so in this chapter we're going to talk about injuries to the head and spine in chapter 28 we talked about facial injuries not necessarily head injuries and we talked about neck injuries but not again not necessarily spinal injuries so we're going to talk about uh recognition management of life threats in spinal trauma pathophysiology the assessment management of spinal trauma spinal trauma and skull fractures we're going to talk about the nervous system the pathophysiology the assessment and management of traumatic brain injuries and spinal cord injuries so the nervous system is really kind of a cool system it's one that i always found kind of complicated but then the more i'm exposed to it the more i get accustomed to it and i really think it's a really cool system so it includes this the your brain your spinal cord and all your nerves and nerve fibers so everything that transmits that signal to the brain and down the spinal cord obviously you're spring spring it's been a long day i'm so sorry my the brain is protected by the skull so and the spinal cord itself is protected by the spinal canal in your back so again really even though we have these protections built in you can have serious damage to your nervous system so you have your central nervous system and then you have your peripheral nervous system we have the two different systems that we need to talk about so again your your brain and your spinal cord are going to be your central nervous system and then anything outside of that is your peripheral nervous system all the way to your fingers and your toes so the central again we talked about being the brain and spinal cord it's uh the center of consciousness and then you have your brain divided by divided up into the three major areas your cerebrum cerebellum and your brain stem so you need to know those three different parts of the brain and if you look at a drawing or uh the amp of the brain and that the cerebrum is the biggest part of the brain the cerebellum the little bell is the smaller part and then the brain stem itself is where everything goes into your spinal cord siree brum controls most of your activities your voluntary motor functions your conscious thought about 75 of your total brain volume is the cerebrum and then there's two hemispheres and four lobes cerebellum the little belt coordinates balance and body movements and then the brain stem man that is the thing that the the functions of your body for living uh that's all there and they say it's the best protected part too well it's it's kind of in the center of everything your spinal cord is made up of fibers that go from your brain's nerve cells and it carries it all the way down your spinal column and it carries that signal down your back protective coverings the whole system is protected if you will in this framework of your skull and your spinal canal that's the bones that protect it and then besides the bones protecting it you have meninges or linings that cover your brain and your spinal cord the outer layer of your meninges is the called the dura mater which is the tough mother and that's what it means it's a fibrous layer and it's it's really tough and it's protective and then you have inner layers called the arachnoid and your pia mater or your soft mother containing blood vessels and this is kind of a depiction of it your your skin your fascia your muscle your skull and then all of a sudden you have that dura mater the hard layer your arachnoid is the middle layer and then the pia matter the soft is against your brain so that makes sense that the hard layer is away from your brain and the soft layer is attached to your brain or right in contact with your brain then we have cerebral spinal fluid and that's a again something that's going to help protect your brain because it's really a shock absorber it's a fluid that that when you have your brain moving around inside his skull it's it's a shock absorber that fluid protects the brain there's 31 pairs of spinal nerves and you don't need to know these for emt again it conducts impulses from the skin and other organs to the spinal cord so when you touch something with your fingers and it's hot or it's cold it's a it's a sending a signal to your spinal cord and here they are the peripheral nervous system anything outside your surroundings central nervous system is your peripheral nervous system there's 12 pairs of cranial nerves you'll need to know those in paramedic class nursing class or physician and they transmit information to or from the brain and we those are the big ones that we talk about with the head the face seeing smelling tasting hearing all those things are going to be part of those 12 cranial nerves there's two types of peripheral nerves there's a sensory and motor nerves you were taught to do your patient assessment and in your patient assessment you check all four extremities for cms circulation motor sensory now this is part of the this is one part of those so you have sensory carry only one type of information from the body to the brain and then motor nerves for each muscle that you have you have a motor nerve and it carries information from the central nervous system to the muscles telling the muscles what to do so that's part of your patient assessment there's connecting nerves