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11
Head and Spinal Head and Spinal Cord TraumaCord Trauma
May 2011 CEMay 2011 CECondell Medical Center Condell Medical Center
EMS SystemEMS SystemSite Code #107200E-1211Site Code #107200E-1211
Objectives by: Mike Higgins, FF/PM Grayslake Fire Objectives by: Mike Higgins, FF/PM Grayslake Fire DepartmentDepartment
Packet by: Sharon Hopkins, RN, BSN, EMT-PPacket by: Sharon Hopkins, RN, BSN, EMT-P
22
ObjectivesObjectivesUpon successful completion of this module, the Upon successful completion of this module, the EMS provider will be able to:EMS provider will be able to:
1.1. List risky behaviors contributing to brain and List risky behaviors contributing to brain and spinal cord injuries.spinal cord injuries.
2.2. Describe typical injury patterns related to Describe typical injury patterns related to specific mechanisms of injury.specific mechanisms of injury.
3. Describe the anatomy of the brain.3. Describe the anatomy of the brain.4. List contents of the skull.4. List contents of the skull.5. Describe the mechanisms for the development 5. Describe the mechanisms for the development
of secondary brain injury.of secondary brain injury.6. Describe the pathophysiology of traumatic brain 6. Describe the pathophysiology of traumatic brain
injuries including pressures related to brain injuries including pressures related to brain blood flow.blood flow.
7. Explain the normal anatomy and physiology of 7. Explain the normal anatomy and physiology of the spinal column and spinal cord.the spinal column and spinal cord.
33
Objectives cont’dObjectives cont’d8. Describe the pathophysiology of traumatic spinal 8. Describe the pathophysiology of traumatic spinal
cord injuries.cord injuries.
9. Describe components of a neurological 9. Describe components of a neurological assessment in the field.assessment in the field.
10. List signs and symptoms of spinal cord injuries.10. List signs and symptoms of spinal cord injuries.
11. Describe the pathophysiology of neurogenic 11. Describe the pathophysiology of neurogenic shock.shock.
12. Describe prehospital treatment based on Region 12. Describe prehospital treatment based on Region X SOP’s of the patient with a head or spinal cord X SOP’s of the patient with a head or spinal cord injury.injury.
13. Review ventilation rates of the stable and 13. Review ventilation rates of the stable and unstable patients with head and/or spinal cord unstable patients with head and/or spinal cord injuries.injuries.
44
Objectives cont’dObjectives cont’d14. Review the Region X Infield Spinal Clearance 14. Review the Region X Infield Spinal Clearance
SOP.SOP.15. Review measurement of fitting a cervical 15. Review measurement of fitting a cervical
collar.collar.16. Review the procedure for demonstrating the 16. Review the procedure for demonstrating the
standing backboard takedown procedure.standing backboard takedown procedure.1717. . Demonstrate the proper measurement Demonstrate the proper measurement
and placement of a cervical collar.and placement of a cervical collar.18. Demonstrate the standing take down 18. Demonstrate the standing take down
with the back board.with the back board.19. Actively participate in case scenario 19. Actively participate in case scenario
discussion.discussion.20. Successfully complete the post quiz with a 20. Successfully complete the post quiz with a
score of 80% or better.score of 80% or better.
55
What’s The Big Deal?What’s The Big Deal?Traumatic brain injury (TBI)Traumatic brain injury (TBI)– Major cause of death and disability in Major cause of death and disability in
multiple trauma patientsmultiple trauma patients– Severe injury indicated with GCS <9Severe injury indicated with GCS <9
66
TBI StatisticsTBI Statistics
Many Many patients will patients will be minors, be minors, therefore, therefore, you will also you will also be dealing be dealing with with parents and parents and caregiverscaregivers
77
Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)40% of trauma patients have CNS injury40% of trauma patients have CNS injuryDeath rate twice as high (35%) as patient Death rate twice as high (35%) as patient without CNS injurywithout CNS injuryAccount for 25% of all trauma deathsAccount for 25% of all trauma deathsAccount for up to 50% of all MVC deathsAccount for up to 50% of all MVC deathsCost worldwide is hugeCost worldwide is huge– Lives lostLives lost– Families destroyedFamilies destroyed– Money spent for careMoney spent for care
CNS – central nervous systemCNS – central nervous system
88
Risky Activities Resulting in Spinal Risky Activities Resulting in Spinal Cord InjuriesCord Injuries
MVC – 44.5% - major causeMVC – 44.5% - major cause– SUV’s & jeeps prone to flippingSUV’s & jeeps prone to flipping
Falls 18.1% Falls 18.1% – Most common in persons >45 years of ageMost common in persons >45 years of age
Violence 16.6% Violence 16.6% – More common in urban settingsMore common in urban settings
Sports 12.7%Sports 12.7%– Diving most common contributing sportDiving most common contributing sport
Other medical causes make up <10%Other medical causes make up <10%
99
Typical Head/Neck Injury PatternsTypical Head/Neck Injury PatternsT-bone – lateral impactT-bone – lateral impact– Coup/contrecoup head injuriesCoup/contrecoup head injuries– Neck strain up to fracturesNeck strain up to fractures– Most injuries from collision with inside of vehicleMost injuries from collision with inside of vehicleRear impactRear impact– Hyperextension of neck esp if head rest not fittedHyperextension of neck esp if head rest not fitted– Lumbar spine injury if seat breaksLumbar spine injury if seat breaksRolloverRollover– Body impacted in all directions so injury potential Body impacted in all directions so injury potential
highhigh– Increased chance for axial loading on spineIncreased chance for axial loading on spine– Often lethal injuries when ejectedOften lethal injuries when ejected
1010
