hello and welcome to chapter 29 head and spine injuries of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand how to manage trauma-related issues of the head and spine you will learn how to recognize life threats associated with these injuries as well as the need for immediate spinal stabilization and potentially airway and breathing support the curriculum includes details anatomy and physiology of the nervous system and the pathophysiology assessment and management of traumatic brain and spinal cord injuries this chapter provides details about traumatic brain injury including initial mechanism of injury and primary versus secondary injury transport considerations are discussed with a focus on potential deterioration this chapter is skills intensive with detail on bandaging traumatic airway control in line stabilization placement of a cervical collar immobilization of a lying patient sitting or standing and helmet removal okay so let's get into it the nervous system is a complex network of nerve cells that enables all parts of the body to function the nervous system includes the brain spinal cord nerve fibers and nerves the nervous system is well protected the brain is protected by the skull the spinal cord is protected by the bony spinal canal and despite its this protection though serious injuries can damage the nervous system so first let's talk about the anatomy and physiology the nervous system is divided into two on atomic parts okay so you have the central nervous system and then the peripheral nervous system the figure on this slide shows the two components of the nervous system the central and the peripheral so let's talk about the central nervous system first it includes the brain and spinal cord the brain controls the body and is the center of consciousness the brain is divided into three major areas the cerebrum cerebellum and brainstem the figure shows the parts of the brain the cerebrum co controls a wide variety of activities including most voluntary motor function and conscious thought contains about 75 of the brain's total volume it's divided into two hemispheres and four lobes the cerebellum coordinates violence and body movements the brain stem controls most functions necessary for life including cardiac and respiratory systems and nerve function transmissions it's the best protected part of the central nervous system the spinal cord is mostly made up of fibers that extend from the brain's nerve cells carries messages between the brain and the body via the gray and white matter of the spinal cord and then you have protective coverings the brain and spinal cord are covered with thick bony structures the central nervous system is further protected by the meninges which are three distinct layers of tissues that suspend the brain and the spinal cord within the skull and the spinal canal outer layer the dura mater is a tough fibrous layer that forms a sac to contain the central nervous system the inner two layers are called the arachnoid mater and the pia mater and they contain the blood vessels that nourish the brain and spinal cord the figure on this slide shows the layers of the protective covering surrounding the brain cerebral spinal fluid or csf is produced in a chamber inside the brain this is called the third ventricle csf primarily acts as a shock absorber when an injury does penetrate in all the protective layers clear watery csf may leak from the nose ears or an open skull fracture so let's talk about the peripheral nervous system now you have 31 pairs of spinal nerves they conduct impulses from the skin and other organs to the spinal cord and they conduct motor impulses from the spinal cord to the muscles the figure shows the major muscles or major nerves of the peripheral nervous system you also have 12 pairs of cranial nerves they transport information directly to or from the brain they perform special functions in the head and face including sight smell taste hearing and facial expressions there are two major types of peripheral nerves first you have the sensory nerves and they carry only one type of information and that's from the body to the brain via the spinal cord then you have motor nerves and motor nerves carry information from the central nervous system to the muscles the connecting nerves are found only in the brain and spinal cord and they connect the sensory and motor nerves with short fibers this allows the exchange of simple messages how the nervous system works the nervous system controls virtually all of the body functions including reflex activities voluntary activities and involuntary activities the connecting nerve in the spinal cord form a reflex arch a sensory nerve in this arch detects an irritating stimulus it bypasses the brain and sends the message directly to the motor nerve causing a response this figure shows that reflex arch okay so then we have the somatic or voluntary nervous system and it handles voluntary activities the autonomic which is the involuntary nervous system handles the body's functions that occur without conscious effort it's divided into two sections you have the sympathetic nervous system and the parasympathetic nervous system when confronted with threatening situations the sympathetic nervous system reacts to the stress with the fight or flight response the parasympathetic nervous system has the opposite effect on the body causing blood vessels to dilate slows heart rate and relaxes muscle sphincters the two divisions of the autonomic nervous system tend to balance each other so that the basic body functions remain stable and effective this is