Ch34 Head and Spine Trauma.docx

Chapter 34 Head and Spine Trauma Unit Summary In this chapter you will learn about injury to the central nervous system. The central nervous system (CNS) consists of the brain and the spinal cord, both of which are encased in and protected by bone. The brain, located within the cranial cavity, is the largest component of the CNS. It contains billions of neurons that serve a variety of vital functions. An understanding of the form and function of spinal anatomy and a high index of suspicion for spinal cord injury is essential to good patient care with this type of traumatic injury. National EMS Education Standard Competencies Trauma Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Head, Facial, Neck, and Spine Trauma Recognition and management of • Life threats (pp 1653-1655) • Spine trauma (p 1656) Pathophysiology, assessment, and management of • Penetrating neck trauma (see chapter, Face and Neck Trauma) • Laryngotracheal injuries (see chapter, Face and Neck Trauma) • Spine trauma Dislocations/subluxations (p 1670) Fractures (p 1671) Sprains/strains (p 1683-1684) • Facial fractures (see chapter, Face and Neck Trauma) • Skull fractures (pp 1662-1664) • Foreign bodies in the eyes (see chapter, Face and Neck Trauma) • Dental trauma (see chapter, Face and Neck Trauma) • Unstable facial fractures (see chapter, Face and Neck Trauma) • Orbital fractures (see chapter, Face and Neck Trauma) • Perforated tympanic membrane (see chapter, Face and Neck Trauma) • Mandibular fractures (see chapter, Face and Neck Trauma) Nervous System Trauma Pathophysiology, assessment, and management of • Traumatic brain injury (p 1664) • Spinal cord injury (pp 1670, 1671-1673) • Spinal shock (p 1672) • Cauda equina syndrome (p 1672) • Nerve root injury (p 1650) • Peripheral nerve injury (p 1650) Knowledge Objectives List the major bones of the skull and spinal column and their related structures, and describe their functions as related to the nervous system. (pp 1644-1646, 1648-1650) Describe the regions of the brain, including the cerebrum, diencephalon, brainstem, and the cerebellum, and their functions. (pp 1645-1647) Describe the anatomy and physiology of the spinal cord and spinal nerves. (pp 1648-1650) Describe the steps in the patient assessment process for a person who has a suspected head or spine injury, including specific variations that may be required as related to the type of injury. (pp 1652-1655) Discuss mechanisms of injury (MOIs) that are potential causes of head and spine injuries and which the paramedic should consider when performing a patient assessment. (pp 1652, 1655-1656) Describe when endotracheal intubation should be performed in a patient with a head injury versus a spinal cord injury. (pp 1653-1654) Discuss specific assessments to perform for a patient with possible spinal cord injury, including a neurologic exam. (pp 1658-1661) Discuss when it would be appropriate to establish intravenous access in a patient with a head or spine injury, including the importance of judicious fluid administration. (p 1655) Discuss general signs and symptoms of a head injury. (p 1668) Discuss types of skull fractures, including linear, depressed, basilar, and open skull fractures. (pp 1662-1664) Define traumatic brain injury, and explain the difference between a primary (direct) injury and a secondary (indirect) injury, providing examples of possible MOIs that may cause each one. (p 1664) Discuss the pathophysiology of intracranial pressure and posturing that can occur in the presence of brain injury. (pp 1664-1665) Discuss diffuse brain injuries including cerebral concussion and diffuse axonal injury, and their corresponding signs and symptoms. (pp 1665-1666) Discuss focal brain injuries including cerebral contusion and the various types of intracranial hemorrhage, and signs and symptoms of each. (pp 1666-1668) Describe management of head and brain injuries, including thermal management, treatment of associated injuries, and pharmacologic therapy. (pp 1668-1669) Discuss assessment and management of scalp lacerations. (pp 1669-1670) Discuss MOIs that may damage the cervical, thoracic, or lumbar spine, including flexion, rotation with flexion, vertical compression, and hyperextension. (pp 1670-1671) Define primary spinal cord injury versus secondary spinal cord injury, including complete versus incomplete cord injury. (pp 1671-1673) Discuss various cord syndromes and their signs and symptoms, including anterior cord syndrome, central cord syndrome, posterior cord syndrome, cauda equina syndrome, and Brown-Séquard syndrome. (p 1672) Discuss signs and symptoms of neurogenic shock and spinal shock. (pp 1672-1673) Describe the process of providing emergency medical care to a patient with a spinal injury, including the implications of not properly caring for patients with injuries of this nature, and the steps for performing manual in-line stabilization, including immobilizing a supine patient, a seated patient, and a standing patient. (pp 1673-1677, 1679-1680) Discuss when rapid extrication should be performed, and how to perform it. (pp 1677-1679) Discuss how to package and remove a patient who is found in the water with a potential spinal injury. (pp 1680-1681) Explain the different circumstances in which a helmet should be either left on or taken off a patient with a possible head or spinal injury, and then list the steps paramedics must follow to remove a helmet, including the alternate method for removing a football helmet. (pp 1680-1682) Describe prehospital pharmacologic treatment of patients with spinal cord injury. (p 1682) Discuss complications of spinal cord injury, including prehospital management of autonomic dysreflexia. (pp 1682-1683) Discuss nontraumatic spinal conditions, including causes of low back pain and prehospital treatment. (pp 1683-1684) Skills Objectives Demonstrate how to immobilize a supine patient with a suspected spinal injury to a long backboard. (pp 1674-1676) Demonstrate how to immobilize a patient with a suspected spinal injury who was found in a sitting position. (pp 1676-1677) Demonstrate how to perform rapid extrication. (pp 1677-1679) Demonstrate how to immobilize a patient with a suspected spinal injury who was found in a standing position. (pp 1679-1680) Demonstrate how to immobilize a patient who is found in the water. (pp 1680-1681) Demonstrate how to remove a helmet from a patient with a suspected head or spinal injury. (pp 1680-1682) Readings and Preparation • Review all instructional materials including Chapter 34 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials. • Review all instructional materials from Section 7 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, pertaining to head, facial, and neck trauma. Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation Enhancements • Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities. • If you have access to a local trauma center, obtain a guest speaker on this subject and attempt to obtain CT scan film of neuro injuries. Content connections: Many topics found in Section 7 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, are beneficial to this chapter. Teaching Tips There are a lot of opportunities for visual learning with this chapter. Think of visual representations rather than providing lecture and memorization. Unit activites will offer some ideas. Unit Activities Writing activities: Assign students a portion of the central nervous system to discuss in writing. Some of the topics that should be covered include structure, function, potential for injury, field treatment, and ongoing patient care within the hospital setting. Student presentations: Students may present their written assignment to the class or the group assignment can be used. Group activities: Have groups of students construct the spinal column and corresponding spinal nerves. This can be done with cardboard, paper towel rolls, string, clay, etc. Have each group present their project. Visual thinking: Provide students with a blank picture of a human body in anatomical position. Have students draw a dermatome on the picture. When they are finished, describe an injury and have the students map the deficit on their dermatome. Pre-Lecture You are the Medic “You are the Medic” is a progressive case study that encourages critical-thinking skills. Instructor Directions Direct students to read the “You are the Medic” scenario found throughout Chapter 34. • You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. • You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. The central nervous system (CNS) consists of the brain and spinal cord. 1. Both are encased in and protected by bone. 2. Understanding spinal cord anatomy is critical to being able to decipher the subtle findings associated with spinal cord injury (SCI). 3. Two primary divisions of insult: a. Head injuries i. Skull fracture ii. Traumatic brain injury b. Spinal cord injury 4. The head and spine are often injured in association with each other. II. Anatomy and Physiology A. The scalp 1. For protection, the brain is housed within several layers of soft and hard wrappings: a. Skin, with hair b. Subcutaneous tissue that contains major scalp veins that bleed when lacerated c. Galea aponeurotica i. A tendon expansion that connects frontal and occipital muscles of cranium d. Loose connective tissue (alveolar tissue) that is easily stripped from the layer beneath in scalping injuries. e. Periosteum i. Dense fibrous membrane covering the surface of bones. B. The skull 1. Consists of 28 bones in three anatomic groups. a. Auditory ossicles i. Six, function in hearing ii. Three on each side of head b. Cranium c. Face 2. Cranial vault consists of eight bones that protect the brain: a. Parietal b. Temporal c. Frontal d. Occipital e. Sphenoid f. Ethmoid 3. Foramen magnum: Large opening at the base of the skull where the brain connects to the spinal cord 4. Sutures: Special joints where the bones of skull are connected a. Sagittal suture joins together the paired parietal bones. b. Coronal suture joins together the parietal bones and the frontal bone. c. Lambdoid suture joins together the occipital bone and the parietal bone. d. Fontanelles: Fibrous tissues that link the sutures i. Under normal circumstances, brain cannot be felt through fontanelles. ii. Sutures solidify and fontanelles close at 18 months of age. 5. Mastoid process: Cone-shaped section of bone at the base of each temporal bone a. Attachment site for various muscles b. A portion contains hollow mastoid air cells. 