found only in the brain and spinal cord and they they're they're short really and they just simple information between the bright the brain and the spinal cord so how does this whole system work well we have reflex activities voluntary muscles or voluntary activities and involuntary involuntary activities so we start with the connecting nerves in the spinal cord they form a reflex arc if a sensory nerve in this arc detects an irritating stimulus it bypasses the brain and sends a message directly to a motor nerve so you feel something hot it doesn't always go up to your brain it just says pull away dummy and that's what it does right there it just is a short um circuit basically it bypasses the brain and just tells you hey pull away voluntary activities are what we have to think about before we perform them so somatic or voluntary nervous system handles all those voluntary activities the autonomic or the involuntary nervous system handles body functions that's where you have the sympathetic or the parasympathetic nervous system that's the fight-or-flight response so when you're your body's introduced to some type of stress what does it do and then the parasympathetic has the opposite effect sympathetic gets ready to run away or fight that's that stressor and then the parasympathetic we call that sometimes defeated and breathes where everything goes back to normal we talked about the skull already and the facial bones we talk about the brain being connected to the spinal cord through the foramen magnum that's the hole in your skull that's the only opening in your skull other than that it's it's an enclosed rigid structure four major bones make up the cranium the occipital the temporal the parietal and the frontal bones there's 14 bones the maxilla zygomas the mandible and the orbits and we kind of covered that with injuries to the face the spinal column made up of uh the this vertebrae and there's five sections your cervical which is your neck your thoracic which is your torso lumbar which is your lower back and then it goes down into your tailbone which is like your sacral and coccygeal i love this picture because i had a student point out to me that she had learned cervic the number of cervical vertebrae are seven because that's breakfast thoracic is 12 that's lunch lumbar is five that's dinner so breakfast lunch and dinner you can tell how many vertebrae are in each one of those areas an injury to the vertebrae or the the bones in your back can lead to possible paralysis not always but it can lead to it and in between each one of those bones of your vertebrae are little cushions or discs and that's the somebody says they have a slipped disc well that's that disc that is kind of moved out of place or they say i have a bulging disc and that's kind of where there's some inflammation on that disc and then again your spinal column is surrounded by muscles you know and that's going to help protect that as well and provide for movement traumatic injury to the head may result uh in a soft tissue or bony structures or the brain um we have these this traumatic brain injuries or tbi as we call them traumatic brain injury that account for more than half of all traumatic deaths half of the deaths are result from a traumatic brain injury or head injury and again they probably have some other type of injury or some type of other trauma and it's not just always just isolated to the head with closed head injuries that's where the brain has been injured but yet there's no opening into the brain itself and with open injuries that's where you have an opening to the they say to the outside world um i always kind of think of like somebody being hit in the head with a hatchet or a hammer and that creates that opening and you might actually see exposed brain tissue motor vehicle collisions really bad ones you might see that as well motorcycle wrecks without helmets falls in motor vehicle collisions again they might be a victim of an assault like we talked about or during sports related incidents so riding a bicycle without a helmet and you crash skateboarding without a helmet that kind of thing so here's a table uh the signs and symptoms of a head injury and you can go through this list and you can see that there's a lot of different types of signs and symptoms that can be associated to a head injury or an injury to the brain itself so there's a ton of things scalp lacerations we already talked about this with facial and and even though they look bad it might not be so bad but it could be bad enough to lead to hypovolemic shock depending on how bad the laceration is you know if it's a really deep laceration it's going to bleed a lot number one uh and number two if we can't stop it it might lead to shock but the guys out there know what i'm saying is if you lit nick yourself when you're shaving it always seems to bleed more than it really should skull fractures again you have so much force that is applied to your skull that you actually fracture that which is going to be tremendous amounts of energy you might have an open or closed injury depending on whether you have that overlying laceration of the scalp that leads to an opening injuries from bullets or other penetrating weapons often result in skull fracture so getting shot in the head suicide