1 Head and Spinal Cord Trauma May 2011 CE Condell Medical Center EMS System Site Code #107200E-1211...

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Head and Spinal Head and Spinal Cord TraumaCord Trauma

May 2011 CEMay 2011 CECondell Medical Center Condell Medical Center

EMS SystemEMS SystemSite Code #107200E-1211Site Code #107200E-1211

Objectives by: Mike Higgins, FF/PM Grayslake Fire Objectives by: Mike Higgins, FF/PM Grayslake Fire DepartmentDepartment

Packet by: Sharon Hopkins, RN, BSN, EMT-PPacket by: Sharon Hopkins, RN, BSN, EMT-P

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ObjectivesObjectivesUpon successful completion of this module, the Upon successful completion of this module, the EMS provider will be able to:EMS provider will be able to:

1.1. List risky behaviors contributing to brain and List risky behaviors contributing to brain and spinal cord injuries.spinal cord injuries.

2.2. Describe typical injury patterns related to Describe typical injury patterns related to specific mechanisms of injury.specific mechanisms of injury.

3. Describe the anatomy of the brain.3. Describe the anatomy of the brain.4. List contents of the skull.4. List contents of the skull.5. Describe the mechanisms for the development 5. Describe the mechanisms for the development

of secondary brain injury.of secondary brain injury.6. Describe the pathophysiology of traumatic brain 6. Describe the pathophysiology of traumatic brain

injuries including pressures related to brain injuries including pressures related to brain blood flow.blood flow.

7. Explain the normal anatomy and physiology of 7. Explain the normal anatomy and physiology of the spinal column and spinal cord.the spinal column and spinal cord.

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Objectives cont’dObjectives cont’d8. Describe the pathophysiology of traumatic spinal 8. Describe the pathophysiology of traumatic spinal

cord injuries.cord injuries.

9. Describe components of a neurological 9. Describe components of a neurological assessment in the field.assessment in the field.

10. List signs and symptoms of spinal cord injuries.10. List signs and symptoms of spinal cord injuries.

11. Describe the pathophysiology of neurogenic 11. Describe the pathophysiology of neurogenic shock.shock.

12. Describe prehospital treatment based on Region 12. Describe prehospital treatment based on Region X SOP’s of the patient with a head or spinal cord X SOP’s of the patient with a head or spinal cord injury.injury.

13. Review ventilation rates of the stable and 13. Review ventilation rates of the stable and unstable patients with head and/or spinal cord unstable patients with head and/or spinal cord injuries.injuries.

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Objectives cont’dObjectives cont’d14. Review the Region X Infield Spinal Clearance 14. Review the Region X Infield Spinal Clearance

SOP.SOP.15. Review measurement of fitting a cervical 15. Review measurement of fitting a cervical

collar.collar.16. Review the procedure for demonstrating the 16. Review the procedure for demonstrating the

standing backboard takedown procedure.standing backboard takedown procedure.1717. . Demonstrate the proper measurement Demonstrate the proper measurement

and placement of a cervical collar.and placement of a cervical collar.18. Demonstrate the standing take down 18. Demonstrate the standing take down

with the back board.with the back board.19. Actively participate in case scenario 19. Actively participate in case scenario

discussion.discussion.20. Successfully complete the post quiz with a 20. Successfully complete the post quiz with a

score of 80% or better.score of 80% or better.

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What’s The Big Deal?What’s The Big Deal?Traumatic brain injury (TBI)Traumatic brain injury (TBI)– Major cause of death and disability in Major cause of death and disability in

multiple trauma patientsmultiple trauma patients– Severe injury indicated with GCS <9Severe injury indicated with GCS <9

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TBI StatisticsTBI Statistics

Many Many patients will patients will be minors, be minors, therefore, therefore, you will also you will also be dealing be dealing with with parents and parents and caregiverscaregivers

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Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)40% of trauma patients have CNS injury40% of trauma patients have CNS injuryDeath rate twice as high (35%) as patient Death rate twice as high (35%) as patient without CNS injurywithout CNS injuryAccount for 25% of all trauma deathsAccount for 25% of all trauma deathsAccount for up to 50% of all MVC deathsAccount for up to 50% of all MVC deathsCost worldwide is hugeCost worldwide is huge– Lives lostLives lost– Families destroyedFamilies destroyed– Money spent for careMoney spent for care

CNS – central nervous systemCNS – central nervous system

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Risky Activities Resulting in Spinal Risky Activities Resulting in Spinal Cord InjuriesCord Injuries

MVC – 44.5% - major causeMVC – 44.5% - major cause– SUV’s & jeeps prone to flippingSUV’s & jeeps prone to flipping

Falls 18.1% Falls 18.1% – Most common in persons >45 years of ageMost common in persons >45 years of age

Violence 16.6% Violence 16.6% – More common in urban settingsMore common in urban settings

Sports 12.7%Sports 12.7%– Diving most common contributing sportDiving most common contributing sport

Other medical causes make up <10%Other medical causes make up <10%

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Typical Head/Neck Injury PatternsTypical Head/Neck Injury PatternsT-bone – lateral impactT-bone – lateral impact– Coup/contrecoup head injuriesCoup/contrecoup head injuries– Neck strain up to fracturesNeck strain up to fractures– Most injuries from collision with inside of vehicleMost injuries from collision with inside of vehicleRear impactRear impact– Hyperextension of neck esp if head rest not fittedHyperextension of neck esp if head rest not fitted– Lumbar spine injury if seat breaksLumbar spine injury if seat breaksRolloverRollover– Body impacted in all directions so injury potential Body impacted in all directions so injury potential

highhigh– Increased chance for axial loading on spineIncreased chance for axial loading on spine– Often lethal injuries when ejectedOften lethal injuries when ejected

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Typical Head/Neck Injury PatternsTypical Head/Neck Injury Patterns

ATVATV– Injuries depend on MOI and part of body Injuries depend on MOI and part of body

impactedimpacted– High index of suspicions for head and High index of suspicions for head and

spinal injuriesspinal injuries

Falls from heightFalls from height– Evaluate distance, body area impacted, Evaluate distance, body area impacted,

type of surface strucktype of surface struck– Landing on feet, check for axial loading Landing on feet, check for axial loading

to lumbar and cervical spine areasto lumbar and cervical spine areas

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Anatomy of Anatomy of the Skullthe Skull

Scalp highly vascularScalp highly vascularSkull is rigid boneSkull is rigid bone– Serves as protectionServes as protection