6. The floor of the cranial vault a. Divided into three compartments: i. Anterior fossa ii. Middle fossa iii. Posterior fossa b. Crista galli: Prominent bony ridge in the center of the anterior fossa i. Point of attachment for meninges (three layers of membranes that surround brain and spinal cord) c. Cribriform plate: Horizontal bone on the other side of the crista galli i. Many openings (foramina) allow passage of the olfactory nerve filaments from the nasal cavity. (a) Olfactory nerves (nerves for smell) send projections through foramina into nasal cavity. 7. The base of the skull a. Occipital condyles lie on either side of foramen magnum. i. Points of articulation between the skull and the vertebral column b. Portions of the maxilla and palatine bone form the hard plate (bony anterior part of the roof of the mouth). c. Zygomatic arch: Bone that extends along the front of the skull below the orbit C. The brain 1. Occupies 80% of cranial vault 2. Contains billions of neurons that serve various vital functions 3. Major regions include: a. Cerebrum b. Diencephalon (thalamus and hypothalamus) c. Brainstem (medulla, pons, midbrain) d. Cerebellum 4. Accounts for 2% of body weight a. Metabolizes 25% of body’s glucose b. Consumes 20% of total body oxygen 5. Totally dependent on a constant source of oxygen and glucose via cerebral blood flow a. Continually manipulates physiology as needed to guarantee supply is available. b. Loss of blood flow for 5 to 10 seconds will result in unconsciousness. 6. The cerebrum a. Largest portion of the brain b. Responsible for higher functions, such as reasoning c. Divided into right and left hemispheres d. Cerebral cortex: Largest portion of cerebrum i. Regulates voluntary skeletal movement and the level of awareness ii. Injury may result in paresthesia, weakness, and paralysis of extremities. e. Each hemisphere is divided into specialized areas call lobes. i. Frontal lobe controls voluntary motor action and personality traits. (a) Injury could result in seizures or placid reactions. ii. Parietal lobe controls somatic or voluntary sensory and motor functions for the opposite side of the body, as well as memory and emotions. iii. Occipital lobe processes visual information. (a) Blow to the back of the head causes one to see stars. iv. Temporal lobe controls speech, long-term memory, hearing, taste, and smell. 7. The diencephalon a. Located between brainstem and cerebrum b. Includes the: i. Thalamus (a) Processes sensory input (b) Influences mood and general body movements ii. Subthalamus (a) Controls motor functions iii. Epithalamus (a) Functions are unclear. iv. Hypothalamus (a) Controls many body functions, including: (1) Heart rate (2) Digestion (3) Sexual development (4) Temperature regulation (5) Emotion (6) Hunger and thirst (7) Vomiting (8) Regulation of the sleep cycle 8. The cerebellum a. Located beneath the cerebral hemispheres in the inferoposterior part of the brain b. Sometimes called “athlete’s brain” i. Responsible for maintenance of posture, equilibrium, and coordination 9. The brainstem a. Consists of midbrain, pons, and medulla b. Located at the base of brain c. Connects the spinal cord to rest of brain d. Houses many structures critical to maintenance of vital functions i. Reticular activating system (RAS) (a) Responsible for maintenance of consciousness ii. Centers that control heart rate, blood pressure, and respiration iii. Basal ganglia: Help with coordination of motor movements and posture iv. Limbic system: Influences emotions, motivation, mood, and sensations of pain and pleasure v. Oculomotor nerve: Controls pupillary size and reactivity e. The pons lies below the midbrain and above the medulla. i. Contains important nerve fibers including those for sleep, respiration, and the medullary respiratory center f. The medulla is the inferior portion of the midbrain. i. Serves as a conductive pathway for ascending and descending nerve tracts ii. Coordinates heart rate, blood vessel diameter, breathing, swallowing, vomiting, coughing, and sneezing D. The meninges 1. Protective layers that surround and enfold the entire CNS a. Dura mater: Strong, fibrous outermost layer i. Covers entire brain ii. Forms the tentorium (structure that separates the hemispheres from the cerebellum and brainstem) iii. Firmly attached to internal wall of skull b. Arachnoid: Delicate, transparent second layer c. Pia mater: Thin, translucent, and highly vascular third layer i. Adheres directly to surface of the brain 2. Float in cerebrospinal fluid (CSF) a. Manufactured by cells within the choroid plexus in the ventricles b. Similar in composition to plasma c. Meninges and CSF form fluid-filled sac that protects the brain and spinal cord. E. The spine 1. Consists of 33 irregular bones (vertebrae) which form the vertebral column. a. Stabilized by ligaments and muscle b. Support and protect neural elements. c. Allow for fluid movement and erect stature. d. Identified by their location as cervical, thoracic, sacral, or coccyx. e. Components include: i. Lamina ii. Pedicles iii. Spinous processes 2. Each vertebra is unique in appearance but shares basic characteristics a. Except the atlas and axis (C1 and C2) 3. Transverse spinous processes comprise junction of each pedicle and lamina on each side of vertebra. 4. Posterior spinous process is formed by fusion of posterior lamina. 5. The cervical spine includes the first seven bones of the vertebral column. a. Protects cervical spinal cord b. Supports weight of head c. Provides high degree of mobility d. Atlas and axis allow rotational movement of skull. 6. The thoracic spine consists of 12 vertebrae. a. Stabilized by rib attachments b. Spinous processes are slightly larger. 7. The lumbar spine includes the five largest bones in the vertebral column. a. Integral in carrying a large portion of the upper body weight b. Especially susceptible to injury 8. The sacrum is composed of five fused vertebrae. a. Form the posterior plate of the pelvis 9. The coccyx is made up of three to five small fused vertebrae. 10. Each vertebra is separated and cushioned by intervertebral disks, a. As the body ages, these disks become thinner, i. Causes height loss associated with aging b. Stress on vertebral column can cause disks to herniate into spinal cord. i. May result in nerve root injury (a) Nerves can also be injured at the peripheral level (peripheral nerve injury). c. The vertebral column can sustain normal flexion and extension of 60% to 70% without stressing the spinal cord. 11. The spinal cord a. Transmits nerve impulses between the brain and the body b. Located at the base of the brain c. Leaves the skull through the foramen magnum d. At base of skull, spinal cord separates into cauda equine (collection of individual nerve roots). i. Thirty-one pairs of spinal nerves emerge from each side of spinal cord. e. Central core is made up of gray matter composed of neural cell bodies and synapses i. Divided into: (a) Posterior horns that carry sensory input (b) Anterior horns that innervate the motor nerve of that segment. ii. Surrounded by three columns of peripheral white matter (a) Composed of ascending and descending fiber pathways (b) Ascending tracts carry information to the brain. (c) Descending tracts carry information to the body. 12. Spinal nerves a. Thirty-one pairs emerge from each side of the spinal cord. b. Named for the region and level from which they arise i. Eight cervical roots perform functions in the scalp, neck, shoulders, and arms. ii. Twelve thoracic nerve roots have varying functions (a) Upper thoracic nerves supply muscles of the chest. (b) Lower thoracic nerves provide abdominal muscle control and contain nerves of the sympathetic nervous system. iii. Five lumbar nerve roots supply hip flexors and leg muscles. iv. Five sacral nerves provide bowel and bladder control, sexual function, and sensation in posterior legs and rectum. v. Coccyx has a single nerve root. c. Plexus: Cluster of nerve roots that function as a group 13. The sympathetic nervous system a. Controlled by the hypothalamus b. The thoracolumbar system provides sympathetic stimulation through alpha and beta receptors. i. Alpha receptor stimulation induces smooth muscle contraction in blood vessels and bronchioles. ii. Beta receptors respond with relaxation of smooth muscles in blood vessels and bronchioles. c. Controls sweating, pupil dilation, temperature regulation, and “flight or fight” responses. d. Loss of sympathetic stimulation can disrupt homeostasis i. Leaves the body poorly equipped to deal with changes in the environment 14. The parasympathetic nervous system a. Includes fibers arising from brainstem and upper spinal cord b. Carries signals to organs of the abdomen, heart, lungs, and skin above the waist c. Slows heart rate in an attempt to control increasing blood pressure when the sympathetic nerves are stimulated III. Patient Assessment A. Scene size-up 1. Determine scene safety, and consider the need for additional resources. 