chapter 29 injuries to the head and spine. anatomy review

CHAPTER 29

Injuries to the Head and Spine

Anatomy ReviewAnatomy Review

Nervous SystemNervous System

Nervous System – provides overall control of thought, sensation, and the voluntary and involuntary motor functions of the body. The major components of the nervous system are the brain and the spinal cord.

Central Nervous System – consists of the brain and spinal cord

Peripheral Nervous System – the nerves that enter and exit the spinal cord between the vertebrae and the twelve pairs of cranial nerves that travel between the brain and organs without passing through the spinal cord, and all of the body’s other motor and sensory nerves

Autonomic Nervous System – controls involuntary functions such as heartbeat, breathing, control of the diameter of your vessels, control of the round sphincter muscles closing your bladder and bowel and digestion

Nervous SystemNervous System

Brain – controlling organ of the body and the center of consciousness; occupies the entire space within the cranium, and each type of brain cell has a specific function and certain parts of the brain perform certain functions

Spinal Cord – consist of long tracts of nerves that join the brain with all body organs and parts, and protected by the spinal column

Nerves – sensory nerves send information to the brain on what the different parts of the body are doing relative to their surroundings while the motor nerves carry messages from the brain and result in stimulation of a muscle or organ

*** Prior to traveling down the spinal cord, they cross over the opposite side of the body, which means that the nerves originating from the right side of the brain, control the left side of the body and vice versa ***

Functions of the Functions of the Central Nervous Central Nervous SystemSystem

• Automatic

• Reflex

• Conscious

• Voluntary control of muscles

• Involuntary control of muscles

Skull and Facial Bones

Cranium - the portion of the skull that encloses the brain (formed by the forehead, top , back and upper sides of the skull). The cranial floor is the inferior wall of the brain case. The bones are fused together.

Facial Bones – 14 irregularly shaped bones that form the face, which are fused into immovable joints except the mandible

Skull and Facial BonesSkull and Facial Bones

CRANIUM

FACE

Zygomatic(cheek bones)

Maxilla(fused bones of theUpper jaw)

Mandible(lower jaw bone)

Orbit

Nasal bones

(Surrounds the eyes)

(Provides some structure of nose)

Cranium (houses and protects the brain)

Skull (houses and protects the brain; consists of the cranium and the face)

Contentsof the Skull

BoneDura materArachnoidPia mater

Subarachnoid spaceSubdural spaceIntracerebral

Epidural space (potential)

Dura materArachnoid

Skull

Pia mater

Cervical

Thoracic

Lum bar

Sacrum

Coccyx

SpinalSpinalColumnColumn(made up of 33 (made up of 33 vertebrae, vertebrae, which are the which are the separate bones separate bones of the spinal of the spinal column)column)

Spinal ColumnSpinal Column

Division Corresponding AnatomyNumber of Vertebrae

Cervical Neck 7

Thoracic Thorax, ribs, upper back 12

Lumbar Lower back 5

Sacral Back wall of pelvis 5

Coccyx Tailbone 4

Spinal Column

• Spinous Process – the bony bump on a vertebra – you can feel this on a person’s back

• Spinal Cord – travels through the hollow portion of the each vertebra

• Cerebral Spinal Fluid – the fluid that surrounds the brain and spinal cord

Spinal InjurySpinal Injury

Spinal Injury Considerations

Thoracic spine is usually not injured due to the sternum and spine

Pelvic-sacral spine attachment helps to protect the sacrum in the same way

Cervical and lumbar are more injury prone due to no other support by bony structures

Mechanisms of Spinal Injury

Compression

Falls

Diving accidents

Motor vehicle accidents

Excessive Flexion, Extension, and Rotation

Lateral Bending

Mechanisms of Spinal Injury

Distraction

Pulling apart of the spine

Hangings

Mechanisms of Spinal InjuryMaintain a high index of suspicion

Motor Vehicles crashes

Pedestrian – vehicles collisions

Falls

Blunt Trauma

Penetrating trauma to the head, neck and torso

Motorcycle crashes

Hangings

Diving accidents

Unconscious trauma victims

Mechanisms ofMechanisms ofSpinal InjurySpinal Injury

WhiplashWhiplash

Signs & Symptoms of Spinal Injuries

Ability to walk, move extremities or feel sensation; or lack of pain or numbness to spinal column does not rule out the possibility of spinal column or cord damage. DO NOT check for ROM

