Trauma to the head, neck,, and spine - chap.33

Central nervous system (subdivision of nervous system)

• brain and spinal cord

Peripheral nervous system (subdivision of nervous system)

• vertabral nerves

• cranial nerves

• motor and sensory nerves

Sensory nerves

• messages from the body to brain

Motor nerves

• message from brain to body

• control voluntary movenment

• cross to opposite side of the body with the left Brian controlling the right body

Skull- cranium

• Frontal

• parietal

• temporal

• occipital

Skull facial bones

• Mandible

• maxillae

• nasal

• malars

• orbits

Cranial and facial bones

have immovable joints

Cerebrospinal fluid (CSF)

batehs brain and circulates down the spine

Vertebrae

Divided into 5 areas

• cervical(7)

• Thoracic(12 to which ribs attach )

• Lumbar (5)

• coccygeal (4)

Scalp Injuries

• has many small blood vessels

• bleed profusely

• control bleeding with direct pressure

• dress as any other soft-tissue injury

• if possible skull injury, use loose gauze dressing instead of direct pressure

Skull injuries

• include facial and cranial fractures

• open head injury when bones of cranium are fractured

• closed- when scalp is lacerated but cranium is intact

• always suspect spine injury with brain/skull injury

direct injuries

occur with open head injuries

• Brian lacerated, punctured, bruised by broken bones or foreign object

indirect brain injuries

• with open or closed head injuries

• shock of impact on the skull is transferred to the brain

• includes concussions and contusions

traumatic brain injury (TBI) Concussion and (2) laceration

disrupts the normal functioning of the brain ( can be brief/long-term)

- when head is struck and force is transferred to the brain

(2) cut to the brain caused by the same forces that cause contusion

(TBI) : Contusion

- bruised Brian caused by a blow forceful enough to rupture blood vessels in brain

• coup injury occurs on the side of the blow

• countercoup- on the opposite side

TBI : Hematoma

is collection of blood within brain tissue

• Subdural : blood collects between the brain and dura

• epidural: Blood collects between the dura and skull

• Intracerebral : blood pools within the brain

• As it developed, intracranial pressure (ICP) increases inside the skull

(ICP) Intracranial pressure

• as it hematome developes

• ICP builds, brain tissue compresses and progressive neurological abnormalities develop

• rising ICP forces the brain toward the foramen magnum

• time for symptoms to develope, depends on rate of bleeding into skull and location of the bleed

• When ICP increases, BP increases to pump blood into and prefuse the brain

• When ICP increases, BP increases to pump blood into and prefuse the brain

• the heart rate may slow in response to the BP or due to vagus nerve compression

• rising BP an slowing HR: Cushing reflex

• As ICP increases and perfusion decreases, CO2 levels increase and brain tissue swells

Hematoma grows

• swelling worsens, brainstem is compressed and breathing patterns change

• - tachypnea

• cheyne-stokes breathing

• central neurogenic hypervenntilation

• ataxic respirations

• as brain herniates, decorticate or decerebrate posturing and neurogenic posturing may occur

• S&S of rising ICP may be immediate/delayed

S&S of skull fractures and Brian injuries

• visible bone fragment and brain tissue

• AMS

• Deep laceration or sever bruise or hematoma on scalp or forehead

• depressions, deformity, swelling on skulll

• sever pain at the injury site

• bruising behind the ear (Battle sign))

• Pupils unequal or nonreactive to light

• Raccoon eyes

• Increased BP and decreased pulse rate( CUshing reflex)

• Decorticate or decerebrate posturing

Patient assessment: Skull and brain injuries

if shock with head injuries in adult ateint - look for indications of blood loss elsewhere on body

• assume skull/brain injury when MOI and location of the injury indicate a possible head injury

Patient care: Skull and brain injuries

• Standard precautions

• consider possibility of spine injury

• open and maintain airway

• control bleeding

• keep patient at rest

Glasgow Coma Scale (GCS)

• with AVPU for neurologic assessment

• when eye opening

• verbal response ( orientated, confused, inappropriate words, incomprehensible sounds, no verbal)

• motor response (Obey command, localizes pain, withdraw after painful stimulation, posturing after painful stimulation, no motor response to pain)

• calculate en route

Cranial injuries with impaled objects

• don’t remove an impaled object- stabilize with bulky dressing

Injuries to the face and jaw

facial fracture usually by an impact

• prepared to remove airway obstruction from the mouth and to use suction

• treat for a suspected skull or brain injury

• Mandible is subjected to dislocation and fracture

Injuries to the face and jaw treatment

• prepare to suction to remove debris

• ise jaw-thrust maneuver to open airway of spinal injury is suspected

• control profuse bleeding

• consider c-spine

• position the patient to allow drainage from the mouth

• treat for shock

Nontraumatic brain injuries

• many sings of brain injury may be caused by an internal brain event like a hemorrhage or blood clot

• sign or nontraumatic stroke different from traumatic injury in that only one side is likely to be affected

