EMT: Chapter 28 [head and spine injuries]

how to apply a cervical collar:

1. inline stabilization 2. measure proper collar size 3. place chin support first 4. wrap collar around neck and secure 5. ensure fit and neutral stabilization

how to remove a helmet:

1. kneel at pt's head w partner at one side; open face shield; remove eyeglasses 2. prevent head movement by placing hands on either side of helmet and fingers on the lower jaw; have partner loosen strap 3. have partner place one hand at angle of lower jaw and other at the occiput 4. gently slip the helmet halfway off, then stop 5. have partner move hand from occiput to back of head to prevent it from snapping back 6. remove helmet and stabilize; cc; long backboard

how to perform inline stabilization:

1. standard precautions; firmly place hands around the base of skull on either side 2. support lower jaw with index and long fingers; lift head into neutral position aligned with torso 3. support head while partner places rigid cervical collar around neck

Following a head injury, a 20-year-old female opens her eyes spontaneously, is confused, and obeys your commands to move her extremities. You should assign her a GCS score of:

14

face

14 bones - maxillae - zygomas - mandible - orbit

The central nervous system (CNS) is composed of the:

brain and spinal cord

The _________ is the best-protected part of the CNS and controls the functions of the cardiac and respiratory systems.

brain stem

Coordination of balance and body movement is controlled by the:

cerebellum

A temporary loss or alteration of part or all of the brain's abilities to function without physical damage to the brain MOST accurately describes a(n):

cerebral concussion

The MOST common and serious complication of a significant head injury is:

cerebral edema

The brain is divided into three major areas

cerebrum, cerebellum, brainstem

The five sections of the spinal column, in descending order, are the:

cervical, thoracic, lumbar, sacral and coccygeal

It would be MOST appropriate to perform a focused secondary assessment on a patient who:

fainted and fell to the ground from a standing position

coup-contrecoup injury

front-and-rear injury to the brain in a frontal MVC

Hyperextension injuries of the spine are MOST commonly the result of:

hangings

When placing a patient onto a long backboard, the EMT at the patient's _________ is in charge of all patient movements.

head

When securing a pt to a backboard, which area of the body should you secure last?

head

When immobilizing a child on a long backboard, you should:

place padding under the child's shoulders as needed

What part of the nervous system controls the body's voluntary activities?

somatic

The spinal cord is encased in and protected by the:

spinal canal

neck rigidity, bloody CSF, and headache are associated with what kind of bleeding in the brain?

subarachnoid hemorrhage (think bacterial meningitis symptoms)

During your primary assessment of a 19-year-old unconscious male who experienced severe head trauma, you note that his respirations are rapid, irregular, and shallow. He has bloody secretions draining from his mouth and nose. You should:

suction his oropharynx for up to 15 seconds

helmets must be removed in all of the following cases EXCET:

when there are no impending airway or breathing problems

Which of the following statements regarding secondary brain injury is correct?

hypoxia and hypotension are the two most common causes of secondary brain injury

The effectiveness of positive-pressure ventilations when treating a head-injured patient can ONLY be determined by:

immediate reassessment following the intervention

You are treating a patient who might have a skull fracture. What should you do if a dressing you have applied to a head wound becomes soaked?

place a clean dressing over the bloody one

cerebrum

- 75% of brain's total volume - voluntary motor function, conscious thought

MOIs for head injuries

- MVCs (2/3 people have head injuries) - assault - falling (older adults) - sports-related incidents

primary: spinal immobilization considerations

- assess patient in position found - determine whether to apply a cervical collar after ABCs (manual stabilization sometimes good enough until then) - after applying a cervical collar, do not remove it unless airway issues - patient on backboard may have pain due to ischemia to the skin - obese patients may not be able to breathe (consider placing padding under)

scalp lacerations

- can lead to significant blood loss due to rich blood supply - may contribute easily to hypovolemia - often indicators of deeper, more serious injuries

