9/10/2012
Head & Spinal Trauma
Lesson Goal

Learn assessment of patients with head or
spinal injuries and how to treat those injuries
Lesson Objectives

State nervous system components

List central nervous system (CNS) functions


Define structure of skeletal system as it
relates to nervous system
Relate MOI to potential head & spinal injuries
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
1
9/10/2012
Lesson Objectives



Explain implications of not properly caring for
potential spinal injuries
State signs & symptoms of potential spinal
injury
Describe method of determining whether a
responsive patient may have a spinal injury
Lesson Objectives



Relate airway emergency medical care
techniques for a patient with suspected spinal
& head injuries
Describe how to stabilize the cervical spine
Discuss indications for immobilizing the spine
using various devices (e.g., cervical
immobilization device, spine board)
Lesson Objectives



Identify different types of helmets and indicate
when to remove and when to leave on patient
Explain preferred and alternate methods for
removing a helmet
Demonstrate how to open the airway in a
patient with suspected spinal cord injury
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
2
9/10/2012
Introduction

Thorough and proper assessment and
treatment can have a positive affect on the
outcome for a patient with a head or spinal
injury
Nervous System Review



Seat of control of body functions
Major function—communication between
body & environment
Well protected by skull & vertebral column

Significant forces can result in injury
Nervous System Review

Central nervous system



Brain
Spinal cord
Peripheral nervous
system

Motor & sensory nerves
outside brain & spinal cord
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
3
9/10/2012
Central Nervous System (CNS)

Cerebrum controls
Vision
Speech
 Balance
 Emotion



Cerebellum coordinates fine motor skills

Brainstem—controls vital vegetative functions
CNS—Pathways of the Brain
Central Nervous System

Spinal cord


Extends from brainstem,
through opening in floor
of skull, into spinal
column
Continues to level of L2
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
4
9/10/2012
CNS

Nervous tissue cannot regenerate if damaged

Brain is protected by several layers of tissue

Muscle underlies scalp, covering skull

Meninges




Dura mater
Arachnoid
Pia mater
Cerebrospinal fluid
Peripheral Nervous System (PNS)

Cranial & spinal nerves

Somatic (voluntary) nervous system

Autonomic (involuntary) nervous system
Peripheral Nervous System

12 Pairs of cranial nerves

31 Pairs of spinal nerves
Sensory impulses
Motor impulses
 Reflex arc


Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
5
9/10/2012
Skeletal System Review
Skeletal System Review

Spinal column
Skeletal System Review

33 vertebrae

Separated by
intervertebral disks
• 7 Cervical
• 12 Thoracic
• 5 Lumbar
• 5 (fused) Sacral
• 4 (fused) Coccygeal
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
6
9/10/2012
Injuries to the Spine

Activities with significant energy can lead
to injury
MVCs
Contact sports
 Falls


Injuries to the Spine

Mechanisms producing injury:






Axial loading
Hyperflexion
Hyperextension
Excessive lateral bending
Hyperrotation
Distraction
Axial Loading

Compression of the spine



Shallow water diving
Jumping from height
Injuries


Ruptured disks
Vertebral fractures
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
7
9/10/2012
Excessive Range of Motion

Hyperflexion

Hyperextension

Hyperrotation

Lateral bending
Distraction Injuries

Mechanism pulls head and body in opposite
directions

Separation of vertebrae may occur

Spinal cord may be stretched or torn
Injuries to the Spine
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
8
9/10/2012
Suspicious Mechanisms

Significant force to head, neck, torso, pelvis

Vehicle or motorcycle crash

Pedestrian-vehicle crash


Sudden acceleration, deceleration, or lateral bending
forces
Fall from significant height
Suspicious Mechanisms

Fall in which one part of the body is suddenly
stopped

Unrestrained victim in rollover, ejection

Explosion

Shallow water diving

Blunt or penetrating trauma to head, neck, or torso
Suspicious Findings

Unconscious trauma victim

Head injury with LOC changes

Significant helmet damage

Legs and hips fractures

Injuries to spinal area
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
9
9/10/2012
Assessment

Assessment begins as you approach scene
and patient

Evaluate MOI

Assess ABCs and intervene as needed

Determine patient’s mental status
Assessment: Specific Questions

“Does your neck or back hurt?”