called homeostasis all right so let's talk about the skeletal system uh the skeletal system of course is the first is a skull and it's composed of two groups of bones the cranial and the facial bones the brain connects to the spinal cord through a large opening at the base of the skull called the form magnum four major bones make up the cranium the occipital the temporal the parental and the frontal the face is composed of 14 bones you have the maxilla the zagma the mandible nasal and frontal bones in the spinal cord that's the body's central supporting structure it has 33 vertebrae and they are divided into five sections you have the cervical thoracic lumbar sacral and cocksicle the figure on this shows the five sections of the spinal cord the front part of each vertebrae consists of a round solid block of bone and it's called the vertebral body the back forms the bony arch the series of arches form a tunnel called the spinal canal which encompasses and protects the spinal cord the vertebra are connected by ligaments and separated by cushions these are intervertebral discs so let's talk about head injuries a head injury is a traumatic insult to the head that may result in injury to soft tissue bony structures or the brain head injuries account for more than half of all traumatic deaths fatal injuries invariably involve the brain be alert to the fact that the patient may have sustained additional trauma there are generally two types of head injuries and there's the closed head injury and the open head injury closed head injuries are those in which the brain has been injured but there is no opening into the brain an open head injury is one in which the opening from the brain to the outside world exists often caused by penetrating trauma brain tissue may be exposed all right so let's talk about falls and motor vehicle crashes and those are the most common mechanism of injury common mechanisms of injury include assaults and sports related incidents the table on the slide shows the general signs and symptoms of a head injury okay so let's talk about scalp lacerations and they can be minor or serious even small lacerations can quickly lead to significant blood loss especially in children in patients with multiple injuries bleeding from the scalp or facial aspirations may contribute to hypovolemia and then their skull fractures so a significant force applied to the head may cause a skull fracture it may be open or closed depending on whether there is underlying laceration of the scalp injuries or bullets or other penetrating weapons frequently result in fracture of the skull so let's talk about the signs and symptoms of the skull fracture and the patient's head could be appeared deformed you could see a visible crack in the skull you could see echomosis that develops under the eyes and these are called raccoon eyes or you could see echomosis that developed behind one ear or over the mastoid process and this is a battle sign and these figures show echomosis under the eyes and then behind the ear these are both signs of a skull fracture linear skull fractures they account for about 80 of all fractures to the skull radiographs or x-rays are required to diagnose a linear skull fracture because there are often no physical signs of such deformity then there are depressed skull fractures and they result in a high energy direct trauma to the head with a blunt object the frontal and parabola bones of the skull are the most susceptible and bony fragments may be driven into the brain resulting in an injury patients often present with signs of a neurologic injury such as loss of consciousness then you have the basilar skull fractures and those are associated with high energy trauma but usually occur following diffuse impact to the head these injuries generally result from extension of a linear fracture to the base of the skull and are usually diagnosed with the ct of the head signs of a basilar skull fracture include central cerebral spinal fluid draining from the ears raccoon eyes or battle signs and then you have open skull fractures and these are often associated with trauma to multiple body systems brain tissue may be exposed to the environment which significantly increases the risk of a bacterial infection and they have a very high mortality rate next we're going to talk about traumatic brain injuries and these are defined by the national head injury foundation as a traumatic insult to the brain capable of producing physical intellectual emotional social and vocational changes they're classified by two broad categories primary injury which is the direct injury or the secondary is an indirect injury primary injuries result um from the impact to the brain and then secondary injuries increase the severity of the primary injury so the secondary injury increases the severity and it could be caused by cerebral edema intracranial hemorrhage increased intracranial pressure or cerebral ischemia or infection hypoxia and hypotension are the most common causes of the secondary brain injury and will increase death and disability significantly in patients with a head injury secondary injuries may occur anywhere from a few minutes to several days following the initial head injury it can result from blunt or penetrating trauma coup contra coup injury the initial impact injuries the front part of the brain the head falling back against the head rest then injures the rear part of the brain so that's a coup contra coup injury cerebral edema may not develop until several hours following the initial injury low blood oxygen levels aggravate cerebral edema and