Last saved by: JRGinder

Chapter 26
Head and Spine Injuries
National EMS Education Standard Competencies (1 of 4)
Trauma
Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.
National EMS Education Standard Competencies (2 of 4)
Head, Facial, Neck, and Spine Trauma
•	Recognition and management of
–	Life threats
–	Spine trauma

National EMS Education Standard Competencies (3 of 4)
Head, Facial, Neck, and Spine Trauma (cont’d)
•	Pathophysiology, assessment, and management of
–	Spine trauma
–	Skull fractures

National EMS Education Standard Competencies (4 of 4)
Nervous System Trauma
•	Pathophysiology, assessment, and management of 
–	Traumatic brain injury
–	Spinal cord injury
Introduction (1 of 2)
•	The nervous system is a complex network of nerve cells that enables all parts of the body to function.
•	It includes:
–	Brain
–	Spinal cord
–	Several billion nerve fibers
Introduction (2 of 2)
•	The nervous system is well protected.
–	The brain is protected by the skull.
–	The spinal cord is protected by the spinal canal.
•	Despite this protection, serious injuries can damage the nervous system.
Anatomy and Physiology (1 of 2)
•	The nervous system is divided into two anatomic parts.
–	Central nervous system
–	Peripheral nervous system
Anatomy and Physiology (2 of 2)
Central Nervous System (1 of 9)
•	Includes the brain and spinal cord
•	The brain controls the body, and is also the center of consciousness.
•	Brain is divided into three major areas:
–	Cerebrum
–	Cerebellum
–	Brain stem
Central Nervous System (2 of 9)
Central Nervous System (3 of 9)
•	Cerebrum
–	Controls a wide variety of activities, including most voluntary motor function and conscious thought
–	Contains about 75% of the brain’s total volume
–	Divided into two hemispheres with four lobes
Central Nervous System (4 of 9)
•	Cerebellum
–	Coordinates balance and body movements
•	Brain stem
–	Controls most functions necessary for life
–	Most primitive part of the CNS
–	Best-protected part of the CNS
Central Nervous System (5 of 9)
•	Spinal cord
–	Made up of fibers that extend from the brain’s nerve cells
–	Carries messages between the brain and the body via the grey and white matter of the spinal cord
Central Nervous System (6 of 9)
•	Protective coverings
–	The entire CNS is contained within a protective framework.
–	The thick, bony structures of the skull and spinal canal withstand injury very well.
–	The CNS is further protected by the meninges.
Central Nervous System (7 of 9)
•	Meninges
–	Outer layer (dura mater) is a tough, fibrous layer that forms a sac to contain the CNS
–	Inner two layers (arachnoid and pia mater) contain the blood vessels
Central Nervous System (8 of 9)
Central Nervous System (9 of 9)
•	Cerebral spinal fluid (CSF)
–	Produced in a chamber inside the brain called the third ventricle
–	Approximately 125 to 150 mL of CSF in the brain at one time
–	Primarily acts as a shock absorber
Peripheral Nervous System 
(1 of 5)
•	31 pairs of spinal nerves
–	Conduct impulses from the skin and other organs to the spinal cord
–	Conduct motor impulses from the spinal cord to the muscles
–	The spinal nerves serving the extremities are arranged in complex networks.
Peripheral Nervous System 
(2 of 5)
Peripheral Nervous System 
(3 of 5)
•	12 pairs of cranial nerves
–	Transmit information directly to or from the brain
–	Perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions

Peripheral Nervous System 
(4 of 5)
•	Two types of peripheral nerves
–	Sensory nerves
•	Carry only one type of information from the body to the brain via the spinal cord
–	Motor nerves
•	One for each muscle
•	Carry information from the CNS to the muscles

Peripheral Nervous System 
(5 of 5)
•	Connecting nerves
–	Found only in the brain and spinal cord
–	Connect the sensory and motor nerves with short fibers
–	Allow the exchange of simple messages
How the Nervous System Works (1 of 5)
•	Controls virtually all the body’s activities, including:
–	Reflex activities
–	Voluntary activities
–	Involuntary activities
How the Nervous System Works (2 of 5)
•	Connecting nerves in the spinal cord form a reflex arc
–	If a sensory nerve in this arc detects an irritating stimulus, it bypasses the brain and sends the message directly to a motor nerve.
