Chapter 24 Injuries to the Head and Spine Learning Objectives State components of the nervous system List functions of the central nervous system Define structure of the skeletal system as it relates to the nervous system Relate MOI to potential spinal injuries Describe implications of not properly caring for patients with potential spinal injuries 2 Learning Objectives State signs/symptoms of potential spinal injury Describe method of determining whether responsive patient may have spinal injury Describe airway emergency medical care techniques for patient with suspected spinal injury Describe how to stabilize cervical spine 3 1
Learning Objectives Establish relationship between airway management and a patient with head/spinal injuries Relate MOI to potential head injuries Explain rationale for using rapid extrication approaches only when making difference between life & death Describe indications for rapid extrication 4 Learning Objectives List steps for performing rapid extrication Identify different helmet types Describe unique characteristics of sports helmets Explain preferred methods to remove helmets Describe how patient s head is stabilized to remove helmet 5 Introduction Emergency care goal: ensure brain viability Majority trauma deaths result from direct injury to nervous system Brain - control center for other vital organ systems Respiration Circulation Dysfunction results in: Cardiopulmonary failure Death 6 2
Introduction Nervous system - center for consciousness Intellectual, emotional, behavioral functions that make up characteristics of personality, human behavior Receives and interprets stimuli from internal & external environment Directs & regulates other organs & tissues Some activities are conscious; much is unconscious or involuntary 7 Anatomy & Physiology Nervous system composed of central nervous system (CNS) & peripheral nervous system (PNS) CNS - computer Receives information about outside environment & functions within body Organizes, analyzes information Directs activity of organs, muscles, other tissues Receives, transmits information by nerves or special tracts of nerve tissues that extend through CNS, extend into PNS 8 Anatomy & Physiology Nervous system composed of CNS, PNS PNS - communicator Composed of nerves outside CNS, extend from brainstem, spinal cord Sensory nerves carry messages to spinal cord, brain Motor nerves carry messages back to muscles, organs 9 3
Anatomy & Physiology CNS Brain, spinal cord Central computer Processes sensory input from sensory nerves Organizes responses Transmits to body by outgoing motor nerves 10 Anatomy & Physiology 11 Anatomy & Physiology CNS Brain Cerebrum Divided into hemispheres Hemispheres divided into lobes Frontal lobe Parietal lobe Occipital lobe Temporal lobe 12 4
Anatomy & Physiology 13 Anatomy & Physiology CNS Brain Brainstem Lower part of brain Made up of bundles and tracts of nerves traveling down to spinal cord from cerebrum Some nerve centers located in brainstem control muscles of eyes and iris Distinct nerve cell centers of its own Communicates by cranial nerves 14 Anatomy & Physiology CNS Brain Cerebellum Outpocketing of brain located posterior to brainstem 15 5
Anatomy & Physiology CNS Spinal cord Emerges from brainstem, is a continuation of nerve tracts from all parts of brain Has own processing centers Reflex action 16 Anatomy & Physiology CNS Protection of brain & spinal cord Protected, encased within strong bones that make up skull, vertebral column 3 layers of membranes under bones separate bone from brain and spinal cord Offer more protection 17 Anatomy & Physiology CNS Protection of brain & spinal cord Cerebrospinal fluid (CSF) Between 2 innermost membranes Absorbs shocks Adds layer of protection Provides nutrition to cells Clear and colorless, also provides some nutrition to nerve cells 18 6
Anatomy & Physiology CNS Protection of brain & spinal cord Skull Face, lower jaw, mandible Cranium bones are flat, irregularly shaped Bones, outer cranium surface 19 Anatomy & Physiology 20 Anatomy & Physiology 21 7
Anatomy & Physiology CNS Protection of brain & spinal cord Skull After birth and during infancy, bones do not meet, soft spots present Cerebrum - largest part of brain Foramen magnum - opening in the midline base of skull Space within cranium holds 1 L of fluid After infancy, when cranial bones fuse, cranial space is nonexpandable 22 Anatomy & Physiology CNS Protection of brain & spinal cord Skull Filled almost entirely with brain tissue Remaining contents: spinal tissue and circulating blood If bleeding occurs, pressure transmitted to brain tissue Brain tissue is susceptible to pressure, can result in loss of brain function Severe pressure; brain may herniate through foramen magnum 23 Anatomy & Physiology CNS Protection of brain & spinal cord Spinal column 33 vertebra, extending from base of skull to coccyx 24 8
