very important first aid skills from a neurosurgical overview.

1. Dr. Mohammad A. Hamza,
MD Neurosurgery, Assiut University.
Fellowship of Charité University ,Berlin.

2.  First Aid is care given to an
injured person to stabilize and
keep him / her safe until he /
she can receive professional
medical attention.

3. RAPABCH

4. Scenario:
A man has been hit by a car and thrown into the
street. He is wearing shorts, and blood is flowing, but
not spurting, from his leg. What looks like a bone is
sticking out of his leg.
What are the two major concerns when giving first
aid to this victim?

5. First, safety of the rescuer from traffic
and the safety of the of the victim.
Second, unless the victim is in a life-
threatening situation, he should not be
moved.

6. a. The first rule of first aid and the primary concern
is:
b. The second concern is, unless the victim is in a
life-threatening situation, he or she should:
Fundamentals of First Aid
Safety
Not Be Moved

7. Giving First Aid
RAPABCH
R is for Responsiveness
Is the victim conscious?
Touch their shoulder, ask if they are alright.
Ask if they need help.
If they say no, then proceed no further
If yes, or no response, then proceed to A

8. Giving First Aid
RAPABCH
A is for Activate EMS or 123

9.  Your name
 The emergency
 The location of the emergency
 Condition of the victim
How to Use the 123 System
4. What are the four things you need to
remember when making a 123 call?
Stay on the line with the operator until help arrives.

10.  Check the victim for
responsiveness. If they do not
respond or if they tell you
that they need help, then
contact EMS.
How To Use the 123 System
When should EMS / 123 be called?

11. When To Move An Injured
Person
P is for Position
Only re-position the victim if the victim is in
further danger in their present location.
And / or there does not seem to be spinal injury
and additional care requires moving them.

12.  If there are suspected spinal injuries,
do not move the victim (except when the
victim is in a life threatening situation).
Explain when an injured person
should and should not be moved?

13. Use the mnemonic “ABCH”
Four Steps of Victim
Assessment
A is for airway
Use your finger to sweep the mouth to remove any seen object.
If this fails, then perform the Heimlich maneuver or abdominal
thrusts. We will learn these techniques later.
-check to see if the airway is blocked.

14.  B is for breathing
Four Steps of Victim
Assessment
Look, listen and feel by watching the
chest and placing your cheek a few
inches above the mouth of the victim to
sense any movement of air. If the victim
is not breathing, they may need their
head repositioned.
If they are still not breathing they need
rescue breathing, do not give unless you
are trained.

15.  C is for circulation
Four Steps of Victim
Assessment
If there is not a pulse, then this
person needs CPR.
The best place to check for a
pulse is the carotid artery along
the side of the neck along the
windpipe.
If you are not trained in CPR,
then find someone who is.

16.  H is for Hemorrhaging
Four Steps of Victim
Assessment
If the victim is bleeding, then provide the necessary
care.
If not, then begin a secondary assessment.

17. RAPABCH Review
1. Safety is the primary concern.
2. R = Responsiveness (Is the victim conscious?)
3. A = Activate EMS or 123
4. P = Position (no spinal injury, position according
to injury)
5. A = Airway (is it blocked? Check head position)

18. 6. B = Breathing (is the victim breathing? Check!)
7. C = Circulation (Is there a pulse? Check!)
8. H = Hemorrhaging (Is the victim bleeding?)
9. Perform secondary survey. Examine the victim
for other injuries and wait for medical attention to
arrive.

19. Heimlich Maneuver
 Used only when the victim is conscious and is
unable to breath or cough.
 Victim coughing, encourage to continue.
 If the victim goes unconscious, use Abdominal
Thrusts

20. Heimlich Maneuver
1. Stand behind victim.
2. Wrap arms around victim’s
waist and not around the
ribs.
3. Make a fist and place the
thumb side of your fist just
slightly above the navel.
4. Grab your fist with your
other hand.

21. Heimlich Maneuver
5. Press into the victim’s
stomach with five quick
upward thrusts. Each
thrust should have a
pause in between.
6. After every five
thrusts, recheck the
victim. Repeat until the
object has been
dislodged of until the
victim loses
consciousness.

22. Abdominal Thrusts
1. Place victim on his or her
back.
2. Straddle the victim by
sitting on their thighs.
3. Place the heel of one hand
just slightly above their
navel. Your fingers should
be angled slightly upward,
pointed toward the victim’s
head.

