Head and Spinal Cord Trauma

1
Head and Spinal Cord Trauma

• May 2011 CE
• Condell Medical Center
• EMS System
• Site Code 107200E-1211
• Objectives by Mike Higgins, FF/PM Grayslake Fire
  Department
• Packet by Sharon Hopkins, RN, BSN, EMT-P

2
Objectives

• Upon successful completion of this module, the
  EMS provider will be able to
• List risky behaviors contributing to brain and
  spinal cord injuries.
• Describe typical injury patterns related to
  specific mechanisms of injury.
• 3. Describe the anatomy of the brain.
• 4. List contents of the skull.
• 5. Describe the mechanisms for the development of
  secondary brain injury.
• 6. Describe the pathophysiology of traumatic
  brain injuries including pressures related to
  brain blood flow.
• 7. Explain the normal anatomy and physiology of
  the spinal column and spinal cord.

3
Objectives contd

• 8. Describe the pathophysiology of traumatic
  spinal cord injuries.
• 9. Describe components of a neurological
  assessment in the field.
• 10. List signs and symptoms of spinal cord
  injuries.
• 11. Describe the pathophysiology of neurogenic
  shock.
• 12. Describe prehospital treatment based on
  Region X SOPs of the patient with a head or
  spinal cord injury.
• 13. Review ventilation rates of the stable and
  unstable patients with head and/or spinal cord
  injuries.

4
Objectives contd

• 14. Review the Region X Infield Spinal Clearance
  SOP.
• 15. Review measurement of fitting a cervical
  collar.
• 16. Review the procedure for demonstrating the
  standing backboard takedown procedure.
• 17. Demonstrate the proper measurement and
  placement of a cervical collar.
• 18. Demonstrate the standing take down with the
  back board.
• 19. Actively participate in case scenario
  discussion.
• 20. Successfully complete the post quiz with a
  score of 80 or better.

5
Whats The Big Deal?

• Traumatic brain injury (TBI)
• Major cause of death and disability in multiple
  trauma patients
• Severe injury indicated with GCS lt9

6
TBI Statistics

• Many patients will be minors, therefore, you will
  also be dealing with parents and caregivers

7
Traumatic Brain Injury (TBI)

• 40 of trauma patients have CNS injury
• Death rate twice as high (35) as patient without
  CNS injury
• Account for 25 of all trauma deaths
• Account for up to 50 of all MVC deaths
• Cost worldwide is huge
• Lives lost
• Families destroyed
• Money spent for care
• CNS central nervous system

8
Risky Activities Resulting in Spinal Cord Injuries

• MVC 44.5 - major cause
• SUVs jeeps prone to flipping
• Falls 18.1
• Most common in persons gt45 years of age
• Violence 16.6
• More common in urban settings
• Sports 12.7
• Diving most common contributing sport
• Other medical causes make up lt10

9
Typical Head/Neck Injury Patterns

• T-bone lateral impact
• Coup/contrecoup head injuries
• Neck strain up to fractures
• Most injuries from collision with inside of
  vehicle
• Rear impact
• Hyperextension of neck esp if head rest not
  fitted
• Lumbar spine injury if seat breaks
• Rollover
• Body impacted in all directions so injury
  potential high
• Increased chance for axial loading on spine
• Often lethal injuries when ejected

10
Typical Head/Neck Injury Patterns

• ATV
• Injuries depend on MOI and part of body impacted
• High index of suspicions for head and spinal
  injuries
• Falls from height
• Evaluate distance, body area impacted, type of
  surface struck
• Landing on feet, check for axial loading to
  lumbar and cervical spine areas

11
Anatomy of the Skull

• Scalp highly vascular
• Skull is rigid bone
• Serves as protection
• Dura mater
• Tough fibrous
  covering of brain
• Arachnoid mater
• Lies under dura
• Arteries veins
  suspended from this
• Pia mater
• On surface of brain

12
Anatomy of the Brain

• Each lobe has a unique function
• Identified disabilities can help pinpoint area of
  insult or injury
• Proper assessment can point to area of injury
• Always reassess watching for trends

