27)Injuries To The Head And Spine

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27)Injuries To The Head And Spine

  1. 1. Injuries to the Head and Spine
  2. 2. The Nervous System <ul><li>Function </li></ul><ul><ul><li>Controls voluntary/involuntary activity </li></ul></ul><ul><li>Components </li></ul><ul><ul><li>Central Nervous System (Computer) </li></ul></ul><ul><ul><ul><li>Brain </li></ul></ul></ul><ul><ul><ul><li>Brainstem </li></ul></ul></ul><ul><ul><ul><li>Spinal Cord </li></ul></ul></ul><ul><ul><li>Peripheral Nervous System (Communicator) </li></ul></ul><ul><ul><ul><li>Associated nerves </li></ul></ul></ul><ul><ul><ul><li>Sensory- Carry info from body to brain </li></ul></ul></ul><ul><ul><ul><li>Motor – Carry info from the brain to the body </li></ul></ul></ul><ul><ul><ul><li>Divided into </li></ul></ul></ul><ul><ul><ul><ul><li>Somatic NS = voluntary </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Autonomic NS= Involuntary </li></ul></ul></ul></ul>
  3. 4. Divisions of the Autonomic Nervous System <ul><li>Sympathetic </li></ul><ul><ul><li>“Fight or flight” </li></ul></ul><ul><li>Parasympathetic </li></ul><ul><ul><li>“Feed or breed” </li></ul></ul>OR
  4. 6. The Nervous System The Brain <ul><li>Cerebrum </li></ul><ul><ul><li>Largest most superior portion of the brain </li></ul></ul><ul><ul><li>Divided into R & L hemispheres </li></ul></ul><ul><ul><li>Hemispheres divided into specialized lobes </li></ul></ul><ul><ul><ul><li>Frontal = Intellect and motor function </li></ul></ul></ul><ul><ul><ul><li>Occipital = Eyesight </li></ul></ul></ul><ul><ul><ul><li>Temporal = Smell/Hearing </li></ul></ul></ul><ul><ul><ul><li>Parietal = Sensory information </li></ul></ul></ul><ul><li>Brainstem </li></ul><ul><ul><li>Lower part of the brain </li></ul></ul><ul><ul><li>Circulation, Respiration, BP </li></ul></ul><ul><li>Cerebellum </li></ul><ul><ul><li>Outpocketing of brain, posterior to brainstem </li></ul></ul><ul><ul><li>Coordination and movement </li></ul></ul>
  5. 8. The Nervous System The Brain: Blood Supply <ul><li>Cerebral Blood Supply </li></ul><ul><ul><li>15% of Cardiac output </li></ul></ul><ul><ul><li>80% of blood is supplied by the carotid arteries </li></ul></ul><ul><ul><li>Vertebral arteries supply the rest </li></ul></ul><ul><ul><ul><li>Circle of Willis </li></ul></ul></ul><ul><ul><li>Each area of the brain has its own blood supply </li></ul></ul><ul><li>Sensitivity to Deprivation of glucose and O2 </li></ul><ul><ul><li>Cannot store glucose itself </li></ul></ul><ul><ul><ul><li>Deprivation = AMS </li></ul></ul></ul><ul><ul><li>Interruption in O2 supply </li></ul></ul><ul><ul><ul><li>Unconsciousness 5-10 seconds </li></ul></ul></ul><ul><ul><li>Blockage of O2 supply </li></ul></ul><ul><ul><ul><li>Neural death 4-6 minutes </li></ul></ul></ul>
  6. 9. Axial Skeleton Skull <ul><li>Skull </li></ul><ul><ul><li>22 bones </li></ul></ul><ul><ul><li>Cranium + Face </li></ul></ul><ul><ul><li>Encases brain </li></ul></ul><ul><ul><li>Brain + CSF + Vessels </li></ul></ul><ul><ul><ul><li>Little space </li></ul></ul></ul><ul><li>Facial Bones </li></ul><ul><ul><li>Orbits </li></ul></ul><ul><ul><ul><li>Eyes </li></ul></ul></ul><ul><ul><li>Nasal Bones </li></ul></ul><ul><ul><li>Maxilla </li></ul></ul><ul><ul><ul><li>Upper Jaw </li></ul></ul></ul><ul><ul><li>Zygomatics </li></ul></ul><ul><ul><ul><li>Cheekbones </li></ul></ul></ul><ul><ul><li>Mandible </li></ul></ul><ul><ul><ul><li>Lower Jaw </li></ul></ul></ul>
