Head, Spine, & Chest
Injuries
Head Injuries
• Leading cause of death due to trauma
• Major causes:
– Airway compromise
– Brain stem laceration, c-spine lesion
• Death within 1-3 hours:
– Epidural hematoma
– Subdural hematoma
Significant Mechanisms of Injury
•
•
•
•
•
•
•
•
Motor vehicle crashes
Pedestrian-motor vehicle collisions
Falls
Blunt or penetrating trauma
Motorcycle crashes
Hangings
Driving accidents
Recreational accidents
Head Injury Types
• Scalp lacerations
• Skull fractures (open or
closed)
• Brain injuries
• Medical conditions
• Complications of head injuries
Scalp Lacerations
• Scalp is extremely
vascular (lots of
blood.)
• Remember that there
may be more serious,
deeper injuries.
• Fold skin flaps back
down onto scalp.
• Control bleeding by
direct pressure.
Skull Fracture
• Indicates significant
force
• Signs
– Obvious deformity
– Visible crack in the
skull
– Raccoon eyes
– Battle’s sign
Skull Fractures
Concussion
• Brain injury
• Temporary loss or
alteration in brain
function
• May result in
unconsciousness,
confusion, or amnesia
(repetitive sayings)
• Brain can bruise when
skull is struck
• Internal bleeding &
swelling
• Bleeding will increase
pressure within the
skull
Coup/Contrecoup Injuries
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 (airway compromise)
Leakage of cerebrospinal fluid
Assessing Head Injuries
• Common causes, think MOI:
– Motor vehicle crashes
– Direct blows
– Falls from heights
– Assault
– Sports Injuries
• Evaluate and monitor LOC
Head Injury Signs and Symptoms
• Lacerations, contusions, hematomas to scalp
• Soft areas or depression upon palpation
• Visible skull fractures or deformities
• Ecchymosis around eyes and behind the ear
(remember these are LATE signs!)
• Clear or pink CSF leakage
Head Injury Signs and Symptoms
• Failure of pupils to respond to light
• Unequal pupils
• Loss of sensation and/or motor function
• Period of unconsciousness
• Amnesia
• Seizures
Head Injury Signs and Symptoms
• Numbness or tingling in the extremities
• Irregular respirations
• Dizziness
• Visual complaints
• Combative or abnormal behavior
• Nausea or vomiting
Level of Consciousness
• Change in level of consciousness is the
single most important observation.
• Use the AVPU scale or Glasgow Coma
Scale (depending on local protocols)
• Reassess
– Every 15 minutes if patient is stable.
– Every 5 minutes if patient is unstable.
Change in Pupil Size
• Unequal pupil size may indicate increased
pressure on one side of the brain.
Head Injury Management
• Secure airway
• High flow O2, assist ventilations if needed
• C-spine stabilization
• Control major bleeding
• Backboard
• VS, transport
• Medics?
Spinal Injuries
Spinal Injuries
• Think about the
significance of the
injury to the area of
the spinal cord
• Paralysis, paraplegia,
quadraplegia, and
death can result
dependent upon the
injury location
Signs and Symptoms of Spinal
Injury
•
•
•
•
•
•
•
Pain or tenderness of spine
Deformity of spine
Tingling/pain in the extremities
Loss of sensation or paralysis
Incontinence
Injuries to the head
Priaprism
Spinal Injury Assessment
•
•
•
•
•
ABC’s
LOC
Need to palpate the entire spine
Look for signs of injuries (DCAP/BTLS)
Pulse, motor, sensory function on all
extremities
Spinal Injury Management
• Secure airway
• Assist ventilations, high flow O2
• C-spine precautions
• Secure to backboard
• Monitor VS, transport
• Medics?
Cervical Spine Stabilization
• Hold head firmly with both
hands.
• Support the lower jaw.
• Move to eye-forward
position.
• Maintain the position until
patient is secured to a
backboard.