13
Anatomy of the Brain

• Cerebrum
• Frontal lobe
• Personality
• Judgment
• Temporal lobe
• Hearing
• Memory
• Parietal lobe
• Language
  formation
  processing senses
• Occipital lobe
• Vision

14
Anatomy contd

• Cerebellum
• Control of movement, balance,
  coordination
• Brainstem
• arousal consciousness center
  involved in basic life functions
• breathing, reflexes
• Pons motor sensory relay
  center
• Medulla- controls autonomic
  functions (breathing,
  digestion, heart blood
  vessel function

15
Contents of the Skull

• There is no extra space
• If one component increases, usually brain tissue
  swelling, it is usually at sacrifice of one of
  the other components
• Brain 80
• Blood volume 10 (150 ml)
• CSF 10 (150 ml )
• CSF cerebral spinal fluid

16
Brain Function

• Brain VERY sensitive to levels of oxygen and
  glucose
• Brain has a high metabolic rate both at rest or
  engaged in activity
• Brain is 2 of total body weight
• Receives 15 of cardiac output
• Consumes 20 of bodys oxygen
• Relies on aerobic metabolism
• Needs constant availability of glucose, thiamine
  (to metabolize glucose), and oxygen

17
Comparative Blood Flow in ml/minute
Organ At rest During strenuous activity
Heart 250 750
Skin 400 1900
Other 600 400
Brain 750 Steady at 750
Skeletal muscle 1000 12,500
Kidneys 1200 600
Viscera 1400 600
Total 5600 17,500
18
Adding Insult to Injury

• Coup-contrecoup injuries
• Brain shifts/floats inside skull
• Base of skull rough causes more injury
• Injuries at point of impact and away from point
  of impact
• Ex forehead injury
  can result in
  additional
  injury to
  occipital area

19
Secondary Injury

• Primary injury occurs at time of insult
• Secondary injury occurs later as a result of what
  happens initially
• Initial swelling causes decreased perfusion
• Secondary complications stem from hypoxia and
  decreased perfusion

20
What is your major focus?

• Management of injury focused on
• Proper care
• Identification of injuries
• An accurate general impression leads to
  appropriate care
• Appropriate interventions initiated
• Rapid transport to secondary care
• Do things right to prevent contributing to
  secondary injuries

21
Common Problems Related To TBI

• Airway compromise
• Inadequate ventilation
• Hypotension
• An independent risk factor contributing to
  mortality
• Focus on these critical aspects and perform
  appropriate interventions as needed

22
Pressures Related to Blood flow

• ICP is pressure of brain and contents within
  skull
• CPP - cerebral perfusion pressure
• Pressure of blood flowing thru brain pressure
  necessary to perfuse brain (CPPMAP-ICP)
• MAP - mean arterial pressure
• Average pressure within an artery pressure
  maintained in vascular system

23
Reflexive Response to ?ICP

• Cushings reflex
• Protective response to preserve blood flow to the
  brain
• B/P will increase
• Systolic B/P increasing as diastolic B/P stays
  same or increases
• Widening pulse pressure
• Heart rate will decrease
• Effort to lower elevating blood pressure
• Respirations may be irregular
• Note vital signs move opposite to shock

24
Cerebral Perfusion

• Brain requires unique range to function
• Increased ICP causes brain herniation
• Hypotension not tolerated with ?ICP
• Examples of problems
• MAP constant ICP ? ? CPP
• MAP decreases ICP steady ? CPP
• MAP decreases ICP ? CPP critical
• Any negative change in B/P or ICP affects blood
  flow in brain
• Normal values of MAP, ICP, and CPP listed in
  Notes section

25
Signs and Symptoms Head Injury

• Use inspection/observational skills with
  mechanism of injury to increase suspicion of head
  and neck injuries

26
Brain Injuries - Concussion

• Prevalent in athletic activities
• No structural injury to brain
• Often brief loss of consciousness or, at minimum,
  confusion, then return to normal
• Possible amnesia (short-term retrograde)
• Short term memory loss will ask repetitive
  questions
• Dizziness, headache, ringing in ears, nausea

27
Brain Injuries Cerebral Contusion

• Bruised brain tissue
• History prolonged unconsciousness or serious
  altered level of consciousness (confusion,
  amnesia, abnormal behavior)
• Focal neurological signs
• Related to a specific area of the brain
• Weakness, speech problems, personality or
  behavioral changes