2. The following events should prompt a search for signs and symptoms of head and traumatic brain injuries: a. Motor vehicle crashes b. Direct blows c. Falls from heights d. Assault e. Sports-related injuries 3. The following high-risk injuries strongly suggest spinal injury and indicate full spinal motion restriction should be applied: a. High-velocity crash (greater than 40 mph) with severe vehicle damage b. Unrestrained occupant of moderate- to high-speed motor vehicle crash c. Vehicular damage with compartmental intrusion (12 inches) into patient’s seating area d. Fall from three times patient’s height e. Penetrating trauma near spine f. Ejection from moving vehicle g. Motorcycle crash of greater than 20 mph with separation of rider from vehicle h. Diving injury i. Auto-pedestrian or auto-bicycle crash of greater than 5 mph j. Death of occupant in same passenger compartment k. Rollover crash (unrestrained) 4. Mechanisms of uncertain risk for spine injury include: a. Moderate- to low-velocity motor vehicle crash (less than 40 mph) b. Patient involved in motor vehicle crash has isolated injury without positive assessment findings for SCI. c. Isolated minor head injury without positive mechanism for spine injury d. Syncopal event in which patient was already seated or supine e. Syncopal event in which patient was assisted to supine position by bystander B. Primary assessment 1. Form a general impression. a. Note age and gender. b. Observe position patient is found. c. Determine whether patient’s condition is life threatening. d. Manually stabilize the cervical spine in a neutral, in-line position. e. Determine the level of consciousness. f. Sedation or rapid sequence intubation (RSI) procedures may be required. 2. Airway and breathing a. Ensure an open airway. i. Sonorous respirations indicate a positional problem. ii. Gurgling respirations indicate need for suction. b. Maintain head and neck in neutral position, and clear the mouth. i. Suction if necessary. ii. Be prepared to roll the patient to the side to prevent aspiration. iii. If it is safe to do so, manually remove any large debris from the mouth by sweeping the oropharynx with your gloved finger. c. Open the airway with the jaw-thrust maneuver if the patient is unresponsive or unable to maintain his or her own airway. i. If successful, insert an oropharyngeal or nasopharyngeal airway. (a) An intact gag reflex is a contraindication for an oropharyngeal airway. (b) Facial fractures and suspicion for a basilar skull fracture are contraindications for a nasopharyngeal airway. (c) If resistance is met, abandon the attempt. d. If the patient is awake with an impaired airway, consider drug-assisted advanced airway placement with in-line stabilization. e. If intubation is required: i. Preoxygenate with 100% oxygen for 2-3 min or to a saturation level of 100%. ii. Administer 1 to 1.5mg/kg of lidocaine IV push. iii. Perform intubation with head in neutral in-line position. iv. If patient will not tolerate laryngoscopy and endotracheal (ET) tube placement, perform pharmacologically assisted intubation. f. Evaluate breathing, noting rate, depth, and symmetry of respirations. g. Monitor oxygen saturation, and maintain at 95% or higher. h. Administer 100% oxygen via a nonrebreathing mask if patient is breathing adequately i. Patients with inadequate ventilation should receive bag-mask ventilation and 100% oxygen. i. Ventilate a brain-injured adult at a rate of 10 breaths/min. ii. Avoid routine hyperventilation. (a) The Brain Trauma Foundation (BTF) recommends hyperventilation only if signs of cerebral herniation are present. iii. Optimally, you should ventilate the patient to maintain the ETCO2 between 30 and 40 mm Hg. j. Inadequate respirations with or without evidence of decreased oxygenation require assisted ventilation with a bag-mask device. i. 12 to 15 L/min of supplementary oxygen flowing at 10 to 12 breaths/min 3. Circulation a. In absence of pulse, immediately initiate CPR. b. Control major bleeding with direct pressure. i. Do not apply excessive pressure to scalp lacerations in which an underlying fracture is suspected. c. Compare radial and carotid pulses. i. Presence, rate, quality, regularity, and equality d. Examine skin color, temperature, and moisture. e. Volume resuscitation might be necessary if absent or diminished pulse. i. Establish at least one large-bore IV line with normal saline or lactated Ringer’s solution. ii. Do not administer dextrose-containing solutions because they may worsen cerebral edema. iii. Restrict your use of IV fluids for patients with a severe closed head injury (a) If hypotension develops, infuse fluids as needed to maintain a systolic blood pressure of at least 110 to 120 mm Hg f. Patients in pure neurogenic shock may need vagolytic drugs and vasopressors. g. Use a cardiac monitor for any critically injured patient. 4. Transport decision a. Early on, decide whether or not to transport patient immediately. i. If patient is unstable, transport immediately. b. Consider air transport if your transport time will be prolonged for any reason. c. Patients with severe brain injuries and increased ICP require neurosurgical intervention. i. Transport the patient directly to a trauma center that has neurosurgical capabilities C. History taking 1. Patient’s reliability should be assessed. a. Patients should be considered unreliable if they present with: i. Acute stress reaction ii. Distracting injuries iii. Alteration in mental status due to brain injury or intoxication b. Unreliable patients should have continuous spine protection until the presence of an injury can be excluded at the hospital. 2. Maintain a high index of suspicion. a. Treat all patients who experience multiple trauma or who are found unresponsive as if a spinal injury exists. 3. Obtain SAMPLE history. a. Circumstances of incident? b. Types of energy imparted? c. Blunt or penetrating trauma? d. Flexion injury? e. Torsion of neck? f. In case of a fall: i. Height of fall? ii. Was anything struck on the way down? iii. How did the patient land? iv. What did the patient land on? g. In case of a vehicular crash: i. Use and positioning of restraints? ii. Patients position in vehicle? iii. Degree of damage to the vehicle? h. Time of initial injury? i. Change in patient’s presentation? D. Secondary assessment 1. Obtain a complete set of baseline vital signs. 2. Modify the physical examination of any patient with suspected SCI based on: a. Level of consciousness b. Reliability as a historian c. Mechanism of injury 3. In case of SCI, exam includes rapid inspection and palpation of head, neck, chest, abdomen, pelvis, extremities, and back. a. Use DCAP-BTLS to remember specific points. i. Deformity ii. Contusion iii. Abrasion iv. Puncture/penetration wounds v. Bruising vi. Tenderness vii. Laceration viii. Swelling 4. Evaluate distal PMS (pulse, motor, and sensory function) for all four extremities. 5. Expose the patient for your examination. a. Cut away the patient’s clothes. b. Observe the back for penetrating trauma. c. Palpate the spine to assess for deformity or displacement. d. Once completed, cover the patient with a blanket to maintain normal temperature. 6. Placement on the backboard a Document assessment before and after immobilizing the patient. b. Most patients can be log rolled with visualization and palpation. i. The absence of pain may eliminate the need for manual in-line spinal immobilization. ii. Paralyzed limbs should always be protected with appropriate immobilization. c. Patients in severe pain may require an alternative method of transfer. i. Use of a scoop stretcher results in less movement, but visual inspection is no longer possible. d. Keep time on backboard to minimum. i. Skin breakdown can be a major complication of SCI. ii. If you have a high suspicion of spinal injury or a long transport time, consider: (a) Vacuum mattress to help prevent pressure ulcers from forming (b) Back Raft to take pressure off specific areas of the back (c) Slightly flexing and separating the legs to increase patient comfort (d) Concave backboards to conform more closely to a patient’s anatomy e. Complete a full-body exam en route to hospital. i. Head ii. Neck (a) Palpate cervical spine for pain, deformity, or dislocation. iii. Chest (a) Assess for symmetry of chest wall movement, work of breathing, and use of accessory muscles. (b) Auscultate to assess breath sounds. iv. Abdomen (a) Inspect for evidence of trauma. (b) Palpate all four quadrants for tenderness, guarding, or rigidity. v. Pelvis (a) In men, assess the ureteral meatus for evidence of blood, scrotal swelling, and scrotal ecchymosis. vi. Extremities (a) Inspect for deformity, contusion, abrasions, punctures, lacerations, and edema. (b) Palpate for deformity, tenderness, instability, or crepitus. vii. Back viii. Buttocks f. Obtain a glucose level in patients who show evidence of alterations in sensation. 7. Level of consciousness a. Obtain a complete GCS score. b. Level of consciousness indicates extent of brain dysfunction. c. GCS is based on three measurements: i. Eye opening ii. Verbal response iii. Motor response d. GCS score classifies the severity of the brain injury. e. There is an adjusted GCS scoring system for infants and children. 