what causes ICP

- epidural hematoma - subdural hematoma - intracerebral hematoma - subarachnoid

Cushing triad signs

- hypertension - bradycardia - irregular respirations (Cheyne-Stokes) AKA herniation syndrome: ICP so great that it forces brain stem and midbrain through foramen magnum treatment: controlled hyperventilations goal ETCO2 level = 30-35 mm Hg

standing patients

- in-line stabilization w cc - place board upright behind pt - EMTs on either side of pt and third behind them maintaining in-line stabilization - lateral EMTs grab handholds by going through patient's arms - lower down pt - head EMT makes sure head stays stabilized

skull fractures

- may be open or closed - can be the result of penetrating weapons - if head deformed keep high index of suspicion signs include: - raccoon eyes (ecchymosis under eyes) - Battle sign (ecchymosis behind one ear over the mastoid process)

how to use a vacuum mattress:

- more comfortable than backboard - provides thermal insulation - cannot be used if patients weight more than 350 lb 1. place mattress on flat surface with head end at patient's head 2. keep valve stem open to allow air to enter the mattress 3. smooth mattress 4. connect pump to mattress 5. if log-rolling patient, partially evacuate mattress until it is semi rigid 6. move patient onto attress 7. open valve again to allow air to enter until mattress is pliable 8. connect mattress to each side of patient's head; hold head blocks and have another person hold sides of mattress until it's evacuated of air 9. secure patient's chests, hips, legs 10. secure head and pad voids at top of shoulders 11. evacuate remaining air to achieve immobilization 12. disconnect pump and close valve 13. adjust straps around chest, hips, legs 14. check neurovascular status prior to lifting

contraindications of inline stabilization

- muscle spasms in neck - increased pain - numbness, tingling, weakness - compromised airway

how to remove a helmet: (2)

- remove chin strap by cutting it - remove the face mask - pop jaw pads out of place using tongue depressor - one EMT puts fingers inside helmet and rocks it back off the top of the head; other EMT holds occiput and jaw of pt - put padding behind head and behind occiput (especially important in children)

how to secure a patient to a long backboard:

- slide patient on OR use 4-person log roll depending on patient's condition + resources 1. maintain cervical stabilization; assess distal functions in all extremities 2. apply a cervical collar 3. rescuers kneel on one side and place hands on far side of pt 4. rescuers roll pt towards themselves, examine the back, slide backboard under pt, and roll pt onto backboard 5. center pt on backboard 6. secure upper torso 7. secure pelvis and upper legs 8. secure pt's head with commercial immobilization device or rolled towels 9. secure device with tape 10. reassess distal functions after straps secure

how to secure a patient found in a sitting position:

- use short backboard (and then secure to long backboard) - use rapid extrication (lower onto long backboard) IF pt in danger, cannot be accessed, or has urgent injuries 1. stabilize head and neck in in-line position; assess PMS in extremities; apply cc 2. insert immobilization device between upper back and seat 3. open side flaps and position them around the patient's torso around their armpits 4. secure upper-torso flaps and mid torso flaps 5. secure groin straps 6. secure forehead strap and fasten lower strap around cc 7. long backboard next to butt, under legs 8. turn and lower pt onto long backboard; life pt and slip long backboard under short 9. secure short and long backboard; release groin straps; assess PMS

A patient with a head injury presents with abnormal flexion of his extremities. What numeric value should you assign to him for motor response?

3

how many EMTs are required to immobilize a standing patient?

3

PNS

31 pairs of spinal nerves - brachial plexus controls arms - lumbosacral plexus controls legs 12 pairs of cranial nerves - transmit information to/from brain

spinal column

33 bones (vertebrae) divided into five sections: - cervical - thoracic - lumbar - sacral - coccygeal vertebrae connected by ligaments and separated by cushions (intervertebral disks) surrounded by muscles can palpate posterior spinous process of each vertebra - best is seventh cervical

The ideal procedure for moving an injured patient from the ground to a backboard is:

4-person log roll

The cervical spine is composed of _____ vertebrae.