23. Abdominal Thrusts
4. Grasp your hand by placing
your other hand on top and
lacing your fingers into the
first hand.
5. Press inward and upward with
five quick thrusts. Each
thrust should have a pause in
between.

24. Injuries to the Head and
Spine

25. Anatomy and Physiology of the CNS System

26. Anatomy and Physiology of the CNS System
Spine
 33 stacked
vertebrae
○ Cervical
○ Thoracic
○ Lumbar
○ Sacral
○ Coccyx

27. Assessment
 If you think there is a possibility of a spinal
injury—treat as if there IS a spinal injury
 Immediately take steps to manually control
C-Spine
 Maintain manual C-Spine control until
patient is immobilized (note C-Collar alone not
adequate!)
 Patient’s ability to walk, move extremities,
experience foot sensation, or lack of pain to
column does NOT rule out possibility of column
or cord damage.

28.  General S/Sx of spinal injury:
 Pain-in provoked pain in area of injury, along
spine, in lower legs
 Tenderness
 Deformity of spine
 Soft tissue injury assoc. w/trauma
 Paralysis
 Painful movement
 Parasthesia (pins and needles)
 Loss of bowel, bladder; priapism, impaired
breathing
Assessment

29. General points to keep in mind during
rapid assessment:
Assume any unresponsive trauma patient
has a spinal injury
Remember that patients that deny
tenderness in area of spine may still have
a spinal injury
Never ask a patient to move to test spine
for pain
Assessment

30. Assessing Responsive Patient
 Perform brief neruo exam:
 Can you move your fingers and toes?
 Squeeze my fingers (compare)
 Push against my hands like pressing gas pedal
(compare)
 Can you feel it when I touch your fingers, toes?
 During SAMPLE Hx ask:
 What happened?
 Does your neck and/or back hurt?
 Can you move hands/feet?
 Do you have any pain, numbness or tingling in
arms or legs?
 Did you move or did anyone move you before I got
here?

31. Assessing Unresponsive Pt:
S/Sx
 Tenderness of spine in area of injury
 Deformity of spine
 Soft tissue injuries associated w/spinal injury
 Loss of sensation or paralysis below the level of
suspected spinal injury
 Loss of sensation or abnormal sensation
 Priapism
 Evidence of bladder or bowel incontinence
 Impaired breathing
 Pain along spinal column
 Pain in buttocks or legs

32. Immobilization
 Spinal immobilization devices Indications
○ Use with any suspected spinal injury based on
Hx, PE, S/Sx
○ Use in conjunction with long and short
backboards
 Precautions
○ C-Spine immobilization devices alone do not
provide adequate immobilization
○ Manual immobilization must be maintained until
Pt is secured to board

33. Immobilization
 Manual in-line stabilization
 Place the head in a neutral in line position
unless the patient complains of pain or the
thread is not easily moved into position
 Place head in alignment with spine
 Maintain constant manual inline immobilization
until the patient is properly secured to a LSB
 C-collars
 Should be rigid and properly sized
○ An improperly sized collar will do more harm
than good.

35. Immobilization
 Short spinal immobilization devices
 Several different types, such as vest and short
board
○ Become familiar with the type used by your service
 Provide stabilization and immobilization to the head
neck and torso
 Used to immobilize non critical sitting patients with
suspected spinal injuries
 General application:
○ Provide and maintain manual C-Spine control
○ Assess motor power in all extremities
○ Assess the cervical area
○ Size and apply a rigid C-Collar

36. ○ Position the immobilization device behind the
patient
○ Secure the patient’s torso to the device using
chest and groin straps
○ Evaluate how well the patient is secured to the
device
○ Evaluate the position of the head against the
device to maintain a neutral, inline position
○ Secure the Pt’s head to the device
○ lower the patient to a supine position on a LSB
○ Immobilize the Pt to LSB
○ Reassess PMS in all extremities

37. Immobilization
 Full body spinal immobilization devices
 Several types
 Stabilize head, neck, torso, pelvis, extremities
 Used to immobilize patients found in lying, standing
or sitting positions
 Sometimes used in conjunction with short spinal
immobilization devices
 General application:
○ Provide C-Spine control manually
○ Assess PMS in all extremities
○ Assess the cervical area