Typical Head/Neck Injury PatternsTypical Head/Neck Injury Patterns
ATVATV– Injuries depend on MOI and part of body Injuries depend on MOI and part of body
impactedimpacted– High index of suspicions for head and High index of suspicions for head and
spinal injuriesspinal injuries
Falls from heightFalls from height– Evaluate distance, body area impacted, Evaluate distance, body area impacted,
type of surface strucktype of surface struck– Landing on feet, check for axial loading Landing on feet, check for axial loading
to lumbar and cervical spine areasto lumbar and cervical spine areas
1111
Anatomy of Anatomy of the Skullthe Skull
Scalp highly vascularScalp highly vascularSkull is rigid boneSkull is rigid bone– Serves as protectionServes as protection
Dura materDura mater– Tough fibrous covering of Tough fibrous covering of
brainbrainArachnoid materArachnoid mater– Lies under duraLies under dura– Arteries & veins Arteries & veins
suspended from thissuspended from thisPia materPia mater– On surface of brainOn surface of brain
1212
Anatomy of the BrainAnatomy of the Brain
Each lobe has a unique functionEach lobe has a unique function
Identified disabilities can help Identified disabilities can help pinpoint area of insult or injurypinpoint area of insult or injury– Proper assessment can point to area of Proper assessment can point to area of
injuryinjury– Always reassess watching for trendsAlways reassess watching for trends
1313
Anatomy of the BrainAnatomy of the Brain
CerebrumCerebrum– Frontal lobeFrontal lobe
PersonalityPersonalityJudgmentJudgment
– Temporal lobeTemporal lobeHearingHearingMemoryMemory
– Parietal lobeParietal lobeLanguage Language formation; formation; processing processing sensessenses
– Occipital lobeOccipital lobeVisionVision
1414
Anatomy cont’dAnatomy cont’dCerebellumCerebellum– Control of movement, Control of movement,
balance, coordinationbalance, coordinationBrainstem Brainstem – arousal & consciousness center; arousal & consciousness center;
involved in basic life functions involved in basic life functions breathing, reflexesbreathing, reflexes
– Pons – motor & sensory relay Pons – motor & sensory relay centercenter
– Medulla- controls autonomic Medulla- controls autonomic functions (breathing, functions (breathing, digestion, heart & blood digestion, heart & blood vessel functionvessel function
1515
Contents of the SkullContents of the Skull
There is no extra spaceThere is no extra spaceIf one component increases, usually If one component increases, usually brain tissue swelling, it is usually at brain tissue swelling, it is usually at sacrifice of one of the other componentssacrifice of one of the other components– Brain – 80%Brain – 80%– Blood volume – 10% (150 ml) Blood volume – 10% (150 ml) – CSF – 10% (150 ml )CSF – 10% (150 ml )
CSF – cerebral spinal fluidCSF – cerebral spinal fluid
1616
Brain FunctionBrain FunctionBrain VERY sensitive to levels of Brain VERY sensitive to levels of oxygenoxygen and and glucoseglucose– Brain has a high metabolic rate both at Brain has a high metabolic rate both at
rest or engaged in activityrest or engaged in activity– Brain is 2% of total body weightBrain is 2% of total body weight– Receives 15% of cardiac outputReceives 15% of cardiac output– Consumes 20% of body’s oxygenConsumes 20% of body’s oxygen– Relies on aerobic metabolismRelies on aerobic metabolism– Needs constant availability of glucose, Needs constant availability of glucose,
thiamine (to metabolize glucose), and thiamine (to metabolize glucose), and oxygenoxygen
1717
Comparative Blood Flow in ml/minuteComparative Blood Flow in ml/minute
OrganOrgan At restAt rest During strenuous During strenuous activityactivity
HeartHeart 250250 750750
SkinSkin 400400 19001900
OtherOther 600600 400400
BrainBrain 750750 Steady at 750Steady at 750
Skeletal muscleSkeletal muscle 10001000 12,50012,500
KidneysKidneys 12001200 600600
VisceraViscera 14001400 600600
TotalTotal 56005600 17,50017,500
1818
Adding Insult to InjuryAdding Insult to InjuryCoup-contrecoup injuriesCoup-contrecoup injuries– Brain shifts/floats inside skullBrain shifts/floats inside skull
Base of skull rough – causes more injuryBase of skull rough – causes more injury
– Injuries at point of impact and away Injuries at point of impact and away from point of impactfrom point of impact
Ex: forehead injury Ex: forehead injury can result in can result in additional injury additional injury to occipital areato occipital area
1919
Secondary InjurySecondary Injury
Primary injury occurs at time of insultPrimary injury occurs at time of insult
Secondary injury occurs later as a Secondary injury occurs later as a result of what happens initiallyresult of what happens initially
Initial swelling causes decreased Initial swelling causes decreased perfusionperfusion
Secondary complications stem from Secondary complications stem from hypoxia and decreased perfusionhypoxia and decreased perfusion
2020
What is your major focus?What is your major focus?Management of injury focused onManagement of injury focused on– Proper care Proper care
Identification of injuries Identification of injuries – An accurate general impression An accurate general impression
leads to appropriate careleads to appropriate careAppropriate interventions initiatedAppropriate interventions initiated
– Rapid transport to secondary careRapid transport to secondary care
Do things right to prevent Do things right to prevent contributing to secondary injuriescontributing to secondary injuries
2121
Common Problems Related To TBICommon Problems Related To TBI
Airway compromiseAirway compromiseInadequate ventilationInadequate ventilationHypotension Hypotension – An independent risk factor contributing An independent risk factor contributing
to mortalityto mortality
Focus on these critical aspects and Focus on these critical aspects and perform appropriate interventions as perform appropriate interventions as neededneeded
2222
