1. Hamburg High School EMT Program
Head & Spine Injuries
Hamburg High School
EMT Program

2. Nervous System Components
Central Nervous System
Brain
Spinal Cord
Peripheral Nervous System
Motor nerves
Sensory nerves

3. Brain Body’s controlling organ Weighs 3 lbs.
Responsible for organizing functions of other body organ systems
Meninges – 3 thin tough membranes covering the brain/spinal cord

4. Brain Functions localized to specific areas Cerebrum Cerebellum
Brainstem

5. Cerebrum Frontal lobe Parietal lobe Temporal lobe Occipital lobe
Center for conscious perception, thoughts, personality, feeling – “You”
Frontal lobe
Foresight, planning, judgment
Movement
Parietal lobe
Sensation from body surface
Temporal lobe
Hearing
Speech
Occipital lobe
Vision

6. Cerebrum Left side of cerebrum Right side of cerebrum
Sensory, motor functions of body’s left side
Sensory, motor functions of body’s right side

7. Cerebellum
Posture
Balance
Equilibrium
Fine motor skills

8. Pons – “Bridge” Connects cerebrum, cerebellum and medulla
Coordinate communication between brain and spinal cord

9. Brain Stem Automatic functions below level of consciousness Heart rate
Respirations
Blood pressure
Body temperature

10. Medulla Oblongata
Top of the cord – controls heart rate, respirations, blood pressure

11. Cerebrospinal Fluid (CSF)
Surrounds brain, spinal cord in space between arachnoid and pia mater (subarachnoid space)
High in glucose to provide nourishment for the brain
Acts as a shock absorber
Protects brain from jolts, shocks

12. Spinal Cord Connects brain with body through a long tract of nerves
Surrounded and protected by spinal column
Damage cuts brain off from body structures distal to injury site

13. Spinal Regions Cervical – neck C1 – C7 Thoracic – (chest) T1 – T12
Lumbar – (lower back) L1 – L5
Sacral – (sacrum) 5 fused vertebrae
Coccyx – (tail bone) 4 fused vertebrae
Spinal regions most vulnerable to injury are the cervical and lumbar

14. Peripheral Nerves
Brain
Spinal Cord
Sensory Nerves
Motor Nerves

15. Nerves Sensory Nerves Motor Nerves
Send information to the brain on what the different parts of the body are doing relative to their surroundings
Motor Nerves
Cause stimulation of a muscle or organ

16. Functions of Central Nervous System
Automatic
Reflex
Conscious
Voluntary control of muscles
Involuntary control of muscles

17. Injuries to Brain and Skull

18. Scalp Lacerations VERY vascular area
Control bleeding with direct pressure
Can distract EMT from possible underlying injuries
Care for laceration, but ask yourself, “WHAT HAPPENED TO BRAIN AND NECK?”

19. Scalp Lacerations
Bleeding usually NOT severe enough to produce hypovolemic shock
Exceptions
Laceration that involves a large artery
Scalp injuries in children.

20. Injury to the Brain
Injury of the brain tissue or bleeding into the skull will cause an increase of pressure within the skull

21. Skull Fractures Indicates significant force
What happened to brain and neck?

22. Types of Skull Fracture
Linear
Most common
Crack in skull
Detected only on x-ray
Comminuted
Multiple cracks radiate from impact point (egg shell fracture)

23. Types of Skull Fracture
Depressed
Bone fragments pressed inward
Places pressure on brain
Brain tissue may be exposed through injury
Basilar
Fractures in floor of skull
Diagnosis made clinically
Signs and symptoms
Periorbial ecchymosis (Raccoon eyes)
Battle’s sign
CSF drainage from nose, ears

24. Skull Injury – signs and symptoms
Contusions, lacerations, hematomas to the scalp
Deformity of the skull
Unequal pupil dilation
Blood or fluid (cerebrospinal fluid) leakage from the ears or nose
Bruising around the eyes (raccoons eyes) Bruising behind the ears (battle sign)
DO NOT TRY TO STOP FLOW OF BLOOD, FLUID FROM NOSE OR EARS

25. Concussion Temporary disturbance in brain function
Due to brain being “rattled” inside the skull by a blow to the head
Can present confused or unconscious
Retrograde amnesia--“What happened?”
Effects clear without residual effects

