This document provides information on injuries to the head and spine, including mechanisms of injury, patient assessment signs and symptoms, and emergency care procedures. It discusses direct and indirect brain injuries, types of spinal injuries like whiplash and compression, and signs of spinal injury like pain, numbness, and deformity. It outlines steps for cervical spine immobilization, rapid extrication, helmet removal, and immobilizing a child in or out of a car seat.

1. Chapter Injuries to the Head and Spine Twenty-Four

2. Chapter Mechanism of head and spine injury How to stabilize the cervical spine Proper application of a cervical spine immobilization device for patients found standing, seated, or supine How and when to do rapid extrication Procedures for helmet removal Proper immobilization of child in car seat Twenty-Four CORE CONCEPTS

3. Anatomy Review: Nervous System

4. Spinal Column

5. Anatomy Review: Skull and Facial Bones

6. Bone Dura mater Arachnoid Pia mater Subarachnoid space Subdural space Intracerebral Dura mater Arachnoid Skull Pia mater Contents of the Skull Epidural space (potential)

7. I NJURIES TO THE HEAD

8. Soft tissue injuries may Injuries to brain cause internal bleed profusely. bleeding and increased intracranial pressure. Head Injuries Overview

9. Direct Occurs when the brain is lacerated, punctured, or bruised by the broken bones of the skull, by bone fragments, or by foreign objects. Brain Injury Indirect Can be the result of closed injuries to the skull and certain types of open skull injuries.

10. May occur due to clot Can cause altered mental status. or hemorrhage. Signs and symptoms are similar to traumatic injury (but no trauma) . Brain Injury Nontraumatic

11. Patient ASSESSMENT Head Injury Signs and Symptoms Altered or decreased mental status Irregular breathing patterns Mechanism of injury present (Continued)

12. Patient ASSESSMENT Head Injury Signs and Symptoms Contusions, lacerations, or hematomas Deformity of skull Blood/fluid from ears or nose Bruising around eyes, behind ears (Continued)

13. Patient ASSESSMENT Head Injury Signs and Symptoms Neurologic disability Nausea and/or vomiting Unequal pupil size with altered mental status Seizures

14. Patient CARE Head Injury Emergency Care Steps Body substance isolation Airway, ventilation, oxygen Initial assessment with C-spine stabilization (Continued)

15. Patient CARE Head Injury Emergency Care Steps Complete assessment. Immobilize spine. Monitor airway, breathing, pulse, mental status closely. (Continued)

16. Patient CARE Head Injury Emergency Care Steps Control bleeding. Do not apply pressure to open or depressed skull injury. Dress and bandage wound. (Continued)

17. Patient CARE Head Injury Emergency Care Steps Be prepared for changes in Transport immediately. Monitor vital signs every 5 minutes patient condition. en route.

18. Tell new EMT-Bs that an epidural hematoma is often associated with severe blows to the temporal regions of the head. If they recognize an epidural hematoma in its early stages and promptly transport the patient to a trauma center, it can make the difference between life and death. Tell them to be aggressive if they suspect an epidural hematoma may be developing. P RECEPTOR P EARL

19. I NJURIES TO THE SPINE

20. Motor vehicle crashes Auto-pedestrian collisions Falls Blunt or penetrating trauma Motorcycle crashes Hangings Diving accidents Unconscious trauma patients Mechanisms of Spinal Injury

21. Mechanisms of Spinal Injury

22. Whiplash

23. Tell new EMT-Bs that as a rule of thumb, they should assume any fall three times the patient’s height or with enough force to cause open PSDEs to the ankles will also be accompanied by a spine injury. P RECEPTOR P EARL

24. Compression Distraction (pulling apart) Lateral bending Flexion, rotation, extension Types of Spinal Injuries

25. Patient ASSESSMENT Spinal Injury Signs and Symptoms Pain and tenderness Deformity of spine upon palpation Numbness, weakness, or tingling in extremities (Continued)

26. Patient ASSESSMENT Spinal Injury Signs and Symptoms Pain upon movement: Never move or allow a patient to move in order to elicit a pain response. (Continued)

27. Patient ASSESSMENT Spinal Injury Signs and Symptoms Loss of sensation or paralysis In extremities Below level of injury (Continued)

28. Patient ASSESSMENT Spinal Injury Signs and Symptoms (Continued) Impaired breathing: “ C-3, -4, -5 keep the diaphragm alive”

29. Patient ASSESSMENT Spinal Injury Signs and Symptoms Soft-tissue injuries associated with trauma Incontinence (Continued) Priapism

30. Patient ASSESSMENT Spinal Injury Signs and Symptoms Instruct the patient not to move. Stabilize cervical spine during initial assessment. Evaluate mechanism of injury. (Continued)

31. Patient ASSESSMENT Spinal Injury Signs and Symptoms Ask: What happened? Where does it hurt? Does your neck or back hurt? (Continued)

32. Patient ASSESSMENT Spinal Injury Signs and Symptoms Ask: Can you move your hands and feet? Can you feel me touching your fingers? Toes?

