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					Injuries to the Head, Neck, Spine
              and Face




                                1
                       Skull
 Skullmade up of cranium & facial bones
 Cranium includes
  •   Frontal Lobe
  •   Parietal Lobe
  •   Occipital Lobe
  •   Temporal Lobe
 Brain occupies 80 to 90%
 Swelling and bleeding limited in brain
                                           2
        Types of Skull Fractures
 Linear- linear crack in the skull (most common)
 Comminuted - multiple cracks radiating from
  center of impact
 Depressed - pieces of skull pushed inward
 Penetrating - penetrate skull and lodged in brain
 Basal - base of the skull
    • Demonstrated by clear or bloody fluids in the nose and
      ears

                                                               3
    Signs/Signs of a Skull Fracture
    Mechanism of injury
   Contusions, lacerations, hematomas to the scalp
   Deformity of the skull
   Blood or clear fluid (cerebrospinal fluid) draining from the
    ears or nose.
   Bruising (discoloration) around eyes. Black and blue eyes.
    Bruising (discoloration) behind the ears (mastoid process).
    • Battle signs - which is usually a late sign of a skull fracture.



                                                                         4
                           Brain
 Cerebrospinal       Fluid
  •   Protects brain & spinal cord against impact
  •   Clear and colorless
  •   Combats against infection and cleanses
  •   Skull fracture results in leakage from nose or
      ears.
       – Classic sign of basilar skull fracture


                                                       5
                  Meninges
3   layers to protect brain from injury
  • Dura mater - (hard mother) outermost layer
  • Arachnoid mater - middle layer
  • Pia mater (soft mother) in contact with brain
 All3 layers enclose brain and spinal cord
 Subarachnoid space
  • Separates arachnoid and pia mater
  • Tissue filled with cerebrospinal fluid
                                                    6
                Cerebrum
 Largest  part of brain
 Called the “gray matter”
 4 distinct lobes
 Responsible
  • Conscious and sensory functions
  • Emotions
  • Personality
                                      7
                Cerebellum
 Called“little brain”
 Responsible
  • Equilibrium
  • Controls muscle activity




                               8
                Brain Stem
 Consists of numerous nerves and vessels
 Controls most automatic functions of the
  body
  • Cardiac, respiratory, and others
 Composition
  • pons
  • medulla - all messages pass through here

                                               9
                   Scalp
 Very vascular - profuse bleeding
 Presence of blood under intact skin can
  mimic skull deformation
 Consider more serious brain injury




                                            10
              Brain Injuries
 Direct
  • Penetrating trauma
 Indirect
  • Blow to the skull
 Secondary
  • Lack of oxygen
  • Build-up of carbon dioxide
  • Change in B.P.
                                 11
          Closed Head Injuries
 Scalplacerated but skull intact
 Consider MOI for extent of injury




                                      12
           Open Head Injuries
 Breakin the skull
 Causes
  •   Direct impact
  •   Punctures/Penetrations
  •   Infection
  •   Lacerations


                                13
            Epidural Hematoma
 Blood flows between dura mater skull
 Mostly profuse arterial bleeding (TRUE
  EMERGENCY)
 Often associated with severe blows to the temple
    • Batters Helmets
   Dramatic rise in ICP



                                                     14
Epidural Hematoma Signs & Symptoms
   Often patient will be unconscious, followed by a lucid
    interval then suffer a second loss of consciousness
   Severe headache during lucid interval
   Pupils fixed and dilated on side of impact
   Seizures
   Late signs
    • Fixed, dilated pupils
    • absent reflexes
    • Decreasing vital signs


                                                             15
             Subdural Hematoma
   Most common type
   Usually venous bleeding between brain and dura mater
   Brain becomes displaced due to pressure
   Skull fracture not usually present
   Can occur rapidly or over a prolonged period of time
   Causes
     • Coup-contracoup
     • acceleration/deceleration


