CHAPTER 29

Head and Spine

Injuries

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National EMS Education Standard Competencies (1 of 4)

Trauma

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Applies fundamental knowledge to provide basic emergency care and
transportation based on assessment findings for an acutely injured patient.
National EMS Education Standard Competencies (2 of 4)

Head, Facial, Neck, and Spine Trauma

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Recognition and management of
Life threats
Spine trauma
National EMS Education Standard Competencies (3 of 4)

Head, Facial, Neck, and Spine Trauma (cont’d)

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Pathophysiology, assessment, and management of
Spine trauma
Skull fractures
National EMS Education Standard Competencies (4 of 4)

Nervous System Trauma

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Pathophysiology, assessment, and management of
Traumatic brain injury
Spinal cord injury
Introduction (1 of 2)

The nervous system is a complex network of nerve cells that enables all parts
of the body to function.

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Includes:
Brain
Spinal cord
Nerves and nerve fibers
Introduction (2 of 2)

The nervous system is well protected.

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The brain is protected by the skull.
The spinal cord is protected by the spinal canal.
Despite this protection, serious injuries can damage the nervous system.
Anatomy and Physiology (1 of 2)

The nervous system is divided into two anatomic parts.

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Central nervous system
Peripheral nervous system
Anatomy and Physiology (2 of 2)

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FIGURE 29-1 The nervous system has two anatomic components:
the central nervous system and the peripheral nervous system. The
central nervous system is composed of the brain and the spinal cord.
The peripheral nervous system conducts sensory and motor impulses
from the skin and other organs to the spinal cord.
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Central Nervous System (1 of 9)

Includes the brain and spinal cord

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The brain controls the body and is the center of consciousness.
Brain is divided into three major areas:
Cerebrum
Cerebellum
Brainstem
Central Nervous System (2 of 9)

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FIGURE 29-2 The brain is part of the central nervous system and
is the organ that controls the body. It is divided into three major
areas: the cerebrum, the cerebellum, and the brainstem.
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Central Nervous System (3 of 9)

Cerebrum

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Controls a wide variety of activities, including most voluntary motor function
and conscious thought
Contains about 75% of the brain s total volume
Divided into two hemispheres with four lobes
Central Nervous System (4 of 9)

Cerebellum

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Coordinates balance and body movements
Brainstem
Controls most functions necessary for life
Best-protected part of the CNS
Central Nervous System (5 of 9)

Spinal cord

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Made up of fibers that extend from the brain’s nerve cells
Carries messages between the brain and the body via the grey and white matter of
the spinal cord
Central Nervous System (6 of 9)

Protective coverings

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The entire CNS is contained within a protective framework.
The thick, bony structures of the skull and spinal canal withstand injury very well.
The CNS is further protected by the meninges.
Central Nervous System (7 of 9)

Meninges

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Outer layer (dura mater) is a tough, fibrous layer that forms a sac to contain the CNS.
Inner two layers (arachnoid mater and pia mater) contain the blood vessels.
Central Nervous System (8 of 9)

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FIGURE 29-3 The central nervous system has several layers
of protective coverings: the skin, muscles and their fascia,
bone, and the meninges. The three layers of the meninges are
the dura mater, the arachnoid, and the pia mater.
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Central Nervous System (9 of 9)

Cerebrospinal fluid (CSF)

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Produced in a chamber inside the brain called the third ventricle
Approximately 125 to 150 mL of CSF in the brain at any time
Primarily acts as a shock absorber
Peripheral Nervous System (1 of 5)

31 pairs of spinal nerves

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Conduct impulses from the skin and other organs to the spinal cord
Conduct motor impulses from the spinal cord to the muscles
Peripheral Nervous System (2 of 5)

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FIGURE 29-4 The peripheral nervous system is a complex
network of motor and sensory nerves. The brachial plexus
controls the arms, and the lumbosacral plexus controls the legs.
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Peripheral Nervous System (3 of 5)

12 pairs of cranial nerves

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Transmit information directly to or from the brain
Perform special functions in the head and face, including sight, smell, taste,
hearing, and facial expressions
Peripheral Nervous System (4 of 5)

Two types of peripheral nerves

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Sensory nerves
Carry only one type of information from the body to the brain via the
spinal cord
Motor nerves
One for each muscle
Carry information from the CNS to the muscles
Peripheral Nervous System (5 of 5)

Connecting nerves

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Found only in the brain and spinal cord
Connect the sensory and motor nerves with short fibers
Allow the exchange of simple messages
How the Nervous System Works (1 of 5)

Controls virtually all the body s activities, including:

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Reflex activities
Voluntary activities
Involuntary activities
How the Nervous System Works (2 of 5)

Connecting nerves in the spinal cord form a reflex arc.

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If a sensory nerve in this arc detects an irritating stimulus, it bypasses the brain
and sends the message directly to a motor nerve.
How the Nervous System Works (3 of 5)

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FIGURE 29-5 The connecting nerves in the spinal cord form a reflex
arc. If a sensory nerve in this arc detects an irritating stimulus, it will
bypass the brain and send a direct message to a motor nerve.
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How the Nervous System Works (4 of 5)

Voluntary activities are activities we consciously perform.