  7. 11. Axial Skeletal Vertebral Column <ul><li>Function </li></ul><ul><ul><li>Support </li></ul></ul><ul><li>Components </li></ul><ul><ul><li>33 Vertebrae </li></ul></ul><ul><ul><li>Intervertebral disks </li></ul></ul><ul><li>Divisions of Vertebrae </li></ul><ul><ul><li>Cervical (C-) = 7 Neck </li></ul></ul><ul><ul><ul><li>C1 = Atlas </li></ul></ul></ul><ul><ul><ul><li>C2 = Axis </li></ul></ul></ul><ul><ul><li>Thoracic (T-)= 12 Chest </li></ul></ul><ul><ul><li>Lumbar (L-)= 5 Lower Back </li></ul></ul><ul><ul><li>Sacral (S-)= 5 Back of pelvis (fused) </li></ul></ul><ul><ul><li>Coccyx (C-)= 4 Tailbone (fused) </li></ul></ul>
  8. 12. Injuries to the Spine Compression <ul><li>Compression </li></ul><ul><ul><li>When one vertebrae is driven into another </li></ul></ul><ul><ul><li>Compress vertebrae to point of crushing </li></ul></ul><ul><ul><li>Drives bony fragments into spinal canal </li></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><ul><ul><li>Falls </li></ul></ul></ul><ul><ul><ul><li>Diving Accidents </li></ul></ul></ul><ul><ul><ul><li>MVA </li></ul></ul></ul>
  9. 13. Injuries to the Spine Flexion <ul><li>Flexion </li></ul><ul><ul><li>Usually involve fixed and mobile vertebrae </li></ul></ul><ul><ul><li>Head is driven forward by sudden deceleration </li></ul></ul><ul><ul><li>Body of vertebrae are wedged together anteriorly </li></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><ul><ul><li>Head on MVA </li></ul></ul></ul><ul><ul><ul><li>Head striking windshield in flexed position </li></ul></ul></ul><ul><ul><ul><li>Lap belt injuries </li></ul></ul></ul><ul><ul><ul><li>Falls </li></ul></ul></ul>
  10. 14. Injuries to the Spine Extension <ul><li>Extension </li></ul><ul><ul><li>The head is suddenly jerked backward </li></ul></ul><ul><ul><li>Example </li></ul></ul><ul><ul><ul><li>Whiplash </li></ul></ul></ul><ul><ul><ul><li>Impacting windshield with face </li></ul></ul></ul>
  11. 15. Injuries to the Spine Other injuries <ul><li>Lateral bending </li></ul><ul><li>Excessive Rotation </li></ul><ul><li>Distraction </li></ul><ul><ul><li>Pulling apart of the spine </li></ul></ul><ul><ul><li>Example </li></ul></ul><ul><ul><ul><li>Hangings </li></ul></ul></ul>
  12. 16. “ Hangman’s Fracture”
  13. 17. High Index of Suspicion <ul><li>MVA </li></ul><ul><li>Pedestrian v. Vehicle </li></ul><ul><li>Falls </li></ul><ul><li>Blunt trauma </li></ul><ul><li>Penetrating trauma to: </li></ul><ul><ul><li>Head </li></ul></ul><ul><ul><li>Neck </li></ul></ul><ul><ul><li>Chest </li></ul></ul><ul><li>Motorcycle crashes </li></ul><ul><li>Hangings </li></ul><ul><li>Diving accidents </li></ul><ul><li>Unconscious </li></ul>
  14. 18. Injuries to the Spine S/S <ul><li>Tenderness in injured area </li></ul><ul><li>Pain assoc with moving </li></ul><ul><li>Pain independent of movement/palpation </li></ul><ul><ul><li>Along spinal column </li></ul></ul><ul><ul><li>Lower legs </li></ul></ul><ul><ul><li>May be intermittent </li></ul></ul><ul><li>Deformity of the spine </li></ul><ul><li>Soft tissue injuries assoc with trauma </li></ul><ul><ul><li>Head and neck to C-spine </li></ul></ul><ul><ul><li>Shoulders, back , abd, = Thoracic/Lumbar </li></ul></ul><ul><li>Numbness, weakness, tingling in extremities </li></ul><ul><li>Loss of sensation/paralysis below injury </li></ul><ul><li>Loss of sensation/paralysis in upper extremities </li></ul><ul><li>Incontinence </li></ul>