Pressures Related to Blood flowPressures Related to Blood flowICP is pressure of brain and contents ICP is pressure of brain and contents within skullwithin skullCPP - cerebral perfusion pressureCPP - cerebral perfusion pressure– Pressure of blood flowing thru Pressure of blood flowing thru
brain; pressure necessary to brain; pressure necessary to perfuse brain (CPP=MAP-ICP)perfuse brain (CPP=MAP-ICP)
MAP - mean arterial pressureMAP - mean arterial pressure– Average pressure within an artery; Average pressure within an artery;
pressure maintained in vascular pressure maintained in vascular systemsystem
2323
Reflexive Response to Reflexive Response to ICPICPCushing’s reflexCushing’s reflex– Protective response to preserve blood flow to Protective response to preserve blood flow to
the brainthe brainB/P will increaseB/P will increaseSystolic B/P increasing as diastolic B/P Systolic B/P increasing as diastolic B/P
stays same or increasesstays same or increasesWidening pulse pressureWidening pulse pressure
Heart rate will decrease Heart rate will decrease Effort to lower elevating blood pressureEffort to lower elevating blood pressure
Respirations may be irregularRespirations may be irregular
Note vital signs move opposite to Note vital signs move opposite to shockshock
2424
Cerebral PerfusionCerebral PerfusionBrain requires unique range to functionBrain requires unique range to functionIncreased ICP causes brain herniationIncreased ICP causes brain herniationHypotension not tolerated with Hypotension not tolerated with ICPICPExamples of problems*:Examples of problems*:– MAP constant + ICP MAP constant + ICP = = CPP CPP– MAP decreases + ICP steady = MAP decreases + ICP steady = CPP CPP– MAP decreases + ICP MAP decreases + ICP = CPP critical= CPP critical
Any negative change in B/P or ICP affects Any negative change in B/P or ICP affects blood flow in brainblood flow in brain
*Normal values of MAP, ICP, and CPP listed in Notes section*Normal values of MAP, ICP, and CPP listed in Notes section
2525
Signs and Symptoms Head InjurySigns and Symptoms Head Injury
Use inspection/observational skills Use inspection/observational skills with mechanism of injury to increase with mechanism of injury to increase suspicion of head and neck injuriessuspicion of head and neck injuries
2626
Brain Injuries - ConcussionBrain Injuries - ConcussionPrevalent in athletic activitiesPrevalent in athletic activitiesNo structural injury to brainNo structural injury to brainOften brief loss of consciousness or, at Often brief loss of consciousness or, at minimum, confusion, then return to minimum, confusion, then return to normalnormalPossible amnesia (short-term retrograde)Possible amnesia (short-term retrograde)Short term memory loss – will ask Short term memory loss – will ask repetitive questionsrepetitive questionsDizziness, headache, ringing in ears, Dizziness, headache, ringing in ears, nauseanausea
2727
Brain Injuries – Cerebral ContusionBrain Injuries – Cerebral Contusion
Bruised brain tissueBruised brain tissueHistory prolonged unconsciousness History prolonged unconsciousness or serious altered level of or serious altered level of consciousness (confusion, amnesia, consciousness (confusion, amnesia, abnormal behavior)abnormal behavior)Focal neurological signsFocal neurological signs– Related to a specific area of the brainRelated to a specific area of the brain– Weakness, speech problems, personality Weakness, speech problems, personality
or behavioral changesor behavioral changes
2828
Brain Injuries – Subarachnoid Brain Injuries – Subarachnoid HemorrhageHemorrhage
Blood in subarachnoid spaceBlood in subarachnoid space– Traumatic injury or spontaneousTraumatic injury or spontaneous
Blood causes irritationBlood causes irritation
Severe headacheSevere headache– ““Worst headache of my life”Worst headache of my life”
ComaComa
VomitingVomiting
2929
Brain Injuries – Diffuse Axonal Brain Injuries – Diffuse Axonal InjuryInjury
Most common type of injury from Most common type of injury from blunt head traumablunt head trauma
Generalized, diffuse edemaGeneralized, diffuse edema
UnconsciousUnconscious
No focal deficitsNo focal deficits– Swelling, edema, injury too widespread Swelling, edema, injury too widespread
so no specific isolated sign/symptom so no specific isolated sign/symptom pointing to 1 area of the brainpointing to 1 area of the brain
3030
Brain Injuries – Acute Epidural Brain Injuries – Acute Epidural HematomaHematoma
Bleeding between dura and skullBleeding between dura and skullOften from tear in middle meningeal artery Often from tear in middle meningeal artery from skull fracture in temporal areafrom skull fracture in temporal area– Runs along inside of skull in temporal areaRuns along inside of skull in temporal area– Arterial bleed so onset usually rapid for Arterial bleed so onset usually rapid for
signs/symptomssigns/symptoms
Initial loss of consciousness and now lucidInitial loss of consciousness and now lucidSigns Signs ICP after few hours ICP after few hours– Vomiting, headache, altered mental statusVomiting, headache, altered mental status– Motor deficit opposite side to injury (contralateral)Motor deficit opposite side to injury (contralateral)– Dilated, fixed pupil on side of injury (ipsilateral)Dilated, fixed pupil on side of injury (ipsilateral)
3131
Brain Injuries – Acute Subdural Brain Injuries – Acute Subdural HematomaHematoma
Bleeding between dura and arachnoidBleeding between dura and arachnoid
Bleeding is venousBleeding is venous
Slow onset to Slow onset to ICP (hours, days) ICP (hours, days)
Headache, changing level of consciousness, Headache, changing level of consciousness, focal neurological signsfocal neurological signs– Weakness one sided, slurred speechWeakness one sided, slurred speech
Poor prognosis due to associated brain tissue Poor prognosis due to associated brain tissue injuryinjury
High risk: elderly, anticoagulant use, chronic High risk: elderly, anticoagulant use, chronic alcoholicsalcoholics
3232
