HEAD AND SPINE INJURIES OEC Chapter 21 HEAD AND SPINE INJURIES Steve Labalme and Philip Klinck

The Central Nervous System (CNS) The part of the nervous system that includes the brain and spinal cord CNS controls a person’s ability to sense and react to the external world CNS injuries are among the most serious that OEC Technicians encounter: CNS trauma associated with high mortality and morbidity rates, severely impacted quality of life It is imperative that OEC Technicians: --understand the mechanisms responsible for traumatic CNS injuries --are able to quickly recognize the signs and symptoms of specific CNS injuries --be able to safely manage patients with traumatic head, neck and back injuries while minimizing additional injury

Traumatic Brain Injury (TBI) Physical trauma to the brain, can be localized or diffuse One of the most severe forms of CNS trauma Leading cause of traumatic death in individuals under 45 (occurs approximately every 15 seconds in the U.S.) Side effects: memory loss, reduced problem-solving capacity, stress and anger-management issues, depression, chronic seizure disorders, increased risk of Alzheimer's, Parkinson’s, and other brain disorders that become more prevalent with age

Anatomy: Axial Skeleton Composed of skull, ____ vertebrae 33 Cervical 1-7 Thoracic 1-12 Lumbar 1-5 Atlas (C1) Axis (C2) Sacrum 1-5 Coccyx (4 fused into 1)

CNS Anatomy: Brain Cerebrum Cerebellum Brain Stem Integrates sensory perception and motor control Involved in attention, processing language, music, and other sensory stimuli Cerebellum Integration of sensory perception and motor control (coordination) Brain Stem Adjoining and structurally continuous with spinal cord

CNS Anatomy: Brain Brain Stem Cerebral cortex Outer cortex controls sensory perception, voluntary movement, attention; processes language, music, and other sensory stimuli Controls basic body functions: cardiac, respiratory, and brain-processing functions. Composed of: Hypothalamus Thalamus Control center for autonomic nervous system (body temperature, hunger, thirst, sleep) Pons Medulla oblongata

CNS Anatomy: Brain Brain is made up of gray and white matter: Gray matter: closely packed neuron cell bodies involved in muscle control, sensory perceptions (seeing, hearing, etc.) memory, emotions, and speech. White matter: neuronal tissue mainly containing long nerve cells called axons. Axons are long, slender projections of nerve cells (neurons) that conduct electrical impulses away from the neuron’s cell body

CNS Anatomy: Spinal Cord Tubular bundle of nervous tissue that extends from the brain downward to the sacrum within the vertebral canal. Peripheral nerves connect, forming PNS Brain and spinal cord protected by three-layered membrane called the meninges. Cerebrospinal fluid (CSF): serum-like fluid that functions in shock absorption for CNS structures; circulates through brain and within meninges surrounding brain and spinal cord Brain and spinal cord, which together make up the central nervous system

Divisions of the Spinal Cord Cervical (1-8): control vital functions, movement of upper body Thoracic (1-12): control temperature regulation, trunk muscles Lumbar (1-5): control leg motion, some reproductory functions Sacral (1-5): control foot motion, rep. function “C3, 4, 5, keep the diaphragm alive” Phrenic nerve originates at C3-5, controls movement of diaphragm (breathing) Right above where the nerves to your arm come out, which is why some quadriplegics can still breathe on their own

Common MOIs Most common mechanisms of injury to CNS: Rapid deceleration (impact-related trauma) Rapid acceleration Compression injury to spinal column (falling object, diving) Penetrating or impaled object Near drowning Hypothermia and hyperthermia Electrical injury, including lightning strikes Important in scene assessment: determine if there is a potential for neurologic injury: Fall greater than 3 times the patient’s height Moderate to high-speed motor vehicle collision Pedestrian or cyclist being struck by a motor vehicle Skier/skier collision, skier collides with a fixed object like a lift pole or tree Gunshot wound Avalanche burial Lightning strike

Coup-Contrecoup Injury Caused by rapid deceleration of the head: upon impact, brain keeps moving forward and strikes front of skull, then rebounds and strikes back of skull Can result in severe intracranial bleeding, swelling, and can compromise normal brain function Pediatric and geriatric patients experience more severe coup-contrecoup injuries due to increased room for brain to move within skull

Common Injuries to the CNS Two Types: -Closed Injuries → Injuries in which the integrity of the cranium and spinal column is not compromised → include contusions; hematomas; fractures of the skull, vertebrae, scapula, and posterior ribs; diffuse axonal injury -Open Injuries → Injuries in which brain matter or bone fragments are exposed, or injuries in which CSF is leaking

Skull Fractures -Open or closed skull fractures are the result of blunt trauma to the skull -- linear skull fracture: a single nondisplaced fracture line → significant swelling and tenderness -- depressed skull fracture: a comminuted fracture with displacement → a “soft spot” over the fracture is typical -- basilar fracture: a fracture at the base of skull → typically results from high-velocity blunt trauma (like skiing into a tree!) → a leakage of CSF is common is common, battle signs and raccoon eyes will likely be present.

