Emergency Care Textbook Professional Responders-part-12.pdf
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12 Head and Spinal Injuries Key Content Mechanism of Injury for Head and Spinal Injuries............... 228 Head Injuries........................... 228 Skull Fracture....................... 228 Objects Impaled in the Skull................................... 230 Injuries to the Brain............. 23...
12 Head and Spinal Injuries Key Content Mechanism of Injury for Head and Spinal Injuries............... 228 Head Injuries........................... 228 Skull Fracture....................... 228 Objects Impaled in the Skull................................... 230 Injuries to the Brain............. 230 Cerebral Hematoma............ 232 Spinal Injuries.......................... 233 Spinal Motion Restriction (SMR)................................. 233 Care for Serious Head and Spinal Injuries...................... 242 Rapid Extrication..................... 242 Removing Helmets and Other Equipment................. 242 Introduction Fortunately, prompt care can help minimize the damage from most head and spinal injuries. For this reason, it is important to learn to recognize situations that should make you suspect a serious head and/or spinal injury. Injuries to the head and spine can damage both bone and soft tissue, including brain tissue and the spinal cord. It is difficult to determine the extent of damage in head and spinal injuries. Signs and symptoms of a serious head and/or spine injury may be slow to develop, especially in the case of trauma to the brain. In most cases, the only way to assess the HEAD AND SPINAL INJURIES Injuries to the head and spine can cause damage to the central nervous system (the brain and spinal cord), and this can result in paralysis, impaired mental function (e.g., behavioural disorders, speech or memory issues), or death. 227 full extent of the damage is by having an X-ray or scan conducted. Since you cannot know exactly how severe an injury is in the field, always provide initial care as if the injury is serious. Remember to treat head and/or spinal injuries before minor injuries such as lacerations. Head and spinal injuries can cause challenges when you are prioritizing care. A patient with a suspected spinal injury should have his or her spine protected from further injury, but if protecting the spine interferes with life-saving interventions, protecting the patient’s life must be the highest priority. Similarly, if you have the choice between saving a patient’s limb and protecting the patient’s spine, the spine should be your priority. MECHANISM OF INJURY FOR HEAD AND SPINAL INJURIES HEAD AND SPINAL INJURIES The mechanism of injury is often the best guide to determining whether someone has suffered a head and/or spinal injury (Figure 12–1). Survey the scene and think about the forces that may have been involved in the injury: Powerful blunt forces are likely to cause severe injury to the head and spine. For example, a driver whose head breaks a car windshield in a crash or a diver who hits his or her head on the bottom of a swimming pool is likely to have suffered a serious head and/or spinal injury. When evaluating the scene and talking to patients and bystanders, watch for clues that could indicate that a serious head and/or spinal injury has occurred. If the patient is found in a position that makes his or her back visible, check for signs of trauma such as bleeding, deformity, discoloration, or muscle spasms. 228 You should consider the possibility of a head and/ or spinal injury whenever the body is subjected to powerful blunt forces (or when the cause of trauma is unknown). These situations include: A patient found unresponsive with an unknown cause. Any fall from a height greater than approximately 1 metre (3.3 feet). Any motor vehicle collision. Any injury in which a patient’s helmet is badly damaged or broken. Any injury involving a severe blunt force to the head or trunk. Any penetrating injury to the head, neck, or trunk. Any head injury that occurs when a patient is diving. Any incident involving electrocution (including lightning strikes). HEAD INJURIES There is a significant difference between a head injury and an injury to the head. An injury to the head is often a superficial injury (e.g., a cut to the face or scalp), whereas a head injury often involves brain trauma. Some trauma will result in both a head injury and an injury to the head: For example, a forceful blow could cause both contusions (injury to the head) and a concussion (head injury). Soft tissue injuries to the head are discussed in Chapter 9. Skull Fracture Because of the risk of brain trauma, skull fractures are very serious. The signs and symptoms of a skull fracture include: Visible damage to the scalp. Deformity of the skull or face. Pain. Swelling. Fluid (clear or pinkish) coming from the nose, ears, mouth, or a head wound. Unusual pupil size. Bruising around the eyes (raccoon eyes). Bruising behind the ears (Battle’s sign). With a skull fracture, spinal precautions are indicated. ORBIT FRACTURES Trauma to the face may result in a fracture of the bones that form the orbits, or eye sockets (Figure 12–2). A patient with an orbit injury may complain of double or decreased vision. He or she may also experience numbness above the eyebrow or over the cheek, or massive discharge of fluid from the nose. Distraction Flexion Rotation Hyperextension Penetration Figure 12–1: The mechanism of injury may help you to determine if the patient has suffered a head and/or spine injury. HEAD AND SPINAL INJURIES Compression 229 Figure 12–2: Facial trauma may result in a fracture of the eye sockets. Fractures of the lower part of the orbit are most common. They can cause paralysis of the upward gaze: the patient’s eyes will not be able to follow your finger upward. Place cold packs around the injured orbit to help reduce the swelling, without putting any pressure on the fracture site. A patient with an orbit fracture should be rapidly transported in a supine position, as surgery is usually necessary and permanent visual impairment is possible. Injuries that cause orbit fractures are often associated with concussions. Objects Impaled in the Skull If an object is impaled in the skull, leave it in place and stabilize it with bulky dressings. Dress the area around the wound with sterile gauze, but allow blood to drain. Avoid putting direct pressure on the head if you suspect a skull fracture. HEAD AND SPINAL INJURIES If an object has penetrated the skull but is not visibly protruding (e.g., a bullet), cover the wound lightly with sterile dressings. 