Tenderness in the area of injury

Pain associated with

Pain independent of movement or palpation (do not intentionally check for this)

Along spinal column

Lower legs

May be intermittent

Obvious deformity of the spine upon palpation – rare sign in the field


Soft tissue injuries associated with trauma

Head, neck and cervical spine

Shoulders, back or abdomen – thoracic/lumbar

Lower extremities – lumbar/sacral

Numbness, weakness or tingling in the extremities – paralysis is probably the most reliable sign of spinal cord injury in conscious patients – check for PMS


Loss of sensation or paralysis below the suspected level of injury

Loss of sensation or paralysis in the upper or lower extremities

Incontinence

Priapism

Posturing


Impaired breathing – if little or no movement of the chest, the patient is breathing with the diaphragm alone; reversal of normal breathing patterns with the rib cage collapsing on inspiration and rising on expiration; “C–3, –4, –5 keep the diaphragm alive”

Severe spinal shock – neurogenic shock can be caused by the failure of the nervous system to control the diameter of the blood vessels


Assessing Spinal Injury

Questions to ask:

What happened?

Where does it hurt?

Does your neck or back hurt?

Continued…


Responsive Patient

MOI

Questions to ask??? Does your neck or back hurt?

What happened?

Where does it hurt?

Can you move your hands and feet?

Can you feel me touching your fingers?

Can you feel me touching your toes?

DO NOT ask the patientDO NOT ask the patientto move to try to elicitto move to try to elicit

a painful response. Doa painful response. Donot move the patient to not move the patient to

test for a painful response.test for a painful response.


Inspect for DCAP-BTLS

Assess quality of strength of extremities

Hand grip

Gently push feet against hands

Assess distal pulses

Assess sensation in all extremities.Assess sensation in all extremities.

Assess motor function.Assess motor function.

Assess strength Assess strength –– feet. feet.

Assess strength Assess strength –– hands. hands.

Assessing Spinal InjuryUnresponsive Patient

MOI

Initial assessment

Inspect for:

Contusions

Deformities

Lacerations

Punctures/Penetrations

Swelling

Palpate for areas of deformity and tenderness

Obtain information from others at the scene to determine information relevant to mechanism of injury or patient mental status prior to the EMT-B’s arrival

Complications of Spinal InjuryPatients with head and spine injuries may be unable to maintain their own airway and breathes on their own. Airway management is essential with every patient. Such patients require cervical spine precautions. Consider:

Loss of consciousness

Foreign materials

Swelling

Unstable bone fractures

Paralysis

Waist down = paraplegic

Neck down = quadriplegic

Treating Spinal Injury

Take BSI precautions.

Establish and maintain in-line

Place the head in a neutral (eyes looking forward) position unless the patient complains of pain or the head is not easily moved into position

Maintain constant manual in-line immobilization until the patient is properly secured to a backboard with the head immobilized


Perform initial assessment

Whenever possible, airway control must be done with in-line immobilization, using the jaw-thrust maneuver

Whenever possible, artificial ventilation must be done with in-line immobilization, using the jaw-thrust maneuver

Assess PMS in all extremities.

Assess the cervical region and neck


Apply a rigid, cervical immobilization device.

Properly size the cervical immobilization device. If it doesn't fit use a rolled towel and tape to the board and have rescuer hold the head manually.

An improperly fit immobilization device will do more harm than good. A collar that is too large will hyperextend the neck, a collar that is too small could cause flexion, and a collar that is too loose could allow for lateral movement. A collar that is too tight could interfere with the patient’s airway.

If found in a lying position, immobilize the patient to a long spine board

Move the patient onto the device by log-rolling him/her

(1) One EMT-Basic must maintain in-line immobilization of the head and spine.

(2) EMT-Basic at the head directs the movement of the patient.

(3) One to three other EMT-Basics control the movement of the rest of the body.

(4) Quickly assess posterior body if not already done in focused history and physical exam.

(5) Position the long spine board under the patient.


