Head, Spine, & Chest Injuries

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Head, Spine, Chest Injuries
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Head Injuries

• Leading cause of death due to trauma
• Major causes
• Airway compromise
• Brain stem laceration, c-spine lesion
• Death within 1-3 hours
• Epidural hematoma
• Subdural hematoma

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Significant Mechanisms of Injury

• Motor vehicle crashes
• Pedestrian-motor vehicle collisions
• Falls
• Blunt or penetrating trauma
• Motorcycle crashes
• Hangings
• Driving accidents
• Recreational accidents

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Head Injury Types

• Scalp lacerations
• Skull fractures (open or closed)
• Brain injuries
• Medical conditions
• Complications of head injuries

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Scalp Lacerations

• Scalp is extremely vascular (lots of blood.)
• Remember that there may be more serious, deeper
  injuries.
• Fold skin flaps back down onto scalp.
• Control bleeding by direct pressure.

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Skull Fracture

• Indicates significant force
• Signs
• Obvious deformity
• Visible crack in the skull
• Raccoon eyes
• Battles sign

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Skull Fractures
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Concussion

• Brain injury
• Temporary loss or alteration in brain function
• May result in unconsciousness, confusion, or
  amnesia (repetitive sayings)

• Brain can bruise when skull is struck
• Internal bleeding swelling
• Bleeding will increase pressure within the skull

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Coup/Contrecoup Injuries
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Intracranial Bleeding

• Laceration or rupture of blood vessel in brain
• Subdural
• Intracerebral
• Epidural

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Other Brain Injuries

• Brain injuries are not always caused by trauma.
• Medical conditions may cause spontaneous bleeding
  in the brain.
• Signs and symptoms of nontraumatic injuries are
  the same as those of traumatic injuriesthere is
  no mechanism of injury.

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Complications of Head Injury

• Cerebral edema
• Convulsions and seizures
• Vomiting (airway compromise)
• Leakage of cerebrospinal fluid

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Assessing Head Injuries

• Common causes, think MOI
• Motor vehicle crashes
• Direct blows
• Falls from heights
• Assault
• Sports Injuries
• Evaluate and monitor LOC

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Head Injury Signs and Symptoms

• Lacerations, contusions, hematomas to scalp
• Soft areas or depression upon palpation
• Visible skull fractures or deformities
• Ecchymosis around eyes and behind the ear
  (remember these are LATE signs!)
• Clear or pink CSF leakage

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Head Injury Signs and Symptoms

• Failure of pupils to respond to light
• Unequal pupils
• Loss of sensation and/or motor function
• Period of unconsciousness
• Amnesia
• Seizures

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Head Injury Signs and Symptoms

• Numbness or tingling in the extremities
• Irregular respirations
• Dizziness
• Visual complaints
• Combative or abnormal behavior
• Nausea or vomiting

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Level of Consciousness

• Change in level of consciousness is the single
  most important observation.
• Use the AVPU scale or Glasgow Coma Scale
  (depending on local protocols)
• Reassess
• Every 15 minutes if patient is stable.
• Every 5 minutes if patient is unstable.

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Change in Pupil Size

• Unequal pupil size may indicate increased
  pressure on one side of the brain.

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Head Injury Management

• Secure airway
• High flow O2, assist ventilations if needed
• C-spine stabilization
• Control major bleeding
• Backboard
• VS, transport
• Medics?

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Spinal Injuries
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Spinal Injuries

• Think about the significance of the injury to the
  area of the spinal cord
• Paralysis, paraplegia, quadraplegia, and death
  can result dependent upon the injury location

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Signs and Symptoms of Spinal Injury

• Pain or tenderness of spine
• Deformity of spine
• Tingling/pain in the extremities
• Loss of sensation or paralysis
• Incontinence
• Injuries to the head
• Priaprism

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Spinal Injury Assessment

• ABCs
• LOC
• Need to palpate the entire spine
• Look for signs of injuries (DCAP/BTLS)
• Pulse, motor, sensory function on all extremities

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Spinal Injury Management

• Secure airway
• Assist ventilations, high flow O2
• C-spine precautions
• Secure to backboard
• Monitor VS, transport
• Medics?