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Involuntary activities are the actions that are not under conscious control.
Somatic (voluntary) nervous system handles voluntary activities.
How the Nervous System Works (5 of 5)

Autonomic (involuntary) nervous system handles body functions.

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Divided into two sections: sympathetic and parasympathetic nervous systems
Sympathetic nervous system reacts to stress with a fight-or-flight response.
Parasympathetic nervous system has the opposite effect on the body.
Skeletal System (1 of 5)

Skull
Composed of two groups of bones:

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cranium and facial bones.

FIGURE 29-6 The skull includes two large structures:

the cranium and the face.
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Skeletal System (2 of 5)

Skull (cont d)

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The brain connects to the spinal cord through the foramen magnum.
Four major bones make up the cranium: occipital, temporal, parietal, and frontal.
Face is composed of 14 bones: maxillae, zygomas, mandible, and orbit.
Skeletal System (3 of 5)

Spinal column

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Body s central supporting structure
33 vertebrae are divided into five sections:
Cervical
Thoracic
Lumbar
Sacral
Coccygeal
Skeletal System (4 of 5)

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FIGURE 29-7 The spinal column is the body’s central
supporting system and consists of 33 bones divided into
five sections. Injury to the vertebrae may cause paralysis.
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Skeletal System (5 of 5)

Spinal column (cont d)

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Injury to the vertebrae can result in paralysis.
Vertebrae are connected by ligaments and separated by cushions, called
intervertebral disks.
Spinal column is almost entirely surrounded by muscles.
Head Injuries (1 of 4)

Traumatic insult to the head that may result in injury to soft tissue, bony
structures, or the brain.

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Account for more than half of all traumatic deaths
The patient may have sustained additional trauma.
Head Injuries (2 of 4)

Closed injuries

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The brain has been injured but there is no opening into the brain.
Open injuries
An opening from the brain to the outside world exists.
Often caused by penetrating trauma
May be bleeding and exposed brain tissue
Head Injuries (3 of 4)

Falls and motor vehicle crashes are among the most common MOI.

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Head injuries also commonly occur:
In victims of assault
During sports-related incidents
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Head Injuries (4 of 4)
Scalp Lacerations

Can be minor or serious

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Even small lacerations can lead to significant blood loss.
May be severe enough to cause hypovolemic shock
They are often an indicator of deeper, more serious injuries.
Skull Fracture (1 of 7)

Significant force applied to the head may cause a skull fracture.

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May be open or closed, depending on whether there is an overlying laceration
of the scalp
Injuries from bullets or other penetrating weapons often result in skull fractures.
Skull Fracture (2 of 7)

Signs of skull fracture include:

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Patient s head appears deformed.
Visible cracks in the skull
Ecchymosis (bruising) that develops under the eyes (raccoon eyes)
Ecchymosis that develops behind one ear over the mastoid process (Battle sign)
Skull Fracture (3 of 7)

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FIGURE 29-10 Signs of skull fracture include ecchymosis
under the eyes (raccoon eyes) (A) or behind one ear over
the mastoid process (Battle sign) (B).
A: © E. M. Singletary, MD. Used with permission; B: © Mediscan/Alamy.
Skull Fracture (4 of 7)

Linear skull fractures

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Account for about 80% of all skull
fractures
Radiographs are required to
diagnose a linear skull fracture
because there are no physical
signs.

FIGURE 29-11A Types of skull fractures. Linear.

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Skull Fracture (5 of 7)

Depressed skull fractures

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Result from high-energy direct
trauma to the head with a blunt
object
Frontal and parietal bones are
most susceptible.
Bony fragments may be driven into
the brain.

FIGURE 29-11B Types of skull fractures. Depressed.

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Skull Fracture (6 of 7)

Basilar skull fractures

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Associated with high-energy
trauma
Usually occur following diffuse
impact to the head
Signs include CSF drainage from
the ears, raccoon eyes, and
Battle sign.

FIGURE 29-11C Types of skull fractures. Basilar.

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Skull Fracture (7 of 7)

Open skull fractures

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Often associated with trauma to
multiple body systems
Brain tissue may be exposed to the
environment.
High mortality rate

FIGURE 29-11D Types of skull fractures. Open.

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Traumatic Brain Injuries (1 of 4)

Most serious of all head injuries

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Two broad categories: primary (direct) injury and secondary (indirect) injury
Primary brain injury results instantaneously from impact to the head.
Secondary brain injury increases the severity of the primary injury.
Traumatic Brain Injuries (2 of 4)

Secondary injury may be caused by:

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Hypoxia
Hypotension
Cerebral edema
Intracranial hemorrhage
Increased intracranial pressure
Cerebral ischemia
Infection
Traumatic Brain Injuries (3 of 4)

The brain can be injured directly by a penetrating object or indirectly as a result

of external forces.

