Ch. 29 Headandspineinjuries Flashcards
The nervous system is divided into two anatomic parts:___ (FIGURE 29-1). The CNS is composed of the brain and the spinal cord, including the nuclei and cell bodies of most nerve cells. Long nerve fibers link these cells to the body’s various organs through openings in the spinal column.
These nerve fibers constitute the PNS.
the central nervous system (CNS) and the peripheral nervous system (PNS)
The system that controls virtually all activities of the body, both voluntary and involuntary
Nervous system
The brain and spinal cord
Central nervous system
The part of the nervous system that consists of 31 pairs of spinal nerves and 12 pairs of cranial nerves; these may be sensory nerves, motor nerves, or connecting nerves
Peripheral nervous system
The ___conducts sensory and motor impulses from the skin and other organs to the spinal cord.
peripheral nervous system
The__, which contains about 75% of the brain’s total volume, controls a wide variety of activities, including most voluntary motor function and conscious thought. It is the main part of the brain and is divided into two hemispheres with four lobes.
cerebrum
The CNS is composed of the___ and spinal cord. The___ is the organ that controls the body; it is also the center of consciousness. It is divided into three major areas: the cerebrum, the cerebellum, and the brainstem
brain
Underneath the cerebrum lies the__, which coordinates balance and body movements.
cerebellum
The most primitive part of the CNS, the___, controls virtually all the functions that are necessary for life, including the cardiac and respiratory systems and nerve function transmissions. Located deep within the cranium, the___ is the best-protected part of the
brainstem
The spinal cord, the other major portion of the CNS, is mostly made up of fibers that extend from the brain’s nerve cells.
The spinal cord carries messages between the brain and the body via the_____ of the spinal cord.___ is composed of neural cell bodies and synapses, which are connections between nerve cells. ____consists of fiber pathways.
gray matter
White matter
An extension of the brain, composed of virtually all the nerves carrying messages between the brain and the rest of the body. It lies inside of and is protected by the spinal canal
Spinal cord
The cells of the brain and spinal cord are soft and easily injured. Once damaged, they cannot be regenerated or reproduced.
Therefore, the entire____ is contained within a protective framework.
The thick, bony structures of the skull and spinal canal withstand injury very well. The skull is covered by layers of muscle, superficial fascia, and thick skin, which usually bears hair. Superficial fascia connects the muscle to the skin and contains white blood cells that are used to destroy pathogens when there is an open wound. The spinal canal is also surrounded by a thick layer of skin and muscles.
The CNS is further protected by the meninges, three distinct layers of tissue that suspend the brain and the spinal cord within the skull and the spinal canal (FIGURE 29-3). The outer layer, the dura mater, is a tough, fibrous layer that closely resembles leather. This layer forms a sac to contain the__, with small openings through which the peripheral nerves exit.
CNS
The CNS is further protected by the__, three distinct layers of tissue that suspend the brain and the spinal cord within the skull and the spinal canal (FIGURE 29-3). The outer layer, the dura mater, is a tough, fibrous layer that closely resembles leather. This layer forms a sac to contain the CNS, with small openings through which the peripheral nerves exit.
meninges
____connects the muscle to the skin and contains white blood cells that are used to destroy pathogens when there is an open wound.
Superficial fascia
The three layers of the __ are the dura mater, the arachnoid, and the pia mater
Meninges
The____ has several layers of protective covering: the skin, muscles and their fascia, bone, and the meninges
central nervous system
The inner two layers of the __, called the arachnoid and the pia mater, are much thinner than the dura mater. They contain the blood vessels that nourish the brain and spinal cord
Meninges
Cerebrospinal fluid (CSF) is produced. in a chamber inside the brain, called the___. CSF is located in the subarachnoid space below the arachnoid, which is a weblike structure.
third ventricle
There is approximately __ to __ mL of CSF in the brain at any one time. CSF primarily acts as a shock absorber. The brain and spinal cord essentially float in this fluid, buffered from injury. The brain depends on a rich supply of oxygenated blood to function properly. When this supply is interrupted, even for short periods of time, serious damage to the brain tissue may occur
125 to 150 mL
Fluid produced in the ventricles of the brain that flows in the subarachnoid space and bathes the meninges
Cerebrospinal fluid
When an injury does penetrate all of these protective layers, clear, watery CSF may leak from the nose, the ears, or an open skull fracture. Therefore, if a patient with a head injury has what looks like a runny nose or reports a salty taste at the back of the throat, you should assume that the fluid is CSF
Ironically, the closed bony structure of the skull (which is similar to a vault) and the meninges, the layers of tissue that isolate and protect the CNS, may lead to serious problems in closed head injuries. Severe injury may cause bleeding within the skull, referred to as___. Such bleeding increases pressure inside the skull and compresses softer brain tissue. In many cases, only prompt surgery can prevent permanent brain damage.
