Injuries to the Head and Spine

Injuries to the Head and Spine
CHAPTER 29 Injuries to the Head and Spine

Anatomy Review

Nervous System Nervous System – provides overall control of thought, sensation, and the voluntary and involuntary motor functions of the body. The major components of the nervous system are the brain and the spinal cord. Central Nervous System – consists of the brain and spinal cord Peripheral Nervous System – the nerves that enter and exit the spinal cord between the vertebrae and the twelve pairs of cranial nerves that travel between the brain and organs without passing through the spinal cord, and all of the body’s other motor and sensory nerves Autonomic Nervous System – controls involuntary functions such as heartbeat, breathing, control of the diameter of your vessels, control of the round sphincter muscles closing your bladder and bowel and digestion

Nervous System Brain – controlling organ of the body and the center of consciousness; occupies the entire space within the cranium, and each type of brain cell has a specific function and certain parts of the brain perform certain functions Spinal Cord – consist of long tracts of nerves that join the brain with all body organs and parts, and protected by the spinal column Nerves – sensory nerves send information to the brain on what the different parts of the body are doing relative to their surroundings while the motor nerves carry messages from the brain and result in stimulation of a muscle or organ *** Prior to traveling down the spinal cord, they cross over the opposite side of the body, which means that the nerves originating from the right side of the brain, control the left side of the body and vice versa ***

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

Skull and Facial Bones Cranium - the portion of the skull that encloses the brain (formed by the forehead, top , back and upper sides of the skull). The cranial floor is the inferior wall of the brain case. The bones are fused together. Facial Bones – 14 irregularly shaped bones that form the face, which are fused into immovable joints except the mandible

Skull and Facial Bones CRANIUM FACE Orbit Nasal bones Zygomatic
Skull (houses and protects the brain; consists of the cranium and the face) Cranium (houses and protects the brain) CRANIUM (Surrounds the eyes) Orbit Nasal bones Zygomatic (cheek bones) (Provides some structure of nose) Maxilla (fused bones of the Upper jaw) FACE Mandible (lower jaw bone)

Contents of the Skull Bone Dura mater Arachnoid Pia mater
Epidural space (potential) Subarachnoid space Subdural space Intracerebral Arachnoid Dura mater Skull Pia mater

Spinal Column (made up of 33 vertebrae, which are the separate bones of the spinal column)

Corresponding Anatomy
Spinal Column Division Corresponding Anatomy Number of Vertebrae Cervical Neck 7 Thoracic Thorax, ribs, upper back 12 Lumbar Lower back 5 Sacral Back wall of pelvis Coccyx Tailbone 4

Spinal Column Spinous Process – the bony bump on a vertebra – you can feel this on a person’s back Spinal Cord – travels through the hollow portion of the each vertebra Cerebral Spinal Fluid – the fluid that surrounds the brain and spinal cord

Spinal Injury

Spinal Injury Considerations
Thoracic spine is usually not injured due to the sternum and spine Pelvic-sacral spine attachment helps to protect the sacrum in the same way Cervical and lumbar are more injury prone due to no other support by bony structures

Mechanisms of Spinal Injury
Compression Falls Diving accidents Motor vehicle accidents Excessive Flexion, Extension, and Rotation Lateral Bending

Distraction Pulling apart of the spine Hangings

Maintain a high index of suspicion Motor Vehicles crashes Pedestrian – vehicles collisions Falls Blunt Trauma Penetrating trauma to the head, neck and torso Motorcycle crashes Hangings Diving accidents Unconscious trauma victims

Whiplash

Signs & Symptoms of Spinal Injuries
Ability to walk, move extremities or feel sensation; or lack of pain or numbness to spinal column does not rule out the possibility of spinal column or cord damage. DO NOT check for ROM Tenderness in the area of injury Pain associated with

Pain independent of movement or palpation (do not intentionally check for this) Along spinal column Lower legs May be intermittent Obvious deformity of the spine upon palpation – rare sign in the field

Soft tissue injuries associated with trauma Head, neck and cervical spine Shoulders, back or abdomen – thoracic/lumbar Lower extremities – lumbar/sacral Numbness, weakness or tingling in the extremities – paralysis is probably the most reliable sign of spinal cord injury in conscious patients – check for PMS

Loss of sensation or paralysis below the suspected level of injury Loss of sensation or paralysis in the upper or lower extremities Incontinence Priapism Posturing

