head and spinal injuries part 1

Head and Spinal InjuriesHead and Spinal Injuries

Given a (simulated) patient with Given a (simulated) patient with demonstrated/suspected head and/or demonstrated/suspected head and/or spinal injuries in a pre-hospital spinal injuries in a pre-hospital environment, describe the appropriate environment, describe the appropriate assessment and management techniques assessment and management techniques to properly immobilize the patient for to properly immobilize the patient for transport to a medical treatment facility transport to a medical treatment facility IAW Chapter 30, Emergency Care and IAW Chapter 30, Emergency Care and Transportation of the Sick and Injured, 8th Transportation of the Sick and Injured, 8th Edition, American Academy of Orthopedic Edition, American Academy of Orthopedic Surgeons (AAOS). Surgeons (AAOS).

Terminal Learning ObjectiveTerminal Learning Objective

Given an overview of the anatomy and Given an overview of the anatomy and physiology of the nervous system and the physiology of the nervous system and the signs and symptoms associated with a signs and symptoms associated with a spinal injury, describe the techniques for spinal injury, describe the techniques for manual stabilization, full immobilization and manual stabilization, full immobilization and preparation for transport to a medical preparation for transport to a medical treatment facility IAW Emergency Care and treatment facility IAW Emergency Care and Transportation of the Sick and Injured, 8th Transportation of the Sick and Injured, 8th Edition, American Academy of Orthopedic Edition, American Academy of Orthopedic Surgeons (AAOS).Surgeons (AAOS).

Enabling Learning ObjectivesEnabling Learning Objectives

Given an overview of the characteristics of Given an overview of the characteristics of head injuries and the associated head injuries and the associated complications resulting from brain trauma, complications resulting from brain trauma, describe the techniques for assessing and describe the techniques for assessing and managing the head injury, with or without managing the head injury, with or without spinal involvement, IAW Emergency Care spinal involvement, IAW Emergency Care and Transportation of the Sick and Injured, and Transportation of the Sick and Injured, 8th Edition, American Academy of 8th Edition, American Academy of Orthopedic Surgeons (AAOS).Orthopedic Surgeons (AAOS).

Enabling Learning ObjectivesEnabling Learning Objectives

Central Nervous System: Brain & spinal cord control all basic bodily functions and respond to external changes

Periferal Nervous System: Nerves in the body control motor (voluntary) movements and sensory nerve fibers connect the CNS to the rest of the body

Anatomy and Physiology of Anatomy and Physiology of the Nervous Systemthe Nervous System

Autonomic Nervous System: Nerves, ganglia, plexuses that carry impulses to all smooth muscles, secretory glands, and the heart. Regulates the activities of visceral organs, which are usually not under voluntary control

Anatomy and Physiology of Anatomy and Physiology of the Nervous Systemthe Nervous System

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The Brain:The Brain:

– Cerebrum (Cerebral Cerebrum (Cerebral Cortex)Cortex)

–Voluntary motor and Voluntary motor and thoughtthought

– CerebellumCerebellum

–Coordinates movementCoordinates movement

– BrainstemBrainstem

–Controls life functionsControls life functions

Central Nervous SystemCentral Nervous System

Protective CoveringsProtective Coverings

Peripheral Nervous SystemPeripheral Nervous System How the Nervous System Works:How the Nervous System Works:

Protective CoveringsProtective Coverings Cranial Vault:Cranial Vault:

Skeletal SystemSkeletal System

Spinal ColumnSpinal Column

Mechanism Mechanism Of InjuryOf Injury

Signs and SymptomsSigns and Symptoms

Localized pain, muscle spasmsLocalized pain, muscle spasmsLoss of sensation, numbnessLoss of sensation, numbnessParesthesias (tingling, pins and needles)Paresthesias (tingling, pins and needles)ParalysisParalysisPriapismPriapismIncontinenceIncontinence

Spinal Cord InjuriesSpinal Cord Injuries

Primary Damage- occurs at the time of Primary Damage- occurs at the time of injury from the cord being cut, torn, injury from the cord being cut, torn, crushed, or it’s blood supply being cut off.crushed, or it’s blood supply being cut off.Secondary Damage- occurs later from Secondary Damage- occurs later from hypotension, hypoxia, injury to blood hypotension, hypoxia, injury to blood vessels, swelling or compression of the vessels, swelling or compression of the cord from surrounding hemorrhage.cord from surrounding hemorrhage.