How the Nervous System Works (3 of 5)
How the Nervous System Works (4 of 5)
•	Voluntary activities are activities we consciously perform.
•	Involuntary activities are the actions that are not under conscious control.
•	Somatic (voluntary) nervous system handles voluntary activities

How the Nervous System Works (5 of 5)
•	Autonomic (involuntary) nervous system handles body functions
–	Divided into two parts: sympathetic and parasympathetic nervous systems
–	Sympathetic nervous system reacts to stress with a fight-or-flight response
–	Parasympathetic nervous system has the opposite effect on the body
Skeletal System (1 of 5)
•	Skull
–	Composed of two groups of bones: the cranium, which protects the brain, and the facial bones
Skeletal System (2 of 5)
•	Skull (cont’d)
–	Cranium is composed of 80% brain tissue, 
10% blood supply, and 10% CSF
–	Four major bones make up the cranium: occiput, temples, parietal regions, and frontal region
–	Face is composed of 14 bones
Skeletal System (3 of 5)
•	Spinal column
–	Body’s central supporting structure
–	Has 33 bones called vertebrae
–	Divided into five sections:
•	Cervical
•	Thoracic
•	Lumbar
•	Sacral
•	Coccygeal
Skeletal System (4 of 5)
Skeletal System (5 of 5)
•	Spinal column (cont’d)
–	Injury to the vertebrae can result in paralysis.
–	Vertebrae are connected by ligaments and separated by cushions, called intervertebral disks
–	Spinal column is almost entirely surrounded by muscles
Head Injuries (1 of 4)
•	Traumatic insult to the head that may result in injury to soft tissue, bony structures, or the brain
•	52,000 deaths occur annually in the United States as the result of severe head injury.
•	Account for more than half of all traumatic deaths
Head Injuries (2 of 4)
•	Closed injuries
–	The brain has been injured but there is no opening into the brain.
•	Open injuries
–	An opening from the brain to the outside world exits.
–	Often caused by penetrating trauma
–	May be bleeding and exposed brain tissue
Head Injuries (3 of 4)
•	Motor vehicle crashes are the most common MOI.
–	Head injuries also commonly occur:
•	In victims of assault
•	When elderly people fall
•	During sport-related incidents
•	In a variety of incidents involving children
–	Any head injury is potentially serious.
Head Injuries 
(4 of 4)
Scalp Lacerations
•	Can be minor or serious
•	Even small lacerations can lead to significant blood loss.
–	This blood loss may be severe enough to cause hypovolemic shock.
•	They are often an indicator of deeper, more serious injuries.
Skull Fracture (1 of 7)
•	Significant force applied to the head may cause a skull fracture.
•	May be open or closed, depending on whether there is an overlying laceration of the scalp
•	Injuries from bullets or other penetrating weapons often result in skull fractures.
Skull Fracture (2 of 7)
•	Signs of skull fracture include:
–	Patient’s head appears deformed
–	Visible cracks in the skull
–	Ecchymosis (bruising) that develops under the eyes (raccoon eyes)
–	Ecchymosis that develops behind one ear over the mastoid process (Battle’s sign)
Skull Fracture (3 of 7)
Skull Fracture (4 of 7)
•	Linear skull fractures
–	Account for about 80% of all skull fractures
–	Radiographs are often required to diagnose a linear skull fracture because there are often no physical signs.
Skull Fracture (5 of 7)
•	Compressed skull fractures
–	Result from high-energy direct trauma to the head with a blunt object
–	Frontal and parietal bones are most susceptible
–	Bony fragments may be driven into the brain
Skull Fracture (6 of 7)
•	Basilar skull fractures
–	Associated with high-energy trauma
–	Usually occur following diffuse impact to the head
–	Signs include CSF drainage from the ears, raccoon eyes, and Battle’s sign
Skull Fracture (7 of 7)
•	Open skull fractures
–	Result when severe forces are applied to the head
–	Often associated with trauma to multiple body systems
–	Brain tissue may be exposed to the environment
Traumatic Brain Injuries (1 of 3)
•	Most serious of all head injuries
•	Two broad categories: primary (direct) injury and secondary (indirect) injury
–	Primary brain injury results instantaneously from impact to the head.