Anatomy & Physiology CNS Protection of brain & spinal cord Spinal column Held together by ligaments Separated by cartilaginous disks Ligaments allow movement, maintain proper alignment of vertebral column Spinal vertebrae, named according to location and structure, starting from head 25 Anatomy & Physiology CNS Protection of brain & spinal cord Spinal column Vertebrae have anterior body, posterior spinous process, allows for ligament attachment Arcs of bone connect body, spinous process of each vertebra Each vertebra has openings where peripheral nerves travel to body 26 Anatomy & Physiology CNS Protection of brain & spinal cord Membranous coverings Also called meninges 3 layers CSF circulates between arachnoid and pia mater 27 9
Anatomy & Physiology 28 Anatomy & Physiology CNS Protection of brain & spinal cord Cerebrospinal fluid Helps protect, cushion brain Acts like a liquid shock absorber Continually being formed and absorbed from blood-rich plexuses Serves nutritional role as it circulates around brain, spinal cord 29 Anatomy & Physiology Peripheral nervous system Each spinal nerve has sensory & motor components 1 spinal nerve leaves each side of vertebral column 31 pairs spinal nerves together with 12 cranial nerves leaving brainstem compose PNS As an EMT, you are expected to test motor function & muscle strength of lower & upper extremities 30 10
Anatomy & Physiology Peripheral nervous system Dermatomes Nerves exiting from nearby segments of vertebral column innervate particular segments of skin Sensory components of nerves follow dermatome patterns Same true for skeletal muscles Patients can present with no sensation below level of injury 31 Anatomy & Physiology 32 Function of Nervous System Nervous system divided by function Voluntary or somatic nervous system Connects CNS with sensory and motor nerves that direct conscious activities Involuntary or autonomic nervous systems Controls vital body functions Divided into parasympathetic, sympathetic 33 11
Function of Nervous System O 2 & glucose - essential nutrients of CNS Needs adequate O 2 supply Patients who are hypoxic have altered brain function or AMS If finding of AMS Question whether adequate O 2 being delivered to brain Glucose - another essential nutrient of CNS If levels too low, may have altered brain function Ranging from agitation to coma 34 Function of Nervous System Nerve cells and pressure Sensitive to pressure Outside force applied to nerves, function compromised Amount of pressure and length of time affect amount of nerve damage 35 Head injuries associated with spinal injuries Assessment of head and spinal injuries are integrated into approach to patient MOI Most injuries to spinal cord occur because of damage to spinal column that protects cord 36 12
MOI Spinal column can be crushed, displaced in any direction, or broken Most common site of injuries; where vertebrae that allow motion meet fixed vertebra Thoracic vertebrae are fixed by ribs and allows little motion Cervical vertebrae; highly mobile, allowing greater range of motion of head and neck 37 MOI Specific MOI Maintain level of suspicion when approaching injured patients Understand dynamic forces set in motion after impact Most spinal cord injuries are closed injuries 38 MOI Specific MOI Compression injuries 1 vertebra driven onto another Compress vertebrae to the point bones are crushed 39 13
40 MOI Specific MOI Flexion Injuries Involve fixed and mobile vertebrae Head driven forward by sudden deceleration or force applied to back of skull Adjacent vertebrae wedged together anteriorly, resulting fracture to body of vertebra Deceleration forces place maximal stress on thoracic and lumbar vertebra 41 42 14
MOI Specific MOI Extension injuries Head is suddenly jolted backward Anterior ligaments supporting spine tear Whiplash injury term used to describe hyperextension of neck 43 MOI Specific MOI Other forces that may injure spine Distraction forces hanging Gunshot wounds Knife wounds When spinal injury suspected, appropriately immobilize Reconstruct MOI during scene size-up No external evidence of injury; MOI provides rationale for immobilization and treatment 44 45 15
