Chapter 28: Head and Spine Injuries

Contusion

1. Bruising of the brain tissue resulting from blunt trauma 2. A contusion is far more serious than a concussion. a. Involves physical injury to the brain tissue b. May produce long-lasting and even permanent damage 3. A patient who has sustained a brain contusion may exhibit any or all of the signs of brain injury.

Anatomy and Physiology of the PNS

1. 31 pairs of spinal nerves a. Conduct impulses from the skin and other organs to the spinal cord b. Conduct motor impulses from the spinal cord to the muscles 2. 12 pairs of cranial nerves a. Transmit information directly to or from the brain 3. There are two major types of peripheral nerves. a. Sensory nerves i. Carry only one type of information from the body to the brain via the spinal cord b. Motor nerves i. Carry information from the CNS to the muscles 4. The connecting nerves are found only in the brain and spinal cord. a. Connect the sensory and motor nerves with short fibers b. Allow the exchange of simple messages

Concussion

1. A blow to the head or face may cause concussion of the brain. 2. Classified as mild TBIs 3. It is a closed injury with a temporary loss or alteration of part or all of the brain's abilities to function without demonstrable physical damage to the brain. 4. Approximately 90% of patients who sustain a concussion do not experience a loss of consciousness. 5. A patient with a concussion may be confused or have amnesia. 6. Usually a concussion lasts only a short time. a. Ask about symptoms of concussion in any patient who has sustained an injury to the head. 7. Assume that a patient with signs or symptoms of concussion has a more serious injury until proven otherwise by a CT scan at the hospital or by evaluation by a physician.

Intracranial pressure

1. Accumulation of blood within the skull or swelling of the brain can rapidly lead to an increase in intracranial pressure (ICP). a. Increased ICP squeezes the brain against bony prominences within the cranium. 2. Signs of increased intracranial pressure: a. Abnormal respiratory patterns such as Biot and Cheyne-Stokes b. Decreased pulse rate, headache, nausea, vomiting, decreased alertness, bradycardia, sluggish or nonreactive pupils, decerebrate posturing, and increased or widened blood pressure c. Cushing reflex: the symptom triad of increased systolic blood pressure, decreased pulse rate, and irregular respirations 3. Intracranial hemorrhage a. Bleeding inside the skull also increases the ICP. b. Bleeding can occur between the skull and dura mater, beneath the dura mater but outside the brain, or within the tissue of the brain itself. 4. Epidural hematoma a. Accumulation of blood between the skull and dura mater b. Nearly always the result of a blow to the head that produces a linear fracture of the thin temporal bone c. Arterial bleeding into the epidural space will result in rapidly progressing symptoms. d. Often, the patient loses consciousness immediately following the injury. e. This is often followed by a brief period of consciousness (lucid interval), after which the patient lapses back into unconsciousness. i. Death will follow very rapidly without surgery to evacuate the hematoma. 5. Subdural hematoma a. An accumulation of blood beneath the dura mater but outside the brain b. Usually occurs after falls or injuries involving strong deceleration forces c. More common than epidural hematomas and may or may not be associated with a skull fracture d. A subdural hematoma is associated with venous bleeding, so the signs typically develop more gradually than with an epidural hematoma. e. The patient often experiences a fluctuating level of consciousness or slurred speech. f. Any patient with a suspected subdural hematoma needs to be evaluated by a physician. 6. Intracerebral hematoma a. Involves bleeding within the brain tissue itself b. Can occur following a penetrating injury to the head or rapid deceleration forces c. Many small, deep intracerebral hemorrhages are associated with other brain injuries. d. Intracerebral hematomas have a high mortality rate, even if the hematoma is surgically evacuated. 7. Subarachnoid hemorrhage a. Bleeding occurs into the subarachnoid space, where the CSF circulates b. Results in bloody CSF and signs of meningeal irritation c. Common causes include trauma or rupture of an aneurysm. d. A sudden, severe subarachnoid hemorrhage usually results in death; survivors often have permanent neurologic impairment.