monitor the patient for any seizure activity with any head injury what we're worried about is of course the injury but also the intracranial pressure and it accumulations of blood within the skull or swelling of the brain can rapidly lead to an increase icp which is intracranial pressure increase endocrine pressure increased icp squeezes the brain against the bony prominences within the cranium signs of increased icp include abnormal respiratory patterns such as a toxic and chain stokes breathing pattern okay decrease pulse rate headache nausea vomiting decrease alertness bradycardia sluggish or non-reactive pupils to cerebral posturing and increased or widened blood pressures there's also a thing called cushing's reflex and this is the symptom it's a triad of increased systolic blood pressure decreased pulse rate and irregular respirations intracranial hemorrhage so that's bleeding inside the skull that usually increases the in icp bleeding can occur between the skull and the dura mater beneath the dura mater but outside the brain or within the tissues of the brain itself so now let's talk about bleeding in the brain okay so an epidural hematoma that's accumulation of the blood between the skull and the dura mater nearly always the result of a blow to the head that produces a linear fracture of a thin of the thin temporal bone the middle artery running along a groove in the temporal bone so the arterial bleeding into the epidural space will result in rapidly progressing symptoms often the patient loses consciousness immediately following the injury this is often followed by a brief period of consciousness and it's called the lucid interval after which the patient lapses back into unconsciousness the pupil on the side of the hematoma becomes fixed and dilated and death will follow very rapidly without surgery to evacuate the hematoma now we're going to talk about the subdural hematomas and this is an accumulation of blood beneath the dura mata but outside the brain usually occurs after falls or injuries involving strong deceleration forces more common than epidural hematomas and may or may not be associated with a skull fracture it's associated with a venous bleed so the signs typically develop more gradually than with the epidural hematoma okay the patient often experiences a fluctuating level of consciousness or surge speech any patient with a suspected subdural hematoma needs to be evaluated by a physician and then you have an intracerebral hematoma and this involves bleeding within the brain itself it can occur following a penetrating injury to the head or because of a rapid deceleration forces many small deep intracerebral hemorrhages are associated with other brain injuries the progression of increased icp depends on the presence of other brain injuries the region of the brain and which is involved in the size of the hemorrhage intracerebral hematomas have a high mortality rate even if the hematoma is surgically evacuated and then you have subarachnoid hemorrhages and this is bleeding and it often occurs in the subarachnoid space where the cerebral spinal fluid circulates results in bloody csf and signs of a meningeal irritation such as neck rigidity or headache common causes include trauma or rupture of an aneurysm patients report a sudden severe headache as bleeding increases the patient will experience signs and symptoms of an increased icp a sudden severe subarachnoid hematoma usually results in death survivors often have permanent neurologic impairment then you can have concussions and that's a blow to the head or face and it may cause a concussion to the brain classified by mild traumatic brain injury it is a closed injury with a temporary loss of or alteration of the part of the brain's ability to function without demonstratable physical damage to the brain approximately 90 percent of patients who sustained a concussion do not experience any loss of consciousness a patient with a concussion may be confused or have amnesia um there are two different types there's retrograde amnesia and that's the ability to remember everything but the events leading up to the injury and then there's anterior grade amnesia and that's the ability to remember the events of the injury usually a concussion lasts only a short time so ask about symptoms of a concussion such as dizziness weakness visual changes or changes in the mood in any patient who has sustained an injury to the head additional signs and symptoms include nausea vomiting ringing in the ear slurred speech and the ability to focus assume that a patient with signs or symptoms of a concussion has a more serious injury until proven otherwise by a ct scan at the hospital or evaluation by the physician and then there's a contusion so contusion is bruising of the bone tissue which is results from the blunt trauma a contusion is far more serious than a concussion it involves physical injury to the brain tissue and may produce long-lasting and even permanent damage patients who have sustained a brain contusion may exhibit all of the signs of a brain injury and then there's other brain injuries so brain injuries can also arise from medical conditions such as blood clots or hemorrhages problems with blood vessels high blood pressure and or other problems may cause spontaneous bleeding in the brain the signs and symptoms of a non-traumatic injury are often the same as those of a traumatic brain injury okay so let's move on to the spine injuries the cervical thoracic and lumbar portions of the spine can be injured in a variety of ways you can have compression injuries and that can result