8. Pupillary assessment a. Frequently monitor size, equality, and reactivity of pupils. i. When a light is shined into the eye, the pupil should briskly constrict. (a) Sluggish to contract is an early sign of increased ICP. (b) Unequal or bilaterally fixed and dilated pupils are more ominous signs of increased ICP. 9. Assessing ICP a. ICP cannot be quantified in prehospital setting, but severity of increase can be estimated. b. Critical treatment decisions are based on the presence or absence of key findings. i. Posturing ii. Hypotension or hypertension iii. Abnormal pupil signs c. Use serial assessments of GCS scores and pupillary assessment as indicators of the progression of ICP. 10. Neurologic exam a. Intended to establish a baseline for later comparison and to determine whether to immobilize the patient. b. Determine the level of consciousness. i. Note AVPU in primary assessment. ii. Address GCS level during further assessment. c. Myotomes: Regions in the body where motor components of spinal nerves innervate discrete tissues and muscles. i. Bilaterally assess each major motor group from top down. ii. Ask the patient to flex (C5) and extend (C7) both elbows and then wrists (C6). iii. Ask the patient to abduct and adduct fingers against resistance (T1). (a) As an alternative, ask the patient to curl fingers while applying resistance (C8). iv. Ask the patient to bend and extend the knees. v. Ask the patient to plantar flex the feet and ankles (S1-S2) vi. Ask the patient to dorsiflex the toes to gravity and against resistance (L5). vii. Motor integrity in an unresponsive patient can be assessed via response to painful stimulus. (a) Test on several locations before assuming an absence of response. d. Dermatomes: Regions in the body where sensory components of spinal nerves innervate i. Test general loss of sensation. ii. Ask about abnormal sensations. (a) Pins and needles (b) Electric shock (c) Hyperacute pain to touch (hyperesthesia) iii. Assess bilaterally from the feet up. iv. Reflexes can provide valuable information about sensory input. (a) In significant SCIs, reflexes are usually absent but return several hours or weeks later. (b) If reflexes intact, preservation of motor and sensory activities is likely. (c) Positive Babinski reflex occurs if toes move upward in response to stimulation on sole of foot. E. Reassessment 1. Necessary to determine whether patient is stabilizing, improving, or deteriorating. 2. Monitor vital signs every 5 minutes in unstable patient. 3. Monitor vital signs every 15 minutes in stable patient. 4. Be alert for hypotension without other signs of shock. a. Combination of hypotension with a normal or slow pulse and warm skin suggest neurogenic shock. b. Pale, cold, clammy skin and tachycardia suggest hypovolemic shock. 5. Check interventions. 6. Repeat the physical exam, and reprioritize the patient. 7. Document suspected spinal cord injury, noting: a. Area involved b. Sensation c. Dermatomes d. Motor function e. Areas of weakness IV. Pathophysiology, Assessment, and Management of Head Injuries A. Head injury: Traumatic insult to the head that can result in injury to soft tissue, bony structures, or the brain 1. More than 50% of all traumatic deaths are a result of head injury. 2. Common mechanisms of injury include: a. Motor vehicle crash b. Assault c. Falls in elderly people d. Sports-related incidents e. Incidents involving children 3. Two general types of head injuries: a. Closed head injury i. Usually associated with blunt trauma ii. Dura mater remains intact, and brain tissue is not exposed. iii. May result in skull fractures, focal brain injuries, or diffuse brain injuries iv. Often complicated by increased ICP b. Open head injury i. Dura mater and cranial contents are penetrated, and brain tissue is exposed. ii. Almost always significant neurologic deficits B. Skull fracture 1. Significance is related to: a. Type of fracture b. Amount of force applied c. Area of head that sustained the blow 2. Potential complications include: a. Intracranial hemorrhage b. Cerebral damage c. Cranial nerve damage 3. Four types of skull fractures: a. Linear skull fractures i. Account for 80% of all fractures to the skull ii. Approximately 50% occur in the temporal-parietal region of the skull. iii. Radiographic evaluation is required to diagnose. (a) No gross physical signs b. Depressed skull fractures i. Result from high-energy direct trauma to small surface area of the head with a blunt object. ii. Frontal and parietal regions are most susceptible because the bones are relatively thin. iii. Patients often present with neurologic signs. c. Basilar skull fractures i. Associated with high-energy trauma but usually occur following diffuse impact to head. ii. Can be difficult to diagnose with radiography iii. Signs include: (a) CSF drainage from ears and freely flowing CFS through the ear. (b) Periorbital ecchymosis that develops around the eyes (Raccoon eyes) (c) Ecchymosis behind the ear (Battle sign) d. Open skull fractures i. Result of severe force being applied to head ii. Often associated with trauma to multiple body systems iii. Brain tissue might be exposed to environment. iv. High mortality rate C. Traumatic brain injury 1. Classified into: a. Primary brain injury i. Injury to the brain and its associated structures ii. Results instantaneously from impact to head b. Secondary brain injury i. Refers to the aftereffects of primary injury ii. Includes abnormal processes, such as: (a) Cerebral edema (b) Intracranial hemorrhage (c) Increased ICP (d) Cerebral ischemia and hypoxia (e) Infection iii. Can occur anywhere from a few minutes to several days following the initial injury 2. The most common cause of brain injury is a motor vehicle crash. a. Coupe-contrecoup: Front-and-rear type of injury i. The passenger’s head hits the windshield on impact, and the brain continues to move forward until it strikes the inside of the skull. (a) Results in compression injury to the anterior portion of the brain and stretching or tearing of the posterior portion ii. The head falls back against the headrest and/or seat, and the brain slams into the rear of the skull. iii. Same type of injury may occur on opposite sides of the brain in a lateral crash. b. Injured brain starts to swell due to cerebral vasodilation and an increase in cerebral water (cerebral edema). 3. Intracranial pressure a. An increase in ICP can be caused by accumulation of blood within the skull or swelling of the brain. b. Increased ICP squeezes the brain against bony prominences within the cranium. c. Normal ICP in adults ranges from 0 to 15 mm Hg. d. Increase in ICP decreases cerebral perfusion pressure (CPP) and cerebral blood flow. i. CPP = Difference between mean arterial pressure (MAP) and ICP. (a) CPP = MAP - ICP e. The critical minimum threshold (minimum CPP required to perfuse the brain) is 60 mm Hg in an adult. i. CPP of less than 60 mm Hg leads to cerebral ischemia. f. Body responds to decrease in CPP by increasing MAP (process known as autoregulation) i. Results in cerebral vasodilation and increased cerebral blood flow ii. Increase in cerebral blood flow causes further increase in ICP. g. Prehospital treatment should focus on maintaining CPP while mitigating ICP. i. Increased ICP left untreated can result in herniation. (a) Brain forced into cranial vault either through foramen magnum or over the tentorium. h. Early warning signs of ICP include: i. Vomiting ii. Headache iii. Altered level of consciousness iv. Seizures i. More ominous signs include: i. Hypertension ii. Bradycardia iii. Irregular respirations (Cushing triad) iv. Nonreactive pupil v. Coma vi. Posturing (a) Decorticate (flexor) posturing: flexion of arms and extension of legs. (b) Decerebrate (extensor) posturing: extension of arms and legs. 4. Diffuse brain injuries a. Affects the entire brain b. Cerebral concussion i. Brain is jarred around in the skull. ii. Caused by rapid acceleration-deceleration forces iii. Results in transient dysfunction of the cerebral cortex iv. Signs include: (a) Confusion (b) Disorientation (c) Loss of consciousness (d) Retrograde amnesia: Loss of memory relating to events that occurred before injury (e) Autograde (posttraumatic) amnesia: Loss of memory relating to events that occurred after injury c. Diffuse axonal injury (DAI) i. Associated with or similar to a concussion ii. Often associated with a poor prognosis iii. Involves stretching, shearing, tearing of nerve fibers and axonal damage (a) Axon: Long, slender extension of a neuron that conducts impulses away from the neuronal soma (cell body) in the brain iv. Caused by high-speed, rapid acceleration-deceleration forces v. Classified as mild, moderate, or severe 5. Focal brain injuries a. Specific, grossly observable brain injury b. Cerebral contusion i. Brain tissue bruised and damaged in local area ii. Greater neurologic deficits iii. Frontal lobe most commonly affected. iv. Swelling of the brain leads to increased ICP. c. Intracranial hemorrhage i. Epidural hematoma (a) Accumulation of blood between skull and dura mater (b) Happens in 0.5% to 1% of all head injuries (c) Always the result of a blow to the head (d) Patient often immediately loses consciousness, regains it for a brief period, and loses it again. (e) Death will follow without surgery. ii. Subdural hematoma (a) Accumulation of blood beneath dura mater outside the brain (b) Occurs in 5% of all head injuries (c) Associated with venous bleeding (1) ICP develops more gradually. (d) Patient often experiences a fluctuating level of consciousness, focal neurologic signs, or slurred speech. (d) Classified as acute or chronic iii. Intracerebral hematoma (a) Bleeding in brain tissue (b) Patients condition deteriorates quickly. (c) High mortality rate iv. Subarachnoid hemorrhage (a) Bleeding into subarachnoid space (b) Results in bloody CSF and meningeal irritation (c) Causes include trauma or rupture of aneurysm (d) Patient typically presents with a sudden, severe headache. (e) As bleeding increases, signs and symptoms of increased ICP develop. (1) Decreased level of consciousness (2) Pupillary changes (3) Posturing (4) Vomiting (5) Seizures (f) Usually results in death v. Subgaleal hemorrhage (a) Bleeding between periosteum and galea aponeurosis (b) Can result in enough blood loss to precipitate hypovolemia in infants vi. Supragaleal hemorrhage (a) Firm, nodular mass D. Assessment and management 1. Should be guided by factors such as: a. Severity of injury b. Patient’s level of consciousness 2. Thermal management a. Do not allow patient to develop hyperpyrexia (high body temperature). i. Can worsen the condition of the brain b. Do not cover a patient with blankets if ambient temperature is 70°F (21°C) or higher. 