Patient found lying on back continued…

(6) Place patient onto the board at the command of the EMT-Basic holding in-line immobilization using a slide, proper lift, log roll or scoop stretcher so as to limit movement to the minimum amount possible. Which method to use must be decided based upon the situation, scene and available resources.

(7) Pad the void under the shoulders of the infant and child to establish a neutral position.

(8) Immobilize torso to the board.

(9) Secure the legs to the board.

(10) Immobilize the patient's head to the board.

(11) Reassess pulses, motor and sensation and record.


If found in a sitting position, immobilize the patient with a short spine immobilization device. Exception: If the patient must be removed urgently because of his injuries, the need to gain access to other, or dangers at the scene, he/she must then be lowered directly onto a long board and removed with manual stabilization


Secure the patient onto the device by :

(1) Position device behind the patient.

(2) Secure the device to the patient's torso.

(3) Evaluate torso fixation and adjust as necessary without excessive movement of the patient.

(4) Secure the patient’s legs to the device.

(5) Secure the patient's head to the device.

(6) Insert a long board under the patient's buttocks and rotate and lower him to it. If not possible, lower him to the long spine board.

(7) Reassess pulses, motor and sensory in all extremities and record.


If the patient is found in the standing position, immobilize the patient to a long spine board using the “standing takedown” method

(1) Take BSI precautions

(2) Tallest crew member should be behind patient and have him manually stabilize the had and neck – this person remains here until the patient is strapped to the board

(3) A second EMT applies a properly sized cervical collar to the patient

(4) The second EMT and another EMT place a long board behind the patient being careful not to disturb the positioning of the 1st EMTs stabilization of the patient

(5) The second EMT looks at the long board from the front and does any necessary repositioning


“Standing takedown” method contiued…(6) The second and third EMTs reach arm that is nearest

patient under patient’s armpits and grasp the long board; to keep the patient’s arms secure, they will use other hand to grasp the patient’s arm just above elbow and hold it against body

(7) The second and third EMTs grasp a handhold on the spine board at patient’s armpit level or higher

(8) Slowly the board is lowered to the ground on the command of EMT at the head (EMT at the head is walking backwards, and the other two EMTs are walking slowly and evenly). The two EMTs that are on the sides of the board are moving into a squatting position so as not to injure their backs.

(9) The EMT at the head never lets go of the patient’s head until he/she is fully immobilized on the back board


Maintain stabilization; apply collar.Maintain stabilization; apply collar.

Position boardPosition boardand EMTand EMT––Bs.Bs.

Grasp the boardGrasp the boardafter reaching after reaching under the patient’sunder the patient’sshoulders.shoulders.

Carefully Carefully lower patient; lower patient; then secure then secure the board.the board.

“Standing takedown” method contiued…

If the patient is critically injured, perform a rapid extrication

If the patient has paralysis or weakness of the extremities, administer high-concentration oxygen via non-rebreather

If the patient is pregnant, once she is secured to the board, tilt the backboard onto its left side and support with pillows

Reassess sensory and motor function in all four extremities

Transport the patient immediately


Head InjuriesHead Injuries

Head Injuries – Overview

Injuries to the scalp

Very vascular, may bleed more than expected

Injuries to the brain

injury of the brain tissue or bleeding into the skull will cause an increase of pressure within the skull

May occur due to clot or hemorrhage

Can be a cause of altered mental status

Signs and symptoms may parallel those of traumatic injury (but no trauma)

Brain Injury – Non-traumatic

Open head injury – when the bones of the cranium and face fracture, and the overlying scalp is lacerated

Closed head injury – when the scalp is lacerated, but the cranium remains intact

Skull Injury – Traumatic

Signs & Symptoms ofSkull Injuries

Mechanism of Trauma

Contusion, laceration, hematoma to the scalp

Deformity to the skull

Blood/fluid from ears or nose

Bruising around eyes (raccoon's eyes)

Bruising behind ears (Battle’s Sign)

Brain Injuries

Whenever you suspect skull or brain injury, also suspect spine injury

Traumatic

Concussion – mild closed head injury without detectable damage to the brain; caused by an indirect force when the head is struck by a blunt object or comes into contact with the floor/ground after a fall, a certain amount of force is transferred through the skull to the brain

Continued….