26. Cerebral Contusion Bruising, swelling
Results from brain hitting skull’s inside
Coup-contracoup pattern
Since brain is in closed box, pressure increases as brain swells, blood flow to the brain decreases

27. Cerebral Contusion Signs and Symptoms Personality changes
Loss of consciousness
Paralysis (one-sided or total)
Unequal pupils
Vomiting

28. Epidural Hematoma

29. Epidural Hematoma
Usually associated with skull fracture in temporal area
Fracture damages artery on skull’s inside = rapid onset of symptoms
Blood collects in epidural space between skull and dura mater
Since skull is closed box, intracranial pressure rises

30. Epidural Hematoma Signs and Symptoms
Loss of consciousness followed by return of consciousness (lucid interval)
Headache
Deterioration of consciousness
Dilated pupil on side of injury
Weakness, paralysis on side of body opposite injury
Seizures

31. Subdural Hematoma

32. Subdural Hematoma
Usually results from tearing of large veins between dura mater and arachnoid
Blood accumulates more slowly than in epidural hematoma
Signs and symptoms may not develop for days to weeks

33. Because of slow or delayed onset, may be mistaken for stroke
Subdural Hematoma
Signs and Symptoms
Deterioration of consciousness
Dilated pupil on side of injury
Weakness, paralysis on side of body opposite the injury
Seizures
Because of slow or delayed onset, may be mistaken for stroke

34. Epidural =
Rapid Onset
Subdural =
Gradual Onset

35. Cerebral Laceration Tearing of brain tissue
Can result from penetrating or blunt injury
Can cause:
Massive destruction of brain tissue
Bleeding into cranial cavity with increased intracranial pressure

36. Assessment of Head Injury
Level of consciousness is BEST indicator of patient’s condition
AVPU system
Glasgow scale - GCS

37. AVPU System Alert Unresponsive Responds to Verbal Stimulus
Responds to Painful Stimulus
Unresponsive

38. Score each response then total scores
Glasgow Scale
Eye Opening
Spontaneous = 4
To Voice = 3
To Pain = 2
None = 1
Verbal Response
Oriented = 5
Confused = 4
Inappropriate Words = 3
Incomprehensible Sounds = 1
None = 1
Motor Response
Follows Commands = 6
Localizes Pain = 5
Withdraws = 4
Flexion = 3
Extension = 2
None = 1
Score each response then total scores
Maximum Score = 15
Minimum Score = 3

39. Assessment of Head Injury
Vital Signs
Early detection of increased intracranial pressure is critical
Body responds to increasing intracranial pressure by raising BP
Increased BP moves blood into brain against rising ICP
Heart rate falls in response to rising BP
Increased BP
Slow Pulse
Altered Breathing
Cushing’s Triad

40. Dilated pupil is on SAME side as injury
Pupils
Cerebral edema (contusion, hematoma)
Dilated
Equal
Sluggish or absent response
Unequal
Dilated pupil sluggish or fixed
Dilated pupil is on SAME side as injury

41. Assessment of Head Injury
Other Indicators of Increased ICP
Headache
Nausea
Vomiting (often projectile)
Seizures
Decorticate
Abnormal flexion, toes pointed away from the body.
Arms pulled up to the chest
Decerebrate
Abnormal extension, toes pointed away from the body
Arms down along-side the body

43. Management of Head Injury
ABCs with C-spine control
C-collar, long board
Any patient with significant head injury has neck injury until proven otherwise
Ensure adequate oxygenation
If signs of increased ICP present, controlled hyperventilation with BVM at breaths/minute

44. Management of Head Injury
Controlled hyperventilation
Lowers blood carbon dioxide levels
Causes constriction of blood vessels in brain
As vessels constrict brain shrinks
As brain shrinks intracranial pressure drops

45. Management of Head Injury
Do NOT apply pressure to open or depressed skull fractures
Do NOT attempt to stop flow of blood or CSF from nose or ears
Do NOT remove penetrating objects