Dura materDura mater– Tough fibrous covering of Tough fibrous covering of

brainbrainArachnoid materArachnoid mater– Lies under duraLies under dura– Arteries & veins Arteries & veins

suspended from thissuspended from thisPia materPia mater– On surface of brainOn surface of brain

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Anatomy of the BrainAnatomy of the Brain

Each lobe has a unique functionEach lobe has a unique function

Identified disabilities can help Identified disabilities can help pinpoint area of insult or injurypinpoint area of insult or injury– Proper assessment can point to area of Proper assessment can point to area of

injuryinjury– Always reassess watching for trendsAlways reassess watching for trends

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Anatomy of the BrainAnatomy of the Brain

CerebrumCerebrum– Frontal lobeFrontal lobe

PersonalityPersonalityJudgmentJudgment

– Temporal lobeTemporal lobeHearingHearingMemoryMemory

– Parietal lobeParietal lobeLanguage Language formation; formation; processing processing sensessenses

– Occipital lobeOccipital lobeVisionVision

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Anatomy cont’dAnatomy cont’dCerebellumCerebellum– Control of movement, Control of movement,

balance, coordinationbalance, coordinationBrainstem Brainstem – arousal & consciousness center; arousal & consciousness center;

involved in basic life functions involved in basic life functions breathing, reflexesbreathing, reflexes

– Pons – motor & sensory relay Pons – motor & sensory relay centercenter

– Medulla- controls autonomic Medulla- controls autonomic functions (breathing, functions (breathing, digestion, heart & blood digestion, heart & blood vessel functionvessel function

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Contents of the SkullContents of the Skull

There is no extra spaceThere is no extra spaceIf one component increases, usually If one component increases, usually brain tissue swelling, it is usually at brain tissue swelling, it is usually at sacrifice of one of the other componentssacrifice of one of the other components– Brain – 80%Brain – 80%– Blood volume – 10% (150 ml) Blood volume – 10% (150 ml) – CSF – 10% (150 ml )CSF – 10% (150 ml )

CSF – cerebral spinal fluidCSF – cerebral spinal fluid

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Brain FunctionBrain FunctionBrain VERY sensitive to levels of Brain VERY sensitive to levels of oxygenoxygen and and glucoseglucose– Brain has a high metabolic rate both at Brain has a high metabolic rate both at

rest or engaged in activityrest or engaged in activity– Brain is 2% of total body weightBrain is 2% of total body weight– Receives 15% of cardiac outputReceives 15% of cardiac output– Consumes 20% of body’s oxygenConsumes 20% of body’s oxygen– Relies on aerobic metabolismRelies on aerobic metabolism– Needs constant availability of glucose, Needs constant availability of glucose,

thiamine (to metabolize glucose), and thiamine (to metabolize glucose), and oxygenoxygen

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Comparative Blood Flow in ml/minuteComparative Blood Flow in ml/minute

OrganOrgan At restAt rest During strenuous During strenuous activityactivity

HeartHeart 250250 750750

SkinSkin 400400 19001900

OtherOther 600600 400400

BrainBrain 750750 Steady at 750Steady at 750

Skeletal muscleSkeletal muscle 10001000 12,50012,500

KidneysKidneys 12001200 600600

VisceraViscera 14001400 600600

TotalTotal 56005600 17,50017,500

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Adding Insult to InjuryAdding Insult to InjuryCoup-contrecoup injuriesCoup-contrecoup injuries– Brain shifts/floats inside skullBrain shifts/floats inside skull

Base of skull rough – causes more injuryBase of skull rough – causes more injury

– Injuries at point of impact and away Injuries at point of impact and away from point of impactfrom point of impact

Ex: forehead injury Ex: forehead injury can result in can result in additional injury additional injury to occipital areato occipital area

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Secondary InjurySecondary Injury

Primary injury occurs at time of insultPrimary injury occurs at time of insult

Secondary injury occurs later as a Secondary injury occurs later as a result of what happens initiallyresult of what happens initially

Initial swelling causes decreased Initial swelling causes decreased perfusionperfusion

Secondary complications stem from Secondary complications stem from hypoxia and decreased perfusionhypoxia and decreased perfusion

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What is your major focus?What is your major focus?Management of injury focused onManagement of injury focused on– Proper care Proper care

Identification of injuries Identification of injuries – An accurate general impression An accurate general impression

leads to appropriate careleads to appropriate careAppropriate interventions initiatedAppropriate interventions initiated

– Rapid transport to secondary careRapid transport to secondary care

Do things right to prevent Do things right to prevent contributing to secondary injuriescontributing to secondary injuries

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Common Problems Related To TBICommon Problems Related To TBI

Airway compromiseAirway compromiseInadequate ventilationInadequate ventilationHypotension Hypotension – An independent risk factor contributing An independent risk factor contributing

to mortalityto mortality

Focus on these critical aspects and Focus on these critical aspects and perform appropriate interventions as perform appropriate interventions as neededneeded

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Pressures Related to Blood flowPressures Related to Blood flowICP is pressure of brain and contents ICP is pressure of brain and contents within skullwithin skullCPP - cerebral perfusion pressureCPP - cerebral perfusion pressure– Pressure of blood flowing thru Pressure of blood flowing thru

brain; pressure necessary to brain; pressure necessary to perfuse brain (CPP=MAP-ICP)perfuse brain (CPP=MAP-ICP)

MAP - mean arterial pressureMAP - mean arterial pressure– Average pressure within an artery; Average pressure within an artery;

pressure maintained in vascular pressure maintained in vascular systemsystem

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Reflexive Response to Reflexive Response to ICPICPCushing’s reflexCushing’s reflex– Protective response to preserve blood flow to Protective response to preserve blood flow to

the brainthe brainB/P will increaseB/P will increaseSystolic B/P increasing as diastolic B/P Systolic B/P increasing as diastolic B/P

stays same or increasesstays same or increasesWidening pulse pressureWidening pulse pressure

Heart rate will decrease Heart rate will decrease Effort to lower elevating blood pressureEffort to lower elevating blood pressure