from a fall regardless of whether the patient landed on his or her feet or experience a direct blow to the crown of the skull coccyx or top of the head forces that compress the spine vertebrae body can cause herniation of the disc subsequently compression on the spinal cord and nerve roots and fragmentation into the spinal canal motor vehicle crashes or other types of trauma can over extend or hyperflex the cervical spine and damage the ligaments and joints rotation flexion injuries of the spine result from rapid acceleration forces any unnatural motion can result in a fracture or a neurological deficit when the spine is pulled along its length so that's hyper extension it can cause fractures in the spine as well as ligament and muscle injuries when the bone of the spine are altered from traumatic forces they can fracture or move out of place permanent damage may occur common findings include pain and tenderness on palpation if you suspect these types of injuries take extra precautions when stabilizing the spine all right so let's get into the patient assessment portion of this chapter and always we're gonna um suspect a spinal um possible head or spinal cord injury anytime you encounter any of the following mechanisms of injury okay so when we have a motor vehicle collision and especially those involving motorcycles snowmobiles and all-terrain vehicles also pedestrian or motor vehicle collision where falls greater than 20 feet or less than 10 feet for pediatric blunt trauma penetrating trauma to the head back torso rapid deceleration injuries hangings axial loading injuries or diving accidents okay so scene size up make sure you have the scene safe evaluate every scene for hazards to your health and the health of your team or bystanders be prepared with appropriate standard precautions before you approach the patient in a motor vehicle crash and call for advanced life support to there as soon as possible so you have your mechanisms of injuries or nature of illness usually we're going to looking for the mechanism of injury so consider how the mechanism of injury produce the injuries expected then you're going to do your primary assessment you want to focus on identifying and managing life threatening concerns the threats to circulation airway breathing are considered life-threatening and must be treated immediately reduction of on scene time and recognition of critical patients increase the patient's chances for survival or a reduction in the amount of irreversible damage next we're going to talk about spinal immobilization concerns so you need to be aware that any unnecessary movement of the patient can cause additional injuries begin by assessing the scene to determine the risk of injury then form a general impression of your patient based on his or her level of consciousness and chief complaint if the patient is absolutely clear in his or her thinking and does not have any neurological deficits spinal pain or tenderness evidence of intoxication or other illness or injuries that may mask a spinal injury you may consider not placing the patient in spinal restriction the backboard not so rigid and often places the patient in an autonomous atomically incorrect position for a long period of time circulation to the areas of the skin may be compromised and some patients could experience respiratory compromise because they're laying flat and their stomach is pushing on their diaphragm so try to minimize the amount of time a patient is on a backboard you want to apply a cervical collar as soon as you have assessed the airway and breathing and provided necessary treatments once the cervical collar is on do not move it unless it causes a problem with maintaining the airway or the patient so some sign of increasing icp if the device needs to be removed maintain manual stabilization of the cervical spine until it can be replaced so assessing for signs and symptoms of a head injury begin by asking the responsive patient the following questions ask them what happens where does it hurt does your neck or back hurt can you move your hands and feet did you hit your head confused or slurred speech repetitive questionings or amnesia in responsive patients are good indications of a head injury in the setting of trauma resume or assume your patient has a head injury until your assessment proves otherwise the decreased blood glucose levels may mimic these symptoms however patients with a decreased level of responsiveness should be considered to have a spinal cord injury based on their chief complaint all right so then the a b and c if the spinal injury is suspected you need to open the and assess the airway it's very important manually holding the patient's head still while you will assess the airway use the jaw thrust maneuver to open the airway if the jaw thrust maneuver is ineffective it is acceptable to use the chin the hell tilt chin lift maneuver as the last result vomiting may occur in a patient with a head injury irregular breathing such as shine stokes respirations may result from that increased icp you want to administer high flow oxygen and it's indicated for patients with a head and spinal injuries pulse ox values should not fall below 90 and ideally should be 95 or higher hyperventilation which is ventilating too fast or with too much force use only when capnography is available to ensure an end tidal co2 between 30 to 35. pulse that is too slow in the setting of a hinge injury can indicate a serious condition in your patient a single episode of hypoperfusion in a patient with a head injury can lead to a significant brain damage and