SPM 100 Skills Lab 4 Notes:

C-spine Immobilization, Hemorrhage Control and Splinting Extremities

Brain Injuries

Direct Injuries: open head, lacerated, punctured or broken bones or foreign object (impaled).

Indirect Injuries: either closed or open; shock impact to the brain transferred from the skull. (concussions and contusions) (epidural/sbudoural hematomas)

Signs of Brain injuries and skull fractures:

Visible bone fragmentsIrregular breathing pattern

Altered mental StatusTemperature increase

Deep laceration or BruisingBlurred or multiple-image vision

Any severe painImpaired hearing / Equilibrium problems

“Battle’s signs” (bruising behind ears)Forceful or Projectile vomiting - repeated

Pupils unequal or non-reactivePosturing*

“Raccoon eyes” (Bilateral Black eyes)Paralysis or disability on one side of the body

Open eye appears to be depressedBleeding/Clear fluid from the ears and/or nose

Personality changesSeizures

Increased blood pressure and Deteriorating Vital signs

decreased pulses (Cushing’s syndrome) Unitlateral Dilated pupil – non-reactive

*Posturing – flexing arms and wrist and extending legs and feet (decorticate posture) or extending arms with the shoulders rotated inward and wrist flexed, legs extended (decerebrated posture); may be spontaneous or in response to painful stimulus.

Emergency Care for Brain Injuries and Skull Fractures

Universal precautionsKeep patient at rest

Assume spinal injurySpeak to conscious patients

Monitor patient (vital signs, pulse oximeter -Monitor/manage for shock

every 5 minutes)Vomiting

Apply C-collarEarly Neurosurgical Consultation

Oxygen

Control Bleeding / Dress & Bandage wound

Glosgow Coma Scale:

Eye Opening ADULTCHILD/ADOLESCENTINFANT

Opens spontaneously SpontaneousSpontaneous4

Opens eyes to verbal commandTo voiceTo voice 3

Opens eyes to painTo painTo pain2

Does not open eyesNoneNone1

Verbal Response

Alert and oriented OrientedBabbles, easily consoled5

Converses but disoriented ConfusedIrritable, difficult to console4

Speaking but nonsensical InappropriateCries to pain3

Moans or makes unintelligible soundsGarbledMoans to pain2

No responseNoneNone1

Motor Response

Follows commandsObeys commandsNormal movement6

Localizes painLocalizes pain Withdraws to touch5

Movement or withdrawal to painWithdraws to painWithdraws to pain only4

Abnormal flexion (decorticate)Flexion (decorticate)Flexion (decorticate) 3

Abnormal extension (decerebate) Extension (decerebrate) Extension (decerebrate)2

No responseNoneNone1

Total Score: 3-15

The GCS helps the health care professional assess and determine what intervention to apply to the head injury. Moderate: GCS 9-12. Severe: GSC 8. (For GSC 8 – intubate)

Spinal Injuries

Signs of Spinal Injuries:

Paralysis to the extremitiesPosturing

Pain with or without movementLoss of bowel or bladder control

Tenderness anywhere along the spineSevere spinal shock (neurogenic shock -

Impaired BreathingHR & BP)

Deformity (rare)Soft tissue injuries

Priapism

Emergency Care for Spinal Injuries

Manual in-line c-spine immobilization

Assess ABC’s

Apply C-collar

Assess sensory and motor function in extremities

Oxygen

Spinal Immobilization

  1. Place head in neutral, in-line position and maintain manual immobilization of head. Assess pulses, motor, and sensory functions.
  2. Stabilize the head by applying appropriate size rigid cervical collar (c-collar).
  3. Log roll patient by having someone maintain cervical immobilization while others are placed at shoulder, waist, and knees. Reach across the patient and turn toward you as a unit. The person holding immobilization is in-control.
  4. Place patient on a spine board and secure.

Hemorrhage (Bleeding)

Hemorrhage is the major cause of shock (hypoperfusion). Hemorrhage and Bleeding is classified as either external or internal. Blood and open wounds pose a high risk of infection to the health care provider, always use universal precautions (mask, gloves, gowns & eye protection).

Arterial Bleeding - rapid and profuse, spurting with heart beat

Venous Bleeding – steady flow, dark red; Venous pressure may be lower than atmosphere pressure, large veins may actually suck in debris or air bubble (neck). This may cause abnormal heart rhythms, brain damage and lung injury.

Capillary Bleeding – slow and oozing (minor and easily controlled)

Patient assessment and care always begins with the ABC’s. Always control severe external bleeding in the initial assessment.

Several Major Methods of controlling External Bleeding:

Direct Pressure – most common and effective way to control bleeding; apply direct pressure over the wound until bleeding is controlled then apply bandage – May take 3-5 minutes.

Elevation – elevate the injury above the level of the heart, helps to reduce blood pressure slowing bleeding; avoid using if you suspect musculoskeletal injury, spinal injury

Pressure Points – used when direct pressure and elevation fail to stop external bleeding; it is a site where a large artery lies close to the surface of the body and directly over a bone. Brachial artery is used for bleeding from the upper extremities. Femoral artery is used for bleeding from the lower extremities.

Tourniquet – LAST RESORT; ONLY FOR LIFE-THREATENING. Note the time of application.

Splinting

Care for all painful, swollen, or deformed extremities is splinting. Splinting is used to immobilize adjacent joints and bone ends around injury. For splinting to be effective it must minimize the movement of the injury and decrease pain. Splinting also helps prevent further injury or soft tissue damage. Realignment of a deformed extremity aids in restoring circulation (no pulse).

Three Basic Splints:

  1. Rigid splint – extremity to be moved into anatomical position; provide the best support; Ex: cardboard, wood and pneumatic.
  2. Formable splint – cane be molded to different angles; commonly used for immobilizing joints.
  3. Traction splint – for femur fractures

Before applying a splint, expose the injury. You need to assess the injury and then decide the best device to use. Always assess pulses and sensations distal to the injury. Always splint the injury to stabilize the injury site and adjacent joint and then reassess pulse.

A hazard to splinting can be getting too wrapped up in the splinting process and neglecting the patients ABC’s. Always continue to assess the airway, breathing and circulation.

References: O’Keefe, M., Limmer, D., Grant, H. & etc. (1998) Emergency Care (5th edition); New Jersey; Brady/Prentice Hall.

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