Chapter 38
Head, Face, Neck
and Spine Trauma
Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
38-1
Objectives
38-2
Central Nervous System
38-3
Anatomy
• Central nervous system
– Brain
– Spinal cord
• Scalp
• Meninges
– Pia mater
– Arachnoid layer
– Dura mater
38-4
Areas of the Brain
38-5
Spinal Cord
• Center for many
reflex activities
38-6
Spinal Cord
• Long tracts of nerves
join the brain with all
body organs and parts
– Motor nerves
– Sensory nerves
38-7
Spinal Cord Injuries
• Signs and symptoms
depend on type and
location of the injury
38-8
Peripheral Nervous System
• Nervous tissue found
outside the brain and
spinal cord
– 12 pairs of cranial
nerves
– 31 pairs of spinal
nerves
38-9
Peripheral Nervous System
• Two divisions
– Somatic
– Autonomic
• Two divisions
– Sympathetic
» Fight or flight response
» Widespread effects
– Parasympathetic
» Conserves and restores energy
» Localized effects
38-10
Injuries
to the Head
38-11
Injuries to the Head
• Head injury
– A traumatic insult to the head that may
result in injury to soft tissue, bony
structures, and/or brain injury
• Traumatic brain injury
– Occurs when an external force to the head
causes the brain to move within the skull
or the force causes the skull to break and
directly injures the brain
38-12
Mechanism of Injury
• Mechanisms of blunt trauma
• Mechanisms of penetrating trauma
• Airway management and breathing support
are critical in the head-injured patient
38-13
Injuries to the Scalp
• Scalp
– Outermost part of the head
– Consists of five layers that contains
tissue, hair follicles, sweat glands, oil
glands, and a rich supply of blood vessels
– Protected by the skull
– A scalp injury may or may not cause an
injury to the brain.
38-14
Injuries to the Scalp
• When injured, the scalp may bleed heavily.
– May produce shock in children
– In adults, shock is usually not caused by a
scalp wound or internal skull injuries.
• Control bleeding with direct pressure.
38-15
Injuries to the Skull
• The skull is made up
of two main groups
of bones.
– Bones of the
cranium
– Bones of the face
• The cranium
contains bones that
house and protect
the brain.
38-16
Head Injury
• Closed head injury
– Skull remains intact
– Brain can be injured by forces or objects
that strike the skull
38-17
Head Injury
• Skull
– Rigid, closed container
– Bleeding within the skull can result in
increased pressure within the container
38-18
Head Injury
• Open head injury
– Skull is not intact
– Increased risk of infection
– If the skull is cracked, blood and
cerebrospinal fluid can leak through the
crack
38-19
Skull Fractures
• Depressed
• Compound
• Basilar
38-20
Signs of a Skull Fracture
38-21
Skull Fracture
Signs and Symptoms
• Bruises or cuts to the
scalp
• Deformity to the skull
• Discoloration around
the eyes (raccoon eyes)
• Discoloration behind
the ears (Battle’s sign)
• Loss of consciousness
• Confusion
• Convulsions
• Restlessness, irritability
• Drowsiness
• Blood or clear watery
fluid (cerebrospinal
fluid) leaking from the
ears or nose
• Visual disturbances
• Changes in pupils
• Slurred speech
• Difficulties with
balance
• Stiff neck
• Vomiting
38-22
Patient Assessment
• Scene size-up
– Assess mechanism of
injury
– Put on appropriate PPE
• Primary survey
– Manually stabilize
patient’s head and neck
– Glasgow Coma Scale
38-23
Head/Brain Injury Severity
Classification
Glasgow Coma Scale Score
Minor
13 to 15
Moderate
9 to 12
Severe
3 to 8
38-24
Patient Assessment
• Hypoxia can cause further damage in already
injured tissue.
– Use a pulse oximeter
– Maintain the patient’s oxygen saturation at
90% or above.
– Obtain and monitor the patient’s vital
signs.
38-25
Emergency Care
•
•
•
•
•
•
•
•
Cervical spine precautions
Ensure open airway
Give oxygen
Assist ventilation as needed
Control bleeding
Be prepared for seizures
Transport to an appropriate trauma center
Air medical transport may be needed
38-26
Injuries to the Face
• Blood supply
– Arteries
– Veins
• Orbits
• Nose
• Midface
38-27
Injuries to the Eye
• Blood supply
• Conjunctiva
38-28
Injuries to the Eye
• Outer layer
– Fibrous tunic
– Sclera
– Cornea
38-29
Injuries to the Eye
• Middle layer
– Vascular tunic
– Iris
– Ciliary
body
– Choroid
38-30
Injuries to the Eye
• Innermost layer
– Nervous tunic, retina
38-31
Injuries to the Eye
• Anterior chamber
• Posterior chamber
38-32
Mechanism of Injury
• Blunt trauma
– Fists and clubs
– Falls
– Windshields, dashboards, and steering
wheels in motor vehicle crashes
• Penetrating trauma
– Gunshot wounds, stabbings, dog bites,
human bites, or biting the tongue
38-33
Injuries to the Mouth
• Tongue lacerations
• Teeth may be fractured or avulsed
• Lip lacerations
38-34
Injuries to the Nose
• Palpate the nose for tenderness or crepitus.