Preparing vacuum mattresses for transport

1. An alternative to the long backboard is a vacuum mattress. a. The mattress molds to the specific contours of the patient's body, reducing pressure-point tenderness and therefore providing better comfort. b. It also provides thermal insulation. c. Excellent for the elderly or a patient with abnormal curvature of the spine d. Drawback to the device is its thickness e. Cannot be used for patients who weigh more than 350 lb f. Can be used on a supine, sitting, or standing patient g. Patient can be moved onto the vacuum mattress with a scoop stretcher or a log roll. 2. Follow the steps in Skill Drill 28-4.

Managing the circulation of a patient with a head injury

1. Begin CPR if the patient is in cardiac arrest. 2. Active blood loss aggravates hypoxia by reducing the available number of oxygen-carrying red blood cells. a. Bleeding inside the skull may cause the ICP to rise to life-threatening levels. 3. You can almost always control bleeding from a scalp laceration by applying direct pressure over the wound. a. If you suspect a skull fracture, do not apply excessive pressure to the open wound. b. If the dressing becomes soaked, do not remove it. Instead, place a second dressing over the first. 4. Shock a. Usually the result of hypovolemia caused by bleeding from other injuries b. Transport immediately to a trauma center. 5. Cushing's triad a. Increased blood pressure (hypertension), decreased heart rate (bradycardia), and irregular respirations (Cheyne-Stokes or Biot) b. If this process is allowed to continue, it is a fatal injury. c. Perform controlled hyperventilation of your patient via positive-pressure ventilations at a rate of 20 breaths/min.

Other brain injuries

1. Brain injuries can also arise from medical conditions, such as blood clots or hemorrhages. 2. Problems with the blood vessels, high blood pressure, or other problems may cause spontaneous bleeding into the brain. 3. The signs and symptoms of nontraumatic injuries are often the same as those of TBIs.

Preparing spinal immobilizations devices

1. During assessment, pain in the spine may be missed because of shock or because the patient's attention is directed to more painful injuries. 2. Because any manipulation of the unstable cervical spine may cause permanent damage to the spinal cord, you must assume the presence of spinal injury in all patients who have sustained head injuries. 3. Use manual in-line immobilization stabilization or a cervical collar and long backboard. 4. Short backboards a. The most common short backboards are the vest-type device and the rigid short board. b. These devices are designed to immobilize and restrict movement of the head, neck, and torso. c. Used to immobilize noncritical patients who are found in a sitting position and have possible spinal injuries 5. Long backboards a. These devices provide full body spinal immobilization and motion restriction to the head, neck, torso, pelvis, and extremities. b. Long backboards are used to immobilize patients who are found in any position, sometimes in conjunction with short backboards.

