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Hi. Uh welcome to this lecture on head and spinal injuries. My name is Shepard. I'm an emergency medicine doctor based in Sheffield and I'll hope you'll be on your course in September. So I hope you meet somebody there, a lecture are to recognize and assess head and spinal injuries and to be able to manage and move head and spinal injuries and to recognize when evacuation is indicated. So we start with an assessment of head and spinal injuries. Um So your history taking. So when, where how it happened? Um Did they have any loss of consciousness? Do they remember the event? Vomiting? How many times have they vomited? Um loss of movement, sensation, seizures, visual changes, neck pains. It's a long list. But um feel free to use a cheat sheet if you are assessing someone with a head injury, importantly, is any past medical history or are they on any blood thinners for neck injuries? Make sure you ask them if they were able to get out of the situation themselves and walk around straight away or if they needed someone to help them out. So for example, car accidents were they able to get out of the car themselves and then just think about um, the mechanism of injury that they've, um, that they've told you. Um, so was it a high speed road traffic accident? Did the car roll over? Were they ejected from the car? They fall more than five steps though? Her first, more than five steps. Do they have an axial load? Which means that they have a load coming from above them onto their spine. It's diving into a pool or something falling on their head, just make sure you can see the neck injury and any significant injury above the collarbone. We go on to the examination of um head and spinal injuries. So you're starting with your doctor ABCD E. So making sure the environment is safe seeing if they're responding and then your airway breathing circulation. Um that would be a priority. Um But we're going to focus for this on the D and E aspect in terms of assessing head and spinal injuries. So I hope you've heard of um a um which is your assessment of conscious level. Um So that's here. So a being alert, orientated place, person time, they know who they are, they know where they are, they know what time it is and responding appropriately to questions and it see your confusion. Um So new onset acute or worsening confusion um for any, any sort of way and then your v is responsive to voices out of someone who will be unconscious. But if you say their name, if she shouts at them, they will rouse and then go back to being unconscious and then the same with pain. So the arrows when a painful stimulus as a pride. So this painful stimulus, which we'll practice during the week, um can be applied by pressing to supraorbital notch, which is just on the medial aspect of the eyebrow. Um orthopedia squeeze. So this muscle here is squeezing out quite hard or by a painful stimulus, uh unresponsive, so not responsive to any painful voice and then you're looking at the pupil response. Um So shining a bright light in their pupils and seeing if they're reacting and seeing if they're dilated. So this second one here would be a dilated pupil. So as if it's not reactive, this is quite a severe sign for head injury. This here would be a a commonly constricted people that more signs of sort drug intoxication. Um and we'll talk about power sensation in limbs. So just in terms of a brief exam, getting to move the arms, move the legs, can you feel your f, can you feel them touching your fingers? Can you feel them touching your toes and then on to e exposure? Um So what you're looking for for head injuries. So any bruising under the eyes under, behind the ears. So that's here called raccoons, eye battle sign. So those are signs of a basal skull fracture, any large bulgy, swelling on the head and any lacerations as well in um occur in multiple different ways. Um So some sort of scalp injuries, this includes scalp lacerations, bruising swelling. Um It can be more severe because it's enlarged arteries that run within the scalp. Um So it can produce it quite severely. Um Then skull injuries is skull fractures, um and also basal skull fractures. So skull, basal skull fractures are sort of underneath inside here and they can be quite difficult and stuff um and damage to blood vessels in the brain. So you can damage to the veins um by sort of the shearing of the vessels. Um these produce quite an insidious slow bleed. Um So it's sort of slowly deteriorating um patients and then arterial bleeds. So these typically um produce um initially you get the initial unconsciousness from the head injury and then they come around and have a lucid phase um for an hour or so as the bleeding is still going on in the brain, as the pressure increases in the brain, they then have the following um drop in conscious level and become very unwell. Um vomiting um changes weakness in the arms legs, that kind of thing. This occurs because there's only a set of volume inside the skull. Um and as it's bleeding in the brain, it causes pressure within that set volume. Um so it causes pressure in all areas of the brain. Uh injuries to the brain. Itself. Um So just essentially bruising to the brain, the same skull is a solid box. Um So as you get a head injury, the brain sort of shakes about in that solid box and can cause bruising. So this isn't a specific bleed but kind of bruising and swelling. Um With the game with severe symptoms, we have a look at an assessment of a cervical side injury. So what we use in the hospital is something called um the nexus criteria. Um So we go through that criteria when assessing a spine injury. Um firstly, you need to think of a spine injury, cervical spine injury is um likely from the mechanism of injury to any significant injury above the collarbone, which you may suspect a spine injury and any of those um severe um high energy mechanisms that I described in a previous slide shows me concerned. So, firstly, neurological deficits, what we mean by this is any weakness in the arms or the legs, any sensory change in the arms or the legs, any pupil discrepancy, any change in speech, any change in swallowing, any facial droop, um any uh that kind of thing and then move on to midline spinal tenderness. So this you palpate the back of the neck. So this is assuming you haven't got a very high index of suspicion um because otherwise you are immobilizing them. Um so palpate the back of the neck and if they have any spinal tendons present. So this is mid spine rather than either side of the neck, you can get um pain in sort trapezius muscles, um just from the muscular injury from your your neck pain. So make sure you're palpating in the midline spine that any altered level of consciousness, you can't accurate as that kind of thing if someone has an altered level of consciousness, so should automatically face your suspicions, any intoxication. Again, you can't assess anything if they're intoxicated. Um So this should automatically raise your suspicions and any distracting injury. Um So by this, you mean like if