1. Copyright 2009 Seattle/King County EMS Overview of CBT 445 Head, Spine and Chest Trauma Complete course available at www.emsonline.net

2. Copyright 2009 Seattle/King County EMS Introduction Head, Spine and Chest Trauma Head, spine, chest have contain the most vital organs You must determine SICK or NOT SICK, assess the extent of the injuries and stabilize so that no further injury occurs

3. Copyright 2009 Seattle/King County EMS Practical Skills Rapid trauma exam Backboard Control of major bleeding Jaw thrust To receive CBT or OTEP credit, you must perform the following practical skills:

4. Copyright 2009 Seattle/King County EMS Terms arachnoid — A delicate membrane that encloses the spinal cord and brain and lies between the pia mater and dura mater. brain herniation — A condition in which part of the brain is squeezed through an opening in the skull. cardiac tamponade — Accumulation of fluid in the pericardial space which reduces ventricular filling and causes shock. cerebral edema — Swelling of the brain. dura mater — The tough fibrous membrane covering the brain and the spinal cord and lining the inner surface of the skull. It is the outermost of the three meninges.

5. Copyright 2009 Seattle/King County EMS Terms, continued meninges — The membranes that cover the brain and spinal cord: the dura mater, the arachnoid mater and the pia mater. parasthesia — A pins and needles sensation in the arms or legs. paresis — Weakness petechiae — Small red or purple spots on the skin, caused by broken capillary blood vessels. pia mater — The fine vascular membrane that closely envelops the brain and spinal cord under the arachnoid and the dura mater.

6. Copyright 2009 Seattle/King County EMS Brain Structures Different body functions are controlled by cerebrum, cerebellum, brain stem Graphic illustration credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

7. Copyright 2009 Seattle/King County EMS Layers of Defense Skull Meninges - dura mater, arachnoid, pia mater Cerebrospinal fluid (CSF) Graphic illustration credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

8. Copyright 2009 Seattle/King County EMS Spine Thirty-two vertebrae form spinal column Tendons, ligaments, muscles secure and protect Graphic illustration credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

9. Copyright 2009 Seattle/King County EMS Spinal Cord Made of nerve tissue Surrounded by CSF

10. Copyright 2009 Seattle/King County EMS Nervous System Brain and spinal cord make up central nervous system Peripheral nervous system is made up of all nerves that project out of brain and spinal cord

11. Copyright 2009 Seattle/King County EMS Chest Contains heart, lungs and great vessels Protected by ribs, sternum, scapulae, clavicles, spine Graphic illustration credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

12. Copyright 2009 Seattle/King County EMS Head Injuries Scalp laceration Concussion Contusion Skull fracture Head bleed

13. Copyright 2009 Seattle/King County EMS Cerebral Edema Swelling of the brain Early sign is unconsciousness Late signs of cerebral edema and increased intracranial pressure (ICP): – Irrational or combative behavior – Changing level of consciousness – Abnormal respiratory pattern – Unequal pupils – Posturing

14. Copyright 2009 Seattle/King County EMS Level of Consciousness A change in level of consciousness is the single most important observation you can make in assessing the severity of brain injury.

15. Copyright 2009 Seattle/King County EMS Hypovolemic Shock If a head-injured patient shows signs of hypovolemic shock, assess for other internal injuries.

16. Copyright 2009 Seattle/King County EMS Care for a Head Injury Emergency care for potential internal head injury: Protect airway Provide oxygen and ventilatory assistance, if needed Maintain neutral in-line, cervical stabilization and stabilize spine Closely monitor vital signs and neurologic status Control bleeding

17. Copyright 2009 Seattle/King County EMS Forces That Can Injure the Spine Compression Flexion Extension Rotation Lateral Distraction Penetration Graphic illustration credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

18. Copyright 2009 Seattle/King County EMS Symptoms of Spine Injury Weakness Numbness Tingling or paralysis in the extremities Pain along spine

19. Copyright 2009 Seattle/King County EMS Care for a Spine Injury Open airway using jaw thrust Provide neutral, in-line cervical stabilization Provide oxygen Assist ventilation, if needed Immobilize spine using a backboard

20. Copyright 2009 Seattle/King County EMS Care for a Spine Injury, cont. Keep backboard in a level position, if pt. is hypotensive* Monitor vital signs Monitor neurological status Therefore we recommend keeping a hypotensive, backboarded patient in a supine and level position. For non-backboarded patients, use the shock position (legs only elevated). *There is little data to support the use of the Trendelenburg position when compare to a flat, level position. Follow your local protocols.

21. Copyright 2009 Seattle/King County EMS When Not to Immobilize Immobilization may be unnecessary if ALL apply: No significant MOI No back or neck pain with or without movement No pain or tenderness of back or neck on exam No altered LOC No history of loss of consciousness No recent alcohol or drug use Patient is reliable historian

22. Copyright 2009 Seattle/King County EMS Helmet Removal Leave football helmet and shoulder pads on if it stabilizes head and does not impair breathing or airway If you need to remove: – Manually stabilize neck and head and remove face guard – Remove chinstrap and have one rescuer stabilize head while another removes helmet Remove motorcycle and bicycle helmets

23. Copyright 2009 Seattle/King County EMS Chest Trauma Pneumothorax Hemothorax Tension pneumothorax Flail chest Traumatic asphyxia Myocardial contusion Cardiac tamponade Lacerations of great vessels (e.g., aortic tear)

24. Copyright 2009 Seattle/King County EMS Care for a Chest Injury Ensure ABC’s Administer high flow oxygen via NRB Assist ventilations, if needed Anticipate cardiac arrest Treat for shock

25. Copyright 2009 Seattle/King County EMS Summary Structures of the brain are cerebrum, cerebellum, brain stem Signs of cerebral edema and increasing ICP: Irrational or combative behavior Changing LOC Abnormal respiratory pattern Unequal pupils Posturing

26. Copyright 2009 Seattle/King County EMS Summary, continued Emergency care for a potential internal head injury: Protect airway Provide oxygen and ventilatory assistance Maintain neutral in-line, cervical stabilization and stabilize spine Monitor vital signs and neurological status Control bleeding Major symptoms for spine injury are weakness, numbness, tingling, impaired sensation or paralysis in the extremities, pain in the spinal area.

27. Copyright 2009 Seattle/King County EMS Summary, continued You may not need to immobilize the spine if ALL these criteria are met: No significant MOI No back or neck pain with or without movement No pain or tenderness of back or neck on exam No altered LOC No history of loss of consciousness No recent alcohol or drug use Patient is a reliable historian

28. Copyright 2009 Seattle/King County EMS Summary, continued Care for spine injury: Manually stabilize the head and aligning neck in a neutral, in-line position Apply cervical collar Carefully move patient and place on a backboard and secure Assessment and treatment of the ABC’s is your highest priority for a suspected spine injury

29. Copyright 2009 Seattle/King County EMS Summary, continued Signs of an internal chest injury Localized pain and tenderness Possible dyspnea Care for a chest injury may require: Ensure ABC’s High flow oxygen via NRB Assist ventilations, if needed Anticipate cardiac arrest Treat for shock