Impaired breathing – if little or no movement of the chest, the patient is breathing with the diaphragm alone; reversal of normal breathing patterns with the rib cage collapsing on inspiration and rising on expiration; “C–3, –4, –5 keep the diaphragm alive” Severe spinal shock – neurogenic shock can be caused by the failure of the nervous system to control the diameter of the blood vessels

Assessing Spinal Injury
Questions to ask: What happened? Where does it hurt? Does your neck or back hurt? Continued…

Responsive Patient MOI 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?

test for a painful response.
DO NOT ask the patient to move to try to elicit a painful response. Do not move the patient to test for a painful response.

Inspect for DCAP-BTLS Assess quality of strength of extremities Hand grip Gently push feet against hands Assess distal pulses

Assess sensation in all extremities.

Assess motor function.

Assess strength – feet.

Assess strength – hands.

Unresponsive Patient MOI Initial assessment Inspect for: Contusions Deformities Lacerations Punctures/Penetrations Swelling Palpate for areas of deformity and tenderness Obtain information from others at the scene to determine information relevant to mechanism of injury or patient mental status prior to the EMT-B’s arrival

Complications of Spinal Injury
Patients with head and spine injuries may be unable to maintain their own airway and breathes on their own. Airway management is essential with every patient. Such patients require cervical spine precautions. Consider: Loss of consciousness Foreign materials Swelling Unstable bone fractures Paralysis Waist down = paraplegic Neck down = quadriplegic

Treating Spinal Injury
Take BSI precautions. Establish and maintain in-line Place the head in a neutral (eyes looking forward) position unless the patient complains of pain or the head is not easily moved into position Maintain constant manual in-line immobilization until the patient is properly secured to a backboard with the head immobilized

Perform initial assessment Whenever possible, airway control must be done with in-line immobilization, using the jaw-thrust maneuver Whenever possible, artificial ventilation must be done with in-line immobilization, using the jaw-thrust maneuver Assess PMS in all extremities. Assess the cervical region and neck

Apply a rigid, cervical immobilization device. Properly size the cervical immobilization device. If it doesn't fit use a rolled towel and tape to the board and have rescuer hold the head manually. An improperly fit immobilization device will do more harm than good. A collar that is too large will hyperextend the neck, a collar that is too small could cause flexion, and a collar that is too loose could allow for lateral movement. A collar that is too tight could interfere with the patient’s airway.

If found in a lying position, immobilize the patient to a long spine board Move the patient onto the device by log-rolling him/her (1) One EMT-Basic must maintain in-line immobilization of the head and spine. (2) EMT-Basic at the head directs the movement of the patient. (3) One to three other EMT-Basics control the movement of the rest of the body. (4) Quickly assess posterior body if not already done in focused history and physical exam. (5) Position the long spine board under the patient.

Patient found lying on back continued… (6) Place patient onto the board at the command of the EMT-Basic holding in-line immobilization using a slide, proper lift, log roll or scoop stretcher so as to limit movement to the minimum amount possible. Which method to use must be decided based upon the situation, scene and available resources. (7) Pad the void under the shoulders of the infant and child to establish a neutral position. (8) Immobilize torso to the board. (9) Secure the legs to the board. (10) Immobilize the patient's head to the board. (11) Reassess pulses, motor and sensation and record.

If found in a sitting position, immobilize the patient with a short spine immobilization device. Exception: If the patient must be removed urgently because of his injuries, the need to gain access to other, or dangers at the scene, he/she must then be lowered directly onto a long board and removed with manual stabilization

Secure the patient onto the device by : Position device behind the patient. Secure the device to the patient's torso. Evaluate torso fixation and adjust as necessary without excessive movement of the patient. Secure the patient’s legs to the device. Secure the patient's head to the device. Insert a long board under the patient's buttocks and rotate and lower him to it. If not possible, lower him to the long spine board. Reassess pulses, motor and sensory in all extremities and record.