Brain Injuries

Laceration – a cut to the brain can occur from the same forces that cause a contusion

Contusion – bruised brain; can occur with closed head injuries, when the force of the blow if great enough to rupture blood vessels on or within the brain

Coup – when the bruising of the brain occurs on the side of the blow

Contrecoup – when the bruising of the brain occurs on the side opposite the blow

Continued…

Brain InjuriesHematoma – collection of blood within tissue; when a hematoma develops, pressure inside the skull increases making it difficult for normal blood flow to enter the head. This causes blood pressure to increases, and as a result of decreased blood flow, the brain becomes starved for oxygen and high in waste carbon dioxide, causing even more swelling. Also, head injury may cause decreased respiratory effort, which further worsens oxygen starvation and swelling in the brain.

Subdural hematoma – collection of blood between the brain and the dura

Epidural hematoma – blood between the dura and the skull

Intracerebral hematoma – occurs when blood pools within the brain

Altered or decreasing mental status is the best indicator of brain injury

Confusion, disorientation, or repetitive questioning

Conscious – derteriorating mental status

Unresponsive

Personality change – ranging from irritable to irrational behavior

Signs & Symptoms ofBrain Injuries

AVPU

Alert – awake and oriented; can understand you and obey requests

Verbal – inappropriate words, sounds, confused; doesn’t answer questions appropriately

Pain – patient responds to pressure on sternum or nail bed

Unresponsive – patient does not respond in any way to any stimulation

Irregular breathing pattern


Elevated blood pressure with decreasing pulse (Cushing’s Triad)

Consideration of MOI

Deformity of windshield

Deformity of helmet

Contusion, laceration, hematoma, or deformity to the scalp or forehead – do not probe or separate to discover wound depth

Deformity to the skull, visible bone fragments, pieces of brain tissue


Blood/fluid from ears or nose

Bruising around eyes (raccoon's eyes)

Bruising behind ears (Battle’s Sign)

Neurologic disability

Nausea/vomiting – projectile

Unequal/unreactive pupil size with altered mental status; one eye may appear to be sunken; blurred or multiple-image vision in one or both eyes


Seizure activity may be seen

Incontinence

Priapism

Posturing – patient may exhibit flexing arms and wrists and extending legs and feet (decorticate posture) or extending arms with the shoulders rotated inward and wrists flexed, legs extended (decerebrate posture) – typically after a painful stimulus


Severe pain at the site of the injury

Temperature increase – late sign

Impaired hearing or ringing in the ears

Equilibrium problems

Deteriorating vital signs


Emergency Care ofHead Injuries

BSI.

Initial assessment. Maintain airway/artificial ventilation/oxygenation using the jaw-thrust method. If patient is unconscious, insert an oropharyngeal airway. Have suction ready because these patients are likely to vomit. Monitor the unconscious patient for changes in breathing and be prepared to assist if necessary. If the patient shows signs of a critical brain injury (increased blood pressure with decreased pulse, fixed and dilated pupils, altered mental status), hyperventilate the patient at a rate of 20 – 24 breaths per minute (Hyperventilation will help reduce brain tissue swelling by lowering CO2 levels and increasing O2 levels, but it will also decrease blood flow to the brain).


With any head injury, suspect spinal injury. Apply a rigid cervical collar and immobilize the neck and spine. Determine method of extrication (rapid, standing take-down, etc…)

Closely monitor the airway, breathing, pulse, and mental status for deterioration. Keep the patient at rest and calm. Talk to the patient, providing emotional support and asking him/her questions that he/she will have to concentrate on.

Control bleeding

Do not apply pressure to an open or depressed skull injury.

Dress and bandage open wound as indicated in the treatment of soft tissue injuries – loose gauze dressings.


If a medical condition exists, place patient on the left side (i.e. pregnant female)

Be prepared for changes in patient condition. Manage the patient for shock even if signs are not yet present. DO NOT elevate the legs unless signs of shock are present and protocols permit. DO NOT overheat.

Immediately transport the patient.

Monitor vital signs every 5 minutes.

Complete a Prehospital Care Report. Document all pertinent findings of the patient assessment; treatment; and transport decisions.

SpinalSpinalImmobilizationImmobilization

Cervical Spine ImmobilizationDevices

Indications

Any suspected injury to the spine based on mechanism of injury, history or signs and symptoms.