230 Injuries to the Brain Brain damage can occur with an open or closed wound. The severity of the injury often depends on the mechanism of injury and the force involved. All head injuries should be considered serious. The signs and symptoms vary depending on the location and severity of the injury, but they may include: Changes in level of responsiveness. Paralysis or flaccidity of muscles (i.e., limp, lacking tone), usually on one side of the body. Unequal facial movements and/or disturbances in vision or pupils. Ringing in the ears or other disturbances in hearing. Limb rigidity. Loss of balance. Rapid, weak pulse. High blood pressure with slow pulse. Breathing problems. Vomiting. Incontinence. Cushing’s reflex (or Cushing’s response) is the body’s natural response to an increase in intracranial pressure (for example, as a result of cerebral hematoma) and often indicates a serious head injury. The three characteristic signs of this response are often referred to collectively as Cushing’s triad (Figure 12–3). These signs are: 1. A change in respiration (irregular and often deep). 2. An increase in blood pressure (especially a widening of the gap between systolic and diastolic pressure). 3. Bradycardia. If the patient has a serious head injury, blood or cerebrospinal fluid (CSF) may drain from the ear. Cover the ear lightly with a sterile dressing without applying direct pressure. If CSF drains into the nose or mouth, airway management will be necessary. CONCUSSION A concussion is one of a subset of traumatic brain injuries (TBI) that involves a temporary alteration in brain function. An impact to the head or upper body can create forces that cause the brain to shake inside the skull. This shaking can cause the brain to collide with the bony structures that make up the skull’s inner shell, which sometimes causes swelling and/or bleeding, or to rotate within the skull, which can shear or tear the brain nerve fibres and sometimes stretch and damage the brain cells. When the brain sustains an acceleration (or moving) injury, there is usually (but not always) damage at two points. The brain initially strikes the skull, called the coup effect, and then there is a second point of damage when the brain strikes the skull on the opposite side (the contrecoup effect). A concussion can result from even a seemingly minor injury, and the signs and symptoms may not be immediately obvious (see Table 12–1). Concussions are evolving injuries, with the effects intensifying, dissipating, or changing unexpectedly in the days and weeks following the initial injury. Depending on the severity of the concussion, signs and symptoms can last for days, weeks, or even months. The majority of concussions, however, resolve in a short period of time. A patient does not have to have lost consciousness to have incurred a concussion. A patient who has had one concussion is at increased risk for future concussions. Identifying signs and symptoms of a concussion in a child is more difficult than in an adult. It is particularly difficult for a young child or infant, since these patients may not be able to describe the symptoms. In addition to the standard signs of a concussion, a child or infant may exhibit the following signs: Disturbed sleeping and eating patterns Excessive crying Disinterest in activities or favourite toys Respiration changes Cushing’s Triad Bradycardia Increased blood pressure Figure 12–3: Cushing’s triad consists of three signs characteristic of increased intracranial pressure. TABLE 12–1: SIGNS AND SYMPTOMS OF A CONCUSSION Confusion Clouded or foggy mindset Stunned or dazed appearance Temporary memory loss regarding the event of the injury Difficulty concentrating Difficulty remembering or recalling events Slowed reaction times PHYSICAL Neck pain, headache, or pressure within the head Fatigue or low energy Short-term loss of responsiveness Dizziness or loss of balance Double or blurred vision, or “seeing stars” Ringing in the ears Nausea or vomiting Mumbled or indistinct speech Sensitivity to light and/or noise Not feeling “right” Seizure or convulsion EMOTIONAL Irritability Sadness or depression Heightened emotions Nervousness or anxiety Personality changes SLEEP Drowsiness Sleeping more or less than usual Difficulty sleeping HEAD AND SPINAL INJURIES THINKING AND REMEMBERING 231 Children may also express simply “feeling off” or “not feeling right” following a physical impact. This is also a possible symptom of a concussion. Anyone suspected of having a concussion should be examined by a physician as soon as possible. If a patient sustains a suspected concussion during an activity, he or she should cease all activity immediately and be monitored closely until he or she can be examined and evaluated by a physician. For example, athletes who have sustained a significant blow to the head should be removed from the activity immediately and not be allowed to return to the current game or practice regardless of whether they have signs and symptoms of a concussion. The player should not be left alone and should be monitored closely. The player should be medically evaluated and follow a supervised return-to-sport process. A player should complete any prescribed return-to-school process before beginning the return-to-sport process. Cerebral Hematoma The brain requires large amounts of oxygen and so contains many arteries and veins. When the brain is injured, there is a significant risk of internal bleeding from these blood vessels. Blood from a ruptured vessel in the brain can accumulate in the skull (Figure 12–4). Because there is very little empty space in the skull, the buildup of blood creates intracranial pressure (ICP), which can cause further damage to brain tissue. Depending on whether the damage is to