Chapter 34
Head and Spine Trauma
National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan.
National EMS Education
Standard Competencies
Head, Facial, Neck, and Spine
Trauma
Recognition and management of
• Life threats
• Spine trauma
National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of
• Penetrating neck trauma
• Laryngotracheal injuries
• Spine trauma
− Dislocations/subluxations
− Fractures
− Sprains/strains
National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of (cont’d)
•Facial fractures
•Skull fractures
•Foreign bodies in the eyes
•Dental trauma
National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of (cont’d)
•Unstable facial fractures
•Orbital fractures
•Perforated tympanic membrane
•Mandibular fractures
National EMS Education
Standard Competencies
Nervous System Trauma
Pathophysiology, assessment, and
management of
•
Traumatic brain injury
•
Spinal cord injury
•
Spinal shock
National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of (cont’d)
•Cauda equina syndrome
•Nerve root injury
•Peripheral nerve injury
Introduction
• The central nervous system (CNS) consists
of the brain and spinal cord.
• Two primary divisions of insult:
− Head injuries
− Spinal cord injury
The Scalp
• The brain is housed within several layers:
− Skin, with hair
− Subcutaneous tissue
− Galea aponeurotica
− Loose connective tissue
− Periosteum
The Skull
• Consists of 28 bones in three anatomic
groups.
− Auditory ossicles
− Cranium
− Face
The Skull
The Skull
• Sutures: Special
joints where the
bones of skull are
connected
− Fontanelles are
tissues that link the
sutures.
The Skull
• Mastoid process: Cone-shaped section of
bone at the base of each temporal bone
The Skull
• The floor of the
cranial vault is
divided into three
compartments:
− Anterior fossa
− Middle fossa
− Posterior fossa
The Skull
• Base of the skull
− The occipital
condyles are points
of articulation
between the skull
and the vertebral
column.
The Brain
The Brain
• Cerebrum
− Largest portion
− Responsible for
higher functions
− Divided into
hemispheres
The Brain
• Diencephalon
− Includes the:
• Thalamus
• Subthalamus
• Epithalamus
• Hypothalamus
The Brain
• Cerebellum
− Sometimes called “athlete’s brain”
− Responsible for maintenance of posture,
equilibrium, and coordination
The Brain
• Brainstem
− Consists of midbrain, pons, and medulla
− Connects spinal cord to rest of brain
− Houses many structures critical to maintenance
of vital functions
• Reticular activating system (RAS)
• Limbic system
The Meninges
• Protective layers that surround and enfold
the entire CNS
• Float in cerebrospinal fluid (CSF)
The Spine
• Consists of 33
irregular bones
(vertebrae)
• Components
include:
− Lamina
− Pedicles
− Spinous processes
The Spine
• Each vertebra is unique in appearance but
shares basic characteristics.
− Except the atlas and axis (C1 and C2)
The Spine
The Spine
• Each vertebra is
separated by
intervertebral
disks.
− Stress on vertebral
column can cause
disks to herniate.
• May result in nerve
root injury
The Spine
• Spinal cord
− Transmits nerve
impulses between
brain and body
The Spine
• Spinal nerves
− 31 pairs
− Named for region
and level
− Plexus: Cluster
that function as a
group
The Spine
• Sympathetic nervous system
− Controlled by the hypothalamus
− Controls sweating, pupil dilation, temperature
regulation, and “flight or fight” responses
− Loss of stimulation can disrupt homeostasis.
The Spine
• Parasympathetic nervous system
− Carries signals to organs of the abdomen,
heart, lungs, and skin above the waist
− Slows heart rate when the sympathetic nerves
are stimulated
Scene Size-Up
• Determine scene safety.
• The following should prompt a search for
signs of head and brain injuries:
−
−
−
−
−
Motor vehicle crashes
Direct blows
Falls from heights
Assault
Sports-related injuries
Scene Size-Up
• The following indicate the need for full
spinal motion restriction:
− High-velocity crash with severe vehicle damage
− Unrestrained occupant of vehicle crash
− Vehicular damage with compartmental intrusion
− Fall from three times patient’s height
− Penetrating trauma near spine
Scene Size-Up
• The following indicate the need for full
spinal motion restriction (cont’d):
− Ejection from moving vehicle
− Motorcycle crash
−
−
−
−
Diving injury
Auto-pedestrian or auto-bicycle crash
Death of occupant in same compartment
Rollover crash (unrestrained)
Primary Assessment
• Form a general impression.
