injuries to the head and spine

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Injuries to the Head and SpineInjuries to the Head and SpineChapter 29Chapter 29


Case HistoryCase History

You respond to a 60-year-old man who fell while You respond to a 60-year-old man who fell while riding a motorcycle without a helmet. He has a riding a motorcycle without a helmet. He has a contusion on the left side of his forehead and fluid contusion on the left side of his forehead and fluid leaking from his nose, mouth, and ears. He is leaking from his nose, mouth, and ears. He is verbally combative but cannot move his upper and verbally combative but cannot move his upper and lower extremities.lower extremities.


Central and Peripheral Central and Peripheral Nervous SystemNervous System


BrainBrain


Layers of the BrainLayers of the Brain


Blood Supply to the BrainBlood Supply to the Brain


Skeletal SystemSkeletal System

Provides structure and supportProvides structure and support

Protects vital organsProtects vital organs

Allows movement, in conjunction with musclesAllows movement, in conjunction with muscles


SkullSkull


Base of the SkullBase of the Skull


Nerve Cells and PressureNerve Cells and Pressure

Nerve cells are very sensitive to pressure.Nerve cells are very sensitive to pressure.

When pressure is applied to nerve cells, function When pressure is applied to nerve cells, function becomes compromised.becomes compromised.

Determinants of injury from pressure:Determinants of injury from pressure: The amount of pressure applied on nerveThe amount of pressure applied on nerve The period of time over which it is appliedThe period of time over which it is applied


Mechanism of Injury –Mechanism of Injury –Compression ForcesCompression Forces


Mechanism of Injury –Mechanism of Injury – Hyperflexion Hyperflexion


Mechanism of Injury – Mechanism of Injury – HyperextensionHyperextension


Lateral BendingLateral Bending

DistractionDistraction Pulling apart of the spinePulling apart of the spine Example: HangingExample: Hanging


High Index of Suspicion for High Index of Suspicion for Spinal InjurySpinal Injury

Motor vehicle crashesMotor vehicle crashes

Pedestrian vs. vehicle collisionsPedestrian vs. vehicle collisions

FallsFalls

Blunt traumaBlunt trauma


High Index of Suspicion for High Index of Suspicion for Spinal InjurySpinal Injury

Penetrating trauma to head, neck, or torsoPenetrating trauma to head, neck, or torso

Motorcycle crashesMotorcycle crashes

HangingsHangings

Diving accidentsDiving accidents

Unconscious trauma victimsUnconscious trauma victims


Spinal Injuries –Spinal Injuries –Signs and SymptomsSigns and Symptoms

Tenderness in the area of injury Tenderness in the area of injury

Pain associated with movingPain associated with moving Do not ask the patient to move to try to elicit a pain response.Do not ask the patient to move to try to elicit a pain response. Do not move the patient to test for a pain response.Do not move the patient to test for a pain response. Tell the patient not to move while you are asking questions.Tell the patient not to move while you are asking questions.

Normal function does not rule out spinal injury.Normal function does not rule out spinal injury.


Spinal Injuries –Spinal Injuries –Signs and SymptomsSigns and Symptoms

Pain independent of movement or palpationPain independent of movement or palpation Along spinal columnAlong spinal column Lower legsLower legs May be intermittentMay be intermittent

Obvious deformity of the spine on palpationObvious deformity of the spine on palpation

Soft tissue injuries associated with traumaSoft tissue injuries associated with trauma From head and neck to cervical spineFrom head and neck to cervical spine Shoulders, back, or abdomen (thoracic, lumbar region)Shoulders, back, or abdomen (thoracic, lumbar region) Lower extremities (lumbar, sacral region)Lower extremities (lumbar, sacral region)


Motor and Sensory Function –Motor and Sensory Function –Upper ExtremitiesUpper Extremities


Motor and Sensory Function –Motor and Sensory Function –Lower ExtremitiesLower Extremities


Loss of Sensation and Function Loss of Sensation and Function Below Level of InjuryBelow Level of Injury

Loss of sensation and paralysisLoss of sensation and paralysis C4: claviclesC4: clavicles T4: nipple lineT4: nipple line T10: navelT10: navel L1: groinL1: groin

