Chapter 33: Trauma to Head, Neck, and Spine

Motor vs sensory neurons

• Motor nerves from brain, sensory to brain

Cranium definition and parts

• Cranium: portion of skull enclosing brain. Frontal, temporal (ears) , occipital (back), parietal (top of head), cranial floor is beneath the brain. Cranial bones fused to create sutures, immovable joints

Face bones

• Face bones: mandible (lower jaw, only non suture of face), temporomandibular joint (joint of mandible), maxillae (upper jaw), nasal bones, malar/zygomatic (cheekbones), orbits (eye sockets), lacrimal (tear ducts)

Foramen Magnum

space where spinal cord meets brain

Meninges layers

• Dura mater

• Arachnoid

• Pia mater

Spinous process

• bumpy part of spinal column you feel along back

Atlas vs Axis

• Atlas: C1, holds up head

• Axis:C2 allows head to turn

5 sections of vertebrae and amounts

• Cervical (C1-7)

• Thoracic (T1-12)

• Lumbar (L1-5)

• Sacrum (S1-5)

• Coccyx (CO1-4)

Scalp

has lots of vessels so injury causes bleeding, direct pressure and treat like soft tissue injury, tho careful if skull injury don't apply pressure if injury site shows bone fragments or depression of bone or brain exposed, just use loose gauze

Direct vs indirect injuries on brain

• Direct: from open head injuries

• Indirect: open or closed, shock of impact on skull transferred to brain

Traumatic brain injury

• Traumatic brain injury: disrupts normal function of brain

Concussion

• force transferred to the brain from fall or blunt force. May lose memory or have headache/lose consciousness for a few seconds, arms/groggy, sensitivity to light, nausea

Contusion

• bruised brain, when force of blow great enough to rupture blood vessels, often caused by brain hitting skull and bouncing. Contrecoup injury: when bruising happens on side opposite of blow (coup opposite)

Laceration and Hematoma

• Laceration: can occur from same thing contusion does since inside of skull has sharp ridges, or from penetrating object

Hematoma: can be subdural (between brain and dura) epidural (between dura and skull) intracerebral (blood within brain)

Process of interracial pressure

• When hematoma happens pressure builds inside skull, causes neurologic issues, reduces blood to brain, can cause herniation which is when brain forced downward towards foramen magnus, compressing brainstem (causes ams dilated pupils, increased systolic, decreased pulse, abnormal respirations)

  • Abnormal respirations include cheynes stokes breathing (quick breathing then stops, quick stops), central neurogenic hyperventilation (rapid breathing), ataxic respirations (irregular/unpredictable)

• Small subdural hematoma could  take long for signs, epidural can instantly

• Cushings reflex:Will see increased bp as brain tries to perfuse, slow heart rate from rest of body reacting or from compression of vagus nerve

• Carbon dioxide will build causing pressure to increase more

• As herniation continues may have decerebrate (extended, arched back) or decorticate posturing (arms look like gonna fight)

• For significant hematoma sequence looks like

1. Strikes head, may have brief loc

2. After 10m slight ams

3. Ams worsens bp starts to increase

4. Seizure (can happen at any time from pressure or injury)

5. Unresponsive, cushing's reflex

6. Decorticate →decerebrate→death

Herniation

brain forced downwared towards foramen magnus from pressure buildup

Cheynes Stokes Breathing

 (quick breathing then stops, quick stops),

Central neurogenic hyperventilation

rapid breathing

ataxic respirations

irregular/unpredictable

cvushings reflex

• Will see increased bp as brain tries to perfuse, slow heart rate from rest of body reacting or from compression of vagus nerve

decerabrate vs decorticate posturing

• As herniation continues may have decerebrate (extended, arched back) or decorticate posturing (arms look like gonna fight)

signs/care of interracial pressure

• Ams, laceration/hematoma, goose egg, battles sign (late, bruise behind ear), pupils unequally/unreactive, raccoon eyes (late) CSF from ears/nose, irregular breathing, cushings, personality change, trouble balance, seizures, temp increase, vomiting.

• Hypoperfusion Shock not normally sign except in infants cause not enough space in skull for bleeding

• High priority, care like normal, keep person calm, don't stop cSD from flowing, lose gauze dressing

gcs

neck wounds + care

• Lots of large vessels, pressure lower than atmosphere so could suck air and cause embolism, 

• Care: direct pressure, occlusive dressing (2 inches post wound), dressing over occlusive pressure as needed dont compress both carotid arteries at once, once bleeding stopped bandage dressing in place

primary vs secondary spine injuries

• Primary injuries (occur immediately and from direct force, often irreversible since nerves dont heal well)

• Secondary injuries: (after initial insult from things like hypoxia, shock, swelling of cord, hypoglycemia)