Primary assessment

1. Focus on identifying and managing life-threatening concerns. a. Threats to circulation, airway, or breathing are considered life threatening and must be treated immediately. b. Reduction of on-scene time and recognition of a critical patient increase the patient's chances for survival or a reduction in the amount of irreversible damage. 2. Spinal immobilization considerations a. When assessing a patient, be aware that any unnecessary movement of the patient can cause additional injury. b. Begin by assessing the scene to determine the risk of injury, then form a general impression of your patient based on his or her level of consciousness and the chief complaint. c. If the patient is absolutely clear in his or her thinking and does not have any neurologic deficits, spinal pain or tenderness, evidence of intoxication, or other illnesses or injuries that may mask a spinal injury, you may consider not placing the patient in spinal restriction. d. The backboard is rigid and often places the patient in an anatomically incorrect position for a long period of time. e. Apply a cervical collar as soon as you have assessed the airway and breathing and provided necessary treatments. i. Once the cervical collar is on, do not remove it unless it causes a problem with maintaining the airway. ii. If the device needs to be removed, maintain manual stabilization of the cervical spine until it can be replaced. 3. Assessing for signs and symptoms of a head or spine injury a. Begin by asking the responsive patient the following questions: i. What happened? ii. Where does it hurt? iii. Does your neck or back hurt? iv. Can you move your hands and feet? v. Did you hit your head? b. Confused or slurred speech, repetitive questioning, or amnesia in responsive patients are good indications of a head injury. c. In the setting of trauma, assume your patient has a head injury until your assessment proves otherwise. i. Decreased blood glucose level can mimic these symptoms. d. Unresponsive trauma patients should be assumed to have a spinal injury. e. Patients with a decreased level of responsiveness (AVPU scale) should be considered to have a spinal injury based on their chief complaint. 4. Airway, breathing, and circulation considerations a. When a spinal injury is suspected, how you open and assess the airway is important. i. Begin by manually holding the patient's head still while you assess the airway. Use a jaw-thrust maneuver to open the airway. ii. If the jaw-thrust maneuver is ineffective, it is acceptable to use the head tilt-chin lift maneuver. iii. An oropharyngeal or nasopharyngeal airway may assist in maintaining the airway; proper BLS maneuvers have been shown to adequately protect the patient's airway. b. Vomiting may occur in the patient with a head injury. c. Irregular breathing, such as Cheyne-Stokes respirations, may result from increased pressure on the brain because of bleeding or swelling in the cranium. d. Prehospital administration of high-flow oxygen is indicated for patients with head and spinal injuries. e. Pulse oximeter values should not fall below 90% and ideally should be 95% or higher. f. Hyperventilation (ventilating too fast or with too much force): i. Should be reserved for specific conditions and performed under specific guidelines ii. Can increase the severity of head injuries iii. Should be avoided except in cases where signs of herniation have been identified g. A pulse that is too slow in the setting of a head injury can indicate a serious condition. i. A single episode of hypoperfusion in a patient with a head injury can lead to significant brain damage and even death. h. Assess for signs and symptoms of shock and treat appropriately. i. Control bleeding. 5. Manner of transport a. Several transport considerations for patients with head trauma: i. Patients with impaired airways, open head wounds, or abnormal vital signs, or patients who do not respond to painful stimuli, may need to be rapidly extracted from a motor vehicle and transported. ii. Ensuring a patent airway and providing high-flow oxygen is paramount. iii. There is a probability of vomiting and seizures, so suction should be readily available. iv. A head trauma patient may deteriorate rapidly and require aeromedical transport. v. In supine patients, the head should be elevated 30 degrees, if possible, to help reduce ICP. vi. Remember to maintain stabilization of the spine. b. The use of lights and sirens does not significantly reduce transport time and may increase the patient's level of distress. c. Patients who are conscious and aware of the inability to move their limbs may need emotional support.

PReparing supine patients for transport

1. Immobilize a supine patient by securing the patient to a long backboard or vacuum mattress. 2. Another procedure to move a patient from the ground to a backboard is the four-person log roll. 3. You may also slide the patient onto a backboard or vacuum mattress. 4. To secure a patient to a backboard, follow the steps in Skill Drill 28-3.

Immobilization of the cervical spine

1. Immobilize the head and trunk so that bone fragments do not cause further damage. 2. Even small movements can cause significant injury to the spinal cord. 3. Follow the steps in Skill Drill 28-1. 4. Assess the pulse, motor functions, and sensations in all extremities. 5. Assess the cervical spine area and neck. 6. Never force the head into a neutral, in-line position; do not move the head any farther if the patient reports any of the following symptoms: a. Muscle spasms in the neck b. Substantial increased pain c. Numbness, tingling, or weakness in the arms or legs d. Compromised airway or ventilations 7. In these situations, stabilize the patient in his or her current position.

Preparing standing patients for transport

1. Immobilize the patient to a long backboard before proceeding with assessment. 2. This process will require three EMTs. a. Begin by establishing manual, in-line stabilization and applying a cervical collar. b. Position the board upright directly behind the patient. The EMTs should be positioned with one on either side of the patient, and the third directly behind the patient, maintaining in-line stabilization. c. The two EMTs at the patient's sides grasp the handholds at shoulder level or slightly above by reaching under the patient's arms, and carefully lower the patient as a unit. d. The EMT at the head must ensure that the patient's head stays against the board and must carefully rotate his or her hands as the patient is being lowered to maintain in-line stabilization.

