Ch. 29 - Head, Neck, and Spine Trauma

dermatome

An area of the skin that is innervated by a single spinal nerve can be used to identify loss of function associated with a particular area

temporal bone

Bone that forms part of the sides of the skull and floor of the cranial cavity

hematoma

In a head injury, a collection of blood within the skull or brain

orbits

The bony structures around the eyes; the eye sockets

foramen magnum

The opening at the base of the skull through which the spinal cord passes from the brain

You are treating a 45-year-old male who was involved in a high-speed car crash. You have decided to use the rapid extrication technique, which is typically used in all of the following situations except when: a. moving a patient rapidly from an unsafe scene. b. a stable, low-priority patient must be immobilized. c. more seriously injured patients must be accessed. d. moving a high-priority patient.

b

When a patient has a scalp injury: a. expect minimal bleeding. b. determine the wound depth. c. expect profuse bleeding. d. palpate the site with the fingertips.

c

Cheyne-Stokes breathing

distinct pattern of breathing characterized by quickening and deepening respirations followed by a period of apnea

immobilization of patient wearing helmet

do everything the same as you would, but decide whether to keep helmet on or off can also life face shield and face guards be removed to assess further

cauda equina

fan of nerves at base of spinal cord

decorticate posture

flexing arms and wrists, extending legs and feet (corpse like) result of increased ICP; may be spontaneous positioning or only in response to painful stimuli

mechanisms of spine injury

flexion and extension of neck causing injury to cervical spine (ex. whiplash, over rotation or twisting sports injury, excessive compression/axial loading, distraction injury from hanging) higher risk with osteoporosis, ligament laxity, pregnancy, Down syndrome; fused vertebrae or fixed flexion deformities

regions of skull

frontal, parietal, temporal, occipital

NEXUS criteria

national emergency x-radiography utilization study

spinal restriction in seated patient

normal extrication technique - manually stabilize head and neck during primary assessment - apply c-collar - secure patient to short spine board of extrication vest - secure torso first then head - extricate

secondary spinal injury

occurs after initial insult

signs and symptoms of spinal injury

paralysis of extremities changes in neurological function including paraesthesias, tingling pain with neck and back movement midline spinal tenderness impaired breathing reversed respiratory movements due to diaphragm collapse priapism loss of bladder/bowel control spinal deformity neurogenic shock

intracerebral hematoma

pooling of blood within the brain

meninges

protect brain and spinal cord

nontraumatic brain injuries

signs of brain injury can be caused by internal brain event such as hemorrhage or blood clot basically only difference between traumatic and nontraumatic brain injuries is mechanism of injury

thoracic and lumbar spine dysfunction

sympathetic nervous system dysfunction of heart rate, vascular tone, and bronchial dilation

central neurogenic hyperventilation

very rapid breathing associated with brainstem damage

ICP and brain hematoma

when hematoma develops, ICP increases which leads to progressive neurological abnormalities pressure also reduces perfusion of brain tissue brain tissue can also be forced out the skull and compress the brainstem which causes dysregulation of many vital functions

immobilization of standing patient

- patients who are ambulatory or able to self-extricate without causing pain can move themselves to a supine position on the backboard after application of cervical collar - can manually stabilize while standing, place collar, then place backboard behind patient standing up, slowly lift down

spinal motion restriction of cervical spine

restrict movement of head and neck use C-collar or extrication collar

natural curvature of spine

rigid backboard does not account for natural curvature of spine, so have to pad voids vacuum mattress does conform to curvature

immobilization devices for spine

rigid spine board back board vacuum mattress

shock and brain injuries

shock from blood loss during brain injury typically only occurs in infants/young children not enough bleeding in adult brain to cause shock

indirect brain injury

shock of impact causes concussions and contusions of brain can occur with open or closed head injuries

direct brain injury

where brain is lacerated, punctured, or bruised can occur with open head injury

special considerations for application of short spine board

- assess posterior of body prior to laying down - angle board to fit between arms of rescuer who is stabilizing head from behind patient - uppermost holes must be level with patient's shoulders - base of board should not extend past coccyx - never place chin strap on patient if it will prevent them from spitting up or vomiting - avoid applying torso strap too tightly if it will limit respirations or aggravate abdominal injury - do not pad between collar and board if not a pediatric patient - pad occipital region to fill void with natural curvature of spine

