Head, Spine & Chest Injuries

Head, spine, and chest injuries carry the highest morbidity and mortality of all traumatic conditions. Early recognition and appropriate management are critical to patient survival.

Traumatic Brain Injury (TBI)

Concussion (Mild TBI):

• Temporary disruption of brain function
• May or may not involve loss of consciousness
• Symptoms: headache, confusion, amnesia, nausea, dizziness
• Repeated concussions can cause cumulative damage

Cerebral Contusion:

• Bruising of brain tissue
• More severe than concussion with longer-lasting symptoms
• May involve focal neurological deficits depending on location

Epidural Hematoma:

• Bleeding between the skull and dura mater (usually arterial - middle meningeal artery)
• Classic presentation: brief loss of consciousness, followed by a "lucid interval" (patient appears to improve), then rapid deterioration
• Requires emergency surgical intervention (craniotomy)

Subdural Hematoma:

• Bleeding between the dura mater and the brain surface (usually venous)
• Can be acute (rapid onset) or chronic (gradual, especially in elderly patients on blood thinners)
• Presents with progressive headache, altered mental status, and unilateral neurological deficits
• Higher mortality than epidural hematoma

Signs of Increased Intracranial Pressure (ICP)

Cushing's Triad (late, ominous sign):

1. Hypertension (rising blood pressure, especially widening pulse pressure)
2. Bradycardia (decreasing heart rate)
3. Irregular respirations (Cheyne-Stokes or ataxic breathing patterns)

Other signs of increased ICP:

• Altered mental status (decreasing GCS)
• Unequal pupils (anisocoria) - the dilated pupil is usually on the side of the injury
• Vomiting (often projectile, without nausea)
• Posturing: decorticate (arms flexed to chest) or decerebrate (arms extended and internally rotated)

Glasgow Coma Scale (GCS)

GCS Interpretation:

• 13-15: Mild TBI
• 9-12: Moderate TBI
• 3-8: Severe TBI (generally indicates need for advanced airway management)

Spinal Motion Restriction (SMR)

Indications for SMR (apply when MOI suggests spinal injury AND any of the following are present):

• Midline spinal tenderness or pain
• Neurological deficit (numbness, tingling, weakness, paralysis)
• Altered mental status (GCS < 15, intoxication)
• Distracting injury (painful injury that may mask spinal symptoms)

SMR Technique:

• Manual in-line stabilization of the cervical spine
• Appropriately sized cervical collar (measure from shoulder to jaw angle)
• Secure patient to a long backboard or use a scoop stretcher
• Pad voids (especially behind the head in children, who have proportionally larger occiput)
• Secure the torso first, THEN the head (so the head doesn't move independently if the board shifts)

Cervical Collar Sizing:

• Measure from the top of the shoulder to the angle of the jaw
• Select a collar that matches this measurement
• The collar should fit snugly without hyperextending or flexing the neck
• A collar alone does NOT provide complete spinal motion restriction

Chest Injuries

Pneumothorax (Simple):

• Air enters the pleural space, causing partial or complete lung collapse
• Presents with: dyspnea, decreased breath sounds on the affected side, chest pain
• EMT management: high-flow oxygen, monitor, transport

Tension Pneumothorax:

• A one-way valve effect allows air to enter the pleural space but not escape
• Pressure builds, compressing the lung, shifting the mediastinum, and obstructing venous return to the heart
• Signs: Severe respiratory distress, absent breath sounds on affected side, tracheal deviation (toward opposite side - a late sign), JVD, hypotension, tachycardia, cyanosis
• EMT management: High-flow oxygen, immediate transport, notify hospital for needle decompression preparation; if trained and authorized by protocol, perform needle decompression

Open Pneumothorax (Sucking Chest Wound):

• A wound in the chest wall allows air to enter the pleural space directly
• Characterized by a sucking or bubbling sound with breathing
• Management: Apply an occlusive dressing sealed on three sides (creating a flutter-valve effect: air escapes on exhalation but cannot enter on inhalation) OR use a commercial vented chest seal
• Monitor for development of tension pneumothorax (if condition worsens, briefly lift a corner of the dressing to release trapped air)

Hemothorax:

• Blood accumulates in the pleural space
• Presents with: dyspnea, decreased breath sounds, signs of shock
• Each hemithorax can hold 2-3 liters of blood
• EMT management: treat for shock, high-flow oxygen, rapid transport

Flail Chest:

• Three or more adjacent ribs fractured in two or more places each, creating a free-floating segment
• Paradoxical movement: The flail segment moves inward on inhalation and outward on exhalation (opposite of normal)
• The underlying lung contusion is often the more life-threatening component
• Management: Positive pressure ventilation with BVM if needed, stabilize the segment (position patient on the injured side or use bulky padding), high-flow oxygen, rapid transport