CH. 28 Head and Spine Injuries

11. Explain emergency medical care of a patient with a head injury; include the three general principles designed to protect and maintain the critical functions of the CNS and ways to determine if the patient has a traumatic brain injury. ((pp 1001-1003)

-do not apply pressure to head injuries, anticipate and prepare for vomiting, treat other injuries, dress open wounds as indicated, prepare for convulsions, transport promptly 3 principles: 1. establish adequate airway 2. control bleeding and provide adequate circulation to maintain cerebral perfusion 3. assess baseline LOC and monitor it -managing the airway is the most important. O2 is very important for any pt with a head injury Common signs and symptoms of a serious head injury include all of the following, EXCEPT: A. a rapid, thready pulse. Signs of Cushing triad include: Increased blood pressure (hypertension) Decreased heart rate (bradycardia) Irregular respirations such as Cheyenne-Stokes respiration and Biot respiration

14. Explain the different circumstances in which a helmet should be left on or taken off a patient with a possible head or spinal injury. (p 1018)

-leave helmet on if these is any chance the pt could be harmed -Remove a helmet if: It is a full-face helmet. It makes assessing or managing airway problems difficult and removal of a face guard to improve airway access is not possible. It prevents you from properly immobilizing the spine. It allows excessive head movement. A patient is in cardiac arrest.

12. Explain emergency medical care of a patient with a spinal injury; include the implications of not properly caring for patients with injuries of this nature, the steps for performing manual in-line stabilization, implications for sizing and using a cervical spine immobilization device, and key symptoms that contraindicate in-line stabilization. (pp 1003-1007)

-perform jaw thrust to a pt with a spinal injury and airway obstruction -consider oral airway -have suction ready -provide O2 -do skill drill 28-1 -follow skill drill for cervical collars 28-2 contraindications for in-line stabilization: -muscle spasms in the neck -substantial increased pain -numbness, tingling, or weakness in the arms or legs -compromised airway or ventilations

13. Explain the process of preparing patients who have suspected head or spinal injuries for transport; include the use and functions of a long backboard, vacuum mattress, short backboard, and other short spinal extrication devices to immobilize the patient's cervical and thoracic spine. (pp 1007-1018)

-skill drill 28-3 for backboards -four-person log roll The recommended procedure for moving a patient with a suspected spinal injury from the ground to a long backboard or other spinal immobilization device. vacuum mattress -vacuum mattress is good for old people. It reduces pressure-point tenderness and is more comfortable. Downside is its thickness -skill drill 28-4 Short backboard -use for sitting pts -short backboard is secured to long backboard -provide manual in-line stabilization as you move the pt -follow skill drill 28-5 standing -begin with manual stabilization -instruct pt to remain still -EMTs should be positioned with one on either side of the patient and a third directly behind the patient, maintaining in-line stabilization. long backboard Long backboards are used to immobilize patients who are found in any position (standing, sitting, supine), sometimes in conjunction with short backboards. -when log rolling, examine the back -fill spaces between the body and backboard with padding

3. Demonstrate how to apply a cervical collar to a patient with a suspected spinal injury. (pp 1005-1006, Skill Drill 28-2)

-you must maintain manual support until the pt has been secured completely on a backboard... 1. apply in-line stabilization 2. measure the proper size collar 3. place the chin support first 4. wrap the collar around the neck and secure the collar 5. ensure proper fit and maintain neutral, in-line stabilization until the pt is secured to a backboard

4. Demonstrate how to secure a patient with a suspected spinal injury to a long backboard. (pp 1007-1009, Skill Drill 28-3)

1. apply and maintain manual cervical stabilization. Assess distal functions in all extremities 2. apply a cervical collar 3. rescuers kneel on one side of the pt and place their hands on the far side of the pt 4. on command, rescuers roll the pt toward themselves, quickly examine the back, slide the backboard under the pt, and roll the pt onto the backboard 5. center the pt on the backboard 6. secure the upper torso first 7. secure the pelvis and upper legs 8. begin to secure the pt's head using a commercial immobilization device or rolled towels 9. place tape across the pt's head to secure the immobilization device 10. check all straps and readjust if needed. Reassess distal functions in all extremities

7. Demonstrate how to remove a helmet from a patient with a suspected head or spinal injury. (pp 1019-1020, Skill Dril 28-6)

