EMT-Basic Exam: The Basics of Trauma - Injuries to the Head and Spine

Head and spinal injuries can be very dangerous and require extremely careful assessment and immobilization on the scene. Because of the potential consequences of head and spinal injuries, rapid transport to a medical facility is of the utmost importance. EMT-Basics use an array of devices to ensure proper immobilization of patients with head and spine injuries.

1. The Nervous and Skeletal Systems
The nervous system is responsible for all the body’s voluntary and involuntary actions. It consists of two distinct systems: the central nervous system and the peripheral nervous system. The central nervous system is composed of the brain and spinal cord. The brain is situated inside the cranium and the spinal cord is located inside the spinal column, which runs between the brain and the lumbar vertebrae. A substance called cerebrospinal fluid surrounds and protects both the brain and the spinal cord. The peripheral nervous system is a network of sensory and motor nerves. Sensory nerves send information from the body to the spinal cord and on to the brain. Motor nerves send information from the brain and spinal cord to the rest of the body.

The skeletal system has three basic functions: providing body shape, protecting the internal organs, and assisting with body movement. The skull provides the brain with protective housing. The structure of the face and skull consists of an array of fused bones. These bones include the orbital bones of the eye, nasal bones, the maxilla, the mandible, and the zygomatic bones (or cheekbones).
The spinal column runs the length of the trunk and neck and includes 33 vertebrae. Among these vertebrae are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal vertebrae. The spinal column encases and protects the spinal cord. Twelve pairs of ribs connect to the thoracic vertebra. The first ten ribs are also attached anteriorly to the sternum. The eleventh and twelfth ribs don’t connect to the sternum and are commonly called floating ribs.



The four regions of the vertebral column.

2. Devices for Immobilization
Any patient who may have suffered a head and/or spinal injury must be immobilized in order to reduce the risk of further injury. Full-body immobilization is indicated even when trauma is localized to one small part of the spinal column.
The most commonly used immobilization device is the cervical spine immobilization device. Also known as a cervical collar, this device is used with any suspected spinal injury. Cervical spine immobilization devices should always be used in conjunction with short or long backboards. These backboards are made of a rigid material. The anterior portion is built to firmly fit the chin and rest on the chest. When the cervical spine immobilization device is properly applied, patients shouldn’t be able to move their heads up and down.
Cervical spine immobilization devices must be properly fitted before being applied. The sizing may vary depending on the type and design of the specific device. Using an improperly sized device can lead to further injury. A device that is too tight can restrict the patient’s airway and cause the head to bend forward.
Before placing a cervical collar, be sure that the patient’s head is in a neutral position. In the event that you can’t put the head in a neutral position or you don’t have a collar that fits the patient, you may use rolled-up blankets or towels as an alternative means of immobilization.
Other important immobilization tools are the short and long backboards. Short backboards are used to immobilize the head, neck, and torso of a patient in the seated position. Long backboards are used for immobilizing the entire body when the patient is lying or standing. Long backboards are commonly used in conjunction with short backboards, cervical collars, or other head immobilization devices.
It is very important to ensure that all immobilization devices are used properly. This will prevent the patient from suffering further injury.

3. Injuries to the Spine
The first step in assessing a spinal injury is to size up the scene and determine the mechanism of injury. The mechanism of injury can help you determine the type of injury and the severity of the injury.
 

There several types of spinal injury. Compression injuries occur when the head is pushed downward, compressing the spine. These injuries are often found in victims of car accidents, diving accidents, and falls. Spinal injuries also occur as a result of extreme flexion, extension, rotation, or lateral bending of the spine. The most common causes of these spinal injuries are car accidents in which the victim experiences whiplash, a rapid backward, and then forward flexion of the neck.

Distraction spinal injuries occur when the spine is pulled apart. Spinal separation often results when the head is pulled away from the spine. Distractions are most commonly seen in hanging victims.

Assessment and treatment of spinal injury patients should begin with airway management and bleeding control. Victims of spinal injuries will often experience tenderness around the injury site or pain related to movement. Patients may sometimes feel pain without movement or palpation along the spinal column or extremities. Be sure that the patient doesn’t move at any time.

When assessing a spinal injury, you may find soft tissue injuries or spinal deformity. Other injuries may indicate which part of the spine has been injured. Head and neck injuries may indicate a cervical spine injury. Thoracic or lumbar spine injuries are often accompanied by shoulder, back, or abdominal injuries. Soft tissue injuries found on the lower extremities may indicate a lumbar or sacral spine injury.
Spinal injuries that damage the spinal cord may result in numbness, weakness, tingling, or paralysis below the injury site. These patients may also experience a loss of bowel control.
 

If the patient is responsive, use the DCAP-BTLS method to assess the injuries. Have the patient grasp your hands or push your hands with his or her feet to determine if strength is equal on both sides of the body. You should acquire and record important information from responsive patients quickly, as they may become unresponsive at any time.