Neurogenic ShockNeurogenic Shock

-Malfunction of the autonomic nervous system due to spinal trauma-Autonomic nervous system regulates blood vessel tone and cardiac output-Patient has normal skin color and temperature with hypotension and a slow heart rate-Hypovolemic shock = cool clammy skin, hypotension and rapid pulse

Rapid extrication necessary?Access HABCTreat any life threatening situationsMaintain in-line C-spine stabilization Hand placement on shoulders (not the side of the head) with the head cradled between forearms

In a tactical situationIn a tactical situation

The scalp has a rich The scalp has a rich blood supply.blood supply.

There may be more There may be more serious, deeper serious, deeper injuries.injuries.

Fold skin flaps back Fold skin flaps back down down onto scalp. onto scalp.

Scalp LacerationsScalp Lacerations

Indicates significant Indicates significant force.force.

Signs:Signs:– Obvious deformityObvious deformity– Visible crack in the skullVisible crack in the skull– Raccoon eyesRaccoon eyes– Battle’s signBattle’s sign

Skull FractureSkull Fracture

Brain injury.Brain injury. Temporary loss or alteration in brain Temporary loss or alteration in brain

function.function. May result in unconsciousness, confusion May result in unconsciousness, confusion

or amnesia.or amnesia. Brain can sustain bruise when skull is Brain can sustain bruise when skull is

struck.struck. There will be bleeding and swelling.There will be bleeding and swelling. Bleeding will increase the pressure within Bleeding will increase the pressure within

the skull.the skull.

ConcussionConcussion

Bruise to the brain.Bruise to the brain. Far more serious than a concussion.Far more serious than a concussion. Patient may suffer long-lasting and even Patient may suffer long-lasting and even

permanent damage. permanent damage.

ContusionContusion

Laceration or rupture of blood vessel in Laceration or rupture of blood vessel in brain.brain.– Subdural:Subdural:

Intracranial BleedingIntracranial Bleeding

Laceration or rupture of blood vessel in Laceration or rupture of blood vessel in brain.brain.– Intracerebral: Intracerebral:


Laceration or rupture of blood vessel in brain.Laceration or rupture of blood vessel in brain.– Epidural:Epidural:


Brain injuries are not always caused by Brain injuries are not always caused by trauma.trauma.

Medical conditions may cause Medical conditions may cause spontaneous bleeding in the brain.spontaneous bleeding in the brain.

Signs and symptoms of nontraumatic Signs and symptoms of nontraumatic injuries are the same as those of injuries are the same as those of traumatic injuries.traumatic injuries.– There is no obvious mechanism of injuryThere is no obvious mechanism of injury

Other Brain InjuriesOther Brain Injuries

Cerebral edema.Cerebral edema. Convulsions and Convulsions and

seizures. seizures. Vomiting.Vomiting. Leakage of CSF.Leakage of CSF.

Complications of Head InjuryComplications of Head Injury

Lacerations, contusions, Lacerations, contusions, hematomas to scalp.hematomas to scalp.

Soft areas, depressions.Soft areas, depressions. Visible skull fractures or Visible skull fractures or

deformities.deformities. Ecchymosis around eyes Ecchymosis around eyes

and behind the ear.and behind the ear. Clear or pink CSF Clear or pink CSF

leakage.leakage.


Failure of pupils to respond to light.Failure of pupils to respond to light. Unequal pupils.Unequal pupils.


Loss of sensation and/or motor function.Loss of sensation and/or motor function. Period of unconsciousness.Period of unconsciousness. Amnesia.Amnesia. Seizures.Seizures.


Numbness or tingling in the extremities.Numbness or tingling in the extremities. Irregular respirations.Irregular respirations. Dizziness.Dizziness. Visual complaints.Visual complaints. Combative or abnormal behavior.Combative or abnormal behavior. Nausea or vomiting.Nausea or vomiting.


Compression injuries occur from a fall.Compression injuries occur from a fall. Motor vehicle crashes or other types of Motor vehicle crashes or other types of

trauma can overextend, flex, or rotate trauma can overextend, flex, or rotate the spine.the spine.