Anatomy and Physiology of the CNS

1. Includes the brain and spinal cord. 2. The brain controls the body and is the center of consciousness. 3. The brain is divided into three major areas: a. Cerebrum b. Cerebellum c. Brainstem 4. The cerebrum controls a wide variety of activities, including most voluntary motor function and conscious thought. 5. The cerebellum coordinates balance and body movements. 6. The brainstem controls most functions necessary for life, including the cardiac and respiratory systems and nerve function transmissions. 7. The spinal cord is mostly made up of fibers that extend from the brain's nerve cells. a. Carries messages between the brain and the body via the gray and white matter of the spinal cord 8. Protective coverings a. The brain and spinal cord are covered with thick, bony structures. b. The CNS is further protected by the meninges, three distinct layers of tissue that suspend the brain and the spinal cord within the skull and the spinal canal. i. The outer layer, the dura mater, is a tough, fibrous layer that forms a sac to contain the CNS. ii. The inner two layers, called the arachnoid mater and the pia mater, contain the blood vessels that nourish the brain and spinal cord. c. Cerebrospinal fluid (CSF) is produced in a chamber inside the brain, called the third ventricle. i. CSF primarily acts as a shock absorber. ii. When an injury does penetrate all the protective layers, clear, watery CSF may leak from the nose, the ears, or an open skull fracture.

History taking of Head and Spine injuries

1. Investigate the chief complaint. a. Obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives. b. If the patient is not responsive, attempt to obtain the history from other sources, such as friends, family members, medical identification jewelry, and cards in wallets.

Traumatic Brain Injuries

1. Most serious of all head injuries 2. Classified into two broad categories: primary (direct) injury and secondary (indirect) injury a. Primary brain injury results instantaneously from impact to the head. b. Secondary brain injury increases the severity of the primary injury, and may be caused by: i. Cerebral edema ii. Intracranial hemorrhage iii. Increased intracranial pressure iv. Cerebral ischemia v. Infection c. Hypoxia and hypotension are the two most common causes of secondary brain injury. 3. Can result from blunt or penetrating trauma 4. Coup-countercoup injury a. The initial impact injures the front part of the brain. b. The head falling back against the headrest then injures the rear part of the brain. 5. Cerebral edema (swelling of the brain) may not develop until several hours following the initial injury. 7. Low blood oxygen levels aggravate cerebral edema and can be minimized by maintaining high oxygen saturations. 8. Monitor the patient for any seizure activity.

Managing the Airway

1. Perform the jaw-thrust maneuver to open the airway. 2. Consider inserting an oropharyngeal airway. 3. Have a suctioning unit available. 4. Provide supplemental oxygen if needed.

Cervical collars

1. Provide preliminary, partial support 2. Should be applied to every patient who has a possible spinal injury based on the MOI, history, or signs and symptoms. 3. To be effective, a rigid cervical collar must be the correct size for the patient. 4. Follow the steps in Skill Drill 28-2. 5. Once the patient's head and neck have been manually stabilized, assess the pulse, motor functions, and sensation in all extremities. Then, assess the cervical spine area and neck.