an artery or a vein, bleeding in the skull can occur rapidly or slowly, sometimes even over a period of days. This bleeding will affect the brain, causing neurological effects such as changes in responsiveness. An altered level of responsiveness is often the first and most important sign of a serious head injury. This can be assessed using the Glasgow Coma Scale (described on page 93). There are four types of bleeding that can occur in the skull (Figure 12–5): 1. Epidural Hematoma 2. Subdural Hematoma 3. Subarachnoid Hematoma 4. Intracerebral Hematoma EPIDURAL HEMATOMA An epidural hematoma is arterial bleeding that occurs between the skull and the dura mater. It usually results from a low-velocity blow to the head (Figure 12–6). The signs and symptoms appear quickly, and the patient usually presents with a brief loss of responsiveness, followed by regained responsiveness and then a rapid decline in responsiveness. As this decline occurs, the patient’s pupils may become sluggish, dilated, or non-reactive. Motor function may also be impaired on one side of the body, which will be the side opposite the injury. HEAD AND SPINAL INJURIES SUBDURAL HEMATOMA 232 A subdural hematoma is venous bleeding in the subdural space resulting from a violent blow to the head (Figure 12–7). Neurological deficits may be obvious immediately after the blow, or they may develop up to days later. While the signs and symptoms of subdural hematoma may not appear immediately after the impact, other signs of trauma may be visible. As the pressure resulting from the bleeding increases, signs and symptoms will begin to appear. Possible symptoms include headaches, visual disturbances, personality changes, difficulty speaking, and deficits in motor function. SUBARACHNOID HEMATOMA Figure 12–4: Blood from a ruptured vessel in the brain can accumulate in the skull. A subarachnoid hematoma is arterial bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater Intracerebral hematoma Dura mater Epidural hematoma Skull Subarachnoid hematoma Figure 12–5: The four main types of cerebral hematomas. surrounding the brain. The subarachnoid space is the path through which the cerebrospinal fluid circulates, and it is responsible for protecting the brain from serious injuries. Subarachnoid hematomas may occur spontaneously from a ruptured cerebral aneurysm, or they may result from a head injury. Possible signs and symptoms include a severe headache with rapid onset, vomiting, seizures, confusion, and a lowered level of responsiveness. INTRACEREBRAL HEMATOMA An intracerebral hematoma is caused by blunt or penetrating trauma that damages blood vessels in the brain itself. Often, there is more than one contusion, and they can enlarge over time. Specific neurological consequences depend on the location and size of the hematoma. SPINAL INJURIES Injuries to the spine can fracture the vertebrae and sprain the ligaments; however, these injuries usually heal without complications. The greater concern with serious spinal injuries is that the vertebrae may shift, compressing, lacerating, or severing the spinal cord. This can cause temporary or permanent paralysis, or even death. The extent of the neural damage can depend on which area of the spinal cord is damaged. Signs and symptoms that indicate a spinal injury may be immediately obvious or may have a delayed onset. Signs and symptoms of spinal injuries include the following: Changes in the level of responsiveness Severe pain or pressure in the neck or back Swelling in the injured area Tingling or loss of sensation in the extremities Partial or complete loss of movement of any body part Unusual bumps or depressions on the neck or back External hemorrhaging from the neck or back Irregular or impaired breathing Nausea or vomiting Loss of balance Incontinence Specific changes in blood pressure and pulse While signs and symptoms alone do not always suggest a spinal injury, they may do so in combination with the MOI. Regardless of the situation, spinal motion restriction (SMR) should be initiated for any patient with a suspected spinal injury. These patients should be in the rapid transport category. Spinal Motion Restriction (SMR) When a head and/or spinal injury is suspected, spinal motion restriction (SMR) should be considered before extricating or transporting a patient. Moving a patient with a suspected spinal injury may cause additional damage to the spine. SMR refers to any technique for limiting movement of the patient’s neck and/or spine. It may be done manually or with special equipment (e.g., a cervical collar or backboard). Protocols around SMR vary widely between jurisdictions, so these techniques are presented as general guidelines only: Ensure that you are familiar with the protocols that apply to you within your scope of practice. HEAD AND SPINAL INJURIES Subdural hematoma 233 When determining whether to initiate SMR protocols, consider as many factors as possible, including the patient’s signs and symptoms, MOI, age, and medical history. If you have good reason to suspect a spinal injury based on these factors and the patient’s overall condition, consider initiating SMR protocols. This rule is not a definitive diagnostic tool. Rather, it provides a useful system for ruling out major risk factors and assessing whether spinal motion restriction is necessary. In the past, spinal motion restriction was used for a large percentage of trauma patients, even those with almost no risk of spinal injuries: In addition to being uncomfortable for patients, this practice had the potential to aggravate existing injuries. The Canadian C-Spine Rule allows responders to determine whether there is a reasonable justification for spinal motion restriction, and to use it only in those cases. Figure 12–8 shows the steps of the assessment process. CANADIAN C-SPINE RULE The Canadian C-Spine Rule is a process that was developed to simplify and standardize the assessment of patients with suspected spinal injuries. It is used by both pre- and in-hospital providers of emergency care. In a hospital setting, it is used to determine whether there is sufficient risk of spinal injury to warrant radiography (i.e., X-rays and other scans). While