1. kneel at the pt's head with your partner at one side. Open the face shield to assess airway and breathing. Remove eyeglasses if present 2. prevent head mvmt by placing your hands on either side of the helmet and fingers on the lower jaw. Have your partner loosen the strap. 3. Have your partner place one hand at the angle of the lower jaw and the other at the occiput 4. gently slip the helmet about halfway off, then stop 5. have your partner slide the hand from the occiput to the back of the head to prevent the head from snapping back 6. remove the helmet and stabilize the cervical spine. Apply a cervical collar and secure the pt to a long backboard Pad as needed to prevent neck flexion or extension

5. Demonstrate how to secure a patient with a suspected spinal injury using a vacuum mattress. (pp 1008, 1010-1013, Skill Drill 28-4)

1. place the mattress on a flat surface near the patient, with the head end of the mattress at the pt's head 2. allow air to enter the mattress. Keep the valve stem open until the mattress is soft and pliable 3. smooth the mattress. Remove any sharp or bulky items that may damage the mattress 4. connect the pump to the mattress 5. determine method to move pt to mattress. If using log roll, evacuate mattress until it is partially rigid. If using scoop stretcher, you do not need to partially evacuate mattress at this stage 6. move pt onto vacuum mattress using the method you determined during the previous step. Maintain spinal alignment. 7. if vacuum mattress is partially rigid, open the valve to allow air to enter Keep the valve open until the mattress is pliable. 8. conform the mattress to the pt's head, close to the shoulders but not to the top of head. Continue to hold these head blocks that you have formed, and have a second person hold up the sides of the mattress to the pt's hips until the mattress is evacuated or air completely 9. Secure the pt's chest, hips, and legs. 10. secure the head. Pad any voids at the top of the shoulders 11. ensure the pt is comfy, then evacuate the remaining air to achieve immobilization 12. disconnect the vacuum pump and ensure that the valve is closed or secured 13. reassess and adjust the straps around the chest, hips, and legs 14. check pt's neurovascular status and re-check all straps prior to lifting or moving the pt

6. Explain the difference between a primary (direct) injury and a secondary (indirect) injury; include examples of possible MOIs that may cause each one. (p 988)

1. primary (direct) injury: -impact to the head 2. secondary (indirect) injury: Processes that increase the severity of a primary brain injury and negatively impact the outcome -may be caused by cerebral edema (swelling in the brain), intracranial hemorrhage, increased intracranial pressure, cerebral ischemia, and infection. -Hypoxia and hypotension are the two most common causes.

Skills Objectives 1. Demonstrate how to perform a jaw-thrust maneuver on a patient with a suspected spinal injury. (p 1003)

1. stabilize the neck in a neutral, in-line position 2. push the angle of the lower jaw uward

2. Demonstrate how to perform manual in-line stabilization on a patient with a suspected spinal injury. (pp 1003-1004, Skill Drill 28-1)

1. take standard precautions. Kneel behind the pt and firmly place your hands around the base of the skull on either side. 2. support the lower jaw with your index and long fingers, and head with your palms. Gently life the head into a neutral, eyes forward, position, aligned with the torso. Do not move the head or neck excessively, forcefully, or rapidly 3. Continue to manually support the head while your partner places a rigid cervical collar around the neck. Maintain manual support until you have completely secured the pt to a backboard

6. Demonstrate how to secure a patient with a suspected spinal injury who was found in a sitting position. (pp 1013-1016, Skill Drill 28-5)

1. take standard precautions. stabilize head and neck in a neutral, in-line position. Assess pulse, motor, and sensory function in each extremity. Apply a cervical collar 2. insert and immobilization device btw the pt's upper back and the seat 3. open the side flaps and position them around the pt's torso, snug around the armpits 4. secure the upper-torso flaps, then the mid-torso flaps 5. secure the groin (leg) straps. check and adjust the torso straps 6. pad btw the head and the device as needed. Secure the forehead strap and fasten the lower head strap around the cervical collar 7. place a long backboard next to the pt's buttocks, perpendicular to the trunk 8. turn and lower the pt onto the long backboard. Lift the pt, and slip the long backboard under the immobilization device. 9. secure the immobilization device and long backboard to each other. Loosen or release the groin straps. Reassess pulse, motor, and sensory function in each extremity