Respirations may be irregularRespirations may be irregular

Note vital signs move opposite to Note vital signs move opposite to shockshock

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Cerebral PerfusionCerebral PerfusionBrain requires unique range to functionBrain requires unique range to functionIncreased ICP causes brain herniationIncreased ICP causes brain herniationHypotension not tolerated with Hypotension not tolerated with ICPICPExamples of problems*:Examples of problems*:– MAP constant + ICP MAP constant + ICP = = CPP CPP– MAP decreases + ICP steady = MAP decreases + ICP steady = CPP CPP– MAP decreases + ICP MAP decreases + ICP = CPP critical= CPP critical

Any negative change in B/P or ICP affects Any negative change in B/P or ICP affects blood flow in brainblood flow in brain

*Normal values of MAP, ICP, and CPP listed in Notes section*Normal values of MAP, ICP, and CPP listed in Notes section

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Signs and Symptoms Head InjurySigns and Symptoms Head Injury

Use inspection/observational skills Use inspection/observational skills with mechanism of injury to increase with mechanism of injury to increase suspicion of head and neck injuriessuspicion of head and neck injuries

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Brain Injuries - ConcussionBrain Injuries - ConcussionPrevalent in athletic activitiesPrevalent in athletic activitiesNo structural injury to brainNo structural injury to brainOften brief loss of consciousness or, at Often brief loss of consciousness or, at minimum, confusion, then return to minimum, confusion, then return to normalnormalPossible amnesia (short-term retrograde)Possible amnesia (short-term retrograde)Short term memory loss – will ask Short term memory loss – will ask repetitive questionsrepetitive questionsDizziness, headache, ringing in ears, Dizziness, headache, ringing in ears, nauseanausea

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Brain Injuries – Cerebral ContusionBrain Injuries – Cerebral Contusion

Bruised brain tissueBruised brain tissueHistory prolonged unconsciousness History prolonged unconsciousness or serious altered level of or serious altered level of consciousness (confusion, amnesia, consciousness (confusion, amnesia, abnormal behavior)abnormal behavior)Focal neurological signsFocal neurological signs– Related to a specific area of the brainRelated to a specific area of the brain– Weakness, speech problems, personality Weakness, speech problems, personality

or behavioral changesor behavioral changes

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Brain Injuries – Subarachnoid Brain Injuries – Subarachnoid HemorrhageHemorrhage

Blood in subarachnoid spaceBlood in subarachnoid space– Traumatic injury or spontaneousTraumatic injury or spontaneous

Blood causes irritationBlood causes irritation

Severe headacheSevere headache– ““Worst headache of my life”Worst headache of my life”

ComaComa

VomitingVomiting

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Brain Injuries – Diffuse Axonal Brain Injuries – Diffuse Axonal InjuryInjury

Most common type of injury from Most common type of injury from blunt head traumablunt head trauma

Generalized, diffuse edemaGeneralized, diffuse edema

UnconsciousUnconscious

No focal deficitsNo focal deficits– Swelling, edema, injury too widespread Swelling, edema, injury too widespread

so no specific isolated sign/symptom so no specific isolated sign/symptom pointing to 1 area of the brainpointing to 1 area of the brain

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Brain Injuries – Acute Epidural Brain Injuries – Acute Epidural HematomaHematoma

Bleeding between dura and skullBleeding between dura and skullOften from tear in middle meningeal artery Often from tear in middle meningeal artery from skull fracture in temporal areafrom skull fracture in temporal area– Runs along inside of skull in temporal areaRuns along inside of skull in temporal area– Arterial bleed so onset usually rapid for Arterial bleed so onset usually rapid for

signs/symptomssigns/symptoms

Initial loss of consciousness and now lucidInitial loss of consciousness and now lucidSigns Signs ICP after few hours ICP after few hours– Vomiting, headache, altered mental statusVomiting, headache, altered mental status– Motor deficit opposite side to injury (contralateral)Motor deficit opposite side to injury (contralateral)– Dilated, fixed pupil on side of injury (ipsilateral)Dilated, fixed pupil on side of injury (ipsilateral)

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Brain Injuries – Acute Subdural Brain Injuries – Acute Subdural HematomaHematoma

Bleeding between dura and arachnoidBleeding between dura and arachnoid

Bleeding is venousBleeding is venous

Slow onset to Slow onset to ICP (hours, days) ICP (hours, days)

Headache, changing level of consciousness, Headache, changing level of consciousness, focal neurological signsfocal neurological signs– Weakness one sided, slurred speechWeakness one sided, slurred speech

Poor prognosis due to associated brain tissue Poor prognosis due to associated brain tissue injuryinjury

High risk: elderly, anticoagulant use, chronic High risk: elderly, anticoagulant use, chronic alcoholicsalcoholics

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Brain Injuries – Intracerebral Brain Injuries – Intracerebral HemorrhageHemorrhage

Bleeding within brain tissueBleeding within brain tissue

Blunt or penetrating injuriesBlunt or penetrating injuries

Surgery not often helpfulSurgery not often helpful

Signs and symptoms depend on region of Signs and symptoms depend on region of brain injuredbrain injured

Patterns similar to a patient with a strokePatterns similar to a patient with a stroke

Altered level of consciousness commonAltered level of consciousness common

If awake, complain of headache & If awake, complain of headache & vomitingvomiting

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Spinal ColumnSpinal Column

Spinal column is the bony tube Spinal column is the bony tube of 33 vertebrae separated by of 33 vertebrae separated by discs that act as shock discs that act as shock absorbersabsorbers

Alignment maintained by Alignment maintained by strong ligaments and musclesstrong ligaments and muscles

Supports body in upright Supports body in upright positionposition

Allows use of extremitiesAllows use of extremities

Protects delicate spinal cordProtects delicate spinal cord

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Spinal CordSpinal Cord

Electrical conduitElectrical conduit

Extension of brain stemExtension of brain stem

Continues down to first lumbar Continues down to first lumbar vertebrae then separates into nervesvertebrae then separates into nerves

Surrounded and bathed by Surrounded and bathed by cerebrospinal fluidcerebrospinal fluid

Cerebrospinal fluid and flexibility Cerebrospinal fluid and flexibility provide some protectionprovide some protection

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Spinal Column/CordSpinal Column/Cord

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Spinal Cord cont’dSpinal Cord cont’dNerve roots exit at each vertebral levelNerve roots exit at each vertebral level– Nerve roots carry signals from brain to Nerve roots carry signals from brain to

specific sitesspecific sites– Nerve roots carry sensory signals from Nerve roots carry sensory signals from

body to spinal cord to brainbody to spinal cord to brain– Susceptible to Susceptible to

traumatic injurytraumatic injury

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Spinal Cord cont’dSpinal Cord cont’d

Integrates/brings together the Integrates/brings together the autonomic nervous systemautonomic nervous system– 2 components: parasympathetic 2 components: parasympathetic

and sympathetic nervous systemand sympathetic nervous system– Assists in controlling Assists in controlling

Heart rateHeart rate

Blood vessel toneBlood vessel tone

Blood flow to skinBlood flow to skin

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Mechanisms of InjuryMechanisms of InjuryPenetrating Penetrating injuriesinjuries– Secure the Secure the

object in object in position position foundfound

– Do no Do no further further harm!harm!