Level of injury – respiratory paralysisLevel of injury – respiratory paralysis Above C3, complete paralysis/respiratory arrestAbove C3, complete paralysis/respiratory arrest Below C5, intercostals and abdominals, diaphragmatic breathing onlyBelow C5, intercostals and abdominals, diaphragmatic breathing only

Upper or lower extremities Upper or lower extremities

IncontinenceIncontinence


Assessment of Spine-Injured Assessment of Spine-Injured Responsive PatientResponsive Patient

Mechanism of injuryMechanism of injury

Questions to askQuestions to ask Does your neck or back hurt?Does your neck or back hurt? What happened?What happened? Where does it hurt?Where does it hurt? Can you move your hands and feet?Can you move your hands and feet? Can you feel me touching your fingers?Can you feel me touching your fingers? Can you feel me touching your toes?Can you feel me touching your toes?


Assessment of Spine-Injured Assessment of Spine-Injured Unresponsive PatientUnresponsive Patient

Mechanism of injuryMechanism of injury

Initial assessmentInitial assessment

Inspect forInspect for Contusions Contusions Deformities Deformities Lacerations Lacerations Punctures/penetrationsPunctures/penetrations SwellingSwelling


Assessment of Spine-Injured Assessment of Spine-Injured Unresponsive PatientUnresponsive Patient

Palpate for areas of tenderness or deformity.Palpate for areas of tenderness or deformity.

Obtain information from others.Obtain information from others. Mechanism of injuryMechanism of injury Mental statusMental status


ComplicationsComplications

Inadequate breathing Inadequate breathing efforteffort Prepare for positive-Prepare for positive-

pressure ventilation.pressure ventilation. Maintain manual inline Maintain manual inline

stabilization.stabilization.

ParalysisParalysis


Emergency Medical CareEmergency Medical Care

Body substance Body substance isolationisolation Determined by Determined by

presenting problempresenting problem• GogglesGoggles

• GlovesGloves

• MaskMask

• GownGown


Critically Injured PatientCritically Injured Patient

Perform a rapid extrication.Perform a rapid extrication.

Bring body into alignment.Bring body into alignment.

Transfer to long board without Transfer to long board without short spine board.short spine board.

Transport immediately.Transport immediately.


Injuries to the Head –Injuries to the Head –StructuralStructural

Specific sections of the Specific sections of the brain are injured.brain are injured. Brain lacerationsBrain lacerations Brain contusionsBrain contusions Blockage of vessels Blockage of vessels

(stroke)(stroke)

Injuries can be Injuries can be traumatic or traumatic or nontraumatic.nontraumatic.


Structural Injuries –Structural Injuries –Signs and SymptomsSigns and Symptoms

Result in localized Result in localized findings (unilateral)findings (unilateral) Unequal pupilsUnequal pupils One-sided paralysisOne-sided paralysis One-sided sensory lossOne-sided sensory loss


Metabolic InjuriesMetabolic Injuries

Interruption of energy needed for cell lifeInterruption of energy needed for cell life

PoisoningPoisoning

HypoxiaHypoxia

Low blood sugarLow blood sugar


Metabolic Injuries – Metabolic Injuries – Signs and SymptomsSigns and Symptoms

Symmetrical findingsSymmetrical findings

General signs of CNS dysfunctionGeneral signs of CNS dysfunction


Structural vs. Metabolic Structural vs. Metabolic FindingsFindings


Secondary Complications of Secondary Complications of Brain InjuryBrain Injury

HypoxiaHypoxia

HypotensionHypotension

HypoglycemiaHypoglycemia

InfectionsInfections

Increased intracranial Increased intracranial pressurepressure


Significance of Secondary Significance of Secondary ComplicationsComplications

Occur with direct brain injuryOccur with direct brain injury

Aggravate brain functionAggravate brain function

Management is important to overall care.Management is important to overall care.

Treatment prevents further injury to the brain.Treatment prevents further injury to the brain.


Injuries to the Brain and SkullInjuries to the Brain and Skull

Most common cause of traumatic deathMost common cause of traumatic death May be immediateMay be immediate May occur over timeMay occur over time

Rapid recognition and management is key.Rapid recognition and management is key.