that kind of stuff signs that you might have a skull fracture include the skull appears to be deformed visible cracks in the skull echimosis are bruising under the eyes we call that raccoon eyes or you have ecchimosis or bruising behind one ear called battle signs really bad depiction of raccoon eyes on the top and behind the ears over the mastoid process you see battle signs i think battle signs came from a surgeon during the civil war going out and looking at dead bodies after a battle and seeing that bruising to indicate a major skull fracture linear skull fractures about 80 of all skull fractures and again you can't see these uh because there's there's no way that you can physically see them but there's fractures to the skull that the physicians or the hospital are going to see depressed skull fracture this would be like that guy getting hit in the head with a hammer again the the the the skull gets depressed in the area where it's the trauma has been applied and some of those bro bone fragments might have actually been driven into the brain itself basil or skull fracture that's a high energy trauma if i'm not mistaken i think this is the dale earned heart of nascar racing when he died again usually occur following diffuse impact to the head and you have cerebral spinal fluid draining from the ears you have raccoon eyes and battle signs that's a a huge huge amount of trauma applied to the skull you might have an open fracture where you actually see part of the brain again you if you see that it's probably going to be on a dead person probably traumatic brain injuries again that's probably the most severe of all your head trauma or your head injuries so you might have a primary head injury a brain injury and a secondary brain injury so again primary is the direct injury to the brain itself and the secondary is the indirect injury what do we mean by that so the secondary injuries might be caused by hypoxia hypotension cerebral edema swelling of the brain inner cranial hemorrhage bleeding within the that your cranium increased intracranial pressure so we're having excuse me we're going to talk about this later but it's pressure building up in your in your skull and that pressure has nowhere to go except out the only opening the foramen magnum and what's what's contained in there and that's your brain stem and so it really tries to push your brain stem out that opening and that's what kills people infections might be a secondary brain injury so that it can be injured directly by a penetrating object or indirectly by those external forces too the coup contra coup injury so basically like your head hits the windshield the brain keeps moving forward until it strikes the inside of the skull and then your head goes back against your head rest and then the brain follows and it goes backwards as well so it's kind of like ping-pong balling back within your skull back and forth until it comes to a stop cerebral edema that's that swelling that might take hours to develop who knows low blood oxygen levels that can aggravate that cerebral edema that swelling so one of the signs that you might want to kind of keep an eye out for a seizures out with a head injury that might indicate you have swelling in the brain and again the brain is contained within that rigid structure it has nowhere to go that pressure has nowhere to go if the brain keeps swelling and keeps swelling it's going to push that uh brain stem out and it's going to kill the person in a cranial pressure we talked about this that's what we're talking about it might be blood or some other fluid in the skull the swelling of the brain and again it's going to squeeze the brain inside that skull so there's some signs and symptoms that we can recognize as emts that indicate this this person has intracranial pressure one is that chains stokes respirations or ataxic and biops respirations if you're not familiar with those you need to go back and review those because those are super important erratic respirations you might have a decreased pulse rate they go on to say headache nausea vomiting everything in ems does decreased alertness bradycardia which is the decreased pulse rate sluggish or non-reactive pupils deceibrate posturing which is the worst kind of posturing and increased or widening blood pressure so this is the cushing's reflex or the cushing's phenomenon so you have a decreased pulse an increased blood pressure and erratic respirations and that's indicative of having intracranial pressure so your pulse goes down your blood pressure goes up and you have erratic respirations and that's all because of the pressure being put on the brain stem inner cranial hemorrhage or bleeding again we have different areas where we could have this bleeding it could be between the skull and the dura mater it could be betw beneath the dura mater but outside the brain or it could actually be the brain itself that is bleeding so epidural hematoma so this is blood between the skull and the dura mater so it if they say nearly always the result of a blow to the head so epidural hematomas always occur quickly so natasha richardson she was married to that actor uh liam nielsen and natasha richardson if i remember write the story going she was skiing in europe she hit a tree knocked her out ski patrol