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Mechanisms of Blunt Spinal InjuryMechanisms of Blunt Spinal Injury

HyperextensionHyperextension– Excessive posterior movement of head Excessive posterior movement of head

or neckor neckFace into windshieldFace into windshieldElderly person falling to floor, striking chinElderly person falling to floor, striking chinFootball tacklerFootball tacklerDive into shallow waterDive into shallow water

HyperflexionHyperflexion– Excessive anterior movement of head Excessive anterior movement of head

onto chestonto chestRider thrown from horse or motorcycleRider thrown from horse or motorcycleDive into shallow waterDive into shallow water

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Mechanisms cont’dMechanisms cont’d

CompressionCompression– Weight of head or pelvis driven into Weight of head or pelvis driven into

stationary neck or torsostationary neck or torsoDive into shallow waterDive into shallow water

Fall onto head or legs >10-20 feetFall onto head or legs >10-20 feet

RotationRotation– Excessive rotation of torso or head & Excessive rotation of torso or head &

neck; moves one side of spinal column neck; moves one side of spinal column against other sideagainst other side

Rollover MVCRollover MVC

Motorcycle crashMotorcycle crash

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Mechanism cont’dMechanism cont’dLateral stressLateral stress– Direct lateral force on spinal column; Direct lateral force on spinal column;

typical shearing one level of cord from typical shearing one level of cord from anotheranother

T-bone MVCT-bone MVC

DistractionDistraction– Excessive stretching of column and cordExcessive stretching of column and cord

HangingHangingChild inappropriately wearing shoulder belt Child inappropriately wearing shoulder belt around neckaround neck““Clothes lining” with snowmobile or Clothes lining” with snowmobile or motorcycle riders and passengersmotorcycle riders and passengers

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Disk ProblemsDisk Problems

A preexisting A preexisting problem can problem can be aggravated be aggravated at time of at time of injuryinjury

4343

Spinal Cord InjuriesSpinal Cord InjuriesComplete injuryComplete injury– No function, sensation, voluntary No function, sensation, voluntary

movement below level of injurymovement below level of injury– Both sides affected equallyBoth sides affected equally

Incomplete injuryIncomplete injury– Some function preserved below level of Some function preserved below level of

injuryinjury– May move 1 limb more than otherMay move 1 limb more than other– May have more function on 1 side of May have more function on 1 side of

body than otherbody than other– May have sensation but no movementMay have sensation but no movement

4444

Spinal Cord InjuriesSpinal Cord InjuriesTetraplegia (also referred to as Tetraplegia (also referred to as quadriplegia)quadriplegia)– Injury in cervical areaInjury in cervical area– Loss of muscle strength in all 4 extremitiesLoss of muscle strength in all 4 extremities

ParaplegiaParaplegia– Injury in spinal cord in thoracic, lumbar or Injury in spinal cord in thoracic, lumbar or

sacral segmentssacral segments– Level of impairment dependent on level of Level of impairment dependent on level of

injuryinjury

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Spinal Cord Injury PatternsSpinal Cord Injury PatternsCervical area injury = quadriplegicCervical area injury = quadriplegic

C1-C2 – may lose involuntary function of C1-C2 – may lose involuntary function of breathingbreathing– Watch for excessive use of abdominal muscles Watch for excessive use of abdominal muscles

to breathto breath

C4 and above – often require use of C4 and above – often require use of ventilator for breathingventilator for breathing

C5 – shoulder/bicep control but no control C5 – shoulder/bicep control but no control of hand or wristof hand or wrist

C6 – wrist control but no hand functionC6 – wrist control but no hand function

4646

Spinal Cord Injury PatternsSpinal Cord Injury PatternsC7-T1 – can straighten arms, dexterity C7-T1 – can straighten arms, dexterity problem with fingers and handsproblem with fingers and handsThoracic level and below = paraplegicThoracic level and below = paraplegicT1-T8 – has control of hands, poor T1-T8 – has control of hands, poor trunk control due to lack of abdominal trunk control due to lack of abdominal muscle controlmuscle controlT9-T12 – good trunk & abdominal T9-T12 – good trunk & abdominal muscle control; sitting balance good. muscle control; sitting balance good. Decreased control hip flexor and legsDecreased control hip flexor and legs

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Spinal Cord Injury ConsequencesSpinal Cord Injury Consequences

Often experience:Often experience:– Bowel and bladder dysfunctionBowel and bladder dysfunction– Male fertility often affectedMale fertility often affected– Inability to regulate B/P; hypotension Inability to regulate B/P; hypotension

usualusual– Inability to sweat below level of injuryInability to sweat below level of injury– Decrease control to regulate body Decrease control to regulate body

temperaturetemperature– Chronic painChronic pain

4848

DermatomesDermatomes

Mapping of Mapping of bodybodyEasier to Easier to identify identify injured areas injured areas by isolating by isolating location of location of complaints as complaints as related to related to zones of zones of altered altered sensationsensation

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Neurogenic ShockNeurogenic ShockOccurs when brain signals Occurs when brain signals interrupted for autonomic functionsinterrupted for autonomic functionsAbility to vasoconstrict limitedAbility to vasoconstrict limited– No sympathetic tone, vessels dilateNo sympathetic tone, vessels dilate

Relative hypovolemiaRelative hypovolemia preloadpreload ventricular filling ventricular filling Frank Frank

Starling reflex Starling reflex contraction strengthcontraction strength cardiac outputcardiac output

– No hormone release to No hormone release to heart rateheart rate

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Neurogenic ShockNeurogenic Shock