individual protocols vary, many responders use the Canadian C-Spine Rule as the protocol for determining whether spinal motion restriction (SMR) is necessary and, if so, to what degree: In general, any patient for whom radiography is indicated should be rapidly transported with some form of SMR. The Canadian C-Spine Rule can be used with most patients. The rule should be applied if all of the following are true: The patient experienced trauma. The patient is alert (Glasgow Coma Scale score of 15—see page 93). The patient’s vital signs are stable. The patient is 16 years old or older. The patient has no acute paralysis. CANADIAN C-SPINE RULE WHEN TO APPLY RULE: 1. HIGH-RISK FACTOR PRESENT? Trauma indicated The patient is alert Age ≥ 65 years Stable vital signs Paresthesia in extremities Age ≥ 16 years Dangerous MOI No acute paralysis No No vertebral disease Yes No previous C-spine surgery 2. SAFE TO ASSESS RANGE OF MOTION? MOI = Simple rear-end MVC Position = Sitting Ambulatory at any point post injury No Deferred onset of neck pain post injury HEAD AND SPINAL INJURIES No midline C-spine tenderness No Yes 3. ABLE TO ACTIVELY ROTATE HEAD? Rotates head 45 degrees left and right Yes SMR not indicated Figure 12–8: The assessment process for the Canadian C-Spine Rule. 234 Spinal motion restriction (SMR) indicated. Skull Figure 12–6: An epidural hematoma is an arterial bleed between the skull and the dura mater. The patient has no known vertebral disease. The patient has had no previous C-spine surgery. First, determine whether the patient has any highrisk factors. If any of the following are true, spinal immobilization may be indicated for the patient: The patient is 65 years old or older. The patient has paresthesia (a tingling, burning, or prickling sensation) in the extremities. There was a dangerous MOI (defined as one of the following): ◆ Fall from a height greater than 1 metre (3.3 feet) or 5 stairs ◆ An axial load injury to the head (struck on the top of the head—e.g., while diving) ◆ A high-speed motor vehicle collision (greater than 100 km/h or 60 mph), vehicle rollover, or vehicle ejection ◆ A motorized recreational vehicle collision ◆ A motor vehicle–bicycle collision If the patient has no high-risk factors, determine whether it is safe to assess his or her range of motion. If any of the following are true, the patient is unlikely to require spinal motion restriction: MOI was a simple rear-end motor vehicle collision. The patient is in a sitting position. Dura mater Skull Figure 12–7: A subdural hematoma is a venous bleed in the subdural space. The patient has been ambulatory (walking) at any point since the injury. The patient has no immediate onset of neck pain after the injury. The patient has no midline C-spine tenderness. If any of these factors apply to the patient, assess the patient’s range of motion by having the patient gently rotate his or her head 45 degrees left and right. If he or she is able to do so, spinal motion restriction may not be indicated. If the patient cannot rotate his or her head, at least partial spinal motion restriction may be indicated. IN-LINE STABILIZATION To bring a patient’s head into neutral alignment, use a technique called in-line stabilization. The head is in neutral alignment when the chin is in line with the neck and the spine is straight. In-line stabilization can be performed on a patient in several positions, including supine, sitting, standing, and in the recovery position. To perform in-line stabilization: 1. Direct the patient to remain still. 2. Ensure that your arms or elbows are completely stable. 3. Simultaneously place one hand on each side of the patient’s head. 4. Slowly and gently rotate the head until the patient’s chin is in line with his or her body’s midline (the middle of the chest). HEAD AND SPINAL INJURIES Dura mater 235 5. Slowly and gently tilt the head into the neutral position. 6. Maintain manual stabilization. a If you encounter any resistance, or if the patient complains of any neck pain, stop moving the head and maintain manual stabilization in the current position. Maintaining the head in this neutral, anatomically correct position helps prevent further damage to the spinal column (Figure 12–9, a-b). If a second responder is available, he or she can complete assessments and interventions for any other conditions while the first responder keeps the head and neck stable. If you are alone, place a safe object such as a sandbag, an IV bag, or a rolled-up towel on each side of the head. b While in-line stabilization is recommended for most cases of suspected head and/or spinal injuries, it should not be used under the following circumstances: The patient’s head is severely angulated to one side. The patient complains of pain, pressure, or muscle spasms in the neck when you begin to align the head with the body. You feel resistance when attempting to align the head with the body. In these circumstances, support the patient’s head in the position in which you found it, unless this position negatively affects the patient’s airway. HEAD AND SPINAL INJURIES Rotate the head along only one axis at a time (i.e., up and down or left and right, not both at once). 236 Once you have manually stabilized the head and neck, do not remove your hands until the patient has been fully secured to a spinal motion restriction device or (if permitted by your scope of practice) it is determined that there is no longer a need for SMR. MANUAL SPINAL MOTION RESTRICTION There are a number of effective methods for manually stabilizing a patient’s head. You should choose the method that is most appropriate for the patient’s position and/or the procedure you are performing. Figure 12–9, a-b: Support the patient’s head in line with the body using in-line stabilization. Head Grip This is a basic manoeuvre that is suitable for patients in a supine position (Figure 12–10). It is the preferred method for supporting a patient while a cervical collar is applied. To perform a head grip: 1. Kneel behind the patient’s head, facing the patient’s chest. 