gets there she regains consciousness they take her back to her villa and she goes to sleep and never wakes up again so that is a quick bleed um they talk about it being characterized by um being unconscious and having a lucid period which everything is fine and then you go out and you stay out hematoma this is slow this is beneath the dura mater but outside the brain so this is going to be subdural so epidural epi means fast epi epi is fast i always think about epinephrine the drug it's fast subdural i think of slow sub is going to be maybe the geriatric patient who tripped on the rug and fell and hit his head on the coffee table but at the time it didn't create any injuries or any big injuries a week later his wife calls 911 saying he's acting strange bizarre altered mentally that's because this bleed has been accumulating slowly over a period of time if you have intracerebral bleeding that's bleeding in the brain itself that's probably going to be caused by getting shot or something like that um or that might be again in that car crash where you have that coup contra coup bouncing back and forth within the brain or within the skull subarachnoid hemorrhage that's the third one you know we have epidural we have subdural now we have sub arachnoid that's the middle layer uh that's where the cerebral spinal fluid really kind of circulates around the brain and again you might have bloody cerebral spinal fluid um and again it might be a trauma or actually like a rupture of an aneurysm or like in a stroke concussions this is another common head injury or common brain injury a blow to the head or face causes a concussion many of you out there probably had a concussion yourself and then when we think about the the signs and symptoms there's a wide variety of signs and symptoms you know out amongst you that are out there right now if i were to ask you what were your signs and symptoms from your concussion there's probably going to be a wide variety about 90 percent of patients don't lose consciousness without with a concussion now maybe you did again 90 typically don't lose consciousness uh they might be confused or have amnesia and again concussions only last for a short time it's not a permanent brain injury these are the signs and symptoms i was talking about you might have dizziness weakness you can't see clearly you might have blurred vision or double vision nausea and vomiting go with everything ringing in the ears a slurred speech or an inability to focus those might be a wide variety of types of signs and symptoms for a concussion a contusion is different than a concussion a contusion is more serious that involves the brain tissue it might be long lasting it might even be a permanent damage to your brain again may exhibit any or all of the signs of a brain injury other brain injuries such as blood clots or hemorrhages i mean that's strokes typically those are the non-traumatic brain injuries but they have the same signs and symptoms so as you're assessing a stroke you might have the speech or the inability to focus uh inability to speak clearly spinal injuries we think about motor vehicle collisions or falls from like you fell off the roof and you hurt your back might be herniation of a disc remember the discs in between each one of the vertebrae might be a rotational flexion injury the spine from rapid acceleration uh forces and again or over extending your spine when the spine is pulled along its length you have a hyper extension any of these unnatural motions and really this is why a lot of us in ems have back injuries or back pain now after being in ems for so long we love to lift properly we know how to lift properly but it doesn't always happen that way so again any kind of unnatural motion can lead to back injuries always suspect a possible head or spinal injury with a motor vehicle crash car versus pedestrian a fall blunt trauma or penetrating trauma to the head neck back or torso so if i get shot in my torso or my back it may have created a spinal injury rapid deceleration injuries hangings for spinal injuries axial loading injuries in other words you dive into the low end of the swimming pool and you hit your head on the bottom that's that loading uh with those diving injuries or you have a large weight dropped on your head so scene safety bsi all that stuff call for als look what the mechanism of injury is and you kind of think about how with that mechanism of injury what injuries or what could have happened to our patient focus on the life-threatening yet we know that again scene time less than 10 minutes is going to be the best outcome for our patient the faster we get them to the hospital the better but faster doesn't mean we compromise or make compromises in their spinal immobilization assessment the position found we determine whether or not a c collar or cervical collar needs to be applied we assess the scene for the risk of the injury and our general impression is based on their level of consciousness or their chief complaint again if they're unconscious that's their chief complaint backboards here we go this is again very controversial in ems right now but a backboard with a spinal injury is really in uh indicated so it places the patient in an anatomically incorrect position for a long period of time though