Determine whether spinal injury exists Determine and document level injury Scene size-up 46 Initial (primary) assessment Gain access, initiate essential treatment No immediate danger to life Lifesaving measures are needed Spinal injury suspected Signs of inadequate ventilation, circulation; lifethreatening conditions 47 Focused (secondary) assessment Reconstruct MOI, events leading to injury Ask bystanders or witnesses Condition of patient determines if history can be obtained at same time treatment rendered 48 16
Focused (secondary) assessment Important questions and observations When did injury occur? What was position at time of injury? Was patient thrown on impact? MVCs? Did patient lose consciousness before injury? Did patient experience period of cyanosis or apnea? Falls - estimate height of fall, surface struck on landing Do you suspect drug or alcohol use? What is previous medical history? 49 Rapid trauma assessment Pay special attention to spine Use log roll to assess spine for tenderness or deformities Look for other signs of injury (DCAP/BTLS) Important questions What happened? Does neck or back hurt? Where does it hurt? Can you move hands and feet? Can you feel me touching your fingers and toes? 50 Rapid trauma assessment Perform brief examination of sensory and motor functions before transport 51 17
Rapid trauma assessment Systematic examination; important to identify level of injury and compare 1 side to other Check arms, starting at hands Have patient grasp your fingers in palm of one hand 52 Rapid trauma assessment Systematic examination; important to identify level of injury and compare 1 side to other Check sensation in lower extremities Assess motor function of lower extremities Note muscle strength as absent, weak, or present 53 54 18
Special assessment considerations Respirations Respiratory function - major concern Rate, depth of respirations Type of breathing All nerves that innervate respiratory muscles pass through cervical and thoracic portions of spinal column 55 Special assessment considerations Respirations Diaphragm - main muscle of respiration Nerves from 2 nd to 8 th thoracic vertebrae innervate intercostal muscles (T2 to T8) Nerves from T8 tot12 innervate abdominal muscles If spinal cord damaged at level of C3, all muscles of respiration paralyzed 56 Special assessment considerations Respirations Injuries at or above C5, loss of intercostals, diaphragmatic breathing only 57 19
Special assessment considerations Pulse & BP Spinal injury can alter findings Spinal cord severed at or above upper thoracic level Sympathetic nerves control tone of blood vessels 58 Special assessment considerations Pulse & BP Neurogenic shock Trauma causing cord damage may cause other injuries 59 Special assessment considerations Priapism Sustained penile erection Condition explained by loss of sympathetic influence Bladder and bowel functions altered 60 20
Special assessment considerations Unresponsive patient Rely on MOI, history from bystanders Perform initial assessment Rapid trauma assessment Injury, related signs Perform thorough physical exam, identify hidden injuries 61 Ongoing assessment Repeat sensorimotor examination, mental status assessment, vital signs Record findings on PCR Specifically note changes in motor or sensory function level 62 Management Airway AMS or evidence of neurologic dysfunction Give high-concentration O 2 If doubt exists about inadequate ventilations Assist with PPV Have suction ready to clear airway while head is immobilized 63 21
Injury to Spine Management Stabilization of c-spine Ensure open airway Maintain manual inline stabilization until fully immobilized Immobilize before moving 64 65 Disruption of brain blood supply Traumatic or medical conditions Direct blow Loss of vital nutrients Drugs 66 22
Structural injuries Disruption of specific sections of brain tissue or nerves; results in loss of specific functions Injuries that involve specific areas Injuries may be traumatic or non-traumatic Example: Stroke If findings are asymmetrical, one side of body may be affected while the other is not 67 Metabolic injuries Energy necessary for cell function compromised Example: Lack of O 2 after cardiac arrest Symptoms Loss of consciousness No response to stimuli or pain No ability to move Loses control of vital functions Affect CNS tissues equally Both sides of brain affected 68 Secondary complications Brain injury Hypoxia Hypotension Hypoglycemia Infections Increased ICP 69 23