–	Secondary brain injury increases the severity of the primary injury.
Traumatic Brain Injuries (2 of 3)
•	Secondary injury may be caused by:
–	Hypoxia
–	Hypotension
–	Cerebral edema
–	Intracranial hemorrhage
–	Increased intracranial pressure
–	Cerebral ischemia
–	Infection
Traumatic Brain Injuries (3 of 3)
•	The brain can be injured directly by a penetrating object or indirectly as a result of external forces.
•	A coup-countercoup injury can result from striking a windshield.
–	Initial impact injures front part of brain
–	Head falling back against headrest injures rear part of brain
Intracranial Pressure (1 of 7)
•	Accumulations of blood within the skull or swelling of the brain can rapidly lead to an increase in ICP.
–	Increased ICP squeezes the brain against bony prominences within the cranium.

Intracranial Pressure (2 of 7)
Intracranial Pressure (3 of 7)
•	Intracranial hemorrhage
–	Bleeding inside the skull also increases the ICP.
–	Bleeding can occur:
•	Between the skull and dura mater
•	Beneath the dura mater but outside the brain
•	Within the tissue of the brain itself
Intracranial Pressure (4 of 7)
•	Epidural hematoma
–	Accumulation of blood between the skull and dura mater
–	Nearly always a result of a blow to the head that produces a linear fracture
Intracranial Pressure (5 of 7)
•	Subdural hematoma
–	Accumulation of blood beneath the dura mater but outside the brain
–	Occurs after falls or injuries involving strong deceleration forces
Intracranial Pressure (6 of 7)
•	Intracerebral hematoma
–	Bleeding within the brain tissue itself
–	Can occur following a penetrating injury to the head or because of rapid deceleration forces
Intracranial Pressure (7 of 7)
•	Subarachnoid hemorrhage
–	Bleeding occurs into the subarachnoid space, where the CSF circulates
–	Results in bloody CSF and signs of meningeal irritation
–	Common causes include trauma or rupture of an aneurysm.
Concussion (1 of 4)
•	A blow to the head or face may cause concussion of the brain.
–	Closed injury with a temporary loss or alteration of part or all of the brain’s abilities to function without demonstrable physical damage to the brain
–	About 90% of patients do not experience a loss of consciousness.
Concussion (2 of 4)
•	A patient with a concussion may be confused or have amnesia.
•	Usually a concussion lasts only a short time.
•	Ask about these symptoms:
–	Dizziness
–	Weakness
Concussion (3 of 4)
•	Ask about these symptoms (cont’d):
–	Visual changes
–	Nausea and vomiting
–	Ringing in the ears
–	Slurred speech
–	Inability to focus
–	Lack of coordination
Concussion (4 of 4)
•	Ask about these symptoms (cont’d):
–	Delay of motor functions
–	Inappropriate emotional responses
–	Temporary headache
–	Disorientation
Contusion
•	Far more serious than a concussion
•	Involves physical injury to brain tissue
•	May sustain long-lasting and even permanent damage
•	A patient may exhibit any or all of the signs of brain injury.
Other Brain Injuries
•	Brain injuries can also arise from medical conditions, such as blood clots or hemorrhages.
•	Signs and symptoms of nontraumatic injuries are often the same as those of traumatic brain injuries.
–	Except that there is no obvious history of MOI or any external evidence of trauma
Spine Injuries
•	Compression injuries can result from a fall.
•	Motor vehicle crashes can overextend, flex, or rotate the spine.
•	The spine can be pulled along its length, called distraction.
•	Subluxation occurs when vertebrae are no longer aligned.