− Note age and gender.
− Observe position.
− Determine whether condition is life threatening.
− Manually stabilize the cervical spine.
− Determine the level of consciousness.
Primary Assessment
• Airway and breathing
− Ensure an open airway.
− Maintain head and neck in neutral position, and
clear the mouth.
− Open the airway with the jaw-thrust maneuver if
unresponsive or unable to maintain airway.
Primary Assessment
• Airway and breathing (cont’d)
− If intubation is required:
• Preoxygenate with 100% oxygen.
• Administer lidocaine IV push.
• Perform intubation with head in neutral in-line
position.
Primary Assessment
• Airway and breathing (cont’d)
− Evaluate breathing.
− Monitor oxygen saturation, and maintain at 95%
or higher.
− Inadequate respirations require ventilation.
Primary Assessment
• Circulation
− In absence of
pulse, initiate CPR.
− Control major
bleeding with direct
pressure.
− Compare radial
and carotid pulses.
Primary Assessment
• Circulation (cont’d)
− Examine skin color, temperature, and moisture.
− Volume resuscitation might be necessary.
• Do not administer dextrose-containing solutions.
• Restrict use for severe closed head injury.
Primary Assessment
• Transport decision
− If patient is unstable, transport immediately.
− Consider air transport if time will be prolonged.
− Patients with severe brain injuries and
increased ICP require neurosurgical
intervention.
History Taking
• Patient’s reliability should be assessed.
− Unreliable patients should have continuous
spine protection until injury can be excluded.
• Maintain a high index of suspicion.
• Obtain SAMPLE history.
Secondary Assessment
• Obtain complete set of baseline vital signs.
• Modify examination of any patient with
suspected SCI based on:
− Level of consciousness
− Reliability as a historian
− Mechanism of injury
Secondary Assessment
• Use DCAP-BTLS.
• Evaluate distal PMS for all four extremities.
• Expose the patient for your examination.
− Cut away the patient’s clothes.
− Observe the back and palpate the spine.
Secondary Assessment
• Placement on the
backboard
− Document before
and after
immobilizing.
− Most patients can
be log rolled.
− Keep time on
backboard to
minimum.
Secondary Assessment
• Complete a full-body exam en route.
− Head
− Neck
− Chest Abdomen
−
−
−
−
Pelivs
Extremities
Back
Buttocks
Secondary Assessment
• Level of
consciousness
− Obtain a complete
GCS score.
− Indicates extent of
brain dysfunction
Secondary Assessment
• Pupillary assessment
− Monitor size, equality, and reactivity of pupils.
− When a light is shined into the eye, the pupil
should briskly constrict.
AAOS
Secondary Assessment
• Assessing ICP
− Critical treatment
decisions are
based on key
findings.
−
Secondary Assessment
• Neurologic exam
− Intended to establish a baseline for later
comparison.
− Determine the level of consciousness.
Secondary Assessment
• Neurologic exam
− Myotomes: Regions where motor components
of spinal nerves innervate tissues and muscles
Secondary Assessment
Secondary Assessment
Secondary Assessment
• Dermatomes: Regions where sensory
components of spinal nerves innervate
Reassessment
• Monitor vital signs:
− Every 5 minutes in unstable patient
− Every 15 minutes in stable patient
• Be alert for hypotension without other signs
of shock.
Reassessment
• Check interventions.
• Repeat the physical exam and reprioritize.
• Document suspected spinal cord injury.
Head Injuries
• Traumatic insult to the head that can result
in injury to soft tissue, bony structures, or
the brain
• Two general types:
− Closed head injury
− Open head injury
Skull Fracture
• Significance is
related to:
− Type of fracture
− Amount of force
− Area of head that
sustained the blow
• Potential
complications:
− Intracranial
hemorrhage
− Cerebral damage
− Cranial nerve
damage
Skull Fracture
• Linear skull
fractures
− Account for 80% of
all skull fractures
− No gross physical
signs
Skull Fracture
• Depressed skull
fractures
− Result from highenergy direct
trauma
− Patients often
present with
neurologic signs.
Skull Fracture
• Basilar skull
fractures
− Usually occur
following diffuse
impact to head
− Signs include:
• CSF drainage
• Raccoon eyes
• Battle sign
Skull Fracture
• Open skull
fractures
− Result of severe
force
− Brain tissue might
be exposed.