Secondary complications Hypoxia Unconscious with head trauma, obstructed airway May have both head injury and injury to respiratory system or chest wall Pulse oximetry determines oxygenation 70 Secondary complications Hypotension Aggravates brain injury by decreasing brains perfusion with oxygenated blood Signs of hypovolemic shock present Spinal injury can lead to hypotension, caused by vasodilation BP stabilization ALS intercept/rapid transport 71 Secondary complications Hypoglycemia May precede traumatic brain injury; assess glucose level in patient Increased intracranial pressure Skull space confined, additional content increases pressure Can occur after recovery from initial event 72 24
Secondary complications Infection Open skull fracture Head injury & cervical spine injury Paralysis and death are possible if cervical spine fracture not handled properly Suspect all patients with head injury might also have cervical spine injury 73 Scalp wounds Result from head injuries Skull fractures and injury to brain may or may not be present Scalp has numerous small blood vessels Best controlled with direct pressure Can bleed to death Hypotensive 74 75 25
Skull fractures Significant force required Does not mean brain damage has occurred May have few or no signs of injury No fracture, still may have lethal injury Temporal area, causes severe damage Middle meningeal artery travels along groove on inside surface of temporal bone 76 77 Skull fractures Open Skin over fracture is not intact, allowing communication between outside environment and meninges Increased infection risk Closed Skin above fracture intact 78 26
Skull fractures Types of skull fractures Simple lines or cracks Depression of skull fragments into brain Confused with hematoma, both have soft center easily depressed on palpation 79 80 Skull fractures Types of skull fractures Injuries to base or floor of skull 81 27
Traumatic brain injuries Concussion Transient loss of consciousness or neurologic function from blow to brain Blow sends shock waves that temporarily disrupt brain function 82 Traumatic brain injuries Concussion Degrees Least severe, most common; momentary loss of function, immediately after impact More severe injuries cause direct damage, bruising, contusion of brain Bleeding can occur after head injury 83 Traumatic brain injuries Increased intracranial pressure (ICP) Signs and symptoms Headaches Nausea Vomiting Level of consciousness may begin to deteriorate; most sensitive indicator Children experience drowsiness, nausea, vomiting after minor head injuries 84 28
Traumatic brain injuries Eye & motor findings As ICP increases, brain forced down through opening in skull base Eye nerves leave brainstem at this area, the are compressed between herniating brain and bony structures Eye findings Dilated pupil on 1 side May not constrict with light Eyelid may begin to droop 85 Traumatic brain injuries Eye & motor findings Nerve tracts bearing sensory, motor nerves to entire body can be compressed 1-sided weakness, paralysis, sensory loss or combination of findings As pressure increases, sensorimotor findings may extend to both sides 86 Traumatic brain injuries Eye & motor findings Further deterioration, may assume abnormal body positions or postures Classic postures If brain herniation continues With transmission of more ICP to brainstem, centers controlling vital functions affected 87 29
88 Traumatic brain injuries Respirations Abnormal respiratory patterns indicate damage to different levels of brain Describe patterns during presentation to hospital personnel 89 Traumatic brain injuries Pulse & BP Late sign of ICP; increasing BP with slow pulse Effort to restore perfusion by drastic increase in systolic BP to overcome increased ICP BP receptors outside head note increased BP, signal for slower heart rate Leads to increased BP and slower pulse Bleeding can also occur within the coverings of the brain inside the skull, exerting more pressure on brain 90 30
Traumatic brain injuries Epidural hematoma Laceration of arteries along inner surface of cranium can lead to hematomas in space outside dura 91 Traumatic brain injuries Epidural hematoma Early recognition of signs, increased ICP important Bleeding must be stopped, clot surgically evacuated Typically present with short period of unconsciousness after blunt trauma to head Some do not have initial LOC Within short time Death occurs if untreated Blow itself is not cause of deterioration 92 Traumatic brain injuries Subdural hematoma Veins rupture under dura, bleeding confined to space between dura & arachnoid membrane Because of speed cranium hematomas cause death, early transport necessary Hospital relies on accurate, knowledgeable record of: MOI Initial signs/symptoms Subsequent evaluations of status en route Responsible for complete report 93 31