Secondary assessment of Head and Spine injuries

1. Remember that the ability to walk, move the extremities, or feel sensation, as well as the absence of pain, does not necessarily rule out a spinal cord injury. 2. Instruct the patient to keep still and not to move the head or neck. 3. Physical examinations a. May be a systematic head-to-toe, full-body scan or a systematic assessment that focuses on a certain area or region of the body b. If time allows, perform a secondary assessment while en route. c. Obtaining a complete set of baseline vital signs is essential. i. Significant head injuries may cause the pulse to slow and the blood pressure to rise. ii. With neurogenic shock, the blood pressure may drop and the heart rate may increase to compensate. iii. Respirations will become erratic with complications from both head and spine injuries. iv. Hypotension may be present with cervical or high thoracic spine injuries. The heart rate may become slow or fail to increase in response to hypotension. d. In addition to hands-on assessment, you should use monitoring devices to quantify your patient's oxygenation and circulatory status. ii. Maintain ETCO2 between 35 and 40 mm Hg 5. Physical examination considerations a. Examine the entire body using DCAP-BTLS and examine the head, chest, abdomen, extremities, and back. b. Check perfusion, motor function, and sensation in all extremities prior to moving the patient. c. A decreased or altered level of consciousness is the most reliable sign of a head injury. d. Determine whether there is decreased movement and/or numbness and tingling in the extremities. e. Look for blood or CSF leaking from the ears, nose, or mouth and for bruising around the eyes and behind the ears. f. Assess pupil size and reaction to light and continue to monitor the pupils; any change in their reactions over time may indicate progressive brain injury. g. Do not probe open scalp lacerations with your gloved finger because this may push bone fragments into the brain. h. Do not remove an impaled object from an open head injury. 6. Neurologic examination a. Perform a baseline assessment using the Glasgow Coma Scale (GCS). b. If your jurisdiction uses the Revised Trauma Score (RTS), then the findings from the GCS will be used in determining the RTS value. c. Record levels of consciousness that fluctuate or deteriorate. 7. Spine examination a. If there is a potential spine injury, examine the spine. b. Inspect for DCAP-BTLS and check the extremities for circulation, motor, or sensory problems. c. If there is impairment, note the level. d. Pain or tenderness when you palpate the spinal area is a warning sign that a spinal injury may exist. e. Other signs and symptoms include an obvious deformity; numbness, weakness, or tingling in the extremities; and soft-tissue injuries in the spinal region

Reassessment of Head and Spine injuries

1. Repeat the primary assessment. 2. Reassess vital signs and the chief complaint. 3. Recheck patient interventions. a. These injuries can suddenly affect the respiratory, circulatory, and nervous systems. b. The patient's condition should be reassessed at least every 5 minutes. 4. Interventions a. Compare baseline vital signs with repeated vital signs; changes will often tell you if treatments have been effective. b. Rapid deterioration of neurologic signs following a head injury is a sign of an expanding intracranial hematoma or rapidly progressing brain swelling. c. You will notice deterioration in a conscious patient's awareness of time, place, and person (self), in that order. d. You must act quickly to evaluate and treat these patients. e. If CSF is present, cover the wound with sterile gauze to prevent further contamination, but do not bandage it tightly. f. Hyperventilation should be used with caution and only when capnography is available. g. Your protocol should include the administration of high-flow oxygen and the application of a cervical collar, if indicated, as part of spinal immobilization restriction. h Reassessment should take place as the patient is transported to an appropriate trauma facility. 5. Communication and documentation a. Provide complete and detailed information to the destination facility. b. Hospitals may better prepare for seriously injured patients with more advanced warning and a description of the most serious problems found during your assessment. c. More seriously injured patients should have documented vital signs every 5 minutes. d. More stable patients should have documented vital signs every 15 minutes. e. You may be requested to testify as a witness.

Scene Size-up of Head and spine injuries

1. Scene safety a. Evaluate every scene for hazards to your health and the health of your team or bystanders. b. Be prepared with appropriate standard precautions before you approach the patient in a motor vehicle crash. 2. Mechanism of injury/nature of illness a. Look for indicators of the MOI. b. Consider how the MOI produced the injuries expected.

Skull fractures

1. Significant force applied to the head may cause a skull fracture. 2. A skull fracture may be open or closed, depending on whether there is an overlying laceration of the scalp. 3. Injuries from bullets or other penetrating weapons frequently result in fracture of the skull. 4. Signs of skull fracture include: a. Patient's head appears deformed b. Visible cracks in the skull c. Ecchymosis (bruising) under the eyes (raccoon eyes) d. Ecchymosis behind one ear over the mastoid process (Battle's sign) 5. Linear skull fractures a. Account for approximately 80% of all fractures to the skull b. Radiographs are often required to diagnose a linear skull fracture because there are often no physical signs such as deformity. 6. Depressed skull fractures a. Result from high-energy direct trauma to the head by a blunt object b. The frontal and parietal bones of the skull are most susceptible. c. Bony fragments may be driven into the brain, resulting in injury. d. Patients often present with neurologic signs (such as loss of consciousness). 7. Basilar skull fractures a. Associated with high-energy trauma, but usually occur following diffuse impact to the head b. These injuries generally result from extension of a linear fracture to the base of the skull and can be difficult to diagnose without radiography. c. Signs of a basilar skull fracture include CSF drainage from the ears, raccoon eyes, and Battle's sign. 8. Open skull fractures a. Often associated with trauma to multiple body systems b. Brain tissue may be exposed to the environment, which significantly increases the risk of a bacterial infection. c. High mortality rate

