CH 12: Spinal & Head Injuries

Question 1

General functions of the different lobes of the brain.

Answer 1

Frontal: Executive functions (intentions and how to accomplish them) cognition, memory/recall, abstract ideas, reasoning.

Temporal: Primary auditory cortex, memory storage, speech comprehension (Wernicke’s area)

Parietal: Tactile sensations, proprioception, kinesthesia, understanding of objects + their relationship to you

Occipital: Primary high-order visual cortex, deals with vision and seen things relationship to you, EXCEPT the ability to see.

Question 2

How many PAIRS of nerve roots exit each vertebra?

Answer 2

1 pair on each side

Question 3

What landmark does the spine enter the skull?

Answer 3

Foramen magnum

Question 4

When the spinal cord is severely damaged or severed altogether, where does loss of function occur?

Answer 4

Function is impaired or lost entirely BELOW the site of injury.

Question 5

What vertebrae control the phrenic nerve and why is that important for FR’s?

Answer 5

C3,C4 & C5 control the phrenic nerve which controls the diaphragm which controls the ability to breathe.

Question 6

How can you tell the difference between a sprain/strain & a spinal cord injury?

Answer 6

Muscle sprains and ligament strains are usually localized and tender on palpation.

Spinal cord damage would yield crepitus of vertebrae and referred pain/numbness in places in the body inferior to site of damage.

Question 7

What are 3 bony landmarks useful for locating specific vertebrae?

Answer 7

Scapular spine: T2/T3
Inf. angle of scapula: T7/T8
Iliac crest: L1/L2

Question 8

What are the most common dangerous MOI’s? (8)

Answer 8

1) Fall from height >1m
2) Axial load to head
3) Anyone involved in a Motor vehicle accident
4) Unresponsive w/ unknown cause
5) Severe blunt force to head
6) Penetrating trauma to head, neck, or torso
7) Cracked helmet
8) Lighting strike/electrocution

Question 9

What are the 5 types of motion involved in head/spine injuries?

Answer 9

• Hyper-extension
• Hyper-flexion
• Hyper-rotation
• Axial load
• Whiplash motion

Question 10

When stabilizing the head during manual SMR, what is the motion that is most important to limit?

Answer 10

Extension of the neck

Question 11

Describe axial load, and the movements commonly associated with it.

Answer 11

A force that is directed through the top of the head and through the spine.

Because it is rare to just land directly on top of one’s head, axial load is usually in combination with hyper extension and/or hyper flexion

Question 12

What blood vessel weaves through the vertebral facet joints to provide 20% of blood flow to the brain?

Answer 12

The vertebral artery. As little as 20% rotation/extension can decrease blood flow through this vessel.

Question 13

What are the terms used to describe bruising around the eyes and ears?

Answer 13

Periorbital ecchymosis: bruising under/around eyes (racoon eye’s)

Periauricular ecchymosis: Bruising under/around ears (Battle’s sign)

Question 14

What are the terms used to describe CSF leaking from facial orifices?

Answer 14

Rhinorrhea: CSF leakage out of nose

Otorrhea: CSF leakage out of ear.

Question 15

What is the halo effect?

Answer 15

When blood is mixed with leaking CSF. Looks like a fried egg.

Question 16

What does periorbital ecchymosis usually a sign of? (More specific than just head trauma)

Answer 16

Facial bone fractures. The articulations of the facial bones compared the larger skull bones are much weaker and susceptible to fractures.

Question 17

Why was the Canadian C-spine rule created?

Answer 17

The CCR was developed to simplify and standardize the assessment of patients with suspected spinal injuries.

Question 18

What are the 5 steps to rule out a spinal injury using the CCR?

Answer 18

1) Do you have numbness/tingling in fingers? (Grip test)
2) Do you have pain in your neck?
3) Was your neck pain immediate or delayed? (Immediate = bad)

If ALL previous questions were answered “no” then proceed to step 4:

4) Palpate C-spine. Bones not soft tissue.
5) Ask patient to slowly rotate head 45 degrees left & right.

