3.4 Head, Spine & Chest Injuries

Head, spine, and chest injuries carry the highest morbidity and mortality of all traumatic conditions. Early recognition and the correct, specific intervention for each one are decisive for survival, and these topics are densely tested on the NREMT exam.

Traumatic Brain Injury (TBI)

Concussion (mild TBI): a temporary disruption of brain function, with or without loss of consciousness. Symptoms include headache, confusion, amnesia, nausea, and dizziness. Repeated concussions cause cumulative harm and risk second-impact syndrome.

Cerebral contusion: actual bruising of brain tissue, more severe than concussion, often with focal deficits depending on location.

Epidural hematoma: arterial bleeding (usually the middle meningeal artery) between the skull and dura. The classic course is a brief loss of consciousness, then a lucid interval in which the patient seems fine, then rapid deterioration as the clot expands. It demands emergency surgery (craniotomy).

Subdural hematoma: venous bleeding between the dura and the brain surface. It can be acute or chronic (slow, especially in elderly patients on anticoagulants), presenting with progressive headache, declining mental status, and unilateral deficits. Mortality is higher than for epidural hematoma.

The brain is protected by a rigid skull, so the central danger is secondary brain injury from hypoxia, hypotension, and rising pressure. The single most important EMT actions in TBI are to maintain oxygenation (SpO2 at least 94%) and a normal blood pressure - a single episode of hypotension dramatically worsens TBI outcome.

Signs of Increased Intracranial Pressure (ICP)

Cushing's triad is a late, ominous sign of impending herniation: hypertension (often with a widening pulse pressure), bradycardia, and irregular respirations (Cheyne-Stokes or ataxic). Other signs include a falling GCS, unequal pupils (anisocoria, with the blown pupil usually on the side of the lesion), projectile vomiting without nausea, and posturing - decorticate (arms flexed toward the core) or the more ominous decerebrate (arms extended).

For a herniating patient with these signs, controlled mild ventilation may be directed by protocol, but routine hyperventilation is avoided because it reduces cerebral blood flow.

Glasgow Coma Scale (GCS)

GCS ranges from 3 (worst) to 15 (best). Interpretation: 13-15 mild, 9-12 moderate, 3-8 severe TBI. A GCS of 8 or less generally signals the need for advanced airway management - remember "less than 8, intubate."

Spinal Motion Restriction (SMR)

Modern EMS uses spinal motion restriction (SMR), which has replaced the outdated term "spinal immobilization" because no device truly immobilizes the spine. Current joint guidance from NAEMSP, ACEP, and the ACS Committee on Trauma limits routine long-backboard use; the long backboard is now an extrication tool, and patients are moved off it as soon as practical onto the cot, a scoop stretcher, or a vacuum mattress to prevent pressure injury and respiratory compromise.

Apply SMR when the mechanism suggests spinal injury and any of the following are present: midline spinal tenderness or pain, a neurologic deficit (numbness, tingling, weakness, paralysis), altered mental status (GCS under 15 or intoxication), or a distracting injury. A reliable, alert, sober patient with no midline tenderness, no deficit, and no distracting injury generally does not require SMR.

Technique: maintain manual in-line stabilization, apply a correctly sized rigid cervical collar (measured from the top of the shoulder to the angle of the jaw), pad voids - including behind a small child's proportionally large occiput - and secure the torso first, then the head. A collar alone does not provide full SMR.

Chest Injuries

Simple Pneumothorax: air in the pleural space partially collapses a lung, producing dyspnea, decreased breath sounds on the affected side, and chest pain. EMT care is high-flow oxygen, monitoring, and transport.

Tension Pneumothorax: a one-way valve traps air in the pleural space, collapsing the lung, shifting the mediastinum, and choking off venous return. Signs include severe respiratory distress, absent breath sounds on the affected side, JVD, hypotension, and tachycardia; tracheal deviation toward the opposite side is a rare, very late sign - act on the earlier signs without waiting for it. Definitive field treatment is needle chest decompression, performed by providers trained and authorized by protocol; otherwise give high-flow oxygen and rapid transport with early hospital notification.

Open Pneumothorax (sucking chest wound): seal it with a commercial vented chest seal or an occlusive dressing taped on three sides to create a flutter valve - air escapes on exhalation but cannot enter on inhalation. If a tension pneumothorax then develops, briefly lift a corner ("burp" the seal) to release trapped air.

Hemothorax: blood collects in the pleural space (each side can hold 2-3 liters), causing dyspnea, decreased breath sounds, and shock. Treat for shock, give oxygen, and transport rapidly.

Flail Chest: three or more adjacent ribs each fractured in two or more places create a free segment that moves paradoxically - inward on inhalation, outward on exhalation. The underlying pulmonary contusion is often the greater threat. Support ventilation with a BVM if breathing is inadequate, give oxygen, and transport rapidly.