Patient Assessment (1 of 3)
•	Always suspect a possible head or spinal injury with:
–	Motor vehicle collisions
–	Pedestrian–motor vehicle collisions
–	Falls
–	Blunt trauma
–	Penetrating trauma to the head, neck, back, or torso
Patient Assessment (2 of 3)
•	Always suspect a possible head or spinal injury with (cont’d):
–	Motorcycle crashes
–	Rapid deceleration injuries
–	Hangings
–	Diving accidents
–	Recreational accidents
Patient Assessment (3 of 3)
•	Patient assessment steps
–	Scene size-up
–	Primary assessment
–	History taking
–	Secondary assessment
–	Reassessment
Scene Size-Up (1 of 3) 
•	Scene safety
–	Evaluate every scene for hazards to your health and the health of your team or bystanders.
–	Be prepared with appropriate standard precautions, including gloves, a mask, and eye protection.
–	Call for ALS as soon as possible.
Scene Size-Up (2 of 3)
•	Scene safety (cont’d)
–	When assessing a patient with a possible closed head injury, consider the MOI.
•	Did the patient fall?
•	Was he or she in an automobile crash or the victim of an assault?
•	Was there deformity of the windshield or deformity of the helmet?
Scene Size-Up (3 of 3)
•	Mechanism of injury/nature of illness
–	Look for indicators of the MOI.
–	Consider how the MOI produced the injuries expected.
Primary Assessment (1 of 6)
•	Focus on identifying and managing life-threatening concerns.
•	Form a general impression.
–	Ask about the chief complaint.
–	Confused or slurred speech, repetitive questioning, or amnesia in responsive patients is a good indication of a head injury.
Primary Assessment (2 of 6)
•	Form a general impression (cont’d).
–	If the patient is found unresponsive, emergency responders, family members, or bystanders may have helpful information.
–	An MOI that suggests a potential spinal injury should lead you to provide complete spinal motion restriction.
Primary Assessment (3 of 6)
•	Airway and breathing
–	Use a jaw-thrust maneuver to open the airway.
–	If the jaw-thrust maneuver is ineffective, use the head tilt–chin lift maneuver.
–	Vomiting may occur in the patient with a head injury.
–	Apply a cervical spine immobilization device.
Primary Assessment (4 of 6)
•	Airway and breathing (cont’d)
–	Move the patient as little as possible and as carefully as possible.
–	Oxygen is always indicated for patients with head and spinal injuries.
–	Pulse oximeter values should be maintained above 90%.
Primary Assessment (5 of 6)
•	Circulation
–	A pulse that is too slow in the setting of a head injury can indicate a serious condition.
–	A single episode of hypoperfusion in a patient with a head injury can lead to significant brain damage and even death.
–	Assess for signs and symptoms of shock.
–	Control bleeding.
Primary Assessment (6 of 6)
•	Transport decision
–	Reduction of on scene time and recognition of a critical patient increases the patient’s chances for survival.
–	Providing the patient with a patent airway and high-flow oxygen is paramount.
–	Suction should be readily available.
–	Maintain stabilization of the spine.
History Taking
•	Investigate the chief complaint.
–	Obtain a medical history and be alert for injury-specific signs and symptoms as well as pertinent negatives.
–	Using OPQRST may provide some background on isolated extremity injuries.
–	Gather as much SAMPLE history as you can while preparing for transport.
Secondary Assessment (1 of 6)
•	Instruct the patient to keep still and not to move the head or neck.
•	Physical examinations
–	Perform a full-body scan using DCAP-BTLS and examine the head, chest, abdomen, extremities, and back.
–	Check perfusion, motor function, and sensation in all extremities prior to moving the patient.
Secondary Assessment (2 of 6)
•	Physical examinations (cont’d)
–	A decreased level of consciousness is the most reliable sign of a head injury.
–	Look for leaking blood or CSF.
–	Evaluate the patient’s pupils.
–	Do not probe open scalp lacerations with your gloved finger.
Secondary Assessment (3 of 6)
•	Head injury
–	Perform a neurologic examination using the Glasgow Coma Scale (GCS).
–	Always use simple, easily understood terms when repeating the level of consciousness.
Secondary Assessment (4 of 6)
Secondary Assessment (5 of 6)
•	Spinal injuries
–	Inspect for DCAP-BTLS and check the extremities for circulation, motor, or sensory problems.
–	If there is impairment, note the level.