If the patient is found in the standing position, immobilize the patient to a long spine board using the “standing takedown” method Take BSI precautions Tallest crew member should be behind patient and have him manually stabilize the had and neck – this person remains here until the patient is strapped to the board A second EMT applies a properly sized cervical collar to the patient The second EMT and another EMT place a long board behind the patient being careful not to disturb the positioning of the 1st EMTs stabilization of the patient The second EMT looks at the long board from the front and does any necessary repositioning

“Standing takedown” method contiued… (6) The second and third EMTs reach arm that is nearest patient under patient’s armpits and grasp the long board; to keep the patient’s arms secure, they will use other hand to grasp the patient’s arm just above elbow and hold it against body (7) The second and third EMTs grasp a handhold on the spine board at patient’s armpit level or higher (8) Slowly the board is lowered to the ground on the command of EMT at the head (EMT at the head is walking backwards, and the other two EMTs are walking slowly and evenly). The two EMTs that are on the sides of the board are moving into a squatting position so as not to injure their backs. (9) The EMT at the head never lets go of the patient’s head until he/she is fully immobilized on the back board

Maintain stabilization; apply collar.

Position board and EMT–Bs.

Grasp the board after reaching under the patient’s shoulders.

Carefully lower patient; then secure the board.

“Standing takedown” method contiued… If the patient is critically injured, perform a rapid extrication If the patient has paralysis or weakness of the extremities, administer high-concentration oxygen via non-rebreather If the patient is pregnant, once she is secured to the board, tilt the backboard onto its left side and support with pillows Reassess sensory and motor function in all four extremities Transport the patient immediately

Head Injuries

Head Injuries – Overview
Injuries to the scalp Very vascular, may bleed more than expected Injuries to the brain injury of the brain tissue or bleeding into the skull will cause an increase of pressure within the skull

Brain Injury – Non-traumatic
May occur due to clot or hemorrhage Can be a cause of altered mental status Signs and symptoms may parallel those of traumatic injury (but no trauma)

Skull Injury – Traumatic
Open head injury – when the bones of the cranium and face fracture, and the overlying scalp is lacerated Closed head injury – when the scalp is lacerated, but the cranium remains intact

Signs & Symptoms of Skull Injuries
Mechanism of Trauma Contusion, laceration, hematoma to the scalp Deformity to the skull Blood/fluid from ears or nose Bruising around eyes (raccoon's eyes) Bruising behind ears (Battle’s Sign)

Brain Injuries Whenever you suspect skull or brain injury, also suspect spine injury Traumatic Concussion – mild closed head injury without detectable damage to the brain; caused by an indirect force when the head is struck by a blunt object or comes into contact with the floor/ground after a fall, a certain amount of force is transferred through the skull to the brain Continued….

Brain Injuries Laceration – a cut to the brain can occur from the same forces that cause a contusion Contusion – bruised brain; can occur with closed head injuries, when the force of the blow if great enough to rupture blood vessels on or within the brain Coup – when the bruising of the brain occurs on the side of the blow Contrecoup – when the bruising of the brain occurs on the side opposite the blow Continued…

Brain Injuries Hematoma – collection of blood within tissue; when a hematoma develops, pressure inside the skull increases making it difficult for normal blood flow to enter the head. This causes blood pressure to increases, and as a result of decreased blood flow, the brain becomes starved for oxygen and high in waste carbon dioxide, causing even more swelling. Also, head injury may cause decreased respiratory effort, which further worsens oxygen starvation and swelling in the brain. Subdural hematoma – collection of blood between the brain and the dura Epidural hematoma – blood between the dura and the skull Intracerebral hematoma – occurs when blood pools within the brain

Signs & Symptoms of Brain Injuries
Altered or decreasing mental status is the best indicator of brain injury Confusion, disorientation, or repetitive questioning Conscious – derteriorating mental status Unresponsive Personality change – ranging from irritable to irrational behavior

AVPU Alert – awake and oriented; can understand you and obey requests Verbal – inappropriate words, sounds, confused; doesn’t answer questions appropriately Pain – patient responds to pressure on sternum or nail bed Unresponsive – patient does not respond in any way to any stimulation Irregular breathing pattern

Elevated blood pressure with decreasing pulse (Cushing’s Triad) Consideration of MOI Deformity of windshield Deformity of helmet Contusion, laceration, hematoma, or deformity to the scalp or forehead – do not probe or separate to discover wound depth Deformity to the skull, visible bone fragments, pieces of brain tissue

Blood/fluid from ears or nose Bruising around eyes (raccoon's eyes) Bruising behind ears (Battle’s Sign) Neurologic disability Nausea/vomiting – projectile Unequal/unreactive pupil size with altered mental status; one eye may appear to be sunken; blurred or multiple-image vision in one or both eyes

