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

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.

Central and Peripheral Nervous System

Brain

Layers of the Brain

Blood Supply to the Brain

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

Skull

Base of the Skull

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

Mechanism of Injury – Compression Forces

Mechanism of Injury – Hyperflexion

Mechanism of Injury – Hyperextension

Lateral Bending Distraction Pulling apart of the spine Example: Hanging

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

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

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.

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)

Motor and Sensory Function – Upper Extremities

Motor and Sensory Function – Lower Extremities

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

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?

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

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

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

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

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

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.

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

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

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

Structural vs. Metabolic Findings

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

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.

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

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

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

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

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

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

Concussion – More Severe Brain contusion Vision loss Paralysis Sensory deficits

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

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

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

Abnormal Posturing

Respirations Abnormal respiratory patterns

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

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.

Epidural Hematoma

Subdural Hematoma

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

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

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

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

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

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

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

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.

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.

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

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.

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.

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.

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

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

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

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.

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

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

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

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.