neutral position.(8) Immobilize torso to the board.(9) Secure the legs to the board.(10) Immobilize the patient's head to the board.(11) Reassess pulses, motor and sensation and record.
39Treating Spinal Injury If found in a sitting position, immobilize the patient with a short spine immobilization device. Exception: If the patient must be removed urgently because of his injuries, the need to gain access to other, or dangers at the scene, he/she must then be lowered directly onto a long board and removed with manual stabilization
40Treating Spinal Injury Secure the patient onto the device by :Position device behind the patient.Secure the device to the patient's torso.Evaluate torso fixation and adjust as necessary without excessive movement of the patient.Secure the patient’s legs to the device.Secure the patient's head to the device.Insert a long board under the patient's buttocks and rotate and lower him to it. If not possible, lower him to the long spine board.Reassess pulses, motor and sensory in all extremities and record.
41Treating Spinal Injury If the patient is found in the standing position, immobilize the patient to a long spine board using the “standing takedown” methodTake BSI precautionsTallest crew member should be behind patient and have him manually stabilize the had and neck – this person remains here until the patient is strapped to the boardA second EMT applies a properly sized cervical collar to the patientThe second EMT and another EMT place a long board behind the patient being careful not to disturb the positioning of the 1st EMTs stabilization of the patientThe second EMT looks at the long board from the front and does any necessary repositioning
42Treating Spinal Injury “Standing takedown” method contiued…(6) The second and third EMTs reach arm that is nearest patient under patient’s armpits and grasp the long board; to keep the patient’s arms secure, they will use other hand to grasp the patient’s arm just above elbow and hold it against body(7) The second and third EMTs grasp a handhold on the spine board at patient’s armpit level or higher(8) Slowly the board is lowered to the ground on the command of EMT at the head (EMT at the head is walking backwards, and the other two EMTs are walking slowly and evenly). The two EMTs that are on the sides of the board are moving into a squatting position so as not to injure their backs.(9) The EMT at the head never lets go of the patient’s head until he/she is fully immobilized on the back board
47Treating Spinal Injury “Standing takedown” method contiued…If the patient is critically injured, perform a rapid extricationIf the patient has paralysis or weakness of the extremities, administer high-concentration oxygen via non-rebreatherIf the patient is pregnant, once she is secured to the board, tilt the backboard onto its left side and support with pillowsReassess sensory and motor function in all four extremitiesTransport the patient immediately
49Head Injuries – Overview Injuries to the scalpVery vascular, may bleed more than expectedInjuries to the braininjury of the brain tissue or bleeding into the skull will cause an increase of pressure within the skull
50Brain Injury – Non-traumatic May occur due to clot or hemorrhageCan be a cause of altered mental statusSigns and symptoms may parallel those of traumatic injury (but no trauma)
51Skull Injury – Traumatic Open head injury – when the bones of the cranium and face fracture, and the overlying scalp is laceratedClosed head injury – when the scalp is lacerated, but the cranium remains intact
52Signs & Symptoms of Skull Injuries Mechanism of TraumaContusion, laceration, hematoma to the scalpDeformity to the skullBlood/fluid from ears or noseBruising around eyes (raccoon's eyes)Bruising behind ears (Battle’s Sign)
53Brain InjuriesWhenever you suspect skull or brain injury, also suspect spine injuryTraumaticConcussion – mild closed head injury without detectable damage to the brain; caused by an indirect force when the head is struck by a blunt object or comes into contact with the floor/ground after a fall, a certain amount of force is transferred through the skull to the brainContinued….
