Skill Station D

DISABILITY

LEARNING OBJECTIVES

1. Perform a brief neurological examination, including 5. Identify the signs, symptoms, and treatment of
calculating the Glasgow Coma Scale (GCS) score, neurogenic shock.
performing a pupillary examination, and examining
the patient for lateralizing signs. 6. Demonstrate proper helmet removal technique.

2. Identify the utility and limitations of CT head 7. Identify the signs and symptoms of spinal cord
decision tools. injury in a simulated patient.

3. Identify the utility and limitations of cervical spine 8. Demonstrate the hand-over of a neurotrauma
imaging decision tools. patient to another facility or practitioner.

4. Perform proper evaluation of the spine while

restricting spinal motion, including evaluating the
spine, logrolling the patient, removing the backboard,
and reviewing cervical spine and head CT images.

Sk ill s Inc luded in this STEP 2. Shine light into eyes and note pupillary
Sk ill S tation response.

•• Brief or Focused Neurological Examination Determine New GCS Score

•• Evaluation of Cervical Spine
STEP 3. Assess eye opening.
•• Transfer Communication
•• Helmet Removal A. Note factors interfering with communi-
cation, ability to respond, and other
•• Detailed Neurological Exam injuries.
•• Removal of Spine Board
B. Observe eye opening.
•• Evaluation of Head CT Scans
•• Evaluation of Cervical Spine Images C. If response is not spontaneous, stimulate
patient by speaking or shouting.

Brief or Focused D. If no response, apply pressure on fingertip,

Neurological Ex amination trapezius, or supraorbital notch.

E. Rate the response on a scale of not testable

Examine Pupils (NT), 1–4.

STEP 1. Note size and shape of pupil. STEP 4. Assess verbal response.