7

the most prominent and most easily palpable spinous process is at the _________________ cervical vertebra at the base of the neck.

7th

cranium

80% brain tissue, 10% blood supply, 10% CSF - occiput - temporal regions - parietal regions - frontal region

linear skull fracture

80% of all skull fractures not life-threatening if no brain injury risk of infection/bleeding inside brain if scalp laceration with linear fracture (open fracture)

Which of the following statements regarding the cranium is correct?

80% of the cranium is occupied by brain tissue

Which of the following acts as a shock absorber for the CNS?

CSF

signs of ICP

Cheyne-Stokes respirations: fast, then slow, with intervening periods of apnea Ataxic respirations: irregular rate, pattern volume of breathing with intermittent apnea decreased pulse rate, headache, nausea, vomiting, decreased LOC, bradycardia, sluggish pupils cushing reflex (along with increased systolic BP, decreased pulse rate, irregular respirations)

You are treating a patient who went face-first through a windshield. She has extensive head injuries and is displaying hypertension, bradycardia, and Cheyne-Stokes respirations. Which of the following should you suspect?

Cushing triad

secondary: spinal

DCAP, PMS signs: - constant pain along spinal cord or in extremities - obvious deformities during palpation - numbness, weakness, tingling - soft-tissue injuries in spinal region - loss of sensation below suspected level of injury, incontinence - limited ability to expand diaphragm and abdominal excursion ("belly breathing") physiological issues: - inability to maintain body temperature - priapism - loss of bowel or bladder control

secondary: physical

DCAP-BTLS - look for bruising/blood on scalp - look for CSF leakage PMS (perfusion, motor function, sensation) - ask pt to squeeze hands and push each foot against your hands - can patient smile? - any numbness/tingling in extremities? pupil size - one dilated = compressing injury on one side of the brain

secondary: neurologic

GCS (4 eye opening, 5 verbal response, 6 motor response) - is speech clear? - does pt answer in logical manner? - is pt aware of surroundings? - is pt alert to person/place/time? - can pt remember events leading up to incident? - can pt recall major current events?

Cushing triad in a patient is a sign of which of the following?

ICP

history taking

OPQRST SAMPLE - does patient remember what happened? - does patient have a history of unresponsiveness?

Which of the following statements regarding cervical collars is correct?

a cervical collar is used in addition to, not instead of, manual immobilization

The MOST reliable sign of a head injury is:

a decreased LOC

An indicator of an expanding intracranial hematoma or rapidly progressing brain swelling is:

a rapid deterioration of neurologic signs

Common signs and symptoms of a serious head injury include all of the following, EXCEPT:

a rapid, thready pulse

subdural hematoma

accumulation of blood between dura and arachnoid layer occurs after falls/injuries involving strong deceleration forces more common than epidural; not associated with skull fracture as much veins bridging cerebral cortex and dura rupture and cause bleeding - signs of ICP develop gradually due to venous bleeding

epidural hematoma

accumulation of blood between the skull and dura mater result of a blow to the head that produces a linear fracture of the thin temporal bone and bleeding of the middle meningeal artery

When immobilizing a seated patient with a short backboard or vest-style immobilization device, you should apply a cervical collar:

after assessing distal neurovascular functions

A short backboard or vest-style immobilization device is indicated for patients who:

are in a sitting position and are clinically stable

After your partner assumes manual in-line stabilization of the patient's head, you should:

assess distal neurovascular status in the extremities

A female patient with a suspected spinal injury is breathing with a marked reduction in tidal volume. The MOST appropriate airway management for her includes:

assisting ventilations at an age-appropriate rate

Which of the following sets of vital signs depicts Cushing's triad?