Wounds to neck

• pressure in large vein is lower than atmospheric pressure

• air can be sucked in and causing an air embolism is great

• embolus can travel to the lungs and become a pulmonary air embolism

• can lead to cardiac arrest

Wounds to neck -treatment

• direct pressure is lifesaving step in treating hemorrhage from neck wounds

• 1. stop bleeding

• 2. preventing an embolus

• take care to avoid interfering with breathing when applying pressure

wounds to neck - patient care

• open airway

• place gloved hand over wound

• apply an occlusive dressing

• place a dressing over the occlusive dressing

• apply pressure to stop the bleeding

• bandage the dressing in place

• immobilize the spine if the MOI suggests cervical injury

Injuries to spine - identifying potential spine and spinal cord injury specific column injuries

• fractures with or without bone displacement

• dislocations

• muscular strains

• disk injury including compression

• can occur without cord damage

identifying potential spine and spinal cord injury: Primary and (2)secondary

1. occur immediately due to direct force

2. after the initial insult

• can cause greater harm

• not typically caused by damage bone ends moving into the spinal cord

• hypoxia, shock, cord swelling, and hypoglycemia can lead to devastating cord damage

Identifying Potential

Spine and Spinal Cord Injury

energy that forces the spine beyond its normal range of motion

• flexion and extension injuries (whiplash)

• overrotation (twisting sports injury )

• compression (shallow-water diving)

• distraction injury ( hanging)

• penetrating truama

• lateral bending or disk injury ( Improper lifting )

Injuries to the spine

• cervical and lumbar vertebrae most susceptible to injury bc they aren’t supported by other structures

Medical conditions make the spine more vulnerable to injury

• osteoporosis in older adults

• ligament laxity in pregnant women and patients with down syndrome

• fused vertabrae and fixed deformities in ankylosing spondylitis

Mechanisms of Spine Injury

Some MOI have a higher risk for spinal injury

• falls greater than 1meter (3ft) or down more 5 stairs

• axial loading (compression injuries)

• high-speed motor vehicle crashes- such as rollover or ejection

• motorized recreational vehicle (ATV) crashes

• bicycle collisions

Injuries to the Spine

Some MOI are low-risk mechanisms

• low energy MOI, low threat of spinal injury

• penetrating trauma is low risk unless trauma was on the spine itself

Dermatome

• an area of the body surface innervated by a single spinal nerve

• can be used to identify loss of function at particular area of cord

Additional key indicators of spinal injury

• paralysis of extremities

• changes in neurological function

• tenderness anywhere along spin

• priapism

NEXUS

• used to identify likelihood of spinal injury

• any pain or tenderness along the midline spine?

• are there focal/neurologic S&S

• is there a distracting injury/circumstance

• What’s the MOI in a pediatric patient

Rigid spinal immobilization

• can have negative sie effects

• flat immobilization of patients with lung injury can be uncomfortable and deadly

• short period on a spine boardd can cause Hypothermia and pressure sores

For ANY spinal injury you must:

• aggressively assure oxygenation and ventilation

• actively treat sever bleeing

• pay attention to blood glucose

Primary assessment spinal injury

treating hypoxia and shock is the same priority as spinal motion restriction

Spinal motion restriction

• prevents secondary cord damage by limiting the movement of individual vertebrae

3 centers of mass in body

• head

• shoulder girdle

• pelvis

  when all are prevented from moving, the spine generally remain stable

Spine shape

• S-shape curve

• vertabrae are maintained in a position of function that best represents their natural anatomic position

• known as an inline neutral position

Manual stabilization of head

• is first step in spinal motion restriction-

• maintain an inline neutral position

• maintain manual stabilization even after the collar is in place until patient on a backboard

• onces cervical spine is immobilize, remainder of the spinal column’s motion must be restricted

Backboards

• ambulance stretchers: considered padded backboards- provide appropriate spinal protection in combination with collars and straps

When:

• transporting is short

• ‘big splint’ is needed for multiple injuries

• the patient will likely need cpr

• moving from a backboard to a stretcher - cause excessive movenments

backboards contraindications

• resporatory distress

• conditions that impact breathing

Vacuum mattresses

have positive aspect of backboards but accommodate a natural anatomic position

• are hollow bags- allow air to be pumped out to create a rigid form

• more comfortable

• can leak air and lose rigidity Iver time

• can rob heat from patient

2 options for spinal motion restriction in a seated patient

• plase a long spine board under the patients buttocks and lower the patient to the board in supine position

• have patient self-extricated by standing and then sitting on stretcher

spinal consideration whens applying short board

• assess the back, shoulder blades, arms and collarbones before placing decive

• must angle to fit between arms of the rescuer stabilizing head

• uppermost holes mist be level with pateins shoulders

• never place chin cup or strap on the patient

applying long backboard

• secure head last

• tilt pregnant patients to the left after immobilization

• for children 6 under, pa beneath the shoulder blades- for neutral position for the head

standing patient

• apply cervical collar

• guide patient into supine or semi-sitting position

Pateint wearing helmet

face, neck, and spine care and airway management or resuscitation may require helmet removal

• if airway intact- don’t remove if cuasing pain or difficult to remove

When to leave a helmet in place:

• no airway or breathing issues

• proper spinal immobilization can be done with the helmet in place

when to remove helmet

• it interferes with EMT’s ability to assess + manage the airway

• improperly fitted

• cardiac arrest

• if needed to be removed": 2-rescuer

IF wearing shoulder pads and helmet

• either remove both or neither