even death so assess for signs and symptoms of shock and treat appropriately also control bleeding so the manner of transport is important with these trauma patients several transport considerations should be kept in the mind for patients with a head trauma patients with impaired airways open head wounds or normal vital signs or patients who do not respond to painful stimuli may need to be rapidly extricated from the motor vehicle and transported ensuring a patient's airway and providing high flow oxygen is paramount there is probably probability of vomiting and seizures so suction should be readily available a head trauma patient may deteriorate rapidly and require air medical transport in supine patients the head should be elevated 30 degrees if possible to help with icp remember to maintain immobilization of the spine investigate the chief complaint for your history taking so obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives if the patient is not responsive obtain attempt to obtain a history from other sources such as friends family members medical identification jewelry and cards and wallets make every attempt to obtain sample history for your patient and then there's the secondary assessment the ability to walk move extremities or feel sensations as well as the absence of pain does not necessarily rule out a spinal cord injury instruct the patient to keep still and not to move the head or neck when you do your physical exam you may you want it to be systematic from head to toe full body scan or systematic assessment to focus on a certain area or region of body so if time perform a secondary assessment while you're in route and then obtain a complete set of vitals vital signs are essential in addition to hands-on assessment you should be using monitoring vices to qualify uh quantify your patient's oxygen and circulatory status you want to maintain end tidal between 30 and 40 35 and 40 and an spo2 above 94. when you do your physical exam the considerations you want to use that decap btls exam to examine the head chest abdomen extremities and back check perfusion motor function and sensation and all extremities prior to moving the patient a decreased level of consciousness is the most reliable sign of head injury determine whether there is decreased movement or numbness and tingling in the extremities also look for blood or cerebral spinal fluid leaking from the ears mouth or nose or for bruising around the eyes or behind the ears assess pupil size and reaction to light and continue to monitor the pupils do not probe open scalp lacerations with your glove finger because this may push bone fragments into the brain and do not remove an impaled object from an open head injury next is your neurologic examination perform on a baseline assessment using the glass glaucoma score if your jurisdiction uses the revised trauma score then find findings from the glass calculator will be made using the revised trauma score record levels of consciousness that fluctuate or deteriorate the table on this slide shows the categories of the glass glaucoma score all right and then we're going to do the spine exam so inspect for decap btls and check for the extremities for circulations if there is impairment note the level pain or tenderness when you palpate is a warning sign that the spine injury may exist other signs and symptoms include an obvious deformity numbness weakness or tingling of the extremities and soft tissue emergencies in the spinal region obvious injuries to the head or neck may indicate injury to the cervical spine and then the reassessment so repeat the primary assessment reassess signs and symptoms in the chief complaint and recheck the patient's interventions the patient's condition should be reassessed at least every five minutes all right and then the interventions so compare baseline vital signs with repeated vital signs rapid deterioration of neurologic signs following a head injury is a sign of an expanding intracranial hematoma or rapidly progressing brain swelling if csf is present cover the wound with a sterile gauze to prevent further contamination but do not bandage it tightly your protocol should include and administration of high flow 2 and the application of a cervical collar if indicated as part of a spinal immobilization reassessment should take place as the patient is transported to an appropriate trauma facility next we're going to talk about the communication and documentation so provide complete and detailed information to that destination facility hospitals may be better prepared for seriously injured patients with a more advanced warning and a description of the most serious problems found during your assessment more seriously injured patients should be documented and you should document their vital signs every five minutes more stable patients you can document them every 15 minutes you may be requested to testify as a witness so be sure to properly document so let's talk about emergency care for these head injuries there are three general principles and they are designed to protect and maintain the critical functions of this central nervous system you need to establish an adequate airway control bleeding and provide adequate circulation to maintain cerebral perfusion you want to assess the patient's baseline level of consciousness and continuously monitor that so when it comes to mandatory manage managing the airway the most important step is establishing and maintaining that adequate airway once the airway is open maintain the head and cervical spine in a neutral inline position until you have