Signs and symptomsSigns and symptoms– BradycardiaBradycardia– HypotensionHypotension– Cool, moist, pale skin above cord Cool, moist, pale skin above cord

injuryinjury– Warm, dry, flushed skin below cord Warm, dry, flushed skin below cord

injuryinjury

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Neurological AssessmentNeurological AssessmentSerial vital signs – watch for:Serial vital signs – watch for: ICP: ICP: B/P; B/P; pulse ratepulse rate– Neurogenic shock Neurogenic shock B/P; B/P; pulse; skin warm and pulse; skin warm and

dry below level of injurydry below level of injury

Serial AVPUSerial AVPUSerial GCSSerial GCSPupillary responsePupillary responseResponse to motor and sensoryResponse to motor and sensory– Included in CMS, SMV, PMS assessmentIncluded in CMS, SMV, PMS assessment

Babinski reflex present – big toe extends Babinski reflex present – big toe extends up when sole stroked from heel to toeup when sole stroked from heel to toe

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Signs and Symptoms Spinal Cord Signs and Symptoms Spinal Cord Injury (ie: “Clues”)Injury (ie: “Clues”)

Pain on movement of back or spinal cordPain on movement of back or spinal cordDeformityDeformityGuarding against movementGuarding against movementLoss of sensationLoss of sensationInability to moveInability to moveWeak or flaccid musclesWeak or flaccid musclesAbnormal positioningAbnormal positioningLoss of control of bladder or bowelsLoss of control of bladder or bowelsPriapism – erection of penisPriapism – erection of penisNeurogenic shockNeurogenic shock

5353

Focus of Field TreatmentFocus of Field TreatmentProvide adequate airwayProvide adequate airway

Monitor for effective oxygenation and Monitor for effective oxygenation and ventilationventilation

Maintain CPP (cerebral perfusion pressure)Maintain CPP (cerebral perfusion pressure)– Can’t measure easily in fieldCan’t measure easily in field– So watch systolic blood pressureSo watch systolic blood pressure

Something EMS can monitor in the Something EMS can monitor in the fieldfield

Assume low B/P due to hypovolemia until Assume low B/P due to hypovolemia until proven otherwiseproven otherwise

5454

Region X SOPRegion X SOPRoutine trauma careRoutine trauma care– Scene size-upScene size-up

Determining mechanism of injury could be Determining mechanism of injury could be good tip-off to suspected injuriesgood tip-off to suspected injuries

– Initial/primary surveyInitial/primary surveyIdentify and treat life threatsIdentify and treat life threats

– Identify transport priorityIdentify transport priority– Perform rapid trauma survey if critical or Perform rapid trauma survey if critical or

life threats foundlife threats found– Focused exam on minor injuriesFocused exam on minor injuries

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Region X SOP Head/Spinal InjuriesRegion X SOP Head/Spinal Injuries

Routine trauma careRoutine trauma careObtain GCSObtain GCS– GCS<9 indicates severe brain injuryGCS<9 indicates severe brain injury

IV fluid challenge (200 ml IV fluid challenge (200 ml increments) if B/P <90mmHgincrements) if B/P <90mmHgIf altered LOC obtain blood glucoseIf altered LOC obtain blood glucose– If <60 treat with DextroseIf <60 treat with Dextrose

Assess oxygenationAssess oxygenation– Maintain SpOMaintain SpO22 >94% >94%

5656

Ventilation RatesVentilation Rates Stable Head/Spinal Injuries Stable Head/Spinal Injuries

Relatively stable patient needing BVM Relatively stable patient needing BVM assistance with 100% Oassistance with 100% O22

Adult 10 breaths/min Adult 10 breaths/min

1 breath every 6 seconds1 breath every 6 seconds

Child 20 breaths/minChild 20 breaths/min

1 breath every 3 seconds1 breath every 3 seconds

Infant 25 breaths/min Infant 25 breaths/min

1 breath every 2.5 seconds1 breath every 2.5 seconds

5757

Ventilation RatesVentilation Rates Unstable Head/Spinal Injuries Unstable Head/Spinal Injuries

Rapid neurological deteriorationRapid neurological deterioration– Unequal pupils, posturing, lateralizing Unequal pupils, posturing, lateralizing

signssignsSigns indicating a deficit related to one of the Signs indicating a deficit related to one of the hemisphereshemispheres

– Example: speech problem, hemiparesis, abnormal Example: speech problem, hemiparesis, abnormal reflexes, facial asymmetry, abnormal eye movementreflexes, facial asymmetry, abnormal eye movement

– Ventilate with BVM and 100% OVentilate with BVM and 100% O22

Adult 20 breaths/minute (1 every 3 seconds)Adult 20 breaths/minute (1 every 3 seconds)

Child 30 breaths/minute (1 every 2 seconds)Child 30 breaths/minute (1 every 2 seconds)

Infant 35 breaths/min (1 every 1.7 seconds)Infant 35 breaths/min (1 every 1.7 seconds)

5858

Hazards of HyperventilationHazards of HyperventilationHyper/hypoventilation refers to level of Hyper/hypoventilation refers to level of COCO22 maintained in body maintained in body

Capnography is the ideal measurement Capnography is the ideal measurement tool for exhaled COtool for exhaled CO2 2 levelslevels

Levels of COLevels of CO22 influence vessel size influence vessel size RR RR COCO2 2 retained retained vasodilationvasodilation

RRRR COCO22 retained retained vasoconstrictionvasoconstriction

– Either way, the brain does not get perfused Either way, the brain does not get perfused

Hypoxia developsHypoxia develops– Hypoxia Hypoxia anaerobic metabolism anaerobic metabolism acidosisacidosis

5959

Unhealthy EnvironmentUnhealthy Environment

Hypo and hyperventilation both with Hypo and hyperventilation both with adverse consequences for the adverse consequences for the patientpatient

Development of hypoxia and acidosisDevelopment of hypoxia and acidosis– Hypoxia is NOT tolerated in the brainHypoxia is NOT tolerated in the brain

Cells do not function well in this Cells do not function well in this environmentenvironment

Interventions not effective in this Interventions not effective in this environmentenvironment

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Trauma PatientTrauma Patient

Assume any injury from the clavicles Assume any injury from the clavicles on up includes a head and/or spinal on up includes a head and/or spinal cord injurycord injury– Cannot clear the c-spineCannot clear the c-spine– Perform spinal motion restrictionPerform spinal motion restriction

Also referred to as c-spine controlAlso referred to as c-spine control

Avoid use of word “traction” as you are not Avoid use of word “traction” as you are not pulling on the head and neckpulling on the head and neck