intracranial hemorrhage
The PNS has two anatomic parts:__ pairs of spinal nerves and___ pairs of cranial nerves
31
12
The peripheral nervous system is a complex network of motor and sensory nerves. The____ controls the arms, and the___ controls the legs.
brachial plexus
lumbosacral plexus
The 31 pairs of spinal nerves conduct sensory impulses from the skin and other organs to the spinal cord. They also conduct motor impulses from the spinal cord to the muscles. Because the arms and legs have so many muscles, the spinal nerves serving the extremities are arranged in complex networks. The___ controls the arms, and the lumbosacral plexus controls the legs.
brachial plexus
___nerves are the 12 pairs of nerves that emerge from the brainstem and transmit information directly to or from the brain. For the most part, they perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions.
Cranial
There are two major types of peripheral nerves. The___, with endings that perceive only one type of information, carry that information from the body to the brain via the spinal cord. The__, one for each muscle, carry information from the CNS to the muscles. The connecting nerves, found only in the brain and spinal cord, connect the sensory and motor nerves with short fibers, which allow the cells on either end to exchange simple messages.
sensory nerves
motor nerves
The nervous system controls virtually all of the body’s activities, including reflex, voluntary, and involuntary activities.
In connecting the sensory and motor nerves of the limbs, the connecting nerves in the spinal cord form a___. If a sensory nerve in this arc detects an irritating stimulus, such as heat, it will bypass the brain and send a message directly to a motor nerve, causing a response such as pulling away from the heat
reflex arc
_____are the actions that we consciously perform, in which sensory input determines the specific muscular activity-for example, reaching across the table for a salt shaker or to pass a dish.____ are the actions that are not under our conscious control, such as breathing; in most instances, we inhale and exhale without consciously thinking about it. Many of our body’s functions occur independently of thought, or involuntarily.
Voluntary activities
Involuntary activities
The part of the nervous system that regulates or controls our voluntary activities, including almost all coordinated muscular activities, is called the___. The mechanism of the somatic nervous system is simple. The brain interprets the sensory information that it receives from the peripheral and cranial nerves and responds by sending signals to the voluntary muscles.
somatic (voluntary) nervous system
The body functions that occur without conscious effort are regulated by the much more primitive___. The ____system controls the functions of many of the body’s vital organs, over which the brain has no voluntary control.
autonomic (involuntary) nervous system
The autonomic nervous system is divided into two sections:__
the sympathetic nervous system and the parasympathetic nervous system.
When confronted with a threatening situation, the ____reacts to the stress with the fight-or-flight response. This response causes the pupils to dilate, smooth muscle in the lungs to dilate, heart rate to increase, and blood pressure to rise. This response also causes the body to shunt blood to vital organs and to skeletal muscle. During this time of stress, a hormone called epinephrine (also known as adrenaline) is released, which is responsible for much of these activities inside the body.
sympathetic nervous system
The____ has the opposite effect on the body, causing blood vessels to dilate, slowing the heart rate, and relaxing the muscle sphincters. When this portion of the autonomic nervous system is activated, the body shunts blood to the organs of digestion. As the body attempts to maintain homeostasis (balance), these two divisions of the autonomic nervous system tend to balance each other so that basic body functions remain stable and effective.
parasympathetic nervous system
The skull is composed of two groups of bones: the cranium, which protects the brain, and the facial bones (FIGURE 29-6).
The cranium is composed of several thick bones that fuse together to form a shell above the eyes and ears that holds and protects the brain. It is occupied by 80% brain tissue,
10% blood supply, and 10% CSF. The brain connects to the spinal
cord through a large opening at the base of the skull called the___.
foramen magnum
The part of the skull that encloses the brain and is composed of eight bones
Cranium
The spinal canal is closed by birth and must grow and expand as the child grows. Neural tube deformities can result in serious birth defects. The most discussed neural tube deformity is__, in which the lower portion of the spine does not close prior to birth. As an EMT, you may be called on to treat or transport a child with one of these birth defects.
spina bifida
Four major bones make up the___. The most posterior portion of the___ is called the occiput. On each side of the cranium, the lateral portions are called the temples or temporal regions. Between the temporal regions and the occiput lie the parietal regions. The forehead is called the frontal region.
cranium
The face is composed of _ bones. The upper immobile jawbones are called the maxillae, the cheek bones are called the zygomas, and the mandible is the lower, moveable portion of the jaw
14
The __ (eye socket) is made up of two facial bones: the maxilla and the zygoma. The __ also includes the frontal bone of the cranium. Together, these bones form a solid bong run that protrudes around the eye to protect it.