Use in conjunction with short and long backboards.

Sizing

Various types of rigid cervical immobilization devices exist, therefore, sizing is based on the specific design of the device.

An improperly sized immobilization device has a potential for further injury.

Cervical Spine ImmobilizationDevices

Sizing cont’d…

Do not obstruct the airway with the placement of a cervical immobilization device.

If cervical immobilization device cannot be applied, consider using a rolled towel and tape to the board and manually support the head. An improperly fitted device will do more harm than good.

Precautions

Cervical immobilization devices alone do not provide adequate in-line immobilization.

Manual immobilization must always be used with a cervical immobilization device until the head is secured to a board.

Applying aCervical SpineImmobilization

Device

Stabilize and measure.Stabilize and measure.

Choose correct collar size.Choose correct collar size.

Prepare collar.Prepare collar.

Slide collar under chin.Slide collar under chin.

Secure collar; maintain in-line position.Secure collar; maintain in-line position.

Use of ShortSpine Boards:Seated Patient

Short Spine Boards

Several different types of short board immobilization devices exist

Vest type

Rigid short spine board

Provides stabilization to the head, neck, torso

Used to immobilize non-critical sitting patients with suspected spinal injury

Applying a ShortBoard Immobilization

Device (KED)

Select immobilization device.Select immobilization device.

Manually stabilize patient’s head in Manually stabilize patient’s head in neutral, in-line position.neutral, in-line position.

Assess distal pulse, motor function, and Assess distal pulse, motor function, and sensation (PMS).sensation (PMS).

Assess the cervical area. Apply the Assess the cervical area. Apply the appropriately sized extrication collar.appropriately sized extrication collar.

Position the device behind patient.Position the device behind patient.

Secure device to patient’s torso.Secure device to patient’s torso.

Evaluate torso and groin fixation and Evaluate torso and groin fixation and adjust as necessary to maintainadjust as necessary to maintainin-line immobilization.in-line immobilization.

Evaluate and pad behind patient’s head Evaluate and pad behind patient’s head as necessary. Secure patient’s head to as necessary. Secure patient’s head to device.device.

Final Steps for KED

Release manual stabilization of head

Rotate or lift the patient to the long spine board

Immobilize patient to long spine board

Reassess PMS

Use of LongSpine Boards:Supine Patient

Long Spine Boards

Provides stabilization and immobilization to the head, neck, torso, pelvis, and extremities.

May be applied in:

Lying, standing, and sitting positions

Conjunction with short spine boards

Maintain stabilization Maintain stabilization Assess PMS in all extremitiesAssess PMS in all extremities

Assess the cervical area and apply collarAssess the cervical area and apply collar

Prepare and position devicePrepare and position device..

Performing the Log Roll

Move the patient onto the device by log roll, suitable lift or slide, or scoop stretcher. A log roll is:

One EMT-Basic must maintain in-line immobilization.

EMT-Basic at the head directs the movement of the patient.

One to three other EMT-Basics control the movement of the rest of the body

Quickly assess posterior body if not already done in initial assessment

Position the long spine board under the patient

Roll patient onto the board at the command of the EMT-Basic holding in-line immobilization.

Move patient onto board. Apply padding Move patient onto board. Apply padding to voids especially of the infant/childto voids especially of the infant/child

Immobilize torso to the board by applyingImmobilize torso to the board by applyingstraps across the chest and pelvis – adjuststraps across the chest and pelvis – adjustas needed. Immobilize the patient’s headas needed. Immobilize the patient’s headto the device.to the device.

Reassess PMS.Reassess PMS.

Rapid ExtricationRapid Extrication

Unsafe scene

Unstable patient condition

Patient blocks EMT–B’s access to an unstable patient

Rapid extrication is based on time and the patient, not the EMT-Bs preference

Indications

Rapid Extrication

Does not provide optimal spinal stabilization

Use with “C” or “U” patients

Use when the patient’s safety is compromised

Should be

limited to

life/death

situations

Rapid Extrication

Manually stabilize; apply collar.Manually stabilize; apply collar.

After putting end of board next to patient, After putting end of board next to patient, position hands on legs/pelvis and position hands on legs/pelvis and chest/arms.chest/arms.

Rotate patient and reposition hands.Rotate patient and reposition hands.