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A coup-contrecoup injury can result from striking a windshield.
Head hits the windshield; brain comes to an abrupt stop by striking the inside of
the skull.
Head falls back against headrest; brain slams into the rear of the skull.
Traumatic Brain Injuries (4 of 4)

Cerebral edema may not develop for several hours.

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Low blood oxygen levels aggravate cerebral edema.
Monitor the patient for any seizure activity.
Intracranial Pressure (1 of 7)

Accumulations of blood within the skull or swelling of the brain can rapidly lead
to an increase in ICP.

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Increased ICP squeezes the brain against bony prominences within the cranium.
Intracranial Pressure (2 of 7)

Signs of increased intracranial pressure

Cheyne-Stokes respirations

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Ataxic (Biot) respirations
Decreased pulse rate, headache, nausea, vomiting, decreased alertness,
bradycardia, sluggish or nonreactive pupils, decerebrate posturing, and increased
or widened blood pressure.
Cushing reflex
Intracranial Pressure (3 of 7)

Intracranial hemorrhage

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Bleeding inside the skull also increases the ICP.
Bleeding can occur:
Between the skull and dura mater
Beneath the dura mater but outside the brain
Within the tissue of the brain itself
Intracranial Pressure (4 of 7)

Epidural hematoma
Accumulation of blood between the

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skull and dura mater
Nearly always the result of a blow to
the head that produces a linear
fracture

FIGURE 29-13 An epidural hematoma is usually

the result of a blow to the head that produces a
linear fracture of the temporal bone and damages the
middle meningeal artery. Blood accumulates
between the dura mater and the skull.
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Intracranial Pressure (5 of 7)

Subdural hematoma
Accumulation of blood beneath the

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dura mater but outside the brain
Occurs after falls or injuries involving
strong deceleration forces
May or may not be skull fracture

FIGURE 29-14 In a subdural hematoma, venous

bleeding occurs beneath the dura mater but
outside the brain.
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Intracranial Pressure (6 of 7)

Intracerebral hematoma
Bleeding within the brain tissue itself

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Can occur following a penetrating injury
to the head or because of rapid
deceleration forces

FIGURE 29-15 An intracerebral hematoma

involves
bleeding
© within
Jones & Bartlett the brain tissue itself.
Learning.
Intracranial Pressure (7 of 7)

Subarachnoid hemorrhage

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Bleeding occurs into the subarachnoid space, where the CSF circulates.
Results in bloody CSF and signs of meningeal irritation
Common causes include trauma or rupture of an aneurysm.
Concussion (1 of 3)

A blow to the head or face may cause concussion of the brain.

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Closed injury with a temporary loss or alteration of part or all of the brain s abilities
to function without demonstrable physical damage to the brain
About 90% of patients do not experience a loss of consciousness.
Concussion (2 of 3)

A patient with a concussion may be confused or have amnesia.

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Usually a concussion lasts only a short time.
Concussion (3 of 3)

Ask about these symptoms:

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Dizziness
Weakness
Visual changes
Nausea and vomiting
Ringing in the ears
Slurred speech
Inability to focus
Contusion

Far more serious than a concussion

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Involves physical injury to brain tissue
May sustain long-lasting and even permanent damage
A patient may exhibit any or all of the signs of brain injury.
Other Brain Injuries

Brain injuries can also arise from medical conditions, such as blood clots or
hemorrhages.

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Signs and symptoms of nontraumatic injuries are often the same as those of
traumatic brain injuries.
Spine Injuries (1 of 2)

Compression injuries can result from a fall.

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Forces that compress the patient’s vertebral body can cause herniation of disks.
Motor vehicle crashes can overextend the spine.
Rotation-flexion injuries of the spine result from rapid acceleration forces.
Spine Injuries (2 of 2)

When the spine is pulled along its length (hyperextension), it can cause
fractures.

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Any one of these unnatural motions, as well as excessive lateral bending, can
result in fractures or neurologic deficit.
When bones of the spine are altered from traumatic forces, they can fracture
or move out of place.
Patient Assessment (1 of 2)

Always suspect a possible head or spinal injury with:

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Motor vehicle collisions
Pedestrian–motor vehicle collisions
Falls
Blunt trauma
Penetrating trauma to the head, neck, back, or torso
Patient Assessment (2 of 2)

Always suspect a possible head or spinal injury with (cont d):

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Rapid deceleration injuries
Hangings
Axial loading injuries
Diving accidents
Scene Size-up (1 of 2)

Scene safety

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Evaluate every scene for hazards to your health and the health of your team or
bystanders.
Be prepared with appropriate standard precautions.
Call for ALS as soon as possible.
Scene Size-up (2 of 2)

Mechanism of injury/nature of illness

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Look for indicators of the MOI.
Consider how the MOI produced the injuries expected.
Primary Assessment (1 of 10)

Focus on identifying and managing life-threatening concerns.

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Reduction of on-scene time and recognition of a critical patient increase the
patient’s chances for survival or a reduction in the amount of irreversible
damage.
Primary Assessment (2 of 10)

Spinal immobilization considerations

Assess the patient in the position found.

