30: Head and Spine Injuries

Cognitive Objectives (1 of 5)

5-4.1 State the components of the nervous system.

5-4.2 List the functions of the central nervous system.
5-4.3 Define the structure of the skeletal system as it
relates to the nervous system.
5-4.4 Relate mechanism of injury to potential injuries of
the head and spine.
5-4.5 Describe the implications of not properly caring
for potential spine injuries.
5-4.6 State the signs and symptoms of a potential
spine injury.
 Cognitive Objectives (2 of 5)

5-4.7 Describe the method of determining if a

responsive patient may have a spine injury.
5-4.8 Relate the airway emergency medical care
techniques to the patient with a suspected spine
injury.
5-4.9 Describe how to stabilize the cervical spine.
5-4.10 Discuss indications for sizing and using a
cervical spine immobilization device.
5-4.11 Establish the relationship between airway
management and the patient with head and
spine injuries.
 Cognitive Objectives (3 of 5)

5-4.12 Describe a method for sizing a cervical spine

immobilization device.
5-4.13 Describe how to log roll a patient with a
suspected spine injury.
5-4.14 Describe how to secure a patient to a long
spine board.
5-4.15 List instances when a short spine board should
be used.
5-4.16 Describe how to immobilize a patient using a
short spine board.
 Cognitive Objectives (4 of 5)

5-4.17 Describe the indications for the use of rapid

extrication.
5-4.18 List the steps in performing rapid extrication.
5-4.19 State the circumstance when a helmet should
be left on the patient.
5-4.20 Discuss the circumstances when a helmet
should be removed.
5-4.21 Identify different types of helmets.
5-4.22 Describe the unique characteristics of sports
helmets.
 Cognitive Objectives (5 of 5)

5-4.23 Explain the preferred methods to remove a

helmet.
5-4.24 Discuss alternative methods for removal of a
helmet.
5-4.25 Describe how the patient’s head is stabilized to
remove the helmet.
5-4.26 Differentiate how the head is stabilized with a
helmet compared to without a helmet.
 Affective Objectives (1 of 2)

5-4.27 Explain the rationale for immobilization of the

entire spine when a cervical spine injury is
suspected.
5-4.28 Explain the rationale for utilizing immobilization
methods apart from the straps on the cots.
5-4.29 Explain the rationale for utilizing a short spine
immobilization device when moving a patient
from the sitting to the supine position.
 Affective Objectives (2 of 2)

5-4.30 Explain the rationale for utilizing rapid

extrication approaches only when they indeed
will make the difference between life and death.
5-4.31 Defend the reasons for leaving a helmet in
place for transport of a patient.
5-4.32 Defend the reasons for removal of a helmet
prior to transport of a patient.
 Psychomotor Objectives (1 of 3)

5-4.33 Demonstrate opening the airway in a patient

with a suspected spinal cord injury.
5-4.34 Demonstrate evaluating a responsive patient
with a suspected spinal cord injury.
5-4.35 Demonstrate stabilization of the cervical spine.
5-4.36 Demonstrate the four-person log roll for a
patient with a suspected spinal cord injury.
5-4.37 Demonstrate how to log roll a patient with a
suspected spinal cord injury using two people.
 Psychomotor Objectives (2 of 3)

5-4.38 Demonstrate securing a patient to a long spine

board.
5-4.39 Demonstrate using the short board
immobilization technique.
5-4.40 Demonstrate the procedure for rapid extrication.
5-4.41 Demonstrate preferred methods for stabilization
of a helmet.
5-4.42 Demonstrate helmet removal techniques.
 Psychomotor Objectives (3 of 3)