3. Treatment of associated injuries a. Apply loose, sterile dressings to oozing head injuries. b. Objects impaled in the skull should be stabilized. 4. Pharmacologic therapy a. Usually not indicated for brain-injured patients b. May be ordered if transport will be prolonged. i. Mannitol (Osmitrol) ii. Furosemide (Lasix) c. Seizures must be terminated as soon as possible. i. Benzodiazepines should be used. d. No neuroprotective agents are currently administered in a prehospital setting. V. Pathophysiology, Assessment, and Management of Scalp Lacerations A. Scalp lacerations can vary between minor and serious, but even small lacerations can lead to significant blood loss due to the scalp’s rich blood supply. 1. Do not become distracted by the injury at the risk of missing an underlying injury. 2. Hypovolemic shock in adults is rarely caused by scalp lacerations alone. a. Look for other possible causes of volume loss. 3. Scalp lacerations often indicated deeper, more severe injuries. B. Assessment and management 1. When assessing the laceration, consider the mechanism. a. Inspect for indications of missing tissue, impaled objects, or residual contaminants. b. Subgaleal and supragaleal hematomas may mask the presence of a depressed skull fracture. c. Evaluate for signs of continued bleeding, and reevaluate often. d. If determination is impossible, assume that skull involvement is present. 2. In isolated lacerations, stop the bleeding. a. Apply direct pressure for minor to moderate lacerations. b. Pressure dressings and hemostatic agents may be required for significant lacerations. c. If time and other injuries do not prevent it, a quick cleansing rinse can reduce the incidence of infection. 3. Do not explore the injury. a. This may disrupt a clot formation and reinitiate bleeding. VI. Pathophysiology, Assessment, and Management of Spine Injuries A. Spinal cord injury (SCI) has limited treatment options, with therapy relying heavily on rehabilitation over acute intervention. 1. Reducing incidence is best option for decreasing associated morbidity and mortality. 2. In the United States, there are 11,000 new cases each year. 3. In-hospital mortality rate is 7%. a. The leading causes of death for SCI patients who are discharged from the hospital are: i. Pneumonia ii. Pulmonary embolism iii. Septicemia B. Mechanism of injury 1. Flexion injuries a. Result from forward movement of head i. Typically result of rapid deceleration or direct blow to occiput b. At C1-C2 level, forces can produce an unstable dislocation with or without a fracture. i. Dislocation can be complete or partial. (a) Subluxation: Partial dislocation c. Farther down the spinal column, forces can result in an anterior wedge fracture. i. Fracture can be stable or unstable. d. Greater force can result in teardrop fractures. i. Avulsion fractures of the anterior-inferior border of the vertebral body ii. Raise concern for possible SCI; qualify as unstable fractures iii. Can also result in a potentially unstable dislocation e. Strong forces can result in the anterior displacement of facet joints. f. Patients can experience lateral bending. i. Similar to flexion-extension injury, but from left to right rather than from front to back 2. Rotation with flexion a. The only area of the spine that allows for significant rotation is C1-C2. i. Injuries are considered unstable due to high cervical location and scant support. b. Often result from high acceleration forces c. In the thoracolumbar spine, forces typically cause fracture rather than dislocation. 3. Vertical compression a. Transmitted through vertical bodies b. Result from direct blow to crown or rapid deceleration from a fall through the feet, legs, and pelvis c. Forces can cause: i. “Burst” or compression fractures ii. Herniation of disks iii. Compression on the spinal cord and nerve roots iv. Fragmentation into the canal d. Primary SCI can occur when fragments of bone become embedded in the cord. 4. Hyperextension a. Results in fractures and ligamentous injury of variable stability b. Stable with head and neck in flexion c. Unstable in extension due to no structural support C. Categories of spinal cord injuries 1. Primary spinal cord injury a. Occurs at moment of impact b. Penetrating trauma results in transection of nonregenerative neural elements and complete injuries. c. Blunt trauma results in compression of points of the spinal cord or an incomplete dislocation of the vertebral body. d. Spinal cord concussion i. Characterized by a temporary dysfunction that lasts from 24 to 48 hours ii. Considered an incomplete injury iii. May be due to a short-duration shock or pressure wave within the cord. e. Spinal cord contusions i. Caused by fracture, dislocation, or direct trauma ii. Associated with edema, tissue damage, and vascular leakage f. Cord laceration i. Usually occurs when a projectile or bone enters the spinal canal ii. Likely to result in hemorrhage into the cord tissue, swelling, and disruption of some portion of the cord 2. Secondary spinal cord injury a. Occurs when multiple factors permit a progression of the primary SCI i. Minimize further injury through spinal motion restriction and neutral alignment. ii. Also, minimize heat loss and maintain oxygenation and perfusion. b. All SCIs are classified as either complete or incomplete. i. Complete spinal cord injury (a) Complete disruption of all tracts of spinal cord (b) Permanent loss of all cord-mediated functions (c) No sensation, pain, or movement below injury (1) Injury high in the cervical spine results in quadriplegia. (2) Injury high in the thoracic area results in paraplegia. ii. Incomplete spinal cord injury (a) Some degree of cord-mediated function is retained. c. Anterior cord syndrome i. Result of displacement of bony fragments into the anterior portion of the spinal cord (a) Often due to flexion injuries or fractures ii. Physical findings include paralysis below the level of insult with loss of sensation to pain, temperature, and touch. d. Central cord syndrome i. Hyperextension injuries to the cervical area present with hemorrhage or edema. ii. Often occurs in conjunction with tears to the anterior longitudinal ligament iii. Frequently seen in older patients who already have significant degree of cervical spondylosis and stenosis due to arthritis iv. Patient presents with greater loss of function in upper extremities than in lower extremities. v. Many patients regain all motor function. e. Posterior cord syndrome i. Associated with extension injuries ii. Relatively rare syndrome iii. Produces dysfunction of the dorsal columns iv. Presents as decreased sensation to: (a) Light (b) Touch (c) Proprioception (ability to perceive the position and movement of one’s body) (d) Vibration v. Overall prognosis good with therapy and rehabilitation. f. Cauda equina syndrome i. Compression of bundle of nerve roots located at end of spinal cord ii. In the presence of trauma, causes include: (a) Swelling after impact (b) Penetrating objects (c) Bone fragments (d) Expanding hematoma within the spinal column in the lumbar region iii. Can produce the following symptoms: (a) Low back pain (b) Myalgia, paresthesia, or myasthenia in one or both legs (c) Loss of sensation in legs, buttocks, inner thighs, back of legs, or feet (d) Acute bladder/bowel dysfunction (1) Retention or incontinence g. Brown-Séquard syndrome i. Typically occurs after penetrating trauma ii. Accompanied by functional hemisection of the cord and complete damage to all spinal tracts on the involved side. h. Spinal shock i. Temporary local neurologic condition that occurs immediately after spinal trauma. ii. Swelling and edema begin within 30 minutes. iii. Present with variable degrees of spinal injury (a) Flaccid paralysis (b) Flaccid sphincters (c) Absent reflexes iv. Sensory function below the injury will be impaired. v. Usually subsides in hours to weeks. i. Neurologic shock i. Results from temporary loss of autonomic function at the level of injury ii. Hemodynamic and systemic effects are seen: (a) Hypotension (b) Hypovolemia and sensitivity to sudden position changes (c) Decreased stroke volume and cardiac output (d) Bradycardia (e) Hypothermia and absence of sweating (f) Paralytic ileus (paralysis of the small bowel) D. Assessment and management 1. Current principles of spine trauma management include: a. Recognition of potential or actual injury b. Appropriate immobilization c. Reduction or prevention of the incidence of secondary injury 2. The goal should be to spend no more than 10 minutes on the scene. 3. Specific criteria to determine whether complete immobilization is necessary should be reviewed by medical directors. a. The patient may not require immobilization if he or she: i. Has no neurologic deficit ii. Is not under the influence of alcohol, drugs, or medications iii. Has no distracting injuries iv. Has no motor or sensory deficit v. Has no pain or tenderness on movement or palpation b. If there is any doubt, the patient should be immobilized. 