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Determine whether or not a cervical collar needs to be applied.
Assess the scene to determine the risk of injury.
Form a general impression based on level of consciousness and chief complaint.
Primary Assessment (3 of 10)

The backboard often places the patient in an anatomically incorrect position for
a long period of time.

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Circulation to areas of skin may become compromised.
Some patients could experience respiratory compromise while lying flat.
Try to minimize the amount of time a patient is on a backboard.
Primary Assessment (4 of 10)

Cervical collar
Helps maintain spinal motion restriction

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The best time to apply the cervical collar depends on the patient’s injuries.
Once the cervical collar is on, do not remove it unless it causes a problem with
maintaining the airway.
Primary Assessment (5 of 10)

Assessing for signs and symptoms of a head or spine injury

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Ask about the chief complaint.
Confused or slurred speech, repetitive questioning, or amnesia in responsive
patients are good indications of a head injury.
In the setting of trauma, assume your patient has a head injury until your
assessment proves otherwise.
Primary Assessment (6 of 10)

Assessing for signs and symptoms of a head or spine injury (cont d)

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Unresponsive trauma patients should be assumed to have a spinal injury.
Patients with a decreased level of responsiveness should be considered to have a
spinal injury based on their chief complaint.
Primary Assessment (7 of 10)

Airway, breathing, and circulation considerations

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Use a jaw-thrust maneuver to open the airway.
If the jaw-thrust maneuver is ineffective, use the head tilt–chin lift maneuver as a
last resort.
Vomiting may occur in the patient with a head injury.
Irregular breathing may result from increased ICP.
Primary Assessment (8 of 10)

Airway, breathing, and circulation considerations (cont d)

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Oxygen is always indicated for patients with head and spinal injuries.
Pulse oximeter values should be maintained above 90%.
Hyperventilation should be reserved for specific conditions.
Primary Assessment (9 of 10)

Airway, breathing, and circulation considerations (cont d)

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A pulse that is too slow in the setting of a head injury can indicate a serious
condition.
A single episode of hypoperfusion in a patient with a head injury can lead to
significant brain damage and even death.
Assess for signs and symptoms of shock.
Control bleeding.
Primary Assessment (10 of 10)

Manner of transport

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Patients with impaired airways, open head wounds, or abnormal vital signs may
need to be rapidly extracted from a motor vehicle and transported.
Ensuring a patent airway and providing supplemental oxygen is paramount.
Suction should be readily available.
Maintain immobilization of the spine.
History Taking

Investigate the chief complaint.

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Obtain a medical history and be alert for injury-specific signs and symptoms.
Using OPQRST may provide some background on isolated extremity injuries.
Gather as much SAMPLE history as you can while preparing for transport.
Secondary Assessment (1 of 7)

Instruct the patient to keep still and not to move the head or neck.

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Physical examinations
May be a systematic head-to-toe, full-body scan or a systematic assessment that
focuses on a certain area or region of the body
Secondary Assessment (2 of 7)

Physical examinations (cont d)

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Vital signs
Significant head injuries may cause the pulse to be slow and the BP to rise.
With neurogenic shock, the blood pressure may drop, and the heart rate may increase
to compensate.
Respirations will become erratic.
Use monitoring devices.
Secondary Assessment (3 of 7)

Physical examinations (cont d)

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Use DCAP-BTLS to examine the head, chest, abdomen, extremities, and back.
Check perfusion, motor function, and sensation in all extremities prior to moving
the patient.
Secondary Assessment (4 of 7)

Physical examinations (cont d)

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A decreased level of consciousness is the most reliable sign of a head injury.
Look for leaking blood or CSF.
Assess pupil size and reaction to light, and continue to monitor the pupils.
Do not probe open scalp lacerations with your gloved finger.
Secondary Assessment (5 of 7)

Neurologic examination

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Perform baseline assessment using the Glasgow Coma Scale (GCS).
If your jurisdiction uses the Revised Trauma Score (RTS), then the findings from
the GCS will be used in determining the RTS value.
Record levels of consciousness that fluctuate or deteriorate.
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Secondary Assessment (6 of 7)
Secondary Assessment (7 of 7)

Spine examination

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Inspect for DCAP-BTLS, and check the extremities for circulation, motor, or
sensory problems.
If there is impairment, note the level.
Pain or tenderness when you palpate is a warning sign.
Other signs and symptoms: deformity, numbness, weakness, or tingling in the
extremities; and soft-tissue injuries
Reassessment (1 of 4)

Repeat the primary assessment.