– If bruising or tenderness over the bridge of
the nose is present, assume nasal bone
fracture.
– Control bleeding from lacerations to the
nose and anterior epistaxis with direct
pressure.
38-35
Injuries to the Ear
• Treat injuries to the ear like any other softtissue injury.
• Never put anything into the ear to control
bleeding.
• If there is drainage from the ear, apply a
sterile dressing loosely over the ear and
bandage it in place.
38-36
Injuries to the Eyes
• Hyphema
• Blowout fracture
38-37
Injuries to the Eyes
• Ultraviolet keratitis
– “Welder’s flash”
– “Arc eye”
– “Snow blindness”
38-38
Injuries to the Midface
• Palpate the orbital
rims, nose, zygoma,
and maxilla to assess
bone integrity
• Fractures
– Zygoma
– Maxilla
38-39
Injuries to the Mandible
• Second most common fracture of the face
• Risk of airway obstruction
• Frequent reassessment necessary
38-40
Patient Assessment
• Scene size-up
• Wear appropriate PPE
• Cervical spine precautions
• Assess ABCs
• Assess conjunctiva and sclera
• Assess pupils
• Consider psychological trauma
38-41
Emergency Care
• Cervical spine precautions
• Establish and maintain an open airway
– Suction as needed
– Avoid nasal airway in facial trauma
• Give 100% oxygen
– Assist ventilation as needed
38-42
Emergency Care
• Control bleeding by applying direct pressure.
• If signs of shock are present or if internal
bleeding is suspected, treat for shock.
• Dress and bandage any open wounds.
• If dentures or missing teeth are found, they
should be transported with the patient.
• If a knocked-out (avulsed) tooth is found,
handle the tooth by the crown.
– Transport the tooth with the patient to the
hospital.
38-43
Emergency Care
• Eye injuries
– Foreign body
– Chemical burn
– Nonchemical burn
– Eyelid laceration
– Impaled object
– Eviscerated eye
38-44
Emergency Care
• An impaled object in the cheek may be
removed if bleeding obstructs the airway.
– Apply direct pressure to the bleeding site
after removal of the object
38-45
Injuries to the Neck
38-46
Injuries to the Neck
38-47
Injuries to the Neck
• Mechanism of injury
– Hanging
– Impact with a steering wheel
– Knife or gunshot wounds
– Strangulation
– Sports injuries
– “Clothesline” injuries
38-48
Patient Assessment
•
•
•
•
•
Scene size-up
Ensure your safety
Evaluate the mechanism of injury
Put on appropriate PPE
Assess the patient’s ABCs while maintaining
spinal stabilization
38-49
Patient Assessment
• Examine the neck for DCAP-BTLS
• Subcutaneous emphysema
• Stridor
• Look for handprints
• Look for rope marks
• Palpate the trachea
• Palpate the cervical spine
38-50
Patient Assessment
• Laryngeal injuries
– Increase the risk of airway obstruction
• Cricoid cartilage
– Fracture can result in death due to airway
obstruction
38-51
Patient Assessment
• Injuries to the esophagus
– Frequent suctioning may be needed to
maintain an open airway.
38-52
Emergency Care
• Transport to a trauma center
• ALS intercept or air medical transport may
be necessary
• Cervical spine precautions
• Avoid rigid cervical collars or other devices
that obstruct your view of the neck
• Establish and maintain an open airway
• Give oxygen
38-53
Emergency Care
• Control bleeding
– Care for an open neck wound
• Do not remove a penetrating object.
• Dress and bandage any open wounds.