this is why we're kind of when we talk about this so backboards we want to eliminate or minimize the amount of time their patients on a backboard number one number two they have sometimes difficulty breathing lying flat number three you might create pressure ulcers on your elderly patients but again if it's indicated we won't need to use a backboard but we try to uh eliminate backboarding everybody see colors that doesn't really hurt the person again we could put a c collar on them and put them on our ambulance cot and and there would be a lot more comfortable for them assessing for signs and symptoms of a head injury or spine injury ask about their chief complaint they'll tell you their back hurts they tell you their head hurts are they confused or they have slurred speech do they ask you all over and over and over again what happened you'll see that in somebody with a head injury you'll be transporting them to the hospital say what happened and you say well you were in a car crash seriously a couple minutes later can you tell me what happened yes you were in a car crash a minute goes by what happened to me you had a car crash those repetitive questions get really irritating but they can't help that they have a head injury they might have amnesia in responsive patients who are good indicators of head injury again those are good indicators in the setting of trauma assume your patient has a head injury until you can rule it out look for signs and symptoms unresponsive trauma patient we just suspect that they have a spinal injury and we're going to backboard we're not going to take that chance if they have a decreased level of responsiveness you should consider spinal mobilization really on their chief complaint if they say their back hurts then we really need to be considerate of that abcs use a jaw thrust versus the head tilt chin lift if that's ineffective using the jaw thrust do the head tilt chin lift as your last resort because that does move your cervical spine vomiting might occur in a patient with a head injury so again if they're on a backboard and they're vomiting we either have number one have to suction or we have to tilt the backboard and again irregular breathing that chain stokes respirations might be a result of intracranial pressure always always always give them oxygen pulse oximeter values should be maintained above 90 they talk about hyperventilation for specific conditions and i always like to say it's mild or controlled hyperventilation it's not hyperventilating bagging as fast as you can it's mild or controlled hyperventilation with head injuries if your pulse is starting to slow that might be an indication of that inner cranial pressure remember slow pulse high blood pressure erratic respirations that's cushing's a single episode of hypoperfusion in a head injury could lead to significant brain damage or death assess for signs and symptoms of shock control any bleeding how do you transport okay uh again need to be rapidly extracted from motor vehicles and transport make sure that they have oxygen make sure you have suction ready because that nausea and vomiting could be there and always maintaining mobilization of the spine when you're transporting those suspected head and back injuries do your opqrst get a sample history we're going to try to do that on anybody who's conscious instruct your patient to keep still and not move their head or neck tell them don't turn your head to look at me don't excuse me nod your head up and down for yes or side to side for no hold it still then you do your head to toe full body skin and you'll focus on certain areas or regions of the body like the back make sure even if you haven't backboarded you can put your gloved hand under their back and and pull your gloved hand out to see if there's any bleeding vital signs again pulse to be slow blood pressure rise we have cushions blood pressure may drop and the heart rate may increase with neurogenic shock our respirations become erratic and we might need to bag them again o2 saturation above 90 percent is where we want to keep them use decaf excuse me decaf btls check for pure perfusion motor function sensory that's what we talked about in all extremities decreased level of consciousness they get sleepy they keep going in and out of consciousness that by might be a head injury look for leaking blood or cerebral spinal fluid out of the ears the nose that's what we're looking look at the pupils see how they respond to light are they one big and one small who knows i don't even know why they had to put this in here do not probe open scouts scalp lacerations with your glove finger because you might be touching the brain your neurologic exam might be that glasgow coma scale that we have to assess there's also something called the revised trauma score um and your glasgow coma scale might be used to determine that revised trauma score and i've never seen a hospital yet use the revised trauma score now a level one trauma center may use that and again this records the levels of consciousness that fluctuate or deteriorate so your glasgow coma scale numbers are going to be indicative of possibly deterioration of your patient this is the glasgow if you open your eyes spontaneously if you have an oriented conversation and you obey