94 Traumatic brain injuries MOI More than ½ head injuries in United States are the result of MVCs Other common sources: Falls Home accidents Sports accidents Penetrating wounds from knives and guns 95 MOI Blunt trauma Either static or dynamic forces cause head injury Most blunt head injuries are a combination of both mechanisms Static injury Dynamic injury Effects may occur on opposite side of brain Effects of static, dynamic forces are additive 96 32
MOI Penetrating trauma Most gunshot or knife wounds 97 Scene size-up Determine MOI MVCs Estimated speed of impact Point of impact Position of patient in vehicle Seat belt usage 98 Initial assessment ABCs Assume c-spine injury Stabilize c-spine manually Airway maneuver of choice - modified jaw thrust Insert OPA or NPA for unconscious patient Suction to aid keeping airway clear AVPU 99 33
Glasgow Coma Scale (GCS) Assesses eye opening, verbal response, & motor ability Designed for patients with head trauma Also useful for evaluating & describing neurologic status of all unresponsive patients Enables health personnel to speak same language 100 Glasgow Coma Scale Intended for patients with AMS Stimuli applied sequentially Start with verbal questions, commands Painful stimuli, if no response 101 Glasgow Coma Scale Eye opening Open on arrival or open spontaneously without being stimulated = 4 Open on verbal command = 3 Open after painful stimuli = 2 Do not open in response to pain = 1 102 34
Glasgow Coma Scale Verbal response Alert, oriented = 5 Confused but able to respond in conversational manner = 4 Cannot maintain conversation, gives inappropriate responses = 3 Incomprehensible sounds = 2 Does not respond verbally at all = 1 103 Glasgow Coma Scale Motor response Appropriately responds to verbal motor commands = 6 Assumption patient has no fractures or wounds affecting motor function related to commands Measures brain function, not status of other components needed to move 104 Glasgow Coma Scale Painful stimuli Can localize pain, reach for or remove source = 5 Pulls away from pain stimulus = 4 Respond with flexion of 1 or both arms Deeper coma or more extensive brain damage No response = 1 Apply pain stimulus on each side, response does not have to be bilateral 105 35
Glasgow Coma Scale Scoring approach Describe patient, record findings according to subcomponents of GCS score Follow systematic approach Start with eye check, verbal response with series of questions No response to verbal commands, provide painful stimuli, use nail bed pressure 106 Glasgow Coma Scale Infant Glasgow Coma Scale Used because of limited communication skills Questions appropriate for infant s communication level recommended 107 Glasgow Coma Scale Special situations Cannot be assessed for all 3 GCS components; communicate components of score that can be assessed ET tube in airway, score noted as follows Massive injuries about eyes, score noted 108 36
Focused assessment Remain alert for signs/symptoms of brain/skull injury 109 Focused assessment Head & scalp Examine for signs of fractures, such as wounds, swelling, crepitus, other deformities Signs of injury (DCAP/BTLS) Gently palpate swellings, depressed skull fractures may be present Direct pressure to control bleeding Look carefully for features, raccoon eyes, Battle s sign Drainage from ears and nose 110 Focused assessment Pupils Always check, give an indication of brainstem function Easily and readily evaluated Have good reliability Size Equal size Reaction to light 111 37
Focused assessment Motor & sensory examination Neurologic examination in field should be brief Touch on each side; hands then feet Ask to move both hands, then feet Assess sensation of patients with AMS by applying painful stimulus to hands, feet 112 Focused assessment Vital signs Brain controls regulation of temperature Increase in BP with slowing pulse; raise suspicion of increased ICP 113 Focused assessment SAMPLE history When did injury occur? Was there immediate loss of consciousness? Was injury direct blow? Was there a documented period of respiratory arrest or cyanosis at scene? Did presence of blood at scene suggest severe blood loss? Is patient at risk for hypovolemic shock from scalp laceration? Any known diseases that may have contributed to injury? 114 38
