PCTH - Head Injuries

Question 1

What % of multi-system trauma patients will presetn with some form of TBI? How does this increase the mortality rate?

Answer 1

40%; increases mortality rate by 2x

Question 2

List the structures that are considered as part of the head.

Answer 2

1) scalp
2) skull
3) meninges
4) brain tissue
5) CSF
6) vascular components
7) facial structures

Question 3

What does CSF look like?

Answer 3

straw coloured fluid (typically mixed with blood)

Question 4

Brain adjusts its own blood flow in response to _____________. Autoregulation is controlled by the level of what?

Answer 4

metabolic needs

CO₂

Question 5

Hypoventilation would cause an (increase/decrease) of CO₂ in the brain, leading to (vasodilation/vasoconstriction).

Hyperventilation would cause an (increase/decrease) of CO₂ in the brain, leading to (vasodilation/vasoconstriction).

Answer 5

Hypoventilation: increase CO₂; vasodilation

Hyperventilation: decrease in CO_2; vasoconstriction

Question 6

Primary brain injuries occur when…..?

Answer 6

when there is immediate damage to the brain (i.e. baseball bat hitting the skull) - results from mechanical injury at the time of the trauma

Question 7

Secondary brain injuries

Answer 7

• as a result of the initial impact (ex. brain being injured as a result of hitting the inside of the skull, of a bat hitting the skull which is your primary injury)
• can lead to swelling which can cause a decrease in perfusion
• results in hypoxia
• presence of edema increases intracranial pressure and exacerbates reduction in blood flow

Question 8

Coup-Contre Coup Injury

Answer 8

A coup injury occurs on the brain directly under the point of impact (primary impact)

A contrecoup injury occurs on the opposite side of the brain from where the impact occurred (secondary impact)

Question 9

Primary brain injuries are best managed by:

Answer 9

prevention (occupant restraint systems, sports equipment, helmets, etc.

Question 10

Cerebral Herniation

Answer 10

• sudden increase in ICP
• portions of the brain get pushed down into foramen magnum
• increase pressure on brain stem = cerebral herniation

Question 11

What is a concern regarding hyperventilating all patients with TBIs?

Answer 11

you are delivering significant amount of oxygen to the patient which causes vasoconstriction and reduced oxygen flow to brain causing cerebral ischemia

Question 12

oxygen is a vasodilator. true or false?

Answer 12

false. it vasoconstricts

Question 13

S/S of Cerebral Herniation

Answer 13

• rapidly decreasing LOC
• dilated pupil and downward outward deviation of the eye on the side of the injury
• paralysis of the arm and leg on the side of the injury OR decorticate/decerebrate posturing
• Cushing’s Triad/Reflex
• Rapid decline in sx to cardiac arrest

Question 14

Cushings Triad/ Reflex

Answer 14

↑ BP (usually 170-180 SBP)

↓ HR (bradycardia)

irregular RR

Question 15

The purpose of hyperventilating a patient with cerebral herniation is because….?

Answer 15

you want to induce vasoconstriction to reduce swelling pushing into brainstem where respiratory center is

Question 16

As per the Head Injury Standard of the BLS, the paramedic shall:

*long answer ahead

Answer 16

1) Consider potential life/limb/function threats, such as:

• intracranial and/or intracerebral hemorrhage,
• neck/spine injuries
• facial/skull fractures, and
• concussion;

2) observe for:

• fluid from ears/nose (e.g. CSF)
• mastoid bruising
• abnormal posturing
• periorbital ecchymosis
• agitation or fluctuating behaviours
• urinary/fecal incontinence
• emesis (projectile)

3) ventilate patient if patient is apneic or respirations are inadequate,

• a) if ETCO₂ monitoring is available,
  
  • ​i. attempt to maintain ETCO₂ values of 35-45 mmHg,
  • however, if signs of cerebral herniation are present after measures to address hypoxemia and hypotension, hyperventilate patient to attempt to maintain ETCO₂ values of 30-35mmHg. Signs of cerebral hernation include a deteriorating GCS < 9 with any of the following:
    
    • dilated and unreactive pupils,
    • asymmetric pupillary response, or
    • a motor response that show either unilateral or bilateral decorticate (check with brian) or decerebrate posturing, or
• b) if ETCO₂ monitor is unavailable, and measures to address hypoxemia and hypotension have been taken, and patient shows signs of cerebral herniation (as mentioned above), hyperventilate the patient as follows:
  
  • i. adult: approx 20 breaths/min (1 breath every 3 seconds)
  • ii. child: approx 25 breaths/min (1 breath every 2-3 seconds)
  • iii. infant < 1 y.o.: approx 30 breaths/min (1 breath every 2 seconds)

4) if protruding brain tissue is present, cover with non-adherent material (eg. moist, sterile dressing; plastic wrap);

5) if CSF leak is suspected, apply a loose, sterile dressing over source opening;

6) if patient is conscious and SMR is not indicated as per SMR standard, position patient in sitting or semi-sitting

7) if patient is on a spinal board or adjustable break-away stretcher, elevate head 30 degrees; and

8) prepare for potential problems, including,

• respiratory distress/arrest,
• seizures,
• decreasing LOC, and
• agitation and combativeness (from hypoxia)

Question 17

Pupils are controlled by what cranial nerve?