commands you have a glasgow coma score of 15. if you don't open your eyes you don't speak and you have no motor response that's a three so in these yeah a scale a score of 13 to 15 is mild if you're 15 you're great 9 to 12 you're kind of moderately dysfunctional or just have moderate dysfunction and then a score of less than eight is severe dysfunction so the numbers are really for me as a paramedic i remember three is pretty much dead or a rock 15 is great but if we did a glasgow coma scale calculation and we came up with a score of less than eight that's when paramedics intubate so less than eight intubate then we need to secure that airway because they have severe dysfunction inspect for decaf btls and check sensory motor sent circulation mode or sensory problems in the extremities if you find an impairment you kind of note to the level that you have that impairment because that might indicate at what level they have spinal dysfunction pain or tenderness is a warning sign numbness weakness tingling again those might be signs and symptoms of a spinal injury repeat your primary assessment repeat your vital signs and again reassess every five minutes in your unstable patient interventions now this is where we get into what we can do for this person so you're going to just really try to find those signs and symptoms that indicate that they have brain swelling or a bleed you note any cerebral spinal fluid if it's present uh give them oxygen have a c collar communication documentation that's what you're going to tell the doc this is how you found the scene when you got there anything you found during your assessment any treatments you did and how your patient responded to them or didn't respond to them there's three general principles uh in emergency care of head injuries number one airways number one number two control bleeding and number three their baseline level of consciousness so airway bleeding and consciousness are our care for head injuries maintain an airway use a jaw thrust if the jaw thrust doesn't work last resort you can do the head tilt chin lift because again it does move their cervical spine keep them in a neutral inline position until you get a c collar on them and you've secured that patient to a backboard just putting a c collar on does not restrict their the motion of their head it's only when they are secured to a backboard does that see color really keep them in that neutral inline position when your hands go on your patient the next thing you should do is see collar when you manage the airway or things we're thinking about are vomitous or foreign bodies maybe uh broken teeth with a head injury check ventilation are they breathing uh getting good air movement give supplemental oxygen to head injuries begin cpr if you have to uh active blood loss aggravates hypoxia hypoxia so in other words yeah if you're losing the red blood cells then we don't have oxygen to transport that on the red blood cells you can almost always control bleeding from a scalp laceration with direct pressure as long as it's not um a lot of pressure that might push the brain in or the bone into the brain shock is usually a result of hypovolemia so if you see signs and symptoms of shock think of hypovolemia again the ultimate treatment is going to be surgery for these patients cushing's triad i've said this i don't know how many times in this lecture but we think about increased blood pressure decreased pulse and irregular respirations that is cushing's triad it's a triangle those three things yeah intertwined to make this cushions you manage to shock you administer oxygen and if necessary you would start to ventilate using a bbm and it says avoiding hyper ventilation so controlled or mild hyperventilation at a rate of 20 breaths per minute is what were our goal would be manage the airway assess respirations with spinal injuries give supplemental oxygen manage your airway just like we did with the head injuries everything's the same jaw thrust over the head tilt chin lift that's how to do the jaw thrust most students don't know how to do this until you get to your your skills days and then it gives you a chance to practice these skills spinal immobilization mobilize the head and trunk so that the bone fragments don't cause further damage and never force the head into a neutral inline position if you go to move that head into a neutral inline position and you encounter resistance stop you're not going to do it you're not going to create a bigger problem then you just kind of immobilize them in that position found as best you can c collars they provide partial support and again they're not truly secured until they're in a c collar and on a backboard getting a properly fitted c collar is difficult if you use these c collars which most people do they usually make them too tall and you hyper extend the neck be careful and actually put the c collar on properly once the head and neck have been stabilized check cms then assess the cervical spine and neck and then again you maintain support of that head and neck until the patient is fully secured to the backboard or if you use something called a vacuum mattress that actually kind of forms around your patient when you remove the air and these beanbag beads in this mattress kind of form around the