                                                           16
Subdural Hematoma Signs & Symptoms
 Deteriorating   LOC
 Vomiting
 Dilation of one pupil
 Abnormal respirations or apnea
 Possible rising Blood pressure
 Slowing pulse


                                   17
    Concussion Signs & Symptoms
   Momentary confusion/or last for several minutes
   Retrograde amnesia (events before incident)
   Antegrade amnesia (events after incident)
   Repeat questioning of what happened
   Mild or moderate irritability/resistance to
   treatment
   Combativeness/irritability
   Inability to answer questions or obey commands
   Nausea, vomiting, restlessness
   Key factor - when signs & symptoms disappear      18
                 Contusion
 Bleedinginto surrounding tissue
 May or may not cause ICP
 Common causes
  • Coup-contracoup injury
  • Acceleration/deceleration injury



                                       19
  Contusion Signs & Symptoms
 Loss of consciousness ranging from hours
  to months
 Paralysis, one sided or total
 Unequal pupils
 Projectile vomiting
 Altered vital signs
 Profound personality changes
                                             20
         Contusion/Treatment
 As  with any head injury, a contusion can
  lead to swelling of the brain tissue resulting
  in permanent disability or death.
 Hyperventilate 24 to 30 bpm with
  supplemental oxygen - Big O’s
 Stabilize C-spine



                                               21
                  Assessment
 Scene     size-up
   • Look for clues at scene
 Initial   assessment includes
   •   Manual stabilization of C-spine
   •   Mental Status AVPU
   •   Responsive - 15lpm. N.R
   •   Unresponsive - 15lpm. BVM
 Remember       - oxygen helps reduces swelling
                                               22
          Assessment Cont..
 Ifpatient responds to painful stimuli
 May respond in 2 ways
 Purposeful or nonpurposeful response
 Posturing




                                          23
    Purposeful/Nonpurposeful
 Purposeful - patient may try to move away
  or remove the pain
 Nonpurposeful - responds by
  inappropriately moving parts of the body
  • Patient reacts but doesn’t try to stop it
  • Indicates deeper state of unresponsiveness


                                                 24
     Nonpurposeful/Posturing
 Decorticate
  • Flexes arms across chest and extends legs
 Decerebrate
  • Extends both arms at sides, extends legs,
    sometimes arches back
     – Represents lowest level of nonpurposeful pain
       response


                                                       25
                 Glasgow Comma Scale
Eye opening                Spontaneous____________4
                           To Voice______________ 3
                           To Pain________________2
                           None__________________1

Verbal Response            Oriented_______________5
                           Confused______________ 4
                           Inapp. Words___________3
                           Incompreh. Sounds______ 2
                           None_________________ 1

Motor Response             Obeys Commands_______6
                           Localizes Pain__________5
                           Withdraws Pain_________4
                           Flexion Pain___________ 3
                           Extension Pain_________ 2
                           None_________________1

Glasgow coma score total
                                                       26
           Assessment Cont..
 Assess pulse
 Skin color
 Skin temp.
 Do hemorrhage scan
 Transport decision




                               27
     Rapid Trauma Assessment
 Assess head
 Pupils
   • Pearl
   • Eye movement
   • Raccoon eyes - half hour or later
 Ears
   • Obvious leakage of CSF or blood
   • Obvious battle signs
                                         28
Rapid Trauma Assessment Cont..
 PMS  all extremities
 Baseline vital signs - every 5 minutes




                                           29
                          Vitals
   B.P.
     • High or rising ICP
     • Low or dropping- shock
   Pulse
     • High or rising bleeding elsewhere in body - shock
     • Slow or dropping ICP
   Respirations
    • Assess rate, depth, and pattern
    • Slow - something depressing respiratory center
    • Rapid - brain is trying to increase amount of oxygen
                                                             30
                Vitals Cont...
 Depth  of respirations
 Pattern of respirations
  • Cheynes-Stokes Respirations
     – Series of increasing then decreasing breaths with
       periods of apnea in between
  • Biot’s Respirations
     – Agonal, gasping breaths
     – Irregular in rate and depth
  • Both related to increasing ICP, brainstem injury
                                                           31
       Obtain Sample History
 When  did the accident happen
 Patient’s chief complaint
 Did he lose consciousness at any time
 Was the patient moved after the accident
 Any history of previous blows to the head
  • If so, when did it occur
  • Was the patient knocked unconscious
                                              32
 Detailed/Ongoing Assessments
 Conduct   the detailed physical exam during
  transport if time and patient’s condition
  permits.
 Continue ongoing assessment monitoring
  patient’s condition and reassess vitals every
  three to five minutes