28
Brain Injuries Subarachnoid Hemorrhage

• Blood in subarachnoid space
• Traumatic injury or spontaneous
• Blood causes irritation
• Severe headache
• Worst headache of my life
• Coma
• Vomiting

29
Brain Injuries Diffuse Axonal Injury

• Most common type of injury from blunt head trauma
• Generalized, diffuse edema
• Unconscious
• No focal deficits
• Swelling, edema, injury too widespread so no
  specific isolated sign/symptom pointing to 1 area
  of the brain

30
Brain Injuries Acute Epidural Hematoma

• Bleeding between dura and skull
• Often from tear in middle meningeal artery from
  skull fracture in temporal area
• Runs along inside of skull in temporal area
• Arterial bleed so onset usually rapid for
  signs/symptoms
• Initial loss of consciousness and now lucid
• Signs ? ICP after few hours
• Vomiting, headache, altered mental status
• Motor deficit opposite side to injury
  (contralateral)
• Dilated, fixed pupil on side of injury
  (ipsilateral)

31
Brain Injuries Acute Subdural Hematoma

• Bleeding between dura and arachnoid
• Bleeding is venous
• Slow onset to ? ICP (hours, days)
• Headache, changing level of consciousness, focal
  neurological signs
• Weakness one sided, slurred speech
• Poor prognosis due to associated brain tissue
  injury
• High risk elderly, anticoagulant use, chronic
  alcoholics

32
Brain Injuries Intracerebral Hemorrhage

• Bleeding within brain tissue
• Blunt or penetrating injuries
• Surgery not often helpful
• Signs and symptoms depend on region of brain
  injured
• Patterns similar to a patient with a stroke
• Altered level of consciousness common
• If awake, complain of headache vomiting

33
Spinal Column

• Spinal column is the bony tube of 33 vertebrae
  separated by discs that act as shock absorbers
• Alignment maintained by strong ligaments and
  muscles
• Supports body in upright position
• Allows use of extremities
• Protects delicate spinal cord

34
Spinal Cord

• Electrical conduit
• Extension of brain stem
• Continues down to first lumbar vertebrae then
  separates into nerves
• Surrounded and bathed by cerebrospinal fluid
• Cerebrospinal fluid and flexibility provide some
  protection

35
Spinal Column/Cord
36
Spinal Cord contd

• Nerve roots exit at each vertebral level
• Nerve roots carry signals from brain to specific
  sites
• Nerve roots carry sensory signals from body to
  spinal cord to brain
• Susceptible to
  traumatic injury

37
Spinal Cord contd

• Integrates/brings together the autonomic nervous
  system
• 2 components parasympathetic and sympathetic
  nervous system
• Assists in controlling
• Heart rate
• Blood vessel tone
• Blood flow to skin

38
Mechanisms of Injury

• Penetrating injuries
• Secure the object in position found
• Do no further harm!

39
Mechanisms of Blunt Spinal Injury

• Hyperextension
• Excessive posterior movement of head or neck
• Face into windshield
• Elderly person falling to floor, striking chin
• Football tackler
• Dive into shallow water
• Hyperflexion
• Excessive anterior movement of head onto chest
• Rider thrown from horse or motorcycle
• Dive into shallow water

40
Mechanisms contd

• Compression
• Weight of head or pelvis driven into stationary
  neck or torso
• Dive into shallow water
• Fall onto head or legs gt10-20 feet
• Rotation
• Excessive rotation of torso or head neck moves
  one side of spinal column against other side
• Rollover MVC
• Motorcycle crash

41
Mechanism contd

• Lateral stress
• Direct lateral force on spinal column typical
  shearing one level of cord from another
• T-bone MVC
• Distraction
• Excessive stretching of column and cord
• Hanging
• Child inappropriately wearing shoulder belt
  around neck
• Clothes lining with snowmobile or motorcycle
  riders and passengers

42
Disk Problems

• A preexisting problem can be aggravated at time
  of injury

43
Spinal Cord Injuries

• Complete injury
• No function, sensation, voluntary movement below
  level of injury
• Both sides affected equally
• Incomplete injury
• Some function preserved below level of injury
• May move 1 limb more than other
• May have more function on 1 side of body than
  other
• May have sensation but no movement