  15. 19. Complications of injuries to the Spine <ul><li>Inadequate Breathing </li></ul><ul><ul><li>Respiratory distress to arrest </li></ul></ul><ul><ul><li>Phrenic nerve controls diaphragm </li></ul></ul><ul><ul><ul><li>C3 -C5 </li></ul></ul></ul><ul><ul><ul><li>Fx above C3 ALL muscles or resp are paralyzed </li></ul></ul></ul><ul><ul><li>Intercostal muscles </li></ul></ul><ul><ul><ul><li>T2-T8 </li></ul></ul></ul><ul><ul><li>Abdominal muscles </li></ul></ul><ul><ul><ul><li>T8-T12 </li></ul></ul></ul><ul><li>Paralysis </li></ul><ul><li>Priapism </li></ul><ul><ul><li>Loss of sympathetic tone </li></ul></ul><ul><li>Pulse and BP </li></ul><ul><ul><li>Sympathetic nervous system controls tone of blood vessels </li></ul></ul><ul><ul><li>Loss of sympathetic tone via thoracic spine injury </li></ul></ul><ul><ul><li>Massive vasodilation = SHOCK (neurogenic) </li></ul></ul><ul><ul><li>BP 70-80 systolic </li></ul></ul><ul><ul><li>Pulse 60-80 bpm </li></ul></ul><ul><ul><li>Warm, flushed skin </li></ul></ul>
  16. 20. Assessment of injuries to the Spine Responsive Pt <ul><li>Scene Size Up </li></ul><ul><ul><li>Determine MOI </li></ul></ul><ul><ul><li>Anticipate forces involved </li></ul></ul><ul><li>Initial Assessment </li></ul><ul><ul><li>Immediate C-Spine control!!! </li></ul></ul><ul><ul><li>ABCs </li></ul></ul><ul><ul><li>AVPU </li></ul></ul><ul><ul><li>Modified jaw thrust </li></ul></ul><ul><ul><li>If head is flexed, return to normal position </li></ul></ul><ul><ul><ul><li>Stop if resistance is met </li></ul></ul></ul><ul><li>Focused Hx and Px Exam </li></ul><ul><ul><li>Reconstruct MOI and events </li></ul></ul><ul><ul><li>When did the injury occur? </li></ul></ul><ul><ul><li>What was the pt position at time of injury </li></ul></ul><ul><ul><li>Was the pt thrown from the impact </li></ul></ul><ul><ul><li>If MVA, estimate speed, pt position, restraints </li></ul></ul><ul><ul><li>Was there AMS, loss of consciousness before </li></ul></ul><ul><ul><li>If fall, estimate height and surface impacted </li></ul></ul><ul><ul><li>Suspected alcohol or drug use? </li></ul></ul><ul><ul><li>Medical causes.. </li></ul></ul>
  17. 21. Care for injuries of the Spine <ul><li>BSI </li></ul><ul><li>C-Spine control!!! </li></ul><ul><ul><li>Place head in neutral inline position if no resistance </li></ul></ul><ul><ul><li>Apply manual stabilization until pt is fully packaged </li></ul></ul><ul><li>Initial Assessment </li></ul><ul><li>Assess PMS in ALL extremities </li></ul><ul><li>Asses C-Spine </li></ul><ul><li>Apply C-collar </li></ul><ul><li>If pt found in lying position </li></ul><ul><ul><li>Log roll pt to LBB </li></ul></ul><ul><li>Immobilize pt to LBB </li></ul><ul><li>Pad any voids </li></ul><ul><ul><li>Adult = Under head and under torso </li></ul></ul><ul><ul><li>Child= Under shoulders to toes </li></ul></ul><ul><li>Reassess PMS </li></ul>