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Reassess vital signs and the chief complaint.
Recheck patient interventions.
Reassess at least every 5 minutes.
Reassessment (2 of 4)

Interventions

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Compare baseline vital signs with repeated vital signs.
Rapid deterioration of neurologic signs is a sign of an expanding bleed in the brain
or rapidly progressing brain swelling.
Reassessment (3 of 4)

Interventions (cont’d)

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If CSF is present, cover the wound with sterile gauze, but do not bandage tightly.
Administer high-flow oxygen and apply a cervical collar.
Reassessment (4 of 4)

Communication and documentation

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Your documentation should include:
The history you obtained at the scene
Your findings during your assessment
Treatments you provided
How the patient responded to them
Document vital signs for unstable patients every 5 minutes; every 15 for stable
patients.
Emergency Medical Care of Head Injuries (1 of 7)

Three general principles:

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Establish an adequate airway.
Control bleeding and provide adequate circulation to maintain cerebral perfusion.
Assess the patient s baseline level of consciousness, and continuously monitor.
Emergency Medical Care of Head Injuries (2 of 7)

Managing the airway

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Perform the jaw-thrust maneuver.
Once the airway is open, maintain the head and cervical spine in a neutral, in-line
position until you have placed a cervical collar and have secured the patient on a
backboard.
Emergency Medical Care of Head Injuries (3 of 7)

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FIGURE 29-20 Apply a cervical collar as you finish the primary assessment.
© Jones & Bartlett Learning. Photo by Darren Stahlman.
Emergency Medical Care of Head Injuries (4 of 7)

Managing the airway (cont d)

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Remove any foreign bodies, secretions, or vomitus.
Check ventilation.
Give supplemental oxygen to any patient with suspected head injury.
Emergency Medical Care of Head Injuries (5 of 7)

Circulation

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Begin CPR if the patient is in cardiac arrest.
Active blood loss aggravates hypoxia.
You can almost always control bleeding from a scalp laceration by applying direct
pressure over the wound.
Emergency Medical Care of Head Injuries (6 of 7)

Shock is usually the result of hypovolemia.

Indicates that the situation is critical

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Transport immediately to a trauma center.
Emergency Medical Care of Head Injuries (7 of 7)

Cushing triad

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Increased blood pressure (hypertension)
Decreased heart rate (bradycardia)
Irregular respirations (Cheyne-Stokes respirations or Biot respirations)
Manage shock, administer oxygen, and ventilate as necessary, avoiding
hyperventilation.
Emergency Medical Care of Spinal Injuries (1 of 6)

Follow standard precautions.

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Maintain the patient s airway while keeping the spine in the proper position.
Assess respirations and give supplemental oxygen.
Emergency Medical Care of Spinal Injuries (2 of 6)

Managing the airway

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Perform the jaw-thrust maneuver.
Consider inserting an oropharyngeal airway.
Have a suctioning unit available.
Provide supplemental oxygen.
Emergency Medical Care of Spinal Injuries (3 of 6)

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FIGURE 29-22 Jaw-thrust maneuver. A.
Stabilize the neck in a neutral, in-line position. B.
Push the angle of the lower jaw upward.
A, B: © Jones & Bartlett Learning. Courtesy of MIEMSS.
Emergency Medical Care of Spinal Injuries (4 of 6)

Spinal motion restriction of the cervical spine

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Immobilize the head and trunk so that bone fragments do not cause further
damage.
Never force the head into a neutral, in-line position.
Immobilize the patient in his or her current position.
Emergency Medical Care of Spinal Injuries (5 of 6)

Cervical collars
Provide preliminary, partial support

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Should be applied to every patient who
has a possible spinal injury
To be effective, a rigid cervical collar must
be the correct size.

FIGURE 29-23 Proper fit is essential in applying a

cervical
collar. The collar should rest on the shoulder girdle and
provide firm support under both sides of the mandible
without
© obstructing
Jones & Bartlett Learning. the airway or any ventilation efforts.
Emergency Medical Care of Spinal Injuries (6 of 6)

Cervical collars (cont’d)

Once the patient’s head and neck have been manually stabilized, assess the pulse,

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motor functions, and sensation in all extremities. Then assess the cervical spine
area and neck.
Maintain manual support until the patient has been fully secured to the backboard
or vacuum mattress.
Preparation for Transport (1 of 7)

Supine patients

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Secure to a long backboard or vacuum mattress.
Another procedure to move a patient from the ground to a backboard is the four-
person log roll.
You may also slide the patient onto a backboard or vacuum mattress.
Preparation for Transport (2 of 7)

Vacuum mattress

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An alternative to the long backboard is a vacuum mattress.
Molds to the specific contours of patient’s body
Excellent for the elderly or a patient with abnormal curvature of the spine
Can be used on a supine, sitting, or standing patient
Preparation for Transport (3 of 7)

Sitting patients

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Use a short backboard to restrict movement of the cervical and thoracic spine.
Then secure the short board to the long board.
Exceptions include situations in which:
You or the patient is in danger.
You need immediate access to other patients.
The patient s injuries justify urgent removal.
Preparation for Transport (4 of 7)

Standing patients

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Transfer patient to a position in which spinal motion restriction can be maintained.
Clinical indications for spinal motion restriction:
Spinal tenderness or pain
Altered level of consciousness
Neurologic deficits
Obvious spinal deformity
High-energy trauma in an intoxicated patient or one with a distracting injury
Preparation for Transport (5 of 7)

Spinal immobilization devices

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Assume the presence of spinal injury in all patients who have sustained head
injuries.
Use manual in-line stabilization or a cervical collar and long backboard.
Preparation for Transport (6 of 7)

