Ch. 4 Brain and Spinal Injuries

Question 1

If someone sustains and injury to the scalp or skull, what should be your main concern?

Answer 1

Brain Injury. A bruised or lacerated scalp can mask injury to the skull or brain. The scalp will bleed profusely if cut, but examine scalp injuries very carefully for exposed bone or brain, or an indentation (depressed fracture).

Question 2

How do you control bleeding from the scalp?

Answer 2

Apply gentle pressure on the edges of the wound, DO NOT put direct pressure on possibly unstable central areas near the fracture.

Question 3

Skull fractures are not usually life threatening in and of themselves. When do skull fractures become a major life threat?

Answer 3

1. When associated with a Brain or Spinal Cord injury
2. If they are open fractures exposing the brain to the environment
3. If the fracture tears blood vessels that lie between the brain and the skull causing serious bleeding

Question 4

True or False. Serious brain injuries can happen without a skull fracture?

Answer 4

True. The brain can be injured by a direct blow to the head, or by twisting forces that cause deformation and sheering against the inside of the skull. A blow might make the brain move within the skull and tear blood vessels, stretching and sheering brain cells and connections between them.

Question 5

What is a concussion? What are the symptoms?

Answer 5

A mild brain injury. Temporary brain dysfunction or loss of responsiveness following a blow to the head.

Headache disorientation, nausea, lethargy, dizziness, amnesia and photophobia. Can last for weeks.

Question 6

What is a contusion?

Answer 6

Bruising of brain tissue. Can lead to increased pressure in the skull.

Question 7

What are Hemorrhages and Hematomas?

Answer 7

The are bleeding within their brain. Leads to increased pressure in the skull.

Question 8

What are the dangers of pressure building inside the skull due to a Contusion, Hemorrhages and Hematomas?

Answer 8

As pressure builds the swollen vessels inside the brain are compressed against the inner skull wall. The brain tissues are deprived of oxygen. The pressure could crush the brainstem causing the heart and the lungs to malfunction and shut down.

Question 9

What are the signs and symptoms of Brain Injury?

Answer 9

Changes in Level of Responsiveness (LOR) = Loss of responsiveness may be transient or last for hours or days.
They may come to and then fade out periodically. They could be responsive but disoriented, confused, incoherent, exhibiting changes in behavior or personality. Verbal or physical combativeness is possible.

Question 10

Beyond LOR, what other signs and symptoms could be present if a patient has a Brain Injury?

Answer 10

Physical Findings = Headache, vision problems, loss of balance, nausea, vomiting, and paralysis.
Look for the two abnormal body positions Raquel mentioned. (1) Decorticate - legs and feet internally rotated with closed hands and arms clutched in to chest.
(2) Decerebrate Posture - Neck and head arched back, legs straight, toes pointed downward, hands curled.
Seizures are possible.

Question 11

What are the signs and symptoms of Skull Fracture that are physical findings as opposed to changes in LOR?

Answer 11

If blood or clear cerebrospinal fluid (CSF) is leaking from ears, mouth, nose.
Pain, tenderness, swelling, penetrating wounds, or depressed fractures.
Bruising around the eyes (Raccoon sign).
Bruising behind the ear (Battle’s sign). These appear hours after injury as blood pools.

Question 12

Signs and Symptoms of MILD Brain Injury?

Answer 12

Brief change in mental status, or loss of responsiveness.
Temporary blurred vision (seeing stars).
Nausea (isolated vomiting)
Headache, dizziness lethargy
Short-term Amnesia

Question 13

Sings and Symptoms of SERIOUS Brain Injury?

Answer 13

Worsening headache, vision disturbances, protracted vomiting, lethargy, excessive sleepiness, ataxia, and seizures.
Disoriented, irritable, combative, unconscious.
Heart rate decreasing and bounding.
Hyperventilation, erratic respiration.
Pupils are slow and unequal.

Question 14

What should we keep in mind about Combativeness in a patient with possible head injury.

Answer 14

A person with a brain injury may become aggressive due to oxygen deprivation. Supplemental oxygen and maintaining their Airway may help. If it does not, the patient may need to be restrained.

Question 15

In late stages of a severe brain injury, what will the vital signs show?

Answer 15

1. Slow Pulse
2. Rising Blood Pressure (Bounding)
3. Irregular Respirations

These CONTRAST with Rising Pulse, Falling Blood Pressure, and Rapid, Regular Respirations = SHOCK

Question 16

How do you open the airway of a suspected C-Spine patient?

Answer 16

Jaw Thrust = Do not move neck or spine, do not tilt the head back.
Place one hand on each side of head with fingers in front of earlobes and push the jaw forward and up.

