Neurological Injury Management Neurological Injury Management

Objectives Objectives Review the anatomy and physiology of the nervous system and spinal column Review the anatomy and physiology of the nervous system and spinal column Identify the types and mechanisms of head and spine injuries, and describe their features Identify the types and mechanisms of head and spine injuries, and describe their features Describe the assessment of head and spine injuries Describe the assessment of head and spine injuries

Neurological Injuries Neurological Injuries Responsible for one half of the deaths that occur secondary to trauma Responsible for one half of the deaths that occur secondary to trauma The major cause of long-term disability The major cause of long-term disability Caused most frequently by falls and MVA’s Caused most frequently by falls and MVA’s Can be prevented in part by helmets Can be prevented in part by helmets

Anatomy 101 Neuron: nerve cell Neuron: nerve cell Peripheral neurons (nerves outside of the brain and spinal cord) are sheathed with a protective fatty coating called myelin Peripheral neurons (nerves outside of the brain and spinal cord) are sheathed with a protective fatty coating called myelin Nerve impulses are transmitted across synapses (junctions) Nerve impulses are transmitted across synapses (junctions)

Anatomy 101 Anatomy 101 Central Nervous System: Central Nervous System: Brain Spinal Cord Brain Spinal Cord

Anatomy 101 Peripheral Nervous Peripheral Nervous System: System: spinal nerves and spinal nerves and their branches their branches

Anatomy 201 Meninges: protective triple layer cover Meninges: protective triple layer cover Dura mater = outer layer Dura mater = outer layer Arachnoid = middle layer Arachnoid = middle layer Pia mater = inner layer Pia mater = inner layer Cerebral spinal fluid circulates within the Arachnoid Cerebral spinal fluid circulates within the Arachnoid

Anatomy 201 Brain: Brain: Cerebrum Cerebrum Cerebellum Cerebellum Brainstem Brainstem

Anatomy 201 Cranial Nerves: originate at base of the brain Cranial Nerves: originate at base of the brain Provide sensory/motor supply to the head & face Provide sensory/motor supply to the head & face

Anatomy 201 Motor nerves - brain to muscle units Motor nerves - brain to muscle units Sensory nerves - skin back to brain Sensory nerves - skin back to brain

Anatomy 301 Somatic Nervous System: Voluntary Somatic Nervous System: Voluntary

Anatomy 301 Autonomic Nervous System: Involuntary Autonomic Nervous System: Involuntary

Traumatic Brain Injury Severity depends on the amount of primary and secondary brain injury Severity depends on the amount of primary and secondary brain injury Primary Injury: THE INITIAL TRAUMA Primary Injury: THE INITIAL TRAUMA Main cause of secondary injury : HYPOXIA Main cause of secondary injury : HYPOXIA

Traumatic Brain Injuries Categories: Open or Closed Categories: Open or Closed Open Closed Open Closed

Traumatic Brain Injuries Forces: Shearing and Compressive Forces: Shearing and Compressive Shearing Compressive Shearing Compressive

Types of Traumatic Brain Injury Concussion: Temporary Concussion: Temporary loss or alteration of part loss or alteration of part or all of the brain’s or all of the brain’s abilities to function, abilities to function, without apparent without apparent physical damage physical damage to the brain to the brain

Types of Traumatic Brain Injury Cerebral Contusion: Bruised Brain Cerebral Contusion: Bruised Brain Far more serious Far more serious than a concussion! than a concussion! Involves physical Involves physical injury to the brain injury to the brain May be long-lasting May be long-lasting or permanent or permanent

Types of Traumatic Brain Injury Cerebral Hematoma or Bleed Cerebral Hematoma or Bleed Subdural Subdural Intracerebral Intracerebral Epidural Epidural

Traumatic Brain Injury General Signs & Symptoms Traumatic Brain Injury General Signs & Symptoms Headache Headache Dizziness Dizziness Nausea/vomiting Nausea/vomiting Amnesia Amnesia

Traumatic Brain Injury General Signs & Symptoms Traumatic Brain Injury General Signs & Symptoms Decreasing level of responsiveness Decreasing level of responsiveness Confusion Confusion Combativeness Combativeness Loss of Loss of responsiveness responsiveness

Assessing Traumatic Brain Injuries Level of Responsiveness (LOR) LOR usually corresponds to the extent of loss of brain function LOR usually corresponds to the extent of loss of brain function Progressive deterioration usually indicates serious brain injury Progressive deterioration usually indicates serious brain injury