Brain Injuries – Intracerebral Brain Injuries – Intracerebral HemorrhageHemorrhage
Bleeding within brain tissueBleeding within brain tissue
Blunt or penetrating injuriesBlunt or penetrating injuries
Surgery not often helpfulSurgery not often helpful
Signs and symptoms depend on region of Signs and symptoms depend on region of brain injuredbrain injured
Patterns similar to a patient with a strokePatterns similar to a patient with a stroke
Altered level of consciousness commonAltered level of consciousness common
If awake, complain of headache & If awake, complain of headache & vomitingvomiting
3333
Spinal ColumnSpinal Column
Spinal column is the bony tube Spinal column is the bony tube of 33 vertebrae separated by of 33 vertebrae separated by discs that act as shock discs that act as shock absorbersabsorbers
Alignment maintained by Alignment maintained by strong ligaments and musclesstrong ligaments and muscles
Supports body in upright Supports body in upright positionposition
Allows use of extremitiesAllows use of extremities
Protects delicate spinal cordProtects delicate spinal cord
3434
Spinal CordSpinal Cord
Electrical conduitElectrical conduit
Extension of brain stemExtension of brain stem
Continues down to first lumbar Continues down to first lumbar vertebrae then separates into nervesvertebrae then separates into nerves
Surrounded and bathed by Surrounded and bathed by cerebrospinal fluidcerebrospinal fluid
Cerebrospinal fluid and flexibility Cerebrospinal fluid and flexibility provide some protectionprovide some protection
3636
Spinal Cord cont’dSpinal Cord cont’dNerve roots exit at each vertebral levelNerve roots exit at each vertebral level– Nerve roots carry signals from brain to Nerve roots carry signals from brain to
specific sitesspecific sites– Nerve roots carry sensory signals from Nerve roots carry sensory signals from
body to spinal cord to brainbody to spinal cord to brain– Susceptible to Susceptible to
traumatic injurytraumatic injury
3737
Spinal Cord cont’dSpinal Cord cont’d
Integrates/brings together the Integrates/brings together the autonomic nervous systemautonomic nervous system– 2 components: parasympathetic 2 components: parasympathetic
and sympathetic nervous systemand sympathetic nervous system– Assists in controlling Assists in controlling
Heart rateHeart rate
Blood vessel toneBlood vessel tone
Blood flow to skinBlood flow to skin
3838
Mechanisms of InjuryMechanisms of InjuryPenetrating Penetrating injuriesinjuries– Secure the Secure the
object in object in position position foundfound
– Do no Do no further further harm!harm!
3939
Mechanisms of Blunt Spinal InjuryMechanisms of Blunt Spinal Injury
HyperextensionHyperextension– Excessive posterior movement of head Excessive posterior movement of head
or neckor neckFace into windshieldFace into windshieldElderly person falling to floor, striking chinElderly person falling to floor, striking chinFootball tacklerFootball tacklerDive into shallow waterDive into shallow water
HyperflexionHyperflexion– Excessive anterior movement of head Excessive anterior movement of head
onto chestonto chestRider thrown from horse or motorcycleRider thrown from horse or motorcycleDive into shallow waterDive into shallow water
4040
Mechanisms cont’dMechanisms cont’d
CompressionCompression– Weight of head or pelvis driven into Weight of head or pelvis driven into
stationary neck or torsostationary neck or torsoDive into shallow waterDive into shallow water
Fall onto head or legs >10-20 feetFall onto head or legs >10-20 feet
RotationRotation– Excessive rotation of torso or head & Excessive rotation of torso or head &
neck; moves one side of spinal column neck; moves one side of spinal column against other sideagainst other side
Rollover MVCRollover MVC
Motorcycle crashMotorcycle crash
4141
Mechanism cont’dMechanism cont’dLateral stressLateral stress– Direct lateral force on spinal column; Direct lateral force on spinal column;
typical shearing one level of cord from typical shearing one level of cord from anotheranother
T-bone MVCT-bone MVC
DistractionDistraction– Excessive stretching of column and cordExcessive stretching of column and cord
HangingHangingChild inappropriately wearing shoulder belt Child inappropriately wearing shoulder belt around neckaround neck““Clothes lining” with snowmobile or Clothes lining” with snowmobile or motorcycle riders and passengersmotorcycle riders and passengers
4242
Disk ProblemsDisk Problems
A preexisting A preexisting problem can problem can be aggravated be aggravated at time of at time of injuryinjury
4343
Spinal Cord InjuriesSpinal Cord InjuriesComplete injuryComplete injury– No function, sensation, voluntary No function, sensation, voluntary
movement below level of injurymovement below level of injury– Both sides affected equallyBoth sides affected equally
Incomplete injuryIncomplete injury– Some function preserved below level of Some function preserved below level of
injuryinjury– May move 1 limb more than otherMay move 1 limb more than other– May have more function on 1 side of May have more function on 1 side of
body than otherbody than other– May have sensation but no movementMay have sensation but no movement
4444
Spinal Cord InjuriesSpinal Cord InjuriesTetraplegia (also referred to as Tetraplegia (also referred to as quadriplegia)quadriplegia)– Injury in cervical areaInjury in cervical area– Loss of muscle strength in all 4 extremitiesLoss of muscle strength in all 4 extremities
ParaplegiaParaplegia– Injury in spinal cord in thoracic, lumbar or Injury in spinal cord in thoracic, lumbar or
sacral segmentssacral segments– Level of impairment dependent on level of Level of impairment dependent on level of
injuryinjury
4545
Spinal Cord Injury PatternsSpinal Cord Injury PatternsCervical area injury = quadriplegicCervical area injury = quadriplegic
C1-C2 – may lose involuntary function of C1-C2 – may lose involuntary function of breathingbreathing– Watch for excessive use of abdominal muscles Watch for excessive use of abdominal muscles