• Always consider spine injuries when serious trauma to any part of body

whiplash vs axial loading vs distraction spinal injuries

• :most often from energy that forces spine beyond normal range of motion like flexion or extension (whiplash) or from overrotation like twisting or compression (axial loading) or distraction (excessive pulling)

what makes you vulnerable/ what parts are most vulnerable of spine

• :Thorax is typically well protected as well as sacrum. Cervical and lumbar susceptible, osteoporosis makes it more susceptible, ligament laxity from pregnancy/down syndrome as well. Fused vertebrae or fixed flexion deformities at higher risk. Ankylosing spondylitis causes vertebrae to fuse

high risk moi of spine

• Falls over 3 ft or more than 5 stairs

• Axial loading (compression) injuries like diving

• High speed collisions

• Atv crashes

• Bicycle collisions

• Geriatric more severe

low risk moi

penetrating trauma, low energy collisions

assessing spine

• Pain and tenderness in injured area good sign

• Pain with movement, changes in neurologic function or paresthesia, paralysis

• Impaired breathing: if only slight movement of abdomen and no chest movement, diaphragmal breathing from damage to nerves commonly injured, as well as ribs collapsing on inhalation. 

• Priapism, peeing

• Deformity (rare)

• Neurogenic shock

• key elements of nexus

key elements of nexus

•  Is the patient reliable?

•  Is there any pain or tenderness along the midline spine?

• Are there focal or neurologic signs or symptoms?

•  Is there a distracting injury or circumstance?

 What is the MOI in a pediatric patient?

what is bad when lung injury present/what negative effects of spine board

• Flat immobilization of patients with lung injury bad

•  Even short periods on a spine board can cause hypothermia and pressure sores

3 centers of mass that when prevented from moving spine is stable

shoulder girdle, head, pelvis

what shape is spine naturally and what position should vertebrae stay in

s shaped, vertebrae stay in position of function known as inline neutral position

1st step of spinal care

• manual stabilization of head first step (maintain neutral, if out of neutral can move unless complains of pain)

2nd step of spine care

• Collar next to prevent movement (maintain manual until on backboard, check cms in extremities once restricted)

next step of spinal care

• Once cervical spine done, can use ambulance stretchers (considered padded backboards) rigid less commonly used

when to use backboards/when not to

• Backboards used when:

  • Transport time short

  • Likely needs cpr

  • Big splint for multiple injuries

  • Moving from backboard to stretcher causes excessive movement

• Backboard contraindicated when respiratory distress, scoop helpful to move to stretcher

vacuum mattresses

• Vacuum mattresses: more comfy, can lose rigidity over time and rob heat from patient

seated patients

•  can either place long spine board under butt and lower to supine or patient stands then sits on stretcher

  • If using flexible extrication device or short spine board secure torso first head last

special considerations for short board

• Special considerations for short board (Study last)

  • Assess the back, shoulder blades, arms, and collarbones before placing the device

  • – The EMT applying the board must angle it to fit between the arms of the rescuer stabilizing the head

  • – The uppermost holes must be level with the patient’s shoulders; the base should not extend past the coccyx

  • Never place a chin cup or strap on the patient

  • – Avoid applying the first torso strap too tightly

  • – Some buckles have quick-release mechanisms

  • – Do not pad between the collar and the board; only pad to fill an occipital void

how to apply long backboard

log roll onto, pad voids between head and torso, secure head last, blankets for additional head immobilization, tilt pregnant to left after immobilization, strap across upper chest, pelvis, thighs

• 6 and under pad beneath shoulder blades

standing patients care

•  cervical collar and sit on stretcher, guide supine or semi-sitting, secure straps

helmet

•  if airway intact dont remove helmet if it causes pain or is difficult, when it fits snug, can immobilize with helmet, doesnt interfere with assessment, remove if cardiac arrest, don't remove just helmet or just shoulder pads

multiple trauma patients vs multi system trauma

• Multiple Trauma patient: more than one serious injury

Multisystem trauma patient: one+ injuries serious enough to affect >1 body systems

When multi system trauma is severe

• Severe if (physiologic)

  • Ams (gcs<14)

  • Head injury

  • Hypotension (systolic <90) shock, internal bleeding\

  • Abnormal respiratory rates (head injury, later stages of shock)

• Severe if (anatomic)

  • Amputation proximal to wrist/ankle

  • Pelvic fractures

  • open/depressed skull fracture

  • Paralysis

  • Penetrating injuries to head, neck, torso, extremities proximal to elbow/knee

  • Chest wall instability/deformity

  • 2+ proximal long bone fractures

  • Crushed, degloved, mangled, pulseless extremity

• Severe if (MOI)

  • Falls

  • High risk auto crash (intrusion, ejection, death, telemetry data)

• Severe if (Special)

  • Old cant compensate for shock

  • Children to pediatric facility

  • Patients taking anticoagulants/pregnant

golden hour

•  (need for critical patients to get to surgery within 1 hour of injury

trauma scoring

• Includes systolic bp, respiratory rate, gcs, out of 12 lowest 0 rating system, objectively describes severity