Distraction: When spine is pulled along Distraction: When spine is pulled along its length; causes injuries.its length; causes injuries.- Hangings are an exampleHangings are an example

Spine Injuries

MVC.MVC. Pedestrian-MVCs.Pedestrian-MVCs. Falls.Falls. Blunt or penetrating trauma.Blunt or penetrating trauma. Motorcycle crashes.Motorcycle crashes. Hangings.Hangings. Driving accidents.Driving accidents. Recreational accidents.Recreational accidents.

Significant Mechanisms of Injury

Observe scene for hazards; take BSI Observe scene for hazards; take BSI precautions.precautions.

Anticipate problems with ABCs.Anticipate problems with ABCs. Pay attention for changes in level of Pay attention for changes in level of

consciousness.consciousness. Call for ALS backup as soon as possible Call for ALS backup as soon as possible

when serious MOI is present.when serious MOI is present. Look for a deformed helmet or deformed Look for a deformed helmet or deformed

windshield.windshield.

Scene Size-upScene Size-up

Ask the patient:Ask the patient:─ What happened?What happened?─ Where does it hurt?Where does it hurt?─ Does your neck or back hurt?Does your neck or back hurt?─ Can you move your hands and feet?Can you move your hands and feet?─ Did you hit your head?Did you hit your head?

Confused or slurred speech, repetitive Confused or slurred speech, repetitive questioning, or amnesia indicate head injury.questioning, or amnesia indicate head injury.

Ask when patient lost consciousness.Ask when patient lost consciousness. Stabilize the spine.Stabilize the spine.

Initial AssessmentInitial Assessment

Use jaw-thrust maneuver to open airway.Use jaw-thrust maneuver to open airway. Vomiting may occur. Suction immediately.Vomiting may occur. Suction immediately. Move patient as little as possible. Do not Move patient as little as possible. Do not

remove c-collar.remove c-collar. Consider providing positive pressure Consider providing positive pressure

ventilations.ventilations. A pulse that is too slow can indicate a serious A pulse that is too slow can indicate a serious

condition.condition. Assess and treat for shock.Assess and treat for shock.

ABCs

If patient has problems with ABCs, If patient has problems with ABCs, provide rapid transport.provide rapid transport.

Transport Decision

The absence of pain does not rule out a The absence of pain does not rule out a potential spinal injury.potential spinal injury.

Do not ask patients with possible spinal Do not ask patients with possible spinal injuries to move their neck.injuries to move their neck.

Focused History and Physical Exam

Quickly use DCAP-BTLS.Quickly use DCAP-BTLS. Decreased level of consciousness is the Decreased level of consciousness is the

most reliable sign of head injury.most reliable sign of head injury. Expect irregular respirations.Expect irregular respirations. Look for blood or CSF leaking from Look for blood or CSF leaking from

ears, nose, or mouth.ears, nose, or mouth.

Rapid Physical Exam for Significant Trauma

Look for bruising around eyes, behind ears.Look for bruising around eyes, behind ears. Evaluate pupils.Evaluate pupils. Do not probe scalp lacerations. Do not Do not probe scalp lacerations. Do not

remove an impaled object.remove an impaled object.

Rapid Physical Exam for Significant Trauma

Watch for change in level of Watch for change in level of consciousness.consciousness.

Use Glasgow Coma Scale.Use Glasgow Coma Scale. Pain, tenderness, weakness, Pain, tenderness, weakness,

numbness, and tingling are numbness, and tingling are signs of spinal injury.signs of spinal injury.

May lose sensation or become May lose sensation or become paralyzedparalyzed

May become incontinentMay become incontinent

Focused Physical Examfor Nonsignificant Trauma

Complete set of baseline vital signs is essential.Complete set of baseline vital signs is essential. Assess pupil size and reactivity to light; continue to Assess pupil size and reactivity to light; continue to

monitor.monitor. Gather as much history as possible while preparing Gather as much history as possible while preparing

for transport.for transport.