blood pressure 80/40 mm Hg, pulse 30 beat/min, respirations 32 breaths/min

basilar skull fractures

associated with diffuse impact to the head (MVCs, falls) extension of linear fracture to the skull signs: - CSF drainage from ears (ruptured tympanic membrane; risk for bacterial meningitis) - raccoon eyes - Battle sign

open skull fractures

associated with multisystem trauma brain tissue may be exposed, increases risk of infection high mortality rate

The body's functions that occur without conscious effort are regulated by the _________ nervous system.

autonomic nervous system

When controlling bleeding from a scalp laceration with a suspected underlying skull fracture, you should:

avoid excessive pressure when applying the bandage

A man jumped from the roof of his house and landed on his feet. He complains of pain to his heels, knees, and lower back. This mechanism of injury is an example of:

axial loading

You are assessing a man who has a head injury and note that cerebrospinal fluid is leaking from his ear. You should recognize that this patient is at risk for:

bacterial meningitis

cerebellum

balance and body movements

In a(n) ________, CSF flows freely from the patient's ear; this type of injury can be difficult to diagnose with a radiograph.

basilar skull fracture

primary assessment

biggest intervention is spinal immobilization

An epidural hematoma is MOST accurately defined as:

bleeding between the skull and dura mater

subarachnoid hemorrhage

bleeding occurs into the subarachnoid space where CSF circulates signs: - bloody CSF - meningeal irritation signs (neck rigidity, headache) - sudden severe headache causes: - trauma - aneurysm rupture usually results in death or permanent neurologic damage if sudden

intracerebral hematoma

bleeding within the brain tissue itself may follow penetration injury or rapid deceleration associated with other brain injuries development of ICP depends on location of hematoma and size high mortality rate

Rapid deceleration of the head, such as when it impacts the windshield, causes:

compression injuries or bruising to the anterior portion of the brain and stretching/tearing to the posterior portion of the brain

Which of the following nerves allow sensory and motor impulses to be sent from one nerve directly to another?

connecting

When assessing a conscious patient with an MOI that suggests spinal injury, you should:

determine if strength in all tissues is equal

The tough, fibrous outer meningeal layer is called the:

dura mater

When immobilizing a patient on a long backboard, you should:

ensure that you secure the torso before securing the head

Lacerations to the scalp:

may be an indicator of deeper, more serious injuries

Which of the following head injuries would cause the patient's condition to deteriorate MOST rapidly?

epidural hematoma

While performing a secondary assessment of a patient who was hit with a tire iron on the side of the head, you find a depressed area above the patient's left ear. This indicates that the patient could have which of the following?

epidural hematoma

intracranial bleeding outside of the dura mater and under the skull is known as a(n):

epidural hematoma

The MOST important immediate treatment for patients with a head injury, regardless of severity, is to:

establish an adequate airway

reassessment

every 5 minutes document changes in LOC or rapid deterioration of neurologic signs (ICP increase) signs of ICP increase: - slowed pulse - rising BP - irregular respirations neurogenic shock will cause hypotension never pack wound/ear/nose if CSF is leaking from it cover but do not bandage scalp wounds documentation: - history from the scene - findings during assessment - treatments provided - how pt responded to interventions

primary: transport

extricate rapidly... - impaired airways - open head wounds - abnormal vital signs - no response to painful stimuli keep suction readily available en route (ICP = risk of nausea, seizures) elevate supine patients' heads to 30 degrees to reduce ICP

The Glasgow Coma Scale (GCS) is used to assess:

eye opening, verbal response, motor response

A 45-year-old male was working on his roof when he fell approximately 12′,landing on his feet. He is conscious and alert and complains of an ache in his lower back. He is breathing adequately and has stable vital signs. You should:

immobilize his spine and perform a focused secondary assessment

You are reassessing a patient and you find that her left pupil is dilated and fixed. What does this indicate?

increased intracranial pressure

primary (direct) TBI

injury to the brain and its associated structures that results from instantaneous impact to the head