placed a cervical collar and have secured the patient on the backboard figure shows how to stabilize and maintain the head and cervical spine in a neutral inline position and apply a cervical collar remove any foreign body secretions or vomit from the airway and once you have cleared the airway check ventilation give supplemental oxygen to any patient with a suspected head injury particularly anyone who is having trouble breathing use a bvm to assist ventilations if the patient is breathing too slow or too shallow and placement of the airway device may be necessary to maintain airway patency consider calling for als if the patient's airway is compromised and then you have the c so you must begin cpr if the patient is in cardiac arrest active blood loss um can aggrava aggravate have hypoxia bleeding inside the skull may cause increased icp to rise to life-threatening levels you can almost always control bleeding from the scalp laceration by applying a direct pressure over the wound if you suspect a skull fracture do not apply excessive pressure to that wound if the dressing becomes soaked do not remove it just place the second dressing over the first and then there's shock so usually it's a result of hypovolemia caused by bleeding from other injuries transported immediately to the trauma center all right so let's talk about cushing's triad remember that's from increased intracranial pressure and basically it's increased blood pressure and that's hypertension decreased heart rate bradycardia and increa irregular respirations okay so if this process is allowed to continue it is fatal manage shock administer oxygen and ventilate as necessary but avoid hyperventilation so we just talked about managing head injuries now let's talk about managing spinal injuries remember to follow your standard precautions maintain the patient's airway while keeping the spine in the proper position you want to assess respirations and give supplemental oxygen if needed manually manage the airway so you want to do that jaw thrust maneuver to open the airway consider inserting an op have a suction unit available and provide supplemental oxygen if needed and so of course the figure on this slide shows how to perform that jaw thrust maneuver when it comes to spinal mobilization restriction with the cervical spine or of the cervical spine you want to mobilize the head and trunk so that the bone fragments do not cause further damage even small movements can cause significant injury to that spinal cord you want to follow the steps in skill drill 29-1 never force the head into a neutral position do not move the head any further if the patient reports any of the following symptoms the patient has muscle spasms increased pain numbness tingling or weakness in the arms or legs compromised airway or ventilations and these situations stabilize the patient in his or her current position then there's cervical collars so provide prime preliminary partial support that's what they provide it should be applied to every patient who has a possible spinal injury based on the mechanism of injury history or signs and symptoms and to be affected a rigid cervical collar must be the correct size for that patient follow the skills drills 29-2 and once the patient's head and neck have been manually stabilized assess the pulse motor functions and sensations in all extremities then assess the spinal cord area and neck maintain manual support until the patient has been fully secured to the backboard or vacuum mattress okay and then preparation for transport so with supine patients we're going to secure the patient to the long backboard other procedures to move the patient from the ground to the backboard is a fur four person log roll you may also slide the patient onto the backboard or bathroom vacuum mattress to secure patient to the backboard follow the steps in skill drill 29-3 the vacuum mattress so an alternative to that long backboard it molds to the specific contours of the body's reducing pressure point tenderness and therefore providing better comfort it also provides thermal insulation it's excellent for the elderly or a patient with an abnormal curvature of the spine the drawback is of this device is its thickness requiring careful patient movement to maintain that c-spine it can't be used for patients who weigh more than 350 pounds and it can be used on the spine sitting or standing patient so patients can be moved onto the vacuum mattress with a scoop stretcher or a log roll follow the steps in skill drill 29-4 sitting patients use a short board or other spine spinal extrication device to restrict movement of that cervical and thoracic spine then secure the short backboard to the long backboard expectations to this rule include situations in which you have a patient who is in danger and you need to gain immediate access to other patients or the patient's injuries justify our urgent removal in all of their cases follow the steps and skill to 29-5 all right so then standing patience a patient who's already standing and walking should be able to sit down gently and be transferred to the position in which the spine motion restriction can be maintained it's a mechanism and injury and clinical indications suggest spinal injury or the patient's ability to protect his or her spine establish spinal motion restriction clinical indications may include spinal tenderness or pain and alter altered level of consciousness neurologic deficits obvious anatomic deformity to the spine or high energy trauma in a patient who's intoxicated from drugs alcohol or distracting injury so during