− High mortality rate
Traumatic Brain Injury
• Classified into:
− Primary brain injury
• Injury to the brain and its associated structures
− Secondary brain injury
• After-effects of primary injury
Traumatic Brain Injury
• The most common
cause is a motor
vehicle crash.
• Coupe-contrecoup
− Front-and-rear type
of injury
Intracranial Pressure
• An increase in ICP can be caused by:
− Accumulation of blood within the skull
− Swelling of the brain
• Increase in ICP decreases cerebral
perfusion pressure (CPP) and blood flow.
− CPP = MAP - ICP
Intracranial Pressure
• Early warning
signs of ICP:
• Ominous signs:
− Vomiting
− Headache
− Hypertension
− Bradycardia
− Cushing triad
− Altered level of
consciousness
− Seizures
− Nonreactive pupil
− Coma
− Posturing
• Decorticate
• Decerebrate
Diffuse Brain Injuries
• Cerebral concussion
− Brain is jarred around in the skull.
− Signs include:
• Confusion, disorientation
• Loss of consciousness
• Retrograde amnesia
• Autograde (posttraumatic) amnesia
Diffuse Brain Injuries
• Diffuse axonal injury (DAI)
− Associated with or similar to a concussion
− Involves stretching, shearing, tearing of nerve
fibers and axonal damage
− Classified as mild, moderate, or severe
Focal Brain Injuries
• Cerebral contusion
− Brain tissue bruised and damaged in local area
− Greater neurologic deficits
− Swelling of the brain leads to increased ICP.
Focal Brain Injuries
• Intracranial
hemorrhage
− Epidural
hematoma
• Accumulation of
blood between
skull and dura
mater
• Result of blow to
the head
Focal Brain Injuries
• Intracranial
hemorrhage
(cont’d)
− Subdural
hematoma
• Accumulation of
blood beneath
dura mater outside
the brain
• Associated with
venous bleeding
• Acute or chronic
Focal Brain Injuries
• Intracranial
hemorrhage
(cont’d)
− Intracerebral
hematoma
• Bleeding in brain
tissue
• Patient’s condition
deteriorates
quickly.
Focal Brain Injuries
• Intracranial hemorrhage (cont’d)
− Subarachnoid hemorrhage
• Bleeding into subarachnoid space
• Patient presents with sudden, severe headache.
Focal Brain Injuries
• Intracranial hemorrhage (cont’d)
− Subgaleal hemorrhage
• Bleeding between periosteum and galea
aponeurosis
− Supragaleal hemorrhage
• Firm, nodular mass
Assessment and Management
• Should be guided
by factors such as:
− Severity of injury
− Patient’s level of
consciousness
Assessment and Management
• Thermal management
− Do not allow patient to develop hyperpyrexia.
• Treatment of associated injuries
− Apply loose, sterile dressings.
− Objects impaled should be stabilized.
Assessment and Management
• Pharmacologic therapy
− May be ordered if transport will be prolonged
− Benzodiazepines should be used for seizures.
− No neuroprotective agents are currently
administered in a prehospital setting.
Pathophysiology of Scalp
Lacerations
• Can vary between
minor and serious
• Can lead to
significant blood
loss
− Do not become
distracted by the
injury.
Assessment and Management
of Scalp Lacerations
• Consider the mechanism.
− Inspect for missing tissue, impaled objects, or
residual contaminants.
− Evaluate for signs of continued bleeding.
Assessment and Management
of Scalp Lacerations
• In isolated lacerations, stop the bleeding.
• Do not explore the injury.
− This may disrupt a clot formation and reinitiate
bleeding.
Pathophysiology, Assessment,
and Management of Spine Injuries
• Spinal cord injury (SCI) has limited
treatment options.
− Reducing incidence is best option for
decreasing associated morbidity and mortality.
Flexion Injuries
• Result from
forward movement
of head
• Typically result of
rapid deceleration
or direct blow to
occiput
Rotation with Flexion
• The only area of
the spine that
allows for rotation
is C1–C2.
• Injuries are
considered
unstable.
Vertical Compression
• Transmitted through
vertical bodies
• Result from direct blow
to crown or rapid
deceleration from a fall
Hyperextension
• Results in fractures
and ligamentous
injury of variable
stability
Primary Spinal Cord Injury
• Occurs at moment of impact
• Spinal cord concussion
− Temporary dysfunction lasts 24 to 48 hours.