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­358 APPENDIX G n Skills
A. Note factors interfering with communica-
tion, ability to respond, and other injuries.
B. Observe content of speech.
C. If not spontaneous, stimulate by speaking
or shouting.
D. If no response, apply pressure on fingertip,
trapezius, or supraorbital notch.
E. Rate the response on a scale of NT, 1–5.
STEP 5. Assess motor response.
A. Note factors interfering with communication,
ability to respond, and other injuries.
B. Observe movements of the right and left
sides of body.
C. If response is not spontaneous, stimulate
patient by speaking or shouting.
D. If no response, apply pressure on fingertip,
trapezius, or supraorbital notch (if not
contraindicated by injury).
E. Rate the response on a scale of NT, 1–6.
STEP 6. Calculate total GCS score and record its
individual components.
Evaluate for Any Evidence of
Lateralizing Signs
STEP 7. Assess for movement of upper extremities.
STEP 8. Determine upper extremity strength bi-
laterally, and compare side to side.
STEP 9. Assess for movement of the lower extremities.
STEP 10. Determine lower extremity strength
bilaterally, and compare side to side.
E va luation of C erv ic a l
Spine
STEP 1. Remove the front of the cervical collar, if
present, while a second person restricts
patient’s cervical spinal motion.
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STEP 2. Inform the patient that you are going to
examine him or her. The patient should
answer verbally rather than nodding
the head.
STEP 3. Palpate the posterior cervical spine for
deformity, swelling, and tenderness. Note
the level of any abnormality. Look for any
penetrating wounds or contusions. If the
cervical spine is nontender and the patient
has no neurological deficits, proceed to Step
4. If not, stop, replace the cervical collar, and
obtain imaging.
STEP 4. Ask the patient to carefully turn his or her
head from side to side. Note if there is pain,
or any paresthesia develops. If not, proceed
to Step 5. If yes, stop, reapply the cervical
collar, and obtain imaging.
STEP 5. Ask the patient to extend and flex his or
her neck (i.e., say, “Look behind you and
then touch your chin to your chest.”). Note
if there is pain or any paresthesia develops.
If not, and the patient is not impaired, head
injured, or in other high-risk category as
defined by NEXUS Criteria or the Canadian
C-Spine Rule (CCR), discontinue using the
cervical collar. If yes, reapply the cervical
collar and obtain imaging.
Transfer Communic ation
STEP 1. Use the ABC SBAR method of ensuring
complete communication.
A. Airway
B. Breathing
C. Circulation
D. Situation
•• Patient name
•• Age
•• Referring facility
•• Referring physician name
•• Reporting nurse name
•• Indication for transfer
•• IV access site
­359 APPENDIX G n Skills
•• IV fluid and rate
•• Other interventions completed
E. Background
•• Event history
•• AMPLE assessment
•• Blood products
•• Medications given (date and time)
•• Imaging performed
•• Splinting
F. Assessment
•• Vital signs
•• Pertinent physical exam findings
•• Patient response to treatment
G. Recommendation
•• Transport mode
•• Level of transport care
•• Meds intervention during transport
•• Needed assessments and interventions
Helme t R emova l
STEP 1. One person stabilizes the patient’s head and
neck by placing one hand on either side of
the helmet with the fingers on the patient’s
mandible. This position prevents slippage if
the strap is loose.
STEP 2. The second person cuts or loosens the helmet
strap at the D-rings.
STEP 3. The second person then places one hand
on the mandible at the angle, positioning
the thumb on one side and the fingers on
the other. The other hand applies pressure
from under the head at the occipital region.
This maneuver transfers the responsibility
for restricting cervical motion to the
second person.
STEP 4. The first person then expands the helmet
laterally to clear the ears and carefully
removes the helmet. If the helmet has a face
cover, remove this device first. If the helmet
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provides full facial coverage, the patient’s
nose will impede helmet removal. To clear
the nose, tilt the helmet backward and raise
it over the patient’s nose.
STEP 5. During this process, the second person must
restrict cervical spine motion from below to
prevent head tilt.
STEP 6. After removing the helmet, continue
restriction of cervical spine motion from
above, apply a cervical collar.
STEP 7. If attempts to remove the helmet result in
pain and paresthesia, remove the helmet
with a cast cutter. Also use a cast cutter to
remove the helmet if there is evidence of
a cervical spine injury on x-ray film or by
examination. Stabilize the head and neck
during this procedure; this is accomplished
by dividing the helmet in the coronal plane
through the ears. The outer, rigid layer
is removed easily, and the inside layer
is then incised and removed anteriorly.
Maintaining neutral alignment of the head
and neck, remove the posterior portions of
the helmet.
Detailed Neurological Exam
STEP 1. Examine the pupils for size, shape, and
light reactivity.
STEP 2. Reassess the new GCS score.
STEP 3. Perform a cranial nerve exam by having
patient open and close eyes; move eyes
to the right, left, up, and down; smile
widely; stick out the tongue; and shrug
the shoulders.
STEP 4. Examine the dermatomes for sensation
to light touch, noting areas where there
is sensory loss. Examine those areas for
sensation to pinprick, noting the lowest
level where there is sensation.
STEP 5. Examine the myotomes for active movement
and assess strength (0–5) of movement,
noting if limited by pain.
•• Raises elbow to level of shoulder—deltoid,
C5
­360 APPENDIX G n Skills
•• Flexes forearm—biceps, C6
•• Extends forearm—triceps, C7
•• Flexes wrist and fingers, C8
•• Spreads fingers, T1
•• Flexes hip—iliopsoas, L2
•• Extends knee—quadriceps, L3–L4
•• Flexes knee—hamstrings, L4–L5 to S1
•• Dorsiflexes big toe—extensor hallucis
longus, L5
•• Plantar flexes ankle—gastrocnemius, S1
STEP 6. Ideally, test patient’s reflexes at elbows,
knees, and ankles (this step is least
informative in the emergency setting).
R emova l of Spine Boar d
Note: Properly securing the patient to a long spine board
is the basic technique for splinting the spine. In general,
this is done in the prehospital setting; the patient arrives
at the hospital with spinal motion already restricted by
being secured to a long spine board with cervical collar
in place and head secured to the long spine board. The
long spine board provides an effective splint and permits
safe transfers of the patient with a minimal number of
assistants. However, unpadded spine boards can soon
become uncomfortable for conscious patients and pose