Access to surgical intervention is critical.Access to surgical intervention is critical.

Immobilization, airway, and ventilationImmobilization, airway, and ventilation Key to prehospital careKey to prehospital care


Injuries to the Brain and SkullInjuries to the Brain and Skull

ScalpScalp

Skull fractureSkull fracture

ConcussionConcussion

Increased intracranial pressureIncreased intracranial pressure

Epidural hematomaEpidural hematoma

Subdural hematomaSubdural hematoma


Related Nontraumatic ConditionsRelated Nontraumatic Conditions

Clots or hemorrhageClots or hemorrhage

Nontraumatic brain injuriesNontraumatic brain injuries Can be a cause of altered mental statusCan be a cause of altered mental status Signs and symptoms parallel those of traumatic injuriesSigns and symptoms parallel those of traumatic injuries No evidence of traumaNo evidence of trauma Lack of mechanism of injuryLack of mechanism of injury


Skull Injury –Skull Injury –Signs and SymptomsSigns and Symptoms

Mechanism of traumaMechanism of trauma

Scalp injuriesScalp injuries ContusionsContusions LacerationsLacerations HematomasHematomas

Deformity to the skullDeformity to the skull


Skull Injury –Skull Injury –Signs and SymptomsSigns and Symptoms

Blood or fluid leakage from the Blood or fluid leakage from the ears or noseears or nose

Bruising around the eyesBruising around the eyes

Bruising behind the ears (mastoid Bruising behind the ears (mastoid process)process)


ConcussionConcussion

Transient loss of consciousness or neurologic Transient loss of consciousness or neurologic functionfunction

Many degrees of injuryMany degrees of injury Least severeLeast severe

• Momentary loss of function immediately after injuryMomentary loss of function immediately after injury

• Short period of confusionShort period of confusion


Concussion –Concussion –More SevereMore Severe

Brain contusionBrain contusion Vision lossVision loss ParalysisParalysis Sensory deficitsSensory deficits


Signs of Signs of Increased Intracranial Pressure Increased Intracranial Pressure

Conscious patientsConscious patients HeadachesHeadaches NauseaNausea Vomiting (sometimes projectile)Vomiting (sometimes projectile)

Alterations in consciousness may occurAlterations in consciousness may occur SleepySleepy Responds to verbal stimuliResponds to verbal stimuli Responds to painful stimuliResponds to painful stimuli UnresponsiveUnresponsive


Signs of Signs of Increased Intracranial Pressure Increased Intracranial Pressure

in Children in Children

Drowsiness, nausea, vomitingDrowsiness, nausea, vomiting Even after minor head injuryEven after minor head injury

Worsening may be due toWorsening may be due to HypoxiaHypoxia HypotensionHypotension Other causesOther causes


Eye and Motor FindingsEye and Motor Findings

Unilaterally dilated pupilUnilaterally dilated pupil May not constrict with lightMay not constrict with light Eyelid may droopEyelid may droop

Unilateral weakness, paralysis, sensory loss, or a combination may be Unilateral weakness, paralysis, sensory loss, or a combination may be seen.seen.

As pressure increases, motor and sensory findings may affect both As pressure increases, motor and sensory findings may affect both sides.sides.

With further deterioration, abnormal postures or positions may be seen.With further deterioration, abnormal postures or positions may be seen.

Eventual flaccidityEventual flaccidity


Abnormal PosturingAbnormal Posturing


RespirationsRespirations

Abnormal respiratory Abnormal respiratory patternspatterns


Pulse and Blood PressurePulse and Blood Pressure

Late sign of increased intracranial pressureLate sign of increased intracranial pressure

Pulse slows.Pulse slows.

Blood pressure increases.Blood pressure increases.


Epidural HematomaEpidural Hematoma

Requires rapid recognition and early surgical interventionRequires rapid recognition and early surgical intervention

Usually presents with short period of unconsciousness after Usually presents with short period of unconsciousness after blunt trauma to head, fblunt trauma to head, followed by lucid interval, then decrease ollowed by lucid interval, then decrease in LOCin LOC Blown pupil on side of injuryBlown pupil on side of injury Weakness and sensory impairment on opposite side of bodyWeakness and sensory impairment on opposite side of body Abnormal respiratory patternAbnormal respiratory pattern Abnormal posturingAbnormal posturing Possible high blood pressure and slow pulsePossible high blood pressure and slow pulse If left untreated, death occurs.If left untreated, death occurs.