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Cervical Spine Stabilization

• Hold head firmly with both hands.
• Support the lower jaw.
• Move to eye-forward position.
• Maintain the position until patient is secured to
  a backboard.

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Cervical Spine Stabilization

• One attempt to realign head into a neutral,
  in-line position unless
• Muscles spasm
• Pain increases
• Numbness, tingling, or weakness develop
• There is a compromised airway or breathing

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Applying a Cervical Collar

• One EMT-B provides continuous manual in-line
  support of the head.
• Measure the proper size collar.
• Place the chin support snuggly under the chin.
• Wrap the collar around the neck.
• Ensure that the collar fits.

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Chest Trauma
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Chest Trauma

• Second leading cause of trauma deaths after head
  injury
• Accounts for 20 of all trauma deaths
• Initial exam directed toward
• Open/tension pneumothorax
• Flail chest
• Massive hemothorax
• Cardiac tamponade

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Rib Fractures

• Most common chest injury
• Adults (elderly) more than children
• Most common 5th to 9th ribs (poor protection)

• 1st/2nd rib fractures require high force (30
  death rate due to aorta/bronchi injury)
• 8th to 12th rib fractures can cause underlying
  abdominal solid organ damage

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Signs Symptoms

• Localized pain, tenderness
• Increases with cough, movement, and/or
  inspiration
• Chest wall instability
• Deformity, discoloration
• Associated pneumo or hemothorax

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Rib Fracture Management

• ABCs, Oxygen
• Splint using pillows, swathes,
• Encourage patient to breath deeply
• Monitor elderly/COPD patients carefully
• Broken ribs can cause decompensation
• Patients will fail to breath deeply and cough,
  resulting in failure to clear secretions

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Flail Chest

• Two or more ribs broken in two or more places
• Produces free-floating chest wall segment
• Usually secondary to blunt force trauma
• More common in elderly patients

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Signs Symptoms

• Pain leading to decreased ventilation
• Increased WOB
• Contusion of lung
• Paradoxial movement
• May not be present initally due to incostal
  muscle spasms
• Be suspicious with chest wall tenderness and
  crepitus

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Flail Chest Management

• Establish airway
• Suspect spinal injuries
• Assist ventilations with BVM/O2
• Stabilize chest wall
• Medics?

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Simple Pneumothorax

• Air in pleural space with partial or complete
  lung collapse
• Causes
• Chest wall penetration
• Fractured ribs
• May occur spontaneously from coughing, exertion,
  air travel

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Signs Symptoms

• Pain on inhalation
• Difficulty breathing
• Tachypnea
• Decreased or absent breath sounds
• Severity of symptoms depends on the size of
  pneumothorax, speed of lung collapse, and
  patients health status

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Simple Pneumothorax Management

• Establish airway
• Suspect spinal injury based upon MOI
• High concentration O2 via NRB
• Assist decreased or rapid respirations with BVM
• Monitor for tension pneumothorax

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Open Pneumothorax

• Hole in chest wall
• Allows air to enter the pleural space
• Larger hole increases chance more air will enter
  through hole than through the trachea
• Sucking chest wound SCW

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SCW Management

• Close hole with occlusive dressing
• High concentration O2
• Positive pressure ventilations with BVM
• Consider placement on injured side
• Monitor for tension pneumothorax

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Tension Pneumothorax

• One-way valve forms in lung or chest wall
• Air is trapped in pleural space
• Pressure increases causing lung collapse causing
  mediastinal shift decreasing cardiac output

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Signs Symptoms

• Extreme dyspnea
• Restlessness, anxiety, agitation
• Decreased breath sounds
• Hyperresonanace to percussion
• Cyanosis

• Rapid, weak pulse
• Decrease BP
• Tracheal shift away from injured side
• Jugular vein distension
• Subcutaneous emphysema

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Tension Pneumothorax Management

• Secure airway
• High concentration O2 with NRB
• Be ready to assist ventilations with BVM
• Request ALS for pleural decompression

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Hemothorax

• Blood in the pleural spaces
• Most common result of chest wall trauma
• Present in 70 to 80 of penetrating, major
  non-penetrating chest trauma
• Shock precedes ventilatory failure

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Hemothorax Management

• Secure airway
• Assist ventilations with BVM/02
• Rapid transport
• Medics?