Managing the airway of a patient with a head injury

1. The most important step is establishing and maintaining adequate airway. a. Once the airway is open, maintain the head and cervical spine in a neutral, in-line position until you have placed a cervical collar and have secured the patient on a backboard. b. Remove any foreign bodies, secretions, or vomitus from the airway. 2. Once you have cleared the airway, check ventilation. 3. Give supplemental oxygen to any patient with suspected head injury, particularly anyone who is having trouble breathing

How the NS works

1. The nervous system controls virtually all of the body's activities, including: a. Reflex activities b. Voluntary activities (consciously performed) c. Involuntary activities (not under conscious control) 2. The connecting nerves in the spinal cord form a reflex arc. a. If a sensory nerve in this arc detects an irritating stimulus, it bypasses the brain and sends the message directly to a motor nerve. 3. The somatic (voluntary) nervous system handles voluntary activities. 4. The autonomic (involuntary) nervous system handles the body functions that occur without conscious effort. a. Divided into two sections: sympathetic and parasympathetic nervous systems i. When confronted with a threatening situation, the sympathetic nervous system reacts to the stress with a fight-or-flight response. ii. The parasympathetic nervous system has the opposite effect on the body, causing blood vessels to dilate, slowing the heart rate, and relaxing the muscle sphincters.

Skeletal system

1. The nervous system controls virtually all of the body's activities, including: a. Reflex activities b. Voluntary activities (consciously performed) c. Involuntary activities (not under conscious control) 2. The connecting nerves in the spinal cord form a reflex arc. a. If a sensory nerve in this arc detects an irritating stimulus, it bypasses the brain and sends the message directly to a motor nerve. 3. The somatic (voluntary) nervous system handles voluntary activities. 4. The autonomic (involuntary) nervous system handles the body functions that occur without conscious effort. a. Divided into two sections: sympathetic and parasympathetic nervous systems i. When confronted with a threatening situation, the sympathetic nervous system reacts to the stress with a fight-or-flight response. ii. The parasympathetic nervous system has the opposite effect on the body, causing blood vessels to dilate, slowing the heart rate, and relaxing the muscle sphincters.

Preparing sitting patients for transport

1. Use a short backboard or other short spinal extrication device to restrict movement of the cervical and thoracic spine. 2. Then secure the short board to the long board. 3. The exceptions to this rule are situations in which you do not have time to first secure the patient to the short board, including the following situations: a. You or the patient is in danger b. You need to gain immediate access to other patients c. The patient's injuries justify urgent removal 4. In all other cases, follow the steps in Skill Drill 28-5.

Head injuries

A. A head injury is a traumatic insult to the head that may result in injury to soft tissue, bony structures, or the brain. 1. Head injuries account for more than half of all traumatic deaths. 2. Fatal injuries invariably involve the brain. 3. Be alert to the fact that the patient may have sustained additional trauma. B. There are two general types of head injuries: closed head injuries and open head injuries. 1. Closed head injuries: the brain has been injured but there is no opening into the brain 2. Open head injuries: an opening from the brain to the outside world exists C. Motor vehicle crashes are the most common MOI. 1. More than two thirds of people involved in motor vehicle crashes experience a head injury. 2. Other common MOIs include assaults, falls, and sports-related injuries. D. Scalp lacerations 1. Can be minor or serious 2. Even small lacerations can quickly lead to significant blood loss, especially in children.