• Comfort, calm, and reassure
• Reassess as often as indicated
38-54
Injuries to the Brain
38-55
Injuries to the Brain
• Concussion
– Traumatic brain
injury
– Temporary loss of
function in some or
all of the brain
– May or may not
cause a loss of
consciousness
38-56
Injuries to the Brain
• Cerebral contusion
– Brain tissue is bruised and damaged in a
local area
– Bruising at the area of direct impact (coup)
– Bruising on the side opposite the impact
(contrecoup)
38-57
Injuries to the Brain
• Hematomas
– Subdural hematoma
– Epidural hematoma
– Intracerebral hematoma
• Increased intracranial
pressure
– Cushing’s triad
38-58
Injuries to the Brain
• Subdural hematoma
– Venous blood
builds up between
dura and
arachnoid layer
– Acute
– Chronic
38-59
Injuries to the Brain
• Epidural hematoma
– Usually involves
tearing of an artery
– Rapid buildup of
blood between
dura and skull
38-60
Injuries to the Brain
• Intracerebral hematoma
– Collection of blood
within the brain
– Signs and symptoms
depend on the area of
the brain involved, the
amount of bleeding,
and associated injuries
38-61
Emergency Care
• Wear appropriate PPE.
• Cervical spine precautions
• Short on-scene time and rapid transport to
an appropriate trauma center are critical
• ALS intercept or air medical transport may
be necessary
• Establish and maintain an open airway.
• Give 100% oxygen.
– Maintain the patient’s oxygen saturation at
90% or more
38-62
Emergency Care
• Control bleeding
– Do not attempt to stop flow of blood or
CSF from the ears or nose
– Do not remove a penetrating object
• Stabilize it in place
• Treat for shock if present
• Dress and bandage wounds
• Repeat Glasgow Coma Scale score with each
reassessment of the patient
38-63
Injuries to the Spine
38-64
Spinal Cord Injuries
• A spinal column injury (bony
injury) can occur with or
without a spinal cord injury.
• A spinal cord injury can also
occur with or without an
injury to the spinal column.
38-65
Suspect Spinal Injury
• Motor vehicle crashes
• Blunt trauma
• Ejection or fall from a
transportation device
• Electrical injuries,
lightning strike
• Involvement in an
explosion
• Unresponsive trauma
patients
• Hangings
• Any fall, particularly in
an older adult
• Any shallow-water
diving incident
• Any injury in which a
helmet is broken
• Any injury that
penetrates the head,
neck, or torso
• Any pedestrian-vehicle
crash
• Any high-impact, highforce, or high-speed
condition involving the
head, spine, or torso
38-66
Compression Injury
• Can result from a
fall from a
significant height
onto the head or
legs
– Force of injury
can drive weight
of head into
neck or pelvis
into torso
38-67
Excessive Extension
38-68
Excessive Flexion
38-69
Rotation Injury
• Severe rotation of torso or head and
neck can move one side of spinal
column against the other
• Possible causes:
– Motorcycle crash
– Rollover motor vehicle crash
38-70
Lateral Bending Injury
38-71
Distraction
38-72
Paraplegia
• Loss of movement
and sensation in
the body from the
waist down
• Results from
spinal cord injury
at the level of the
thoracic or lumbar
vertebrae
38-73
Quadriplegia
• Loss of movement
and sensation in
both arms, both legs,
and parts of the body
below an area of
injury to the spinal
cord
• Results from a spinal
cord injury at the
level of the cervical
vertebrae
38-74
Signs and Symptoms of
Possible Spinal Injury
• Tenderness in the injured area
• Pain associated with movement
• Pain independent of movement or palpation
along the spinal column
• Pain down the lower legs or into the rib cage
• Pain that comes and goes, usually along the
spine and/or lower legs
• Soft-tissue injuries associated with trauma to
the head and neck
38-75
Signs and Symptoms of
Possible Spinal Injury
• Numbness, weakness, or tingling in the
limbs
• Loss of sensation or paralysis below the site
of injury
• Loss of sensation or paralysis in the upper
or lower limbs
• Difficulty breathing
• Loss of bladder or bowel control
• Inability to walk, move limbs, or feel
sensation
• Deformity or muscle spasm along the spinal
column
38-76
Assessing the Potentially
Spine-injured Patient
38-77
Assessment
• Scene size-up
• Evaluate mechanism of injury
• Put on appropriate PPE
• Perform a primary survey
– Maintain in-line stabilization of head/neck
38-78
Manual Stabilization
38-79
Manual Stabilization
38-80
Manual Stabilization
38-81
Manual Stabilization
38-82
Establish Patient Priorities
• Priority patients are those:
– Who give a poor general impression
– Who have severe pain anywhere
– Who have uncontrolled bleeding
– Who experience difficulty breathing
– Who have signs and symptoms of shock
– Who are unresponsive with no gag reflex
or cough
– Who are responsive and unable to follow
commands
38-83
Physical Exam
• Assess for DCAP-BTLS
• Assess distal pulses
• Assess sensation
• Assess movement
38-84
Physical Exam
• Unresponsive patient
– Assess movement and sensation by
gently pinching each foot and hand
– Note facial movements or movement of
the pinched extremity
38-85
History
•
•
•
•
•
•
•
What happened?