                                              33
            Signs and Symptoms
   Altered mental status
   Irregular breathing pattern
   Increasing BP/decreasing pulse (late sign)
   Obvious signs of injury
   Blood or CSF
   Raccoon eyes, battle signs
   Poor or absent PMS
   Nausea/vomiting
   Unequal pupils
   Visible damage to skull/DCAPBTLS
                                                 34
      Emergency Medical Care
 BSI
 In-line stabilization
 Big O’s
 Control bleeding
 If no trauma, transport on left side
 Be prepared for seizures
 Transport immediately
                                         35
The Spine




            36
             Nervous Systems
 Central   nervous system
  • Consists of brain & spinal cord
 Peripheral   nervous system
  • Nerves outside brain and spinal cord




                                           37
            Skeletal System
 Gives body its framework
 Supports and protects vital organs
 Permits motion




                                       38
           The Spinal Column
 Has 33 bones called vertebrae and 5
 sections.
  •   Cervical spine   7 (Neck)
  •   Thoracic spine   12 (Upper back)
  •   Lumbar spine     5 (Mid back)
  •   Sacral spine     5 (Lower back)
  •   Coccyx           4 (Tail bone)

                                         39
 Common Mechanisms of Injury
 Compression
 Flexion
 Extension
 Rotation
 Distraction
 Penetration


                               40
 The spinal cord is the relay between most
   of the body and the brain. The healing
   power of the brain and nerve tissue is
  limited, once this tissue is damaged to a
 certain extent, function is lost and cannot
                 be restored.
(So now you understand why we as medics,
 protect the patient from further harm by
 completely immobilizing them before we
                 move them)
                                           41
                         Dangers
   It is especially important to provide proper care for patients
    with suspected spinal injuries since damage to the spinal
    cord can result in paralysis.
   Therefore, all unconscious accident patients should be
    treated as if they had spinal injuries and all conscious
    patients should be carefully checked for spine injuries prior
    to movement.
    Accident patients with weakness or numbness of arms or
    legs are assumed to have spine injuries.


                                                                42
 Assessment/Responsive Patient
 Mechanism of injury
 Questions to ask/SAMPLE HISTORY
  • Does your neck or back hurt?
    •   What happened?
    •   Where does it hurt?
    •   Can you move your hands and feet?
    •   Do you have any numbness or tingling in your arms or legs?
    •   Can you feel me touching your toes?
    •   Did you move or did someone move you before we arrived?
    •   Were you up walking around before we got here?
                                                                     43
 Assessment/Responsive Patient Cont..
 Inspect for contusions, deformities,
  lacerations, punctures, penetrations, and
  swelling.
 Palpate for areas of tenderness or deformity.
 Assess equality of strength of extremities.
  • Hand grip
  • Gently push feet against hands

                                              44
Assessment/Unresponsive Patient
 Mechanism of injury
 Initial assessment
 Inspect for DCAPBTLS
 Palpate for areas of tenderness or deformity
 Obtain information from others at the scene to
  determine information relevant to mechanism of
  injury or patient mental status prior to EMT’s
  arrival.
                                                   45
              Signs & Symptoms
   Pain
   Deformity (rare finding)
   Soft tissue injury
   Numbness, weakness, tingling, loss of sensation in
    extremities
   Loss of sensation or paralysis
   Loss of bladder or bowel control
   Priapism
   Impaired breathing