2. Place your elbows on the ground and then place your hands on either side of the patient’s head. Your fingers should not extend past the patient’s ears. 3. Place your thumbs on the patient’s forehead, your index and middle fingers on the cheekbone, and your ring and little fingers below the patient’s ears. 4. If you need to manipulate the patient’s airway, move your index and middle fingers to the angle of the jaw and displace the mandible (the lower jaw) upwards (away from you) while maintaining head support in the neutral position. Trapezius Squeeze (Trap Stabilization) The trapezius squeeze, or trap stabilization, is used when manual stabilization will be necessary for a longer period, as it causes less fatigue for the responder (Figure 12–11). It can also be used when rolling a patient from a supine to a lateral position (if a patient vomits, for example). Modified Trapezius Stabilization The modified trapezius stabilization is used when rolling a patient to a lateral position from either a supine or a prone position (Figure 12–12). It may also be used in place of the trapezius squeeze when the patient is supine. To perform a modified trapezius stabilization: 1. Kneel behind the patient’s head, keeping yourself aligned with the patient’s body. 2. Support your elbow on the ground or against your knee and then grip the patient’s trapezius muscle with one hand while simultaneously placing the palm of your other hand against the side of the patient’s head. Your fingertips should not extend beyond the patient’s earlobe. 3. Apply firm pressure to stabilize the head between your palm and forearm. Figure 12–10: The head grip. Figure 12–11: The trapezius squeeze. Figure 12–12: The modified trapezius stabilization. HEAD AND SPINAL INJURIES To perform a trapezius squeeze: 1. Kneel behind the patient’s head, maintaining alignment with the patient’s body. 2. Place your elbows on the ground or on your knees and then extend your arms along either side of the patient’s head. 3. Slide your hands under the patient’s trapezius muscles, with your thumbs pointing downward on the front of the patient’s trapezius muscles and your fingers pointing along the long axis of the body (parallel to the spine). Do not turn your hands to cradle the patient’s neck. 4. Move your forearms inwards to support the patient’s head (without lifting). 5. Apply firm pressure to maintain support of the patient’s head in a neutral position. 237 Sternal Forehead Grip The sternal forehead grip is typically used for transferring manual spinal restriction of a patient from one responder to another (Figure 12–13). It is used if the responder maintaining the manual stabilization must release the patient. To perform the sternal forehead grip: 1. Kneel with one leg beside the patient’s chest or shoulders and the other leg by the patient’s head. 2. Place your elbow and forearm along the patient’s sternum. 3. Place your hand on the patient’s face, with your thumb on one cheekbone and your index and middle fingers on the other cheekbone. Arch your hand to stay clear of the patient’s nose and mouth. At the same time, place your other elbow on your knee and your other hand on the patient’s forehead. 4. Apply firm pressure to hold the head and neck in position. Avoid rotating the head or compressing the head and neck toward the body. 5. Arching your hand raises your forearm, creating room for sandbags or other devices to be placed or removed from each side of the patient’s neck, or for your partner to adjust his or her grip. Figure 12–13: The sternal forehead grip. Sternal/Spinal Grip HEAD AND SPINAL INJURIES This grip is used when a patient is in a seated position (e.g., on the floor or in a vehicle) (Figure 12–14). 238 To perform a sternal/spinal grip: 1. Kneel at a right angle to the patient, at his or her side. 2. Place your elbow and forearm along the patient’s sternum. 3. Place the hand of the same arm on the patient’s face, with your thumb on one cheekbone or mandible and your index and middle fingers on the other cheekbone or mandible. 4. At the same time, position your other arm along the patient’s spine and grip the occiput (the back of the head). Figure 12–14: The sternal/spinal grip. HARD CERVICAL COLLARS Once the head is manually stabilized in an anatomical position, a rigid cervical collar should be applied (Figure 12–15). This collar helps minimize movement of the head and neck and keeps the head in line with the body. It is important to note that although cervical collars reduce movement and some range of motion, these devices alone do not provide adequate SMR. The collar must always be used in conjunction with manual in-line stabilization or a mechanical motion restriction device. Proper sizing of a hard cervical collar is very important, and there are a wide variety of collars available. If the collar is too short, it will not provide enough support, whereas if it is too tall, it may hyperextend the neck. Hard collars come in a variety of sizes. Some collars are adjustable to accommodate different sizes of patients. Accurate measurement is crucial to support and restrict the area properly without aggravating any injuries. Applying a hard cervical collar requires two responders: Responder A maintains the alignment of the head while Responder B sizes and attaches the collar. To size and apply a hard collar, perform the following steps: 1. Ensure that the patient’s head is in the neutral position. If this is not safe or possible, use manual stabilization instead of a cervical collar. If the patient is supine, the head and shoulders should both be resting on the same surface. 2. Responder A applies manual in-line stabilization from behind the patient and maintains it throughout the procedure. Responder A’s fingertips should not extend beyond the patient’s earlobe, as this makes applying the collar difficult. 3. Responder B removes or cuts away any jewellery or clothing that could interfere with the placement of the collar (e.g., necklaces, collared shirts, jackets) and draws the patient’s Figure 12–16: To select the correct size of cervical collar, measure the distance from the top of the trapezius to the bottom of the chin. HEAD AND SPINAL INJURIES Figure 12–15: A rigid cervical collar. arms gently down towards the waist (so long as this does not aggravate any injuries). 