Cervical Spine Stabilization
• One attempt to realign head into a
neutral, in-line position unless:
– Muscles spasm
– Pain increases
– Numbness, tingling, or weakness
develop
– There is a compromised airway or
breathing
Applying a Cervical Collar
• One EMT-B provides continuous
manual in-line support of the
head.
• Measure the proper size collar.
• Place the chin support snuggly
under the chin.
• Wrap the collar around the neck.
• Ensure that the collar fits.
Chest Trauma
Chest Trauma
• Second leading cause of trauma deaths after
head injury
• Accounts for 20% of all trauma deaths
• Initial exam directed toward:
–
–
–
–
Open/tension pneumothorax
Flail chest
Massive hemothorax
Cardiac tamponade
Rib Fractures
• Most common chest
injury
• Adults (elderly) more
than children
• Most common 5th to
9th ribs (poor
protection)
• 1st/2nd rib fractures
require high force
(30% death rate due to
aorta/bronchi injury)
• 8th to 12th rib fractures
can cause underlying
abdominal solid organ
damage
Signs & Symptoms
• Localized pain, tenderness
• Increases with cough, movement, and/or
inspiration
• Chest wall instability
• Deformity, discoloration
• Associated pneumo or hemothorax
Rib Fracture Management
• ABC’s, Oxygen
• Splint using pillows, swathes,
• Encourage patient to breath deeply
• Monitor elderly/COPD patients carefully
– Broken ribs can cause decompensation
– Patients will fail to breath deeply and cough,
resulting in failure to clear secretions
Flail Chest
• Two or more ribs broken in two or more
places
• Produces free-floating chest wall segment
• Usually secondary to blunt force trauma
• More common in elderly patients
Signs & Symptoms
•
•
•
•
Pain leading to decreased ventilation
Increased WOB
Contusion of lung
Paradoxial movement
– May not be present initally due to incostal
muscle spasms
– Be suspicious with chest wall tenderness and
crepitus
Flail Chest Management
• Establish airway
• Suspect spinal injuries
• Assist ventilations with BVM/O2
• Stabilize chest wall
• Medics?
Simple Pneumothorax
• Air in pleural space with partial or complete
lung collapse
• Causes:
– Chest wall penetration
– Fractured ribs
– May occur spontaneously from coughing,
exertion, air travel
Signs & Symptoms
•
•
•
•
Pain on inhalation
Difficulty breathing
Tachypnea
Decreased or absent breath sounds
Severity of symptoms depends on the size of
pneumothorax, speed of lung collapse, and
patient’s health status
Simple Pneumothorax Management
• Establish airway
• Suspect spinal injury based upon MOI
• High concentration O2 via NRB
• Assist decreased or rapid respirations with
BVM
• Monitor for tension pneumothorax
Open Pneumothorax
• “Hole in chest wall”
• Allows air to enter the
pleural space
• Larger hole increases
chance more air will
enter through hole
than through the
trachea
• Sucking chest wound
SCW
SCW Management
• Close hole with occlusive dressing
• High concentration O2
• Positive pressure ventilations with BVM
• Consider placement on injured side
• Monitor for tension pneumothorax
Tension Pneumothorax
• One-way valve forms
in lung or chest wall
• Air is trapped in
pleural space
• Pressure increases
causing lung collapse
causing mediastinal
shift decreasing
cardiac output
Signs & Symptoms
• Extreme dyspnea
• Restlessness, anxiety,
agitation
• Decreased breath
sounds
• Hyperresonanace to
percussion
• Cyanosis
• Rapid, weak pulse
• Decrease BP
• Tracheal shift away
from injured side
• Jugular vein distension
• Subcutaneous
emphysema
Tension Pneumothorax Management
• Secure airway
• High concentration O2 with NRB
• Be ready to assist ventilations with BVM
• Request ALS for pleural decompression
Hemothorax
• Blood in the pleural
spaces
• Most common result
of chest wall trauma
• Present in 70% to 80%
of penetrating, major
non-penetrating chest
trauma
• Shock precedes
ventilatory failure
Hemothorax Management
• Secure airway
• Assist ventilations with BVM/02
• Rapid transport
• Medics?