Ongoing assessment Repeat neurologic examination, vital signs Prehospital phase of treatment important for ED staff, neurosurgeon Repeat every 5 to 10 minutes Include mental status, vital signs, eye findings, sensory and motor function 115 Management Body substance isolation Ensure open airway Adequate ventilations Effective circulation Airway 116 Management Ventilations Inadequate, assist with bag-mask or other ventilation device Maintain cervical immobilization Good ventilations ensures adequate supply of O 2 and prevents buildup of CO 2 Hypoventilation when CO 2 level in blood increases, cerebral vessels dilate, allow less blood flow to brain 117 39
Management Ventilations Brain Trauma Foundation developed criteria for hypoventilating in field that suggests probability of severe traumatic brain injury, herniation: Includes unconscious, unresponsive patient 118 Management Circulation Treatment of shock, high priority Head injury wounds, take care when applying direct pressure to avoid compounding depressed skull fractures 119 120 40
Immobilization Evaluate head injuries for spinal injuries, treat accordingly Conscious with isolated head injury or nontraumatic brain injury, no suspicion of neck injury Spinal immobilization necessary, long spine board required; supine position is position of choice Nontraumatic or isolated brain injury, use recovery position 121 Immobilization Cervical collars Helps immobilize spine Limit flexion, extension, lateral neck movement Soft foam filled, rigid plastic Proper sizing 122 Immobilization Spine board Essential for lifting, moving suspected spine injuries Several varieties used 123 41
Skill 24-1: Placing Patient on Long Board - Log Roll Apply cervical collar, place patient s arms by side/across chest 1 EMT maintains manual cervical stabilization throughout 124 Skill 24-1: Placing Patient on Long Board - Log Roll Position 3 EMTs at patient s side at level of chest, hips & lower extremities Position long spine board on other side of patient 125 Skill 24-1: Placing Patient on Long Board - Log Roll On command from EMT at head, all rotate patient toward themselves, keeping body in alignment Reach across with 1 hand, pull board toward patient 126 42
Skill 24-1: Placing Patient on Long Board - Log Roll On command from EMT at head, gently roll patient onto board, then roll board to ground 127 Skill 24-1: Placing Patient on Long Board - Log Roll Strap patient s torso, extremities securely to board Immobilize head with head immobilizer or tape 128 Immobilization Kendrick Extrication Device (KED) Short spine board Semirigid form permits easy, speedy application Effective immobilization of spine when secured properly Immobilizes patients found in sitting position 129 43
Skill 24-2: Applying Kendrick Extrication Device 1 EMT maintains cervical spine stabilization from behind patient Apply rigid cervical collar 130 Skill 24-2: Applying Kendrick Extrication Device Position KED behind patient 131 Skill 24-2: Applying Kendrick Extrication Device Pull up KED securely into axillary region 132 44
Skill 24-2: Applying Kendrick Extrication Device Attach chest, abdominal straps securely without hindering breathing Attach groin straps last 133 Skill 24-2: Applying Kendrick Extrication Device Secure head by using Velcro fasteners Padding may be necessary 134 Rapid extrication Removed quickly from vehicle, evacuated directly onto long spine board Recommended through Prehospital Trauma Life Support program, requires at least 3 providers Used with critical, life-threatening injuries, found in sitting position in vehicle 135 45
Spinal immobilization of standing patient Immobilized in rapid takedown procedure, if suspected spinal injury and found upright at scene If MOI is sufficient to cause spinal injury, procedure can be used to secure patient to spine board 136 Skill 24-3: Immobilizing Spine of Standing Patient Position EMT taller than patient behind patient Manually stabilize patient s head, neck 137 Skill 24-3: Immobilizing Spine of Standing Patient 2 nd EMT applies c-collar to patient 138 46
Skill 24-3: Immobilizing Spine of Standing Patient 2 nd EMT carefully positions long board behind patient, working around EMT applying manual stabilization 139 Skill 24-3: Immobilizing Spine of Standing Patient 2 nd EMT ensures long board is centered behind patient 140 Skill 24-3: Immobilizing Spine of Standing Patient Tilt board back, patient suspended temporarily by armpits Grasp board at elbow level with other hand, hold arm next to patient s body 141 47