Orbit
The___ mostly consists of flexible cartilage; in fact, only the proximal third of the___ is formed by bone, with very short bones forming the bridge of the__
nose
The____ is the body’s central supporting structure. It has 33 bones, called vertebrae, and is divided into five sections: cervical, thoracic, lumbar, sacral, and coccygeal (FIGURE 29-7). Injury to the vertebrae, depending on the level at which the injury occurs, may result in paralysis if the underlying spinal cord or nervous structures are also damaged.
spinal column
The front part of each vertebra consists of a round, solid block of bone called the vertebral body; the back part forms a bony arch. From one vertebra to the next, series of arches form a tunnel running the length of the spinal column. This tunnel is the_, which encases and protects the spinal cord
spinal canal
The vertebrae are connected by ligaments and separated by cushions, called___. These ligaments and disks allow the trunk to bend forward and back, but they also limit motion so that the spinal cord is not injured. When the spine is injured or fractured, the spinal cord and its nerves are left unprotected. Therefore, keep the spine aligned throughout transport, using manual stabilization, as necessary. The spinal column itself is almost entirely surrounded by muscles.
However, you can usually palpate the posterior spinous process of some of the vertebrae, which lie just under the skin in the midline of the back. The most prominent and most easily palpable spinous process is at the seventh cervical vertebra at the base of the neck.
intervertebral disks
Tough, elastic structures between adjoining vertebrae that act as shock absorbers
intervertebral disks
When head injuries are fatal, invariably the cause is associated injury to the brain. In addition to the head injury, and dependent on the___, you should be alert to the fact that the patient may have sustained additional trauma such as cervical spine injuries, pelvic injuries, and chest injuries.
mechanism of injury (MOl)
There are two types of head injuries. In a___, the brain has been injured but there is no opening to the brain. For example, a severe blow that fractures the skull but does not create an open wound would be considered a closed head injury. In an__, an opening exists from the outside world to the brain. Obvious skull deformity with a break in the skin is a sign of an open head injury, which is often caused by penetrating trauma. There may be bleeding and exposed brain tissue.
closed head injury
open head injury
Falls and motor vehicle crashes are among the most common___ resulting in head and brain injuries. Head injuries also occur commonly in victims of assault, during sports-related incidents, and in a variety of incidents involving children.
Any head injury is potentially serious. If not properly treated, those injuries that seem minor at first may become a life-threatening brain injury (TABLE 29-1). Conversely, severe lacerations of the scalp or fractures of the skull may occur with little or no brain injury and may lead to minimal or no long-term consequences.
MOls
Following a head injury, any patient who exhibits one or more of these signs or symptoms has potentially sustained a very serious underlying brain injury:
• Lacerations, contusions, or hematomas to the scalp
• Soft area or skull depression on palpation
• Visible fractures or deformities of the skull
• Decreased mentation, confusion
• Irregular breathing pattern
• Widening pulse pressure
• Slow heart rate
• Ecchymosis about the eyes or behind the ear over the mastoid process
• Clear or pink CSF leakage from a scalp wound, the nose, or the ear
• Failure of the pupils to react to light
• Unequal pupil size
• Loss of sensation and/or motor function
• A period of unconsciousness
• Amnesia
• Seizures
• Numbness or tingling in the extremities
• Dizziness
• Visual complaints
• Combative or other abnormal behavior
• Nausea or vomiting
• Posturing (decorticate or decerebrate)
___lacerations can be minor or very serious. Because both the face and the scalp have unusually rich blood supplies, even small lacerations can quickly lead to significant blood loss (FIGURE 29-9). Occasionally, this blood loss may be severe enough to cause hypovolemic shock, particularly in children. In any patient with multiple injuries, bleeding from scalp or facial lacerations may contribute to hypovolemia. In addition, because scalp lacerations are usually the result of direct blows to the head, they are often an indicator of deeper, more serious injuries.
Scalp
Significant force applied to the head may cause a__. As with any fracture, a skull fracture may be open or closed, depending on whether there is an overlying laceration of the scalp. Injuries from bullets or other penetrating weapons frequently result in fracture of the skull. The diagnosis of a skull fracture is usually made in the hospital with a computed tomography (CT) scan, but maintain a high index of suspicion that a fracture is present if the patient’s head appears deformed or if there is a visible crack in the skull within a scalp laceration. Additional signs of skull fracture that you may see include ecchymosis (bruising) that develops under the eyes (raccoon eyes) (FIGURE 29-10A) or behind one ear over the mastoid process (Battle sign) (FIGURE 29-10B). These signs may be less obvious in dark-skinned persons.
skull fracture
A buildup of blood beneath the skin that produces a characteristic blue or black discoloration as the result of an injury
Ecchymosis
Bruising under the eyes that may indicate a skull fracture
Raccoon eyes
Bruising begins an ear over the mastoid process that may indicate a skull fracture
Battle sign
___(nondisplaced skull fractures) account for approximately 80% of all fractures to the skull (FIGURE 29-11A). Radiographs are required to diagnose a_____ because there are often no physical signs such as deformity. If the brain is uninjured and there are no scalp lacerations, then linear fractures are not life threatening. However, if there is a scalp laceration with the__-making it an open fracture-there is a risk of infection and bleeding inside the brain.