Seizure activity may be seen Incontinence Priapism Posturing – patient may exhibit flexing arms and wrists and extending legs and feet (decorticate posture) or extending arms with the shoulders rotated inward and wrists flexed, legs extended (decerebrate posture) – typically after a painful stimulus

Severe pain at the site of the injury Temperature increase – late sign Impaired hearing or ringing in the ears Equilibrium problems Deteriorating vital signs

Emergency Care of Head Injuries
BSI. Initial assessment. Maintain airway/artificial ventilation/oxygenation using the jaw-thrust method. If patient is unconscious, insert an oropharyngeal airway. Have suction ready because these patients are likely to vomit. Monitor the unconscious patient for changes in breathing and be prepared to assist if necessary. If the patient shows signs of a critical brain injury (increased blood pressure with decreased pulse, fixed and dilated pupils, altered mental status), hyperventilate the patient at a rate of 20 – 24 breaths per minute (Hyperventilation will help reduce brain tissue swelling by lowering CO2 levels and increasing O2 levels, but it will also decrease blood flow to the brain).

With any head injury, suspect spinal injury. Apply a rigid cervical collar and immobilize the neck and spine. Determine method of extrication (rapid, standing take-down, etc…) Closely monitor the airway, breathing, pulse, and mental status for deterioration. Keep the patient at rest and calm. Talk to the patient, providing emotional support and asking him/her questions that he/she will have to concentrate on. Control bleeding Do not apply pressure to an open or depressed skull injury. Dress and bandage open wound as indicated in the treatment of soft tissue injuries – loose gauze dressings.

If a medical condition exists, place patient on the left side (i.e. pregnant female) Be prepared for changes in patient condition. Manage the patient for shock even if signs are not yet present. DO NOT elevate the legs unless signs of shock are present and protocols permit. DO NOT overheat. Immediately transport the patient. Monitor vital signs every 5 minutes. Complete a Prehospital Care Report. Document all pertinent findings of the patient assessment; treatment; and transport decisions.

Spinal Immobilization

Cervical Spine Immobilization Devices
Indications Any suspected injury to the spine based on mechanism of injury, history or signs and symptoms. Use in conjunction with short and long backboards. Sizing Various types of rigid cervical immobilization devices exist, therefore, sizing is based on the specific design of the device. An improperly sized immobilization device has a potential for further injury.

Cervical Spine Immobilization Devices
Sizing cont’d… Do not obstruct the airway with the placement of a cervical immobilization device. If cervical immobilization device cannot be applied, consider using a rolled towel and tape to the board and manually support the head. An improperly fitted device will do more harm than good. Precautions Cervical immobilization devices alone do not provide adequate in-line immobilization. Manual immobilization must always be used with a cervical immobilization device until the head is secured to a board.

Applying a Cervical Spine Immobilization Device

Stabilize and measure.

Choose correct collar size.

Prepare collar.

Slide collar under chin.

Secure collar; maintain in-line position.

Use of Short Spine Boards:
Seated Patient

Short Spine Boards Several different types of short board immobilization devices exist Vest type Rigid short spine board Provides stabilization to the head, neck, torso Used to immobilize non-critical sitting patients with suspected spinal injury

Applying a Short Board Immobilization Device (KED)

Select immobilization device.

Manually stabilize patient’s head in neutral, in-line position.

Assess distal pulse, motor function, and sensation (PMS).

Assess the cervical area
Assess the cervical area. Apply the appropriately sized extrication collar.

Position the device behind patient.

Secure device to patient’s torso.

Evaluate torso and groin fixation and
adjust as necessary to maintain in-line immobilization.

Evaluate and pad behind patient’s head as necessary
Evaluate and pad behind patient’s head as necessary. Secure patient’s head to device.

Final Steps for KED Release manual stabilization of head
Rotate or lift the patient to the long spine board Immobilize patient to long spine board Reassess PMS

Use of Long Spine Boards:
Supine Patient

Long Spine Boards Provides stabilization and immobilization to the head, neck, torso, pelvis, and extremities. May be applied in: Lying, standing, and sitting positions Conjunction with short spine boards

Maintain stabilization Assess PMS in all extremities
Assess the cervical area and apply collar

Prepare and position device.