54Brain InjuriesLaceration – a cut to the brain can occur from the same forces that cause a contusionContusion – bruised brain; can occur with closed head injuries, when the force of the blow if great enough to rupture blood vessels on or within the brainCoup – when the bruising of the brain occurs on the side of the blowContrecoup – when the bruising of the brain occurs on the side opposite the blowContinued…
55Brain InjuriesHematoma – collection of blood within tissue; when a hematoma develops, pressure inside the skull increases making it difficult for normal blood flow to enter the head. This causes blood pressure to increases, and as a result of decreased blood flow, the brain becomes starved for oxygen and high in waste carbon dioxide, causing even more swelling. Also, head injury may cause decreased respiratory effort, which further worsens oxygen starvation and swelling in the brain.Subdural hematoma – collection of blood between the brain and the duraEpidural hematoma – blood between the dura and the skullIntracerebral hematoma – occurs when blood pools within the brain
56Signs & Symptoms of Brain Injuries Altered or decreasing mental status is the best indicator of brain injuryConfusion, disorientation, or repetitive questioningConscious – derteriorating mental statusUnresponsivePersonality change – ranging from irritable to irrational behavior
57Signs & Symptoms of Brain Injuries AVPUAlert – awake and oriented; can understand you and obey requestsVerbal – inappropriate words, sounds, confused; doesn’t answer questions appropriatelyPain – patient responds to pressure on sternum or nail bedUnresponsive – patient does not respond in any way to any stimulationIrregular breathing pattern
58Signs & Symptoms of Brain Injuries Elevated blood pressure with decreasing pulse (Cushing’s Triad)Consideration of MOIDeformity of windshieldDeformity of helmetContusion, laceration, hematoma, or deformity to the scalp or forehead – do not probe or separate to discover wound depthDeformity to the skull, visible bone fragments, pieces of brain tissue
59Signs & Symptoms of Brain Injuries Blood/fluid from ears or noseBruising around eyes (raccoon's eyes)Bruising behind ears (Battle’s Sign)Neurologic disabilityNausea/vomiting – projectileUnequal/unreactive pupil size with altered mental status; one eye may appear to be sunken; blurred or multiple-image vision in one or both eyes
60Signs & Symptoms of Brain Injuries Seizure activity may be seenIncontinencePriapismPosturing – patient may exhibit flexing arms and wrists and extending legs and feet (decorticate posture) or extending arms with the shoulders rotated inward and wrists flexed, legs extended (decerebrate posture) – typically after a painful stimulus
61Signs & Symptoms of Brain Injuries Severe pain at the site of the injuryTemperature increase – late signImpaired hearing or ringing in the earsEquilibrium problemsDeteriorating vital signs
62Emergency Care of Head Injuries BSI.Initial assessment. Maintain airway/artificial ventilation/oxygenation using the jaw-thrust method. If patient is unconscious, insert an oropharyngeal airway. Have suction ready because these patients are likely to vomit. Monitor the unconscious patient for changes in breathing and be prepared to assist if necessary. If the patient shows signs of a critical brain injury (increased blood pressure with decreased pulse, fixed and dilated pupils, altered mental status), hyperventilate the patient at a rate of 20 – 24 breaths per minute (Hyperventilation will help reduce brain tissue swelling by lowering CO2 levels and increasing O2 levels, but it will also decrease blood flow to the brain).
63Emergency Care of Head Injuries With any head injury, suspect spinal injury. Apply a rigid cervical collar and immobilize the neck and spine. Determine method of extrication (rapid, standing take-down, etc…)Closely monitor the airway, breathing, pulse, and mental status for deterioration. Keep the patient at rest and calm. Talk to the patient, providing emotional support and asking him/her questions that he/she will have to concentrate on.Control bleedingDo not apply pressure to an open or depressed skull injury.Dress and bandage open wound as indicated in the treatment of soft tissue injuries – loose gauze dressings.
64Emergency Care of Head Injuries If a medical condition exists, place patient on the left side (i.e. pregnant female)Be prepared for changes in patient condition. Manage the patient for shock even if signs are not yet present. DO NOT elevate the legs unless signs of shock are present and protocols permit. DO NOT overheat.Immediately transport the patient.Monitor vital signs every 5 minutes.Complete a Prehospital Care Report. Document all pertinent findings of the patient assessment; treatment; and transport decisions.
66Cervical Spine Immobilization Devices IndicationsAny suspected injury to the spine based on mechanism of injury, history or signs and symptoms.Use in conjunction with short and long backboards.SizingVarious types of rigid cervical immobilization devices exist, therefore, sizing is based on the specific design of the device.An improperly sized immobilization device has a potential for further injury.