44
Spinal Cord Injuries

• Tetraplegia (also referred to as quadriplegia)
• Injury in cervical area
• Loss of muscle strength in all 4 extremities
• Paraplegia
• Injury in spinal cord in thoracic, lumbar or
  sacral segments
• Level of impairment dependent on level of injury

45
Spinal Cord Injury Patterns

• Cervical area injury quadriplegic
• C1-C2 may lose involuntary function of
  breathing
• Watch for excessive use of abdominal muscles to
  breath
• C4 and above often require use of ventilator
  for breathing
• C5 shoulder/bicep control but no control of
  hand or wrist
• C6 wrist control but no hand function

46
Spinal Cord Injury Patterns

• C7-T1 can straighten arms, dexterity problem
  with fingers and hands
• Thoracic level and below paraplegic
• T1-T8 has control of hands, poor trunk control
  due to lack of abdominal muscle control
• T9-T12 good trunk abdominal muscle control
  sitting balance good. Decreased control hip
  flexor and legs

47
Spinal Cord Injury Consequences

• Often experience
• Bowel and bladder dysfunction
• Male fertility often affected
• Inability to regulate B/P hypotension usual
• Inability to sweat below level of injury
• Decrease control to regulate body temperature
• Chronic pain

48
Dermatomes

• Mapping of body
• Easier to identify injured areas by isolating
  location of complaints as related to zones of
  altered sensation

49
Neurogenic Shock

• Occurs when brain signals interrupted for
  autonomic functions
• Ability to vasoconstrict limited
• No sympathetic tone, vessels dilate
• Relative hypovolemia
• ? preload? ?ventricular filling ? ?Frank Starling
  reflex ? ?contraction strength? ?cardiac output
• No hormone release to ?heart rate

50
Neurogenic Shock

• Signs and symptoms
• Bradycardia
• Hypotension
• Cool, moist, pale skin above cord injury
• Warm, dry, flushed skin below cord injury

51
Neurological Assessment

• Serial vital signs watch for
• ?ICP ?B/P ?pulse rate
• Neurogenic shock ?B/P ?pulse skin warm and dry
  below level of injury
• Serial AVPU
• Serial GCS
• Pupillary response
• Response to motor and sensory
• Included in CMS, SMV, PMS assessment
• Babinski reflex present big toe extends up when
  sole stroked from heel to toe

52
Signs and Symptoms Spinal Cord Injury (ie
Clues)

• Pain on movement of back or spinal cord
• Deformity
• Guarding against movement
• Loss of sensation
• Inability to move
• Weak or flaccid muscles
• Abnormal positioning
• Loss of control of bladder or bowels
• Priapism erection of penis
• Neurogenic shock

53
Focus of Field Treatment

• Provide adequate airway
• Monitor for effective oxygenation and ventilation
• Maintain CPP (cerebral perfusion pressure)
• Cant measure easily in field
• So watch systolic blood pressure
• Something EMS can monitor in the field
• Assume low B/P due to hypovolemia until proven
  otherwise

54
Region X SOP

• Routine trauma care
• Scene size-up
• Determining mechanism of injury could be good
  tip-off to suspected injuries
• Initial/primary survey
• Identify and treat life threats
• Identify transport priority
• Perform rapid trauma survey if critical or life
  threats found
• Focused exam on minor injuries

55
Region X SOP Head/Spinal Injuries

• Routine trauma care
• Obtain GCS
• GCSlt9 indicates severe brain injury
• IV fluid challenge (200 ml increments) if B/P
  lt90mmHg
• If altered LOC obtain blood glucose
• If lt60 treat with Dextrose
• Assess oxygenation
• Maintain SpO2 gt94

56
Ventilation Rates Stable Head/Spinal Injuries

• Relatively stable patient needing BVM assistance
  with 100 O2
• Adult 10 breaths/min
• 1 breath every 6 seconds
• Child 20 breaths/min
• 1 breath every 3 seconds
• Infant 25 breaths/min
• 1 breath every 2.5 seconds