to breathto breath
C4 and above – often require use of C4 and above – often require use of ventilator for breathingventilator for breathing
C5 – shoulder/bicep control but no control C5 – shoulder/bicep control but no control of hand or wristof hand or wrist
C6 – wrist control but no hand functionC6 – wrist control but no hand function
4646
Spinal Cord Injury PatternsSpinal Cord Injury PatternsC7-T1 – can straighten arms, dexterity C7-T1 – can straighten arms, dexterity problem with fingers and handsproblem with fingers and handsThoracic level and below = paraplegicThoracic level and below = paraplegicT1-T8 – has control of hands, poor T1-T8 – has control of hands, poor trunk control due to lack of abdominal trunk control due to lack of abdominal muscle controlmuscle controlT9-T12 – good trunk & abdominal T9-T12 – good trunk & abdominal muscle control; sitting balance good. muscle control; sitting balance good. Decreased control hip flexor and legsDecreased control hip flexor and legs
4747
Spinal Cord Injury ConsequencesSpinal Cord Injury Consequences
Often experience:Often experience:– Bowel and bladder dysfunctionBowel and bladder dysfunction– Male fertility often affectedMale fertility often affected– Inability to regulate B/P; hypotension Inability to regulate B/P; hypotension
usualusual– Inability to sweat below level of injuryInability to sweat below level of injury– Decrease control to regulate body Decrease control to regulate body
temperaturetemperature– Chronic painChronic pain
4848
DermatomesDermatomes
Mapping of Mapping of bodybodyEasier to Easier to identify identify injured areas injured areas by isolating by isolating location of location of complaints as complaints as related to related to zones of zones of altered altered sensationsensation
4949
Neurogenic ShockNeurogenic ShockOccurs when brain signals Occurs when brain signals interrupted for autonomic functionsinterrupted for autonomic functionsAbility to vasoconstrict limitedAbility to vasoconstrict limited– No sympathetic tone, vessels dilateNo sympathetic tone, vessels dilate
Relative hypovolemiaRelative hypovolemia preloadpreload ventricular filling ventricular filling Frank Frank
Starling reflex Starling reflex contraction strengthcontraction strength cardiac outputcardiac output
– No hormone release to No hormone release to heart rateheart rate
5050
Neurogenic ShockNeurogenic Shock
Signs and symptomsSigns and symptoms– BradycardiaBradycardia– HypotensionHypotension– Cool, moist, pale skin above cord Cool, moist, pale skin above cord
injuryinjury– Warm, dry, flushed skin below cord Warm, dry, flushed skin below cord
injuryinjury
5151
Neurological AssessmentNeurological AssessmentSerial vital signs – watch for:Serial vital signs – watch for: ICP: ICP: B/P; B/P; pulse ratepulse rate– Neurogenic shock Neurogenic shock B/P; B/P; pulse; skin warm and pulse; skin warm and
dry below level of injurydry below level of injury
Serial AVPUSerial AVPUSerial GCSSerial GCSPupillary responsePupillary responseResponse to motor and sensoryResponse to motor and sensory– Included in CMS, SMV, PMS assessmentIncluded in CMS, SMV, PMS assessment
Babinski reflex present – big toe extends Babinski reflex present – big toe extends up when sole stroked from heel to toeup when sole stroked from heel to toe
5252
Signs and Symptoms Spinal Cord Signs and Symptoms Spinal Cord Injury (ie: “Clues”)Injury (ie: “Clues”)
Pain on movement of back or spinal cordPain on movement of back or spinal cordDeformityDeformityGuarding against movementGuarding against movementLoss of sensationLoss of sensationInability to moveInability to moveWeak or flaccid musclesWeak or flaccid musclesAbnormal positioningAbnormal positioningLoss of control of bladder or bowelsLoss of control of bladder or bowelsPriapism – erection of penisPriapism – erection of penisNeurogenic shockNeurogenic shock
5353
Focus of Field TreatmentFocus of Field TreatmentProvide adequate airwayProvide adequate airway
Monitor for effective oxygenation and Monitor for effective oxygenation and ventilationventilation
Maintain CPP (cerebral perfusion pressure)Maintain CPP (cerebral perfusion pressure)– Can’t measure easily in fieldCan’t measure easily in field– So watch systolic blood pressureSo watch systolic blood pressure
Something EMS can monitor in the Something EMS can monitor in the fieldfield
Assume low B/P due to hypovolemia until Assume low B/P due to hypovolemia until proven otherwiseproven otherwise
5454
Region X SOPRegion X SOPRoutine trauma careRoutine trauma care– Scene size-upScene size-up
Determining mechanism of injury could be Determining mechanism of injury could be good tip-off to suspected injuriesgood tip-off to suspected injuries
– Initial/primary surveyInitial/primary surveyIdentify and treat life threatsIdentify and treat life threats
– Identify transport priorityIdentify transport priority– Perform rapid trauma survey if critical or Perform rapid trauma survey if critical or
life threats foundlife threats found– Focused exam on minor injuriesFocused exam on minor injuries
5555
Region X SOP Head/Spinal InjuriesRegion X SOP Head/Spinal Injuries
Routine trauma careRoutine trauma careObtain GCSObtain GCS– GCS<9 indicates severe brain injuryGCS<9 indicates severe brain injury
IV fluid challenge (200 ml IV fluid challenge (200 ml increments) if B/P <90mmHgincrements) if B/P <90mmHgIf altered LOC obtain blood glucoseIf altered LOC obtain blood glucose– If <60 treat with DextroseIf <60 treat with Dextrose
Assess oxygenationAssess oxygenation– Maintain SpOMaintain SpO22 >94% >94%
5656
Ventilation RatesVentilation Rates Stable Head/Spinal Injuries Stable Head/Spinal Injuries
Relatively stable patient needing BVM Relatively stable patient needing BVM assistance with 100% Oassistance with 100% O22
Adult 10 breaths/min Adult 10 breaths/min
1 breath every 6 seconds1 breath every 6 seconds
Child 20 breaths/minChild 20 breaths/min