4. Explain the different types of head injuries, their potential mechanism of injury (MOI), and general signs and symptoms of a head injury that EMTs should consider when performing a patient assessment. (pp 986-991)

Closed head injuries- brain is injured, but no break in the skin Open head injuries-Obvious skull deformity with a break in the skin is a sign of an open head injury, which is often caused by penetrating trauma. There may be bleeding and exposed brain tissue. -MOI's for both: -car crashes -assaults -older adults falling -sports-related incidents -children incidents Signs and symptoms (look at table) include: -lacerations, contusions, or hematomas -soft area or depression on palpation -visible deformities -altered mental state -irregular breathing pattern -amnesia -vision issues -nausea Types of head injuries scalp lacerations -can be very bloody -usually the result of direct blows to the head Skull fractures -can be open or closed -usually result of bullets or another penetrating weapon -signs include raccoon eyes-- ecchymosis that develops under the eyes or Battle sign Linear skull fractures -nondisplaced skull fractures -accounts for 80% skull fractures -open or closed Depressed skull fractures -result from high-energy direct trauma to the head with a blunt object (such as a baseball bat). -pts present with neurologic signs like loss of consciousness Basilar skull fractures -result of high energy trauma -typically an extension of a linear fracture -Signs of a basilar skull fracture include CSF drainage from the ears, which indicates rupture of the tympanic membrane in the ear, and freely flowing CSF through the ear; raccoon eyes, or battle sign Open skull fractures -severe forces -brain tissue may be exposing, increasing risk of bacterial meningitis infection -cranial vault fractures have a high mortality rate

(cont.) concussions, contusions, and other brain injuries

Concussions are also known as mild traumatic brain injuries. -no clear definition -in general, 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. -can result in unconsciousness or inability to breathe, but pretty unlikely -pt may experience retrograde amnesia or anterograde (posttraumatic) injury -symptoms of head injury: Dizziness Weakness Visual changes Nausea or vomiting Ringing in the ears Slurred speech Inability to focus Contusions -more serious than concussion bc the brain tissue is injured -bleeding and swelling of injured vessels Other brain injuries include: blood clots, hemorrhages, problems with blood vessels themselves, high BP, and other probs that cause spontaneous bleeding in the brain -signs and symptoms are the same as traumatic brain injuries, but there is no MOI or trauma

15. List the steps EMTs must follow to remove a helmet, including the alternate method for removing a football helmet. (pp 1018-1022)

Follow skill drill 28-6 Alternate method for football helmet: -advantage allows helmet to be removed with less force, and less mvmt of neck -disadvantage is that it is more time consuming

8. Describe the different types of injuries that may damage the cervical, thoracic, or lumbar spine; include examples of possible MOIs that may cause each one. (p 991)

Forces that compress the vertebral body include: -herniation of disks -compression on the spinal cord and nerve roots -fragmentation into the spinal cord Cervical spine can be hyperflexed or overextended in car crashes or other trauma -rotation-flexion injuries of the spine happen at C1 and C2 most often -hangings often fracture upper portion of cervical spine When the spine is pulled along its length (hyperextension), it can cause fractures in the spine as well as ligament and muscle injuries. Less commonly you may feel or observe a deformity of the spine, sometimes referred to as a "step-off," where the spinous process may be palpable on physical examination.

7. Describe the different types of brain injuries and their corresponding signs and symptoms, including increased intracranial pressure (ICP), concussion, contusion, and injuries caused by medical conditions. (pp 988-991)