someone has a really severe leg wrist fracture, any burns, anything like that, which might um sort of distract them from the pain in their neck and be unable to examine them properly. So if they have any of these criteria, they put them more high risk. Um and they should probably be assessed for me and they should be immobilized. Um So we look at sort of the um different categories of different levels. Um So firstly, we'll go on to those that could be, um I first start with um what is expected post sort of normal minor head injury. So many patients post minor normal head injury can have some brain fog. Um, they can have some sleep disturbances, some headaches, nausea, dizziness and sort of general irritability. This doesn't tend to last more than two weeks. Um And if it does, that's all the reference concussion syndrome. And if you seek medical attention, um if we move on to the middle, um middle section, so sort of monitoring, considering evacuation. So if they got a progressive headache, um to consider, to monitor them and consider evacuating them and if they have any of these, any of the expected issues, um but are finding it difficult to carry on with whatever daily activities is involved in your world in a setting. Um Because having sleep still is headache, nausea can be very debilitating, especially if they are out and about um sort of exerting themselves sleeping in tents and poor diets. It might be very difficult for them to carry on. So any of these where they're tiny, difficult to carry on, they might be able to consider evacuation or just doing things and then evacuating immediately. So, so dilated people's i facial limb weakness, vomiting, um confusion, seizures, fluid from your ears, your nose, that's not just a nose bleed. Um It's sort of a white fluid, a clear fluid, sorry. Um And then large boggy swelling or laceration. Um So it's not a little bump to the head is when you press the swelling, it's all softened. Um feels like fluid that you're moving around in the knees, the management of head injuries. So initially, so here monitoring them and documenting them, documenting it. So document all of their pupils, um their vision, any disorientation, any vomiting, any pain. Um Just so you can get a timeline of how things if they're getting better or if they're getting worse, they tend to only wound laceration. So I've got some good pictures here. Um So just thinking about arterial bleeds um in the scalp, it can lead to quite a significant amount of blood loss. Um So all of this, making sure you start with, if it's actively bleeding, starting with significant pressure on the wound and making sure you keep that pressure on for a solid 10 minutes or so, not keep looking up and stuff because it's that hemostatic pressure that will cause a blood clot. Um This is what you can do with a clean wound. It's called a hair tie. Um So instead of using any stitches, staples, anything like this, you can probably use this with a combination of some glue. Um you're tying the hair together on either side of the wound to bring the wound together. Um And this is we stapling. I'm not sure if we teach on this course. Um But they're very handy. Um staple gun that's really good at bringing scalp wounds together, especially as the, the scar and gets hit within the hairline. And then if we're suspecting a severe head injury, so they're reduced consciousness, they're vomiting profusely and we wanna keep them sort of head up 45 degrees. Um This may be difficult to manage um if they have a suspected spinal injury, so maybe put them on a or something and get them out of there to evacuate them. Um, trying to protect their airway if they're vomiting, maybe. And I talked briefly about spinal injuries management. So this is sort of quite difficult. Um, so if say, for example, they're in a car accident, if they're able to self extricate, so if they're able to get themselves out of whatever car situation they have ended up in, um, this is good, the patient themselves is more likely to be able to protect their own neck. Um, if they aren't conscious and if we are moving them ourselves, um So this moves on to being very cautious and unconscious or confused patients, they are unable to tell us when there is neck pain and things like that. So that's why we resort to immobilizing the neck, um because they're not able to protect their own neck. Someone with a neck fracture is not going to be wiggling and wobbling their head out and causing worsening fracture. They are gonna be keeping their head really, really still. Um And probably able to control that a lot better than we are able to control it for someone else. Making sure you assess movement, sensation and circulation before and after moving. So this is movement, sensation, circulation of the upper and lower limbs. Um And then if they, if you're gonna be a while, so making sure you look to bowel and bladder care. Anyone with a spinal cord injury will whose um a complete spinal cord injury may lose function of their bowel and bladder. Um, and then evacuation may do need to be a helicopter because I'll need to be on a, um, maybe I sort of spinal border or structure or something. This is a survival collar. Um, they're slightly controversial, um, especially in the prehospital environment. So partially because they're very difficult to fit properly. Um, with, if you've got a special a group with a wide range of size people, um you're not taking multiple different sizes of cervical color cos they're really big, they're really bulky. Um They also cause sort of pressure points and if anyone is confused or agitated, they um this may make them more confused and agitated. Um What we tend to advocate more is something called manual inline stabilization. So it does require a bit more. Oh So these people can like around quite, quite well. Um This is manual inline stabilization. So this is um it's quite um gentle, it's just taking your fingers underneath some of your shoulders and then resting your hand over, making sure not to cover up the ears like this person's doing here. Um It is a bit more labor intensive because you need another person to do it and they need to be staying there. But in this way, you can talk to the patient and reassure them and tell them what's going on as well. Um So if you're immobilizing a neck injury, this is how you should do it and then move on to the log roll. Um So if you need to assess someone's spine, if you need to move them or you need to put a ma under them, you're on the log roll to keep the spine nice and straight. So you need at least three people for this one controlling the head. This is the person who gives you instructions for the role. Um and then hands on shoulders, hips and legs to roll them up, put anything underneath and then roll them back down and that is everything. Um So if you have any questions, feel free to email me, um my email is on the front side um or catch me at the uh practical week. So another practical week will be practicing all these movements and things. Um So we, we have to consolidate some of the um learning that we've done here. OK?