–	Pain or tenderness when you palpate the spinal area is a warning sign.
Secondary Assessment (6 of 6)
•	Vital signs
–	Significant head injuries may cause the pulse to be slow and the BP to rise.
–	Respirations will become erratic.
–	Assess pupil size and reaction to light.
–	Use monitoring devices.
Reassessment (1 of 3)
•	Repeat the primary assessment.
•	Reassess vital signs and the chief complaint.
•	Recheck patient interventions.
–	These injuries can suddenly affect the respiratory, circulatory, and nervous systems.
–	Reassess at least every 5 minutes.
Reassessment (2 of 3)
•	Interventions
–	You must act quickly to evaluate and treat these patients.
–	If CSF is present, cover the wound with sterile gauze, but do not bandage tightly.
–	Hyperventilation should be used with caution.
–	Administer high-flow oxygen and apply a cervical collar.
Reassessment (3 of 3)
•	Communication and documentation
–	Your documentation should include:
•	The history you obtained at the scene
•	Your findings during your assessment
•	Treatments you provided
•	How the patient responded to them
–	Document vital signs for unstable patients every 5 minutes; every 15 for stable
Emergency Medical Care of Head Injuries (1 of 6)
•	Three general principles:
–	Establish an adequate airway.
–	Control bleeding, and provide adequate circulation to maintain cerebral perfusion.
•	Begin CPR, if necessary.
•	Follow standard precautions.
–	Assess the patient’s baseline level of consciousness, and continuously monitor.
Emergency Medical Care of Head Injuries (2 of 6)
•	Managing the airway
–	The most important steps is establishing an adequate airway.
–	Perform the jaw-thrust maneuver.
–	Once the airway is open, maintain the head and cervical spine in a neutral, in-line position.
Emergency Medical Care of Head Injuries (3 of 6)
Emergency Medical Care of Head Injuries (4 of 6)
•	Managing the airway (cont’d)
–	Remove any foreign bodies, secretions, or vomitus.
–	Make sure a suctioning unit is available.
–	Check ventilation.
–	Give high-flow oxygen to any patient with suspected head injury.
Emergency Medical Care of Head Injuries (5 of 6)
•	Circulation
–	Begin CPR if the patient is in cardiac arrest.
–	Active blood loss aggravates hypoxia.
–	You can almost always control bleeding from a scalp laceration by applying direct pressure over the wound.
Emergency Medical Care of Head Injuries (6 of 6)
•	Cushing’s triad
–	Increased blood pressure (hypertension)
–	Decreased heart rate (bradycardia)
–	Irregular respirations (Cheyne-Stokes respirations, central neurogenic hyperventilation, or Biot respirations)
Emergency Medical Care of Spinal Injuries (1 of 4)
•	Follow standard precautions.
•	Maintain the patient’s airway while keeping the spine in the proper position.
•	Assess respirations and give supplemental oxygen.
•	Managing the airway
–	Perform the jaw-thrust maneuver.
Emergency Medical Care of Spinal Injuries (2 of 4)
•	Managing the airway (cont’d)
–	After you open the airway, consider inserting an oropharyngeal airway.
–	Have a suctioning unit available.
–	Provide high-flow oxygen.
•	Stabilization of the cervical spine
–	Immobilize the head and trunk so that bone fragments do not cause further damage.
Emergency Medical Care of Spinal Injuries (3 of 4)
•	Stabilization of the cervical spine (cont’d)
–	Follow the steps in Skill Drill 26-1.
–	Assess the pulse, motor functions, and sensations in all extremities.
–	Assess the cervical spine area and neck.
–	Never force the head into a neutral, in-line position.
Emergency Medical Care of Spinal Injuries (4 of 4)
Preparation for Transport (1 of 9)
•	Supine patients
–	Secure to a long backboard.
–	The ideal way to move a patient from the ground to a backboard is the four-person log roll.
–	You may also slide the patient onto a backboard or use a scoop stretcher.
–	Follow the steps in Skill Drill 26-2.
Preparation for Transport (2 of 9)
Preparation for Transport (3 of 9)
•	Sitting patients
–	If there is time, use a short backboard to immobilize the cervical and thoracic spine.