4. Responder B measures the distance between the top of the patient’s trapezius and the bottom of the patient’s chin using his or her fingers (Figure 12–16). This measurement indicates the appropriate size of the collar. Familiarize yourself with the brand of hard collar you are using and the manufacturer’s measurement marks. 5. Responder B prepares the collar for application. As always, refer to the manufacturer’s directions. 6. Responder B properly angles the collar for placement and slides the end with the attached strap towards the back of the neck. 7. Responder B positions the front of the collar beneath the patient’s chin while Responder A maintains the patient’s head in the neutral position. The chin piece should rest snugly beneath the patient’s chin, supporting it gently. The lower portion of the collar should be centred and resting on the patient’s sternum. 8. Responder B reaches carefully behind the neck to grasp the end of the strap and draw it around the back of the neck. 9. Responder B secures the collar with the attached strap. 10. After the collar is applied, Responder B visually checks to make sure it is correctly placed and fitted properly, and Responder A confirms this assessment. 239 11. Gently tug the collar where it meets the sternum, then check the collar at the sternum, at each shoulder, and at the chin to ensure that the collar is positioned correctly at each point. If the patient is responsive, ensure that he or she is comfortable and can breathe normally. 12. Responder A maintains in-line stabilization until the patient is fully secured to a spinal restriction device. SPINAL IMMOBILIZATION Once the cervical collar has been applied, the patient’s entire body should be immobilized. Manual SMR should be maintained throughout this process. Spinal immobilization may be accomplished with a long backboard, though local protocol may dictate other procedures. Long backboards and scoop stretchers (clamshell stretchers) may also be used for extrication: In some cases, the patient may then be transferred to a multi-level stretcher with a soft pad for transportation. HEAD AND SPINAL INJURIES Once the cervical collar is in place, the patient can be positioned on the backboard. This is done by log-rolling the patient onto the board. Log-rolling helps to keep the head in line with the body. It requires a minimum of two responders: one to maintain in-line stabilization and another to position the backboard and roll the patient’s body onto it while keeping the spine in a straight line. However, if possible, it is preferable to perform this technique with at least three responders. With three responders, one can provide in-line stabilization while the second and third log-roll the patient and position the backboard (Figure 12–17). 240 If a patient is prone, he or she must be rolled into a supine position. This requires a minimum of two responders. When rolling the patient into the supine position, consider rolling him or her directly onto the backboard in order to limit further movement. The head should be kept in the position found during this roll. It may be moved into the neutral position using in-line stabilization once the roll is complete (if indicated). Figure 12–17: Log-roll a patient onto a backboard while keeping the spine in as straight a line as possible. Babies and children have large heads and may require padding under the body when being placed on a board. Collars and other equipment specifically designed for children should be used when possible. Before applying the straps, ensure that the patient is in the correct position on the backboard: The top of the patient’s head should not go beyond the end of the board. Otherwise, you must adjust the patient’s position (using the appropriate technique to maintain spinal motion restriction). Once the patient’s body is positioned on the backboard, ensure that the head is in the proper neutral position. If necessary, place padding under or around the head to maintain this neutral position. Next, secure the chest to the backboard, followed by the pelvis and legs (Figure 12–18). Padding any cavities between the body and the board (e.g., behind the knees) helps reduce the risk of injury and increases the patient’s comfort. The straps should be snug, but not so tight that they cause discomfort or restrict the patient’s respiration. Always secure the head last. Use tape or a commercial head restriction device. It is important to maintain manual in-line stabilization until the patient’s head is fully secured. To reduce the risk of injury, you may also secure the patient’s hands over the abdomen before moving him or her. Figure 12–18: Use several straps and/or triangular bandages to secure the patient to the backboard. Figure 12–20: A patient with a hard cervical collar on a soft mattress. to as short boards) and flexible models that can be wrapped around a patient’s sides. These devices can be used to restrict movement of a patient’s cervical spine when long backboards are not practical (for example, in a confined space or inside a motor vehicle). A short board can also be used as a long backboard for an injured child. Figure 12–19: There are commercially available head restriction devices. You may have a commercially made head restriction device available (Figure 12–19). Many of these devices use Velcro® straps to secure the head. Follow the manufacturer’s directions when using these devices. While manufacturer recommendations vary and should be followed, the following general steps are used to secure a patient to an upper body motion restriction device: 1. Place the device behind the patient. This can be performed after manual in-line stabilization and the application of a rigid cervical collar. 2. Secure the middle torso by fastening the middle and lower chest straps. The straps should be snug so that fingers cannot be slipped beneath them. In some cases, it may be sufficient to apply a hard cervical collar and place the patient supine on a soft mattress (Figure 12–20). UPPER BODY MOTION RESTRICTION DEVICES An upper body motion restriction device is a board approximately 1 metre (about 3 feet) long that can be used to restrict motion in the upper body of a patient (Figure 12–21). Multiple types are available, including rigid models (often referred Figure 12–21: Attaching the head straps on an upper body motion restriction device (e.g., Kendrick Extrication Device, or K.E.D.