Epidural HematomaEpidural Hematoma


Subdural HematomaSubdural Hematoma


Brain Injury –Brain Injury –Signs and SymptomsSigns and Symptoms

Altered or decreasing mental statusAltered or decreasing mental status Confusion, disorientation, or repetitive questioningConfusion, disorientation, or repetitive questioning Best indicator of a brain injuryBest indicator of a brain injury

UnresponsiveUnresponsive Irregular breathing patternIrregular breathing pattern

Consideration of mechanism of injuryConsideration of mechanism of injury Deformity of windshieldDeformity of windshield Deformity of helmetDeformity of helmet


Brain Injury –Brain Injury –Signs and SymptomsSigns and Symptoms

Contusions, lacerations, hematomas to scalpContusions, lacerations, hematomas to scalp Deformity to skullDeformity to skull Blood or fluid leakage from ears and noseBlood or fluid leakage from ears and nose Bruising around eyesBruising around eyes Bruising behind ears (mastoid process)Bruising behind ears (mastoid process) Neurologic disabilityNeurologic disability Nausea and/or vomitingNausea and/or vomiting Unequal pupil size with altered mental statusUnequal pupil size with altered mental status Seizure activity may be seenSeizure activity may be seen


Open Head Injury –Open Head Injury –Signs and SymptomsSigns and Symptoms

Bruising around eyesBruising around eyes

Bruising behind ears (mastoid process)Bruising behind ears (mastoid process)

Nausea and/or vomitingNausea and/or vomiting

Brain injuryBrain injury Possible signs and symptoms of a closed head injuryPossible signs and symptoms of a closed head injury


Glasgow Coma ScaleGlasgow Coma Scale

Objective assessment of mental statusObjective assessment of mental status

Three parametersThree parameters Eye openingEye opening Verbal responseVerbal response Motor abilityMotor ability


Eye OpeningEye Opening

ScoresScores 4 – Open spontaneously (no stimuli)4 – Open spontaneously (no stimuli) 3 – Open to verbal stimuli3 – Open to verbal stimuli 2 – Open to painful stimuli2 – Open to painful stimuli 1 – Do not open1 – Do not open


Verbal ResponseVerbal Response

ScoresScores 5 – Alert and oriented5 – Alert and oriented 4 – Confused (attention can be maintained)4 – Confused (attention can be maintained) 3 – Inappropriate (attention cannot be 3 – Inappropriate (attention cannot be

maintained)maintained) 2 – Incomprehensible sounds2 – Incomprehensible sounds 1 – No response1 – No response


Motor AbilityMotor Ability

ScoresScores 6 6 –– Obeys verbal commands Obeys verbal commands

5 5 –– Localized to pain (reaches to source of pain) Localized to pain (reaches to source of pain)

4 4 –– Withdraws (rolls or moves from pain) Withdraws (rolls or moves from pain)

3 3 –– Flexion (flexes arms to pain) Flexion (flexes arms to pain)

2 2 –– Extension (extends arms to pain) Extension (extends arms to pain)

1 1 –– No response to pain No response to pain


Emergency Medical CareEmergency Medical Care Use personal protection measures.Use personal protection measures.

Suspect spinal injury; immobilize spine.Suspect spinal injury; immobilize spine.

Maintain airway/artificial ventilation/oxygenation.Maintain airway/artificial ventilation/oxygenation.

Perform initial assessment.Perform initial assessment.

Immobilization spine.Immobilization spine.

Complete detailed physical examination en route.Complete detailed physical examination en route.



MonitorMonitor Airway, breathing, pulse, and mental statusAirway, breathing, pulse, and mental status

Control bleeding.Control bleeding. Do not apply pressure to open or depressed skullDo not apply pressure to open or depressed skull

Dress and bandage open wound.Dress and bandage open wound.



Nontraumatic injuryNontraumatic injury Place patient on the left side.Place patient on the left side.

Be prepared for changes in patient’s condition.Be prepared for changes in patient’s condition.