Intracranial pressure (ICP) is the pressure within the cranial vault. Increased ICP squeezes the brain against bony prominences within the cranium. -signs include Cheyne-Stokes respirations (resps that are fast and then become slow, with intervening periods of apnea), ataxic resps, decreased pulse rate, headache, nausea, vomiting, decreased alertness, bradycardia, sluggish or nonreactive pupils, decerebrate posturing, and increased or widened blood pressure. -cushing reflex signifies increased ICP and presents with increased systolic pressure, decreased pulse rate, and irregular resps Cushing triad is a sign of intracranial pressure. Intracranial hemorrhage -bleeding in the brain -skull does not allow for this extra space, so ICP increases epidural hematoma An accumulation of blood between the skull and the dura mater. -result of blow to the head that produces a linear fracture -pt has loss of consciousness -pupil on side of hematoma becomes fixed and dilated Subdural hematoma an accumulation of blood beneath the dura mater but outside the brain that usually occurs after falls or injuries involving strong deceleration forces. -more common than epidural hematomas -older people and alcoholics are at greater risk intracerebral hematoma involves bleeding within the brain tissue itself. -may be the result of a penetrating injury or bc of a rapid deceleration force -once symptoms appear, the pt's condition deteriorates quickly -high mortality rate subarachnoid hemorrhage -bleeding occurs into the subarachnoid space, where the CSF circulates, resulting in bloody CSF and signs of meningeal irritation (such as neck rigidity and headache). -causes are trauma or the rupture of an aneurysm -as bleeding increases, the pt has signs and symptoms of ICP: --decreased LOC --change in the pupils --vomiting --seizures

10. List the mechanisms of injury that cause a high index of suspicion for the possibility of a head or spinal injury. (p 992)

Motor vehicle crashes (including motorcycles, snowmobiles, and all-terrain vehicles) Pedestrian-motor vehicle crashes Fall >20 feet (adult) Fall >10 feet (pediatric) Blunt trauma Penetrating trauma to the head, neck, back, or torso Rapid deceleration injuries Hangings Axial loading injuries (injuries where load is applied along the vertical or longitudinal axis of the spine; for example, falling from a height and landing on the feet in an upright position) Diving accidents

1. Describe the anatomy and physiology of the nervous system, including its divisions into the central nervous system (CNS) and peripheral nervous system (PNS) and the structures and functions of each. (pp 981-984)

Nervous system = CNS + Peripheral NS CNS: 1. cerebrum- controls most voluntary motor function and conscious thought 2. cerebellum- Coordinates balance and body movements 3. spinal cord -carries messages between the brain and the body via the gray and white matter of the spinal cord. -Gray matter is composed of neural cell bodies and synapses, which are connections between nerve cells. -White matter consists of fiber pathways. meninges Three distinct layers of tissue that surround and protect the brain and the spinal cord within the skull and the spinal canal. 1. dura mater -outer layer -forms a sac to contain the CNS, with small openings through which the peripheral nerves exit. 2. arachnoid mater 3. pia mater -both contain blood vessels that nourish the brain and spinal cord -CSF is located in the subarachnoid space below the arachnoid mater, a web-like structure. Peripheral -31 pairs of spinal nerves --Conduct motor impulses from the spinal cord to the muscles -12 pairs of cranial nerves --Perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions -2 types of peripheral nerves: sensory and motor -sensory: Endings perceive only one type of information, and carry that information from the body to the brain via the spinal cord. -motor: One for each muscle. Carry information from the CNS to the muscles

8. Demonstrate the alternate method for removal of a football helmet from a patient with a suspected head or spinal injury. (pp 1021-1022)

Remove the chin strap by cutting or carefully unsnapping it. Remove the face mask. After the face mask has been removed, pop the jaw pads out of place using a tongue depressor. Place your fingers inside the helmet, allowing greater control of the helmet during removal as the helmet is gently rocked back off the top of the head. Insert padding behind the occiput to prevent neck extension. 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. Place blanket rolls between the child and the sides of an adult-sized backboard to prevent the child from slipping to one side or the other.

9. Explain the steps in the patient assessment process for a person who has a suspected head or spine injury; include specific variations that may be required as related to the type of injury. (pp 991-1001)

