Injuries to the Head and Spine

The Nervous and Skeletal Systems  The nervous system is composed of  Brain  Spinal cord  The nervous system is divided into:  Central nervous system (Brain & Spinal Cord)  Peripheral nervous system

Head Injuries:  Account for about one half of all trauma deaths  Survivors range from baseline function to severe morbidity  Even “minor” head injury can have severe impact  As with most trauma, broken down into blunt and penetrating

 There are certain behaviors that increase the risk of sustaining brain or craniofacial injuries.  These behaviors include: 1.Acute or chronic alcohol ingestion 2.Use of mind-altering drugs 3.Incorrect use or nonuse of motor vehicle safety restraint systems' 4.Nonuse of safety helmets when riding motorcycles or bicycles 5.Participating in team sports without protective equipment"

Injuries to the Brain & Skull  Scalp injuries  Skull injuries  Brain injuries

Scalp Injuries  Scalp has many blood vessels so injury may bleed profusely.  Control bleeding with direct pressure.  Don’t apply pressure when there is possible skull injury.

Skull injuries  It include fractures to the cranium and the face, can be associated with brain injury.  It is divided into:  Open skull fracture: cranium is fractures and scalp is lacerated.  Closed skull fracture: scalp is lacerated but cranium is intact.

Brain Injuries  It is classified into:  Direct injuries to the brain can occur in open head injuries, with brain lacerated, punctured, or bruised by the broken bones or by foreign objects.  Indirect injuries to the brain may occur with either closed or open head injuries. They include: concussions and contusions.

Direct (Primary) Brain Injuries  It can occur in open head injuries  Direct damage done to brain parenchyma  Brain tissue can be lacerated, punctured or bruised by broken bones or foreign bodies  Damage is already done  Irreversible  Damage control (debridement)

Indirect (Secondary) Brain Injury  Damage that occurs after the initial insult  Expanding mass lesions, swelling or bleeding quickly overwhelm buffers  End result is increased intracranial pressure (ICP) and/or herniation  Diagnosis and treatments target minimizing the effects of these indirect insults

S & S of Increased ICP  Early signs and symptoms:  Headache  Nausea and vomiting  Amnesia for events before or after the injury  Altered level of consciousness  Restlessness, drowsiness and changes in speech.  Late signs:  Dilated, non reactive pupil  Unresponsiveness to verbal or painful stimuli  Abnormal motor posturing patterns (e.g., flexion, extension, or flaccidity)  Changes in respiratory rate and frequency  Increased systolic blood  Widening pulse pressure  Decreased pulse rate  The last three signs are known as the Cushing's response

Herniation  Other possible result of insult is to displace brain parenchyma itself  Damage to brain from trauma against the dura itself as well as producing ischemia as well

S & S of Skull Fractures and Brain Injuries  Visible bone fragments  Altered mental status  Deep lacerated or severe bruise or hematoma  Depression or deformity of the skull  Severe pain at site of injury  Battle’s Sign  Unequal or unreative pupils  Raccoon’s eye  Sunken eye  Bleeding from the ears and/or nose  Clear fluid flow from ears and/or nose  Personality change  Increased blood pressure, decreased pulse rate and widening pulse pressure (Cushing’s Syndrome)  Irregular breathing pattern  Temperature increase  Blurred or multiple vision  Impaired hearing or ringing  Equilibrium problems  Forceful or projectile vomiting  Posturing  Paralysis or disability on one side of the body  Seizures  Deteriorating vital signs

ER Care of Skull Fractures and Brain Injuries  Take appropriate body substance isolation precautions.  Assume spine injury  Monitor conscious patient for changes in breathing  Apply rigid collar, immobilize the neck and spine  Administer high concentration oxygen by NRM  Control bleeding  Keep patient at rest  Talk to conscious patient (emotional support)  Dress and bandage open wounds  Mange the patient for shock  Be prepared for vomiting  Transport patient promptly  Monitor vital signs every five minutes

Brain Injuries – Brain Concussion  Usually caused by blunt injuries.  Mild injury usually with no detectable brain damage.  May have brief loss of consciousness.  Headache grogginess and short memory loss are common.

Brain Injuries – Brain Contusion  A bruised brain or contusion can occur with closed head injuries.  Usually caused by blow that causes the brain to hit inside the skull  Unconsciousness or decreased level of consciousness can occur

Brain Injuries – A hematoma  Is a collection of blood within tissue.  Hematoma inside the cranium is named according to its location:  Subdural hematoma: blood collection between brain and dura  Epidural hematoma: blood collection between dura and the skull  Intracerebral hematoma: blood collection within the brain

Subdural Hematomas  Blood beneath the dura, overlying the brain and arachnoid, resulting from tears to bridging vessels  Crescent shaped density that may run length of skull  Very common in the elderly

Epidural Hematomas  Blood between inner table of the skull and the dura  Lens shaped hematomas that do not cross suture lines on CT  Rare in elderly

Intracranial Hematoma  Focal areas of hemorrhage within the parenchyma

Cranial Injuries with Impaled Objects  Don’t remove impaled objects.  Stabilize the object with bulky dressings.

Injuries to the Face and Jaw  S & S:  Eye discoloration  Deformity  Facial bruises  Loose, missing or improperly aligned teeth  Swollen jaw  Management:  The primary concern is the airway.  Use jaw thrust maneuver to open airway  Control bleeding  Apply rigid collar  Care for shock

Injuries to the Spine  Varied mechanisms of injury (flexion, extension, rotation, distraction, compression, lateral flexion, combination of forces)  Mostly blunt, some penetrating  Spinal cord injury obviously feared, particularly for cervical spine  Range from unstable injuries to stable

Common causes of spinal cord injury  Motor vehicle accidents.  Acts of violence.  Falls.  Sports and recreation injuries.  Diseases.

Signs and Symptoms  The signs and symptoms of a spinal cord injury depend on two factors: 1.The location of the injury. 2.The severity of the injury.  Spinal cord injuries are classified as partial or complete, depending on how much of the cord width is damaged. 1.A partial spinal cord injury, which may also be called an incomplete injury, the spinal cord is able to convey some messages to or from the brain. 2.A complete injury is defined by complete loss of motor function and sensation below the area of injury.

Signs and Symptoms  Paralysis of extremities (The most reliable sign in conscious patient)  Pain with/without movement  Tenderness anywhere along the spine  Impaired breathing  Deformity  Priapism  Posturing  Loss of bowel or bladder control  Nerve impairment to the extremities  Severe spinal shock  Soft tissue injury associated with trauma

Diagnostic Procedures  X-rays.  Computerized tomography (CT) scan: is beginning to become the study of choice in many trauma centers and emergency departments  Magnetic resonance imaging (MRI). Myelography.

Emergency Care Steps  Manual stabilization for head and neck  Assess A, B & C  Assess head & Neck and apply rigid cervical collar  Assess sensory & motor function in all extremities  Apply appropriate spinal immobilization device  Administer Oxygen via NRM if patient has paralysis or weakness.  Reassess motor and sensory in all extremities

Steroid Protocol for Spinal Cord Injury  Solumedrol 30 mg/kg bolus followed by infusion 5.4 mg/kg over next 23 hours  Controversy exists