Chapter 28: Head & Spine Injuries

Spinal Cord

Relays messages to brain

Nerve fibers connecting the brain to the body

Spinal Injury Severity

Higher up on the cord the worse the injury is

Spinal Injuries MOI

Compression

Excessive flexion, extension, rotation

Lateral bleeding

Spinal Injury Classifications

Sprains

Strains

Fractures

Dislocations

Sacral fractures

Coccygeal fractures

Cord injuries

Immobilize Patients with...

Suspected spinal trauma

Signs and symptoms of SCI

Assume Spinal Injury if...

Significant trauma and use of intoxicating substances

Seizure activity

Pain/paresthesia in neck/arms

Neck tenderness

Unconsciousness because of head injury

Significant injury above clavicle

Fall more than three times patient's height

Fall and fracture of both heels

Injury from car crash at high speed

Damage Further Complicated by...

Age

Preexisting bone disease

Congenital spinal cord anomalies

When do Primary Injuries Happen?

Occur at time of impact

When do Secondary Injuries Happen and why?

Later due to swelling, ischemia, movement of bony fragments

Cord Injuries

Concussed

Contused

Compressed

Lacerated

Severity of Injuries Depend on...

Amount and type of force

Duration of injury

Cord Lesions Classified by...

Complete

Incomplete

Complete Cord Lesions

Usually spinal fracture/dislocation

Absence of pain, pressure, and joint sensation

Complete motor paralysis below injury

Automatic dysfunction

Signs of Autonomic Dysfunction

Bradycardia

Hypotension

Priapism

Loss of sweating/shivering

Loss of bowel/bladder control

Incomplete Lesions

Central Cord Syndrome

Central Cord Syndrome

Seen with hyperextension or flexion cervical injuries

Greater motor impairment of upper than lower extremities

Signs and Symptoms of Central Cord Syndrome

Paralysis of arms

Decreased sensation of pain and temperature below lesion

Intact light touch and position sensation

Quadriplegia

Inability to move all four limbs or entire body below the neck

Injury at cervical level

Loss of function below injury site

Paraplegia

Total inability to move both legs and usually the lower part of the trunk

Result of disease/injury of spine

Thoracic/lumbar level injury

Loss of lower trunk function

Hemiplegia

Total or partial inability to move experienced on one side of the body, caused by brain disease or injury

Reflex Resposnses

Some indicate autonomic injury

Babinski's sign

Babinski's Sign

Plantal reflex

Dorsiflexion of great toe with or without fanning of toes

Absence of Neurological Deficits...

Does not rule out spinal injury

Ability to walk...

Should not be a factor in determining need for spinal precautions

MOI

Decreased LOC in trauma patient

Pain in spine or paraspinal area

Pain in back of head, shoulders, legs, arms

Absent, altered sensation (numbness, paresthesias, loss of temperature, position, touch sense)

Absent, altered motor functions

Management

ABC with C-spine

Ensure adequate oxygenation, ventilation

Keep entire spine immobilized

Repeatedly assess, document neurologic status

Repeatedly monitor respirations and blood pressure

Neurologic Status

Position sense

Pain

Motion

Treating Spinal Injuries

Instruct the patient not to move

Stablize cervical spine and ABC

Evaluate MOI

Evaluate neurological system

Assess pulse, movement, sensation in extremities

Assess neck and spine

Administer oxygen

Apply properly sized cervical spine immobilization device

Apply and secure patient to appropriate immobilization device

Significant Head Injury =

Neck injury until proven otherwise

Lordosis

Swayback

Spine of person curves significantly inward at the lower back

Kyphosis

Abnormally rounded upper back

More than 50 degrees of curvature

Scoliosis

Sideways curve of spine

S/C shaped

Non-Trauma Transportation

Transport in position of comfort

Trauma Transportation

Move to backboard maintain C spine stabilization

Pad under patient's head if needed

Skull

Divided into 2 major areas

Bones used as locations when describing area involved in injury

2 Areas of Skull

Cranium and face

Lobes of the Brain

frontal, parietal, occipital, temporal

Cerebrum

Most anterior portion of the brain

Largest and most developed portion of the brain

75% of total brain volume

Responsible for movement, sensory processing, olfaction, language and communication, learning and memory