4. Spinal splinting procedures a. When splinting, spine should be considered one long bone. i. No such thing as partial immobilization. b. Supine patients i. Patient can be immobilized by securing him or her to a long backboard. (a) Take standard precautions, and then begin manual in-line stabilization. (b) Support the lower jaw with your index and middle fingers, and support the head with your palms. (1) Gently move the patients head until the head and torso are in line. (2) Do not remove your hands until the patient is properly secured. (c) Assess distal PMS function in each extremity. (d) Apply an appropriately sized cervical collar. (1) If you do not have the correct size, tape a rolled towel to the backboard around the patient’s head. (e) The other team members should position the backboard and place their hands on the far side of the patient. (f) On command, the rescuers should roll the patient toward themselves. (1) One rescuer should slide the backboard behind and under the patient. (2) The team should then roll the patient back onto the board. (g) Make sure the patient is centered on the board. (h) Secure the upper torso to the board. (i) Secure the pelvis and upper legs. (j) Immobilize the head to the board by positioning an immobilization device or towel rolls. (k) Secure the head by taping the head immobilization device across the forehead. (l) Pad the voids. (m) Check and readjust straps as needed to ensure the entire body is snugly secured. (n) Reassess distal PMS function in each extremity. ii. Do not force the head into a neutral, in-line position if the patient has: (a) Muscle spasms in the neck (b) Increased pain with movement (c) Numbness, tingling, or weakness (d) Compromised airway or ventilation iii. In these situations, immobilize the patient in the position found. iv. Do not place pillows under the patient’s head. v. Patients found in a prone position or on their side should be log rolled into the supine position, and then immobilized. c. Seated patients i. A rigid cervical collar should be measured and placed appropriately. ii. A vest-type board should be used to transfer the patient onto a long backboard. (a) Exceptions include the following situations: (1) You or the patient is in danger. (2) You need to gain immediate access to other patients. (3) The patient’s injuries justify urgent removal. (b) In these situations, lower the patient directly onto a long backboard. iii. In all other cases, follow these steps to immobilize a seated patient: (a) Stabilize the head, and then maintain manual in-line stabilization. (b) Assess distal PMS function in each extremity. (c) Apply the rigid cervical collar. (1) Continue manual stabilization until the patient is fully immobilized. (d) Insert a short board between the patient’s upper back and the seat back. (e) Open the board’s side flaps, and position around the patient’s torso. (f) Once the device is properly positioned, secure the upper torso straps. (g) Position and fasten both groin loops. (h) Pad any space between the patient’s head and the device. (i) Secure the forehead strap or tape the head securely, then fasten the lower head strap. (j) Place the long backboard next to the patient’s buttocks. (k) Turn the patient parallel to the long board, and slowly lower him or her onto it. (l) Lift the patient and the vest-type board together as a unit, and slip the long backboard underneath. (m) Release the leg straps, and loosen the chest strap. (n) Secure the short board and long backboard together. (o) Reassess distal PMS function in all four extremities. d. Rapid extrication i. Use in the following situations: (a) The vehicle or scene is unsafe. (b) The patient cannot be properly assessed before being removed from the car. (c) The patient needs immediate intervention. (d) The patient’s condition requires immediate transport. (e) The patient blocks your access to another seriously injured patient. ii. Requires a team of three experienced providers iii. Follow these steps: (a) The first rescuer provides manual in-line stabilization of the patient’s head and cervical spine from behind. (b) The second rescuer gives the commands to coordinate the team’s moves, applies a rigid cervical collar, and performs the primary assessment. (c) The second rescuer provides continuous support of the patient’s torso until the patient is supine on the backboard. (d) The third rescuer rotates the patient’s legs and feet as the torso is turned. (e) The patient is rotated 90° so his or her back faces out the driver’s door and the feet are on the passenger’s seat. (f) At some point, the first rescuer will be unable to follow the torso rotation. (1) The third rescuer should assume manual in-line stabilization until the first rescuer can regain control. (g) Once the patient has been fully rotated, the backboard is placed against the patient’s buttocks on the seat. (h) As soon as the backboard is in place, the second and third rescuers lower the patient onto the board. (i) The third rescuer moves across the front seat to be in position at the patient’s hips. (j) The fourth rescuer maintains in-line support of the head and takes over giving the commands. (k) The second rescuer grasps the patient’s shoulders or armpits. (l) On command, the second and third rescuers slide the patient 8 to 12 inches along the backboard, until the patient’s hips are on the backboard. (m) The third rescuer gets out of the vehicle and takes control at the shoulders, and the second rescuer takes control of the hips. (1) On command, these two rescuers move the patient until he or she is completely on the board. (n) The first rescuer continues to maintain manual in-line support. (o) The second and third rescuers grasp their side of the board, and carry it and the patient onto the stretcher. iv. Once the patient has been placed on the stretcher, begin lifesaving treatment. e. Standing patients i. Carefully take down the patient if you suspect underlying head, neck, or spine injuries. ii. Requires a minimum of three rescuers. iii. Use the following steps: (a) Establish manual, in-line stabilization, apply a rigid cervical collar, and instruct the patient to remain still. (b) Position the board upright, directly behind the patient. (c) Two rescuers stand on either side of the patient; the third is directly behind the patient. (d) The two rescuers grasp the handholds at shoulder level or slightly above. (e) Prepare to lower the patient to the ground. (f) Carefully lower the patient as a unit under the direction of the rescuer at the head. 5. Packaging and removal of injured patients from the water a. When the patient may have sustained a spine injury in a diving accident, spinal immobilization must be initiated before the patient is removed from the water. b. Assume spinal injury for the following: i. Diving injury ii. Boating injury iii. Watercraft injury iv. Falls from heights c. If respiratory arrest is suspected, ventilation can be done while still in the water. d. In case of cardiac arrest when a spine injury is not obvious, immediately remove the patient from the water and begin CPR. e. If there is indication of a spine injury, follow these steps to: i. If the patient is prone, approach from the top of the head, and place your arm under the body. ii. Place your other arm across the head and back. iii. Continuing to support the patient’s head and neck, take a step backward and turn the patient to the supine position. iv. Open the airway and begin ventilation. v. Float a buoyant backboard under the patient as you continue ventilation. vi. Secure the head and trunk to the backboard. vii. Remove the patient from the water, on the backboard. viii. Remove wet clothes, and cover the patient with a blanket. (a) Give supplementary oxygen if the patient is breathing adequately (b) Give positive-pressure ventilation if the patient is apneic or breathing inadequately. (c) Begin CPR if there is no pulse. ix. Consider using an advanced airway device if needed. x. Place the patient on a cardiac monitor, and treat dysrhythmias. 6. Patients wearing helmets a. Helmets can inhibit full exposure of the patient, hindering efforts at airway management and spinal stabilization. b. The removal of helmets can result in spinal motion. c. The Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete recommended helmet removal in the following situations: i. The helmet and chin strap fail to hold the head securely. ii. The helmet and chin strap design prevent adequate airway control. iii. A helmet with a face mask cannot be removed after a reasonable amount of time. iv. The helmet prevents proper immobilization for transport. d. Only providers who are familiar with the procedure should attempt helmet removal. i. Kneel at the patient’s head while your partner kneels on one side of the patient. ii. Stabilize the helmet by placing your hands on either side of it, with your fingers on the patient’s lower jaw. (a) Once your hands are in position, your partner can loosen the face strap. iii. Your partner should open the face shield and assess airway and breathing. iv. Once the strap is loosened, your partner should place one hand on the patient’s lower jaw and the other behind the head. v. Gently slip the helmet partly off the patient’s head, stopping at the halfway point. vi. Your partner then slides his or her hand from the back of the helmet to the occiput. vii. Remove the helmet and provide manual in-line cervical spine stabilization. viii. Apply a rigid cervical collar, and secure the patient to the backboard. ix. You may need to add padding under the shoulders or head to prevent flexion of the neck. D. Pharmacotherapy of spinal cord injury 1. Short-acting, reversible sedatives are commonly recommended for acute agitated patients. 2. Pain medication may be necessary. 3. Corticosteroids are sometimes used in the acute phase of SCI. a. Many recent protocols avoid their use. b. More likely to lead to significant complication than to improved outcome. E. Complications of spinal cord injury 1. Complications of SCI are a cause of high morbidity and mortality. 2. Potential for aspiration or respiratory arrest, especially with high cervical injuries 3. Loss of intercostal muscles impairs coughing and deep breathing. a. Predisposes patient to atelectasis and pneumonia 4. Deep vein thrombosis and pulmonary embolism are late complications. 