Question 17

Should you allow someone with a mild brain injury to sleep? What about a more serious brain injury?

Answer 17

Sleep is important for those with brain injuries, they need physical and cognitive rest.

If you observe any changes in mental status or other signs of a worsening brain injury, wake the patient periodically (every 90 minutes) to take vitals and assess LOR.

Question 18

How do we treat a Brain Injury??

Answer 18

1. ABCs - The injured brain needs oxygen, so maintain their Airway!
2. If they are vomiting - log-roll the patient on to their side while maintaining cervical spine stabilization. Hold their head and have them put their head on their own arm with the other arm’s elbow forward across their chest. Let their top leg come across their body with the knee forward.
3. Control Bleeding- Cover open wounds with bulky dressing. You can clean scalp wounds, but if there is an open skull injury avoid cleaning as it may infect the brain.
4. Do Not Control Internal Bleeding - Let blood or CSF drain so we don’t increase pressure in the skull.
5. Elevate Head or keep horizontal- Do not elevate legs as it may increase blood flow to the head.
6. Record Neurological Assessment - What and record any changes in mental status.

Question 19

What is the threshold for evacuation for Brain Injuries?

Answer 19

Rapidly Evacuate = Any patient that was unresponsive even for a minute or two.
If they have vision or balance disturbances, irritability, lethargy, nausea or vomiting after a blow to the head (regardless of whether the person lost responsiveness) they must be evacuated.

If someone loses responsiveness, but wakes quickly and without any other symptoms, they may have a concussion, it is possible to walk this patient out of the wilderness. Just make sure you have a support party on standby to quickly evacuate if their condition starts to worsen.

Question 20

What is the Spinal Cord? What protects the Spinal Cord?

Answer 20

The extension of the brain outside the skull.
Protected by the 33 vertebrae. If any of these are fractured or dislocated they can pinch, bruise or cut the spinal cord, damaging the nerve connections.

It is possible to fracture vertebrae, damage ligaments and muscles in the back without damage to the spinal cord.

Question 21

What are the signs and symptoms of a Spinal Cord Injury?

Answer 21

1. Pain/Tenderness on the spine
2. Weakness in extremities
3. Loss of Sensation and Motor in extremities.
4. Numbness/tingling in hands/feet
5. Incontinence
6. Signs/Symptoms of Shock
7. Shortness of breath

Question 22

How do we assess for a spinal cord injury?

Answer 22

1. Palpate the spine from top of neck to the pelvis.
2. Check CSM in hands and feet one at a time
3. Take pedal pulse in the foot or posterior tibia pulse in the ankle.
4. Ask if they have numbness/tingling, hot/cold, and check sensation on toes.
5. Ask them to push or pull their feet against your hand

Question 23

How do we treat a possible spinal cord injury?

Answer 23

1. Protect the Spine! Place hands on either side of head or use improvised cervical collar, head blocks. You can return the head to a neutral position but stop if there is resistance or pain. Establish and maintain neutral alignment of head and spine.
2. Check CSM
3. Carefully move the patient on a pad to prevent hypothermia/shock. Move with the Logroll, Lift or Slide.
4. Evacuate immediately, preferably with commercial spine protection device (Vacuum splint)

Question 24

What is the Focused Spine Assessment and when is it used?

Answer 24

Focused Spine assessment is a tool for ruling out spinal injury so we do not immobilize people unnecessarily.
If the patient has a MOI suggesting possible spinal injury (e.g., fall from height, high velocity fall, diving accident, or blow to head with loss of responsiveness or altered mental status) assume the worst, control the head.
If MOI is questionable, or no signs of spinal injury are found during the patient assessment, then perform Focused Spine assessment.

Question 25

What are the steps in the Focused Spine Assessment meant to rule out spinal injury?

Answer 25

1. Patient must be reliable (A=Ox3 or 4; Sober, able to focus on assessment).
2. Normal CSM in all four extremities
   C= warm, pink digits, pedal/radial pulse
   S= no numbness, tingling, etc.
   M= Motor in all four extremities
3. No pain or tenderness when spine is palpitated

Question 26

Evacuation Guidelines for Brain and Spinal Injuries?

Answer 26

1. Evacuate if there is a loss in responsiveness even if they recover to A=Ox3 or 4.
2. Evacuate if headache, nausea, vomiting, irritability or other signs of mild head injury do not improve over 24hrs. Even if they have not lost responsiveness.
3. RAPIDLY EVACUATE if there are distinct changes in mental status (disoriented, irritable, combative).
   If there is persistent vomiting, lethargy, excessive sleep , seizure, worsening headache, vision disturbances, or signs of skull fracture.
4. RAPIDLY EVACUATE anyone with a possible spinal cord injury.