When did the injury occur?
Where does it hurt?
Does your neck or back hurt?
Were you wearing a seat belt?
Did you pass out before the accident?
Did you move or did someone move you
before we arrived?
• Have your symptoms changed from the time
of the injury until the time we arrived?
38-86
Emergency Care
38-87
Emergency Care
• Establish and maintain open airway
– Jaw thrust preferred
• Insert oral airway if needed
• Give oxygen, assist breathing if needed
• Control bleeding if present
• Cover open wounds
• Splint bone or joint injuries
38-88
Spinal Stabilization Techniques
38-89
Spinal Stabilization Techniques
• Remember that the joint above and the joint
below the injured area must be immobilized
– Cervical spine or thoracic spine injury
• Stabilize from head to pelvis
– Lumbar spine injury
• Stabilize thoracic spine, pelvis, and hips
• Secure the patient’s legs to the board
• Stabilize head if possible cervical spine injury
38-90
Rigid Cervical Collar
Purpose
• Temporarily splints the head and neck in a
neutral position
• Limits movement of the cervical spine
• Supports the weight of patient’s head while
he is in a sitting position
• Helps maintain the cervical spine in a neutral
position when the patient is lying on his back
• Reminds the patient and others that the
mechanism of injury suggests a possible
spinal injury
38-91
Applying a Cervical Collar
38-92
Applying a Cervical Collar
38-93
Applying a Cervical Collar
38-94
Applying a Cervical Collar
38-95
Applying a Cervical Collar
• Apply a rigid cervical collar only if it fits
properly
– Too tight
• Can reduce blood flow in the neck
– Too loose
• Can cause an airway obstruction
• Will not adequately stabilize head/neck
– Too short or too tall
• Will not provide adequate stabilization
38-96
Logroll
• Technique used to move a patient from a
facedown to a face-up position while keeping
the head and neck in line with the rest of the
body
• Also used to place a patient with a suspected
spinal injury on a backboard
38-97
Three-Person Logroll
38-98
Three-Person Logroll
38-99
Three-Person Logroll
38-100
Three-Person Logroll
38-101
Three-Person Logroll
38-102
Three-Person Logroll
38-103
Immobilization on a Long Backboard
38-104
Immobilization on a Long Backboard
38-105
Immobilization on a Long Backboard
38-106
Immobilization Using a Short Backboard
• Short backboard uses:
– To immobilize a seated patient who has a
suspected spinal injury and stable vital
signs
– To immobilize a patient in a confined
space
– As a long backboard for a small child
38-107
Spinal Immobilization
Seated Patient
38-108
Spinal Immobilization
Seated Patient
38-109
Spinal Immobilization
Seated Patient
38-110
Spinal Immobilization
Seated Patient
38-111
Spinal Immobilization
Seated Patient
38-112
Spinal Immobilization
Seated Patient
38-113
Spinal Immobilization
Seated Patient
38-114
Spinal Immobilization
Seated Patient
38-115
Spinal Immobilization
Standing Patient
38-116
Spinal Immobilization
Standing Patient
38-117
Spinal Immobilization
Standing Patient
38-118
Spinal Immobilization
Standing Patient
38-119
Rapid Extrication
• Urgent move
• Use when there is an immediate threat to life:
– Altered mental status
– Inadequate breathing
– Shock (hypoperfusion)
– Unsafe scene
– Patient blocks access to another, more
seriously injured, patient
38-120
Helmet Removal
• Ask yourself:
– Can I access the patient’s airway?
– Is the patient’s airway clear?
– Is the patient breathing adequately?
– Is there room to apply a face mask if it is
necessary to assist breathing?
– How well does the helmet fit?
– Can the patient’s head move within the helmet?
– Can the spine be immobilized in a neutral position
if the helmet is left in place?
38-121
Helmet Removal
• Leave a helmet in place if:
– There are no impending airway or breathing
problems
– The helmet fits well, with little or no movement of
the patient’s head within the helmet
– Helmet removal would cause further injury to the
patient
– Proper spinal immobilization can be performed
with the helmet in place
– The presence of the helmet does not interfere with
your ability to assess and reassess airway and
breathing
38-122
Removing a Motorcycle Helmet
38-123
Removing a Motorcycle Helmet
38-124
Removing a Motorcycle Helmet
38-125
Removing a Motorcycle Helmet
38-126
Removing a Motorcycle Helmet
38-127
Removing a Motorcycle Helmet
38-128
Questions?
38-129