Linear skull fractures
Fractures that commonly occur in the temporoparietal region of the skull and that are not associated with deformities to the skull; account for 80% of skull fractures; also referred to as nondisplaced skull fractures.
Linear skull fractures
_____result from high-energy direct trauma to the head with a blunt object (such as a baseball bat to the head) (FIGURE 29-11B). The frontal and parietal bones of the skull are most susceptible to these types of fractures because the bones in these areas are relatively thin. As a consequence, bony fragments may be driven into the brain, resulting in injury. The scalp may or may not be lacerated. Patients with____ often present with signs of neurologic injury (such as loss of consciousness).
Depressed skull fractures
____are also associated with high-energy trauma, but they usually occur following diffuse impact to the head (eg, falls, motor vehicle crashes). These injuries generally result from extension of a linear fracture to the base of the skull and are usually diagnosed with a CT scan of the head (FIGURE 29-11C).
Signs of a___ include CSF drainage from the nose or the ears, which indicates rupture of the tympanic membrane in the ear, and freely flowing CSF through the ear. Patients with leaking CSF from either the nose or the ear are
at risk for bacterial meningitis.
Other signs of a basilar skull fracture include raccoon eyes or Battle sign. Depending on the extent of the damage, raccoon eyes and Battle sign may appear relatively quickly, but in many patients, they may not appear until up to 24 hours following the injury, so their absence in the field does not rule out a____
Basilar skull fractures
The eardrum; a thin, semitransparent membrane in the middle ear that transmits sound vibrations to the internal ear by means of auditory ossicles
Tympanic membrane
___of the cranial vault result when severe forces are applied to the head and are often associated with trauma to
multiple body systems (FIGURE 29-11D). Brain tissue may be exposed to the environment, which significantly increases the risk of a bacterial infection (such as bacterial meningitis). Open cranial vault fractures have a very high mortality rate.
Open fractures
The National Head Injury Foundation defines a traumatic brain injury (TBI) as “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes.” TBIs are classified into two broad categories:__
primary (direct) injury and secondary (indirect) injury.
___is injury to the brain and its associated structures that results instantaneously from impact to the head.
Primary (direct) brain injury
____refers to a multitude of processes that increase the severity of a primary brain injury and, therefore, negatively affect the outcome. Secondary injuries may be caused by cerebral edema, intracranial hemorrhage, increased intracranial pressure (ICP), cerebral ischemia, and infection; however, hypoxia and hypotension are the two most common causes. According to the Brain Trauma Foundation, hypoxia or hypotension significantly increases the risk of death and disability in a patient with a head injury. It is important to monitor and address hypoxia and hypotension when identified.____ may occur anywhere from a few minutes to several days following the initial head injury.
Secondary (indirect) brain injury
The brain can be injured directly by a penetrating object, such as a bullet, knife, or other sharp object. More commonly, brain injuries occur indirectly, as a result of external forces exerted on the skull. Consider the most common cause of brain injury, the motor vehicle crash. When the passenger’s head hits the windshield on impact with a fixed object, the brain continues to move forward until it comes to an abrupt stop by striking the inside of the skull. This rapid deceleration results in compression injury (or bruising) to the anterior portion of the brain along with stretching or tearing of the posterior portion of the brain (FIGURE 29-12). As the brain strikes the front of the skull, the body begins its path of moving backward. The head falls back against the headrest and/or seat, and the brain slams into the rear of the skull. This type of front-and-rear injury is known as a___. The same type of injury may occur on opposite sides of the brain in a lateral collision.
coup-contrecoup injury
Based on the mechanism involved with a__, it is possible for a patient to receive a brain injury without directly hitting his or her head. A rapid change in direction of movement of the head can cause the brain to move forward and then back with such force that it impacts the inside of the skull. Do not exclude the possibility of brain injury simply because the patient has no external head injuries.
coup-contrecoup injury
The injured brain starts to swell, initially because of cerebral vasodilation. An increase in cerebral water (cerebral edema) then contributes to further brain swelling.____ (swelling of the brain) may not develop until several hours following the initial injury, however.