®, shown here). HEAD AND SPINAL INJURIES There may be instances in which SMR must be performed for a patient in a prone or lateral position. In these cases, follow local protocols. 241 3. Position and fasten each groin/leg strap separately, forming a loop. These straps prevent the device from moving up and the lower end from moving laterally. 4. Pad the head and secure it to the device. 5. Secure the upper torso by fastening the upper chest strap. 6. Move the patient carefully as a unit to a long backboard by rotating the person and upper body motion restriction device onto the board. The legs are held proximal to the knees and lifted during the transition. 7. Centre the patient on the backboard. Loosen any groin straps, and lower the legs slowly to an in-line position. 8. Secure the patient to the backboard, keeping the upper body motion restriction device in place. CARE FOR SERIOUS HEAD AND SPINAL INJURIES HEAD AND SPINAL INJURIES In addition to the risk of permanent paralysis, head and spinal injuries can become lifethreatening emergencies if the nerve signals for crucial body processes are impaired. An injury to the brain can stop a patient’s respiration or heart, for example, so caring for serious head and spinal injuries includes supporting the respiratory and circulatory systems as necessary. When providing treatment for a patient with a suspected head or spinal injury: Place the patient in the rapid transport category. Initiate spinal motion restriction (SMR) protocols. Control any external bleeding. Monitor responsiveness and be prepared to provide interventions for respiratory or cardiac complications. 242 Caring for a head and/or spinal injury is similar to caring for any other serious soft tissue or musculoskeletal injury. Because movement of an injured head and/or spine can cause irreversible damage to the spinal cord, keep the patient as still as possible until he or she can be transported. RAPID EXTRICATION In some cases, it may be necessary to move a patient quickly using only manual in-line stabilization. Rapid extrication may be required when: The scene becomes unsafe. Life-saving interventions cannot be performed due to the location or position of the patient. It is necessary to move the patient to gain access to another patient who requires life-saving interventions. If the situation requires immediate extrication due to dangers at the scene, pull the patient out of the situation, while taking precautions to stabilize the head and neck in the safest manner possible. REMOVING HELMETS AND OTHER EQUIPMENT If a patient is wearing a helmet that interferes with necessary assessments or interventions, you must remove it correctly and safely to avoid causing further harm to the patient. Helmets fall into multiple categories, including sports helmets and motorcycle helmets (Figure 12–22). While many sports helmets have detachable face masks, it may be safer and easier to remove the entire helmet depending on the type of equipment. Removing any chest or shoulder pads is also advisable, as these can interfere with necessary assessments and interventions. To remove an athletic helmet and shoulder pads, follow these steps: 1. Responder A provides manual stabilization while Responder B cuts away the chinstrap, shoulder pad straps (sides and front), and jersey. 2. Responder B then removes the internal cheek pads (using 2–3 tongue depressors taped together) and/or deflates the helmet’s air bladder system (using a syringe or air pump). These are most common in football helmets, though individual models vary. Removing protective equipment (e.g., a football helmet and shoulder pads) is a skilled technique that requires hours of practice, and often requires several responders trained in this skill. If you encounter this type of situation during an athletic event, look to the certified athletic therapist or trainer to assist in the removal of the face mask, helmet, and shoulder pads, as the necessary tools will be included in their emergency kits. Figure 12–22: Helmets fall into multiple categories. Prior planning and interdisciplinary practice involving the responder, certified athletic therapist or trainer, and emergency department personnel is recommended prior to the beginning of the athletic season, particularly for sports involving helmets and shoulder pads. If you are likely to be responding to injuries sustained during athletic activities, familiarize yourself with the specific types of protective equipment used (especially helmets) to facilitate care. Removing a motorcycle helmet is comparatively simple because the helmet design is less complex and the patient will usually not be wearing shoulder or chest pads as well. The steps for removing motorcycle helmets with two responders are as follows: 1. If the patient is wearing glasses, remove them before attempting to remove the helmet. Ensure that the patient is supine. 2. Responder A holds both sides of the helmet (head grip). 3. Responder B loosens the strap at the D-rings while Responder A maintains stabilization of the patient’s head (Figure 12–23, a). 4. Responder B then places one hand on the patient’s mandible at an angle, with the thumb on one side and the middle and index fingers on the other. With the other hand, Responder B holds the back of the patient’s head (occipital region) (Figure 12–23, b) as high up as possible without lifting the head off of the ground. 5. Responder A carefully slides the helmet gently up until it just clears the patient’s ears, then pauses while Responder B readjusts his or her hand position under the patient’s head. HEAD AND SPINAL INJURIES 3. Responder B then grasps the patient’s mandible with the web space of his or her hand, so the thumb is on one side and the middle and index fingers on the other, while resting his or her forearm on the patient’s sternum for stability. Responder B then slides the other hand between the top of the athlete’s shoulder and the inside of the shoulder pad, underneath the deltoid cup. From here, Responder B continues to slide his or her hand up towards the back of the patient’s neck, through the opening of the shoulder pads, terminating at the back of the patient’s head (occipital region), thus grasping the head without lifting it off of the ground. 