Answer 17

CN III (oculomotor)

Question 18

How can pupils present in head injuries and what is it an indication of? (4)

Answer 18

1) dilated and fixed - likely dead
2) dilated but reactive - probably gonna die
3) unilateral and dilated reactive - early sign of herniation
4) unilateral dilated unreactive - herniation

Question 19

What are important factors to assess in TBI/head injury patients?

Answer 19

1) MOI
2) loss of consciousness
3) level of consciousness/behaviour
4) base line vitals, Cushings
5) Estimated blood loss

*always remember to examine things like helmet

Question 20

How should you manage bleeding in traumatic head wounds?

Answer 20

expect ++ bleeding

large bulky dressings

no hemostatic dressings

avoid direct pressure

Question 21

As per Neck/Back Injury Standard in the BLS, the paramedic shall:

Answer 21

1) if patient has penetrating neck, injury, assume vascular and airway laceration/tears;

2) auscultate patient’s lungs for decreased air entry and adventitious sounds

3) observe for:

• diaphragmatic breathing
• neurological deficits - weakness, lack of coordination, paralysis (any body part), paresthesia, priapism
• priapism, and
• urinary/fecal incontinence/retention;

4) perform, at minimum, a secondary survery to assess,

• for airway and/or vascular penetration (eg. frothy/foamy hemoptysis)
• lungs, for decreased air entry and adventitious sounds through auscultation,
• head/neck, for JVD and tracheal deviation, and
• chest, for subcutaneous emphysema, and

5) if patient has a penetrating wound,

• assess for entry and exit wounds,
• apply pressure lateral to, but not directly over the airway, and
• apply occlusive dressing to wounds; use non-circumferential bandaging

Question 22

With impaled objects in the neck/back, what is would a paramedic’s protocol be?

Answer 22

make no attempt to remove!

stabilize with layers of bulky dressing/bandages (i.e. log cabin) unless otherwise specified by the Standards, or the object is compromising the airway

Question 23

Treatment consideration re: SMR and open neck wounds.

Answer 23

• Apply SMR with caution when treating patients with open neck wounds
• traditional c-collars may impede proper assessment and treatment
• manual stabilization may be required via head blocks/blankets

Question 24

The #1 cause of non-traumatic back pain is

Answer 24

chronic pain

Question 25

As per Back Pain (Non-Traumatic Standard) in the BLS, in situations involving a patient with back pain that is believed to be of a non-traumatic origin, the paramedic shall:

Answer 25

1) consider potential life/limb/function threats, such as,

• abdominal/thoracic aortic aneurysm,
• acute spinal nerve root(s) compression,
• intra-abdominal disease (e.g. pancreatitis; peptic ulcer), and
• possible occult injury (e.g. pathologic fracture); and

2) perform, at a minimum, a secondary survey to assess,

• back, for abnormal appearance/findings,
• chest, as per Chest Pain (Non-Traumatic) Standard,
• abdomen, as per Abdominal Pain (Non-Traumatic) Standard,
• distal pulses, and
• extremities, for circulation, sensation, and movement.

Guideline

If a thoracic aneurysm is suspected, perform bilateral blood pressures (difference of SBP > 30 in each arm can indicate thoracic aneurysm)

Question 26

As per Eye Injury Standard in the BLS, the paramedic shall:

Answer 26

1) assume threats to vision

2) assess patient as per the Head Injury subsection below;

3) assess eye as per Visual Disturbance Standard;

4) notwithstanding paragraph 3 above, leave eyelids shut if swollen shut;

5) if active bleeding, control bleeding using the minimum pressure required;

6) if obvious or suspected rupture or puncture of the globe avoid manipulation, palpation, irrigation, direct pressure, and application of cold packs;

7) cover the eye with a dressing;

8) if injury/pain is severe in the affected eye, cover both eyes;

9) notwithstanding paragraphs 7 and 8 above, if the eye is extruded (avulsed),

• make no attempt to replace it inside the socket, and
• cover the eye with a moist, sterile dressing and protect/stabilize as if an impaled object;

10) advise the patient to keep eye movement to a minimum; and

11) transport the patient supine, with head elevated approximately 30 degrees.