  18. 22. Immobilization of Seated Pts <ul><li>Use Short Spine Board/Kendrick Extrication Device (KED) </li></ul><ul><ul><li>1 EMT positions behind pt </li></ul></ul><ul><ul><li>That EMT maintains manual C-Spine control </li></ul></ul><ul><ul><li>Assess PMS </li></ul></ul><ul><ul><li>Asses C-Spine </li></ul></ul><ul><ul><li>A 2 nd EMT applies a C-Collar </li></ul></ul><ul><ul><li>Place device behind pt </li></ul></ul><ul><ul><li>Have pt inhale and hold it </li></ul></ul><ul><ul><li>2 nd EMT secures device to pt torso </li></ul></ul><ul><ul><ul><li>3 Straps </li></ul></ul></ul><ul><ul><li>Should fit snugly under pt armpits </li></ul></ul><ul><ul><li>Allow pt to exhale </li></ul></ul><ul><ul><li>Apply groin straps </li></ul></ul><ul><ul><li>Pad void behind pt head if needed </li></ul></ul><ul><ul><li>Secure pt head to device </li></ul></ul><ul><ul><li>Insert LBB under pt buttock if possible </li></ul></ul><ul><ul><li>Rotate pt onto LBB </li></ul></ul><ul><ul><li>If not the lower the pt to the LBB </li></ul></ul><ul><ul><li>Reassess PMS </li></ul></ul>
  19. 28. Immobilization of Standing Pts <ul><li>Use LBB = Rapid Takedown </li></ul><ul><ul><li>Position 1 EMT behind pt </li></ul></ul><ul><ul><li>That EMT will maintain C-Spine throughout </li></ul></ul><ul><ul><li>Assess PMS </li></ul></ul><ul><ul><li>2 nd EMT applies C-collar </li></ul></ul><ul><ul><li>Place LBB behind pt </li></ul></ul><ul><ul><li>Have 1 EMT on each side of pt </li></ul></ul><ul><ul><li>Have 1 EMT at the foot facing the pt </li></ul></ul><ul><ul><li>EMTs at pt side grasp the board under the pt arm with the hand closest to pt, grasping handles just above pt armpit </li></ul></ul><ul><ul><li>EMTs at pt side secure head to board with hand farthest away from pt (if only 2 EMTs) </li></ul></ul><ul><ul><li>EMT’s at pt side place leg closes to LBB behind the board </li></ul></ul><ul><ul><li>Start tipping to board backward </li></ul></ul><ul><ul><li>EMT at foot stabilizes board to prevent slipping </li></ul></ul><ul><ul><li>Lower pt on LBB to ground </li></ul></ul><ul><ul><li>Immobilize pt </li></ul></ul><ul><ul><li>Reassess PMS </li></ul></ul>
  20. 30. Injuries to the Brain and Skull <ul><li>Traumatic </li></ul><ul><ul><li>Head injuries </li></ul></ul><ul><ul><ul><li>Scalp injuries </li></ul></ul></ul><ul><ul><ul><ul><li>VERY vascular = Excessive bleeding </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Control with direct pressure </li></ul></ul></ul></ul><ul><ul><li>Brain injuries </li></ul></ul><ul><ul><ul><ul><li>Increases pressure in the skull </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Herniation of brain </li></ul></ul></ul></ul><ul><li>Non Traumatic </li></ul><ul><ul><li>Can cause AMS </li></ul></ul><ul><ul><li>S/S parallel trauma S/S </li></ul></ul><ul><ul><ul><li>Lack evidence of trauma/MOI </li></ul></ul></ul><ul><ul><ul><ul><li>Clots </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hemorrhages </li></ul></ul></ul></ul>Crocodile Bite Skull from our friend in the intro
  21. 31. Ejection through windshield of MVA