Helmet removal

A. A helmet that fits well prevents the patient's head from moving and should be left on, provided: 1. There are no impending airway or breathing problems. 2. It does not interfere with assessment and treatment of airway or ventilation problems. 3. You can properly immobilize the spine. 4. There is any chance that removing it will further injure the patient. B. Remove a helmet if: 1. It is a full-face helmet. 2. It makes assessing or managing airway problems difficult, and removal of a face guard to improve airway access is not possible. 3. It prevents you from properly immobilizing the spine. 4. It allows excessive head movement. 5. The patient is in cardiac arrest. D. Preferred method 1. Removing a helmet should always be at least a two-person job. 2. However, the technique for helmet removal depends on the actual type of helmet worn by the patient. 3. You and your partner should not move at the same time. 4. You should first consult with medical control about your decision to remove a helmet. 5. Follow the steps in Skill Drill 28-6. E. Alternate method 1. Advantage of this method is that it allows the helmet to be removed with the application of less force, reducing the likelihood of motion occurring in the neck 2. Disadvantage is that it is slightly more time consuming 3. Steps to the alternate method: a. Remove the chin strap. b. Remove the face mask. c. Pop the jaw pads out of place with a tongue depressor. d. Place your fingers inside the helmet during removal of the helmet. e. The person at the side of the patient controls the head by holding the jaw with one hand and the occiput with the other. f. Insert padding behind the occiput to prevent neck extension. g. The person at the side of the patient's chest is responsible for making sure that the head and neck do not move during removal of the helmet. h. Remember that small children may require additional padding to maintain the in-line neutral position.

Patient assessment of Head and Spine Injuries

A. Always suspect a possible head or spinal injury any time you encounter one of the following MOIs: 1. Motor vehicle collisions (including motorcycles, snowmobiles, and all-terrain vehicles) 2. Pedestrian-motor vehicle collisions 3. Falls (>20 feet [adult]; >10 feet [pediatric]) 4. Blunt trauma 5. Penetrating trauma to the head, neck, back, or torso 6. Rapid deceleration injuries 7. Hangings 8. Axial loading injuries: injuries where load is applied along the vertical or longitudinal axis of the spine (falling from a height and landing on the feet in an upright position) 9. Diving accidents

EMC of spinal injuries

A. Remember to follow standard precautions. B. Maintain the patient's airway while keeping the spine in the proper position, assess respirations, and give supplemental oxygen. C. Maintaining the airway D. Immobilization of the cervical spine E. Cervical collars

Preparation for transport

A. Supine patients B. Vacuum mattress 2. Follow the steps in Skill Drill 28-4. C. Sitting patients D. Standing patients E. Spinal immobilization devices

Spine Injuries

A. The cervical, thoracic, and lumbar portions of the spine can be injured in a variety of ways. 1. Compression injuries can result from a fall or a direct blow to the crown of the skull, coccyx, or on the top of the head. 2. Forces that compress the patient's vertebral body can cause herniation of disks, subsequent compression on the spinal cord and nerve roots, and fragmentation into the spinal canal. 3. Motor vehicle crashes or other types of trauma can overextend (hyperflex) the cervical spine and damage the ligaments and joints. 4. Rotation-flexion injuries of the spine result from rapid acceleration forces. 5. Any unnatural motion can result in fractures or neurologic deficit. 6. When the spine is pulled along its length (hyperextension), it can cause fractures in the spine as well as ligament and muscle injuries. 7. When bones of the spine are altered from traumatic forces, they can fracture or move out of place. a. When injuries pinch, pull, or penetrate the spinal cord, permanent damage may occur. b. Common findings include pain and tenderness on palpation. c. If you suspect these types of injuries, take extra precautions when stabilizing the spine.

Introduction

A. The nervous system is a complex network of nerve cells that enables all parts of the body to function. B. The nervous system includes: 1. Brain 2. Spinal cord 3. Several billion nerve fibers that carry information to and from all parts of the body C. Because the nervous system is so vital, it is well protected. 1. The brain is protected by the skull. 2. The spinal cord is protected by the bony spinal canal. 3. Despite this protection, serious injuries can damage the nervous system.

EMC for head injuries

A. Three general principles are designed to protect and maintain the critical functions of the CNS: 1. Establish an adequate airway. 2. Control bleeding and provide adequate circulation to maintain cerebral perfusion. 3. Assess the patient's baseline level of consciousness, and continuously monitor it.