Scene size up -gloves, mask, eye protection -call for ALS when MOI is severe -look for MOI indications -Many mechanisms of injury that cause head and spine injuries also may pose a risk to EMTs. Before you approach the patient, get the "big picture" of scene safety and take any actions necessary to ensure your own well being. Primary -manage life threatening concerns -bleeding first, then ABCs -assess position the pt was found -minimize time a pt is on a backboard -apply cervical collar as soon as airway and breathing are assessed -ask these q's to determine chief complaint: What happened? Where does it hurt? Does your neck or back hurt? Can you move your hands and feet? Did you hit your head? -Confused or slurred speech, repetitive questioning, or amnesia in responsive patients is an indication of a head injury. -use a jaw thrust maneuver to open airway -hyperventilation can increase severity of head injuries, but may be used in conditions where signs of brainstem herniation have been identified -do not apply pressure to the head while bandaging if a skull fracture is suspected -A blanket or one or two towels placed under the long backboard will elevate the head. -provide high flow O2 -suction should be readily available bc seizures are likely with increased ICP History Taking -injury specific signs and symptoms -recall of the incident? -pertinent negatives -OPQRST -SAMPLE Secondary Assessment -Do not ask patients with possible spinal injuries to move their necks as a test for pain. -perform full body assessment, time allowing -obtain complete set of baseline vitals -Significant head injuries may cause the pulse to slow and the blood pressure to rise. -With neurogenic shock, the blood pressure may drop and the heart rate may increase to compensate. -Use pulse oximetry and ETCO2 monitoring on all patients suspected of having a head injury to ensure the patient is not hypoventilating or hyperventilating. -ETCO2 btw 35 and 40 mmHg -take BP manually first -exam whole body for DCAP-BTLS -check perfusion, motor function, and sensations in extremities prior to moving the pt -perform neurologic assessment in a head injury pt -use the GCS -*A change in the level of consciousness is the single most important observation that you can make in assessing the severity of brain injury. Level of consciousness usually corresponds to the extent of loss of brain function. -note the level of a spinal impairment -Patients with severe spinal injury may lose sensation or experience paralysis below the suspected level of injury or be incontinent. -signs of spinal cord trauma: -inability to maintain proper body temp -priapism (persistent erection) -incontinence Reassessment -usual -are treatments working? -documentation includes history you were able to obtain, your findings, treatment, how pt responded

2. Explain the functions of the somatic and autonomic nervous systems. (p 984)

The somatic (voluntary) nervous system regulates voluntary activities. The autonomic (involuntary) nervous system controls the functions of many of the body's vital organs, over which the brain has no voluntary control. -two sections: sympathetic and parasympathetic -sympathetic: fight or flight responses --The pupils to dilate --Smooth muscle in the lungs to dilate --Heart rate to increase --Blood pressure to rise --Shunting of blood to vital organs and to skeletal muscle --epinephrine (adrenaline) is released -parasympathetic: The parasympathetic nervous system causes blood vessels to dilate, slowing the heart rate, and relaxing the muscle sphincters.

7. Understand what range to maintain SPO2 and ETCO2 for TBI patients and how you can maintain those ranges.

This is end-tidal CO2 (ETCO2) which is normally 35-45 mm Hg. Capnography assesses ventilation, which is different from oxygenation. A normal SPO2 is 92-96%. ETCO2 35-45 mm Hg is the normal value for capnography. However, some experts say 30 mm HG - 43 mm Hg can be considered normal.

16. Discuss age-related variations that are required when providing emergency care to a pediatric patient who has a suspected head or spine injury. (p 1021)

You are likely to find infants and children who have been in motor vehicle crashes and are still in their car seats. Follow your local protocols regarding spinal immobilization techniques.

1. Know the correct way to wear a seatbelt and understand which injuries can occur from both correct and incorrect application of the seatbelt.

for an unrestrained driver or passenger, the brain continues to move forward and strikes the inside of the skull, resulting in compression injury to te anterior portion of the brain and stretching of the posterior portion a closed chest injury can occur, usually the result of blunt trauma, such as when a pt strikes the steering wheel or an air bag. Can even occur when a seatbelt is worn. air bags can hide signs such as seat bled marks, that would suggest that a significant force or blow occurred to the chest. Maintain a high degree of suspicion for severe injuries when an air bag has deployed.

3. List the major bones of the skull and spinal column and their related structures; include their functions as they relate to the nervous system. (pp 984-986)

skull = facial bones + cranium cranium = occiput, temporals, parietal, and frontal Face = maxillae, mandible, zygomas, orbit1

5. Define traumatic brain injury (TBI). (p 988)

traumatic brain injuries (TBIs) A traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes. Two categories: 1. primary (direct) injury: -impact to the head 2. secondary (indirect) injury: Processes that increase the severity of a primary brain injury and negatively impact the outcome -may be caused by cerebral edema (swelling in the brain), intracranial hemorrhage, increased intracranial pressure, cerebral ischemia, and infection. -Hypoxia and hypotension are the two most common causes.