− May be due to a short-duration shock or
pressure wave within the cord
Primary Spinal Cord Injury
• Spinal cord contusions
− Caused by fracture, dislocation, or direct trauma
• Cord laceration
− Caused when a projectile or bone enters the
spinal canal
Secondary Spinal Cord Injury
• Occurs when multiple factors permit a
progression of the primary SCI
• Classified as either complete or incomplete
Secondary Spinal Cord Injury
• Anterior cord syndrome
− Displacement of bony fragments into anterior
portion of the spinal cord
− Findings include paralysis below level of insult
• Central cord syndrome
− Hyperextension injuries to the cervical area
− Loss of function in upper extremities
Secondary Spinal Cord Injury
• Posterior cord syndrome
− Associated with extension injuries
− Presents as decreased sensation to:
• Light
• Touch
• Proprioception
• Vibration
Secondary Spinal Cord Injury
• Cauda equina syndrome
− Compression of bundle of nerve roots
− Can produce the following:
• Low back pain
• Myalgia, paresthesia, or myasthenia
• Loss of sensation
• Acute bladder/bowel dysfunction
Secondary Spinal Cord Injury
• Brown-Séquard syndrome
− Functional hemisection of the cord; complete
damage to spinal tracts on involved side
• Spinal shock
− Temporary local neurologic condition that
occurs immediately after spinal trauma.
Secondary Spinal Cord Injury
• Neurologic shock
− Results from temporary loss of autonomic
function at the level of injury
− Hemodynamic and systemic effects are seen.
Assessment and Management
• Current principles of spine trauma
management include:
− Recognition of potential or actual injury
− Appropriate immobilization
− Reduction or prevention of secondary injury
Assessment and Management
• Patient may not require immobilization if:
− No neurologic deficit
− Not under influence of alcohol, drugs, or
medications
− No distracting injuries
− No motor or sensory deficit
− No pain or tenderness
Spinal Splinting Procedures for
Supine Patients
Spinal Splinting Procedures for
Supine Patients
• Do not force the head into a neutral, in-line
position if the patient has:
− Muscle spasms in the neck
− Increased pain with movement
− Numbness, tingling, or weakness
− Compromised airway or ventilation
Spinal Splinting Procedures for
Seated Patients
• A rigid cervical collar should be measured
and placed appropriately.
• A vest-type board should be used to
transfer the patient onto a long backboard.
Spinal Splinting Procedures for
Seated Patients
Spinal Splinting Procedures for
Rapid Extrication
• Use in the following situations:
− Vehicle or scene is unsafe
− Patient cannot be assessed before being
removed from the car.
− Patient needs immediate intervention.
− Patient’s condition requires immediate
transport.
− Patient blocks access to another injured patient.
Spinal Splinting Procedures for
Rapid Extrication
Spinal Splinting Procedures for
Standing Patient
Packaging and Removal of
Injured Patients from the Water
• Assume spinal injury for the following:
− Diving injury
− Boating injury
− Watercraft injury
− Falls from heights
Packaging and Removal of
Injured Patients from the Water
Patients Wearing Helmets
• Helmet removal is recommended in the
following situations:
− Helmet and chin strap fail to hold head securely.
− Helmet and chin strap prevent airway control.
− Helmet with a face mask cannot be removed.
− Helmet prevents proper immobilization.
Patients Wearing Helmets
Pharmacotherapy of Spinal
Cord Injury
• Short-acting, reversible sedatives are
commonly recommended for acute
agitation.
• Pain medication may be necessary.
• Corticosteroids are sometimes used in the
acute phase of SCI.
Complications of Spinal Cord
Injury
• Potential for aspiration or respiratory arrest
• Predisposal to atelectasis and pneumonia
• Deep vein thrombosis and pulmonary
embolism
Complications of Spinal Cord
Injury
• Autonomic dysreflexia
− Potentially life threatening
− Most commonly occurs with injuries above
T4–T6
− Patients present with a massive,
uncompensated cardiovascular response.
Complications of Spinal Cord
Injury
• Autonomic dysreflexia (cont’d)
− Common precipitators include:
• Skin lesions
• Constrictive clothing
• Sharp objects compressing the skin
− Management is usually not a prehospital
intervention.
Nontraumatic Spinal
Conditions
• Back pain is one of the most common
physical complaints.