When assessing unresponsive patients, check the scene for the mechanism of injury and report your findings to the receiving medical facility. The patient should be assessed and immobilized with a long backboard. After treating any life-threatening injuries, quickly assess the patient using the DCAP-BTLS method and ask bystanders or other witnesses for more information regarding the mechanism of injury and the patient’s mental status prior to your arrival.

Spinal injuries can have many complications, including inadequate breathing or paralysis. It is extremely important to limit movement of the patient during immobilization. You should reassess the patient’s condition after each intervention. With combative patients, you should also reassess their condition after any movements they make.

Spinal cord injuries involving the nerves that control diaphragm movement or the accessory muscles may lead to respiratory difficulty. These patients should be monitored very closely and artificially ventilated, if necessary. Some patients may vomit after immobilization, so be sure the patient’s airway remains clear at all times.

Treatment of spinal injuries should begin with manual in-line cervical spinal immobilization, which should continue until the patient is fully immobilized with a long spine board, straps or tape, a cervical immobilization device, and head blocks or towel rolls. You should complete the initial assessment and provide airway control and artificial ventilation, when needed. Check for pulse and motor and sensory function in all of the patient’s extremities.

Lying patients can be moved onto a long backboard with a technique known as a log roll. The log roll is designed to keep the spinal column aligned while transferring the patient with the least amount of movement possible. While executing the log roll, you can assess the patient’s posterior side for DCAP-BTLS.

Patients who are found in a seated position should first be immobilized in that position with a short backboard and then transferred to a long backboard.

4. Injuries to the Brain and Skull
Injuries to the head and brain are often accompanied by spinal cord injuries, so patients with suspected head injuries should be fully immobilized. Head injuries frequently present with scalp or brain injuries. Scalp wounds may appear more severe than they actually are because of the presence of numerous capillary beds in this area. Skull injuries may lead to damaged brain tissue or bleeding inside the skull. This bleeding causes increased pressure inside the skull and may lead to an altered mental state.

As always, you should begin assessment and treatment by securing the airway. If the patient requires artificial ventilation, be sure to ventilate the patient at a normal rate, as rapid ventilation may result in the constriction of brain blood vessels in victims of head trauma.
Initial and focused assessments and immobilization should be carried out before you begin transport. Once you are en route to the receiving medical facility, you may perform a more detailed physical examination.

Tip: Remember to monitor the patient’s airway, breathing, pulse, and mental status for signs of deterioration.

Bleeding should be controlled, but direct pressure should not be applied to open or depressed skull injuries. You should be prepared to administer suction in the event that the patient vomits. Roll the patient to the left side for the most effective airway control. Once the patient is secure, immediate transport is necessary.

In certain instances, you may not be able to fully stabilize a patient with a skull or spine injury. When the scene is unsafe or the patient is unstable, you may need to perform rapid extrication, which is the immediate removal of the patient from the scene. Because this technique is performed without any form of immobilization, it should not be attempted unless absolutely necessary. If rapid extrication is indicated, align the patient’s body, lower the patient onto a long backboard, and extract the patient while providing manual stabilization.

In some cases, you may encounter a patient who is wearing a helmet. You may or may not have to remove the helmet, depending on several factors. The need for removal is based on the fit of the helmet, the patient’s head movement inside the helmet, and the access the helmet allows to the patient’s airway. Helmets with open anterior portions allow for easy access to the patient’s airway and do not usually need to be removed.

Helmets with closed anterior portions, like motorcycle helmets, often obstruct your access to the patient’s airway, and will likely need to be removed in the event of respiratory difficulty. If the helmet immobilizes the patient’s head it can be kept on, but helmets that allow too much movement must be removed. You should also remove the helmet if it is impeding proper spinal immobilization, or if the patient is in cardiac arrest.

Children and infants should be immobilized on a rigid board that is appropriate for their size. Because children and infants have larger heads than adults do, you may need to provide extra padding from the shoulders to the heels in order to keep young patients in a neutral position. Children may also be immobilized by adding pads and tape to their car seats if this adequately limits movement.

As with adults, it is important to ensure that the cervical spinal immobilization device fits the child properly. If you don’t have a cervical collar small enough to fit a young patient, you should pad under the patient’s neck, torso, and legs. You must also maintain manual stabilization of the patient in a neutral position while carrying out this task. Children are often more likely to resist immobilization and may be comforted by the use of a snug, whole-body immobilization device. Tape or loose straps may result in further problems because the child may become frightened and attempt to escape from these restraints.

Immobilizing elderly patients may be complicated by arthritis. The patient may be unable to fully straighten or move some joints. Patients with osteoporosis may have spinal curvature that prevents normal immobilization. You may need to add extra padding between the patient and the immobilization device to ensure proper support.

Related Topics You Should Review:
- Soft tissue damage to the head
- Musculoskeletal injuries