–	Then secure the short board to the long board.
–	Exceptions include situations in which:
•	You or the patient is in danger
•	You need immediate access to other patients
•	The patient’s injuries justify urgent removal
Preparation for Transport (4 of 9)
•	Sitting patient’s (cont’d)
–	Follow the steps in Skill Drill 26-3.
•	Standing patients
–	Immobilize the patient to a long backboard before proceeding with assessment.
Preparation for Transport (5 of 9)
•	Standing patients (cont’d)
–	This process will require three EMTs.
–	Follow the steps in Skill Drill 26-4.
•	Immobilization devices
–	Assume the presence of spinal injury in all patients who have sustained head injuries.
–	Use manual in-line immobilization or a cervical collar and long backboard
Preparation for Transport (6 of 9)
•	Cervical collars
–	Provide preliminary, partial support
–	Should be applied to every patient who has a possible spinal injury
–	Must be the correct size for the patient
–	Follow the steps in Skill Drill 26-5.
Preparation for Transport (7 of 9)
Preparation for Transport (8 of 9)
•	Short backboards
–	Vest-type device and rigid short board
–	Designed to stabilize and mobilize the head, neck, and torso
–	Used to immobilize noncritical patients found in a sitting position
Preparation for Transport (9 of 9)
•	Long backboards
–	Provide full body spinal immobil-ization and motion restriction and immobilization to the head, neck, torso, pelvis, and extremities
–	Used to immobilize patients found in any position
Helmet Removal (1 of 6)
•	A helmet that fits well prevents the patient’s head from moving and should be left on, provided:
–	There are no impending airway or breathing problems.
–	It does not interfere with assessment and treatment of airway or ventilation problems.
–	You can properly immobilize the spine.
Helmet Removal (2 of 6)
•	Remove a helmet if:
–	It makes assessing or managing airway problems difficult 
–	It prevents you from properly immobilizing the spine
–	It allows excessive head movement
–	The patient is in cardiac arrest
Helmet Removal (3 of 6)
•	Preferred method
–	Removing a helmet should always be at least a two-person job.
–	You should first consult with medical control about your decision to remove a helmet.
–	Follow the steps in Skill Drill 26-6.
Helmet Removal (4 of 6)
•	Alternate method
–	The advantage is that it allows the helmet to be removed with the application of less force, therefore reducing the likelihood of motion occurring in the neck.
–	The disadvantage is that it is slightly more time consuming.
Helmet Removal (5 of 6)
•	Alternate method (cont’d)
–	Remove the chin strap.
–	Remove the face mask.
–	Pop the jaw pads out of place.
–	Place your fingers inside the helmet.
–	Hold the jaw with one hand and the occiput with the other.
–	Insert padding behind the occiput.
Helmet Removal (6 of 6)
•	Alternate method (cont’d)
–	The person at the side of the patient’s chest is responsible for making sure that the head and neck do not move during removal of the helmet.
–	Remember that children may require additional padding to maintain the in-line neutral position.
Summary (1 of 6)
•	The nervous system of the human can be divided into two parts: the central nervous system and the peripheral nervous system.
•	The central nervous system consists of the brain and the spinal cord; the peripheral nervous system consists of a network of nerve fibers.

Summary (2 of 6)
•	The central nervous system is well protected by bony structures; the brain is protected by the skull and the spinal cord is protected by the bones of the spinal column.
Summary (3 of 6)
•	A head injury is a traumatic injury to the head that may result in injury to soft tissue, bony structures, or the brain.
•	Motor vehicle crashes, direct blows, falls from heights, assault, and sports injuries are common causes of spinal injury.

Summary (4 of 6)
•	Treat the patient with a head injury according to three general principles: establish an adequate airway, control bleeding, and reassess the patient’s baseline level of consciousness.
Summary (5 of 6)
•	Treat the patient with a spinal injury by maintaining the airway while keeping the spine in proper alignment, assess respirations, and give supplemental oxygen.
Summary (6 of 6)
•	Reduction of on-scene time increases the critical patient’s chances for survival or a reduction in the amount of irreversible damage.