Head and spinal cord injuries require special care and consideration. Rapid assessment, stabilization, extrication, and transportation to definitive care are the primary EMS objectives to facilitate the best opportunity for a functional outcome. Often, injuries to the head and spinal cord are not immediately obvious; therefore, reasonable precautions should be taken to prevent further injury. Detailed in this chapter are pieces of information pertinent to the physiology of brain and spinal cord injuries and the key ways to evaluate, manage, and stabilize patients suffering from these injuries.

1. 
   

   Describe the initial prehospital evaluation and management of head injury.

   
   
2. 
   

   Describe the common causes and mechanisms involved in head trauma.

   
   
3. 
   

   Discuss the role of EMS in the treatment of concussion, and in prevention of secondary brain injury.

   
   
4. 
   

   Describe the initial prehospital evaluation and management of spinal trauma.

   
   
5. 
   

   Discuss potential challenges in airway management in spinal trauma.

   
   
6. 
   

   Discuss water-related spinal trauma.

   
   
7. 
   

   Detail the criteria for the use of selective spinal immobilization.

   
   
8. 
   

   Describe the potential harm to patients from spinal immobilization practices.

   
   
9. 
   

   Discuss the debate concerning the use of spinal immobilization in penetrating trauma.

The initial step in head injury management is the evaluation of mechanism of injury, history of present illness, and possible comorbidities, while maintaining situational awareness of the scene. Evaluation of a patient’s mental status can be quickly attained through the use of the Glasgow coma scale (GCS) (Table 55-1). The GCS aims to give a reliable, reproducible, objective way of recording the conscious state of a patient for initial and subsequent assessments. It is commonly accepted and utilized in trauma care. Some experts advocate using the motor assessment only, but that is not the current care standard.¹

A normal, awake patient should have a GCS of 15. Historically, patients with a GCS of 8 or lower have been considered for intubation as it is thought that their ability to protect their airway may be compromised. The lowest possible score is 3 and represents a patient with a complete lack of neurological response to stimuli and generally indicates a severe brain injury with an accompanying poor prognosis. The GCS is sometimes amended with an “I” for a patient that is intubated to indicate that the scale may be different due to sedation, chemical paralysis, or the noxious stimulus from the endotracheal tube. A 2014 study by Reisner et al revealed an association between poor outcomes from traumatic brain injury when GCS was abnormal and heart rate and blood pressure were also abnormal.²

In addition to the GCS, evaluation of physical findings includes bruising behind the ears (Battle sign) or around the eyes (raccoon eyes) as indicators of basilar skull fracture. If the patient is able to answer questions, evaluate for recall of the events that just transpired checking for loss of consciousness and orientation to person, place, and time. Also inquire about associated symptoms of dizziness, headache, nausea, vomiting, tinnitus, and/or vision disturbances. If the patient is ambulatory and/or cooperative, evaluation for signs of balance and motor disturbance can indicate more subtle signs of injury or intoxication. Examine the eyes for changes in pupil shape and reactivity. Fixed, dilated, and nonreactive pupils are ominous signs of serious brain injury.

MANAGEMENT/STABILIZATION

A common thread in the prehospital management of brain and spinal cord injury is hemodynamic stabilization. It is well accepted that hypotension and hypoxia are associated with poorer outcomes in head injured patients.³ Just as with all trauma patients, the ABCs, (airway, breathing, and circulation) are the first priority in the management of brain and spinal cord injury. Blood pressure should not be lowered as part of a prehospital guideline.

Blood pressure should be monitored closely and consideration of cerebral blood flow must be a top priority for patient with presumed space-occupying bleeds. The main driving force behind CBF is cerebral perfusion pressure (CPP). CPP may be compromised in patients with large intracranial bleeds as the cerebral spinal fluid is forced from the intracranial space and the intracranial pressure rises in response to the loss of compensatory mechanisms. Cerebral perfusion pressure, which is responsible for allowing for proper oxygenation of the brain, is the sum of the mean arterial pressure (MAP), less the intracranial pressure. Normal intracranial pressure (ICP) is considered to be 5 to 15, but if a large intracranial bleed is suspected clinically, an ICP of >25 may be anticipated. CCP should be maintained at 70mm Hg. When there is a presumed increase in ICP the equation yields a needed MAP of around 90 in order to maintain CCP.

Therefore, if the ICP was hypothetically 35mm Hg, the MAP would need to be around 105 in order to ensure the proper CCP. This can be expressed as an algebraic formula, solving for MAP, expressed as x:

This is why hyperventilation, which is known to transiently decrease MAP (and therefore CPP), and mannitol should both be reserved for patients with signs of impending herniation. It is known that mortality increases approximately 20% for each 10 mm Hg loss of CPP. In ideal circumstances, CPP is maintained at 70mm Hg and recommendations are to ensure maintenance of MAP >90mm Hg. There is evidence that early hypotension (systolic blood pressure <90mm Hg) is associated with an increase in morbidity and mortality. Unfortunately, there is not a reasonable way for the ICP to be monitored in the prehospital setting; however, during interfacility transports of patients who have had neurosurgical intervention, particular attention should be paid to ICP and calculations of CCP made at key points of the transport to ensure proper critical care of these severely injured patients.

MECHANISMS OF INJURY

The mechanisms of head injury are complex, but follow the basic laws of energy. All mass in motion has inertia and thus a tendency to continue in motion. Often, head injuries result from rapid deceleration or direct blow and the brain is injured by colliding with the wall of the inner skull.⁴ The brain can also be injured by disruption of cerebral vasculature. Rupture of arteries and/or veins inside the skull causes bleeding with resultant compression of the brain and is a life-threatening emergency.

The history and mechanism of injury may help identify potential secondary injuries. Prehospital personnel may be the only ones that have access to information at the scene to assist in the identification of life-threatening injuries once the patient has arrived at the hospiital.

CONCUSSION AND SECONDARY INJURY

Rapid transport to definitive care is the priority once the ABCs and cervical spine are secured. Immediate extrication and evacuation may be necessary before beginning hemodynamic stabilization and the secondary survey if the scene is not secured. Often, and importantly for severely or multiple injured patients, the secondary survey can take place during transportation. After initial stabilization, it is prudent to survey for signs of concussion and secondary injury.

Concussions are common in closed head injury and should be taken seriously. Even though the patient may not be in critical condition, signs and symptoms of concussion can indicate significant brain injury. Loss of consciousness is a common historical feature that elevates the level of concern for brain injury. Amnesia is a common component of concussion and perseveration of questioning by the patient is frequent. Other signs of concussion include inappropriate somnolence, nausea, vomiting, clouding of thoughts, and headache.