• Risks for developing low back pain include:
− Occupations that require repetitive lifting
− Exposure to vibrations
− Comorbid diseases such as osteoporosis
Nontraumatic Spinal
Conditions
• When evaluating:
− Consider disease processes that can result in
debilitating lesions.
− Keep anatomy and neurophysiology in mind.
− Pay attention to medications.
Nontraumatic Spinal
Conditions
• Degenerative disk disease
− Disk loses height and shock-absorbing effect.
− Disk herniation may be caused.
• Prehospital management is directed at
decreasing pain or discomfort.
Injury Prevention
• Prevention includes safety measures that
can decrease risk of injury.
− Driving safely
− Adhering to posted safety alerts
Summary
• The skull does not accommodate a swelling
brain or accumulations of blood.
• Be familiar with high-risk mechanisms of
injury that can cause head injury, brain
injury, and spinal cord injury.
• Airway is a priority; maintain the head and
neck in neutral alignment while you are
suctioning and performing airway
management.
Summary
• Control major bleeding without placing
pressure on a potential underlying fracture.
• Transport patients with severe injuries
promptly to a trauma center.
• Level of consciousness should continuously
be assessed, including repeat assessments
of the Glasgow Coma Scale score and
pupillary assessment.
Summary
• Head injuries include skull fractures and
traumatic brain injury.
• Increased intracranial pressure can
squeeze the brain against the interior of the
skull and/or press it into sharp edges within
the cranium.
Summary
• Cerebral perfusion pressure is the pressure
of blood flowing through the brain; it is the
difference between the mean arterial
pressure and intracranial pressure.
• If the cerebral perfusion pressure drops
below 60 mm Hg in the adult, cerebral
ischemia will likely occur.
Summary
• Begin treatment of a head-injured patient by
stabilizing the cervical spine, opening the
airway with the jaw-thrust maneuver, and
assessing the ABCs.
• All head-injured patients should receive
100% oxygen as soon as possible.
• Avoid routine hyperventilation of a braininjured adult unless signs of cerebral
herniation are present.
Summary
• Restrict IV fluids in a head-injured patient
unless hypotension (systolic blood pressure
of less than 90 mm Hg) is present.
• Frequently monitor a head-injured patient’s
level of consciousness, and document your
findings.
• Intubation of a brain-injured patient may
require pharmacologic adjuncts.
Summary
• Seizures may occur in a brain-injured
patient and can aggravate intracranial
pressure and cause or worsen cerebral
ischemia.
• A brain-injured patient’s survival depends
on recognition of the injury, prompt and
aggressive prehospital care, and rapid
transport to a trauma center that has
neurosurgical capabilities.
Summary
• Do not become distracted by scalp
lacerations. Once life threats are managed,
evaluate the wound for continued bleeding.
• In order to decipher the often subtle findings
associated with a spinal cord injury, you
need to understand the form and function of
spinal anatomy.
• Acute injuries of the spine are classified
according to the associated mechanism,
location, and stability of injury.
Summary
• Vertebral fractures can occur with or without
associated spinal cord injury.
• Stable fractures typically involve only a
single column and pose a lower risk to the
spinal cord.
Summary
• Primary spinal cord injury occurs at the
moment of impact. Secondary spinal cord
injury occurs when multiple factors permit a
progression of the primary spinal cord
injury.
• Limiting the progression of secondary spinal
cord injury is a major goal of prehospital
management of spinal cord injury.
Summary
• Current principles of spine trauma
management include recognition of
potential or actual injury, appropriate
immobilization, and reduction or prevention
of the incidence of secondary injury.
• Short-acting, reversible sedatives are
recommended for the acute patient after a
correctible cause of agitation has been
excluded.
Summary
• The use of corticosteroids in the acute
phase of spinal cord injury is controversial.
• The complications of spinal cord injury are a
consistent cause of the high morbidity and
mortality associated with this type of injury.
• Back pain is one of the most common
physical complaints to present to
emergency departments throughout the
United States.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Blue – Jones & Bartlett Learning. Courtesy
of MIEMSS; Gold – Jones & Bartlett Learning. Courtesy of
MIEMSS; Green – Jones & Bartlett Learning; Purple –
Jones & Bartlett Learning. Courtesy of MIEMSS; Red – ©
Margo Harrison/ShutterStock, Inc.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for Emergency
Medical Services Systems, or have been provided by the
American Academy of Orthopaedic Surgeons.