1 breath every 3 seconds1 breath every 3 seconds
Infant 25 breaths/min Infant 25 breaths/min
1 breath every 2.5 seconds1 breath every 2.5 seconds
5757
Ventilation RatesVentilation Rates Unstable Head/Spinal Injuries Unstable Head/Spinal Injuries
Rapid neurological deteriorationRapid neurological deterioration– Unequal pupils, posturing, lateralizing Unequal pupils, posturing, lateralizing
signssignsSigns indicating a deficit related to one of the Signs indicating a deficit related to one of the hemisphereshemispheres
– Example: speech problem, hemiparesis, abnormal Example: speech problem, hemiparesis, abnormal reflexes, facial asymmetry, abnormal eye movementreflexes, facial asymmetry, abnormal eye movement
– Ventilate with BVM and 100% OVentilate with BVM and 100% O22
Adult 20 breaths/minute (1 every 3 seconds)Adult 20 breaths/minute (1 every 3 seconds)
Child 30 breaths/minute (1 every 2 seconds)Child 30 breaths/minute (1 every 2 seconds)
Infant 35 breaths/min (1 every 1.7 seconds)Infant 35 breaths/min (1 every 1.7 seconds)
5858
Hazards of HyperventilationHazards of HyperventilationHyper/hypoventilation refers to level of Hyper/hypoventilation refers to level of COCO22 maintained in body maintained in body
Capnography is the ideal measurement Capnography is the ideal measurement tool for exhaled COtool for exhaled CO2 2 levelslevels
Levels of COLevels of CO22 influence vessel size influence vessel size RR RR COCO2 2 retained retained vasodilationvasodilation
RRRR COCO22 retained retained vasoconstrictionvasoconstriction
– Either way, the brain does not get perfused Either way, the brain does not get perfused
Hypoxia developsHypoxia develops– Hypoxia Hypoxia anaerobic metabolism anaerobic metabolism acidosisacidosis
5959
Unhealthy EnvironmentUnhealthy Environment
Hypo and hyperventilation both with Hypo and hyperventilation both with adverse consequences for the adverse consequences for the patientpatient
Development of hypoxia and acidosisDevelopment of hypoxia and acidosis– Hypoxia is NOT tolerated in the brainHypoxia is NOT tolerated in the brain
Cells do not function well in this Cells do not function well in this environmentenvironment
Interventions not effective in this Interventions not effective in this environmentenvironment
6060
Trauma PatientTrauma Patient
Assume any injury from the clavicles Assume any injury from the clavicles on up includes a head and/or spinal on up includes a head and/or spinal cord injurycord injury– Cannot clear the c-spineCannot clear the c-spine– Perform spinal motion restrictionPerform spinal motion restriction
Also referred to as c-spine controlAlso referred to as c-spine control
Avoid use of word “traction” as you are not Avoid use of word “traction” as you are not pulling on the head and neckpulling on the head and neck
6161
In-field Spinal ClearanceIn-field Spinal ClearanceEvaluateEvaluate– Mechanism of injuryMechanism of injury– Signs and symptomsSigns and symptoms– Patient reliabilityPatient reliability
When in doubt, fully immobilizeWhen in doubt, fully immobilizeDocument assessment and findings Document assessment and findings to support application of motion to support application of motion restriction/immobilization devices or restriction/immobilization devices or when not using equipment when not using equipment
6262
Cervical Collar MeasurementCervical Collar Measurement
Why do we keep talking about how to Why do we keep talking about how to measure for placing a cervical collar?measure for placing a cervical collar?– We still see a high number of patients We still see a high number of patients
transported to the ED with cervical transported to the ED with cervical collars in the no-neck positioncollars in the no-neck position
6363
IF THE MAJORITY OF YOUR IF THE MAJORITY OF YOUR PATIENTS ARE WEARING PATIENTS ARE WEARING
A NO-NECK SIZED A NO-NECK SIZED COLLAR, THEN YOU ARE COLLAR, THEN YOU ARE
NOTNOT PROPERLY PROPERLY MEASURING THEM!MEASURING THEM!
6464
Measuring for Cervical CollarMeasuring for Cervical Collar
Measure eyeing Measure eyeing horizontalhorizontal line from line from bottom of chin to top of shoulderbottom of chin to top of shoulder
Measure on collar plastic from Measure on collar plastic from bottom up to closest hole openingbottom up to closest hole opening
Collar should rest on Collar should rest on clavicles & support the clavicles & support the jawjaw
6666
Standing BackboardStanding BackboardPurposePurpose– To place the ambulatory patient into a To place the ambulatory patient into a
supine position without compromising the supine position without compromising the spinespine
To rapidly move the patient into the supine To rapidly move the patient into the supine position will need 3 persons, a cervical position will need 3 persons, a cervical collar, and a long backboardcollar, and a long backboard– Strapping can be (and most often is best) Strapping can be (and most often is best)
applied once the patient is supineapplied once the patient is supine
6767
Standing BackboardStanding BackboardPosition tallest crew member behind patientPosition tallest crew member behind patient– Manual stabilization/motion restriction of c-Manual stabilization/motion restriction of c-
spine takenspine taken
22ndnd EMT measures and applies cervical collar EMT measures and applies cervical collar while manual control maintainedwhile manual control maintained
2 EMT’s position backboard between patient 2 EMT’s position backboard between patient and person maintaining manual and person maintaining manual stabilization/motion restriction of head and stabilization/motion restriction of head and neckneck
6868
Standing BackboardStanding Backboard
22ndnd and 3 and 3rdrd EMT’s reach hand nearest EMT’s reach hand nearest to patient under the patient’s armpit to patient under the patient’s armpit and grasps the backboardand grasps the backboard
Patient will be temporarily suspended Patient will be temporarily suspended by the armpits as the backboard is by the armpits as the backboard is loweredlowered
