An EMS worker needs to know all of the standards for identification, management, and care of a patient with head and spine injuries. This patient population will benefit from an EMT who is well-versed about the potential impacts from injury to the nervous system, skull, and spine.
The nervous system is the master link to every body function. It is made up of two parts: the central and peripheral nervous systems. The skull has two major structures, containing 18 major bones. There are five sections and 33 bones in the spinal column.
The nervous system has two parts, each with a subset of networks and functions. These systems control all of the body’s movements, whether they are voluntary (such as lifting the arm) or involuntary (such as breathing).
The skeletal system is made up of the skull and spinal column. The brain is very well protected and housed in the skull. The skull has two parts: the cranium and the face. The spinal column protects the spinal cord and functions to keep the body aligned and postured to support upright structure and muscles.
Terms/Concepts to Know: parts and functions of the skull, brain, nervous, and skeletal systems; meninges; voluntary (somatic) and involuntary (autonomic) activities; intervertebral discs
The head is made up of the scalp, skull, and brain. A injury to the head could impact any of these structures. The two basic types of injuries to the head are closed and open. These injuries may be a minor insult (such as a superficial scalp abrasion or bump) to something more serious (such as a laceration, hematoma, concussion, contusion, skull fracture, or brain injury).
An injury to the scalp can be very serious. Similar to the facial tissue, the scalp tissue has an abundant blood supply and a laceration may present with quite a bit of blood. The MOI of scalp injuries may be complicated by a, not so obvious, direct impact to the head. Presence of hematomas and bruising may be indications of more serious injuries.
When the skull is injured, a closed or open fracture may be apparent. Types of skull fractures are linear, depressed, basilar, and open. The signs and symptoms may include pain, bruising under the eye or above the ear, or fluid drainage from the nose or ears.
Brain injuries that are classified as traumatic are the result of an external force that makes significant impact on the head, resulting in a disfunction of the brain. There is a wide spectrum of symptoms related to this type of injury, when dysfunction is seen on a cognitive, emotional, and physical level.
The level of pressure inside the skull is referred to as intracranial pressure. Injury can occur when there is increased intracranial pressure. Increased pressure can be caused by blood that pools in the skull or by brain swelling. Symptoms of this condition are numerous and treatment becomes more critical as the pressure increases.
A direct impact to the head that causes the brain to shake inside the skull is referred to as a concussion. This type of trauma typically causes the person to have temporary, short-term amnesia and decreased or arrested brain function. It may also include a variety of temporary symptoms that include dizziness, visual changes, vomiting, head pain, decreased motor function, slurred speech, apneic episodes, and, in some cases, loss of consciousness, with no apparent brain damage.
The direct impact to the head which causes brain tissue bruising, bleeding and/or swelling is referred to as a contusion. This type of trauma is very serious and can cause permanent brain tissue damage because the impact can cause structural injury to the brain. Symptoms are similar and mostly equivalent to those of a patient who has experienced a brain injury.
A number of conditions occurrences may cause brain injuries. These can be referred to as non-traumatic injuries. The symptoms apparent with these conditions are similar to traumatic brain injuries.
The patient with head or brain trauma is at risk for a compromised airway. One of the major and initial steps in patient management is to ensure a patient’s airway. Use of the jaw thrust lift maneuver is the best practice technique for limiting additional injury to the spine. If the jaw thrust does not work, a secondary method is to use the head tilt chin lift maneuver and/or other technologically advanced breathing aids, as they are deemed appropriate and within the EMT scope of practice.
When the patient’s airway has been examined and necessary treatment has been provided, circulatory status should be assessed. Circulation assessment is done by feeling for pulses to determine if it is weak, thready, strong, or abnormally fast or slow. The pulse status will help indicate the degree and type of injury.
Terms/Concepts to Know: racoon eyes, battle sign, types of skull fractures, difference between a contusion and a concussion, signs and symptoms of increased ICP, cerebral edema, intracranial and subarachnoid hemorrhage, intracerebral, subdural and epidural hematoma, retrograde and anterograde amnesia, signs and symptoms of head and spine injury
Spinal injuries are multifaceted due to the degree of anatomy and physiology involved with the area. Injuries may include the spinal cord, nerves, discs, ligaments, joints, muscles or vertebrae. Common complaints include pain and tenderness, as well as loss of muscle control, feeling, or sensation.
The patient assessment of spinal injuries includes scene size up/MOI, primary assessment, patient history, secondary assessment, and reassessment. Special attention should be given to possible compromise of the airway or circulation and assessment of motor and sensory function, pre- and post-stabilization. Assess the spinal area for open wounds or lacerations prior to use of splints, cervical collars, or backboards.
The patient with spine trauma is at risk for a compromised airway. A major initial step with a spinal trauma patient is to ensure the airway. Use of the jaw thrust lift maneuver is the best practice, but the head tilt chin lift may be used if the first method does not work. Other appropriate technologically advanced breathing aids that are within the EMT scope of practice may also be employed.
Placing all patients with suspected spinal injuries on a long backboard and cervical collar has been standard practice in the past. New and best practice information indicates that these devices must be used according to the patient presentation and assessment. In some cases, their use can cause additional or increased trauma. In some jurisdictions, the EMT is able to use a criteria to determine that a backboard or cervical collar is not needed. Other options for immobilization devices include a full body vacuum mattress and short board vest.
Terms/Concepts to Know: axial loading injuries, c-spine clearance, time for application of cervical collar
The following variables should be considered to determine mode and position for emergency transport: patient population, level of consciousness, airway breathing, circulation status, geographic location and type of injuries. Safe position for transport will need to be considered, based on patient needs. It may include sitting, supine, standing, or spinal and/or cervical immobilization. Modes of transport may be considered to include: ambulance, with or without sirens, and air transport.
Terms/Concepts to Know: four person log roll
Helmets are worn for various contact sports and during the riding of recreational vehicles such as three wheelers, bicycles, motorcycles, and skateboards. If a patient is wearing a helmet at the scene of an emergency, precautions need to be taken to avoid complicating the injury and to prevent further damage. Always begin by checking the airway, assess for bleeding, and determine central nervous system (CNS) status.The preferred method for helmet removal requires two people, one at the head and one at the shoulder to carefully follow preferred steps. There is an alternative method that the EMT should be aware for removal of football and other helmets with face mask, guards and pads. This alternative method takes a bit longer and requires removal of straps and screws that secure the pads.
Terms/Concepts to Know: general principles designed to protect and maintain CNS function