5. Autonomic dysreflexia (also called autonomic hyperreflexia) is a late complication. a. Potentially life-threatening b. Most commonly occurs with injuries above T4-T6 c. Results from loss of parasympathetic stimulation d. Patients present with a massive, uncompensated cardiovascular response. i. Cool, pale extremities ii. Systolic blood pressures of greater than 200 mm Hg iii. Diastolic blood pressures of 130 mm Hg or greater iv. Vagal compensation causes bradycardia and vasodilation of peripheral and visceral vessels above the level of the lesion e. Common precipitators include: i. Skin lesions ii. Constrictive clothing iii. Sharp objects compressing the skin f. Management is usually not a prehospital intervention. i. If the source cannot be found or minimized, it may be necessary to reduce blood pressure with vasodilators. VII. Nontraumatic Spinal Conditions A. Back pain is one of the most common physical complaints in emergency departments throughout the United States. 1. Susceptibility to injury or degenerative disease may occur due to the weight an upright posture bears on the lumbar spine. 2. Spinal tumors can also be a cause of pain. 3. Risks for developing low back pain include: a. Occupations that require repetitive lifting b. Exposure to vibrations from vehicles or industrial machinery c. Comorbid diseases such as osteoporosis 4. When evaluating: a. Consider disease processes that can result in debilitating lesions. b. Keep anatomy and neurophysiology of the spine and spinal cord in mind. c. Pay attention to the patient’s medications. 5. Pain may result from strain or sprain of muscles without significant injury to nerves 6. Degenerative disk disease is common in patients older than 50 years. a. Over time, the disk will lose height and some of its shock-absorbing effect b. Disk herniation may be caused in patients with preexisting disk degeneration. i. Typically affects men between ages 30 and 50 years ii. May result from poor lifting technique iii. Most commonly occurs at L4-L5 and L5-S1 iv. Patients present with pain, tenderness, and a limited range of motion. 7. Definitive diagnosis may require multiple modalities of radiographic imaging. 8. Prehospital management is directed at decreasing pain or discomfort. VIII. Injury Prevention A. Prevention of head and spine trauma includes safety measures that can decrease risk of injury. 1. Driving safely a. Motorcycles and all-terrain vehicles should not be ridden by two persons on the same vehicle. 2. Adhering to posted safety alerts a. Example: Those regarding safe diving at swimming pools IX. Summary A. The skull is a rigid, unyielding box that does not accommodate a swelling brain or accumulations of blood. B. Be familiar with high-risk mechanisms of injury that can cause head injury, brain injury, and spinal cord injury, such as motor vehicle crashes, falls, and penetrating trauma. Full spinal motion restriction should be applied unless there is a compelling reason not to. C. Airway is a priority; maintain the head and neck in neutral alignment while you are suctioning and performing airway management. Consider endotracheal intubation in patients with spinal injuries, but remember that endotracheal intubation requires special precautions in patients with head injuries because it may precipitate a dangerous rise in intracranial pressure. D. Control major bleeding without placing pressure on a potential underlying fracture. Provide fluid resuscitation, but restrict use of IV fluids in patients with severe closed head injuries to minimize cerebral edema; however, avoid hypotension. E. Transport patients with severe injuries promptly to a trauma center. Use lights and siren cautiously; a siren could precipitate seizures and exacerbate intracranial pressure. F. Level of consciousness should continuously be assessed, including repeat assessments of the Glasgow Coma Scale score and pupillary assessment. Secondary assessment may include a full-body exam and a neurologic exam. G. Head injuries include skull fractures (linear, depressed, basilar, and open) and traumatic brain injury (cerebral concussion, diffuse axonal injury, cerebral contusion, and intracranial hemorrhage). H. Normal intracranial pressure is 0 to 15 mm Hg in adults. Increased intracranial pressure can squeeze the brain against the interior of the skull and/or press it into sharp edges within the cranium. If severely increased intracranial pressure is not promptly treated, cerebral herniation will occur. I. Cerebral perfusion pressure is the pressure of blood flowing through the brain; it is the difference between the mean arterial pressure and intracranial pressure. J. If the cerebral perfusion pressure drops below 60 mm Hg in the adult, cerebral ischemia will likely occur, increasing the risk of permanent brain damage or death. K. Begin treatment of a head-injured patient by stabilizing the cervical spine, opening the airway with the jaw-thrust maneuver, and assessing the ABCs. L. All head-injured patients should receive 100% oxygen as soon as possible. If the patient is breathing adequately, apply a nonrebreathing mask set at 15 L/min. If the patient is breathing inadequately, assist ventilation and consider intubation. M. Ventilate a brain-injured adult at a rate of 10 breaths/min. Avoid routine hyperventilation unless signs of cerebral herniation are present. Hyperventilation in a brain-injured adult is defined as a ventilation rate of 20 breaths/min. N. Restrict IV fluids in a head-injured patient unless hypotension (systolic blood pressure of less than 90 mm Hg) is present. Hypotension in a brain-injured patient should be treated with crystalloid fluid boluses in a quantity sufficient to maintain a systolic blood pressure of at least 90 mm Hg. O. Frequently monitor a head-injured patient’s level of consciousness, and document your findings. The Glasgow Coma Scale is an effective, reliable tool. Assessment using the Glasgow Coma Scale must be repeated frequently if the score is to be a reliable indicator of the patient’s clinical progression. P. Intubation of a brain-injured patient may require pharmacologic adjuncts (such as sedation, neuromuscular blocking drugs). Q. Seizures may occur in a brain-injured patient and can aggravate intracranial pressure and cause or worsen cerebral ischemia. Treat seizures with a benzodiazepine (such as diazepam, lorazepam). R. A brain-injured patient’s survival depends on recognition of the injury, prompt and aggressive prehospital care, and rapid transport to a trauma center that has neurosurgical capabilities. Consider air transport if ground transport time will be prolonged. S. Do not become distracted by scalp lacerations. Once life threats are managed, evaluate the wound for continued bleeding. With isolated fractures not involving suspected skull fracture, apply direct pressure and use a pressure dressing or hemostatic agent if required. T. Spinal cord injuries are among the most devastating injuries encountered by prehospital providers. In order to decipher the often subtle findings associated with a spinal cord injury, you need to understand the form and function of spinal anatomy. U. Acute injuries of the spine are classified according to the associated mechanism, location, and stability of injury. V. Vertebral fractures can occur with or without associated spinal cord injury. W. Stable fractures typically involve only a single column and pose a lower risk to the spinal cord. X. Primary spinal cord injury occurs at the moment of impact. Secondary spinal cord injury occurs when multiple factors permit a progression of the primary spinal cord injury. The ensuing cascade of inflammatory responses may result in further deterioration. Y. Limiting the progression of secondary spinal cord injury is a major goal of prehospital management of spinal cord injury. Z. Current principles of spine trauma management include recognition of potential or actual injury, appropriate immobilization, and reduction or prevention of the incidence of secondary injury. AA. Short-acting, reversible sedatives are recommended for the acute patient after a correctible cause of agitation has been excluded. BB. The use of corticosteroids in the acute phase of spinal cord injury is controversial. CC. The complications of spinal cord injury are a consistent cause of the high morbidity and mortality associated with this type of injury. DD. Back pain is one of the most common physical complaints to present to emergency departments throughout the United States. Most cases of low back pain are idiopathic and difficult to precisely diagnose. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of paramedic knowledge. Instructor Directions 1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 34. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions 1. Answer: B. Central cord syndrome Rationale: Central cord syndrome will show loss of function of the arms more so than the legs, and is typically seen in hyperextension of the neck. 2. Answer: D. All of the above Rationale: Patients with central cord syndrome may have disturbances of their ability to sense pain and temperature. They may also lose control of bowel and bladder function. 3. Answer: D. Spondylosis Rationale: Spondylosis is degenerative osteoarthritis affecting the vertebrae. This condition diminishes the vertebral foramen, and in the presence of swelling or hemorrhage causes impingement of the spinal cord and neurologic impairment. 4. Answer: C. Both A and B Rationale: In the central portion of the cervical and thoracic cord, more motor (also called efferent) fibers are found than in the periphery of the cord. This would explain her complaint of decreased movement in her upper extremities. 5. Answer: C. weakness in the hands. Rationale: The prognosis for central cord syndrome patients is typically good, with either a total recovery of motor function or some residual weakness in the hands. 