46. Spinal Injuries

47. Significance Spinal injury can lead to spinal cord injury
Spinal cord injury can lead to
Paraplegia
Quadriplegia

48. Most important spinal injury indicator…
MECHANISM

51. Suspect spinal injury with...
Sudden decelerations (MVCs, falls)
Compression injuries (diving, falls onto feet/buttocks)
Significant blunt trauma above clavicles
Very violent mechanisms (explosions, cave-ins, lightning strike)
Distraction (hangings, pulling apart of the spine)
Maintain a high index of suspicion:
MVC’s
Pedestrian-vehicle collisions
Penetrating trauma to head, neck or torso
Motorcycle crashes
Unconscious trauma victims

52. Significant Head Injury = Neck Injury Until Proven Otherwise

53. Other indications Tenderness in the area of the injury
Pain associated with moving
Obvious deformity of the spine upon palpation
Numbness, weakness, tingling in the extremities
Loss of sensation or paralysis
Below the suspected level of injury
In the upper or lower extremities

54. Other indications Incontinence Priapism Posturing
Soft tissue injuries associated with trauma:
Head, neck and cervical spine
Shoulders, back or abdomen – thoracic, lumbar
Lower extremities – lumbar, sacral

55. Management ABCs with C-spine control
Apply a rigid collar
MUST maintain head stabilization until head is secured to the backboard
Ensure adequate oxygenation, ventilation
Keep ENTIRE spine immobilized
Repeatedly assess, document neurologic status: PMS
Monitor respirations, blood pressure

56. Management Rapid Extrication Unsafe scene Use with “C” or “U” patients
When a patient blocks access to another, more seriously injured patient

57. Spinal Trauma Complications
Respiratory Failure
Chest wall innervated from thoracic spine
Diaphragm innervated from C3,4,5: Cord injury can produce paralysis of respiratory muscles, lead to ventilatory failure

58. Spinal Trauma Complications
Neurogenic Shock
Damage to cord produces peripheral vasodilation
Peripheral resistance to blood flow decreases, BP falls
Heart rate remains normal or slows
Skin below level of injury is flushed, dry

59. Immobilizing Infants & Children
If the car seat is intact, you may immobilize the infant in the car seat
If c-collar cannot be applied, consider using a rolled towel
Consider using a KED; acts as a papoose
Pad all voids to maintain neutral immobilization
Try to keep mother and child together; this will help keep the infant calm
Re-assure the child as you are placing them in a c-collar and on a backboard.
Parent presence may be helpful as well

60. Helmet Removal Should only remove helmet when:
Inability to assess airway and breathing
Improperly fitted helmet allowing for excessive head movement within the helmet
Patient has respiratory compromise or is in cardiac arrest

61. Helmet Removal Leave helmet in place if:
There are no pending airway/breathing problems
Removal would cause further injury to the patient
Proper spinal immobilization can be performed with the helmet in place
If the patient is wearing shoulder pads:
Both pads and helmet need to be removed
You MUST have at least 2 people to remove the helmet

62. Eye Injuries

63. Eye Anatomy
Sclera
Iris
Choroid
Pupil
Lens
Cornea
Retina

64. Eye Anatomy

65. Eye Anatomy
Aqueous humor: watery fluid which occupies the space between cornea and lens (anterior chamber)
Vitreous humor: jelly-like fluid which fill space behind lens (posterior chamber)
Conjunctiva: smooth membrane that covers front of eye

66. Types of Eye Injuries Foreign objects – upper lid
Lacerations and contusions
Chemical, heat and light burns

67. Foreign Body Signs and Symptoms Management
Pain, foreign body sensation
Excessive tearing
Reddening of conjunctiva
Decreased visual acuity
Management
Cover BOTH eyes
Avoid putting pressure on the eye
Washing the Eye – use sterile water – wash away from the nose. DO NOT attempt if globe is lacerated or penetrated
Sympathetic eye movement – when one eye moves or compensates for the other eye

68. Impaled Objects Never attempt to remove the object
Make a thick dressing – cut hole the size of the eye
Placing dressing over the object
Place crushed cup over the object. Cover injured eye. Patient in supine position

69. Blunt Trauma Extruded eye
Pressure from blow pushes eye partially out of orbit
Management
Do NOT attempt to replace
Keep eye surface moist
Cover with cup
NO pressure

