Study Notes: Head and Spine Injuries

Chapter 29: Head and Spine Injuries

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National EMS Education Standard Competencies
Trauma

  • Apply fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Head, Facial, Neck, and Spine Trauma

  • Recognition and management of life threats and spine trauma.

Pathophysiology and Assessment

  • Spine Trauma: Understand the pathophysiology, assessment, and management.

  • Skull Fractures: Understand the pathophysiology, assessment, and management.

Nervous System Trauma

  • Recognition and management of traumatic brain injury and spinal cord injury.

Introduction to the Nervous System

  • The nervous system is a complex network enabling body function composed of:

    • Brain

    • Spinal Cord

    • Nerves and Nerve Fibers

  • Protection:

    • The brain is protected by the skull.

    • The spinal cord is protected by the spinal canal.

    • Serious injuries can still damage the nervous system despite this protection.

Anatomy and Physiology of the Nervous System
Division of Nervous System

  • Two Anatomic Parts:

    • Central Nervous System (CNS): Composed of the brain and spinal cord.

    • Peripheral Nervous System (PNS): Conducts sensory and motor impulses from skin and organs to the spinal cord.

Central Nervous System (CNS)

  • Components:

    • Brain: Controls body functions and is the center of consciousness.

    • Divided into three major areas:

      • Cerebrum: Controls voluntary motor functions and conscious thought (75% of brain volume).

      • Cerebellum: Coordinates balance and body movements.

      • Brainstem: Controls vital functions, best-protected part of the CNS.

    • Spinal Cord: Extends from the brain, carrying messages between the brain and body using grey and white matter.

    • Protective Coverings:

    • Surrounded by meninges and contained within the skull and spinal canal.

    • Meninges:

    • Dura Mater: Outer tough layer, forms protective sac.

    • Arachnoid Mater & Pia Mater: Inner layers containing blood vessels.

    • Cerebrospinal Fluid (CSF):

    • Produced in the third ventricle of the brain.

    • Approximately 125 to 150 mL is present in the brain at any time, serving as a shock absorber.

Peripheral Nervous System (PNS)

  • Components:

    • 31 Pairs of Spinal Nerves: Conduct impulses from skin and organs to the spinal cord and motor impulses from the spinal cord to muscles.

    • 12 Pairs of Cranial Nerves: Transmit information straight to/from the brain and perform special functions like sight, smell, and taste.

    • Types of Peripheral Nerves:

    • Sensory Nerves: Carry one type of information to the brain.

    • Motor Nerves: Carry information from the CNS to muscles.

    • Connecting Nerves: Found only in the CNS, allowing for short fiber connections between sensory and motor nerves.

Function of the Nervous System

  • Controls all body activities:

    • Reflex Activities

    • Voluntary Activities

    • Involuntary Activities

  • Reflex Arc Formation: Connecting nerves in the spinal cord bypass the brain during irritant detection, sending messages directly to motor nerves.

Voluntary vs. Involuntary Activities

  • Voluntary Activities: Actions consciously performed (somatic nervous system).

  • Involuntary Activities: Unconscious control (autonomic nervous system).

    • Divisions:

    • Sympathetic Nervous System: Activates fight-or-flight responses during stress.

    • Parasympathetic Nervous System: Opposes sympathetic effects, promoting rest and digestion.

Skeletal System
Skull

  • Composed of two groups:

    • Cranium: Enclosing the brain (4 major bones: occipital, temporal, parietal, frontal).

    • Facial Bones: Comprising 14 bones that form the face (e.g., maxillae, zygomas).

  • The brain connects to the spinal cord via the foramen magnum.

Spinal Column

  • Central supporting structure composed of 33 vertebrae divided into five sections:

    • Cervical

    • Thoracic

    • Lumbar

    • Sacral

    • Coccygeal

  • Vertebrae connected by ligaments and cushioned by intervertebral disks.

  • Injury Implications: Spine injuries can lead to paralysis.

Head Injuries
Definition and Mechanisms of Injury (MOI)

  • Head injuries are traumatic insults that can damage soft tissue, bony structures, or the brain, accounting for over half of all traumatic deaths.

  • Common MOIs: Falls, motor vehicle crashes, assaults, sports-related incidents.

Types of Head Injuries

  • Closed Injuries: No direct opening into the brain (brain injured).

  • Open Injuries: Involves an opening from the brain to the outside world, often with bleeding and possible exposure of brain tissue.

Signs and Symptoms of Head Injuries

  • General Signs and SymptomsV:

    • Lacerations, contusions, or hematomas of the scalp

    • Soft areas or skull depressions on palpation

    • Visible skull fractures or deformities

    • Decreased mentation or confusion

    • Irregular breathing

    • Widening pulse pressure

    • Slow heart rate

    • Ecchymosis (raccoon eyes or Battle sign)

    • Clear or pink CSF leakage (

    • from scalp, nose, or ear

    • Pupil abnormalities (failure to react to light, unequal sizes)

    • Loss of sensation/motor function

    • Unconsciousness or amnesia

    • Seizures

    • Additional symptoms: dizziness, visual complaints, abnormal behavior, nausea/vomiting, posturing (decorticate/decerebrate).

