Chapter 28 Head & Spine Injuries

Cerebral edema

(swelling of the brain) may not develop until several hours following the initial injury. Low blood oxygen levels aggravate cerebral edema and can be minimized by maintaining high oxygen saturations.

Cushing reflex

(triad of increased systolic blood pressure, decreased pulse rate, and irregular respirations) signifies increased ICP.

When confronted with a threatening situation,

, the sympathetic nervous system reacts to the stress with a fight-or-flight response. (a) This response causes the pupils to dilate, smooth muscle in the lungs to dilate, heart rate to increase, and blood pressure to rise. (b) During this time of stress, a hormone called epinephrine (adrenaline) is released 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. As the body attempts to maintain homeostasis, these two divisions of the autonomic nervous system tend to balance each other so that basic body functions remain stable and effective

The peripheral nervous system has two anatomic parts:

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 c. The spinal nerves serving the extremities are arranged in complex networks. 2. 12 pairs of cranial nerves a. Transmit information directly to or from the brain b. Perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions

Securing a Patient to a Long Backboard

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 patient and place hands on the far side of the patient. 4. On command, rescuers roll the patient toward themselves, quickly examine the back, slide the backboard under the patient, and roll the patient onto the backboard 5. Center the patient on the backboard. 6. Secure the upper torso first 7. Secure the pelvis and upper legs. 8. Begin to secure the patient's head using a commercial immobilization device or rolled towels. 9. Place tape across the patient's forehead to secure the immobilization device. 10. Check all straps and readjust as needed. Reassess distal functions in all extremities.

Application of a Cervical Collar

1. Apply in-line stabilization 2. Measure the proper collar size. 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 patient is secured to a backboard.

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

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, affecting the patient's level of consciousness. a. This is known as altered mental status. 3. The signs and symptoms of nontraumatic injuries are often the same as those of TBIs, except there is no obvious history of MOI or any external evidence of trauma.

Scalp lacerations

1. Can be minor or serious 2. Even small lacerations can quickly lead to significant blood loss. 3. Occasionally, this blood loss may be severe enough to cause hypovolemic shock, particularly in children. 4. Because scalp lacerations are usually the result of direct blows to the head, they are often an indicator of deeper, more serious injuries.

The nervous system is divided into what two anatomic parts?

1. Central nervous system 2. Peripheral nervous system

Three general principles are designed to protect and maintain the critical functions of the CNS:

1. Establish an adequate airway. a. If necessary, begin and maintain ventilation, and always provide high-flow supplemental oxygen. 2. Control bleeding and provide adequate circulation to maintain cerebral perfusion. a. Begin CPR, if necessary. b. Be sure to follow standard precautions. 3. Assess the patient's baseline level of consciousness, and continuously monitor it.

Supine patients

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.

Standing patients

1. Immobilize the patient to a long backboard before proceeding with assessment. 2. This process requires three EMTs. a. Begin by establishing manual, in-line stabilization and applying a cervical collar. Instruct the patient to remain still. 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. Carefully lower the patient as a unit under the direction of the EMT at the head. 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.

Central nervous system (CNS)

1. Includes the brain and spinal cord 2. The brain controls the body and is the center of consciousness

History taking

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. Using OPQRST may provide some background on isolated extremity injuries. c. Any information you receive will be very valuable if the patient loses consciousness. d. 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. e. Gather as much SAMPLE history as you can while preparing for transport.

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.

Removing a Helmet

1. Kneel at the patient's head with your partner at one side. Open the face shield to assess airway and breathing. Remove eyeglasses if present. 2. Prevent head movement 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 patient to a long backboard. Pad as needed to prevent neck flexion or extension.

Contusion

1. Like any other soft tissue in the body, the brain can sustain a contusion, or bruise, when the skull is struck. 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.

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

Placing a Patient on a Full-Body Vacuum Mattress

1. Place the mattress on a flat surface near the patient, with the head end of the mattress at the patient'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 which method you will use to move the patient onto the mattress. If you will use the log roll method, evacuate the mattress until it is partially rigid (this step is not needed if using the scoop stretcher method). The surface should be smooth and the beads should be spread out as evenly as possible. If using a scoop stretcher, you do not need to partially evacuate the mattress at this stage. 6. Move the patient onto the vacuum mattress using the method you determined during the previous step. Maintain spinal alignment. 7. If the 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 each side of the patient's head, close to the shoulders but not the top of the 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 patient's hips until the mattress is evacuated of air completely. 9. Secure the patient's chest, hips, and legs. 10. Secure the patient's head. Pad any voids at the top of the shoulders. 11. Ensure the patient is as comfortable as possible, 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 the patient's neurovascular status and re-check all straps prior to lifting or moving the patient.