Performing the Log Roll
Move the patient onto the device by log roll, suitable lift or slide, or scoop stretcher. A log roll is: One EMT-Basic must maintain in-line immobilization. EMT-Basic at the head directs the movement of the patient. One to three other EMT-Basics control the movement of the rest of the body Quickly assess posterior body if not already done in initial assessment Position the long spine board under the patient Roll patient onto the board at the command of the EMT-Basic holding in-line immobilization.

Move patient onto board
Move patient onto board. Apply padding to voids especially of the infant/child

Immobilize torso to the board by applying
straps across the chest and pelvis – adjust as needed. Immobilize the patient’s head to the device.

Reassess PMS.

Rapid Extrication

Rapid Extrication Indications Unsafe scene Unstable patient condition
Patient blocks EMT–B’s access to an unstable patient Rapid extrication is based on time and the patient, not the EMT-Bs preference

Rapid Extrication Should be limited to life/death situations
Does not provide optimal spinal stabilization Use with “C” or “U” patients Use when the patient’s safety is compromised

Manually stabilize; apply collar.

After putting end of board next to patient, position hands on legs/pelvis and chest/arms.

Rotate patient and reposition hands.

Lower patient to board.

Move patient into position on board.

Secure patient and transport.

Helmet Removal

Special Assessment Needs for Patients Wearing Helmets
Airway and breathing Fit of the helmet and patient's movement within the helmet Ability to gain access to airway and breathing

Indications to Leave Helmet in Place
Good fit, little or no movement within the helmet No impending airway or breathing problems Removal would cause further injury Continued…

Indications to Leave Helmet in Place
Proper immobilization is able to be performed with helmet in place No interference with the EMT-Bs ability to assess and reassess airway and breathing

Indications for Removing Helmet
Inability to assess or reassess airway and breathing Restriction of adequate management of the airway or breathing Improper fit/movement within helmet Continued…

Indications for Removing Helmet
Proper spinal immobilization cannot be performed due to helmet Cardiac arrest

Types of Helmets Sports Typically open anterior Motorcycle Other
Easier access to the airway Motorcycle Full Face Shield Skull Cap Other

Be sure to remove eyeglasses.
First EMT stabilizes helmet by placing fingers on patient’s mandible to prevent movement.

Second EMT–B loosens strap.

The second EMT places one hand on the
mandible at the angle of the jaw and the other hand posterior at the occipital region.

The EMT-B holding the helmet pulls the sides of the helmet apart
and gently sips the helmet halfway off the patient’s head and then stops.

The EMT-B holding maintaining stabilization of the neck, repositions, slides the posterior hand superiorly to secure the head from from falling once helmet is removed.

The helmet is removed completely
The helmet is removed completely. Begin routine stabilization and immobilization.

Helmet Odds – n – Ends Leave helmet in place for transport when/if:
There is only one trained rescuer The patient’s breathing is not compromised and immobilization in neutral position is possible Attempts to remove the helmet will compromise the patient’s condition Remove a helmet prior to transport when clinically indicated and more than one trained rescuer is present Helmets may be stabilized using: Tape Head Blocks Rolled Blankets Commercial Devices

Infants and Children

Infants and Children Infants and children - immobilize the infant or child on a rigid board appropriate for size (short, long or padded splint), according to the procedure outline in the spinal immobilization section. Infant and Child Seats - If infant or child is already in a child protective seat, and is stable immobilize in place. Special Considerations: Pad from the shoulders to the heels of the infant or child, if necessary to maintain neutral immobilization. If cervical immobilization device cannot be applied, consider use a rolled towel and tape to the board and manually support the head. An improperly fitted device will do more harm than good.

The Odds and Ends

Cervical Spine Injury Immobilize the entire spine
Movement of the torso effects the stability of the cervical spine. Partial immobilization increases the risk of a torque effect. Cervical spine pain may mask injuries to the lower spine

Long Board Immobilization
Cot mattress does not provide stability Long board provides Stability Facilitates patient transfer Cot Straps Do not immobilize patient to board Must be removed for patient transfers, loosing all security Do not permit “rolling” an immobilized patient who might be vomiting

Disclaimers Opening the Airway with a suspected spinal cord injury; use the modified jaw thrust maneuver without head tilt. Use manufactures recommendations in the use of immobilization devices Complete the Prehospital Care Report Document all pertinent findings of patient assessment; pre and post treatment; and transport decisions.

Injuries to the Head and Spine

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