body supine patients backboard or vacuum mattress which is uh the vacuum mattress is a lot more comfortable over that long backboard and again this part of your skills are going to be how to put a patient onto a backboard these vacuum mattresses you don't see them a lot but they are a great alternative to backboards especially for your elderly again we're thinking about those pressure ulcers where the skin is in contact with the backboard and it creates a sword or they have an abnormal curvature of their spine it really forms around your patient versus trying to make your patient conform to a flat board if they're sitting in a car collision let's say and they have back injuries we use something called a ked or it's a short backboard and then once we have them on that short backboard or ked once we get them out of the car we transition them to a long board this these are not used if the person has an altered mental status they have problems with their abc's or any other reason that an urgent move and an urgent move would be more preferred over those standing patients again you might need to take spinal immobilization if they're standing so you get to a car crash and the person's walking around at the scene of the motor vehicle accident and during your assessment they say you know what my back does hurt you gotta say stop and now we need to take spinal immobilization precautions on a standing patient again assume they have a spinal injury if they've had a head injury and then again maintain manual inline stabilization or c collar in a backboard here's the ked this is a vest type device it's designed to mobilize non-critical patients in a seating position it's it's very cumbersome there's a lot of moving parts to this and it's not a quick thing so when you get to your skills days you will practice this you'll also practice how to put a patient onto a long backboard um the one on the far left the yellow board is called a scoop stretcher and then as you can see there's an opening in the back so it doesn't have your your spinal column resting on that hard plastic helmets we're going to remove a helmet or leave it in place depending on our findings if they don't have any impending airway or breathing problems we can leave it if it fits well doesn't interfere with the treatment of airway or ventilation and you can properly immobilize the spine you can still leave it in place um the thing i think about is more so like a football player motorcycle remove the helmet if it's a full face so the motorcycle riders that have a full face helmet that's going to interfere with our ability to deliver oxygen or manage their airway if it's a problem if it allows for excessive head movement maybe it's a child wearing dad's helmet and again if they're in cardiac arrest it doesn't matter get the helmet off the preferred method of removing a helmet is a two-person job really uh it's it's not an easy thing and you have to it's not a quick thing either so the alternative method um is you'll to the helmet to be allowed within application of less force thereby reducing likelihood of motion again the disadvantage is it's slightly more time consuming so you remove the chin strap you remove the face mask that's like the football player pop out the jaw pads you put your fingers inside the helmet you hold the jaw with one hand and the up occiput the back of the head with the other and then again you you remove that helmet and when they remove the helmet they kind of pull out on the sides of the helmet when they pull out remember children may require additional padding to maintain an inline stabilization or you might need to pad a child or infant's shoulders that kind of helps keep their their cervical spine in line so review the brain a part of the central nervous system is divided into cerebrum cerebellum brain stem cerebrum brain stem spinal cord cerebellum cerebrum spinal cord or spinal cord cerebrum and cerebral cortex so your brain is divided into what parts yep number one a the three parts of the brain cerebrum the largest part the cerebellum the smaller part and the brain stem itself the spinal cord is not part of the brain as you're assessing a 24-0 man with a large laceration to the top of his head you recall that the scalp like unlike other parts of the body has relatively fewer blood vessels blood loss from a scalp laceration may contribute to hypovolemic shock in adults any evolved portions of the scalp should be carefully cut away to facilitate bandaging and most scalp lacerations are superficial and are rarely associated with more serious injuries i really hope you didn't pick c yep b although it's highly vascular and tends to bleed heavily when injured it's rarely the sole cause of hypovolemic shock however it can contribute to hypovolemic shock a patient who experiences an immediate loss of consciousness followed by a lucid interval has an epidural hematoma subdural hematoma concussion or contusion immediate loss of consciousness followed by the lucid interval epidural that's the quick one that's the you hit the tree skiing you're unconscious you come to and you have this lucid interval where everything's fine then you go lay down and you die 44 year old man struck the back of his head and was reportedly unconscious for about 30 seconds he complains