Transport immediately.Transport immediately.


Cervical Spine Immobilization Devices –Cervical Spine Immobilization Devices –IndicationsIndications

Any suspected injury to the spine, based onAny suspected injury to the spine, based on Mechanism of injuryMechanism of injury HistoryHistory Signs and symptomsSigns and symptoms

Used in conjunction with short and long backboards.Used in conjunction with short and long backboards.


Cervical Spine Immobilization Devices –Cervical Spine Immobilization Devices –PrecautionPrecaution

Cervical immobilization devices alone do not provide adequate Cervical immobilization devices alone do not provide adequate inline immobilization. Maintain manual immobilization until the inline immobilization. Maintain manual immobilization until the head is secured to the board.head is secured to the board.


Long BackboardsLong Backboards

Several different types of long board immobilization devices Several different types of long board immobilization devices exist.exist.

Provide stabilization and immobilization to the head, neck and Provide stabilization and immobilization to the head, neck and torso, pelvis, and extremities.torso, pelvis, and extremities.

Use to immobilize patients found in a lying, standing, or sitting Use to immobilize patients found in a lying, standing, or sitting positionposition

Use in conjunction with short backboards.Use in conjunction with short backboards.


Rapid ExtricationRapid Extrication

Unsafe sceneUnsafe scene

Unstable patient conditionUnstable patient condition

Patient blocking access to a seriously injured patientPatient blocking access to a seriously injured patient

Based on Based on TimeTime Patient conditionPatient condition Not the EMT’s preferenceNot the EMT’s preference


Rapid ExtricationRapid Extrication

Apply CISD before move.Apply CISD before move.

Perform smoothly.Perform smoothly.

Coordination from lead person is key.Coordination from lead person is key.

Secure to long spine board after removal.Secure to long spine board after removal.


Helmet Removal –Helmet Removal –Special Assessment NeedsSpecial Assessment Needs

• Ability to gain access to airway and breathingAbility to gain access to airway and breathing

Fit of the helmetFit of the helmet May prevent proper spinal immobilizationMay prevent proper spinal immobilization

Patient movement within the helmetPatient movement within the helmet


Indications for Indications for Leaving Helmet in PlaceLeaving Helmet in Place

Fit of helmet is good with little or no movement of head.Fit of helmet is good with little or no movement of head.

Helmet does not impede airway or cause breathing problems.Helmet does not impede airway or cause breathing problems.

Removal would cause further injury to the patient.Removal would cause further injury to the patient.

Proper spinal immobilization could be performed with helmet in place.Proper spinal immobilization could be performed with helmet in place.

Helmet does not interfere with the ability to assess and reassess airway Helmet does not interfere with the ability to assess and reassess airway and breathing.and breathing.


Indications for Indications for Helmet RemovalHelmet Removal

Inability to assess and/or reassess airway and breathingInability to assess and/or reassess airway and breathing

Restriction of adequate airway or breathing managementRestriction of adequate airway or breathing management

Improperly fitted helmetImproperly fitted helmet

Inability to perform proper spinal immobilization because of helmetInability to perform proper spinal immobilization because of helmet

Cardiac arrestCardiac arrest


Types of HelmetsTypes of Helmets

SportsSports Typically open anteriorlyTypically open anteriorly Easier access to airway Easier access to airway

MotorcycleMotorcycle Full face guardFull face guard ShieldShield OtherOther


General Rules –General Rules –Helmet RemovalHelmet Removal

Technique depends on type of helmet.Technique depends on type of helmet.

Remove patient’s eyeglasses before removing the Remove patient’s eyeglasses before removing the helmet.helmet.


Infants and ChildrenInfants and Children

Require same attention to spinal immobilization as adultsRequire same attention to spinal immobilization as adults

Pad spine boards from the shoulders to the heelsPad spine boards from the shoulders to the heels Accounts for larger head in proportion to rest of bodyAccounts for larger head in proportion to rest of body

If CSID does not fit properly, use rolled towel and tape.If CSID does not fit properly, use rolled towel and tape.

Transport in car seat if assessment, treatment, and Transport in car seat if assessment, treatment, and immobilization can be accomplished.immobilization can be accomplished.

injuries to the head and spine

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