If all steps are passed, SMR can be ruled out and can be brought to their feet and removed from field to proceed with Secondary assessment.

Question 19

Under what conditions can you implement the CCR checklist?

Answer 19

1) Patient must be ALERT (GCS = 15)
2) Vital signs are STABLE
3) >16 years old
4) No previous spinal surgeries

Question 20

What are the 5 types of manual SMR and when are they best used?

Answer 20

1) Head grip: can be used in most SMR situations
2) Trap squeeze: same as head grip
3) Modified trap squeeze: best used for flipping patient
4) Sternal forehead grip: same as 2+3
5) Sternal/spinal grip: best used for patient in seated position or when transitioning during prone-to-supine flip.

Question 21

What is In-Line stabilization and how is it best performed?

Answer 21

Used to bring a patient into “neutral alignment” which means having their chin in line with their neck and their spine is straight.

1) Direct patient to remain still
2) Ensure arms/elbows are completely stable
3) Place in head grip position and:
3a) ROTATE so chin is in line with sternum
3b) TILT or LATERALLY FLEX the head so nose is in line with sternum
3c) FLEX or EXTEND the head IF NECESSARY

Question 22

What are the contra-indications for In-line stabilization?

Answer 22

1) The patients head is extremely angulated to one side
2) The patient complains of pain, pressure, or muscle spasm in the neck when moved
3) You feel resistance or crepitus when attempting re-alignment

Question 23

Can cervical collars be used on their own? What will happen if a collar isn’t sized correctly? How many responders are required to apply?

Answer 23

No, a cervical collar is only to be used in conjunction with manual SMR, and requires 2 responders.

Too small: not enough support

Too tall: hyper extends the neck, possible causing more damage.

Question 24

When would it be appropriate to board a patient?

Answer 24

1) If the environment is no longer safe to remain in.

2) CPR must be performed and the ground is not stable enough to resist the compressions

Question 25

In what order would you apply straps to a boarded patient?

Answer 25

1 - Torso 2 - Pelvis & proximal legs 3 - Distal legs 4 - Head

Question 26

The adult brain is divided into what 4 major brain regions? (Different than lobes)

Answer 26

1) Brain stem - Vital link to brain and rest of body + autonomic functions 2) Cerebellum - Responsible for subconscious motor control (balance) 3) Diencephalon - Contains thalamus, hypothalamus and epithalamus - responsible for information filtering and homeostasis 4) Cerebrum - Seat of intelligence - Supported on diencephalon

Question 27

How should skull fractures be treated?

Answer 27

Always treated with SMR techniques, to minimize chance of brain trauma.

Question 28

What are 4 signs that a patient may be suffering from an orbital fracture?

Answer 28

1) Double or tunnel vision 2) Numbness above eyebrow or over cheek 3) Massive nasal discharge 4) Eyes may not be able to follow moving objects

Question 29

How should a patient with a skull impalement be treated and should the object be removed?

Answer 29

Heavily dress the would area in sterile gauze, with a route for blood to drain. Avoid direct pressure on head and NEVER remove object, unless it prevents BREATHING.

Question 30

Cerebral bleeding management: Epidural Hematoma (7)

Answer 30

- Arterial - Forms between skull and dura mater - Results from a low-velocity blow to head - S/S appear rapidly - LOR will be unresponsive briefly, become alert and then decline rapidly, becoming sluggish - Motor function will be impaired on side of body opposite to injury - High pressure, low SA

Question 31

Cerebral bleeding management: Subdural Hematoma (7)

Answer 31

- Venous - Bleeding in subdural space - Results from violent blow to head - S/S appear much slower, up to days later - Bleeding is slower, so pain will gradually increase over time - Speaking and vision will be disturbed w/ possible personality changes - Lower pressure, over larger SA

Question 32

Cerebral bleeding management: Subarachnoid Hematoma (5)

Answer 32

- Arterial - Found between arachnoid membrane and pia mater - Space is occupied by CSF circulation which builds pressure rapidly - Can occur spontaneously from ruptured aneurysm or head injury - Rapid onset headache

Question 33

Cerebral bleeding management: Intracerebral Hematoma (4)

Answer 33

- Arterial or venous - Blunt force or penetrating trauma that damages brain vessels physically - Usually more than one contusion and can enlarge over time - Specific S/S depend on location and size of hematoma

Question 34

What is Cushing's Triad?