38. ○ Size and apply rigid C-Collar
○ Position the full body spinal immobilization device beside
Pt
○ Move the Pt onto device using the log-roll technique,
○ Pad any voids between the patient and the board
 Adult-under head or torso
 Infant and child-under the shoulders to the heels to establish a
neutral position
○ Immobile the patient’s torso to the device by applying
straps across the pelvis and superior chest
○ Immobilize the Pts head to device using head blocks,
straps and head immobilization device such as towel
rolls
○ Immobilize the Pts legs to the device by applying straps
above and below knees
○ Release C-Spine

39. ○ Advise responsive patients to keep arms
crossed across chest/abd
○ Reassess PMS
Notice the “X”!!!

40. General Emergency Care
 Ensure scene safety
 Establish and maintain C-Spine Control
 Perform initial assessment
 Assess PMS in all extremities
 Assess the C-Spine and anterior neck for injury
 Size and apply rigid C-Collar

41. General Emergency Care
 Select appropriate method and device based
upon condition and position of the Pt
 If Pt is lying on the ground, use LSB and log roll
 Pt in sitting position and is stable, use short spine
device
 A child may be immobilized in child safety seat
 If Pt is standing, use a LSB and standing
takedown technique
 Pt found sitting but is unstable or in danger, use
LSB and rapid extrication technique

42. Rapid Extrication
Indications
 Unsafe scene
 Unstable patient
condition
 Pathway blocked
to more seriously
injured patient

43. General Emergency Care
 Once Pt is immobilized to LSB, reassess PMS
in all extremities
 Transport the patient performing an on going
assessment

45. • Seventy percent of all motor vehicle accidents
result in a head injury.

46. Head Injuries
 Scalp and facial injuries
 Very vascular and may bleed more than expected
 All injuries to facial structures can produce partial or
complete obstruction of the airway
 Skull injuries
 Fx of bones with possible injuries of the brain
 S/Sx:
○ Severe contusions, deep lacerations or hematomas of
the scalp
○ Deformities of the skull such as depressions or sudden
“step-offs”
○ Blood or clear fluid leaking from nose or ears
○ Bruising around eyes (Raccoon sign)
○ Bruising behind ears over mastoid process (Battle sign)

47. Battle’s Sign

48. Raccoon Eyes

49. Head Injuries
 Brain injury
 Severity can vary widely
○ Lacerations or contusions
○ Hematomas
○ Damage at cellular level
 Open head injury
 S/Sx
○ Altered mental status
 Ranges from brief LOC to confusion to complete unresponsiveness
 Use GCS
 Any of the signs suggestive of skull injury
 Nausea and/or projectile vomiting
 Loss of neuro function
 Seizures
 Unequal pupils

50. Head Injury Assessment
Perform thorough size-up
Perform an initial assessment
C-Spine injury?
Mental status?
Protect ABCs
Conduct focused Hx/PE
Be careful when palpating during
the PE!

51. Emergency Care-Head
Injury
 Ensure scene safety and personal safety
 Assume spinal injury exists and treat
accordingly
 Maintain open airway, ensure adequate
oxygenation
 Complete spinal immobilization
 Closely monitor patient status
 Control bleeding
 Transport to closest appropriate facility

52. Helmet Removal
 Many different patient populations are likely
to wear helmets.
 Types: vary greatly
 Indications for leaving helmet in place:
 Helmet does not interfere with assessment and
monitoring of airway and breathing
 There are no current or impending airway or
breathing problems
 The patient can be adequately immobilized with
the helmet in place

53. Helmet Removal
General rules for helmet removal
Vary depending on design of helmet
As a general rule, follow procedures in
Skill Summary 23-30, and Skill Summary
21-31 pg. 586-588
Ensure that C-Spine control in maintained!