33. Assess sensation in all extremities.

34. Assess motor function.

35. Assess strength: feet and hands

36. Patient ASSESSMENT Spinal Injury Signs and Symptoms Inspect. Palpate. Assess strength of extremities. Complications of spinal injury: May cause paralysis. May affect respiratory effort.

37. Patient CARE Spinal Injury Emergency Care Steps Use BSI procedures. Maintain in-line stabilization. Care for airway with in-line stabilization when possible.

38. Patient CARE Breathing Adequacy Emergency Care Steps Assess pulse, movement, and sensation in extremities. Assess the neck and spine. Administer oxygen via nonrebreather mask.

39. Patient CARE Spinal Injury Emergency Care Steps Apply properly sized cervical spine immobilization device. Apply and secure patient to appropriate immobilization device. (Continued)

40. Patient CARE Spinal Injury Emergency Care Steps If proper size collar is not available, use rolled towel and tape. Pad around child as necessary to maintain stabilization.

41. S PINAL IMMOBILIZATION

42. Stabilize and measure.

43. Choose correct collar size.

44. Prepare collar.

45. Slide collar under chin.

46. Secure collar; maintain in-line position.

47. Vest type Rigid short spine board. Stabilize head, neck, torso. Used for noncritical, seated patient. (Continued) Short Spine Boards

48. Select immobilization device.

49. Manually stabilize patient’s head in neutral, in-line position. Assess distal pulse, motor function, and sensation (PMS).

50. Apply the appropriately sized extrication collar. Position device behind patient.

51. Secure device to patient’s torso. Evaluate and pad behind patient’s head as necessary. Secure patient’s head to device.

52. Evaluate and adjust straps. As needed, secure patient’s wrists and legs.

53. Stabilize head, neck, torso, pelvis, and extremities. May be applied in: Lying, standing, and sitting positions Conjunction with short spine boards (Continued) Long Spine Boards

54. Maintain stabilization; apply collar.

55. Prepare and position device.

56. Move patient onto board. Apply padding to voids.

57. Secure body, then head.

58. Reassess PMS.

59. Standing Takedown: Maintain stabilization and apply collar.

60. Standing Takedown: Position board and EMT-Bs.

61. Standing Takedown: Grasp board after reaching under patient’s shoulders.

62. Standing Takedown: Carefully lower patient; then secure board.

63. Unsafe scene Unstable patient condition Patient blocks EMT-B’s Indications access to an unstable patient (Continued) Rapid Extrication

64. Manually stabilize; apply collar.

65. After putting end of board next to patient, position hands on legs/pelvis and chest/arms.

66. Rotate patient and reposition hands.

67. Lower patient to board.

68. Move patient into position on board.

69. Secure patient and transport.

70. H ELMET REMOVAL

71. Patient ASSESSMENT Helmet Removal Signs and Symptoms Decision to remove helmet is Airway and breathing concerns Fit of helmet, movement within helmet Access for airway and ventilation based on:

72. Good fit, little movement. No current or expected airway problems. Removal would cause further injury. Indications to Leave Helmet in Place (Continued)

73. Proper immobilization may be performed. No interference with ongoing assessment. Indications to Leave Helmet in Place

74. Inability to assess or treat airway and breathing Improper fit/movement within helmet Indications for Removing Helmet (Continued)

75. Inability to immobilize spine Cardiac arrest Indications for Removing Helmet

76. Tell new EMT-Bs that many EMS providers put the controversy of helmet removal vs. nonremoval into the following perspective: If your child’s neck was injured in a football accident, would you want the trainer and the EMT-B to remove the helmet at the scene or would you prefer that this be left to the emergency department staff, who probably will not have the assistance of the trainer or the benefit of frequent practice in the helmet removal technique? P RECEPTOR P EARL

77. Stabilize head and helmet. Fingers should be on patient’s mandible. Second EMT-B loosens strap. 1 2

78. Transfer stabilization to second EMT-B. Carefully remove helmet. 3 4

79. Prevent head from falling once helmet removed. Begin routine stabilization and immobilization. 5 6

80. Immobilizing a Child in or Out of Car Seat The car seat is a good place to immobilize the child. The child will need to be “rapid extricated” out of the seat if it becomes necessary to lay the child down in management.

81. 1. Describe the mechanisms of head and spinal injury. 2. When should rapid extrication be used? 3. Describe the steps in helmet removal. 4. When is it appropriate to remove a child from a car seat as opposed to immobilizing the child in the seat? R EVIEW QUESTIONS