Cerebellum

Controls emotion

Motor control

Coordinates body movement

Language and attention

Brain Stem

Posterior part of the brain

Cranial nerves 2-12 emerge from brain stem

Essential controls of the body such as respiratory, circulatory, pain, consciousness

Common Cause of Brain Disorder

Stroke

Seizures

Altered mental status

Cerebrovascular Accident

CVA

Interruption of blood flow to the brain that results in the loss of brain function

Stroke

Loss of brain function that results from CVA

Maxillofacial Injury Causes

Crashes

Home accidents

Athletic injuries

Animal bites

Intentional violent acts

Industrial injuries

Maxillofacial Trauma Classifications

Soft tissue injuries

Facial fractures

Soft Tissue Injuries

Facial soft injuries often appear serious

Usually not life threatening, except when compromised airway, potential for significant bleeding

History of Patient

MOI

Events leading up to injury

Time of injury

Associated medical problems

Allergies

Medications

Last oral intake

Management of Head/Facial Trauma

Spinal precautions

Assess for airway obstructions

Secure/Maintain airway

Ensure ventilation and oxygenation

Control bleeding

Facial Fractures

Common after blunt trauma

Fractures of the mandible

Dislocations of the mandible

Fractures of Zygoma

Articulates with frontal, maxillary, and temporal lobes

Associated with orbital fractures with similar clinical signs

Zygoma

Cheekbone

Fractures of the Orbit

Blowout fractures to orbit

Suspect injury to orbital contents with any facial fracture

Fracture of Nose

Most often fractured

Displace to one side or epistaxis and swelling without skeletal deformity

Epistaxis

Nosebleed

Apply external pressure to anterior nares

Conscious patient- Seat upright/leaning forward with EMT compress nares

Unconscious patient- Positioned on side and treat for shock if bleeding is severe

Management of Facial Fractures

Assume spine is injured and use spinal precautions

Assess airway for obstruction

Ensure adequate ventilation and oxygenation

Control bleeding through direct pressure and bandages

Control epistaxis by external direct pressure

Nasal and Ear Foreign Bodies

Foreign bodies in nose or ear common in children

Remove foreign body in ear if easy

Do not remove nasal foreign body unless airway is compromised or it can be removed without equipment

Ear Trauma

Lacerations and contusions

Usually blunt trauma

Treated with direct pressure to reduce bleeding and ice/cold compress to reduce swelling

Never use pressure to stop bleeding out of the ear canal

Retrieve avulsed tissue if possible wrap in moist gauze, seal in plastic, place on ice, transport for surgical repair

Thermal

Chemical

Traumatic perforations

Eye Trauma Causes

Crashes

Sports activities

Violence

Chemical exposure

Foreign bodies

Animal bites/scratches

Eye Trauma Evaluation

History (mode of injury and use of corrective glasses/contact lenses)

Visual activity (test injured eye and compare to uninjured)

Pupillary reaction

Eye movement

Specific Eye Injuries

Ocular trauma should be evaluated by physician

Foreign bodies

Corneal abrasion

Blunt trauma

Penetrating injury

Protruding intraocular foreign bodies

Chemical injuries to the eye

Contact Lenses

Hard lenses

Soft Hydrophilic lenses

Rigid gas-permeable lenses

Do not remove contact lenses

Plastic lenses can mix with chemical and fuse to cornea

Dental Trauma

32 teeth in adult

Crown and root

Hard and soft tissue of tooth

Tooth Fracture

Tooth Avulsion

Anterior Neck Trauma

Blunt and penetrating trauma

Can damage... skeletal structures, vascular structures, nerves, muscles, and glands of neck

Common MOI of Anterior Neck Trauma

Crashes

Sports activities

Industrial accidents

Violence

Hangings

Evaluation of the neck: Zones

Zone I

Zone II

Zone III

Zone I

Injuries carry highest mortality rate

Zone II

Most common injuries

Lower mortality rate than zone I

Zone III

Greatest risk of injury to distal carotid artery, salivary glands, and pharynx

Asphyxiation

Suffocation

Edema

Swelling

Edema of pharynx, larynx, trachea, epiglottis, and vocal cords may obstruct airways