Scalp Lacerations

  • Can be minor but may lead to significant blood loss and hypovolemic shock.

  • Indicator of deeper injuries.

Skull Fractures

  • Mechanism: Significant force may result in open or closed fractures, often caused by projectiles.

  • Signs:

    • Deformation of the head

    • Visible skull cracks

    • Racoon eyes and Battle sign

  • Types of Skull Fractures:

    • Linear Skull Fractures: 80% of cases lack physical signs.

    • Depressed Skull Fractures: Caused by blunt trauma; fragments may enter the brain.

    • Basilar Skull Fractures: Often result from diffuse impacts; signs include CSF drainage and raccoon eyes.

    • Open Skull Fractures: High mortality rate with exposure of brain tissue.

Traumatic Brain Injuries (TBI)

  • Most serious head injury categorized as:

    • Primary Injury: Instantaneous impact damage.

    • Secondary Injury: Develops later, increases primary injury severity due to factors like hypoxia, hypotension, or increased intracranial pressure.

  • Example: Coup-contrecoup injury results from deceleration forces impacting the brain.

Intracranial Pressure (ICP)

  • Causes of Increased ICP: Accumulation of blood/swelling can squeeze the brain against the skull.

  • Signs of Increased ICP:

    • Cheyne-Stokes and ataxic respirations

    • Headaches, nausea, irregular pulse, and fluctuating blood pressure.

  • Types of Hemorrhage:

    • Epidural Hematoma: Blood accumulation between skull and dura mater; often a result of blunt trauma and leads to increased ICP.

    • Subdural Hematoma: Blood accumulation beneath dura mater; occurs from falls or strong deceleration forces.

    • Intracerebral Hematoma: Bleeding within brain tissue, can result from penetrating injuries.

    • Subarachnoid Hemorrhage: Bleeding into the CSF space leading to irritation.

Concussion

  • Closed injury resulting in temporary brain dysfunction without physical damage.

  • Symptoms include confusion and amnesia; typically brief, without loss of consciousness in 90% of cases.

Contusion

  • More severe than concussions involving physical damage to brain tissue, potentially leading to permanent injury.

Other Brain Injuries

  • Non-traumatic brain injuries (e.g., clots, hemorrhages) may present similar symptoms to traumatic injuries.

Spine Injuries

  • Types of Injury Mechanisms:

    • Compression Injuries: From falls leading to disk herniation.

    • Extension and Rotation-Flexion Injuries: Result from rapid acceleration forces and can trigger fractures.

Patient Assessment
Situations to Suspect Head/Spinal Injury

  • Conditions include:

    • Motor vehicle collisions

    • Falls

    • Blunt or penetrating trauma

    • Rapid deceleration injuries

    • Hangings

    • Diving accidents.

Scene Size-up

  • Evaluate for safety hazards and call for advanced life support (ALS) promptly.

  • Assess mechanism of injury (MOI) to understand injury context.

Primary Assessment

  • Focus on identifying and managing life-threatening concerns.

  • Spinal Immobilization Considerations:

    • Assess in the position found; determine the need for a cervical collar.

    • General impression based on consciousness level and chief complaint.

  • Minimize time on backboards due to potential complications (e.g., skin circulation issues).

Signs and Symptoms Assessment

  • Immediate inquiry into chief complaints; assess for head injury symptoms.

  • For unresponsive patients, assume spinal injury is present.

Airway, Breathing, and Circulation Considerations

  • Utilize a jaw-thrust maneuver to initiate airway management.

  • Prioritize oxygenation for head/spinal injury patients, maintain oximeter readings above 90%.

Documentation and Communication

  • History obtained, findings, treatments given, and patient responses should be accurately documented post-assessment.

Emergency Medical Care of Head Injuries
Principles of Management

  1. Ensure an adequate airway.

  2. Control bleeding for adequate circulation.

  3. Assess consciousness level continuously.

Airway Management Techniques

  • Conduct jaw-thrust maneuver, ensuring neutral spine position.

  • Remove obstructions from the airway and check for ventilation; provide supplemental oxygen as necessary.

Emergency Medical Care of Spinal Injuries
Key Management Steps

  • Maintain proper positioning of the spine and airway.

  • Apply supplemental oxygen and manage airway with jaw-thrust maneuver.

Preparation for Transport
General Transport Guidelines

  • Ensure proper immobilization using backboards or vacuum mattresses.

    • Vacuum mattresses mold to the patient’s body shape, beneficial for odd spinal curvatures.

  • Patient movement techniques, including special procedures for transferring from the ground setting.

Helmet Removal Guidelines

  • Keep helmets on if they provide significant stability unless airway issues arise.

  • Removal procedures should prioritize minimal movement of the neck and involve two operators.

Review Questions and Answers

  • Various review questions examined critical concepts related to symptoms of injuries, management procedures, and understanding for patient handling.