Low oxygen levels in the blood aggravate cerebral edema. Therefore, patients with cerebral edema may be at particular risk if hypoxemia is not adequately corrected. In fact, the brain consumes more oxygen than any other organ in the body. For this reason, you must make sure that the airway is open and that adequate ventilations and high-flow oxygen are given to any patient with significant head injury. This is especially true if the patient is unconscious. Do not wait for cyanosis or other obvious signs of hypoxia to develop. Similarly, do not wait for pulse oximetry to confirm hypoxia.
It is not uncommon for the patient with a head injury to have a convulsion, or seizure. This is the result of excessive excitability of the brain, caused by direct injury or the accumulation of fluid within the brain (edema). Be prepared to manage seizures in all patients who have had a head injury because the brain may have sustained an injury as well.
Cerebral edema
For adults, the skull is a rigid, unyielding globe that allows little, if any, expansion of the intracranial contents. It also provides a hard and somewhat irregular surface against which brain tissue and its blood vessels can be injured when the head sustains trauma
Accumulations of blood within the skull or swelling of the brain can rapidly lead to an increase__, the pressure within the cranial vault. Increased ICP squeezes the brain against bony prominences within the cranium.
Cheyne-Stokes respirations (respirations that are fast and then become slow, with intervening periods of apnea) or ataxic (Biot) respirations (characterized by irregular rate, pattern, and volume of breathing with intermittent periods of apnea) are signs of increased ICP. Central neurogenic hyperventilation is another abnormal breathing pattern associated with increased ICP that is characterized by deep, rapid breathing; this pattern is similar to Kussmaul respirations, but without an acetone breath odor. Other signs and symptoms include decreased pulse rate, headache, nausea, vomiting, decreased alertness, bradycardia, sluggish or nonreactive pupils, decerebrate posturing, and increased or widened pulse pressure (the difference between the systolic and diastolic blood pressures). Signs and symptoms will increase and become more severe as the level of pressure increases
The triad of increased systolic blood pressure, decreased heart rate, and irregular respirations is called Cushing reflex,
and signifies increased ICP.
in intracranial pressure
(ICP)
The triad of increased systolic blood pressure, decreased heart rate, and irregular respirations is called ___ and signifies increased ICP
Cushing reflex
____is another abnormal breathing pattern associated with increased ICP that is characterized by deep, rapid breathing; this pattern is similar to Kussmaul respirations, but without an acetone breath odor.
Central neurogenic hyperventilation
The closed compartment of the skull has no extra room for an accumulation of blood, so bleeding inside the skull also increases the ICP. Bleeding can occur between the skull and dura mater, beneath the dura mater but outside the brain, or within the tissue of the brain itself.
Intracranial hemorrhage
An____ is an accumulation of blood between the skull and dura mater (FIGURE 29-13). An___ is nearly always the result of a blow to the head that produces a linear fracture of the thin temporal bone. The middle meningeal artery runs along a groove in that bone; therefore, it is vulnerable when the temporal bone is fractured. Arterial bleeding into the epidural space will result in rapidly progressing symptoms. Often, the patient has an immediate loss of consciousness following the injury; this is often followed by a brief period of consciousness (lucid interval), after which the patient lapses back into unconsciousness. Meanwhile, as the ICP increases, the pupil on the side of the hematoma becomes fixed and dilated. Death will follow rapidly without surgery to evacuate the hematoma
epidural hematoma
A____ is an accumulation of blood beneath the dura mater but outside the brain (FIGURE 29-14). It usually occurs after falls or injuries involving strong deceleration forces.___ are more common than epidural hematomas and may or may not be associated with a skull fracture. Bleeding within the subdural space typically results from rupture of the veins that bridge the cerebral cortex and dura. A ___ is associated with venous bleeding, so this type of hematoma and the signs of increased ICP typically develop more gradually than with an epidural hematoma. The patient with a ___ often experiences a fluctuating level of consciousness or slurred speech. Any patient who you suspect has a __ needs to be evaluated by a physician
subdural hematoma
Older people, people taking blood-thinning medications, and those with a history of alcohol use are at higher risk for development of a__. This is caused by atrophy of the brain tissue that increases stretching of the bridging veins. Signs and symptoms of the condition may not occur for several hours, days, or weeks. Be sure to get a thorough history of any previous trauma.
subdural hematoma
A ___involves bleeding within the brain tissue itself (FIGURE 29-15). This type of injury may occur following a penetrating injury to the head or because of rapid deceleration forces. Many small, deep intracerebral hemorrhages are associated with other brain injuries. The progression of increased ICP depends on several factors, including the presence of other brain injuries, the region of the brain involved (frontal and temporal lobes are the most common locations), and the size of the hemorrhage. Once symptoms appear, the patient’s condition often deteriorates quickly.___ have a high mortality rate, even if the hematoma is surgically evacuated.
intracerebral hematoma
In a___, bleeding occurs into the subarachnoid space, where the CSF circulates. It results in bloody CSF and signs of meningeal irritation (such as neck rigidity or headache). Common causes of a___ include trauma or rupture of an aneurysm.
