1. Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Injuries to the Head and Spine Chapter 29

2. Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. 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. Slide 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Central and Peripheral Nervous System

4. Slide 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Brain

5. Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Layers of the Brain

6. Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Blood Supply to the Brain

7. Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Skeletal System  Provides structure and support  Protects vital organs  Allows movement, in conjunction with muscles

8. Slide 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Skull

9. Slide 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Base of the Skull

10. Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mechanism of Injury – Compression Forces

12. Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mechanism of Injury – Hyperflexion

13. Slide 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mechanism of Injury – Hyperextension

14. Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Lateral Bending  Distraction  Pulling apart of the spine  Example: Hanging

15. Slide 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. High Index of Suspicion for Spinal Injury  Motor vehicle crashes  Pedestrian vs. vehicle collisions  Falls  Blunt trauma

16. Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. High Index of Suspicion for Spinal Injury  Penetrating trauma to head, neck, or torso  Motorcycle crashes  Hangings  Diving accidents  Unconscious trauma victims

17. Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Motor and Sensory Function – Upper Extremities

20. Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Motor and Sensory Function – Lower Extremities

21. Slide 21 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 22 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 23 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment of Spine-Injured Unresponsive Patient  Mechanism of injury  Initial assessment  Inspect for  Contusions  Deformities  Lacerations  Punctures/penetrations  Swelling

24. Slide 24 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment of Spine-Injured Unresponsive Patient  Palpate for areas of tenderness or deformity.  Obtain information from others.  Mechanism of injury  Mental status

25. Slide 25 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Complications  Inadequate breathing effort  Prepare for positive- pressure ventilation.  Maintain manual inline stabilization.  Paralysis

26. Slide 26 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emergency Medical Care  Body substance isolation  Determined by presenting problem Goggles Goggles Gloves Gloves Mask Mask Gown Gown

27. Slide 27 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Critically Injured Patient  Perform a rapid extrication.  Bring body into alignment.  Transfer to long board without short spine board.  Transport immediately.

28. Slide 28 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 29 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Structural Injuries – Signs and Symptoms  Result in localized findings (unilateral)  Unequal pupils  One-sided paralysis  One-sided sensory loss

30. Slide 30 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Metabolic Injuries  Interruption of energy needed for cell life  Poisoning  Hypoxia  Low blood sugar

31. Slide 31 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Metabolic Injuries – Signs and Symptoms  Symmetrical findings  General signs of CNS dysfunction

32. Slide 32 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Structural vs. Metabolic Findings

33. Slide 33 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Secondary Complications of Brain Injury  Hypoxia  Hypotension  Hypoglycemia  Infections  Increased intracranial pressure

34. Slide 34 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 35 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 36 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Injuries to the Brain and Skull  Scalp  Skull fracture  Concussion  Increased intracranial pressure  Epidural hematoma  Subdural hematoma

37. Slide 37 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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. Slide 38 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Skull Injury – Signs and Symptoms  Mechanism of trauma  Scalp injuries  Contusions  Lacerations  Hematomas  Deformity to the skull

39. Slide 39 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

40. Slide 40 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Skull Injury – Signs and Symptoms  Blood or fluid leakage from the ears or nose  Bruising around the eyes  Bruising behind the ears (mastoid process)

41. Slide 41 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

42. Slide 42 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Concussion  Transient loss of consciousness or neurologic function  Many degrees of injury  Least severe Momentary loss of function immediately after injury Momentary loss of function immediately after injury Short period of confusion Short period of confusion

43. Slide 43 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Concussion – More Severe  Brain contusion  Vision loss  Paralysis  Sensory deficits

44. Slide 44 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

45. Slide 45 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Signs of Increased Intracranial Pressure in Children  Drowsiness, nausea, vomiting  Even after minor head injury  Worsening may be due to  Hypoxia  Hypotension  Other causes

46. Slide 46 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

47. Slide 47 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Abnormal Posturing

48. Slide 48 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Respirations  Abnormal respiratory patterns

49. Slide 49 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Pulse and Blood Pressure  Late sign of increased intracranial pressure  Pulse slows.  Blood pressure increases.

50. Slide 50 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

51. Slide 51 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Epidural Hematoma

52. Slide 52 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

53. Slide 53 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Subdural Hematoma

54. Slide 54 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

55. Slide 55 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

56. Slide 56 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

57. Slide 57 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

58. Slide 58 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

59. Slide 59 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Glasgow Coma Scale  Objective assessment of mental status  Three parameters  Eye opening  Verbal response  Motor ability

60. Slide 60 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Eye Opening  Scores  4 – Open spontaneously (no stimuli)  3 – Open to verbal stimuli  2 – Open to painful stimuli  1 – Do not open

61. Slide 61 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

62. Slide 62 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

63. Slide 63 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

64. Slide 64 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

65. Slide 65 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emergency Medical Care  Nontraumatic injury  Place patient on the left side.  Be prepared for changes in patient’s condition.  Transport immediately.

66. Slide 66 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

67. Slide 67 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

68. Slide 68 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

69. Slide 69 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

70. Slide 70 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Rapid Extrication  Apply CISD before move.  Perform smoothly.  Coordination from lead person is key.  Secure to long spine board after removal.

71. Slide 71 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Helmet Removal – Special Assessment Needs Ability to gain access to airway and breathingAbility to gain access to airway and breathing  Fit of the helmet  May prevent proper spinal immobilization  Patient movement within the helmet

72. Slide 72 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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.

73. Slide 73 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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

74. Slide 74 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Helmets  Sports  Typically open anteriorly  Easier access to airway  Motorcycle  Full face guard  Shield  Other

75. Slide 75 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. General Rules – Helmet Removal  Technique depends on type of helmet.  Remove patient’s eyeglasses before removing the helmet.

76. Slide 76 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 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 CSID does not fit properly, use rolled towel and tape.  Transport in car seat if assessment, treatment, and immobilization can be accomplished.

77. Slide 77 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.