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In-field Spinal ClearanceIn-field Spinal ClearanceEvaluateEvaluate– Mechanism of injuryMechanism of injury– Signs and symptomsSigns and symptoms– Patient reliabilityPatient reliability

When in doubt, fully immobilizeWhen in doubt, fully immobilizeDocument assessment and findings Document assessment and findings to support application of motion to support application of motion restriction/immobilization devices or restriction/immobilization devices or when not using equipment when not using equipment

6262

Cervical Collar MeasurementCervical Collar Measurement

Why do we keep talking about how to Why do we keep talking about how to measure for placing a cervical collar?measure for placing a cervical collar?– We still see a high number of patients We still see a high number of patients

transported to the ED with cervical transported to the ED with cervical collars in the no-neck positioncollars in the no-neck position

6363

IF THE MAJORITY OF YOUR IF THE MAJORITY OF YOUR PATIENTS ARE WEARING PATIENTS ARE WEARING

A NO-NECK SIZED A NO-NECK SIZED COLLAR, THEN YOU ARE COLLAR, THEN YOU ARE

NOTNOT PROPERLY PROPERLY MEASURING THEM!MEASURING THEM!

6464

Measuring for Cervical CollarMeasuring for Cervical Collar

Measure eyeing Measure eyeing horizontalhorizontal line from line from bottom of chin to top of shoulderbottom of chin to top of shoulder

Measure on collar plastic from Measure on collar plastic from bottom up to closest hole openingbottom up to closest hole opening

Collar should rest on Collar should rest on clavicles & support the clavicles & support the jawjaw

6565

Standing BackboardStanding BackboardA Team Effort ApproachA Team Effort Approach

6666

Standing BackboardStanding BackboardPurposePurpose– To place the ambulatory patient into a To place the ambulatory patient into a

supine position without compromising the supine position without compromising the spinespine

To rapidly move the patient into the supine To rapidly move the patient into the supine position will need 3 persons, a cervical position will need 3 persons, a cervical collar, and a long backboardcollar, and a long backboard– Strapping can be (and most often is best) Strapping can be (and most often is best)

applied once the patient is supineapplied once the patient is supine

6767

Standing BackboardStanding BackboardPosition tallest crew member behind patientPosition tallest crew member behind patient– Manual stabilization/motion restriction of c-Manual stabilization/motion restriction of c-

spine takenspine taken

22ndnd EMT measures and applies cervical collar EMT measures and applies cervical collar while manual control maintainedwhile manual control maintained

2 EMT’s position backboard between patient 2 EMT’s position backboard between patient and person maintaining manual and person maintaining manual stabilization/motion restriction of head and stabilization/motion restriction of head and neckneck

6868

Standing BackboardStanding Backboard

22ndnd and 3 and 3rdrd EMT’s reach hand nearest EMT’s reach hand nearest to patient under the patient’s armpit to patient under the patient’s armpit and grasps the backboardand grasps the backboard

Patient will be temporarily suspended Patient will be temporarily suspended by the armpits as the backboard is by the armpits as the backboard is loweredlowered

As the signal is given, the backboard As the signal is given, the backboard is slowly lowered is slowly lowered

6969

Standing BackboardStanding Backboard

Person with manual stabilization Person with manual stabilization walks backward to keep up with the walks backward to keep up with the lowering pitch of the backboardlowering pitch of the backboard

RememberRemember– Heaviest weight of head is in occipital Heaviest weight of head is in occipital

areaarea

Have fingers/hands spread in good Have fingers/hands spread in good position to support the head before position to support the head before changing the patient’s positioningchanging the patient’s positioning

7070

Backboard Backboard slowlyslowly

lowered lowered using multiple using multiple personnel and personnel and keeping head keeping head

and neck and neck immobilizedimmobilized

7171

Standing BackboardStanding BackboardAs the board is lowered, all 3 persons work As the board is lowered, all 3 persons work very closely togethervery closely together

Once the backboard is lowered, the patient Once the backboard is lowered, the patient may need to be adjusted onto the backboard may need to be adjusted onto the backboard

Complete spinal immobilization/motion Complete spinal immobilization/motion restriction process by securing the patient to restriction process by securing the patient to the backboardthe backboard

Rescuers need to watch their own body Rescuers need to watch their own body mechanics to prevent injurymechanics to prevent injury

7272

Case Scenarios Case Scenarios Divide into smaller groupsDivide into smaller groupsRead the presentationRead the presentationForm a general impressionForm a general impressionDiscuss treatment optionsDiscuss treatment optionsDiscuss what/how/when to reassess the Discuss what/how/when to reassess the patientpatientDecide what treatment to continue or what Decide what treatment to continue or what adjustments need to be madeadjustments need to be madePresent to the group and give explanation Present to the group and give explanation to defend your decisionsto defend your decisions

7373

Case Scenario # 1Case Scenario # 117 y/o patient injured at bike track17 y/o patient injured at bike track– Fell head first off bikeFell head first off bike

Conscious, confusedConscious, confusedVS: 92/50; 60; 14VS: 92/50; 60; 14Repeat: 84/46; 54; 14Repeat: 84/46; 54; 14Arms not movingArms not movingLegs moveLegs movec/o pain to neckc/o pain to neckWarm & dryWarm & dry

7474

Case Scenario # 1Case Scenario # 1No allergies; no medicationsNo allergies; no medicationsNo medical historyNo medical historyLast ate 2 hours agoLast ate 2 hours agoDoesn’t remember how he wiped outDoesn’t remember how he wiped outReported to lose control speeding around Reported to lose control speeding around tracktrackUpon arrival, bystanders holding c-spineUpon arrival, bystanders holding c-spineNo movement detected in upper No movement detected in upper extremities; lower ext move spontaneouslyextremities; lower ext move spontaneouslyIf “belly” breathing noted, what does it If “belly” breathing noted, what does it mean?mean?– Excessive use of abdominal musclesExcessive use of abdominal muscles– Watch for respiratory arrestWatch for respiratory arrest

7575

Case Scenario #1Case Scenario #1

Treatment/interventionsTreatment/interventions– C-spine control - Spinal motion C-spine control - Spinal motion

restriction restriction

– IV – OIV – O2 2 – monitor (what should be – monitor (what should be enroute?)enroute?)