54. Head Injuries
Head Injuries
Depressed Linear
Stellate
Basilar
Skull
Fractures

55. Head Injuries
 Linear Fracture
 Usually NOT identified in field
○80% of all skull fractures
 Suspect based on
○Mechanism of injury
○Overlying soft tissue trauma
 Usually NOT emergency
 Temporal region = ~Epidural hematoma

56. Head Injuries
Depressed Skull Fracture
Segment pushed inward
Pressure on brain causes brain injury
○Neurologic signs and symptoms evident

57. Head Injuries
 Basilar Skull Fracture
 Difficult to detect on x-ray
 Signs & Symptoms depend on amount of
damage
 Diagnosis made clinically by finding:
○CSF Otorrhea
○CSF Rhinorrhea
○Periorbital ecchymosis
○Battle’s sign

58. Head Injuries
Cerebrospinal Fluid
Blood clotting delayed
Halo sign
Does not crust on drying
Positive to Dextrostick

59. Head Injuries
Basilar Skull Fracture
Do NOT pack ears
Let drain
Do NOT suction fluid
Do NOT instrument nose

60. Head Injuries
Open Skull Fracture
Cranial contents exposed
Protect exposed tissue with moist, clean
dressing (if possible)
Neurologic signs & Symptoms evident

61. Brain Injuries
Intracranial Hematomas
Epidural
Subdural
Intracerebral

62. Brain Injuries
 Epidural Hematoma
 Blood between skull
and dura
 Usually arterial tear
○ middle meningeal
artery
 Causes increase in
intracranial pressure

63. Brain Injuries
Epidural Hematoma
Unconsciousness followed by lucid interval
Rapid deterioration
Decreased LOC, headache, nausea,
vomiting
Hemiparesis, hemiplegia
Unequal pupils (dilated on side of clot)
Increase BP, decreased pulse (Cushing’s
reflex)

64. Brain Injuries
 Subdural Hematoma
 Between dura mater
and arachnoid
 More common
 Usually venous
○ bridging veins between
cortex and dura
 Causes increased
intracranial pressure

65. Brain Injuries
Subdural Hematoma
Slower onset
Increased ICP
Headache, decreased LOC,
unequal pupils
Increased BP, decreased pulse
Hemiparesis, hemiplegia

66. Brain Injuries
 Intracerebral Hematoma
 Usually due to laceration
of brain
 Bleeding into cerebral
substance
 Associated with other
injuries
○ DAI
 Neuro deficits depend on
region involved and size
○ repetitive w/frontal lobe
 Increased ICP

67. Brain Injuries
Injury to Cerebral Parenchyma
Laceration
Contusion
Concussion

68. Brain Injuries
Brain Laceration
Penetrating wounds
○Stab
○Depressed Fracture
○FAI
Severe blunt trauma
Sudden acceleration/deceleration

69. Brain Injuries
Concussion
Transient loss of consciousness
Retrograde amnesia, confusion
Resolves spontaneously without
deficit
Usually due to blunt head trauma

70. Head Trauma
Concussion
Post-concussion syndrome
○Headaches
○Depression
○Personality changes

71. Head Trauma Assessment
The Brain Is Enclosed In A Box

72. Head Trauma Assessment
Early Detection/Control of Increased ICP
Critical

73. Head Trauma Assessment
 LOC = Best Indicator
 Altered LOC = Intracranial trauma
 Trauma patient unable to follow commands =
25% chance of intracranial injury needing surgery

74. Head Trauma Assessment
Describe LOC changes based on
response to environment

75. Head Trauma Assessment
 AVPU Scale
 A = Alert
 V = Responds to Verbal stimuli
 P = Responds to Painful stimuli
 U = Unresponsive

76. Head Trauma Assessment
Glasgow Scale
Eye Opening
Motor Response
Verbal Response

77. Head Trauma Assessment
Glasgow Scale--Eye Opening
4 = Spontaneous
3 = To voice
2 = To pain
1 = Absent

78. Head Trauma Assessment
Glasgow Scale--Verbal
5 = Oriented
4 = Confused
3 = Inappropriate words
2 = Moaning, Incomprehensible
1 = No response

79. Head Trauma Assessment
Glasgow Scale--Motor
6 = Obeys commands
5 = Localizes pain
4 = Withdraws from pain
3 = Decorticate (Flexion)
2 = Decerebrate (Extension)
1 = Flaccid

80. Head Trauma Assessment
Eyes
Window to CNS
Pupil size, equality, and
response to light

81. Head Trauma Assessment
 Eyes
 Unequal Pupils + Decreased LOC =
○Compression of oculomotor nerve
○Probable mass lesion
 Unequal Pupils + Alert patient =
○Direct blow to eye, or
○Oculomotor nerve injury, or
○Normal inequality