of severe headache and seeing stars he states that he regained his memory shortly before he arrived his presentation is most consistent with a contusion concussion subdural hematoma or intracerebral hemorrhage so he was unconscious for a few seconds see stars because he got hit to the back of his head what would that most consistent be yeah a concussion again some of you have experienced concussions and there's a wide variety of signs and symptoms a young male was involved in a motor vehicle accident experienced a closed head injury he has no memory of the events leading up to the accident but he remembers that he was going to a birthday party what is the correct term used when documenting his memory loss this is a test question that you will see again and again and again is it a concussion cerebral contusion retrograde amnesia or anti enterograde amnesia if i said pronounce that right retro or grade which one is it your reading would tell you that yep it is c um again anterior amnesia is called post amnesia so it's the inability to remember events that occurred or will occur after the injury retrograde is the correct answer so he doesn't remember leading up but he remembers that he was going to a birthday party that's the important part a distraction injury to the cervical spine would most likely occur following diving blunt neck trauma hyperextension of the neck excuse me or a hanging type mechanism a distraction injury to the cervical spine yep the d the hanging cause a distraction injury distraction be a separation of the vertebrae the stretching or tearing of the cervical spine seven during immobilization of patient with a possible spinal injury manual stabilization of the head must be maintained until you have a c cholera on they've been immobilized to a long backboard range of motion test has been completed or pulse motor sensory functions are found to be intact which one yep until they're fully immobilized to a backboard you have to maintain the the c-spine or the the c-spine precautions in a manual stabilization the inline of the head you can't just put a c collar on somebody thinking that's going to work it has to be bad mobilized fully to the backboard during immobilization of a patient with responsible possible spinal injury manual stabilization of the head must be maintained until again they're fully immobilized to a backboard somebody's going to be holding on to that head after you put a c collar on and until the head which is the last part to be immobilized in a backboard you have to hold on to that head until they're fully immobilized so your patient is a 21 year old male with a massive face and head trauma after being assaulted he's supine semi-conscious and has blood in his mouth what do we do insert a nasal airway assess his respirations give him oxygen suction his airway give him oxygen manually stabilize his head log roll him onto his side and suction his mouth or lastly apply a cervical collar suction his airway and begin assisting his ventilations so what are you gonna do good we're gonna do the the treat the airway first because he's got blood in his airboy so we're gonna manually stabilize his head log roll him onto his side and that kind of helps that blood drain out of his mouth and then we can suction if needed we don't put nasal airways into patients with severe head trauma and again b we can give them oxygen and suction but we need to stabilize his spine and get that airway cleared out and again we're not good putting a c collar on takes time so what we're going to do initially is just log roll him up [Music] a man is found slumped over the steering wheel unconscious making snoring sounds after an automobile accident his head is turned to the side and his neck is flexed you should rotate his head to correct the deformity carefully hyper extend his neck to open his airway apply as extrication collar with his head in the position found or manually stabilize his head and move it to a neutral inline position which one do we do yep the last one so stabilize his head move it to a neutral inline position and assess his breathing snoring respirations indicate that an obstruction most likely his tongue um and do not rotate or hyper extend his neck the last review question you should not remove an injured football player's helmet if you should not if a cervical spine injury suspected even if the helmet fits loosely patient has a pain airway even if he is breathing has breathing difficulty if he has broken teeth but only if the helmet does not snug does not fit snugly in place this is very confusing and the face guard can be easily removed and there's no airway compromise you should not remove their helmet if which one yep it's the last one you should leave it on if it fits snugly and does not allow for movement of the head within the helmet if there's no airway problem and he's breathing without difficulty if you can remove the face guard and there's no airway problems leave the helmet on uh the top one is if the head if the helmet fits loosely nope we got to remove it if they have breathing problems we got to remove it the broken teeth part on that is there's a possibility of an airway obstruction so we need to again manage his airway difficult question the last one so that was head and spine injuries