Traumatic Asphyxia
• Blunt force trauma to the
chest that causes:
– Increased intrathoracic
pressure
– Backward flow of
blood out of heart into
the vessels of the upper
chest, neck, and head
Patients looked like
they have been
strangled
Signs & Symptoms
• Possible sternal fracture or central flail
chest
• Shock
• Purplish-red discoloration of head, neck,
and shoulders
• Blood shot, protruding eyes
• Swollen, cyanotic lips
Traumatic Asphyxia Management
• Maintain airway with C-spine management
• Assist ventilations with BVM/O2
• Spinal stabilization
• Rapid transport
• Medics?
Myocardial Contusion
• Bruising of the heart
muscle
• Most common blunt
cardiac injury
• Usually due to
steering wheel impact
• May behave like an
acute MI
• May produce
arrhythmias
• May cause cardiogenic
shock, hypotension
Signs & Symptoms
• Cardiac arrhythmias after blunt chest
trauma
• Angina-like pain unresponsive to NTG
• Chest pain independent of respiratory
movement
• Suspect in all blunt chest trauma
Myocardial Contusion Management
• High concentration O2 via NRB
• Transport
• Rapid transport
• Medics?
Cardiac Tamponade
• Rapid accumulation of
blood in the
pericaridal space
• Heart is compressed
• Blood flow entering
heart is decreased
• Cardiac output falls
Signs & Symptoms
• Hypotension
• Increased venous pressure (distended
neck/arm veins in presence of decreased
arterial pressure)
• Muffled heart tones
• Narrowing pulse pressure
• Pulsus paradoxius
Cardiac Tamponade Management
• Secure airway
• High concentration O2
• Rapid transport
• Medics? (pericardiocentesis)
Thoracic Aortic Rupture
• Caused by sudden
decelerations, massive
blunt force trauma
• Rupture usually occurs
just beyond left
subclavian artery
• Attachment of aorta to
pulmonary artery at
this point produces
shearing force on the
aortic arch
Signs & Symptoms
• Increase BP in absence of head injury
• Decreased femoral pulses with full arm
pulses
• Respiratory distress
• Ache in chest, shoulders, lower back,
abdomen
Aortic Rupture Management
• Maintain a high index of suspicion
• High concentration O2, assist ventilations
• Suspect spinal injury
• Rapid transport
• Medics?
ALS Indicators
• Compromised airway
• Abnormal respiratory patterns
• MOI
• Decreased/altered LOC (GCS<12)
• Paresis/paresthesia
• Brain or spinal cord injury
• ETOH or drug use
Transporting Supine Patients
• Maintain in-line stabilization.
• Have the other team members position the
immobilization device.
• Assess pulse, motor, and sensory function
• Log roll/Seattle roll patient.
• Secure patient to backboard.
• Reassess pulse, motor, and sensory
function in each extremity
Transporting Sitting Patients
•
•
•
•
•
•
•
Maintain manual in-line stabilization.
Apply a cervical collar.
Place KED behind patient.
Position device around patient and secure.
Remove patient and lower to long backboard.
Secure KED and patient to backboard together.
Reassess the pulse, motor function, and
sensation.
Transporting Standing Patients
• Stabilize the head and neck and apply a
cervical collar.
• Position board behind patient.
• Employ standing takedown procedure
• Carefully lower the patient to the ground.
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)
• Prevent head
movement.
Helmet Removal (4 of 4)
• Slide helmet off while partner
supports head.
Pediatric Needs
• Immobilize a child
in the car seat, if
possible.
• Children may need
extra padding to
maintain
immobilization.