Remove a helmet Preferred method

1. Removing a helmet should always be at least a two-person job. 2. 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.

Sitting patients

1. Some patients with a possible spinal injury will be in a sitting position, such as after a vehicle crash. 2. Use a short backboard or other short spinal extrication device to restrict movement of the cervical and thoracic spine. 3. Then secure the short backboard to the long backboard.

Performing Manual In-Line Stabilization

1. Take standard precautions. Kneel behind the patient 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 the head with your palms. Gently lift 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 patient to a backboard.

Securing a Patient Found in a Sitting Position

1. Take standard precautions. Stabilize the head and neck in a neutral, in-line position. Assess pulse, motor, and sensory function in each extremity. Apply a cervical collar. 2. Insert an immobilization device between the patient's upper back and the seat. 3. Open the side flaps, and position them around the patient'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 between 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 patient's buttocks, perpendicular to the trunk. 8. Turn and lower the patient onto the long backboard. Lift the patient, 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.

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.

Other signs and symptoms of spinal injury include:

An obvious deformity as you gently palpate the spine Numbness, weakness, or tingling in the extremities Soft-tissue injuries in the spinal region Patients with severe spinal injury may lose sensation or experience paralysis below the suspected level of injury or be incontinent. Injuries to the cervical area may limit the ability of the diaphragm to function fully and minimize the ability of the chest wall to expand fully. Another sign of spinal injury is abdominal excursion—when the patient is unable to breathe without the assistance of the abdomen. Inability to maintain body temperature Priapism (a persistent erection lasting more than 4 hours) Loss of bowel or bladder control

As bleeding into the subarachnoid space increases, the patient experiences the signs and symptoms of increased ICP:

Decreased level of consciousness Changes in the pupils Vomiting Seizures

Head and Spine Injuries minimum standard precautions that you use.

Gloves, a mask, and eye protection

the two most common causes of secondary brain injury are what?

Hypoxia and hypotension and will increase death and disability significantly in a patient with head injury. Secondary brain injury may occur a few minutes to several days following the initial head injury.

The connecting nerves in the spinal cord form a reflex arc.

If a sensory nerve in this arc detects an irritating stimulus, it bypasses the brain and sends the message directly to a motor nerve, causing a response.

Cervical collars Should be applied to every patient who has a possible spinal injury based on

MOI, history, or signs and symptoms.

The cervical, thoracic, and lumbar portions of the spine can be injured in a variety of ways.

Motor vehicle crashes or other types of trauma can overextend (hyperflex) the cervical spine and damage the ligaments and joints. Rotation-flexion injuries of the spine result from rapid acceleration forces. a. More likely to happen at C1 and C2 When the spine is pulled along its length (hyperextension), it can cause fractures in the spine as well as ligament and muscle injuries. 6. 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. You may feel or observe a deformity of the spine ("step-off") where the spinous process may be palpable. d. If you suspect these types of injuries, take extra precautions when stabilizing the spine.

brainstem

The most primitive part of the CNS Controls virtually all the functions that are necessary for life, including the cardiac and respiratory systems and nerve function transmissions The brainstem is the best-protected part of the CNS.

The progression of increased ICP depends on several factors, including:

The presence of other brain injuries The region of the brain involved (frontal and temporal lobes are the most common locations) The size of the hemorrhage

Intracranial Pressure (ICP)

The pressure within the cranial vault.

Vomiting may occur in the patient with a head injury

With large amounts of emesis, log roll the patient to the side and sweep the mouth of secretions. Roll the patient while keeping the body in as straight a line as possible to minimize spinal injuries. Perform suctioning immediately to remove smaller amounts of secretions.

Traumatic brain injuries (TBI) define

a traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes

Subdural hematoma

a. 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.

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. i. This is often followed by a brief period of consciousness (lucid interval), after which the patient lapses back into unconsciousness. ii. Death will follow very rapidly without surgery to evacuate the hematoma

Basilar skull fractures

a. Associated with high-energy trauma, but usually occur following diffuse impact to the head (falls, motor vehicle crashes) 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.

Primary assessment: 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. If the patient is found unresponsive, emergency responders, family members, or bystanders may have helpful information. e. Unresponsive trauma patients should be assumed to have a spinal injury. f. Patients with a decreased level of responsiveness (AVPU scale) should be considered to have a spinal injury based on their chief complaint.

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.

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. Patient reports a sudden, severe headache. e. A sudden, severe subarachnoid hematoma usually results in death; survivors often have permanent neurologic impairment.