your assessment pain in the spine may be missed because of shock or because the patient's attention is directed to more painful areas because any manipulation of the unstable cervical spine may cause permanent damage to the spinal cord you must assume the presence of a spinal injury and all patients who have sustained a head injury use manual inline stabilization or cervical collar and long backboard this shows a short backboard and it's the most common short bag there backboard they are vest types and they have rigid short boards as well it's designed to mobilize and restrict movement of the head neck and torso and it's used to immobilize non-critical patients who are found in a seated position and have possible spinal injuries then you have the long backboards this is to provide full body stabilization and motion restriction to the head neck torso or pelvis or extremities it's used to immobilize patients who are found in any position sometimes in conjunction with short boards all right let's talk about helmet removal next so a helmet that fits well prevents that patient's head from moving and should be left on providing there's no impending airway or breathing problems and it does not interfere with assessment and treatment of airway and ventilation problems you can properly immobilize the spine you need to remove that helmet though if it's a full face helmet if it makes assessing or managing airway problems difficult and removal of the face guard to improve airway access is not possible or if it prevents you from properly immobilizing the spine also if it allows excessive head movement or patient in cardiac arrest you need to remove it so the preferred method when you're removing a helmet should always be at least two people technique for removal depends on the actual helmet to be worn you and your partner should not move at the same time you should first consult the medical control about your decision to remove that helmet follow the steps and still skill drill 29-6 so an alternate method the disadvantage of this method is to allow the helmet to be removed with the application of less force thereby reducing the likelihood of motion occurring in the neck the disadvantage is that it is slightly more time consuming steps for the alternate method include remove the chin strap remove the face mask pop the jaw pads out of place place your finger inside the helmet during removal of the helmet the person on the side of the patient controls the head by holding the jaw with one hand and the occipit with the other insert padding behind the exhibit to prevent neck extension the person at the side of the patient's chest is responsible for making sure that the head and neck do not move during that removal remember that small children may require additional padding to maintain inline stabilization okay so that concludes the chapter 29 head and spine injuries chapter lecture and now let's see what we've learned all right so number one review question a part of the central nervous system it's divided into three things and we know that that is a the cerebrum cerebellum and that brain stem as you are assessing a 24 year old man with a large laceration to the top of the head you should recall that i think it's b blood loss from the scalp lacerations they contribute to hypovolemic shock they bleed a lot a patient who experiences an immediate loss of consciousness followed by a lucid interview now what kind of do you remember what kind of bleed that was and that was an epidural hematoma okay and that's an artery epidural artery 44 year old male who was struck in the back of the head and was reported unconscious for approximately 30 seconds he complains of a severe headache and seeing stars and states that he's regained his memory shortly after your arrival what does he present with and that is a concussion okay concussion a young male he's involved in a motor vehicle accidents experience a closed head injury he has no memories of the events leading up to the accident and that he was going to the birthday party what is the term we use for for um documenting this now leading up to the event that's retrograde retrograde amnesia the um the actual event is that anterior grade amnesia a distraction injury to the cervical spine would most likely occur following hanging type some type of hanging type mechanism during a mobilization of a patient with a possible spinal injury manual stabilization of the head must be maintained until the patient's fully immobilized on that long backboard your patient is a 21 year old male who has massive face and head trauma after being assaulted he is laying supine semi-conscious and has blood in his mouth what should we do so we know we want to suction but first we have to manually stabilize that head right okay so manually stabilize and then we're going to log roll him and then suction man is found slumped over the steering wheel unconscious and making snoring sounds after an automobile accident his head is turned to the side and his neck is flexed what should we do we need to manually stabilize and move it into the neutral inline position right okay and finally you should not remove an injured football player's helmet if if and what is it the face guard can easily be removed and there's no array compromise we're going to leave that in place okay well thank you for joining me for chapter 29 this is the head and spine injuries lecture if you like this lecture go ahead and subscribe to the channel because we're going to put together the whole book the lectures throughout the whole book okay thank you and have a good night