Short backboards
Vest-type device and rigid short board

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Designed to immobilize and restrict
movement of the head, neck, and torso
Used to immobilize noncritical patients
found in a sitting position

FIGURE 29-25 A common short-board

spinal precaution device is a vest-type device.
© Kendrick EMS.
Preparation for Transport (7 of 7)

Long backboards
Provide full body spinal immobilization and

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motion restriction to the head, neck, torso,
pelvis, and extremities
Used to immobilize patients found in any
position

FIGURE 29-26 Long backboards provide

full-body spinal motion restriction, including
the head, neck, torso, pelvis, and extremities.
© meenon/iStock/Getty Images Plus/Getty Images.
Helmet Removal (1 of 6)

A helmet that fits well prevents the patient s head from moving and should be
left on, provided:

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There are no impending airway or breathing problems.
It does not interfere with assessment and treatment of airway or ventilation
problems.
You can properly immobilize the spine.
Helmet Removal (2 of 6)

Remove a helmet if:

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It is a full-face helmet.
It makes assessing or managing airway problems difficult.
It prevents you from properly immobilizing the spine.
It allows excessive head movement.
The patient is in cardiac arrest.
Helmet Removal (3 of 6)

Preferred method

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Removing a helmet should always be at least a two-person job.
You should first consult with medical control about your decision to remove a
helmet.
Helmet Removal (4 of 6)

Alternate method

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The advantage is that it allows the helmet to be removed with the application of
less force, therefore reducing the likelihood of motion occurring in the neck.
The disadvantage is that it is slightly more time consuming.
Helmet Removal (5 of 6)

Alternate method (cont d)

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Remove the chin strap.
Remove the face mask.
Pop the jaw pads out of place.
Place your fingers inside the helmet.
Hold the jaw with one hand and the occiput with the other.
Insert padding behind the occiput.
Helmet Removal (6 of 6)

Alternate method (cont d)

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The person at the side of the patient s chest is responsible for making sure that the
head and neck do not move during removal of the helmet.
Remember that children may require additional padding to maintain the in-line
neutral position.
Review

1. The brain, a part of the central nervous system (CNS), is divided into the:

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A. cerebrum, cerebellum, and brainstem.
B. cerebrum, brainstem, and spinal cord.
C. cerebellum, cerebrum, and spinal cord.
D. spinal cord, cerebrum, and cerebral cortex.
Review

Answer: A

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Rationale: The brain and spinal cord comprise the central nervous system
(CNS). The brain is divided into three major regions: the cerebrum (the largest
portion), the cerebellum, and the brainstem. Each region of the brain carries out
specific functions.
Review

1. The brain, a part of the central nervous system (CNS), is divided into the:

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A. cerebrum, cerebellum, and brainstem.
Rationale: Correct answer
B. cerebrum, brainstem, and spinal cord.
Rationale: The spinal cord is not part of the brain.
C. cerebellum, cerebrum, and spinal cord.
Rationale: The spinal cord is not part of the brain.
D. spinal cord, cerebrum, and cerebral cortex.
Rationale: The spinal cord is not part of the brain.
Review

2. As you are assessing a 24-year-old man with a large laceration to the top of
his head, you should recall that:

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A. the scalp, unlike other parts of the body, has relatively fewer blood vessels.
B. blood loss from a scalp laceration may contribute to hypovolemic shock in
adults.
C. any avulsed portions of the scalp should be carefully cut away to facilitate
bandaging.
D. most scalp injuries are superficial and are rarely associated with more serious
injuries.
Review

Answer: B
Rationale: Although the scalp is highly vascular and tends to bleed heavily

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when injured, scalp injuries are rarely the sole cause of hypovolemic shock in
adults. However, they can contribute to hypovolemia caused by injuries
elsewhere in the body. Scalp lacerations, whether deep or superficial, should
prompt you to look for more serious underlying injuries, such as a skull fracture.
If the injury involves an avulsion, the avulsed flap of skin should be carefully
replaced to its original position, not cut away.
Review

2. As you are assessing a 24-year-old man with a large laceration to the top of
his head, you should recall that:

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A. the scalp, unlike other parts of the body, has relatively fewer blood vessels.
Rationale: The scalp is highly vascular.
B. blood loss from a scalp laceration may contribute to hypovolemic shock in
adults.
Rationale: Correct answer
C. any avulsed portions of the scalp should be carefully cut away to facilitate
bandaging.
Rationale: The avulsed flap should be carefully replaced to its original position.
D. most scalp injuries are superficial and are rarely associated with more serious
injuries.
Rationale: Deep or superficial scalp lacerations should prompt EMS providers
to assess for more serious underlying injuries.
Review

3. A patient who experiences an immediate loss of consciousness followed by a

lucid interval has a(n):

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A. epidural hematoma.
B. subdural hematoma.
C. concussion.
D. contusion.
Review

Answer: A
Rationale: Epidural hematomas are caused by injury to an artery—usually the