57
Ventilation Rates Unstable Head/Spinal Injuries

• Rapid neurological deterioration
• Unequal pupils, posturing, lateralizing signs
• Signs indicating a deficit related to one of the
  hemispheres
• Example speech problem, hemiparesis, abnormal
  reflexes, facial asymmetry, abnormal eye movement
• Ventilate with BVM and 100 O2
• Adult 20 breaths/minute (1 every 3 seconds)
• Child 30 breaths/minute (1 every 2 seconds)
• Infant 35 breaths/min (1 every 1.7 seconds)

58
Hazards of Hyperventilation

• Hyper/hypoventilation refers to level of CO2
  maintained in body
• Capnography is the ideal measurement tool for
  exhaled CO2 levels
• Levels of CO2 influence vessel size
• ? RR ? ?CO2 retained ?vasodilation
• ? RR? ?CO2 retained ?vasoconstriction
• Either way, the brain does not get perfused
• Hypoxia develops
• Hypoxia ?anaerobic metabolism ?acidosis

59
Unhealthy Environment

• Hypo and hyperventilation both with adverse
  consequences for the patient
• Development of hypoxia and acidosis
• Hypoxia is NOT tolerated in the brain
• Cells do not function well in this environment
• Interventions not effective in this environment

60
Trauma Patient

• Assume any injury from the clavicles on up
  includes a head and/or spinal cord injury
• Cannot clear the c-spine
• Perform spinal motion restriction
• Also referred to as c-spine control
• Avoid use of word traction as you are not
  pulling on the head and neck

61
In-field Spinal Clearance

• Evaluate
• Mechanism of injury
• Signs and symptoms
• Patient reliability
• When in doubt, fully immobilize
• Document assessment and findings to support
  application of motion restriction/immobilization
  devices or when not using equipment

62
Cervical Collar Measurement

• Why do we keep talking about how to measure for
  placing a cervical collar?
• We still see a high number of patients
  transported to the ED with cervical collars in
  the no-neck position

63

• IF THE MAJORITY OF YOUR PATIENTS ARE WEARING A
  NO-NECK SIZED COLLAR, THEN YOU ARE NOT PROPERLY
  MEASURING THEM!

64
Measuring for Cervical Collar

• Measure eyeing horizontal line from bottom of
  chin to top of shoulder
• Measure on collar plastic from bottom up to
  closest hole opening
• Collar should rest on
  clavicles support the
  jaw

65
Standing BackboardA Team Effort Approach
66
Standing Backboard

• Purpose
• To place the ambulatory patient into a supine
  position without compromising the spine
• To rapidly move the patient into the supine
  position will need 3 persons, a cervical collar,
  and a long backboard
• Strapping can be (and most often is best) applied
  once the patient is supine

67
Standing Backboard

• Position tallest crew member behind patient
• Manual stabilization/motion restriction of
  c-spine taken
• 2nd EMT measures and applies cervical collar
  while manual control maintained
• 2 EMTs position backboard between patient and
  person maintaining manual stabilization/motion
  restriction of head and neck

68
Standing Backboard

• 2nd and 3rd EMTs reach hand nearest to patient
  under the patients armpit and grasps the
  backboard
• Patient will be temporarily suspended by the
  armpits as the backboard is lowered
• As the signal is given, the backboard is slowly
  lowered

69
Standing Backboard

• Person with manual stabilization walks backward
  to keep up with the lowering pitch of the
  backboard
• Remember
• Heaviest weight of head is in occipital area
• Have fingers/hands spread in good position to
  support the head before changing the patients
  positioning

70
Backboard slowlylowered using multiple
personnel and keeping head and neck immobilized
71
Standing Backboard

• As the board is lowered, all 3 persons work very
  closely together
• Once the backboard is lowered, the patient may
  need to be adjusted onto the backboard
• Complete spinal immobilization/motion restriction
  process by securing the patient to the backboard
• Rescuers need to watch their own body mechanics
  to prevent injury

72
Case Scenarios

• Divide into smaller groups
• Read the presentation
• Form a general impression
• Discuss treatment options
• Discuss what/how/when to reassess the patient
• Decide what treatment to continue or what
  adjustments need to be made
• Present to the group and give explanation to
  defend your decisions