Skill 24-3: Immobilizing Spine of Standing Patient Same technique performed with 2 EMTs 142 Helmet removal Familiar with special assessment needs, indications, contraindications Proper procedure to avoid movement of cervical spine 1 st concern; assessment and management of airway and ventilation Helmet may prevent proper spinal immobilization 143 Skill 24-4: Removing Helmet 1 EMT stabilizes helmet by placing hands on each side, with fingers on patient s mandible to prevent movement 2 nd second EMT loosens helmet strap 144 48
Skill 24-4: Removing Helmet 2 nd EMT places 1 hand on mandible at angle of jaw, other hand posteriorly at occipital region EMT holding helmet pulls sides of helmet apart, gently slips helmet halfway off patient s head, then stops 145 Skill 24-4: Removing Helmet EMT stabilizing neck repositions, sliding posterior hand superiorly to secure head from falling back after complete helmet removal Completely remove helmet 146 Skill 24-4: Removing Helmet EMT who removed helmet assumes inline stabilization of c-spine, occiput padded as needed 147 49
Injuries to the Head Immobilization of infants & children Require same attention to spinal immobilization as adults 148 Injuries to the Head Immobilization of infants & children C-collars, long/short spine boards, rapid extrication procedures, helmet removal techniques, are all appropriate approaches to spinal immobilization Important to pad spine boards from shoulders to heels of infants & small children 149 Injuries to the Head Immobilization of infants & children If c-collar does not properly fit, use rolled towel & tape If found in car seats, and assessment, treatment, immobilization can be accomplished, transport in seat 150 50
Summary Nervous system includes Central nervous system CNS: brain, spinal cord Peripheral nervous system PNS: motor, sensory nerves Cerebrum divided into areas by function Frontal lobe - motor, intellectual functions Parietal lobe - sensation Temporal lobe - hearing, smell Occipital lobe - vision 151 Summary Autonomic nervous system concerned with involuntary activities such as control of HR, BP, respiration, digestion, consists of parasympathetic/sympathetic divisions 2 membranous coverings around brain are meninges (dura mater, arachnoid, pia mater) CSF contained in space formed by arachnoid & pia mater 152 Summary Brain protected by bones of skull (frontal, parietal, temporal, occipital), face (nasal, maxilla, mandible) Spinal cord protected by spinal vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal) Spinal injuries can occur from compression forces, flexion injuries, extension injuries, penetrating injuries, including stab wounds, missile injuries 153 51
Summary Suspect & treat spinal injuries in all unconscious trauma patients, significant MOI such as MVC, fall/penetrating injury to head/face Signs/symptoms of spinal cord injury Tenderness in area Pain associated with/without movement Soft tissue injuries of head, spine, shoulder Numbness, weakness, tingling in extremities Loss of sensation/paralysis below level of injury/extremities Incontinence 154 Summary Injuries to brain may be structural (injuries/disruptions to specific area of brain) or metabolic (hypoxia, hypoglycemia, infection) Structural injuries may cause unilateral signs Metabolic injuries affect all portions of brain equally; result in global physical findings Secondary complications that occur after brain injury include hypoxia, hypotension, hypoglycemia, increased intracranial pressure, infection 155 Summary Skull fractures may include simple lines/breaks in bone/may be depressed downward toward brain. May involve base of skull, as seen with raccoon eyes or Battle s sign Concussion - sudden, temporary loss of consciousness or neurologic function from blow to brain 156 52
Summary Signs of increased ICP include: Headaches Nausea/vomiting (projectile) Specific respiratory patterns Rising BP Slowing of pulse Dilating pupils Changes in GCS 157 Summary GCS is standardized method for documenting neurologic function (measures eye opening (score 1 to 4), verbal response (score 1 to 5), motor response (score 1 to 6) Measurement of motor & sensory function of extremity can help identify structural causes of brain injury 158 Summary Care for suspected spinal injury patient should include maintaining inline immobilization, using modified jaw thrust to open airway, immobilizing with cervical collar & spinal immobilization device Patients in MVC with significant MOI/other evidence of spinal injury should be immobilized before removal unless patient is unstable Critical patients from MVC should be removed using rapid extrication procedure 159 53
Questions? 160 54