During your primary assessment of a semiconscious 30-year-old female with closed head trauma, you note that she has slow, irregular breathing and a slow, bounding pulse. As your partner maintains manual in-line stabilization of her head, you should:

instruct him to assist her ventilations while you perform a rapid assessment

Bleeding within the brain tissue itself is called a(n):

intracerebral hematoma

autonomic NS

involuntary activities that control body's vital organs sympathetic response: - pupil dilation - smooth muscle dilation - increased HR - increased BP - shunting of blood to vital organs/skeletal muscle - epinephrine release

In contrast to a cerebral concussion, a cerebral contusion:

involves physical injury to the brain tissue

Which of the following breathing patterns is MOST indicative of increased intracranial pressure?

irregular rate, pattern and volume of breathing with intermittent periods of apnea

Once a cervical collar has been applied to a patient with a possible spinal injury, it should not be removed unless:

it causes a problem managing the airway

A tight-fitting motorcycle helmet should be left in place unless:

it interferes with your assessment of the airway

When opening the airway of a patient with a suspected spinal injury, you should use the:

jaw-thrust maneuver

how to manage the airway: (general)

jaw-thrust maneuver (move tongue if unconscious) once airway is open, maintain head and cervical spine in a neutral, in-line position until securing pt on a backboard have suctioning available ventilation important if breathing depressed in respiratory control center of brain always give supplemental O2 to reduce hypoxia and cerebral edema risk

A high school football player was injured during a tackle and complains of neck and upper back pain. He is conscious and alert and is breathing without difficulty. The EMT should:

leave his helmet and shoulder pads in place

When caring for a patient with a possible head injury, it is MOST important to monitor the patient's:

level of consciousness

Which of the following skull fractures would be the LEAST likely to present with palpable deformity or other outward signs?

linear

Accounting for approximately 80% of all skull fractures, which of the following often present with no physical signs?

linear skull fracture

The time between an initial period of unconsciousness and a subsequent loss of consciousness is referred to as what?

lucid interval

primary: assessing for signs/symptoms of a head/spine injury

major questions: - what happened? - where does it hurt? - does your neck or back hurt? - can you move your hands and feet? - did you hit your head? signs: confused or slurred speech, repetitive questioning or amnesia patient has head injury until proven otherwise; unresponsive patients with trauma should be assumed to have spinal injury determination of spinal injury should be guided by AVPU

blood clots, hemorrhages

may be caused by medical reasons such as blood vessel problems or high BP

When a patient experiences a severe spinal injury, he or she:

may lose sensation below the level of injury

concussion

mild TBIs -- approximately 90% of patients do not experience loss in consciousness retrograde (forgets before event) or anterograde (forgets after event) amnesia mild signs: - dizziness, weakness - visual changes - nausea, vomiting - ringing in the ears - slurred speech - inability to focus

contusions

more serious concussion that involves physical injury to the brain tissue associated swelling/bleeding increased pressure within skull

brainstem

most primitive part of CNS; controls virtually all functions that are necessary for life

open head injury

one in which an opening from the brain to the outside world exists - obvious skull deformity with a break in the skin = sign of penetrating trauma - there may be exposed brain tissue

The _________ nervous system consists of 31 pairs of spinal nerves and 12 pairs of cranial nerves.

peripheral

spine injuries

possible injuries: - herniation of disks - compression on the spinal cord and nerve roots - fragmentation into the spinal cord can occur by hyperextension (leads to fractures, ligament/muscle issues) of the cervical spine in MVC or rotation-flexion of C1/C2 how to diagnose: - pain, tenderness on palpation - possibly a "step-off" deformity where you can feel the spinous process

intracranial pressure (ICP)

pressure within cranial vault increased ICP squeezes brain against bony cranium prominences

secondary (indirect) TBI

processes that increase severity of a primary brain injury and negatively impact the outcome occur after the initial head injury ex. cerebral edema, intracranial hemorrhage, cerebral ischemia, infection ex. hypoxia, hypertension

the first step in securing a patient to a short backboard is to:

provide manual stabilization of the cervical spine

When activated, the sympathetic nervous system produces all of the following effects, EXCEPT:

pupillary constriction

depressed skull fracture

result from high-energy trauma to the head - bony fragments may be driven into brain common in frontal/parietal bones present with neurologic signs