                                                         46
 Complications of Spinal Injury
 Inadequate   breathing
 Paralysis
 Inadequate   circulation




                                  47
        Emergency Medical Care
   BSI
   Establish and maintain in-line immobilization
     • Place the head in a neutral in-line position unless the
       patient complains of pain or the head is not easily
       moved into position.
     • Place head in alignment with spine.
     • Maintain constant manual in-line immobilization until
       the patient is properly secured to a backboard with the
       head immobilized.
   Assess Responsiveness
                                                             48
Emergency Medical Care Cont..
   Perform initial assessment.
    • Whenever possible, airway control must be done with in-line
      immobilization
    • Whenever possible, artificial ventilation must be done with with
      in-line immobilization
   Assess pulse, motor, and sensation in all extremities
   Assess the cervical region and neck
   Apply C-collar
    • Properly size C-collar. If it doesn’t fit use a rolled towel and tape
    • An improperly fit C-collar will do more harm than good
   Continue and complete the rest of assessments
                                                                              49
       Other Patient Positions
 Patient in sitting position
 Patient in standing position




                                 50
           Rapid Extrication
 Indications
  • Unsafe scene
  • Unstable patient
  • Patient blocks access to another more seriously
    injured patient
  • Based on time and the patient not EMT
    preference

                                                  51
            Helmet Removal
 Specialassessment needs for patients
  wearing helmets
  • Assess airway and breathing
  • Fit of the helmet and patient’s movement
    within the helmet
  • Ability to gain access to airway and breathing



                                                     52
 Indications for Leaving the Helmet in Place
 Good fit with little or no movement of patient’s
  head within the helmet
 No impending airway or breathing problems
 Removal would cause further injury to the patient
 Proper spinal immobilization could be performed
  with helmet in place
 No interference with the EMT-B’s ability to assess
  and reassess airway and breathing.
                                                  53
    Indications for Removing the Helmet
 Inability to assess and / or reassess airway and
  breathing
 Restriction of adequate management of the airway
  or breathing
 Improperly fitted helmet allowing for excess head
  movement within the helmet
 Proper spinal immobilization could not be
  performed with helmet in place.
 Cardiac arrest.
                                                  54
             Types of Helmets
 Sports
    • Typically open anteriorly
    • Easier access to airway
   Motorcycle
    • Full face
    • Shield


                                  55
           Infants & Children
 Need   to be immobilized on an appropriate
  size board.
 If the infant or child is in a car seat they can
  be immobilized in the seat.
 Be sure to apply C-collar.
 KED and vacuum splint can also be used to
  immobilize an infant or child.
                                                 56
Eye Injuries




               57
                             Design
   Sphere approximately 1 inch in diameter
   Sclera - white of the eye
   Cornea - clear front portion, covers pupil
   Pupil - dilates & constricts according to light.
   Iris - colored portion of the eye
   Lens - focuses light on retina
   Retina - back of the eye
   Conjunctiva - Thin delicate membrane covering sclera and inner
    surface of eyelids
   Aqueous humor - watery fluid that fills anterior chamber
   Vitreous humor - clear jelly behind the lens
   Orbits - bony structures , sockets
                                                                     58
            Eye is a Vital Sign
 Pupils   can be
  •   Dilated
  •   Constricted
  •   Unequal
  •   Fixed




                                  59
                  Assessment
 Orbits - bruising, swelling, lacerations, tenderness
 Eyelids - bruising, swelling, lacerations
 Conjunctivae - redness, pus, foreign bodies
 Globe - redness, abnormal coloring, lacerations
 Pupils - size, shape, equality, reactivity to light
 Eye movements
    • Abnormal gaze
    • Paralysis of gaze
    • Pain on movement                               60
      Emergency Medical Care
 Consult Med. control or follow protocol for
  irrigation.
 Do not apply salve or medicine to the eye
 Do not remove blood or clots from the eye
 Do not force open eyelids except for chemicals
 Have patient lie down and keep calm
 Cover both eyes
 NPO
 Transport all eye injury patients
                                                   61
          Foreign Objects in Eye
   Ask patient if any attempt was made to remove the object
   Attempt removal of objects only in the conjunctiva, not
    those on the cornea or lodged in the globe
   Flush eye with copious amount of water if protocol allows
   If flushing is not possible, use gauze or a swab
 Never    attempt to removed anything lodged
    in the eye