73
Case Scenario 1

• 17 y/o patient injured at bike track
• Fell head first off bike
• Conscious, confused
• VS 92/50 60 14
• Repeat 84/46 54 14
• Arms not moving
• Legs move
• c/o pain to neck
• Warm dry

74
Case Scenario 1

• No allergies no medications
• No medical history
• Last ate 2 hours ago
• Doesnt remember how he wiped out
• Reported to lose control speeding around track
• Upon arrival, bystanders holding c-spine
• No movement detected in upper extremities lower
  ext move spontaneously
• If belly breathing noted, what does it mean?
• Excessive use of abdominal muscles
• Watch for respiratory arrest

75
Case Scenario 1

• Treatment/interventions
• C-spine control - Spinal motion restriction
• IV O2 monitor (what should be enroute?)
• Fluids
• Prepare to support ventilations
• Obtain blood glucose level

76
Case Scenario 1

• Patient had spinal cord injury
• Central cord syndrome most common with
  hyperextension
• Weakness/impairment in arms hands
• Legs are spared
• Variable loss of sensation
• Exhibiting neurogenic shock
• ?B/P bradycardia
• Tank expanded with vasodilation needs IV fluids

77
Case Scenario 1

• Belly breathing indicates cervical injury until
  proven otherwise
• Chest muscles and diaphragm not being used for
  ventilation
• Abdominal muscles back up to ventilate
• Not use to this function
• Will tire/fatigue
• Patient may respiratory arrest

78
Case Scenario 2

• 41 y/o male restrained driver T-boned by SUV
• Unconscious, shallow respirations
• Vital signs 146/82, 94, 32, SpO2 94
• Blood draining from left ear and left nares
• Diminished breath sounds on left
• Deformed left arm, left femur

79
Case Scenario 2

• GCS
• Eye opening none
• Verbal response moans
• Motor Withdrawing on left, no movement on right
• Repeat VS 168/72, 44, 16
• Pupils fixed/dilated left, right minimally
  reactive
• What would raccoon eyes or Battles signs
  indicate?

80
Case Scenario 2

• Treatment/interventions
• C-spine control - Spinal motion restriction
• IV O2 monitor (what should be enroute?)
• BVM support at 20/minute (1 every 3 seconds)
  (patient unstable)
• Rapid transport to highest trauma level within 25
  minutes
• Obtain blood glucose level

81
Case Scenario 2

• Patient injuries
• Fractured skull
• Raccoon eyes indicate anterior basilar skull fx
• Epidural bleed
• Fractured left clavicle
• Fractured ribs with hemothorax
• Fractured left humerous
• Fractured pelvis
• Fractured left femur

82
Case Scenario 3

• 60 y/o female riding her bike
• Hit pothole and fell off bike
• Helmet damaged
• Short loss of consciousness asking repetitive
  questions nauseated complains of headache and
  blurred vision
• Vital signs 132/78, P-98, R-20, SpO2 99

83
Case Scenario 3

• GCS eye opening spontaneous
• Verbal slightly confused
• Motor obeys commands
• Pupils PERL

84
Case Scenario 3

• Treatment/interventions
• C-spine control spinal motion restriction
• Patient not reliable
• IVO2monitor (what should be enroute?)
• Watch for nausea and vomiting to protect airway
• Trend vital signs and level of consciousness
• Check blood sugar level
• Patient has altered level of consciousness

85
Case Scenario 3

• GCS 4-4-6 Total 14
• Patient had a concussion
• Admitted overnight for observation
• Continued to have a mild headache
• Other complaints resolved
• Discharged home next day

86
Case Scenario 4

• 5 y/o is vomiting, has headache, was acting
  bizarre
• Now has an altered level of consciousness
• Hx of falling off jungle gym earlier today
• Initial loss of consciousness for few minutes
  then lucid alert oriented
• B/P 90/46, 104, 24
• Nauseated

87
Case Scenario 4

• GCS
• Eye opening after calling their name
• Verbal response talking nonsense
• Motor response pulling at equipment with right
  hand, trying to get your hands off him
• Pupils - right slower to react, midsize
• Left extremities flaccid
• Bruise and swelling noted over right forehead
  above ear
• Minor scratches to bilateral arms