– FluidsFluids– Prepare to support ventilationsPrepare to support ventilations– Obtain blood glucose levelObtain blood glucose level

7676

Case Scenario #1Case Scenario #1Patient had spinal cord injuryPatient had spinal cord injury– Central cord syndrome most common Central cord syndrome most common

with hyperextensionwith hyperextension– Weakness/impairment in arms & handsWeakness/impairment in arms & hands– Legs are sparedLegs are spared– Variable loss of sensationVariable loss of sensation

Exhibiting neurogenic shockExhibiting neurogenic shock B/P; bradycardiaB/P; bradycardia– Tank expanded with vasodilation – Tank expanded with vasodilation –

needs IV fluidsneeds IV fluids

7777

Case Scenario #1Case Scenario #1Belly breathing indicates cervical Belly breathing indicates cervical injury until proven otherwiseinjury until proven otherwiseChest muscles and diaphragm not Chest muscles and diaphragm not being used for ventilationbeing used for ventilationAbdominal muscles back up to Abdominal muscles back up to ventilateventilate– Not use to this functionNot use to this function– Will tire/fatigueWill tire/fatigue– Patient may respiratory arrestPatient may respiratory arrest

7878

Case Scenario # 2Case Scenario # 2

41 y/o male restrained driver T-boned 41 y/o male restrained driver T-boned by SUVby SUV

Unconscious, shallow respirationsUnconscious, shallow respirations

Vital signs: 146/82, 94, 32, SpOVital signs: 146/82, 94, 32, SpO22 94% 94%

Blood draining from left ear and left Blood draining from left ear and left naresnares

Diminished breath sounds on leftDiminished breath sounds on left

Deformed left arm, left femurDeformed left arm, left femur

7979

Case Scenario # 2Case Scenario # 2GCS:GCS:– Eye opening – noneEye opening – none– Verbal response – moansVerbal response – moans– Motor – Withdrawing on left, no movement on Motor – Withdrawing on left, no movement on

rightright

Repeat VS: 168/72, 44, 16Repeat VS: 168/72, 44, 16Pupils: fixed/dilated left, right minimally Pupils: fixed/dilated left, right minimally reactivereactiveWhat would raccoon eyes or Battle’s signs What would raccoon eyes or Battle’s signs indicate?indicate?

8080


Treatment/interventionsTreatment/interventions– C-spine control - Spinal motion restriction C-spine control - Spinal motion restriction

– IV – OIV – O2 2 – monitor (what should be – monitor (what should be enroute?)enroute?)

– BVM support at 20/minute (1 every 3 BVM support at 20/minute (1 every 3 seconds) (patient unstable)seconds) (patient unstable)

– Rapid transport to highest trauma level Rapid transport to highest trauma level within 25 minuteswithin 25 minutes

– Obtain blood glucose levelObtain blood glucose level

8181


Patient injuriesPatient injuries– Fractured skull Fractured skull

Raccoon eyes indicate anterior basilar skull fxRaccoon eyes indicate anterior basilar skull fx

– Epidural bleed Epidural bleed – Fractured left clavicleFractured left clavicle– Fractured ribs with hemothoraxFractured ribs with hemothorax– Fractured left humerousFractured left humerous– Fractured pelvisFractured pelvis– Fractured left femurFractured left femur

8282


60 y/o female riding her bike60 y/o female riding her bike

Hit pothole and fell off bikeHit pothole and fell off bike

Helmet damagedHelmet damaged

Short loss of consciousness; asking Short loss of consciousness; asking repetitive questions; nauseated; repetitive questions; nauseated; complains of headache and blurred complains of headache and blurred visionvision

Vital signs: 132/78, P-98, R-20, SpOVital signs: 132/78, P-98, R-20, SpO22 99%99%

8383


GCS: eye opening spontaneousGCS: eye opening spontaneous– Verbal – slightly confusedVerbal – slightly confused– Motor – obeys commandsMotor – obeys commands

Pupils: PERLPupils: PERL

8484

Case Scenario #3Case Scenario #3Treatment/interventionsTreatment/interventions– C-spine control – spinal motion restrictionC-spine control – spinal motion restriction

Patient not reliablePatient not reliable– IV–OIV–O22–monitor (what should be enroute?)–monitor (what should be enroute?)– Watch for nausea and vomiting to protect Watch for nausea and vomiting to protect

airwayairway– Trend vital signs and level of Trend vital signs and level of

consciousnessconsciousness– Check blood sugar levelCheck blood sugar level

Patient has altered level of Patient has altered level of consciousnessconsciousness

8585


GCS – 4-4-6; Total 14GCS – 4-4-6; Total 14

Patient had a concussionPatient had a concussion

Admitted overnight for observationAdmitted overnight for observation

Continued to have a mild headacheContinued to have a mild headache

Other complaints resolvedOther complaints resolved

Discharged home next dayDischarged home next day

8686

Case Scenario # 4Case Scenario # 45 y/o is vomiting, has headache, was 5 y/o is vomiting, has headache, was acting “bizarre”acting “bizarre”

Now has an altered level of consciousnessNow has an altered level of consciousness

Hx of falling off jungle gym earlier todayHx of falling off jungle gym earlier today

Initial loss of consciousness for few Initial loss of consciousness for few minutes then lucid; alert & orientedminutes then lucid; alert & oriented

B/P 90/46, 104, 24B/P 90/46, 104, 24

NauseatedNauseated

8787

Case Scenario # 4Case Scenario # 4GCS:GCS:– Eye opening – after calling their nameEye opening – after calling their name– Verbal response – talking nonsenseVerbal response – talking nonsense– Motor response – pulling at equipment with Motor response – pulling at equipment with

right hand, trying to get your hands off himright hand, trying to get your hands off him

Pupils - right slower to react, midsizePupils - right slower to react, midsizeLeft extremities flaccidLeft extremities flaccidBruise and swelling noted over right Bruise and swelling noted over right forehead above earforehead above earMinor scratches to bilateral armsMinor scratches to bilateral arms

8888


Treatment/interventionsTreatment/interventions– C-spine control – spinal motion C-spine control – spinal motion

restrictionrestriction– IV – OIV – O22 – monitor – monitor (what should be (what should be

enroute?)enroute?)

– Anticipate rapid deterioration and Anticipate rapid deterioration and prepare to secure airwayprepare to secure airway

8989

Case Scenario # 4Case Scenario # 4GCS – 3-3-5; Total 11GCS – 3-3-5; Total 11

Patient had right epidural hematomaPatient had right epidural hematoma

Confirmed on CTConfirmed on CT

Emergently taken to OREmergently taken to OR

Hematoma evacuatedHematoma evacuated

Signs and symptoms slowly resolvingSigns and symptoms slowly resolving

Patient discharged home with outpatient Patient discharged home with outpatient physical and occupational therapyphysical and occupational therapy

9090


Patient presents to ED with FB stuck Patient presents to ED with FB stuck in headin head

Awake, talking, following Awake, talking, following commands commands

How do you immobilize How do you immobilize this object?this object?