The patient with a____ reports a sudden, severe headache. As bleeding into the subarachnoid space increases, the patient experiences the signs and symptoms of increased ICP: decreased level of consciousness, changes in the pupils, vomiting, and seizures. A sudden, severe____ usually results in death. People who survive often have permanent neurologic impairment.
subarachnoid hemorrhage
A blow to the head or face may cause concussion of the brain.concussions are also known as mild TBIs. There is no universal definition of a concussion, but in general, it is a BI with a temporary loss or alteration of part or all of the brain’s abilities to function without demonstrable physical damage to the brain. For example, a person who “sees stars” after being struck on the head has sustained a concussion that affects the occipital portion of the brain. A concussion may result in unconsciousness and even the inability to breathe for short periods of time; however, approximately 90% of patients who sustain a concussion do not experience a loss of consciousness. A concussion is a functional change, not a structural change, in the brain.
A patient with a concussion may be confused or have amnesia (loss of memory). Occasionally, the patient can remember everything but the events leading up to the injury; this is called__. Inability to remember events after the injury is called___
Usually, a concussion lasts only a short time. In fact, it has often resolved by the time you arrive. Nevertheless, you should ask about symptoms of concussion in any patient who has sustained an injury to the head because a concussive injury may exist; these symptoms include dizziness, weakness, visual changes, or changes in mood. Additional signs and symptoms you may encounter with a patient who has sustained a concussion may include nausea or vomiting, and the patient may report ringing in the ears. Slurred speech and the inability to focus may also be present. Depending on the severity of the concussion, you may also notice that the patient has a lack of coordination, has delayed motor functions, displays inappropriate emotional responses, or reports feeling “in a fog” or “just not right.” Patients may also report a temporary headache and may appear to be disoriented.
Patients with symptoms consistent with concussion may also have more serious underlying brain injury. A CT scan is necessary to differentiate between these conditions. Always assume that a patient with signs or symptoms of concussion has a more serious injury until proven otherwise. All patients with signs or symptoms of a concussion should be evaluated by a physician or other qualified health care provider.
retrograde amnesia
anterograde (posttraumatic) amnesia.
Bleeding within the brain tissue (parenchyma) itself; also referred to as an intraparenchymal hematoma
Intracerebral hematoma
Like any other soft tissue in the body, the brain can sustain a____, or bruise, when the skull is struck. A___ is often far more serious than a concussion because it involves physical injury to the brain tissue, which may sustain long-lasting and even permanent damage. As with contusions that occur elsewhere in the body, there is associated bleeding and swelling from injured blood vessels. Injury of brain tissue or bleeding inside the skull causes an increase of pressure within the skull. A patient who has sustained a brain contusion may exhibit any or all of the signs of brain injury.
contusion
Brain injuries are not always a result of trauma. Certain medical conditions, such as blood clots or hemorrhages, can also cause brain injuries that produce significant bleeding or swelling. Problems with the blood vessels themselves, high blood pressure, or any number of other problems may cause spontaneous bleeding into the brain, affecting the patient’s level of consciousness. This is known as__. The signs and symptoms of nontraumatic injuries are often the same as those of TBls, except that there is no obvious history of MOl or any external evidence of trauma. Altered mental status is discussed in Chapter 18, Neurologic Emergencies.
altered mental status
The cervical, thoracic, and lumbar portions of the spine can be injured in a variety of ways. Compression injuries can occur as a result of a fall, regardless of whether the patient landed on his or her feet or experienced a direct blow to the crown of the skull, coccyx, or top of the head. The forces that compress the patient’s vertebral body can cause the herniation of disks, subsequent compression of the spinal cord and nerve roots, and fragmentation into the spinal canal. Motor vehicle crashes or other types of trauma can overextend or hyperflex the cervical spine and damage the ligaments and joints. Rotation-flexion injuries of the spine result from rapid acceleration forces. This is more likely to happen at C1 and C2. Injuries to this area of the spine are considered unstable because of the location on the spine and the lack of bony and soft-tissue support.
Any one of these unnatural motions, as well as excessive lateral bending, can result in fractures or neurologic deficit.
When the spine is pulled along its length (hyperextension), it can cause fractures in the spine as well as ligament and muscle injuries. For example, hangings often result in fracture of the vertebrae in the upper portion of the cervical spine.