patient assessment of skull and brain injuries

- check mental status and GCS - note any injuries to head but do not probe further as it may do harm - do not palpate site of injury or tenderness in case of bony deformity - assess PERRL - assess eyes for discoloration/deformity - hemotympanum or hemorrhea - CSF drainage - personality changes - hypertension and decreased heart rate - breathing pattern - temperature increase - visual disturbance - impaired hearing or tinnitus - balance incoordination - forceful vomiting - decorticate or decerebrate posturing - paralysis/focal weakness, especially unilateral - deteriorating vital signs

indications to not remove helmet

- helmet fits snugly and no excessive head movement - no impending airway or breathing problems; no need to resuscitate or provide ventilations - removal could cause further injury - proper spinal immobilization can be done with helmet in place - no interference with EMT's care of life threatening issues - keep any shoulder padding on in addition to keeping helmet

indications to remove helmet

- helmet interferes with airway and breathing management - improperly fitted and allows excessive head movement - interferes with immobilization - cardiac arrest present - remove any shoulder padding in addition if you remove helmet

care of spinal injuries

- immobilization - oxygen administration to prevent spinal tissue from dying - prevent hypoglycemia - provide ventilation if necessary

application of long spine board

- maintain c-spine - apply c-collar - log roll patient onto long backboard after assessing posterior back - pad voids on head and torso - apply head blocks - apply head strap and chin strap - additionally immobilize chest, pelvis, and legs - package patient and transport

pediatric spinal immobilization notes

- make sure to use pediatric sized c-collar - prevent hyperextension of neck - remove a patient from a safety seat after an MVC, as MVC may have compromised safety of seat - can use rapid extrication device and provide full immobilization on that device

spinal restriction in rapid extrication

- manually stabilize head and neck during primary assessment - apply c-collar - lift patient by armpits while other EMT lifts by buttocks/thighs for additional rescuer to slide long spine board under patient, across the vehicle seat (like a bench) - lower patient back down onto spinal board - transition from sitting to laying position while maintaining c-spine; hand off stabilization to additional rescuer at head of spine board

vertebrae

7 cervical 12 thoracic 5 lumbar 5 sacral (fused) 4 coccygeal (fused) 33 in total each are separated by ligaments

neurogenic shock

A state of shock caused by nerve paralysis that is sometimes caused by spinal injuries failure of nervous system to control blood vessel diameter pulse rate may slow due to inability to signal quickening of pulse rate

cervical spine dysfunction

C3-C5 innervates breathing C4 phrenic nerve innervation that controls diaphragm

CO2 levels in brain with ICP

CO2 levels in brain increase and cause brain tissue to swell as ICP increases swelling worsens ICP even further which creates even greater CO2 levels

cerebrospinal fluid

CSF fluid that surrounds brain and spinal cord

autonomic nervous system

Controls involuntary functions

contusion

In brain injuries, a bruised brain caused when the force of a blow to the head is great enough to rupture blood vessels

laceration

In brain injuries, a cut to the brain skull fracture can cause secondary brain laceration due to sharp edges can also be caused by penetrating injury

Concussion

Mild closed head injury without detectable damage to the brain; complete recovery is usually expected

intracranial pressure (ICP)

Pressure inside the skull

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

herniation

Pushing of a portion of the brain through the foramen magnum as a result of increased intracranial pressure

Vertebrae

The bones of the spinal column

nasal bones

The bones that form the upper third, or bridge, of the nose

Spinous process

The bony bump on a vertebra

Cranium

The bony structure making up the forehead and the top, back, and upper sides of the skull

Malar

The cheek bone; also called the zygomatic bone

Cerebrospinal fluid (CSF)

The fluid that surrounds the brain and spinal cord

Temporomandibular joint

The movable joint formed between the mandible and the temporal bones; also called the TMJ

Peripheral nervous system

The nerves that enter and exit the spinal cord between the vertebrae, 12 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

maxillae

The two fused bones forming the upper jaw

After performing the primary assessment and rapid trauma exam on a spine-injured patient, your next step is to: a. determine the patient's priority. b. administer high-concentration oxygen. c. immobilize the patient on a long spine board. d. determine the mechanism of injury.

a

If a responsive patient has the mechanism of injury for a spinal injury, the EMT should do all of the following except: a. assess for spinal pain by asking the patient to move. b. keep the patient still while asking him or her questions. c. assess for equality of strength in the extremities. d. assess for tingling in the extremities.