“Do you know what happened?”

“Where does it hurt?”

“Can you move your hands and feet?”

“Do you feel me touching your fingers?”

“Do you feel me touching your toes?”
Assessment

DCAPBTLS

Check for symmetry

Obtain information from family and/or
bystanders
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
10
9/10/2012
Assessment: Complications

Paralysis

Loss of sensation

Incontinence

Impaired breathing
Spinal Immobilization

When spinal injury is suspected, immobilize
body from head to foot


Long backboard
Begin with neutral, inline, manual stabilization
Helmet Removal

Two types



Open anteriorly
Full face
Helmet removal
Is patient able to breathe adequately with helmet
in place?
 Can I access and control patient’s airway without
removing helmet?
 Does helmet fit well enough to ensure that
patient’s head will not move inside it?

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
11
9/10/2012
Skill 29-1: Motorcycle Helmet
1. EMT 1 takes position above
patient’s head and stabilizes
helmet, head, and neck in as
close to a neutral inline
position as helmet allows
EMT 2 kneels at patient’s
side, opens or removes face
shield, if necessary, and
undoes or cuts chin strap
Skill 29-1: Motorcycle Helmet
2. EMT 2 grasps patient’s
mandible between thumb
and first two fingers at angle
of mandible. EMT’s other
hand is placed under
patient’s neck, on occiput of
the skull, to take control of
manual stabilization. EMT’s
forearms should be resting
on floor, ground, or his/her
thighs for additional support
Skill 29-1: Motorcycle Helmet
3. EMT 1 pulls sides of helmet
slightly apart, away from
patient’s head, and rotates
helmet with up-and-down
rocking motions while pulling
it off patient’s head. Helmet
is moved slowly and
deliberately, and care is
taken as helmet clears
patient’s nose.
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
12
9/10/2012
Skill 29-1: Motorcycle Helmet
4. Continue manual stabilization after removing helmet.
Place padding behind patient’s head to maintain a
neutral inline position and apply properly sized
cervical collar
NOTE: 2 key elements in helmet removal:

At no time should both EMTs be moving their hands (while
one EMT maintains manual stabilization of the patient’s head
and neck, the other EMT moves)

EMT must rotate helmet in different directions, first to clear
patient’s nose and then to clear back of patient’s head
Skill 29-1: Motorcycle Helmet
Video Clip coming soon
Skill 29-2: Bicycle Helmet
1. While EMT 1 stabilizes
head and cervical
spine, EMT 2 releases
chin strap
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
13
9/10/2012
Skill 29-2: Bicycle Helmet
2. EMT 2 supports back of
head and chin so that
EMT 1 can remove
helmet
Skill 29-2: Bicycle Helmet
3. After helmet is
removed, EMT 2
continues to support
patient’s head and
neck. EMT 1 applies
cervical collar and uses
padding to stabilize
head and neck
Skill 29-2: Bicycle Helmet
Video Clip coming soon
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
14
9/10/2012
Skill 29-3: Football Helmet
1. While EMT 1 stabilizes
head and neck, EMT 2
releases face piece by
unscrewing clasps or
cutting them
2. After face piece has
been cleared, EMT 2
supports head and
neck so EMT 1 can
remove helmet
Skill 29-3: Football Helmet
3. After helmet is
removed, EMT 1
stabilizes head and
neck while EMT 2
provides padding and
applies cervical collar
Skill 29-3: Football Helmet
Video Clip coming soon
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
15
9/10/2012
Spinal Immobilization

Before applying cervical
collar (C-collar):




Assess distal neurovascular
function
Assess neck
Select properly sized collar
C-collar limits movement
but does not immobilize
neck
Spinal Immobilization


Improperly sized C-collar can do more harm
than good
C-collar must not restrict breathing or mouth
opening
Spinal Immobilization

Log roll
EMT positioning:
• Head, shoulders, waist, knees
 EMT at head directs moves

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
16
9/10/2012
Spinal Immobilization

Secure the patient:




Torso
Legs
Head
Reassess distal
neurovascular status
Skill 29-4:
Log Roll—Suspected Spinal Injury
1. While EMT 1 stabilizes
head & neck, EMT 2
applies C-collar
Skill 29-4:
Log Roll—Suspected Spinal Injury
2. EMT 1 stabilizes head
& neck; EMTs 2 and 3
take position at
patient’s side placing
their hands in position
to evenly distribute
patient’s weight
3. Patient is rolled onto
side on 3-count by
EMT 1
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
17
9/10/2012
Skill 29-4:
Log Roll—Suspected Spinal Injury
4. While patient is in this
position, an EMT should
examine patient’s back
Skill 29-4:
Log Roll—Suspected Spinal Injury
5. EMT 4 moves
backboard into position;
patient is lowered onto
board on 3-count
6. Patient is strapped to
board in this order:
chest, pelvis, legs, head
Skill 29-4:
Log Roll—Suspected Spinal Injury
7. Head & neck are
stabilized by placing
head blocks or rolls to
maintain proper position
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
18
9/10/2012
Skill 29-4: Log Roll—Suspected Spine Injury
Video Clip coming soon
Skill 29-5: Log Roll—
Suspected Spinal Injury from Prone Position
1. While EMT 1 maintains
manual inline
stabilization of head &
neck, two beside patient
and position hands at
patient’s shoulder, hip,
and upper & lower leg
Skill 29-5: Log Roll—
Suspected Spinal Injury from Prone Position
2. On EMT 1’s count,
patient is rolled toward
other two EMTs as
single unit
3. On EMT 1’s count,
patient is rolled farther
onto back as single unit;
manual stabilization of
head and neck is
continued throughout
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
19
9/10/2012
Skill 29-5: Log Roll—
Suspected Spinal Injury from Prone Position
Video Clip coming soon
Spinal Immobilization



Pad voids between
body and backboard
Adult patients—may
need to pad beneath
head
Pediatric patient—pad
beneath shoulders
Spinal Immobilization

Seated patients


Noncritical—short immobilization device
Critical—rapid extrication
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
20
9/10/2012
Skill 29-6: Short Spine Board
1. Don BSI; manually
immobilize spine and
apply C-collar; assess
pulse, motor function,
and sensation in all
extremities; document
findings
Skill 29-6: Short Spine Board
2. Slide immobilization
device behind patient.
Position device so that
top is level with top of
patient’s head. If device
has body flaps, fold
them toward front of
patient and lift device to
fit securely in armpits.
Minimize patient
movement as much as
possible.
Skill 29-6: Short Spine Board
3. Secure patient’s torso to
device using board straps. If
device has leg straps,
secure at this time. Verify
that device is securely
fastened to torso by
checking tightness of all
straps without excessive
movement of patient
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
21
9/10/2012
Skill 29-6: Short Spine Board
4. Pad behind patient’s head as
needed to maintain neutral
inline position; secure
patient’s head to device
Note: Always secure head last
Skill 29-6: Short Spine Board
5. Prepare to move patient to
long backboard. Place end
of backboard under patient’s
buttocks. Using short
immobilization device, rotate
and lay patient down on
backboard. If unable to slip
backboard under patient’s
buttocks, lift patient to backboard
using short immobilization device
Skill 29-6: Short Spine Board
6. Reassess patient’s pulse, motor function, and
sensation in all extremities. Compare results with
previous ones and document findings. Forward
information to receiving facility
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
22
9/10/2012
Skill 29-6: Short Spine Board
Video Clip coming soon
Spinal Immobilization

Ambulatory patients

Standing immobilization
Skill 29-7: Standing Long Board
1. Ensure BSI precautions are
taken. EMT 1 applies manual
inline stabilization by
approaching patient from front
and placing hands on each
side of patient’s head.
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
23
9/10/2012
Skill 29-7: Standing Long Board
2. EMT 2 assesses patient’s
pulse, motor function, and
sensation in all extremities.
EMT 2 also sizes patient for
C-collar, assesses neck &
spine for injury, and applies
collar
Skill 29-7: Standing Long Board
3. EMT 2 positions long
board behind patient,
between EMT 1’s arms,
while EMT 1 continues
holding patient’s neck
inline. Additional EMTs
place arms under
patient’s armpits and
grasp board. Board
then is placed against
patient’s back
Skill 29-7: Standing Long Board
4. Patient is informed that
EMTs will be leaning
her backward; EMT in
back gives order to lean
patient back and onto
ground
5. Patient’s pulse, motor
function, and sensation
are reassessed; patient
is secured to board as
previously described
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
24
9/10/2012
Skill 29-7: Standing Long Board
Video Clip coming soon
Skill 29-7: Standing Long Board
Video Clip coming soon
Common Pitfalls of Immobilizaiton