  22. 32. Head Injury S/S <ul><li>MOI </li></ul><ul><ul><li>Deformed windshield </li></ul></ul><ul><ul><li>Deformed helmet </li></ul></ul><ul><ul><li>Penetrating injury </li></ul></ul><ul><li>ALOC/Decreasing LOC </li></ul><ul><ul><li>-Confusion, -Disorientation, - Repetitive questioning </li></ul></ul><ul><ul><li>Unresponsive </li></ul></ul><ul><li>Irregular breathing patterns </li></ul><ul><li>DCAP-BTLS to skull </li></ul><ul><li>Soft area or depressed area upon palpation </li></ul><ul><li>Exposed brain tissue </li></ul><ul><li>Bleeding from open bone injury </li></ul><ul><li>Blood/CSF leaking from ears/nose </li></ul><ul><li>Raccoon eyes </li></ul><ul><li>Battle’s signs </li></ul><ul><li>Neurologic disability </li></ul><ul><li>Nausea and/or vomiting </li></ul><ul><li>Unequal pupil size with AMS </li></ul><ul><li>Seizure activity </li></ul>
  23. 33. Cushing’s Reflex Increasing Intracranial Pressure <ul><li>Increasing pressure forces brain through foramen magnum </li></ul><ul><li>Nerves of eyes leave brain in this area </li></ul><ul><li>Compressed between skull and brain </li></ul><ul><ul><li>Unequal pupils </li></ul></ul><ul><li>Pressure on motor nerves </li></ul><ul><ul><li>Posturing </li></ul></ul><ul><ul><ul><li>Decorticate = Abnormal flexion </li></ul></ul></ul><ul><ul><ul><li>Decerebrate = Abnormal extension </li></ul></ul></ul><ul><ul><li>Flaccidity </li></ul></ul><ul><li>Pressure on respiratory centers </li></ul><ul><ul><li>Abnormal respiration patterns </li></ul></ul><ul><li>Collapse of blood vessels in cranium due to increased pressure </li></ul><ul><ul><li>Last ditch effort to compensate = Hypertension </li></ul></ul><ul><li>Compensation for hypertension </li></ul><ul><ul><li>Pressure receptors outside the head note the hypertension </li></ul></ul><ul><ul><li>Pulse rate slows down in attempt to lower BP </li></ul></ul>
  24. 34. Care of head injuries <ul><li>BSI </li></ul><ul><li>C-Spine </li></ul><ul><li>Closely monitor </li></ul><ul><ul><li>ABCs </li></ul></ul><ul><ul><li>Mental status </li></ul></ul><ul><ul><ul><li>GCS score </li></ul></ul></ul><ul><ul><ul><li>PERRL </li></ul></ul></ul><ul><li>Control bleeding </li></ul><ul><ul><li>Do not apply pressure to open or depressed fx </li></ul></ul><ul><ul><li>Dress and bandage open wounds as normal </li></ul></ul><ul><li>Vitals </li></ul><ul><li>Be prepared for pt to decompensate </li></ul><ul><li>IMMEDIATE transport </li></ul>
  25. 35. Immobilization <ul><li>C-Collars </li></ul><ul><ul><li>Any suspected injury to spine based on MOI, S/S, Hx </li></ul></ul><ul><ul><li>Use in conjunction with LBB/Short boards </li></ul></ul><ul><ul><li>Improperly sized C-collars = further injury </li></ul></ul><ul><ul><li>If it doesn’t fit, use a rolled towel and tape to board </li></ul></ul><ul><ul><ul><li>Maintain manual stabilization </li></ul></ul></ul><ul><ul><li>Do not obstruct airway </li></ul></ul><ul><ul><li>Only good as long as manual stabilization is held </li></ul></ul><ul><ul><li>Release when head is secured to LBB </li></ul></ul>
  26. 36. Immobilization <ul><li>Short Back Boards </li></ul><ul><ul><li>Types </li></ul></ul><ul><ul><ul><li>Vest types </li></ul></ul></ul><ul><ul><ul><li>Rigid types </li></ul></ul></ul><ul><ul><li>Immobilizes: </li></ul></ul><ul><ul><ul><li>- Head –Neck –Torso </li></ul></ul></ul><ul><ul><li>Indications: </li></ul></ul><ul><ul><ul><li>Non critical trauma pt in sitting position </li></ul></ul></ul><ul><ul><li>Refer to previous slides as to application </li></ul></ul><ul><li>Long Back Boards </li></ul><ul><ul><li>Immobilizes: </li></ul></ul><ul><ul><ul><li>Full body </li></ul></ul></ul><ul><ul><li>Indications: </li></ul></ul><ul><ul><ul><li>Pt in lying, standing, sitting position </li></ul></ul></ul><ul><ul><li>Refer to previous slides as to application </li></ul></ul>