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Traumatic Asphyxia

• Blunt force trauma to the chest that causes
• Increased intrathoracic pressure
• Backward flow of blood out of heart into the
  vessels of the upper chest, neck, and head
• Patients looked like they have been strangled

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Signs Symptoms

• Possible sternal fracture or central flail chest
• Shock
• Purplish-red discoloration of head, neck, and
  shoulders
• Blood shot, protruding eyes
• Swollen, cyanotic lips

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Traumatic Asphyxia Management

• Maintain airway with C-spine management
• Assist ventilations with BVM/O2
• Spinal stabilization
• Rapid transport
• Medics?

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Myocardial Contusion

• Bruising of the heart muscle
• Most common blunt cardiac injury
• Usually due to steering wheel impact

• May behave like an acute MI
• May produce arrhythmias
• May cause cardiogenic shock, hypotension

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Signs Symptoms

• Cardiac arrhythmias after blunt chest trauma
• Angina-like pain unresponsive to NTG
• Chest pain independent of respiratory movement
• Suspect in all blunt chest trauma

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Myocardial Contusion Management

• High concentration O2 via NRB
• Transport
• Rapid transport
• Medics?

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Cardiac Tamponade

• Rapid accumulation of blood in the pericaridal
  space
• Heart is compressed
• Blood flow entering heart is decreased
• Cardiac output falls

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Signs Symptoms

• Hypotension
• Increased venous pressure (distended neck/arm
  veins in presence of decreased arterial pressure)
• Muffled heart tones
• Narrowing pulse pressure
• Pulsus paradoxius

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Cardiac Tamponade Management

• Secure airway
• High concentration O2
• Rapid transport
• Medics? (pericardiocentesis)

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Thoracic Aortic Rupture

• Caused by sudden decelerations, massive blunt
  force trauma
• Rupture usually occurs just beyond left
  subclavian artery
• Attachment of aorta to pulmonary artery at this
  point produces shearing force on the aortic arch

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Signs Symptoms

• Increase BP in absence of head injury
• Decreased femoral pulses with full arm pulses
• Respiratory distress
• Ache in chest, shoulders, lower back, abdomen

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Aortic Rupture Management

• Maintain a high index of suspicion
• High concentration O2, assist ventilations
• Suspect spinal injury
• Rapid transport
• Medics?

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ALS Indicators

• Compromised airway
• Abnormal respiratory patterns
• MOI
• Decreased/altered LOC (GCSlt12)
• Paresis/paresthesia
• Brain or spinal cord injury
• ETOH or drug use

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Transporting Supine Patients

• Maintain in-line stabilization.
• Have the other team members position the
  immobilization device.
• Assess pulse, motor, and sensory function
• Log roll/Seattle roll patient.
• Secure patient to backboard.
• Reassess pulse, motor, and sensory function in
  each extremity

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Transporting Sitting Patients

• Maintain manual in-line stabilization.
• Apply a cervical collar.
• Place KED behind patient.
• Position device around patient and secure.
• Remove patient and lower to long backboard.
• Secure KED and patient to backboard together.
• Reassess the pulse, motor function, and
  sensation.

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Transporting Standing Patients

• Stabilize the head and neck and apply a cervical
  collar.
• Position board behind patient.
• Employ standing takedown procedure
• Carefully lower the patient to the ground.

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Helmet Removal (1 of 4)

• Is the airway clear and is the patient breathing
  adequately?
• Can airway be maintained and ventilations
  assisted with helmet in place?
• How well does the helmet fit?
• Can the patient move within the helmet?
• Can the spine be immobilized in a neutral
  position with the helmet on?

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Helmet Removal (2 of 4)

• A helmet that fits well prevents the head from
  moving and should be left on, as long as
• There are no impending airway or breathing
  problems
• It does not interfere with assessment and
  treatment of the airway
• You can properly immobilize the spine

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Helmet Removal (3 of 4)

• Prevent head movement.

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Helmet Removal (4 of 4)

• Slide helmet off while partner supports head.

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Pediatric Needs

• Immobilize a child in the car seat, if possible.
• Children may need extra padding to maintain
  immobilization.