The brain is divided into three major areas:

a. Cerebrum b. Cerebellum c. Brainstem

head injury Be alert to the fact that the patient may have sustained additional trauma such as:

a. Cervical spine injuries b. Pelvic injuries c. Chest injuries

Signs of increased intracranial pressure:

a. Cheyne-Stokes respirations b. Ataxic (Biot) respirations c. Decreased pulse rate d. Headache e. Nausea f. Vomiting g. Decreased alertness h. Bradycardia i. Sluggish or nonreactive pupils j. Decerebrate posturing k. Increased or widened blood pressure

Head injuries also occur commonly:

a. In victims of assault b. When elderly people fall c. During sports-related incidents d. In a variety of incidents involving children More than two thirds of people involved in motor vehicle crashes experience a head injury Any head injury is potentially serious if not properly treated.

Cushing 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. d. Follow local protocols and your medical direction in regard to hyperventilation in the presence of herniation.

Intracerebral hematoma

a. Involves bleeding within the brain tissue itself b. Can occur following a penetrating injury to the head or because of 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.

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 In these situations, stabilize the patient in his or her current position.

Linear skull fractures

a. Nondisplaced skull fractures b. Account for approximately 80% of all fractures to the skull c. Radiographs are required to diagnose a linear skull fracture because there are often no physical signs such as deformity. d. If the brain is uninjured and there are no scalp lacerations, then linear fractures are not life threatening.

Open skull fractures

a. Open fractures of the cranial vault result when severe forces are applied to the head and are 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

Signs of skull fracture include:

a. Patient's head appears deformed b. Visible cracks in the skull c. Ecchymosis (bruising) that develops under the eyes (raccoon eyes) d. Ecchymosis that develops behind one ear over the mastoid process (Battle's sign)

The nervous system controls virtually all of the body's activities, including:

a. Reflex activities b. Voluntary activities c. Involuntary activities

Remove a helmet Alternate method

a. Remove the chin strap. b. Remove the face mask (cut or unscrew the plastic clips). 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.

Depressed skull fractures

a. Result from high-energy direct trauma to the head with 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).

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. One for each muscle ii. Carry information from the CNS to the muscles

Manner of transport

a. Several transport considerations should be kept in mind 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. Providing the patient with a patent airway and 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 immobilization of the spine. b. The use of lights and sirens may increase the patient's level of distress. c. Patients who are conscious and aware of the inability to move their limbs need to be offered emotional support.

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

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.

Head and Spine Injuries Primary assessment: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. Life-threatening external hemorrhage must be addressed before airway and breathing concerns. c. Most head injuries are considered mild and result in no or limited permanent disability. i. A number of patients with head or spine injuries will not require much intervention other than a thorough assessment and continued observation during transport. d. In patients who have problems with ABCs or have other conditions for which you decide a rapid transport to the closest appropriate hospital is needed, rapid immobilization of the spine and quick loading into the ambulance may be indicated. e.Reduction of on-scene time and recognition of a critical patient increases the patient's chances for survival or a reduction in the amount of irreversible damage

Primary assessment 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. ii. Use a jaw-thrust maneuver to open the airway. iii. If the jaw-thrust maneuver is ineffective, it is acceptable to use the head tilt-chin lift maneuver as a last resort. iv. An oropharyngeal or nasopharyngeal airway may assist in maintaining the airway. b. Vomiting may occur in the patient with a head injury. i. The patient may need to be log rolled to the side and the mouth swept of secretions. ii. Suctioning should be performed immediately to remove smaller amounts of secretions. 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. Always assess airway and breathing prior to moving on to assessment of circulation. h. A pulse that is too slow in the setting of a head injury can indicate a serious condition in your patient. i. If the pulse is present and adequate, you can continue to evaluate your patient further. j. A single episode of hypoperfusion in a patient with a head injury can lead to significant brain damage and even death. k. Assess for signs and symptoms of shock and treat appropriately. l. Control bleeding. i. When bandaging the head: (a) Be careful not to move the neck if spinal injuries are suspected. (b) Do not apply pressure if a skull fracture is suspected.