5-4.43 Demonstrate alternative methods for

stabilization of a helmet.
5-4.44 Demonstrate completing a prehospital care
report for patients with head and spinal injuries.
Anatomy and Physiology
of the Nervous System
Central Nervous System
 Sensory and Connecting Nerves
• The connecting nerves in the spinal cord form a reflex
arc.
• If a sensory nerve in this arc detects an irritating
stimulus, it will bypass the brain and send a direct
message to a motor nerve.
 How the Nervous System Works
• The nervous system controls virtually all of our
body activities including reflex, voluntary and
involuntary activities
• Voluntary activities are action that we consciously
perform (ie, passing a dish)
• Involuntary activities are actions that are not under
our control (ie, body functions)
• Body functions are controlled by the autonomic
nervous system
 Autonomic Nervous System
• Two components
• Sympathetic nervous system
– Reacts to stress with a flight or fright response.
– Some common responses are dilated pupils,
increased pulse rate, or rising BP.
• Parasympathetic nervous system
– Causes the opposite effect of the sympathetic
nervous system
Spinal Column
 Anatomy and Physiology
of the Skeletal System
• Two layers of bone protect the brain.
• Skull is divided into cranium and face.
• Injury to the vertebrae can cause paralysis.
• Vertebrae are connected by intervertebral disks.
 Head Injuries
• Scalp lacerations
• Skull fractures
• Brain injuries
• Medical conditions
• Complications of head injuries
 Scalp Lacerations
• Scalp has a rich blood supply.
• There may be more serious, deeper injuries.
 Skull Fracture
• Indicates significant force
• Signs
– Obvious deformity
– Visible crack in the skull
– Raccoon eyes
– Battle’s sign
 Concussion (1 of 2)
• Brain injury
• Temporary loss or alteration in
brain function
• May result in
unconsciousness, confusion,
or amnesia
 Concussion (2 of 2)
• Brain can sustain bruise when
skull is struck.
• There will be bleeding and
swelling.
• Bleeding will increase the
pressure within the skull.
 Intracranial Bleeding
• Laceration or rupture
of blood vessel in brain
– Subdural
– Intracerebral
– Epidural
 Other Brain Injuries
• Brain injuries are not always caused by
trauma.
• Medical conditions may cause spontaneous
bleeding in the brain.
• Signs and symptoms of nontraumatic injuries
are the same as those of traumatic injuries.
– There is no mechanism of injury.
Complications of Head Injury
• Cerebral edema
• Convulsions and seizures
• Vomiting
• Leakage of cerebrospinal fluid
 Signs and Symptoms (1 of 3)
• Lacerations, contusions, hematomas to scalp
• Soft areas or depression upon palpation
• Visible skull fractures or deformities
• Ecchymosis around eyes and behind the ear
• Clear or pink CSF leakage
 Signs and Symptoms (2 of 3)
• Failure of pupils to respond to light
• Unequal pupils
• Loss of sensation and/or motor function
• Period of unconsciousness
• Amnesia
• Seizures
 Signs and Symptoms (3 of 3)
• Numbness or tingling in the extremities
• Irregular respirations
• Dizziness
• Visual complaints
• Combative or abnormal behavior
• Nausea or vomiting
 Spine Injuries
• Compression injuries occur from a fall.
• Motor vehicle crashes or other types of trauma can
overextend, flex, or rotate the spine.
• Distraction: When spine is pulled along its length;
causes injuries.
– Hangings are an example.
Significant Mechanisms of Injury
• Motor vehicle crashes
• Pedestrian-motor vehicle collisions
• Falls
• Blunt or penetrating trauma
• Motorcycle crashes
• Hangings
• Driving accidents
• Recreational accidents
• Your unit is on standby at the All American College
during a gymnastic tournament.
• A bystander comes to you and states a 19-year-old
female gymnast has fallen head first from a
balance beam.
• You find the patient prone on a rubber mat awake
and breathing normal. No threats to life are
observed.
You are the provider
• What is the mechanism of injury?
• What injuries do you suspect? You are the provider
continued

• What is the next step in the assessment process?

 Scene Size-up

• Observe scene for hazards; take BSI precautions.