Measures to Treat Edematous Airways

Cool, humidified oxygen

Slight elevation of patient's head

Lacerations and Puncture Wounds

Superficial Injuries

Deep Penetrating Wounds

Superficial Injury Management

Cover the wound

Deep Penetrating Wound Management

Aggressive airway therapy

Ventilatory support

Suction

Hemorrhage control (direct pressure)

Signs and Symptoms of Significant Penetrating Neck Trauma

Shock

Active bleeding

Tenderness on palpation

Mobility

Crepitus

Large or expanding hematoma

Pulse deficit

Neurological deficit

Dyspnea

Hoarseness

Stridor

Subcutaneous emphysema

Hemoptysis

Dysphagia

Hematemesis

Vascular Injury Management

Secure airway with spinal precautions

Adequate ventilatory support

Control hemorrhage by direct pressure

Fluid replacement for hypovolemia guided by medical direction

Esophageal Injury Suspect in Patients with...

Trauma to chest or neck

Tracheal fractures

Penetrating trauma from stab or gunshot wounds

Ingestion of caustic substances

Esophageal Injury Signs/Symptoms

Subcutaneous emphysema

Neck hematoma

Oropharyngeal/nasogastric blood

Subcutaneous Emphysema

Air under the skin

Esophageal Varices

Thinking of esophageal lining

Head Trauma: Scalp

Subcutaneous Tissue (major scalp veins bleed profusely)

Muscle (Attached above eyebrows at base of occiput)

Galea (Freely movable sheet of connective tissue and helps deflect blows)

Loose Connective Tissue (contains emissary veins that drain intracranially)

Soft Tissue Injuries to the Scalp

Irregular linear laceration

May lead to profuse bleeding and hypovolemia

Soft Tissue Injuries to the Scalp Management

Prevent contamination of open wounds

Direct pressure or pressure dressings to decrease blood loss

Consider potential for underlying skull fracture and brain and spinal trauma

Classification of Skull Fractures

Linear

Basilar

Depressed

Open Vault

Linear Fractures

80% of fractures to skull

Not usually depressed

May occur without an overlaying scalp laceration

Generally low complication rate

Basilar Fracture

Battle Signs

Raccoon Eyes

Battle Signs

Mastoid ecchymosis

Indication of fracture of base of the posterior portion of the skull

Raccoon Eyes

Purplish discoloration around the eyes following fracture of the frontal portion of the skull base

Depressed Fractures

Relatively small object strikes head at high speed

Often scalp lacerations

Frontal and parietal bones most often affected

Open Vault Fractures

Direct communication between scalp laceration and cerebral substance

Often occur with multi-system trauma

High mortality rate

May lead to infection (meningitis)

Types of Head Injuries

Open and Closed

Head Injury Symptoms

Nausea

Severe headache

Glossy eyes

Sudden sleepiness

Head Injury

May appear minor but can be life-threatening

Scalp lacerations may not have any brain involvement but can bleed severely leading to significant blood loss

Cerebral Spinal Fluid

CSF

Clear, watery fluid

Produced in the third ventricle, a chamber in the brain

Acts as a shock absorber to spinal cord and brain

Protects brain from being injured, if injured the fluid comes out ears to give room for brain to swell

Halo Test

Detects CSF

Brain Injury

Traumatic or Non-traumatic

Altered or decreased mental status

Irregular breathing patterns

MOI present with traumatic injury

Brain Injury Symptoms

Contusion

Laceration

Hematoma

Blood/fluid from ears/nose

Bruising around eyes and behind ears

Neurologic changes

Nausea/vomiting

Unequal pupil size

Decreased heart rate and increased blood pressure

Seizures

Assessment of Head Injury

Early detection of increased intracranial pressure is critical

If pressure inside skull exceeds average blood pressure, blood flow to brain stops

Increasing intracranial pressure can force brain down into spinal canal, crushing it

AVPU system

Glasgow scale

Vital signs

Vital Signs in Head Injury

Body responds to increasing intracranial pressure by raising blood pressure

Increased BP moves blood into brain against rising ICP

Heart rate falls in response to rising BP

Cushing's Triad

Increased blood pressure

Altered breathing

Slow pulse