Assessing Traumatic Brain Injuries Level of Responsiveness (LOR) AVPU SCALE AVPU SCALE A = Alert A = Alert V = Verbal V = Verbal P = Pain P = Pain U = Unresponsive U = Unresponsive Obtain Baseline Obtain Baseline Monitor Frequently (q minutes) Monitor Frequently (q minutes)

The Progressive Downward Spiral The Progressive Downward Spiral Brain Swelling  Brain Swelling  Increased Intracranial Pressure (ICP)  Hypoxia  Hypoxia  Further Secondary Injury  Further Secondary Injury  More Swelling  More Swelling  Increased ICP Increased ICP

Signs Of Increasing Intracranial Pressure The General Signs of Head Injury Described Previously PLUS Change in pupil size and reactivity to light Change in pupil size and reactivity to light Slowing pulse Slowing pulse Rising BP. Rising BP.

Signs Of Increasing Intracranial Pressure The General Signs of Head Injury Described Previously PLUS Change in respiration Change in respiration Unilateral weakness Unilateral weakness Incontinence Incontinence Seizures Seizures

Urgent Interventions Presume C-Spine injury: immobilize neck Presume C-Spine injury: immobilize neck Open airway, administer oxygen Open airway, administer oxygen Do not hyperventilate Do not hyperventilate Treat bleeding and shock Treat bleeding and shock

Urgent Interventions Prevent aspiration of vomit/secretions Prevent aspiration of vomit/secretions Transport immediately Transport immediately Elevate head 6”, Transport head uphill Elevate head 6”, Transport head uphill

The Spine 33 vertebra – 33 vertebra – 7 cervical 7 cervical 12 thoracic 12 thoracic 5 lumber 5 lumber 5 sacral 5 sacral 4 coccygeal 4 coccygeal

The Spine The Spine Typical Vertebra

Bony Spine Injury Signs & Symptoms Bony Spine Injury Signs & Symptoms Usually produced by compression or bending trauma Usually produced by compression or bending trauma Pain at injury site Pain at injury site Localized acute tenderness Localized acute tenderness Self-splinting or guarding Self-splinting or guarding Deformity – usually not obvious Deformity – usually not obvious

Bony Spine Injury Signs & Symptoms Bony Spine Injury Signs & Symptoms Compression-Cervical 4 Compression-Cervical 4

Bony Spine Injury Signs & Symptoms Bony Spine Injury Signs & Symptoms Bending (Flexion) Trauma Bending (Flexion) Trauma Cervical 5 on Cervical 6 Vertebra Cervical 5 on Cervical 6 Vertebra

Spinal Cord Injury Significance of spine injury depends whether spinal cord injured Significance of spine injury depends whether spinal cord injured Spinal Cord damage more common with neck injury than mid/lower back injury Spinal Cord damage more common with neck injury than mid/lower back injury

Spinal Cord Injury Mechanism: axial compression, hyperextension, hyperflexion, rotation Mechanism: axial compression, hyperextension, hyperflexion, rotation The higher the cord injury, the more The higher the cord injury, the more nerve fibers damaged nerve fibers damaged Cervical 5 Thoracic 5 Cervical 5 Thoracic 5

Types of Spinal Cord Injuries Paraplegia - paralysis of both legs Paraplegia - paralysis of both legs Quadriplegia - paralysis of both arms and both legs Quadriplegia - paralysis of both arms and both legs Hemiplegia - paralysis of an arm and leg on the same side Hemiplegia - paralysis of an arm and leg on the same side

Spinal Cord Injury Signs and Symptoms Spinal Cord Injury Signs and Symptoms Abnormal sensation Abnormal sensation Loss of sensation Loss of sensation Muscle weakness or paralysis Muscle weakness or paralysis

Spinal Cord Injury Signs and Symptoms Signs of neurogenic shock Signs of neurogenic shock Difficulty breathing Difficulty breathing Incontinence Incontinence Priapism Priapism

Emergency Care - Spine Urgent interventions for obstructed airway, abnormal breathing, bleeding Urgent interventions for obstructed airway, abnormal breathing, bleeding Stabilize head and neck manually Stabilize head and neck manually Care for other injuries Care for other injuries

Emergency Care - Spine Transfer to spine board with proper technique to minimize movement Transfer to spine board with proper technique to minimize movement Immobilize on long spine board with CID; apply cervical collar Immobilize on long spine board with CID; apply cervical collar