6. Answer: C. tears to the supporting ligaments. Rationale: This type of injury is typically seen in the elderly and with tears to the longitudinal ligament. Additional Questions 7. Rationale: It is easy to become complacent. Devices that activate EMS allow the elderly to maintain independence and live alone. Unfortunately, if patients leave their house for a longer period of time, such as a vacation, without notifying the company of their absence, this can result in repeated activations. Routine or repeat calls such as this one can cause providers let their guard down. Vigilance should be maintained for each and every call. 8. Rationale: Not only does unneeded forced entry have potential negative public relations consequences, but depending upon the jurisdiction, it may be unlawful to do so without the presence of law enforcement officials. It is best to summon law enforcement to force entry. Also, you may be called as a witness to corroborate why the law enforcement officer chose to break into the residence, so be sure to thoroughly document the call, including the fact that entry was forced. 9. Rationale: Spinal precautions are not a benign procedure and can cause harm. As with all patients (and especially with the elderly) it is important to pad any voids. Patients with kyphosis will need extra padding, and can be particularly challenging when you are immobilizing these patients on a board, especially if airway management is also required. You must be sure to pad and protect the voids that exist between the backboard and the patient, while still maintaining (but not forcing) the patient’s head into a position in which airway management can be achieved. Assignments A. Review all materials from this lesson, and be prepared for a lesson quiz to be administered (date to be determined by instructor). B. Read Chapter 35, Chest Trauma, for the next class session. Unit Assessment Keyed for Instructors 1. What are the structures that make up the cranial vault? Answer: The cranial vault consists of eight bones that encase and protect the brain: the parietal, temporal, frontal, occipital, sphenoid, and ethmoid bones. The brain connects to the spinal cord through a large opening at the base of the skull called the foramen magnum. (p 1644) 2. Describe the floor of the cranial vault. Answer: Viewed from above, the floor of the cranial vault is divided into three compartments: the anterior fossa, middle fossa, and posterior fossa. The crista galli forms a prominent bony ridge in the center of the anterior fossa and is the point of attachment of the meninges, the three layers of membranes that surround the brain and spinal cord. On the other side of the crista galli is the cribriform plate of the ethmoid bone, a horizontal bone that is perforated with numerous openings (foramina), allowing the passage of the olfactory nerve filaments from the nasal cavity. The olfactory nerves, the cranial nerves for smell, send projections through the foramina in the cribriform plate and into the nasal cavity, the chamber inside the nose that lies between the floor of the cranium and the roof of the mouth. (p 1644) 3. How are the bones of the skull connected together? What is different about the skulls of infants? Answer: The bones of the skull are connected at special joints known as sutures. The paired parietal bones join together at the sagittal suture. The parietal bones abut the frontal bone at the coronal suture. The occipital bone attaches to the parietal bones at the lambdoid suture. Fibrous tissues called fontanelles, which are soft in infants, link the sutures. The tissues felt through the fontanelles are layers of the scalp and thick membranes overlying the brain. Under normal conditions, the brain may not be felt through the fontanelles. (p 1644) 4. What are the meninges? Answer: The meninges are protective layers that surround and enfold the entire CNS—specifically the brain and spinal cord . The outermost layer is a strong, fibrous wrapping called the dura mater (meaning “tough mother”). The dura mater covers the entire brain, folding in to form the tentorium, a structure that separates the cerebral hemispheres from the cerebellum and brainstem. The dura mater is firmly attached to the internal wall of the skull. The second meningeal layer is a delicate, transparent membrane called the arachnoid. It is so named because the blood vessels it contains resemble a spider web. The third meningeal layer, the pia mater (“soft mother”), is a thin, translucent, highly vascular membrane that firmly adheres directly to the surface of the brain. (p 1648) 5. How many pairs of spinal nerves are there? What are their functions? Answer: The 31 pairs of spinal nerves emerge from each side of the spinal cord and are named for the vertebral region and level from which they arise. The eight cervical roots perform different functions in the scalp, neck, shoulders, and arms. The 12 thoracic nerve roots have varying functions; the upper thoracic nerves supply muscles of the chest that help in breathing and coughing, whereas the lower thoracic nerves provide abdominal muscle control and contain nerves of the sympathetic nervous system. The five lumbar nerve roots supply hip flexors and leg muscles, as well as provide sensation to the anterior legs. The five sacral nerves provide for bowel and bladder control, sexual function, and sensation in the posterior legs and rectum. The coccyx has a single nerve root. (p 1650) 6. Discuss some of the high risk mechanisms of injury that may indicate a spinal injury. Answer: The following high-risk mechanisms of injury strongly suggest spine injury and indicate that full spinal motion restriction should be applied unless there is a compelling reason not to: High-velocity crash (greater than 40 mph) with severe vehicle damage Unrestrained occupant of moderate to high-speed motor vehicle crash Vehicular damage with compartmental intrusion (12 inches) into the patient’s seating space Fall from three times the patient’s height Penetrating trauma near the spine Ejection from a moving vehicle Motorcycle crash of greater than 20 mph with separation of the rider from the vehicle Diving injury Auto-pedestrian or auto-bicycle crash of greater than 5 mph Death of occupant in the same passenger compartment Rollover crash (unrestrained) (p 1652) 7. When should RSI be considered for a patient with a spinal injury? Answer: In a patient with a spinal injury, a definitive airway with an advanced airway device should follow the placement of any temporary airway device. If the patient is awake with an impaired airway or has a deteriorating Glasgow Coma Scale (GCS) score (8 or less), consider drug-assisted advanced airway placement with in-line stabilization (ie, RSI). (p 1653) 8. What are myotomes and dermatomes? Answer: Motor components of spinal nerves innervate discrete tissues and muscles of the body in regions called myotomes. The examination of these myotomes should take place in the typical head-to-toe fashion, starting with an assessment of the cranial nerves. Cranial nerve assessment is especially important in circumstances suggestive of a high cervical injury. Sensory components of spinal nerves innervate specific and discrete areas of the body surface called dermatomes. In addition to testing a general loss of sensation, ask the patient about abnormal sensations in these areas such as “pins and needles,” electric shock, or hyperacute pain to touch (hyperesthesia). As with the motor exam, sensory integrity must be assessed bilaterally but from the feet up. Determine the lowest level of normal sensation and any areas of intact or “spared” sensation below this level. (p 1660) 9. What are the two classifications of traumatic brain injury? Answer: Traumatic brain injuries are classified into two broad categories: primary (direct) injury and secondary (indirect) injury. Primary brain injury is injury to the brain and its associated structures that results instantaneously from impact to the head. Secondary brain injury refers to the aftereffects of the primary injury; it includes abnormal processes such as cerebral edema, intracranial hemorrhage, increased ICP, cerebral ischemia and hypoxia, and infection. Secondary brain injury can occur anywhere from a few minutes to several days following the initial injury. (p 1664) 10. What are the signs and symptoms for increasing ICP? Answer: You must closely monitor the head-injured patient for signs and symptoms of increased ICP. The exact clinical signs encountered depend on the amount of pressure inside the skull and the extent of brainstem involvement. Early signs and symptoms include vomiting (often without nausea), headache, an altered level of consciousness, and seizures. Later, more ominous signs include hypertension (with a widening pulse pressure), bradycardia, and irregular respirations (Cushing triad), plus a unilaterally unequal and nonreactive pupil (caused by oculomotor nerve compression), coma, and posturing. Decorticate (flexor) posturing is characterized by flexion of the arms and extension of the legs; decerebrate (extensor) posturing is characterized by extension of the arms and legs. (p 1665) Unit Assessment 1. What are the structures that make up the cranial vault? 2. Describe the floor of the cranial vault. 3. How are the bones of the skull connected together? What is different about the skulls of infants? 4. What are the meninges? 5. How many pairs of spinal nerves are there? What are their functions? 6. Discuss some of the high risk mechanisms of injury that may indicate a spinal injury. 7. When should RSI be considered for a patient with a spinal injury? 8. What are myotomes and dermatomes? 9. What are the two classifications of traumatic brain injury? 10. What are the signs and symptoms for increasing ICP?