As the signal is given, the backboard As the signal is given, the backboard is slowly lowered is slowly lowered
6969
Standing BackboardStanding Backboard
Person with manual stabilization Person with manual stabilization walks backward to keep up with the walks backward to keep up with the lowering pitch of the backboardlowering pitch of the backboard
RememberRemember– Heaviest weight of head is in occipital Heaviest weight of head is in occipital
areaarea
Have fingers/hands spread in good Have fingers/hands spread in good position to support the head before position to support the head before changing the patient’s positioningchanging the patient’s positioning
7070
Backboard Backboard slowlyslowly
lowered lowered using multiple using multiple personnel and personnel and keeping head keeping head
and neck and neck immobilizedimmobilized
7171
Standing BackboardStanding BackboardAs the board is lowered, all 3 persons work As the board is lowered, all 3 persons work very closely togethervery closely together
Once the backboard is lowered, the patient Once the backboard is lowered, the patient may need to be adjusted onto the backboard may need to be adjusted onto the backboard
Complete spinal immobilization/motion Complete spinal immobilization/motion restriction process by securing the patient to restriction process by securing the patient to the backboardthe backboard
Rescuers need to watch their own body Rescuers need to watch their own body mechanics to prevent injurymechanics to prevent injury
7272
Case Scenarios Case Scenarios Divide into smaller groupsDivide into smaller groupsRead the presentationRead the presentationForm a general impressionForm a general impressionDiscuss treatment optionsDiscuss treatment optionsDiscuss what/how/when to reassess the Discuss what/how/when to reassess the patientpatientDecide what treatment to continue or what Decide what treatment to continue or what adjustments need to be madeadjustments need to be madePresent to the group and give explanation Present to the group and give explanation to defend your decisionsto defend your decisions
7373
Case Scenario # 1Case Scenario # 117 y/o patient injured at bike track17 y/o patient injured at bike track– Fell head first off bikeFell head first off bike
Conscious, confusedConscious, confusedVS: 92/50; 60; 14VS: 92/50; 60; 14Repeat: 84/46; 54; 14Repeat: 84/46; 54; 14Arms not movingArms not movingLegs moveLegs movec/o pain to neckc/o pain to neckWarm & dryWarm & dry
7474
Case Scenario # 1Case Scenario # 1No allergies; no medicationsNo allergies; no medicationsNo medical historyNo medical historyLast ate 2 hours agoLast ate 2 hours agoDoesn’t remember how he wiped outDoesn’t remember how he wiped outReported to lose control speeding around Reported to lose control speeding around tracktrackUpon arrival, bystanders holding c-spineUpon arrival, bystanders holding c-spineNo movement detected in upper No movement detected in upper extremities; lower ext move spontaneouslyextremities; lower ext move spontaneouslyIf “belly” breathing noted, what does it If “belly” breathing noted, what does it mean?mean?– Excessive use of abdominal musclesExcessive use of abdominal muscles– Watch for respiratory arrestWatch for respiratory arrest
7575
Case Scenario #1Case Scenario #1
Treatment/interventionsTreatment/interventions– C-spine control - Spinal motion C-spine control - Spinal motion
restriction restriction
– IV – OIV – O2 2 – monitor (what should be – monitor (what should be enroute?)enroute?)
– FluidsFluids– Prepare to support ventilationsPrepare to support ventilations– Obtain blood glucose levelObtain blood glucose level
7676
Case Scenario #1Case Scenario #1Patient had spinal cord injuryPatient had spinal cord injury– Central cord syndrome most common Central cord syndrome most common
with hyperextensionwith hyperextension– Weakness/impairment in arms & handsWeakness/impairment in arms & hands– Legs are sparedLegs are spared– Variable loss of sensationVariable loss of sensation
Exhibiting neurogenic shockExhibiting neurogenic shock B/P; bradycardiaB/P; bradycardia– Tank expanded with vasodilation – Tank expanded with vasodilation –
needs IV fluidsneeds IV fluids
7777
Case Scenario #1Case Scenario #1Belly breathing indicates cervical Belly breathing indicates cervical injury until proven otherwiseinjury until proven otherwiseChest muscles and diaphragm not Chest muscles and diaphragm not being used for ventilationbeing used for ventilationAbdominal muscles back up to Abdominal muscles back up to ventilateventilate– Not use to this functionNot use to this function– Will tire/fatigueWill tire/fatigue– Patient may respiratory arrestPatient may respiratory arrest
7878
Case Scenario # 2Case Scenario # 2
41 y/o male restrained driver T-boned 41 y/o male restrained driver T-boned by SUVby SUV
Unconscious, shallow respirationsUnconscious, shallow respirations
Vital signs: 146/82, 94, 32, SpOVital signs: 146/82, 94, 32, SpO22 94% 94%
Blood draining from left ear and left Blood draining from left ear and left naresnares
Diminished breath sounds on leftDiminished breath sounds on left
Deformed left arm, left femurDeformed left arm, left femur
7979
Case Scenario # 2Case Scenario # 2GCS:GCS:– Eye opening – noneEye opening – none– Verbal response – moansVerbal response – moans– Motor – Withdrawing on left, no movement on Motor – Withdrawing on left, no movement on
rightright
Repeat VS: 168/72, 44, 16Repeat VS: 168/72, 44, 16Pupils: fixed/dilated left, right minimally Pupils: fixed/dilated left, right minimally reactivereactiveWhat would raccoon eyes or Battle’s signs What would raccoon eyes or Battle’s signs indicate?indicate?
8080
Case Scenario #2Case Scenario #2
Treatment/interventionsTreatment/interventions– C-spine control - Spinal motion restriction C-spine control - Spinal motion restriction
– IV – OIV – O2 2 – monitor (what should be – monitor (what should be enroute?)enroute?)