Question 27

If chemical injury to the eye, BLS standards state that the paramedics shall:

Answer 27

1) If chemical injury to the eye,

• assess the eye as per the Visual Disturbance Standard, and
• advise patient to remove contact lens if lens is readily removable;

before commencing with treatment, make all attempts to identify material involved

2) with respect to eye irrigation,

• attempt to utilize eye wash station/equipment if available at scene,
• advise patient not to rub eye(s),
• position the patient with his/her affected side down if one eye is affected or supine if both eyes are affected,
• manually open eyelids if required, and
• attempt to irrigate away from tear duct(s);

Question 28

Visual Disturbance Standard of BLS indicates that in situations involving a patient with acute visual disturbances (including generalized eye pain) that is believed to be of a non-traumatic origin, the paramedic shall:

Answer 28

1) consider threats to life/limb/function, such as,

• intracranial, intracerebral or retinal hemorrhage/thrombosis, and
• acute glaucoma;

2) perform, at a minimum, a secondary survey to assess,

• eyes, for,
  
  • pupillary size, equality and reactivity,
  • abnormal movements,
  • positioning,
  • redness,
  • swelling,
  • tearing, and
  • presence of contact lenses,
• eye-lids, for ptosis (droopy eyelids), and
• vision, for
  
  • distortion/diplopia,
  • loss, and
  • visual acuity; and

3) prepare for potential problems, including,

• alterations in level of consciousness,
• neurological deficits, and
• emesis

Guideline - consider patching patient’s eyes (both) for patient comfort and to minimize movement

Question 29

In Face/Nose Injury subsection of the Blunt/Penetrating Injury Standard, the paramedic shall:

Answer 29

1) consider potential concurrent head, C-spine injuries;

2) assess as per the Head Injury subsection below;

3) if nose injury is obvious or suspected, assess the patient as per the Epistaxis (Non-traumatic) Standard;

4) apply a cold pack to the injury site;

5) if the patient is conscious and SMR is not indicated as per the Spinal Motion Restriction (SMR) Standard, position the patient semi-sitting and leaning forward to assist draining and encourage the patient to expectorate blood, as required;

6) if the patient is on a spinal board or adjustable break-away stretcher, elevate the head 30 degrees; and

7) prepare for potential problems, including,

• airway obstruction if severe injury and/or massive or uncontrolled oral hemorrhage, and
• epistaxis.

GUIDELINES:

• If the patient is alert and stable, replace a completely intact, avulsed tooth in the socket and have the patient bite down to stabilize
• If the tooth cannot be replaced, place it in saline or milk (and cold pack)

Question 30

As per Epistaxis (Non-Traumatic) Standard, in situations involving a patient with epistaxis that is believed to be of a non-traumatic origin, the paramedic shall:

Answer 30

1) consider potential life/limb/function threats, such as upper airway obstruction;

2) perform, at a minimum, a secondary survey to assess,

• for estimated blood loss (e.g. hemorrhage duration, rate of flow, presence of clots, quantity of blood-soaked materials at scene, quantity of blood vomited), and
• head/neck, for foreign bodies in nares, and headache;

3) attempt to control bleeding; and

4) prepare for potential problems, including:

• a. airway compromise, and
• b. hypotension.

Question 31

As per Foreign Bodies (Eye/Ear/Nose) Standard, in situations involving a patient with a foreign body in his/her eye, ear or nose, the paramedic shall:

Answer 31

1) advise the patient not to attempt removal of the foreign body or discontinue attempts;

2) inspect the affected area for visible signs of foreign body, injury, bleeding and discharge;

3) if the foreign body is in the eye,

• assess eye as per the Eye Injury subsection in the Blunt/Penetrating Injury Standard, and
• if penetration of the globe is not suspected, flush the affected eye;

4) if the foreign body is in the ear,

• consider the potential for a perforated ear drum if a blunt/penetrating object was inserted, and
• leave the object in place and support/cover; and

5) if the foreign body is in the nose, leave the object in place.

GUIDELINES - For foreign body on the surface of the eye, attempt manual removal if the object is not on the cornea and is visible, accessible and easily removed, e.g. using a wet cotton-tipped swab or gauze.

Question 32

As per Headache (Non-Trauma) Standard, in situations involving a patient with a headache that is believed to be of a non-traumatic origin, the paramedic shall:

Answer 32

1) consider potential life/limb/function threats, such as,

• intracranial/intracerebral events (e.g. hemorrhage, thrombosis, tumour),
• central nervous system or other systemic infection,
• severe hypertension, and
• toxic event/exposure (e.g. carbon monoxide poisoning);

2) perform, at a minimum, a secondary survey to assess,

• head/neck, for pupillary size, equality, and reactivity,
• central nervous system, for,
  
  • abnormal motor function (e.g. hand grip strength, arm/leg movement/drift), and
  • sensory loss; and

3) prepare for potential problems, including seizures.

GUIDELINES - the following signs and symptoms can indicate a serious underlying disorder or cause:

• sudden onset of severe headache with no previous medical history of headache
• Recent onset headache (days, weeks) with sudden worsening
• Change in pattern of usual headaches
• Any of the above accompanied by one or more of the following:
  
  • Altered mental status
  • Decrease in LOC
  • Neurologic deficits
  • Obvious nuchal rigidity and fever or other symptoms of infection
  • Pupillary abnormalities (inequality, sluggish/absent light reactivity)
  • Visual disturbances