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middle meningeal artery—that lies in between the skull and brain. Patients with
an epidural hematoma typically experience an immediate loss of consciousness
followed by a brief period of consciousness (lucid interval) as intracranial
pressure increases. Subdural hematomas are the result of injury to a vein;
therefore, they tend to bleed slowly and usually cause a progressive decline in
level of consciousness. Concussions and contusions may cause a loss of
consciousness, but it is typically brief.
Review

3. A patient who experiences an immediate loss of consciousness followed by a

lucid interval has a(n):

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A. epidural hematoma.
Rationale: Correct answer
B. subdural hematoma.
Rationale: Subdural hematomas tend to bleed slowly and usually cause a
progressive decline in the level of consciousness.
C. concussion.
Rationale: Concussions may cause a loss of consciousness, but it is typically
brief.
D. contusion.
Rationale: Contusions may cause a loss of consciousness, but it is typically
brief.
Review

4. A 44-year-old man was struck in the back of the head and was reportedly
unconscious for approximately 30 seconds. He complains of a severe

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headache and “seeing stars,” and states that he regained his memory shortly
before your arrival. His presentation is MOST consistent with a(n):
A. contusion.
B. concussion.
C. subdural hematoma.
D. intracerebral hemorrhage.
Review

Answer: B

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Rationale: A concussion occurs when the brain is jarred around inside the skull.
It may result in a brief loss of consciousness and occasionally, amnesia. Seeing
stars is a common finding following trauma to the back of the head (occiput), as
this region is primarily responsible for vision. A concussion—the least severe of
all closed head injuries—typically does not result in physical damage to the brain.
Compared to a concussion, a contusion, subdural hematoma, and intracerebral
hemorrhage are usually associated with a more prolonged loss of consciousness.
Review

4. A 44-year-old man was struck in the back of the head and was reportedly
unconscious for approximately 30 seconds. He complains of a severe headache

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and “seeing stars,” and states that he regained his memory shortly before your
arrival. His presentation is MOST consistent with a(n):
A. contusion.
Rationale: This is when brain tissue is damaged, and the patient presents
with prolonged confusion and loss of consciousness.
B. concussion.
Rationale: Correct answer
C. subdural hematoma.
Rationale: This is an accumulation of blood beneath the dura mater.
D. intracerebral hemorrhage.
Rationale: This is bleeding within the brain itself.
Review

5. A young male was involved in a motor vehicle accident and experienced a

closed head injury. He has no memory of the events leading up to the

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accident but remembers that he was going to a birthday party. What is the
correct term to use when documenting his memory loss?
A. Concussion
B. Cerebral contusion
C. Retrograde amnesia
D. Anterograde amnesia
Review

Answer: C

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Rationale: The term amnesia means loss of memory; it is common in patients
who have experienced a cerebral concussion. Amnesia of events leading up to
an injury is called retrograde amnesia. Anterograde amnesia—also called
posttraumatic amnesia—is the inability to remember events that occurred—or
will occur—after the injury.
Review

5. A young male was involved in a motor-vehicle accident and experienced a

closed head injury. He has no memory of the events leading up to the accident

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but remembers that he was going to a birthday party. What is the correct term to
use when documenting his memory loss?
A. Concussion
Rationale: This occurs when the brain is jarred inside the skull.
B. Cerebral contusion
Rationale: This is when tissue is bruised and damaged in a local area. It
may result in prolonged confusion.
C. Retrograde amnesia
Rationale: Correct answer
D. Anterograde amnesia
Rationale: This is the loss of memory relating to events that occurred after
the injury.
Review

6. A distraction injury to the cervical spine would MOST likely occur following:

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A. a diving accident.
B. blunt neck trauma.
C. hyperextension of the neck.
D. hanging-type mechanisms.
Review

Answer: D

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Rationale: Excessive traction on the neck, such as what occurs during hanging-
type mechanisms, can cause a distraction injury of the cervical spine. Distraction
injuries can cause separation of the vertebrae and stretching or tearing of the
spinal cord.
Review

6. A distraction injury to the cervical spine would MOST likely occur following:

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A. a diving accident.
Rationale: This would possibly cause a compression injury.
B. blunt neck trauma.
Rationale: This can result in a fracture or neurologic deficit.
C. hyperextension of the neck.
Rationale: This can result in a fracture or neurologic deficit.
D. hanging-type mechanisms.
Rationale: Correct answer
Review

7. During immobilization of a patient with a possible spinal injury, manual

stabilization of the head must be maintained until:

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A. an appropriate-size extrication collar has been placed.
B. the patient is fully immobilized on a long backboard.
C. a range of motion test of the neck has been completed.
D. pulse, motor, and sensory functions are found to be intact.
Review

Answer: B

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Rationale: Manual stabilization of the patient s head must be maintained until he
or she is fully secured to the long backboard. This includes the application of an
extrication collar, straps, and lateral immobilization (head blocks). Pulse, motor,
and sensory functions must be checked before and after the immobilization
process. Do not assess range of motion in a patient with a possible spinal injury;
this involves moving the patient s neck and may cause further injury.
Review