Answer 34

It is a physiological nervous system response to acute elevations of intracranial pressure. Characterized by 3 specific symptoms: 1) Increase in BP (typically systolic) 2) Bradycardia - onset is over 5-10 mins 3) Irregular or continuous changes in respirations

Question 35

What is a Sport Related Concussion?

Answer 35

A traumatic brain injury caused by a direct blow to the head, neck, or body that results in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities.

Question 36

What are the 5 defining characteristics of a sports related concussion?

Answer 36

1) Initiates a neurotransmitter and metabolic cascade, with possible axonal injury 2) S/S may appear immediately or over minutes to hours 3) All abnormalities are invisible to neuroimaging 4) Results in a range of clinical s/s that may not include loss of responsiveness 5) Does not have specific diagnostic criteria

Question 37

What is the average time it takes for a concussion to resolve?

Answer 37

7-10 days

Question 38

What are the names of concussion-specific MOI?

Answer 38

Coup: Initial, direct cause of damage Typically followed by: Contrecoup: Secondary, recoil damage of the brain hitting the opposite side of the coup

Question 39

What are the 6 clinical domains of a concussion?

Answer 39

1) Symptoms (somatic, cognitive or emotional) 2) Physical signs (LOR amnesia, neurological deficit) 3) Balance impairment (unsteady gait) 4) Behaviour changes (irritability, sadness, aggression) 5) Cognitive impairment (slowed reaction times) 6) Sleep disturbances (Drowsiness and trouble falling/staying asleep)

Question 40

What parts of Primary and Secondary Assessment are modified to detect concussions?

Answer 40

Primary: Refer to list of Red Flags and see if any are present during assessment Secondary: Add a SCAT (Sport Concussion Assessment Tool) to assessment

Question 41

When a player shows ANY signs, or complains of any symptoms of a concussion, what 5 things must be done?

Answer 41

1) Do not allow RTP same day 2) Do not leave player alone 3) Should be assessed and continuously monitored for changes 4) Should be seen be an MD 5) Must follow a closely monitored and gradual return to play process

Question 42

Why is it important to monitor concussed players for hours/days post injury? (Specifically GCS)

Answer 42

Intracranial bleeding can be very delayed for hours or even days post injury. GCS should be assessed at - Time of injury - 2-3 hours post - 24 hours post - 48 hours post - 72 hours post (Best case scenario)

Question 43

What is Post-Concussion Syndrome? When does a normal concussion on average resolve itself?

Answer 43

A blanket term used for the many symptoms that commonly occur after a concussion. Any combination of physical, cognitive, behavioural or emotional symptoms will usually persist beyond 3 months. A normal concussion will normally resolve within 7-10 days.

Question 44

What is Second Impact Syndrome, and why is it relevant for AT's to be aware of it?

Answer 44

Can occur when a second head trauma is inflicted before the first one has resolved. The second blow could occur within minutes days or weeks from primary injury and could be fatal. AT's must recognize S/S because an athlete could have been cleared to RTP prematurely. Very few confirmed cases of this exist, so exact pathophysiology of this is unknown.

Question 45

What is CTE?

Answer 45

Chronic Traumatic Encephalopathy causes nerve cell death, resulting in brain tissue degeneration. Can occur in athletes who have been exposed to multiple concussions/repetitive head impacts. Not well understood but doesn't seem to be related to singular head injuries. At this time, only diagnosable upon death.