• Anticipate problems with ABCs.
• Pay attention for changes in level of
consciousness.
• Call for ALS backup as soon as possible when
serious MOI is present.
• Look for a deformed helmet or deformed
windshield.
• You manually stabilize the spine and log roll the
patient.
• You assess the ABCs and place the patient on
oxygen via nonrebreathing mask.
• She said she felt pain in her neck right away and
has tingling in her arms and legs. You begin a rapid
trauma assessment. You are the provider continued (1
of 2)
• Why did you do a rapid trauma assessment?
• What steps comes next? You are the provider
continued (2 of 2)
 Initial Assessment

• Ask the patient:

– What happened?
– Where does it hurt?
– Does your neck or back hurt?
– Can you move your hands and feet?
– Did you hit your head?
• Confused or slurred speech, repetitive questioning,
or amnesia indicate head injury.
• Ask when patient lost consciousness.
• Stabilize the spine.
 ABCs
• Use jaw-thrust maneuver to open airway.
• Vomiting may occur. Suction immediately.
• Move patient as little as possible. Do not remove
c-collar.
• Consider providing positive pressure ventilations.
• A pulse that is too slow can indicate a serious
condition.
• Assess and treat for shock.
 Transport Decision
• If patient has problems with ABCs, provide rapid
transport.
• You check for an absence of a distal pulse. Pulse
is normal. Bleeding is not noted.
• You determine that this patient is a low-priority
transport.
You are the provider continued (1 of 3)
• What do you need to be sure to ask during the
SAMPLE history? You are the provider continued (2 of 3)

• Describe the rest of your emergency care.

• You quickly inspect and palpate the chest for
DCAP-BTLS. This was unremarkable.
• You start the patient on high-flow oxygen.
• You apply a cervical collar and immobilize her to a
long board. You are the provider continued (3 of 3)

• The patient could vomit. Be ready to reposition the

long board and suction.
 Focused History and Physical Exam

• The absence of pain does not rule out a potential

spinal injury.
• Do not ask patients with possible spinal injuries to
move their neck.
Rapid Physical Exam for Significant
Trauma (1 of 2)
• Quickly use DCAP-BTLS.
• Decreased level of consciousness is the most
reliable sign of head injury.
• Expect irregular respirations.
• Look for blood or CSF leaking from ears, nose, or
mouth.
 Rapid Physical Exam for
Significant Trauma (2 of 2)
• Look for bruising around eyes, behind ears.
• Evaluate pupils.
• Do not probe scalp lacerations. Do not remove an
impaled object.
 Focused Physical Exam
for Nonsignificant Trauma
• Watch for change in level of
consciousness.
• Use Glasgow Coma Scale.
• Pain, tenderness, weakness,
numbness, and tingling are
signs of spinal injury.
• May lose sensation or become
paralyzed
• May become incontinent
 Baseline Vital Signs/
SAMPLE History
• Complete set of baseline vital signs is essential.
• Assess pupil size and reactivity to light; continue
to monitor.
• Gather as much history as possible while
preparing for transport.
 Interventions (1 of 2)
• Control bleeding.
• Fold torn skin flaps back
down onto the skin bed.
• Do not apply excessive
pressure.
• If dressing becomes
soaked, place a second
dressing over it.
 Interventions (2 of 2)
• Once bleeding has been controlled, secure with a
soft self-adhering roller bandage.
• Monitor and treat for shock.
• Protect airway from vomiting.
• Provide immediate transport.
 Detailed Physical Exam

• Perform if time permits.

• Can help identify subtle or covert injuries
 Ongoing Assessment

• Focus on reassessing ABCs, interventions, vital signs.