4. Responder A carefully slides the helmet gently up until it just clears the patient’s ears, then pauses while Responder B readjusts his or her hand position under the patient’s head. 5. Responder A then removes the helmet the rest of the way, making sure to tilt it backwards to avoid hitting the patient’s nose. This may require a gentle forward and backward motion, but care should be taken to avoid motion of the head. Responder B maintains manual stabilization from below to prevent the head from tilting during the helmet removal. 6. From the top of the patient’s head, Responder A then places both hands on the sides of the neck opening of the shoulder pads and pulls straight back along the ground, bringing the shoulder pads up over the patient’s head. Care should be taken to help clear the shoulder pads over the patient’s nose to avoid causing excessive cervical extension. 7. Once the shoulder pads have been removed, Responder A takes over manual stabilization (page 235) of the patient’s head from Responder B and lowers it to the ground. 243 6. Responder A then removes the helmet the rest of the way, making sure to tilt it backwards to avoid hitting the patient’s nose (Figure 12–23, c). This may require a gentle forward and backward motion, but care should be taken to avoid causing any motion of the head. 7. Responder B maintains manual stabilization from below to prevent the head from tilting during the helmet removal. After the helmet has been removed, Responder A lowers the head to the ground while maintaining manual stabilization (page 235). a b HEAD AND SPINAL INJURIES c 244 Figure 12–23, a-c: a, One responder restricts motion of the head by holding both sides of the helmet while the second responder loosens the strap; b, the second responder holds the patient’s mandible and base of the skull; and c, the first responder removes the helmet while the second responder maintains manual stabilization. SUMMARY When to Suspect Head and/or Spinal Injuries A patient found unresponsive with an unknown cause Any fall from a height greater than approximately 1 m (3.3 feet) Any motor vehicle collision Any injury in which a patient’s helmet is badly damaged or broken Any injury involving a severe blunt force to the head or trunk Any penetrating injury to the head, neck, or trunk Any head injury that occurs when a patient is diving Any incident involving electrocution (including lightning strikes) SIGNS AND SYMPTOMS OF DIFFERENT HEAD INJURIES Skull Fracture Visible damage to scalp; deformity of skull or face; pain; swelling; fluid from the nose, ears, mouth, or head wound; unusual pupil size; bruising around the eyes; bruising behind the ears Orbit Fracture Double or decreased vision; numbness of the cheek or above the eyebrow; massive fluid discharge from the nose; paralysis of upward gaze Brain Injury Changes in LOR; paralysis or flaccidity of muscles; unequal facial movements; vision or pupil disturbances; hearing disturbances; limb rigidity; loss of balance; rapid or weak pulse; high blood pressure with slow pulse; respiratory problems; vomiting; incontinence Concussions Physical and emotional changes; disturbances in sleep pattern and drowsiness; memory and mental difficulties (see Signs and Symptoms of a Concussion table below) Epidural Hematoma Changing responsiveness (in and out) that results in rapid decline in responsiveness; slowed pupil response or non-reactive pupils; dilated pupils; impaired motor function on the side opposite the injury Subarachnoid Hematoma Severe headache with rapid onset; vomiting; seizures; confusion; lowered level of responsiveness Intracerebral Hematoma More than one contusion; contusions that enlarge over time; specific signs and symptoms depend on location and size of hematoma Thinking and Remembering Confusion Clouded or foggy mindset Seeming stunned or dazed Temporary memory loss regarding the event of the injury Difficulty concentrating Difficulty remembering or recalling events Slowed reaction times Physical Neck pain, headache, or pressure within the head Fatigue or low energy Short-term loss of responsiveness Dizziness or loss of balance Double or blurred vision, or “seeing stars” Ringing in the ears Nausea or vomiting Mumbled or indistinct speech Sensitivity to light and/or noise Not feeling “right” Seizure or convulsion Emotional Sleep Irritability Sadness or depression Heightened emotions Nervousness or anxiety Personality changes Drowsiness Sleeping more or less than usual Difficulty sleeping HEAD AND SPINAL INJURIES SIGNS AND SYMPTOMS OF A CONCUSSION 245 SUMMARY Signs and Symptoms of Spinal Injuries Changes in the level of responsiveness Severe pain or pressure in the neck or back Swelling in the injured area Tingling or loss of sensation in the extremities Partial or complete loss of movement of any body part Unusual bumps or depressions on the neck or back External hemorrhaging of the neck or back Irregular or impaired breathing Nausea or vomiting Loss of balance Incontinence Specific changes in blood pressure and pulse How to Perform In-Line Stabilization 1. 2. 3. 4. 5. Direct the patient to remain still. Place one hand on each side of the head. Slowly rotate the head until the chin is in line with the body’s midline. Slowly tilt the head into the neutral position. Maintain manual stabilization. Methods for Manual Spinal Motion Restriction (SMR) HEAD AND SPINAL INJURIES 246 General Guidelines for Serious Head or Spinal Injuries Head grip Trapezius squeeze Modified trapezius stabilization Sternal forehead grip Sternal/spinal grip Place the patient in the rapid transport category. Initiate SMR protocols. Control any external bleeding. Monitor responsiveness and prepare to provide interventions for respiratory or cardiac issues. When Rapid Extrication Is Needed The scene becomes unsafe. Location or patient position makes life-saving interventions impossible. The patient is blocking access to another patient with life-threatening injuries.