Spine injuries
When the bones of the spine are altered from traumatic forces, they can fracture or move out of place. When these injuries pinch, pull, or penetrate the spinal cord, permanent damage may occur. Common findings include pain and tenderness on palpation of the region. Less commonly you may feel or observe a deformity of the spine, sometimes referred to as a “step-off” where the spinous process may be palpable on physical examination. If you suspect these types of injuries, take extra precautions when immobilizing the spine, both manually and with adjuncts.
Spinal injuries
When assessing the spine, be aware of the possibility of open wounds from the associated trauma. These open wounds can be penetrating injuries or lacerations. If you follow the mnemonic__, you will discover any open wounds prior to securing the patient to a backboard. Spinal motion restriction is not indicated in patients with penetrating trauma injuries. Taking the time to do this may delay life-saving care.
DCAP-BTLS
You should suspect a possible head or spinal injury anytime you encounter one of the following MOls:
Motor vehicle crashes, direct blows, falls from heights, assault, and sports injuries are common causes of head and spinal injury. A deformed windshield or dented helmet may indicate a major blow to the head, which is likely to have caused TBI (FIGURE 29-16). It is especially important to evaluate and monitor the level of consciousness in patients with suspected head injuries, paying particular attention to any changes that may occur.
• Motor vehicle crashes (including motorcycles, snowmobiles, and all-terrain vehicles)
• Pedestrian-motor vehicle crashes
• Fall >20 feet (>6 m) (adult)
• Fall >10 feet (>3 m) (pediatric)
• Blunt trauma
• Penetrating trauma to the head, neck, back, or torso
• Rapid deceleration injuries
• Hangings
• Axial loading injuries (injuries where load is applied along the vertical or longitudinal axis of the spine; for example, falling from a height and landing on the feet in an upright position)
• Diving accidents
Injuries where load is applied along the vertical or longitudinal axis of the spine; for example, falling from a height and landing on the feet in an upright position
Axial loading injuries
you observe the scene, look for indicators of the MOl. This helps you develop an early___ for underlying injuries in the patient who has sustained a significant MOl. As you put together information from dispatch and your observations of the scene, consider how the MOl produced the injuries suspected. For example, if you respond to a baseball field for a patient who was knocked unconscious by a foul ball, you may begin to suspect that the patient may have a depressed skull fracture and perform a neurologic assessment during the physical examination. Continue to consider the MOl while assessing a patient.
index of suspicion
When assessing a patient with suspected head and/or spine injuries, be aware that any unnecessary movement of the patient can cause additional injury. Assess the patient in the position found. After determining and correcting any life-threatening injuries, determine whether a cervical collar needs to be applied. Begin by assessing the scene to determine the risk of injury, then form a general impression of your patient based on his or her level of consciousness and the chief complaint.
alone is not a reason to perform spinal motion restriction. If the patient is absolutely clear in his or her thinking and does not have any neurologic deficits, spinal pain or tenderness, evidence of intoxication, or other illnesses or injuries that may mask a spinal injury or otherwise cause you to believe that the patient’s reports may be unreliable, you may consider not performing spinal motion restriction. Follow your local protocols regarding use of spinal motion restriction.
MOl
The backboard is rigid and often places the patient in an anatomically incorrect position for a long period of time. During that time, the back is pressed against the board, compromising circulation to areas of skin. The patient may report pain, and in rare circumstances when a patient remains on a board for a prolonged period of time (typically several hours),_____ can develop. Some patients, especially patients who are obese, could experience respiratory compromise while lying flat. Consider moving the patient on a scoop stretcher or vacuum splint board or placing padding under the patient to help minimize the risk of injury and try to minimize the amount of time a patient is on a long backboard. Always follow your local protocols.
decubitus ulcers
Irregular breathing, such as Cheyne-Stokes respirations, may result from increased pressure on the brain because of bleeding or swelling in the cranium. If the___ increases, there will be more periods of apnea. In either situation, determine whether breathing is present and adequate and continue to monitor the patient’s respiratory rate and depth. Prehospital administration of high-flow oxygen is indicated for patients with head and spinal injuries. A single episode of hypoxia in a patient with a head injury significantly increases the risk of death or permanent disability. Pulse oximeter values should not fall below 90% and, ideally, should be 95% or higher. Positive pressure ventilations are not always-necessary; however, if the patient’s breathing rate is too slow or too fast and shallow, provide positive pressure ventilations using a bag-mask device (see Chapter 11, Airway Management). The rate of ventilations should be based on the age of the patient and established BLS guidelines
ICP
When approaching a patient who is unconscious, the obvious question is, “Is this person alive?” Whereas checking immediately to determine whether a pulse is present is tempting, it is more important for you to remember the__.