Baseline Vital Signs/SAMPLE History

Control bleeding.Control bleeding. Fold torn skin flaps back Fold torn skin flaps back

down onto the skin bed.down onto the skin bed. Do not apply excessive Do not apply excessive

pressure.pressure. If dressing becomes If dressing becomes

soaked, place a second soaked, place a second dressing over it.dressing over it.

Interventions

Once bleeding has been controlled, Once bleeding has been controlled, secure with a soft self-adhering roller secure with a soft self-adhering roller bandage.bandage.

Monitor and treat for shock.Monitor and treat for shock. Protect airway from vomiting.Protect airway from vomiting. Provide immediate transport.Provide immediate transport.

Interventions

Perform if time permits.Perform if time permits. Can help identify subtle or covert Can help identify subtle or covert

injuriesinjuries

Detailed Physical Exam

Focus on reassessing ABCs, interventions, Focus on reassessing ABCs, interventions, vital signs.vital signs.

Communication and documentationCommunication and documentation- Hospital may prepare better with info from your Hospital may prepare better with info from your

assessment.assessment.- Document changes in level of consciousness.Document changes in level of consciousness.- Include history.Include history.- Document vital signs every 5 minutes if unstable, Document vital signs every 5 minutes if unstable,

every 15 minutes if stable.every 15 minutes if stable.

Ongoing Assessment

Follow BSI precautions.Follow BSI precautions. Manage the airway.Manage the airway.

– Perform the jaw-thrust maneuver to open Perform the jaw-thrust maneuver to open the airway.the airway.

– Consider inserting an oropharyngeal Consider inserting an oropharyngeal airway.airway.

– Administer oxygen.Administer oxygen. Stabilize the cervical spine.Stabilize the cervical spine.

Emergency Medical Careof Spinal Injuries

Hold head firmly with Hold head firmly with both hands.both hands.

Support the lower Support the lower jaw.jaw.

Move to eyes-forward Move to eyes-forward position.position.

Stabilization of the Cervical Spine

Support head while Support head while partner places partner places cervical collar.cervical collar.

Maintain the Maintain the position until patient position until patient is secured to a is secured to a backboard.backboard.


Do not force the head into a neutral, in-Do not force the head into a neutral, in-line position if:line position if:– Muscles spasmMuscles spasm– Pain increasesPain increases– Numbness, tingling, or weakness developNumbness, tingling, or weakness develop– There is a compromised airway or There is a compromised airway or

breathing problems.breathing problems.


Establish an adequate airway.Establish an adequate airway.

Control bleeding and provide adequate Control bleeding and provide adequate circulation.circulation.

Assess the patient’s baseline level of Assess the patient’s baseline level of consciousness.consciousness.

Emergency Medical Careof Head Injuries

Establish an adequate airway.Establish an adequate airway. Use the jaw-thrust maneuver.Use the jaw-thrust maneuver. Maintain head in neutral, in-line position.Maintain head in neutral, in-line position. Place cervical collar.Place cervical collar. Suction.Suction. Provide high-flow oxygen.Provide high-flow oxygen. Continue to assist ventilations and administer Continue to assist ventilations and administer

oxygen.oxygen.

Managing the Airway

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Begin CPR if patient is in cardiac arrest.Begin CPR if patient is in cardiac arrest. Blood loss aggravates hypoxia.Blood loss aggravates hypoxia. Shock can occur.Shock can occur. Transport immediately to trauma center.Transport immediately to trauma center. If patient becomes nauseated or vomits, If patient becomes nauseated or vomits,

place on left side.place on left side.

Circulation

Apply and maintain in-line Apply and maintain in-line stabilizationstabilization

Assess distal functions (PMS)Assess distal functions (PMS) Apply a rigid C-collarApply a rigid C-collar Position the long spine boardPosition the long spine board Log-roll the patientLog-roll the patient Ensure the patient is centeredEnsure the patient is centered

Preparation for Transport:Preparation for Transport:SupineSupine Patients Patients

Secure upper torsoSecure upper torso Secure pelvis/upper legsSecure pelvis/upper legs Immobilize the head to Immobilize the head to

boardboard Check and readjust Check and readjust

strapsstraps Reassess Pulse, Motor, Reassess Pulse, Motor,

SensorySensory

Preparation for Transport:Preparation for Transport:SupineSupine Patients Patients

head and spinal injuries part 1

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