Traumatic Brain Injury -A mechanical injury to the brain that results in short-term and/or long term neurologic deficit - Males are twice as likely to suffer TBI and four times as likely to be killed by TBI !! Examples of TBIs: concussion, cerebral contusions or hematomas, diffuse axonal injury or intracerebral hemorrhages

Concussion A temporary disruption of coordinated brain function caused by trauma Mild Concussion: Minor disruption of brain function, no loss of responsiveness Symptoms may include confusion, dizziness, nausea, vomiting, headache Moderate Concussion: Loss of responsiveness of less than 5 mins some disruption of brain function Severe Concussion: loss of responsiveness of more than 5 mins significant disruption of normal brain function

Concussion cont’d With both moderate and severe concussions, other symptoms of TBI will likely be present Post-concussive syndrome: Complex range of systems including permanent memory loss Symptoms may lead to difficulty focusing and other behavioral and psychological problems Can take years to resolve itself as the brain heals

Amnesia Amnesia: memory loss (some form of amnesia will usually occur with a concussion) Retrograde amnesia: patients have no recollection of events before the injury, including the injury itself Antegrade amnesia: patients have no recollection of events occurring after the injury Amnesia often presents as a distinctive speech pattern and repetitive questions, this is called perseveration

Recurrent Traumatic Brain Injury -Recurrent mild TBIs that occur in close proximity can cause cumulative damage and even death -If a previous TBI has not completely healed, a second mild TBI can cause serious health complications !!Always ask patients if they have had any recent brain trauma!!

Cerebral Contusion A bruise involving the brain -involves the rupture of small superficial blood vessels and generally affects localized areas of the brain -This is more serious than a concussion, but may present with identical symptoms

Cerebral Hematoma -A hematoma is an accumulation of blood outside the vascular system -As the cranium is an enclosed space, a hematoma with this space can compress the brain and cause serious damage.

Hematomas Cont’d Epidural hematoma: arterial bleeding between the skull and the dura matter → “lucid period” patient is initially unresponsive, then becomes relatively alert before slipping back into unresponsiveness Subdural hematoma: a collection of venous blood between the dura matter and the brain → no “lucid period” Intracranial hematoma: a hemorrhage within the brain matter itself

Hematomas Cont’d -Typically caused by rapid deceleration injuries (skiing into a tree) -Subdural hematomas can be associated with an underlying cerebral contusion; can take hours days or weeks for symptoms to present as blood is venous in origin -All types of hematomas are potentially life threatening and require surgical correction

Diffuse Axonal Injury -Devastating TBI that is caused by high-velocity rotational acceleration/deceleration (skiing reeeeaaally fast into a tree) -It is believed to be caused by a shearing of the white matter away from the gray matter in the brain -suppresses electrical activity within the brain -Patients with DAI may be unresponsive or become unresponsive later -As many as 90% of patients with DAI do not recover.

Intracerebral Hemorrhage A bleed with the brain due to trauma, which, because of the vascular nature of the brain, disrupts normal cerebral function Can be life threatening due to the rise in Intracranial pressure Patients who take blood thinners have an especially poor prognosis

Spinal Injuries Spinal Cord Injuries (SCI) can occur in all four sections of the spine, and are usually associated with high speeds, heights and rapid acceleration/deceleration Common neck and back injuries include soft tissue injuries, muscle or ligament strains, and fractures. Ex: Whiplash Occurs when the head is violently thrown backward

Spinal Injuries Cont’d Spinal Fractures: - Cervical and Lumbar vertebrae are more susceptible to hyperflexion and rotational injury as they have more flexibility Thoracic and Coccygeal vertebrae are prone to blunt and compression trauma Cervical vertebrae are the most prone to fracture as they are the thinnest

Spinal Injuries Cont’d C1 fracture: known as a Jefferson fracture, caused by a severe axial loading of the spine C2 fracture: known as a Hangman’s fracture, generally caused when the face forcibly strikes an object, causing the neck to snap backward A fracture of C1 and C2 is known as an atlas-axis injuries and most often occur when the neck is forcibly hyperextended A fracture to C3-C5 can damage nerves that innervate the diaphragm, making the patient unable to breathe on their own

Spinal Injuries Cont’d Final Things to Know: Fractures of the scapula usually occur as a result of significant blunt trauma Posterior ribs are more prone to fracture than anterior ribs as they are less flexible (connected to thoracic vertebrae) Most common fractures of the spine are lower thoracic and lumbar fractures Injuries to the sacral vertebrae are rare, but to the coccyx is common Neurologic Injuries can result when broken or displaced vertebra lacerate the spinal cord or put pressure on it Can lead to neural ischemia (brain/spinal cord receives too little oxygenated blood, organ damage can result after only a few minutes)

Neurogenic Shock A form of shock that is caused by disruption of the autonomic nervous system This causes blood pressure to drop, bradycardia It is most commonly caused by a SCI, but could also be caused by a TBI Rare, but potentially life threatening complication to any head or spine trauma

tHAnKs!!!