70. Cushing’s Triad
Increased BP
Slow Pulse
Altered Breathing

71. New NYS BLS Protocol Suspected Spinal Injury (not meeting major trauma criteria)

72. Review this first section of the protocol, which outlines the major components of the protocol.

73. Review these two boxes from the protocol.

74. Flow Chart

75. Friday Night Lights 16 year old male football player
Made a spear tackle during the game and remains down
Assessment finds tenderness to the posterior of the neck
Should the patient be immobilized? Why or Why not?
EMS Standby at JV Football Game
After a play, the crew is motioned onto the field to aid a player that hasn’t gotten up
The coach and trainer are talking to a prone patient. The patient is CAOx3 but reports that he doesn’t remember how he got injured.
The coach reports that the patient had made a “spear tackle.”
The patient assessment finds no life threats, normal vital signs, good sensation, motion, and pulses in all extremities. There is mild tenderness on palpation to the posterior of the neck.
The patient SHOULD be immobilized based on the Mechanism of Injury – Axial Loading and Physical Findings – tenderness in the neck.
Either alone would be an indication for immobilization.

76. Motorcycle Accident 35 year old female
Single vehicle accident in the rain
Laid the motorcycle down to avoid striking another car
Pain to left elbow & shoulder
No other unusual findings
Should the patient be immobilized? Why or Why not?
Respond for report of a motorcyclist down
Arrive to find a 35 year old woman sitting on the curb, CAOx3 near her damaged motorcycle. The road is wet from a light rain. She reports she was riding at about 35 mph and had to avoid a vehicle that entered the road from a parking lot. She laid the motorcycle down to avoid the collision. The patient was wearing a helmet and “leathers”
She complains that she has some pain in her left elbow and shoulder, but otherwise she feels fine. Patient assessment finds bruising near left elbow, but no other abnormalities. Good sensation, movement and circulation in all extremities. No pain in neck or back. No signs of intoxication.
The mechanism of injury does not meet the threshold of high speed motor vehicle crash.
The physical findings do not indicate a suspected spinal injury
The patient is not high risk.
EMS providers may immobilize this patient based on provider concern, but it is not required by protocol.

77. Two Cars, Two Drivers Driver # 1 Driver # 2
Ambulatory, Agitated, 50 year old male
Rear ended by driver # 2 at a stoplight
Driver # 2
Belted and still in vehicle 19 year old female
Couldn’t stop in time, struck other vehicle
Should either patient be immobilized?
Why or Why not?
EMS responds and is first on the scene of the MVC at an intersection.
Vehicle # 1 is midsized sedan with crumpled trunk, but no other damage. Windshield is intact. Airbags did not deploy. The driver is walking around the scene inspecting the damage and glaring menacingly at the other driver and holding a bloody handkerchief to his nose.
Vehicle # 2 is a minivan with damage to the grill, umber and front fenders. The front air bags did deploy. The driver is still in the vehicle with her seat belt on and she is on her cell phone visibly crying.
Does either driver fall into mechanism?
Driver # 1- Maybe – What is a violent mechanism? Why is his nose bleeding? The driver reports that he hit himself in the nose with his hand because we was about to call someone on his phone when she hit him.- This is not a violent mechanism. Striking the steering wheel would be.
Would it matter if he was un-belted and struck the wheel or windshield? Its not clear and more information is needed. But if there is doubt, providers should immobilize him.
Driver # 2 –No.
Physical Assessment
Driver #1 Alert and oriented, bleeding from the nose, complains that his left shoulder hurts him, but no other complaints. Neck is not tender and no deformities are noted. Vital signs are slightly elevated, but not worrisome. He exhibits no signs of intoxication during the exam. Should he be immobilized? No – the nose should not be categorized as a distracting injury and nothing else on the patient assessment seems to indicate the need to immobilize.
Driver # 2 Alert and Oriented, but very upset. Complains of burning on her face and keeps repeating that she just didn’t see him in time to stop. The vital signs are normal except the heart rate of 120. Once you get her to get off the phone, she states that nothing hurts except her face. There is not pain on palpation during the physical exam of the neck. No injuries are found and circulation motor and sensation are normal.
High Risk Patient
Neither driver seems to be a high risk patient
Any doubt?
Either patient may be immobilized if EMS crews are unsure, Regardless of the decision, EMS providers need to document their justification to follow a specific path of care.