Always look for evidence of exsanguinating hemorrhage and then assess airway and breathing prior to moving on to assessment of circulation. Patients who are responsive and moving obviously have a pulse; however, you should still check to see if the pulse is weak or strong and if it is generally too fast or too slow. A pulse that is too slow in the setting of a head injury can indicate a serious condition in your patient. If the pulse is present and adequate, continue your evaluation of the patient.
XABCs
Several transport considerations should be kept in mind for patients with head trauma. Patients with impaired airways, open head wounds, or abnormal vital signs and patients who do not respond to painful stimuli may need to be rapidly extracted from a motor vehicle and transported. During transport, providing the patient with a patent airway and high-flow oxygen is paramount. Because of the potential for increasing ICP, there is an increased risk of vomiting and seizures, so suction should be readily available. A patient with head trauma may deteriorate rapidly, thus requiring aeromedical transport depending on your local protocols. In supine patients, the head should be elevated 30°, if possible, to help reduce ICP. Remember to maintain spinal motion restriction.
Manner of transport
A change in the____ is the single most important observation that you can make in assessing the severity of brain injury.____ usually corresponds to the extent of loss of brain function.
level of consciousness
As discussed earlier, the appearance of clear or pink watery___ from the nose, the ear, or an open scalp wound indicates that the dura and the skull have both been penetrated. You should make no attempt to pack the wound, ear, or nose in this situation. Cover the scalp wound, if there is one, with sterile gauze to prevent further contamination, but do not bandage it tightly.
Your local protocol for treatment of a suspected head injury should include the administration of high-flow oxygen and the
application of a cervical collar, if indicated, as part of spinal motion restriction. Reassessment should take place as the patient is transported to an appropriate trauma facility. Monitor the patient’s condition and vital signs and relay this information to the receiving facility, especially if there is a significant or noteworthy change.
CSF
Infants, children, and adults all may have enough blood loss due to scalp lacerations to produce shock; however, this is more common in infants than in older children and adults. Provide oxygen, monitor the airway, treat for shock, and provide immediate transport.
A common response to head injuries, even among children with only very slight head injuries, is vomiting. This is sometimes the result of increased__. In managing such vomiting, pay particular attention to protecting the patient’s airway
ICP
The most important step in the treatment of patients with head injury, regardless of the severity, is to establish an adequate_. If the patient has an airway obstruction, perform the jaw-thrust maneuver to open the airway. Once the airway is open, maintain the head and cervical spine in a neutral, in-line position until you have placed a cervical collar and stabilized the patient on a backboard or other spinal motion restriction device (FIGURE 29-20). Remove any foreign bodies, secretions, or vomitus from the airway. Make sure a suctioning unit is available, because you will often need to clear blood, saliva, or vomitus from the airway.
airway
If the patient’s head injuries are significant enough to cause a TBI, the patient may begin to exhibit the signs of Cushing triad: increased blood pressure (hypertension), decreased heart rate (bradycardia), and irregular respirations such as Cheyne-Stokes respiration or Biot respiration. The Cushing triad identifies the effects seen as the pressure in the skull increases secondary to brain swelling or bleeding. As the pressure in the skull increases, the brainstem and the midbrain may be pushed through the foramen magnum, the hole at the base of the skill. If this process is allowed to continue, the patient will die. Patient outcomes can be worse if the patient is in shock, becomes hypoxic, or is hyperventilated. Manage shock, administer oxygen, and ventilate as necessary, avoiding hyperventilation. If monitoring is available, maintain ETCO2 between 30 and 35 mm Hg (20 breaths/minute for adults, 25 breaths/minute for children, and 30 breaths/minute for infants less than 1 year of age).
Cushing triad
A helmet that fits well prevents the patient’s head from moving and should be left on, provided (1) there are no
impending airway or breathing problems, (2) it does not intertere with assessment and treatment of airway or ventilation problems, and (3) you can properly immobilize the spine. You should also leave on the helmet if there is any chance that removing it will further injure the patient.
Remove a helmet if (1) it is a full-face helmet (FIGURE 29-27), (2) it makes assessing or managing airway problems difficult and removal of a face guard to improve airway access is not possible, (3) it prevents you from properly immobilizing the spine, or (4) it allows excessive head movement. Finally, always remove a helmet from a patient who is in cardiac arrest.
Helmet
Remember that small children may require additional padding to maintain the in-line neutral position. Children are not small adults. They have smaller airways and proportionally larger heads, so padding is important to maintain the airway. Pad under the shoulders to the toes, as needed, to avoid excessive___ (FIGURE 29-30). In addition, place blanket rolls between the child and the sides of an adult-size backboard to prevent the child from slipping to one side or the other (FIGURE 29-31). Appropriate-size backboards are available for children.
neck flexion