9191


Immobilize in position foundImmobilize in position found

Constantly monitor level of Constantly monitor level of consciousnessconsciousness

Possibly need to shorten a FB to Possibly need to shorten a FB to facilitate transfer in the ambulancefacilitate transfer in the ambulance

Not knowing where tip of FB is, Not knowing where tip of FB is, assume head and neck injuries and assume head and neck injuries and treat for bothtreat for both

9292

Case Scenario #5Case Scenario #5Patient taken to ORPatient taken to ORArrow successfully removed with part Arrow successfully removed with part of skullof skullPlate placed in ORPlate placed in ORPost-op patient had altered Post-op patient had altered sense of taste and had sense of taste and had difficulty perceiving tactile difficulty perceiving tactile sensations sensations

9393

Case Scenario # 6Case Scenario # 645 y/o male passenger 45 y/o male passenger

MVC involving a deerMVC involving a deer

Patient unconsciousPatient unconscious

Facial trauma evidentFacial trauma evident

Gurgling respirationsGurgling respirations

Radial and carotid Radial and carotid pulses noted regular pulses noted regular and normaland normal

9494


Vital signs: 92/62, P-74, R-18Vital signs: 92/62, P-74, R-18

Pupils: right reactive, left non-reactivePupils: right reactive, left non-reactive

GCS:GCS:– Eyes – eyelids move when body touchedEyes – eyelids move when body touched– Verbal – silentVerbal – silent– Motor – flexes right arm to pain, left arm Motor – flexes right arm to pain, left arm

straightens to painstraightens to pain

Repeat VS: 88/50, P-62, R-28 irregularRepeat VS: 88/50, P-62, R-28 irregular

9595


Treatment/interventionsTreatment/interventions– C-spine control – spinal motion restrictionC-spine control – spinal motion restriction– Open and secure airway Open and secure airway

Modified jaw thrustModified jaw thrust

– Support ventilations 20 breaths per minuteSupport ventilations 20 breaths per minute

– IV-OIV-O22-monitor (what should be enroute?)-monitor (what should be enroute?)

– Rapid transport once extricatedRapid transport once extricated– Is there a need for helicopter service in Is there a need for helicopter service in

your town/your location?your town/your location?

9696


GCS – 2-1-3; Total 6GCS – 2-1-3; Total 6

Pt had intracerebral hematoma and Pt had intracerebral hematoma and bilateral pneumo/hemothoraxbilateral pneumo/hemothorax

Chest tube placed in ED for chest Chest tube placed in ED for chest injuriesinjuries

Remains on ventilator in ICCURemains on ventilator in ICCU

Unable to do brain surgery due to Unable to do brain surgery due to location of bleedlocation of bleed

9797

New Recommendations of the AANNew Recommendations of the AANAmerican Academy of Neurology statesAmerican Academy of Neurology states

1.1. Any athlete who is suspected to have Any athlete who is suspected to have suffered a concussion suffered a concussion • Remove from participation until Remove from participation until

evaluated by a physician with training evaluated by a physician with training in the evaluation and management of in the evaluation and management of sports concussionssports concussions

2. No athlete should be allowed to 2. No athlete should be allowed to participate in sports if he or she is still participate in sports if he or she is still experiencing symptoms from a experiencing symptoms from a concussionconcussion

9898

AAN Recommendations cont’dAAN Recommendations cont’d

3. Following a concussion, a neurologist or 3. Following a concussion, a neurologist or physician with proper training should be physician with proper training should be consulted prior to clearing the athlete for consulted prior to clearing the athlete for return to participationreturn to participation

4. A certified athletic trainer should be present 4. A certified athletic trainer should be present at all sporting events, including practices, at all sporting events, including practices, where athletes are at risk for concussionwhere athletes are at risk for concussion

5. Education efforts should be maximized to 5. Education efforts should be maximized to improve the understanding of concussion by improve the understanding of concussion by all athletes, parents, and coachesall athletes, parents, and coaches

9999

TBITBIPrevention is the most effective Prevention is the most effective treatmenttreatment– Use of restraints in vehiclesUse of restraints in vehicles

Shoulder/lapShoulder/lapCar seatsCar seats

– Use of helmetsUse of helmets– Following guidelines when players Following guidelines when players

can return to play following can return to play following concussionconcussion

100100

Hands-on PracticeHands-on Practice

All participants to measure a peer for All participants to measure a peer for cervical collar placementcervical collar placement

Practice in groups of 3 standing Practice in groups of 3 standing backboard take-downbackboard take-down– Have 4Have 4thth person role play a patient person role play a patient

101101

BibliographyBibliography

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices Third Edition. Brady. 2009.Campbell, J.E. International Trauma Life Support for Prehospital Care Providers, 6th Edition. Brady. 2008.

Region X SOP March 2007; amended January 1, Region X SOP March 2007; amended January 1, 20082008

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Internet Reference SitesInternet Reference Siteshttp://www.answers.com/topic/intracranial-http://www.answers.com/topic/intracranial-pressurepressurehttp://www.bmj.com/content/338/bmj.b1683.fullhttp://www.bmj.com/content/338/bmj.b1683.fullhttp://faculty.washington.edu/chudler/facts.htmlhttp://faculty.washington.edu/chudler/facts.html

www.link-intl.com/gulfspine/Anatomy.htmlwww.link-intl.com/gulfspine/Anatomy.htmlhttp://neuropathology.neoucom.edu/chapter14/http://neuropathology.neoucom.edu/chapter14/chapter14CSF.htmlchapter14CSF.html http://www.spinal-cord.org/at-risk-activities.htmhttp://www.spinal-cord.org/at-risk-activities.htmhttp://www.spinalinjury.net/html/_spinal_cord_101http://www.spinalinjury.net/html/_spinal_cord_101.html.html

1 Head and Spinal Cord Trauma May 2011 CE Condell Medical Center EMS System Site Code #107200E-1211...

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Transcript of 1 Head and Spinal Cord Trauma May 2011 CE Condell Medical Center EMS System Site Code #107200E-1211...