a

When assessing a suspected spine-injured patient, you note a reversal of the normal breathing pattern. This is likely a result of damage to the nerves that control the: a. rib cage. b. diaphragm. c. abdomen. d. lungs.

a

When immobilizing a 6-year-old or younger child on a long backboard: a. provide padding beneath the shoulder blades. b. it is unnecessary to apply a cervical collar. c. place a chin cup or chin strap on the patient. d. secure the head first and then secure the torso.

a

You are treating a 35-year-old female who failed to wear a helmet and struck her head when she fell off her bike. In most EMS systems, she would be taken to a trauma center if her Glasgow Coma Scale (GCS) score was less than: a. 14 b. 10 c. 12 d. 15

a

You are treating a 52-year-old man who was involved in a serious high-speed collision. If the patient is up and walking around at the scene, you should: a. assess for potential spinal injury. b. check with medical direction for orders. c. check with bystanders about the patient's mental status. d. assume that the patient is uninjured.

a

You suspect your patient may have a traumatic brain injury. His signs and symptoms may include: a. blood or fluid flowing from the ears and/or nose. b. yellow discoloration in the eyes. c. bruising around the base of the nose. d. pain at the base of the neck.

a

Canadian cervical spine rules

another subset of rules to asses cervical spine injury and appropriate treatment

high risk spinal injury

any midline spine pain any tenderness of midline spine of palpation abnormal neurological function in any four extremities in terms of sensory and motor function

Further assessment of the patient in the previous question reveals that he also has discoloration of the soft tissues under both eyes. This finding is called: a. Cushing's syndrome. b. raccoon eyes. c. Battle's sign. d. posturing syndrome.

b

Skull or traumatic brain injury may result in: a. airway swelling and dizziness. b. altered mental status and unequal pupils c. difficulty moving below the waist. d. headache and hypoperfusion.

b

The patient does not complain of any spinal pain. It is important to remember that a lack of spinal pain does not rule out the possibility of spinal-cord injury because: a. spinal injuries seldom cause pain. b. other painful injuries may mask it. c. spinal injuries are not painful until shock sets in. d. a patient may feel the pain but cannot verbalize it.

b

What is the significance of an increase in carbon dioxide in the injured brain? a. it increases the blood pressure. b. It causes brain tissue swelling. c. It raises the heart rate. d. It causes brain tissue shrinkage.

b

You are assessing a 27-year-old male who you suspect has a spine injury. If he complains of pain when you attempt to place his head in a neutral in-line position, you should: a. pad the neck before immobilizing. b. steady the head in the position found. c. continue with the stabilization procedure. d. contact medical direction immediately.

b

Your patient is a 19-year-old male who was involved in a motorcycle crash. You should consider keeping the helmet on the patient: a. if it interferes with breathing management. b. if it has a snug fit that allows no head movement. c. by using a two-rescuer procedure. d. if it hinders immobilization.

b

injuries to face and jaw

bone fragments from fracture may dislodge and cause airway obstruction blood, blood clots, dislodged teeth, separated palate can block airway mandible dislocation

central nervous sytem

brain and the spinal cord

contrecoup injury

bruising occurring on opposite side of blunt force direction

coup injury

bruising occurring on same side as blunt force direction

If a stable 22-year-old male patient is found in a sitting position on the ground and is complaining of back pain, the EMT Should: a. apply a cervical collar and rapidly transport the patient. b. ask the patient to lie down, then immobilize. c. immobilize with a short spine board or extrication vest. d. perform a rapid take-down procedure with a long spine board.

c

You are assessing a 22-year-old male who was involved in a bar fight earlier this evening. It is now 4 a.m. and the family called the ambulance because he has been vomiting. You notice he has a bruise behind the ear. This is called: a. Cushing's syndrome. b. raccoon eyes. c. Battle's sign. d. posturing syndrome.

c

You are treating a 22-year-old male who was assaulted with a knife. The attacker slashed the patient's throat. Initially there was considerable blood, but you were able to control it and bandage the wound. The patient went into sudden cardiac arrest. what is the most likely cause? a. a stroke b. a heart attack c. an air embolism d. infection from the wound

c

Your patient fell down the stairs and may have injured his spine. Examples of findings that may lead you to consider a spine injury include all of the following except: a. the presence of priapism. b. the loss of bladder control. c. an increased pulse rate. d. nerve impairment to the extremities.