67Cervical Spine Immobilization Devices Sizing cont’d…Do not obstruct the airway with the placement of a cervical immobilization device.If cervical immobilization device cannot be applied, consider using a rolled towel and tape to the board and manually support the head. An improperly fitted device will do more harm than good.PrecautionsCervical immobilization devices alone do not provide adequate in-line immobilization.Manual immobilization must always be used with a cervical immobilization device until the head is secured to a board.
75Short Spine BoardsSeveral different types of short board immobilization devices existVest typeRigid short spine boardProvides stabilization to the head, neck, torsoUsed to immobilize non-critical sitting patients with suspected spinal injury
76Applying a Short Board Immobilization Device (KED)
87Long Spine BoardsProvides stabilization and immobilization to the head, neck, torso, pelvis, and extremities.May be applied in:Lying, standing, and sitting positionsConjunction with short spine boards
88Maintain stabilization Assess PMS in all extremities Assess the cervical area and apply collar
90Performing the Log Roll Move the patient onto the device by log roll, suitable lift or slide, or scoop stretcher. A log roll is:One EMT-Basic must maintain in-line immobilization.EMT-Basic at the head directs the movement of the patient.One to three other EMT-Basics control the movement of the rest of the bodyQuickly assess posterior body if not already done in initial assessmentPosition the long spine board under the patientRoll patient onto the board at the command of the EMT-Basic holding in-line immobilization.
91Move patient onto board Move patient onto board. Apply padding to voids especially of the infant/child
92Immobilize torso to the board by applying straps across the chest and pelvis – adjustas needed. Immobilize the patient’s headto the device.
95Rapid Extrication Indications Unsafe scene Unstable patient condition Patient blocks EMT–B’s access to an unstable patientRapid extrication is based on time and the patient, not the EMT-Bs preference
96Rapid Extrication Should be limited to life/death situations Does not provide optimal spinal stabilizationUse with “C” or “U” patientsUse when the patient’s safety is compromised
112The second EMT places one hand on the mandible at the angle of the jaw and theother hand posterior at theoccipital region.
113The EMT-B holding the helmet pulls the sides of the helmet apart and gently sips the helmet halfwayoff the patient’s head and then stops.
114The EMT-B holding maintaining stabilization of the neck, repositions, slides the posterior hand superiorly to secure the head from from falling once helmet is removed.
115The helmet is removed completely The helmet is removed completely. Begin routine stabilization and immobilization.
116Helmet Odds – n – Ends Leave helmet in place for transport when/if: There is only one trained rescuerThe patient’s breathing is not compromised and immobilization in neutral position is possibleAttempts to remove the helmet will compromise the patient’s conditionRemove a helmet prior to transport when clinically indicated and more than one trained rescuer is presentHelmets may be stabilized using:TapeHead BlocksRolled BlanketsCommercial Devices
118Infants and ChildrenInfants and children - immobilize the infant or child on a rigid board appropriate for size (short, long or padded splint), according to the procedure outline in the spinal immobilization section.Infant and Child Seats - If infant or child is already in a child protective seat, and is stable immobilize in place.Special Considerations:Pad from the shoulders to the heels of the infant or child, if necessary to maintain neutral immobilization.If cervical immobilization device cannot be applied, consider use a rolled towel and tape to the board and manually support the head. An improperly fitted device will do more harm than good.
120Cervical Spine Injury Immobilize the entire spine Movement of the torso effects the stability of the cervical spine.Partial immobilization increases the risk of a torque effect.Cervical spine pain may mask injuries to the lower spine
121Long Board Immobilization Cot mattress does not provide stabilityLong board providesStabilityFacilitates patient transferCot StrapsDo not immobilize patient to boardMust be removed for patient transfers, loosing all securityDo not permit “rolling” an immobilized patient who might be vomiting
122DisclaimersOpening the Airway with a suspected spinal cord injury; use the modified jaw thrust maneuver without head tilt.Use manufactures recommendations in the use of immobilization devicesComplete the Prehospital Care ReportDocument all pertinent findings of patient assessment; pre and post treatment; and transport decisions.