7. During immobilization of a patient with a possible spinal injury, manual

stabilization of the head must be maintained until:

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A. an appropriate-size extrication collar has been placed.
Rationale: This is only one small part of the total immobilization process.
B. the patient is fully immobilized on a long backboard.
Rationale: Correct answer
C. a range of motion test of the neck has been completed.
Rationale: Do not assess the range of motion in a patient with a possible
spinal injury.
D. pulse, motor, and sensory functions are found to be intact.
Rationale: This is done before and after complete immobilization.
Review

8. Your patient is a 21-year-old male who has massive face and head trauma
after being assaulted. He is lying supine, is semiconscious, and has blood in

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his mouth. You should:
A. insert a nasal airway, assess his respirations, and give 100% oxygen.
B. suction his airway and apply high-flow oxygen via a nonrebreathing mask.
C. manually stabilize his head, log roll him onto his side, and suction his mouth.
D. apply a cervical collar, suction his airway, and begin assisting his
ventilations.
Review

Answer: C
Rationale: Blood or other secretions in the mouth place the airway in immediate

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jeopardy and must be removed before they are aspirated. At the same time, you
must protect the patient s spine due the mechanism of injury. Therefore, you
should manually stabilize the patient s head, log roll him onto his side (allows
drainage of blood from his mouth), and suction his mouth for up to 15 seconds.
After ensuring that his airway is clear, assess his breathing and give high-flow
oxygen or assist his ventilations. Nasal airways should not be used in patients
with severe facial or head trauma.
Review

8. Your patient is a 21-year-old male who has massive face and head trauma after
being assaulted. He is lying supine, is semiconscious, and has blood in his

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mouth. You should:
A. insert a nasal airway, assess his respirations, and give 100% oxygen.
Rationale: Nasal airways should not be used in patients with severe facial or
head trauma or with suspected fractures.
B. suction his airway and apply high-flow oxygen via a nonrebreathing mask.
Rationale: This must be done after manual stabilization of the spine and rolling
the patient to his side.
C. manually stabilize his head, log roll him onto his side, and suction his mouth.
Rationale: Correct answer
D. apply a cervical collar, suction his airway, and begin assisting his ventilations.
Rationale: The cervical collar should be applied but manual stabilization must
take place first. There are no indications here that the patient s rate of
respirations are inadequate and require assisted ventilations.
Review

9. A man is found slumped over the steering wheel, unconscious and making
snoring sounds, after an automobile accident. His head is turned to the side

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and his neck is flexed. You should:
A. gently rotate his head to correct the deformity.
B. carefully hyperextend his neck to open his airway.
C. apply an extrication collar with his head in the position found.
D. manually stabilize his head and move it to a neutral, in-line position.
Review

Answer: D

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Rationale: The patient s snoring sounds indicate an airway problem, which must
be corrected or he may die. Manually stabilize his head; carefully move it to a
neutral, in-line position; and reassess his breathing. Do not rotate or
hyperextend the neck of a patient with a possible spinal injury; the results could
be disastrous.
Review

9. A man is found slumped over the steering wheel, unconscious and making
snoring sounds, after an automobile accident. His head is turned to the side

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and his neck is flexed. You should:
A. gently rotate his head to correct the deformity.
Rationale: Do not rotate the neck of a patient with a possible spinal injury.
B. carefully hyperextend his neck to open his airway.
Rationale: Do not hyperextend the neck of a patient with a possible spinal
injury.
C. apply an extrication collar with his head in the position found.
Rationale: The head must be placed in a neutral position to open the airway.
D. manually stabilize his head and move it to a neutral, in-line position.
Rationale: Correct answer
Review

10. You should NOT remove an injured football player s helmet if:

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A. a cervical spine injury is suspected, even if the helmet fits loosely.
B. the patient has a patent airway, even if he has breathing difficulty.
C. he has broken teeth, but only if the helmet does not fit snugly in place.
D. the face guard can easily be removed and there is no airway compromise.
Review

Answer: D

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Rationale: In general, you should leave a helmet on if it fits snugly and does not
allow movement of the head within the helmet, the patient s airway is patent, no
airway problems are anticipated, and the patient is breathing without difficulty. If
you can easily remove the face guard (often the case with football helmets) and
there are no airway problems, do so but leave the helmet on. If the helmet is
loose, the airway is in anyway compromised, or the patient has difficulty
breathing or is in cardiac arrest, the helmet must be removed.
Review

10. You should NOT remove an injured football player s helmet if:

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A. a cervical spine injury is suspected, even if the helmet fits loosely.
Rationale: If the helmet allows for movement of the head, it should be
removed.
B. the patient has a patent airway, even if he has breathing difficulty.
Rationale: The helmet must be removed if the patient is having breathing
difficulty.
C. he has broken teeth, but only if the helmet does not fit snugly in place.
Rationale: Broken teeth present a potential for airway obstruction.
D. the face guard can easily be removed and there is no airway compromise.
Rationale: Correct answer