Injuries to the Head and Spine

The Nervous System

• Function• Controls voluntary/involuntary activity

• Components • Central Nervous System (Computer)

• Brain• Brainstem • Spinal Cord

• Peripheral Nervous System (Communicator)• Associated nerves• Sensory- Carry info from body to brain• Motor – Carry info from the brain to the body• Divided into

• Somatic NS = voluntary• Autonomic NS= Involuntary

Divisions of the Autonomic Nervous System

• Sympathetic• “Fight or flight”

• Parasympathetic• “Feed or breed”

OR

The Nervous System The Brain

• Cerebrum• Largest most superior portion of the brain• Divided into R & L hemispheres• Hemispheres divided into specialized lobes

• Frontal = Intellect and motor function• Occipital = Eyesight• Temporal = Smell/Hearing• Parietal = Sensory information

• Brainstem• Lower part of the brain• Circulation, Respiration, BP

• Cerebellum• Outpocketing of brain, posterior to brainstem• Coordination and movement

The Nervous System The Brain: Blood Supply

• Cerebral Blood Supply• 15% of Cardiac output• 80% of blood is supplied by

the carotid arteries• Vertebral arteries supply the

rest• Circle of Willis

• Each area of the brain has its own blood supply

• Sensitivity to Deprivation of glucose and O2

• Cannot store glucose itself• Deprivation = AMS

• Interruption in O2 supply• Unconsciousness 5-10

seconds • Blockage of O2 supply

• Neural death 4-6 minutes

Axial SkeletonSkull

• Skull• 22 bones• Cranium + Face• Encases brain• Brain + CSF + Vessels

• Little space• Facial Bones

• Orbits• Eyes

• Nasal Bones• Maxilla

• Upper Jaw• Zygomatics

• Cheekbones • Mandible

• Lower Jaw

Axial SkeletalVertebral Column

• Function• Support

• Components • 33 Vertebrae• Intervertebral disks

• Divisions of Vertebrae• Cervical (C-) = 7 Neck

• C1 = Atlas• C2 = Axis

• Thoracic (T-)= 12 Chest• Lumbar (L-)= 5 Lower Back• Sacral (S-)= 5 Back of pelvis (fused) • Coccyx (C-)= 4 Tailbone (fused)

Injuries to the SpineCompression

• Compression• When one vertebrae is

driven into another• Compress vertebrae to

point of crushing• Drives bony fragments

into spinal canal • Examples

• Falls• Diving Accidents• MVA

Injuries to the SpineFlexion

• Flexion • Usually involve fixed and

mobile vertebrae • Head is driven forward by

sudden deceleration • Body of vertebrae are

wedged together anteriorly• Examples

• Head on MVA• Head striking windshield in

flexed position• Lap belt injuries• Falls

Injuries to the SpineExtension

• Extension• The head is suddenly

jerked backward• Example

• Whiplash • Impacting windshield

with face

Injuries to the SpineOther injuries

• Lateral bending• Excessive Rotation• Distraction

• Pulling apart of the spine• Example

• Hangings

“Hangman’s Fracture”

High Index of Suspicion

• MVA• Pedestrian v. Vehicle• Falls• Blunt trauma• Penetrating trauma to:

• Head• Neck• Chest

• Motorcycle crashes• Hangings • Diving accidents• Unconscious

Injuries to the Spine S/S

• Tenderness in injured area• Pain assoc with moving• Pain independent of

movement/palpation• Along spinal column• Lower legs• May be intermittent

• Deformity of the spine• Soft tissue injuries assoc with trauma

• Head and neck to C-spine• Shoulders, back , abd, =

Thoracic/Lumbar• Numbness, weakness, tingling in

extremities• Loss of sensation/paralysis below injury• Loss of sensation/paralysis in upper

extremities• Incontinence

Complications of injuries to the Spine

• Inadequate Breathing• Respiratory distress to arrest • Phrenic nerve controls diaphragm

• C3 -C5 • Fx above C3 ALL muscles or resp are paralyzed

• Intercostal muscles• T2-T8

• Abdominal muscles • T8-T12

• Paralysis• Priapism

• Loss of sympathetic tone• Pulse and BP

• Sympathetic nervous system controls tone of blood vessels• Loss of sympathetic tone via thoracic spine injury • Massive vasodilation = SHOCK (neurogenic) • BP 70-80 systolic• Pulse 60-80 bpm• Warm, flushed skin

Assessment of injuries to the Spine Responsive Pt

• Scene Size Up• Determine MOI• Anticipate forces involved

• Initial Assessment• Immediate C-Spine control!!!• ABCs • AVPU• Modified jaw thrust • If head is flexed, return to normal

position• Stop if resistance is met

• Focused Hx and Px Exam• Reconstruct MOI and events • When did the injury occur?• What was the pt position at time of injury• Was the pt thrown from the impact• If MVA, estimate speed, pt position,

restraints• Was there AMS, loss of consciousness

before• If fall, estimate height and surface

impacted• Suspected alcohol or drug use?• Medical causes..

Care for injuries of the Spine

• BSI• C-Spine control!!!