A patient who cannot remember the events that preceded his or her head injury is experiencing:

retrograde amnesia

When assessing a patient with a head injury, you note the presence of thin, bloody fluid draining from his right ear. This indicates:

rupture of the tympanic membrane following diffuse impact to the head

scene size-up

signs of head injury: - MVC - pedestrian-motor crash - fall > 20 feet (adult), > 10 feet (children) - blunt or penetrating trauma to head - rapid deceleration injuries - axial loading injuries (load applied along the vertical axis of the spine, i.e. falling and landing on feet) always look for indicators of the MOI

Battle sign is an indication of which of the following?

skull fracture

You should be MOST suspicious that a patient has experienced a significant head injury if his or her pulse is:

slow

Moderate elevation in intracranial pressure with middle brain stem involvement is characterized by:

sluggishly reactive pupils, widened pulse pressure, bradycardia, posturing

Common signs of a skull fracture include all of the following, EXCEPT:

superficial scalp lacerations

cerebral edema

swelling of the brain that may not develop until several hours after TBI aggravated by low O2 in the blood may produce convulsions or seizure

secondary assessment

take moderate-severe head injuries to trauma hospital ASAP ^ perform secondary assessment en route - splint individual extremities in ambulance; stabilize extremities via backboard on scene watch for signs of neurogenic shock - HR slowed - hypotension - erratic respirations measure ETCO2 to ensure no hypo/hyperventilation

Which of the following statements regarding a basilar skull fracture is correct?

the absence of raccoon eyes or Battle's sign does not rule it out

When the parasympathetic nervous system is activated:

the heart rate decreases and the blood vessels dilate

When immobilizing a trauma patient's spine, the EMT manually stabilizing the head should not let go until:

the patient has been completely secured to the backboard

you are called to a MVC where a 27-year-old women has a bump on her head. You immediately begin manual stabilization of the head. Her airway is open and respirations are within normal limits. Her pulse is a little fast but strong and regular. Distal pulses are present. You can release manual stabilization when:

the patient is secured to a backboard with the head immobilized

closed head injuries

those in which brain has been injured but there is no opening into the brain

meninges

three distinct layers of tissue that suspend the brain and the spinal cord within the skull and spinal canal outer: dura mater (leather-like consistency) middle: arachnoid inner: pia arachnoid/pia much smaller than dura mater and contain blood vessels if penetrated, CSF may leak from nose/ears/open skull fracture - runny nose/salty taste at back of throat injuries lead to severe bleeding within the skull and compression of softer brain tissue

traumatic brain injuries

traumatic insult to the brain which can produce physical, intellectual, emotional, social changes either primary or secondary

how to manage bleeding:

use dry, sterile dressing (and fold torn skin flaps down onto skin bed) before applying pressure do not apply excessive pressure to open wound (could increase ICP, push bone fragments into brain) do not cover mastoid process with bandages do not cover ears or mouth with bandages

primary: ABCs considerations

use jaw-thrust to open airway if vomit, log roll patient to the side to sweep mouth of secretions while minimizing spinal injuries look for Cheynes-Stokes respirations, sign of ICP (more apnea with more pressure) prevent hypoxia at all costs avoid hyperventilation when bandaging head for bleeding, do not move neck if spinal injuries suspected OR apply pressure if skull fracture suspected

If you do not have the appropriate size cervical collar, you should:

use rolled towels to immobilize the patient's head

somatic NS

voluntary activities that are responses to interpretation of sensory information

helmet removal

when to leave a helmet on: - no AB problems - does not interfere w ventilation - you can immobilize the spine when to remove: - full-face - makes AB assessment difficult - prevents spinal immobilization - pt in cardiac arrest