82. Head Trauma Assessment
 Respiratory Patterns
 Cheyne Stokes
○ Diffuse injury to cerebral
hemispheres
 Central neurological hyperventilation
○ Injury to mid-brain
 Apneustic
○ Injury to pons

83. Head Trauma Assessment
 Respiratory Patterns
 Biot (Cluster)
○ Injury to upper medulla
 Ataxic
○ Injury to lower medulla

84. Head Trauma Assessment
Motor Response
Is patient able to move all
extremities?
How do they move?
○Decorticate
○Decerebrate
○Hemiparesis or Hemiplegia
○Paraplegia or Quadraplegia

85. Head Trauma Assessment
Motor Response
Lateralized/Focal Signs =
Lateralized or Focal Deficits
Altered motor function may be
due to fracture/dislocation

86. Head Trauma Assessment
 Vital Signs
 Cushing’s Triad
Suggests Increased Intracranial Pressure
○Increased BP
○Decreased Pulse
○Irregular respiratory pattern

87. Head Trauma Assessment
Vital Signs
Isolated head injury will NOT
cause hypotension in adult
Look for another life threatening
injury
○Chest
○Abdomen
○Pelvis
○Multiple long bone fractures

88. Head Trauma Assessment
Summary
Most important sign = LOC
Direction of changes more important than
single observations
Importance lies in continued reassessment
compared with initial exam
UPO, altered LOC in trauma = Intracranial
injury

89. Head Trauma Management
 Airway
 Open
○Assume C-spine Trauma
○Jaw Thrust with C-spine Control
 Clear - Suction As Needed
 Maintain
○Intubation if No Gag Reflex, or
○RSI
○Avoid nasal intubation

90. Head Trauma Management
 Breathing
 Oxygenate - 100% O2
 Ventilate
 No ROUTINE Hyperventilation
 Hyperventilate at 20 to 24 breaths per minute IF:
○Glasgow less than 8
○Rapid neurologic deterioration
○Evidence of herniation

91. Head Trauma Management
Hyperventilation--Benefits
○Decreased PaCO2
○Vasoconstriction
○Decreased ICP

92. Head Trauma Management
Hyperventilation--Risks
○Decreased cerebral blood
flow
○Decreased oxygen delivery to
tissues
○Increased edema

93. Head Trauma Management
Circulation
 Maintain adequate BP and Perfusion
 IV of LR/NS TKO if BP normal or elevated
 If BP decreased
○LR/NS bolus titrated to BP ~ 90 mm
Hg
○Consider PASG/MAST if BP below
80
 Monitor EKG -- Do NOT treat bradycardia

94. Head Trauma Management
Spinal motion restriction
If BP normal or elevated, spine board
head elevated 300

95. Head Trauma Management
Monitor for hyperthermia
Vasoconstriction
Heat retention
Increased cerebral 02 demand

96. Head Trauma Management
Drug Therapy Considerations
Only after:
Management of ABC’s
Controlled hyperventilation

97. Head Trauma Management
Drug Therapy Considerations
Dexamethasone (Decadron®)
○Steroid
○Decreases cerebral edema
○Effects delayed

98. Head Trauma Management
 Drug Therapy Considerations
Mannitol (Osmitrol®)
○Osmotic diuretic
○Decreases cerebral edema
○May cause hypovolemia
○May worsen intracranial
hemorrhage
○Often reserved for herniation

99. Head Trauma Management
Drug Therapy Considerations
Furosemide (Lasix®)
○Loop diuretic
○Decreases cerebral edema
○May cause hypovolemia
○Often reserved for herniation

100. Head Trauma Management
 Drug Therapy Considerations
Diazepam (Valium®)
○Anticonvulsant
○Give if patient experiences seizures
○May mask changes in LOC
○May depress respirations
○May worsen hypotension

101. Head Trauma Management
Drug Therapy Considerations
Glucose
○Assess blood glucose
○Administer only if hypoglycemic

102. Head Trauma Management
Transport Considerations
Trauma Center
○GCS < 12
Evidence of herniation
Unconscious
Multisystem trauma with head trauma
Consider comorbid factors

103. Head Trauma Management
 Helmet Removal
 Immediate removal if interferes with priorities
○ access to airway or airway management
○ ventilation
○ cervical spine motion restriction
 May only need to remove face piece to access airway
 Consider interference with SMR
 Technique
○ requires adequate assistance
○ training in the procedure
○ padding if shoulder pads left on