Not securing patient adequately to prevent
movement

Not immobilizing head in neutral position

Readjusting torso straps after head is secure
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
25
9/10/2012
Injuries to the Brain & Skull

May or may not be obvious

Suspect injuries to brain & skull based on MOI

All head injuries considered potentially serious
Scalp Lacerations



Scalp lacerations may
be indications of more
serious underlying
injury
Bleeding from scalp can
be significant
Most bleeding from
scalp can be controlled
with direct pressure
Skull Fractures




May be open or closed
Caused by blunt or
penetrating
mechanisms
May or may not show
gross deformity
Check for bruising
around eyes & behind
ears
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
26
9/10/2012
Skull Fractures
Brain Injuries

Direct



Laceration by bone fragments
GSW
Indirect


Contusions
Concussions
Brain Injuries

Concussion
Temporary disruption in brain function without
physical damage
 May see stars, have amnesia


Contusion


Bruising of brain tissue
Swelling can cause an ↑ ICP
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
27
9/10/2012
Intracranial Bleeding

Collection of blood
within the skull; ↑ ICP



Epidural
Subdural
Intracerebral
Epidural Hematoma

Between dura mater & skull

Rapid development

Signs & symptoms
Initial loss of consciousness
Lucid interval
 Secondary loss of consciousness
 Weakness on opposite side of body
 Fixed, dilated pupil on same side


Subdural Hematoma

Collection of blood beneath dura mater but
outside brain

May be slower than epidural bleeding

Signs & symptoms






AMS or personality change
Severe, persistent, or recurring headache
Changes in vision
One-sided changes in body function
Nausea and/or vomiting
Slurred speech
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
28
9/10/2012
Intracerebral Hematoma

Blood collects within brain tissue

Signs & symptoms vary

Seizures—not uncommon
General Signs & Symptoms of Head Injury








Altered LOC
Changes in pupil size, equality, reactivity
MOI
Irregular breathing patterns
Scalp injuries
Deformed skull
Soft or depressed areas of skull
Exposed brain tissue
General Signs & Symptoms of Head Injury






Open skull fx
Blood or CSF fluid from ears and/or nose
Bruising under eyes or behind ears
Nausea and/or vomiting
Seizure activity
↑ BP with ↓ pulse rate
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
29
9/10/2012
Nontraumatic Conditions

Medical conditions (e.g., stroke) may present
similarly to head injury

History of trauma is absent

Treat patient’s signs & symptoms
Airway
Breathing
 Circulation


Management of Head Injury

Provide manual stabilization of C-spine

ABCs

Transport without delay

Obtain baseline VS and LOC; reassess every 5 min

Transport
Infants & Children

Immobilization of pediatric
patients requires
adjustments
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
30
9/10/2012
Skill 29-8: Rapid Extrication
1. EMT 1 holds manual
immobilization of head & neck
while EMT 2 applies C-collar
2. Manual stabilization is
maintained, patient’s upper
torso, lower torso, and legs
are rotted in a series of short,
controlled movements until
patient is positioned such that
manual stabilization can no
longer be maintained
Skill 29-8: Rapid Extrication
3. Patient is rotated until
he/she can be lowered
from vehicle and onto
long board
4. Patient is moved onto
long board and secured
Skill 29-8: Rapid Extrication
Video Clip coming soon
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
31
9/10/2012
Summary


Injuries to the spine & head can have
devastating consequences
Recognition requires an understanding of
anatomy & physiology and MOI
Summary


Proper immobilization is important in
preventing further injury to a patient with
spinal injury
Recognize and appropriately manage
patients with head injuries, paying particular
attention to ABCs and spinal immobilization
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
32