c

scalp injury

can cause profuse bleeding control with direct pressure gently palpate for any bony deformities

subdural hematoma

collection of blood between brain and dura

epidural hematoma

collection of blood between dura and skull

If a patient is found on her back with arms extended above the head, this may indicate a _________ spine injury. a. thoracic b. lumbar c. sacral d. cervical

d

The practice of supine spinal immobilization has recently been on the decline in many services due to possible harmful side effects. These include which of the following? a. hypothermia b. pressure sores c. worsening lung injuries d. all of the above are possible side effects

d

You are treating a patient who fell backward and struck his head. You suspect that he is developing increased ICP. The time it takes to develop the symptoms from a increased ICP depend on: a. the rate of bleeding into the head. b. the location of the bleed. c. the age of the patient. d. all of these are important factors.

d

You are treating a patient who has a steel rod penetrating the skull. You should: a. shorten lengthy objects, using any available tools. b. elevate the patient's legs immediately. c. remove the object and quickly control the bleeding. d. stabilize the object with bulky dressings, provided it is a length that can be transported with the patient.

d

You are treationg a 35-year-old female who has an injury to one of her spinal vertebrae. Based on the frequency of injury, it is most likely one of the: a. lumbar and sacral. b. thoracic and cervical. c. coccygeal and thoracic. d. cervical and lumbar.

d

signs and symptoms of ICP

dilated pupils decreased pupil reaction increased systolic pressure decreased heart rate tachypnea

air embolism

due to pressure in vein lower than atmospheric pressure, injury presents possibility for air to be sucked into a vessel and cause air embolism; which can then be carried into lung and create pulmonary embolism this is why direct pressure cannot be applied to a neck wound

EMS providers can use an assessment tool that physicians use to decide if full spinal immobilization on a long spine board is needed for a possible spinal injury. The key parts of it are: a. conscious and truthful patient to answer questions b. pain along the spinal midline c. pain upon palpation anywhere on the spine d. intact sensory and motor functions in extremities e. all of the above are key parts of the assessment for spinal integrity

e

care of open neck wound

ensure open airway place gloved hand over wound apply occlusive dressing; tape on all four sides apply pressure as needed to further stop bleeding once stopped, apply bandage and dressing immobilize spine if necessary

decerebrate posture

extending arms and shoulders rotated inward, wrists flexed, legs extended (ragdoll, splayed out) result of increased ICP; may be spontaneous positioning or only in response to painful stimuli

parameters of GCS

eye opening: spontaneous - 4 to voice - 3 to pain - 2 none - 1 verbal response: oriented x3 - 5 confused - 4 inappropriate words - 3 incomprehensible sounds, no speech - 2 none - 1 motor response: obeys commands - 6 localizes pain to specific areas when palpating - 5 withdraws from pain - 4 flexion from pain (decorticate posturing) - 3 extension from pain (decerebrate posturing) - 2 none - 1 add up of 15 total

geriatric spinal injuries

fractured spines in elderly patients can be caused by simple falls or spontaneous fractures

skull injury

fractures of cranium and face open skull injury involves cranial bones closed skull injury does not involve cranial bones (ex. scalp laceration)

spinal injuries

fractures, displacement, dislocations, muscular strains, disk injury, compression fractures

GCS

glasgow coma scale

nutrients required by spinal cord tissue

glucose and oxygen

signs and symptoms of concussion

headache brief LOC amnesia grogginess/fatigue altered level of consciousness nausea visual disturbance slurred speech photophobia phonophobia

spinal motion restriction

immobilization of spinal column as if it were a single bone to prevent movement of all individual vertebrae spine generally follows largest areas of mass (head, shoulders, pelvis) so if those are stable, then spine should remain stable

Cushing's reflex

increasing ICP compensated by constricting vessels in brain tissue then slowing heart rate so hypertension and decreased heart rate

ataxic respirations

irregular and unpredictable breathing

mandible

lower jaw bone

facial bones

mandible temporal bone maxillae nasal bones zygomatic bones/malar orbits

concussion

mild closed head injury without detectable damage to the brain symptoms can linger for weeks, months, or even years

primary spinal injury

occurs as a result of direct force

time of onset of neurological symptoms manifesting is dependent on

rate of bleeding and location of bleeding can range from instant to a couple hours later or even 12-24 late onset