  27. 37. Special Considerations Rapid Extrication <ul><li>Rapid Extrication </li></ul><ul><ul><li>Unsafe scene </li></ul></ul><ul><ul><li>Unstable pt condition warranting immediate transport </li></ul></ul><ul><ul><li>Pt blocks access to another more seriously injured pt </li></ul></ul><ul><ul><li>Based on Time and Pt Priority NOT EMTs preference </li></ul></ul><ul><li>Helmet Removal </li></ul><ul><ul><li>Types </li></ul></ul><ul><ul><ul><li>Sports </li></ul></ul></ul><ul><ul><ul><ul><li>Opens anteriorly typically </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Easier access to airway </li></ul></ul></ul></ul><ul><ul><ul><li>Motorcycle </li></ul></ul></ul><ul><ul><ul><ul><li>Full face </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Shield </li></ul></ul></ul></ul><ul><li>Infants and Children </li></ul>
  28. 38. Helmet Removal <ul><li>Indications for leaving it in place: </li></ul><ul><ul><li>Good fit with little to no movement of pt head </li></ul></ul><ul><ul><li>No impending airway/breathing problem </li></ul></ul><ul><ul><li>Spinal immobilization can be performed with it in place </li></ul></ul><ul><ul><li>No interference with EMTs ability to assess airway </li></ul></ul><ul><li>Indications for removal: </li></ul><ul><ul><li>Inability to assess/reassess airway and breathing </li></ul></ul><ul><ul><li>Restriction of management of airway/breathing </li></ul></ul><ul><ul><li>Poor fit with excessive head movement </li></ul></ul><ul><ul><li>Spinal immobilization cannot occur b/c of helmet </li></ul></ul><ul><ul><li>Cardiac arrest </li></ul></ul>
  29. 39. Helmet Removal Guidelines <ul><li>Technique depends on type of helmet </li></ul><ul><li>Take pt eyeglasses off before removal </li></ul><ul><li>1 EMT stabilizes helmet </li></ul><ul><ul><li>Place hands on both sides </li></ul></ul><ul><ul><li>Place fingers on mandible </li></ul></ul><ul><li>2 nd EMT loosens the strap </li></ul><ul><li>2 nd EMT establishes C-Spine </li></ul><ul><ul><li>1 hand on mandible at angle of jaw </li></ul></ul><ul><ul><li>1 hand posterior on the occipital region </li></ul></ul><ul><li>EMT holding the helmet: </li></ul><ul><ul><li>Pulls sides of helmet apart </li></ul></ul><ul><ul><li>Slips helmet halfway off pt head and stops </li></ul></ul><ul><li>EMT maintaining C-Spine repositions </li></ul><ul><ul><li>Moves posterior hand superiorly to prevent head from falling once helmet removed </li></ul></ul><ul><li>Helmet is removed completely </li></ul><ul><li>Proceed as normal </li></ul>
  30. 41. Infants and Children <ul><li>Immobilize on rigid board appropriate for size </li></ul><ul><ul><li>Short </li></ul></ul><ul><ul><li>Long </li></ul></ul><ul><ul><li>Padded </li></ul></ul><ul><li>Pad voids: </li></ul><ul><ul><li>Shoulder to heels </li></ul></ul><ul><li>Properly size C-collar </li></ul><ul><ul><li>If unable to, use a rolled towel and tape to board </li></ul></ul><ul><ul><li>Hold manual stabilization </li></ul></ul>
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