Primary assessment: Spinal immobilization considerations

a. When assessing a patient, be aware that any unnecessary movement of the patient can cause additional injury. i. Assess the patient in the position found. ii. Determine whether or not a cervical collar needs to be applied. b. Begin by assessing the scene to determine the risk of injury. c. Then form a general impression of your patient based on his or her level of consciousness and the chief complaint. d. 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. i. Many jurisdictions allow EMTs to screen patients and to refrain from providing spinal restriction on the basis of specific criteria. e. The backboard is rigid and often places the patient in an anatomically incorrect position for a long period of time. i. Circulation to areas of skin may become compromised, leading to complaints of pain, ischemia to the skin, and, if left long enough, necrosis. ii. Some patients, especially bariatric patients, could experience respiratory compromise while lying flat. iii. Consider placing padding under the patient to help minimize the risk of injury, and try to minimize the amount of time a patient is on a long backboard. f. Apply a cervical collar as soon as you have assessed the airway and breathing and provided necessary treatments. i. Helps maintain spinal immobilization as you treat the airway and breathing ii. The best time to apply the cervical collar depends on the patient's injuries and the seriousness of his or her condition. iii. Once the cervical collar is on, do not remove it unless it causes a problem with maintaining the airway.

The exceptions to this rule are situations in which you do not have time to first secure the Sitting 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

Accumulations 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.

There are two general types of head injuries.

closed or open

Cerebrum

controls a wide variety of activities, including most voluntary motor function and conscious thought. a. Contains about 75% of the brain's total volume b. Divided into two hemispheres with four lobes

cerebellum

coordinates balance and body movements.

Traumatic brain injuries can be the result of

directly by a penetrating object, such as a bullet, knife, or other sharp object, or indirectly, as a result of external forces exerted on the skull. It is not uncommon for the patient with a head injury to have a convulsion, or seizure.

Rapid deterioration of neurologic signs following a head injury is a sign of an

expanding intracranial hematoma or rapidly progressing brain swelling. You will notice deterioration in a conscious patient's awareness of time, place, and person (self), in that order.

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 b. Gray matter is composed of neural cell bodies and synapses. c. White matter consists of fiber pathways.

autonomic nervous system

handles the body functions that occur without conscious effort. Controls the functions of many of the body's vital organs

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.

You should ask about symptoms of concussion in any patient who has sustained an injury to the head, including:

i. Dizziness ii. Weakness iii. Visual changes iv. Nausea v. Vomiting vi. Ringing in the ears vii. Slurred speech viii. Inability to focus ix. Lack of coordination x. Delay of motor functions xi. Inappropriate emotional responses xii. Temporary headache xiii. Disorientation

Traumatic brain injuries (TBI) Secondary

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

Cerebrospinal fluid (CSF)

is produced in a chamber inside the brain, called the third ventricle. i. There is approximately 125 to 150 mL of CSF in the brain at any time. ii. CSF primarily acts as a shock absorber. iii. When an injury does penetrate all the protective layers, clear, watery CSF may leak from the nose, the ears, or an open skull fracture.

1. Brain 2. Spinal cord 3. Several billion nerve fibers that carry information to and from all parts of the body

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.

Cervical collars do not fully immobilize the cervical spine. Therefore, you must

maintain manual support until the patient has been completely secured to a long or short backboard or vacuum mattress.

Concussion

may be confused or have amnesia may have retrograde amnesia, which means he or she can remember everything but the events leading up to the injury. Inability to remember events after the injury is called anterograde (posttraumatic) amnesia.

Concussions are also known as

mild TBIs

Rapid deterioration of neurologic signs following a head injury is a sign of

of an expanding intracranial hematoma or rapidly progressing brain swelling. i. You will notice deterioration in a conscious patient's awareness of time, place, and person (self), in that order. ii. You must act quickly to evaluate and treat these patients.

Traumatic brain injuries (TBI) Classified into two broad categories:

primary (direct) injury and secondary (indirect) injury

Traumatic brain injuries (TBI) Primary

results instantaneously from impact to the head.

signs or symptoms of head injuries.

see image

A head injury is a traumatic insult to the head that may result in injury to

soft tissue, bony structures, or the brain.

A coup-countercoup injury can result from

striking a windshield in a car crash. a. The passenger's head hits the windshield; the brain continues to move forward until it comes to an abrupt stop by striking the inside of the skull. b. The head falls back against the headrest and/or seat, and the brain slams into the rear of the skull.

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

autonomic nervous system Divided into two sections:

sympathetic and parasympathetic nervous systems

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

If the ICP increases,

the pulse may slow, blood pressure may rise, and respirations may become irregular.

If the respiratory control center of the brain is injured,

the rate and/or depth of breathing may be ineffective. Give supplemental oxygen to any patient with suspected head injury, particularly anyone who is having trouble breathing.

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.

An alternative to the long backboard is a

vacuum mattress. a. Molds to the specific contours of the patient's body, reducing pressure-point tenderness and therefore providing better comfort b. 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 i. Requires careful patient movement to maintain spinal stabilization 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.

somatic nervous system handles

voluntary activities. The brain interprets the sensory information that it receives from the peripheral and cranial nerves and responds by sending signals to the voluntary muscles.