                                                            62
              Orbital Fractures
 Consider  spinal immobilization
 DCAPBTLS the face
 If eyeball has not been injured
  • Transport patient in sitting position and apply
    cold packs to help reduce swelling
 If   suspected eyeball injury
  • Avoid cold packs and transport patient in
    supine position
                                                      63
                Lid Injury
 Check  for DCAPBTLS
 Control bleeding with light pressure
 If eyeball is injured do not apply pressure
 Cover eye with saline soaked gauze
 Preserve any avulsed skin and transport
 If eyeball is injured cover both eyes
 If eyeball is not injured, apply cold pack
                                                64
          Injury to the Globe
 Blood  in the anterior chamber
 Noted pressure from fluid in eye
 Best treated at hospital
 Lightly cover both eyes and transport




                                          65
             Chemical Burns
 Dire emergency/damage within seconds
 First 10 minutes determine final outcome
 Immediately apply copious amounts of water or
  saline for at least 20 minutes
 Pour from inside edge to outside edge
 Force lids open if necessary
 Contact lenses must be removed
 Continue irrigation throughout transport
                                                  66
Impaled Object/Extruded Eyeball
 NEVER REMOVE IMPALED OBJECT OR
  REPLACE EXTRUDED EYEBALL!
 Immobilize C-spine
 Apply soft sterile dressing to eye
 Place paper cup over injured eye
 Cover both eyes and bandage in place
 NPO
 Transport
                                         67
Injuries to the Face




                       68
             Emergency Care
 Consider MOI
 Prepare for severe bleeding
 Immobilize C-spine
 Establish airway/don’t use adjuncts if possible
  fracture or deformity
 Inspect mouth/ do not remove dentures unless
  broken
 Suction if necessary
 Consider ALS back-up                              69
        Emergency Care Cont...
 BigO’s 15 lpm NR or BVM if necessary
 Control bleeding
  • Direct pressure with pressure dressing
 Cover  nerves, blood vessels, tendons with
  moist sterile dressing
 Treat for shock and transport


                                               70
             Avulsed Tooth
 Rinse  tooth with saline
 Transport tooth in cup of saline or saline
  soaked gauze
 Never touch the root
 Control bleeding from socket with gauze
  pad
 Treat for shock and transport

                                               71
   Impaled Object to the Cheek
 Push object out the way it entered
 Place gauze inside between patients teeth
  and wound, and on the outside the mouth
 Dress and bandage outside of wound to
  control bleeding
 Consider ALS back-up
 Suction if necessary

                                              72
            Injuries to the Nose
 If   nose is possibly fractured
  •    Consider C-spine immobilization
  •    Maintain airway
  •    Apply cold pack
  •    Transport
 Never    remove an imbedded object in the
  nose.
  • Can ask patient to gently blow his nose
                                              73
          Epistaxis/Nosebleed
 Never  pack the nose
 Have the patient lean forward
 Apply 2x2 gauze between the upper lip and
  gum
 Pinch the nostrils together
 Apply direct pressure to upper lip
 Apply cold pack to bridge of nose
 Transport                                74
              Ear Injuries
 Never  attempt to stop bleeding by packing
  the ears.
 Apply lose dressing to ears and bandage in
  place
 Transport any avulsed tissue with patient
 Never attempt to remove a foreign object in
  the ears
                                            75
              Neck Injuries
 Look for DCAPBTLS
 Neck wound
  • Apply direct pressure with gloved hand
  • Apply occlusive dressing
  • Treat for shock and transport




                                             76
                     Skills
 Applicationof C-Collar (video)
 Long back board
  • Lying
  • Standing
 KED
 Helmet   Removal

                                   77

				
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