a significant risk for pressure sores on posterior bony
prominences (occiput, scapulae, sacrum, and heels).
Therefore, the patient should be transferred from the spine
board to a firm, well-padded gurney or equivalent surface
as soon as it can be done safely. Continue to restrict spinal
motion until appropriate imaging and examination have
excluded spinal injury.
STEP 1. Assemble four people and assign roles: one to
manage the patient’s head and neck and lead
the movement; one to manage the torso; and
one to manage the hips and legs. The fourth
person will examine the spine, perform
the rectal exam, if indicated, and remove
the board.
STEP 2. Inform the patient that he or she will be turned
to the side to remove the board and examine
the back. Instruct the patient to place his
or her hands across the chest if able and to
respond verbally if he or she experiences pain
during examination of the back.
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STEP 3. Remove any blocks, tapes, and straps securing
the patient to the board, if not already
done. The lower limbs can be temporarily
secured together with roll gauze or tape to
facilitate movement.
STEP 4. All personnel assume their roles: The
head and neck manager places his or
her hands under the patient’s shoulders,
palms up, with elbows and forearms
parallel to the neck to prevent cervical
spinal motion. The torso manager places
his or her hands on the patient’s shoulder
and upper pelvis, reaching across the
patient. The third person crosses the
second person’s hand, placing one hand at
the pelvis and the other at the lower
extremities. (Note: If the patient has
fractures, a fifth person may need to be
assigned to that limb.)
STEP 5. The head and neck manager ensures the
team is ready to move, and then the team
moves the patient as a single unit onto his
or her side.
STEP 6. Examine the back.
STEP 7. Perform rectal examination, if indicated.
STEP 8. On the direction of the head and neck
manager, return the patient to the supine
position. If the extremities were tied or
taped, remove the ties.
Evaluation of Head CT Scans
Note: The steps outlined here for evaluating a head CT
scan provide one approach to assessing for significant,
life-threatening pathology
STEP 1. Confirm the images are of the correct patient
and that the scan was performed without
intravenous contrast.
STEP 2 Assess the scalp component for contusion
or swelling that can indicate a site of
external trauma.
STEP 3 Assess for skull fractures. Remember that
suture lines can be mistaken for fractures.
Missile tracts may appear as linear areas of
low attenuation.
­361 APPENDIX G n Skills
STEP 4 Assess the gyri and sulci for symmetry.
Look for subdural hematomas and
epidural hematomas.
STEP 5 Assess the cerebral and cerebellar
hemispheres. Compare side to side for
density and symmetry. Look for areas of high
attenuation that may represent contusion
or shearing injury.
STEP 6 Assess the ventricles. Look for symmetry
or distortion. Increased density represents
intraventricular hemorrhage.
STEP 7 Determine shifts. Hematoma or swelling
can cause midline shift. A shift of more than
5 mm is considered indicative of the need
for surgery.
STEP 8 Assess the maxillofacial structures. Look
for fractures and fluid in the sinuses.
Remember the four things that cause in-
creased density: contrast, clot, cellularity
(tumor), and calcification.
E va luation of C erv ic a l
Spine im ag e s
Note: Before interpreting the x-ray, confirm the patient
name and date of examination.
STEP 1. Assess adequacy and alignment.
A. Identify the presence of all 7 cervical
vertebrae and the superior aspect
of T1.
B. Identify the
•• Anterior vertebral line
•• Anterior spinal line
•• Posterior spinal line
•• Spinous processes
STEP 2. Assess the bone.
A. Examine all vertebrae for preservation of
height and integrity of the bony cortex.
B. Examine facets.
C. Examine spinous processes.
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STEP 3. Assess the cartilage, including examining
the cartilaginous disk spaces for narrowing
or widening.
STEP 4. Assess the dens.
A. Examine the outline of the dens.
B. Examine the predental space (3 mm).
C. Examine the clivus; it should point to the dens.
STEP 5. Assess the extraaxial soft tissues.
A. Examine the extraaxial space and soft tissues:
•• 7 mm at C3
•• 3 cm at C7
Links to Futur e Le arning
“New” Glasgow Coma Scale: www.glasgowcomascale.org
Brain Trauma Foundation Guidelines: Carney M,
Totten AM, Reilly C, Ullman JS et al. “Guidelines for
the Management of Severe Traumatic Brain Injury,
4th Edition” 2016: Brain Trauma Foundation. www.
braintrauma.org
“New Orleans Criteria” for CT scanning in minor
head injury: Haydel MJ, Preston CA, Mills TJ, Luber S,
Blaudeau E, DeBlieux PMC. Indications for computed
tomography in patients with minor head injury. N Engl
J Med. 2000;343:100-105
“Canadian Head CT rules”:
•• Stiell IG, Lesiuk H, Wells GA, et al. The
Canadian CT Head Rule Study for patients
with minor head injury: rationale, objectives,
and methodology for phase I (derivation).
Ann Emerg Med. 2001;38:160-169. 25. Stiell
IG, Lesiuk H, Wells GA, et al. Canadian CT
Head Rule Study for patients with minor head
injury: methodology for phase II (validation
and economic analysis). Ann Emerg Med.
2001;38:317-322.
•• NEXUS criteria: Hoffman JR, Wolfson AB, Todd
K, Mower WR (1998). “Selective cervical spine
radiography in blunt trauma: methodology
of the National Emergency X-Radiography
­362 APPENDIX G n Skills
Utilization Study (NEXUS).”. Ann Emerg Med. 32
(4): 461–9.
Canadian C-spine rules:
•• Stiell IG, Wells GA, Vandemheen KL, Clement
CM, Lesiuk H, De Maio VJ, et al. The Canadian
C-spine rule for radiography in alert and
stable trauma patients. JAMA. 2001 Oct 17.
286(15):1841-8.
•• Stiell IG, Clement CM, O’Connor A, Davies
B, Leclair C, Sheehan P, et al. Multicentre
prospective validation of use of the Canadian
C-Spine Rule by triage nurses in the emergency
department. CMAJ. 2010 Aug 10. 182(11):1173-9.
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Post-ATLS—Evaluate what procedures exist in your
practice setting for rapidly evaluating patients for
traumatic brain injury (TBI). Does your practice setting
have a protocol for prevention of secondary brain injury
once TBI is diagnosed? Also evaluate what procedures
exist in your practice setting for spine immobilization.
Are all staff members who deal with trauma patients
adequately educated in these procedures? Evaluate
your practice setting regarding how the cervical spine
is evaluated and cleared (if appropriate). Are all staff
members who evaluate trauma patients adequately
educated in the existing, evidence-based criteria for
evaluation and clearance of the cervical spine?