88
Case Scenario 4

• Treatment/interventions
• C-spine control spinal motion restriction
• IV O2 monitor (what should be enroute?)
• Anticipate rapid deterioration and prepare to
  secure airway

89
Case Scenario 4

• GCS 3-3-5 Total 11
• Patient had right epidural hematoma
• Confirmed on CT
• Emergently taken to OR
• Hematoma evacuated
• Signs and symptoms slowly resolving
• Patient discharged home with outpatient physical
  and occupational therapy

90
Case Scenario 5

• Patient presents to ED with FB stuck in head
• Awake, talking, following
  commands
• How do you immobilize this
  object?

91
Case Scenario 5

• Immobilize in position found
• Constantly monitor level of consciousness
• Possibly need to shorten a FB to facilitate
  transfer in the ambulance
• Not knowing where tip of FB is, assume head and
  neck injuries and treat for both

92
Case Scenario 5

• Patient taken to OR
• Arrow successfully removed with part of skull
• Plate placed in OR
• Post-op patient had altered sense
  of taste and had difficulty
  perceiving tactile
  sensations

93
Case Scenario 6

• 45 y/o male passenger
• MVC involving a deer
• Patient unconscious
• Facial trauma evident
• Gurgling respirations
• Radial and carotid pulses noted regular
  and normal

94
Case Scenario 6

• Vital signs 92/62, P-74, R-18
• Pupils right reactive, left non-reactive
• GCS
• Eyes eyelids move when body touched
• Verbal silent
• Motor flexes right arm to pain, left arm
  straightens to pain
• Repeat VS 88/50, P-62, R-28 irregular

95
Case Scenario 6

• Treatment/interventions
• C-spine control spinal motion restriction
• Open and secure airway
• Modified jaw thrust
• Support ventilations 20 breaths per minute
• IV-O2-monitor (what should be enroute?)
• Rapid transport once extricated
• Is there a need for helicopter service in your
  town/your location?

96
Case Scenario 6

• GCS 2-1-3 Total 6
• Pt had intracerebral hematoma and bilateral
  pneumo/hemothorax
• Chest tube placed in ED for chest injuries
• Remains on ventilator in ICCU
• Unable to do brain surgery due to location of
  bleed

97
New Recommendations of the AAN

• American Academy of Neurology states
• Any athlete who is suspected to have suffered a
  concussion
• Remove from participation until evaluated by a
  physician with training in the evaluation and
  management of sports concussions
• 2. No athlete should be allowed to participate in
  sports if he or she is still experiencing
  symptoms from a concussion
•    

98
AAN Recommendations contd

• 3. Following a concussion, a neurologist or
  physician with proper training should be
  consulted prior to clearing the athlete for
  return to participation
• 4. A certified athletic trainer should be present
  at all sporting events, including practices,
  where athletes are at risk for concussion
• 5. Education efforts should be maximized to
  improve the understanding of concussion by all
  athletes, parents, and coaches

99
TBI

• Prevention is the most effective treatment
• Use of restraints in vehicles
• Shoulder/lap
• Car seats
• Use of helmets
• Following guidelines when players can return to
  play following concussion

100
Hands-on Practice

• All participants to measure a peer for cervical
  collar placement
• Practice in groups of 3 standing backboard
  take-down
• Have 4th person role play a patient

101
Bibliography

• Bledsoe, B., Porter, R., Cherry, R. Paramedic
  Care Principles Practices Third Edition. Brady.
  2009.
• Campbell, J.E. International Trauma Life Support
  for Prehospital Care Providers, 6th Edition.
  Brady. 2008.
• Region X SOP March 2007 amended January 1, 2008

102
Internet Reference Sites

• http//www.answers.com/topic/intracranial-pressure
  
• http//www.bmj.com/content/338/bmj.b1683.full
• http//faculty.washington.edu/chudler/facts.html
• www.link-intl.com/gulfspine/Anatomy.html
• http//neuropathology.neoucom.edu/chapter14/chapte
  r14CSF.html
• http//www.spinal-cord.org/at-risk-activities.htm
• http//www.spinalinjury.net/html/_spinal_cord_101.
  html