• Place head in neutral inline position if no resistance

• Apply manual stabilization until pt is fully packaged

• Initial Assessment• Assess PMS in ALL extremities• Asses C-Spine• Apply C-collar• If pt found in lying position

• Log roll pt to LBB • Immobilize pt to LBB• Pad any voids

• Adult = Under head and under torso• Child= Under shoulders to toes

• Reassess PMS

Immobilization of Seated Pts

• Use Short Spine Board/Kendrick Extrication Device (KED)• 1 EMT positions behind pt• That EMT maintains manual C-Spine control• Assess PMS• Asses C-Spine• A 2nd EMT applies a C-Collar• Place device behind pt• Have pt inhale and hold it• 2nd EMT secures device to pt torso

• 3 Straps• Should fit snugly under pt armpits • Allow pt to exhale• Apply groin straps • Pad void behind pt head if needed• Secure pt head to device• Insert LBB under pt buttock if possible • Rotate pt onto LBB• If not the lower the pt to the LBB• Reassess PMS

Immobilization of Standing Pts

• Use LBB = Rapid Takedown • Position 1 EMT behind pt• That EMT will maintain C-Spine throughout • Assess PMS• 2nd EMT applies C-collar• Place LBB behind pt• Have 1 EMT on each side of pt• Have 1 EMT at the foot facing the pt• EMTs at pt side grasp the board under the pt arm with the hand closest to pt,

grasping handles just above pt armpit• EMTs at pt side secure head to board with hand farthest away from pt (if only 2

EMTs)• EMT’s at pt side place leg closes to LBB behind the board• Start tipping to board backward• EMT at foot stabilizes board to prevent slipping• Lower pt on LBB to ground• Immobilize pt• Reassess PMS

Injuries to the Brain and Skull

• Traumatic • Head injuries

• Scalp injuries• VERY vascular = Excessive

bleeding• Control with direct pressure

• Brain injuries• Increases pressure in the

skull• Herniation of brain

• Non Traumatic• Can cause AMS• S/S parallel trauma S/S

• Lack evidence of trauma/MOI• Clots • Hemorrhages

Crocodile Bite

Skull from our friend in the intro

Ejection through windshield of MVA

Head Injury S/S

• MOI• Deformed windshield• Deformed helmet• Penetrating injury

• ALOC/Decreasing LOC• -Confusion, -Disorientation, - Repetitive questioning• Unresponsive

• Irregular breathing patterns• DCAP-BTLS to skull• Soft area or depressed area upon palpation• Exposed brain tissue• Bleeding from open bone injury• Blood/CSF leaking from ears/nose• Raccoon eyes• Battle’s signs• Neurologic disability• Nausea and/or vomiting• Unequal pupil size with AMS• Seizure activity

Cushing’s Reflex Increasing Intracranial Pressure

• Increasing pressure forces brain through foramen magnum

• Nerves of eyes leave brain in this area• Compressed between skull and brain

• Unequal pupils • Pressure on motor nerves

• Posturing• Decorticate = Abnormal flexion• Decerebrate = Abnormal

extension• Flaccidity

• Pressure on respiratory centers• Abnormal respiration patterns

• Collapse of blood vessels in cranium due to increased pressure

• Last ditch effort to compensate = Hypertension

• Compensation for hypertension• Pressure receptors outside the head

note the hypertension• Pulse rate slows down in attempt to

lower BP

Care of head injuries

• BSI• C-Spine• Closely monitor

• ABCs• Mental status

• GCS score• PERRL

• Control bleeding• Do not apply pressure to open or depressed fx• Dress and bandage open wounds as normal

• Vitals• Be prepared for pt to decompensate• IMMEDIATE transport

Immobilization

• C-Collars• Any suspected injury to spine

based on MOI, S/S, Hx• Use in conjunction with LBB/Short

boards• Improperly sized C-collars = further

injury• If it doesn’t fit, use a rolled towel

and tape to board• Maintain manual stabilization

• Do not obstruct airway • Only good as long as manual

stabilization is held• Release when head is secured to

LBB

Immobilization

• Short Back Boards• Types

• Vest types• Rigid types

• Immobilizes:• - Head –Neck –Torso

• Indications:• Non critical trauma pt in sitting

position• Refer to previous slides as to

application• Long Back Boards

• Immobilizes:• Full body

• Indications:• Pt in lying, standing, sitting position

• Refer to previous slides as to application

Special ConsiderationsRapid Extrication

• Rapid Extrication• Unsafe scene• Unstable pt condition

warranting immediate transport• Pt blocks access to another

more seriously injured pt• Based on Time and Pt Priority

NOT EMTs preference• Helmet Removal

• Types• Sports

• Opens anteriorly typically• Easier access to airway

• Motorcycle• Full face• Shield

• Infants and Children

Helmet Removal

• Indications for leaving it in place:• Good fit with little to no movement of pt head• No impending airway/breathing problem• Spinal immobilization can be performed with it in place• No interference with EMTs ability to assess airway

• Indications for removal:• Inability to assess/reassess airway and breathing• Restriction of management of airway/breathing• Poor fit with excessive head movement• Spinal immobilization cannot occur b/c of helmet • Cardiac arrest

Helmet Removal Guidelines

• Technique depends on type of helmet• Take pt eyeglasses off before removal• 1 EMT stabilizes helmet

• Place hands on both sides• Place fingers on mandible

• 2nd EMT loosens the strap• 2nd EMT establishes C-Spine

• 1 hand on mandible at angle of jaw• 1 hand posterior on the occipital region

• EMT holding the helmet:• Pulls sides of helmet apart• Slips helmet halfway off pt head and stops

• EMT maintaining C-Spine repositions• Moves posterior hand superiorly to prevent head from falling once helmet removed

• Helmet is removed completely• Proceed as normal

Infants and Children

• Immobilize on rigid board appropriate for size

• Short• Long• Padded

• Pad voids:• Shoulder to heels

• Properly size C-collar• If unable to, use a rolled

towel and tape to board• Hold manual stabilization