• Communication and documentation
– Hospital may prepare better with info from your
assessment.
– Document changes in level of consciousness.
– Include history.
– Document vital signs every 5 minutes if unstable,
every 15 minutes if stable.
 Emergency Medical Care
of Spinal Injuries
• Follow BSI precautions.
• Manage the airway.
– Perform the jaw-thrust maneuver to open the
airway.
– Consider inserting an oropharyngeal airway.
– Administer oxygen.
• Stabilize the cervical spine.
Stabilization of the Cervical Spine (1 of 3)
• Hold head firmly with
both hands.
• Support the lower jaw.
• Move to eyes-forward
position.
Stabilization of the Cervical Spine (2 of 3)
• Support head while
partner places cervical
collar.
• Maintain the position
until patient is secured
to a backboard.
Stabilization of the Cervical Spine (3 of 3)
• Do not force the head into a neutral,
in-line position if:
– Muscles spasm
– Pain increases
– Numbness, tingling, or weakness
develop
– There is a compromised airway or
breathing problems.
 Emergency Medical Care
of Head Injuries
• Establish an adequate airway.
• Control bleeding and provide adequate
circulation.
• Assess the patient’s baseline level of
consciousness.
 Managing the Airway
• Establish an adequate airway.
• Use the jaw-thrust maneuver.
• Maintain head in neutral, in-line position.
• Place cervical collar.
• Suction.
• Provide high-flow oxygen.
• Continue to assist ventilations and administer
oxygen.
 Circulation
• Begin CPR if patient is in cardiac arrest.
• Blood loss aggravates hypoxia.
• Shock can occur.
• Transport immediately to trauma center.
• If patient becomes nauseated or vomits, place on
left side.
 Preparation for Transport:
Supine Patients (1 of 2)
• Maintain in-line stabilization.
• Have the other team members position the
immobilization device.
• Log roll patient.
 Preparation for Transport:
Supine Patients (2 of 2)
• Secure patient to backboard.
• Reassess pulse, motor, and sensory function in
each extremity and continue to do so periodically.
Preparation for Transport:
Sitting Patients (1 of 2)
• Maintain manual in-line stabilization.
• Apply a cervical collar.
• Place a short board behind patient.
• Position device around patient.
 Preparation for Transport:
Sitting Patients (2 of 2)
• Turn patient and lower to long backboard.
• Secure short and long backboards together.
• Reassess the pulse, motor function, and sensation.
 Preparation for Transport:
Standing Patients
• Stabilize the head and neck and apply a cervical collar.
• Position board behind patient.
• Carefully lower the patient to the ground.
 Applying a Cervical Collar (1 of 2)
• One EMT-B provides continuous manual in-line
support of the head.
• Measure the proper size collar.
 Applying a Cervical Collar (2 of 2)
• Place the chin support snuggly under the chin.
• Wrap the collar around the neck.
• Ensure that the collar fits.
 Backboards
• Short backboards
– Used on patients found in a sitting
position
• Long backboards
– Provide full-body immobilization
 Helmet Removal (1 of 4)
• Is the airway clear and is the patient breathing
adequately?
• Can airway be maintained and ventilations
assisted with helmet in place?
• How well does the helmet fit?
• Can the patient move within the helmet?
• Can the spine be immobilized in a neutral
position with the helmet on?
 Helmet Removal (2 of 4)
• A helmet that fits well prevents the head from
moving and should be left on, as long as:
– There are no impending airway or breathing
problems.
– It does not interfere with assessment and
treatment of the airway.
– You can properly immobilize the spine.
 Helmet Removal (3 of 4)
• Open the face
shield.
• Prevent head
movement.
• Partner places
hands.
• Gently slip helmet
off halfway.
 Helmet Removal (4 of 4)
• Partner slides hands from
occiput to back of head.
• Remove helmet.
• Stabilize spine.
• Apply cervical collar.
• Pad as needed.
 Pediatric Needs (1 of 2)
• Immobilize a child in the car seat, if possible.
 Pediatric Needs (2 of 2)
• Children may need extra padding to maintain
immobilization.
• Children may need extra padding under the
shoulders.