Lower patient to board.Lower patient to board.

Move patient into position on board.Move patient into position on board.

Secure patient and transport.Secure patient and transport.

Helmet RemovalHelmet Removal

Special Assessment Needs for Patients Wearing Helmets

Airway and breathing

Fit of the helmet and patient's movement within the helmet

Ability to gain access to airway and breathing

Indications to Leave Helmet in Place

Good fit, little or no movement within the helmet

No impending airway or breathing problems

Removal would cause further injury

Continued…

Proper immobilization is able to be performed with helmet in place

No interference with the EMT-Bs ability to assess and reassess airway and breathing

Indications to Leave Helmet in Place

Inability to assess or reassess airway and breathing

Restriction of adequate management of the airway or breathing

Improper fit/movement within helmet

Continued…

Indications for Removing Helmet

Proper spinal immobilization cannot be performed due to helmet

Cardiac arrest

Indications for Removing Helmet

Sports

Typically open anterior

Easier access to the airway

Motorcycle

Full Face

Shield

Skull Cap

Other

Types of Helmets

Be sure to remove eyeglasses.Be sure to remove eyeglasses.First EMT stabilizes helmet by placing First EMT stabilizes helmet by placing fingers on patient’s mandible to prevent fingers on patient’s mandible to prevent movement.movement.

Second EMTSecond EMT––B loosens strap.B loosens strap.

The second EMT places one hand on theThe second EMT places one hand on the mandible at the angle of the jaw and the mandible at the angle of the jaw and the

other hand posterior at theother hand posterior at theoccipital region.occipital region.

The EMT-B holding the helmet pullsThe EMT-B holding the helmet pullsthe sides of the helmet apartthe sides of the helmet apart

and gently sips the helmet halfwayand gently sips the helmet halfwayoff the patient’s head and then stops.off the patient’s head and then stops.

The EMT-B holding maintaining The EMT-B holding maintaining stabilization of the neck, repositions, stabilization of the neck, repositions, slides the posterior hand superiorly to slides the posterior hand superiorly to secure the head from from falling once secure the head from from falling once helmet is removed.helmet is removed.

The helmet is removed completely. The helmet is removed completely. Begin routine stabilization and Begin routine stabilization and immobilization.immobilization.

Leave helmet in place for transport when/if:

There is only one trained rescuer

The patient’s breathing is not compromised and immobilization in neutral position is possible

Attempts to remove the helmet will compromise the patient’s condition

Remove a helmet prior to transport when clinically indicated and more than one trained rescuer is present

Helmets may be stabilized using:

Tape

Head Blocks

Rolled Blankets

Commercial Devices

Helmet Odds – n – Ends

Infants and ChildrenInfants and Children

Infants and children - immobilize the infant or child on a rigid board appropriate for size (short, long or padded splint), according to the procedure outline in the spinal immobilization section.

Infant and Child Seats - If infant or child is already in a child protective seat, and is stable immobilize in place.

Special Considerations:

Pad from the shoulders to the heels of the infant or child, if necessary to maintain neutral immobilization.

If cervical immobilization device cannot be applied, consider use a rolled towel and tape to the board and manually support the head. An improperly fitted device will do more harm than good.

Infants and Children

The OddsThe Oddsandand

EndsEnds

Immobilize the entire spine

Movement of the torso effects the stability of the cervical spine.

Partial immobilization increases the risk of a torque effect.

Cervical spine pain may mask injuries to the lower spine

Cervical Spine Injury

Cot mattress does not provide stability

Long board provides

Stability

Facilitates patient transfer

Cot Straps

Do not immobilize patient to board

Must be removed for patient transfers, loosing all security

Do not permit “rolling” an immobilized patient who might be vomiting

Long Board Immobilization

Opening the Airway with a suspected spinal cord injury; use the modified jaw thrust maneuver without head tilt.

Use manufactures recommendations in the use of immobilization devices

Complete the Prehospital Care Report

Document all pertinent findings of patient assessment; pre and post treatment; and transport decisions.

Disclaimers

chapter 29 injuries to the head and spine. anatomy review

Documents

digestionnervous system

brain case

type of brain cell

vertebracerebral spinal

motor nerves

facial bones cranium

separate bones

shaped bones