– BVM support at 20/minute (1 every 3 BVM support at 20/minute (1 every 3 seconds) (patient unstable)seconds) (patient unstable)
– Rapid transport to highest trauma level Rapid transport to highest trauma level within 25 minuteswithin 25 minutes
– Obtain blood glucose levelObtain blood glucose level
8181
Case Scenario #2Case Scenario #2
Patient injuriesPatient injuries– Fractured skull Fractured skull
Raccoon eyes indicate anterior basilar skull fxRaccoon eyes indicate anterior basilar skull fx
– Epidural bleed Epidural bleed – Fractured left clavicleFractured left clavicle– Fractured ribs with hemothoraxFractured ribs with hemothorax– Fractured left humerousFractured left humerous– Fractured pelvisFractured pelvis– Fractured left femurFractured left femur
8282
Case Scenario # 3Case Scenario # 3
60 y/o female riding her bike60 y/o female riding her bike
Hit pothole and fell off bikeHit pothole and fell off bike
Helmet damagedHelmet damaged
Short loss of consciousness; asking Short loss of consciousness; asking repetitive questions; nauseated; repetitive questions; nauseated; complains of headache and blurred complains of headache and blurred visionvision
Vital signs: 132/78, P-98, R-20, SpOVital signs: 132/78, P-98, R-20, SpO22 99%99%
8383
Case Scenario # 3Case Scenario # 3
GCS: eye opening spontaneousGCS: eye opening spontaneous– Verbal – slightly confusedVerbal – slightly confused– Motor – obeys commandsMotor – obeys commands
Pupils: PERLPupils: PERL
8484
Case Scenario #3Case Scenario #3Treatment/interventionsTreatment/interventions– C-spine control – spinal motion restrictionC-spine control – spinal motion restriction
Patient not reliablePatient not reliable– IV–OIV–O22–monitor (what should be enroute?)–monitor (what should be enroute?)– Watch for nausea and vomiting to protect Watch for nausea and vomiting to protect
airwayairway– Trend vital signs and level of Trend vital signs and level of
consciousnessconsciousness– Check blood sugar levelCheck blood sugar level
Patient has altered level of Patient has altered level of consciousnessconsciousness
8585
Case Scenario # 3Case Scenario # 3
GCS – 4-4-6; Total 14GCS – 4-4-6; Total 14
Patient had a concussionPatient had a concussion
Admitted overnight for observationAdmitted overnight for observation
Continued to have a mild headacheContinued to have a mild headache
Other complaints resolvedOther complaints resolved
Discharged home next dayDischarged home next day
8686
Case Scenario # 4Case Scenario # 45 y/o is vomiting, has headache, was 5 y/o is vomiting, has headache, was acting “bizarre”acting “bizarre”
Now has an altered level of consciousnessNow has an altered level of consciousness
Hx of falling off jungle gym earlier todayHx of falling off jungle gym earlier today
Initial loss of consciousness for few Initial loss of consciousness for few minutes then lucid; alert & orientedminutes then lucid; alert & oriented
B/P 90/46, 104, 24B/P 90/46, 104, 24
NauseatedNauseated
8787
Case Scenario # 4Case Scenario # 4GCS:GCS:– Eye opening – after calling their nameEye opening – after calling their name– Verbal response – talking nonsenseVerbal response – talking nonsense– Motor response – pulling at equipment with Motor response – pulling at equipment with
right hand, trying to get your hands off himright hand, trying to get your hands off him
Pupils - right slower to react, midsizePupils - right slower to react, midsizeLeft extremities flaccidLeft extremities flaccidBruise and swelling noted over right Bruise and swelling noted over right forehead above earforehead above earMinor scratches to bilateral armsMinor scratches to bilateral arms
8888
Case Scenario #4Case Scenario #4
Treatment/interventionsTreatment/interventions– C-spine control – spinal motion C-spine control – spinal motion
restrictionrestriction– IV – OIV – O22 – monitor – monitor (what should be (what should be
enroute?)enroute?)
– Anticipate rapid deterioration and Anticipate rapid deterioration and prepare to secure airwayprepare to secure airway
8989
Case Scenario # 4Case Scenario # 4GCS – 3-3-5; Total 11GCS – 3-3-5; Total 11
Patient had right epidural hematomaPatient had right epidural hematoma
Confirmed on CTConfirmed on CT
Emergently taken to OREmergently taken to OR
Hematoma evacuatedHematoma evacuated
Signs and symptoms slowly resolvingSigns and symptoms slowly resolving
Patient discharged home with outpatient Patient discharged home with outpatient physical and occupational therapyphysical and occupational therapy
9090
Case Scenario # 5Case Scenario # 5
Patient presents to ED with FB stuck Patient presents to ED with FB stuck in headin head
Awake, talking, following Awake, talking, following commands commands
How do you immobilize How do you immobilize this object?this object?
9191
Case Scenario #5Case Scenario #5
Immobilize in position foundImmobilize in position found
Constantly monitor level of Constantly monitor level of consciousnessconsciousness
Possibly need to shorten a FB to Possibly need to shorten a FB to facilitate transfer in the ambulancefacilitate transfer in the ambulance
Not knowing where tip of FB is, Not knowing where tip of FB is, assume head and neck injuries and assume head and neck injuries and treat for bothtreat for both
9292
Case Scenario #5Case Scenario #5Patient taken to ORPatient taken to ORArrow successfully removed with part Arrow successfully removed with part of skullof skullPlate placed in ORPlate placed in ORPost-op patient had altered Post-op patient had altered sense of taste and had sense of taste and had difficulty perceiving tactile difficulty perceiving tactile sensations sensations
9393
Case Scenario # 6Case Scenario # 645 y/o male passenger 45 y/o male passenger
MVC involving a deerMVC involving a deer
Patient unconsciousPatient unconscious
Facial trauma evidentFacial trauma evident
Gurgling respirationsGurgling respirations
Radial and carotid Radial and carotid pulses noted regular pulses noted regular and normaland normal
9494
Case Scenario # 6Case Scenario # 6
Vital signs: 92/62, P-74, R-18Vital signs: 92/62, P-74, R-18
Pupils: right reactive, left non-reactivePupils: right reactive, left non-reactive
GCS:GCS:– Eyes – eyelids move when body touchedEyes – eyelids move when body touched– Verbal – silentVerbal – silent– Motor – flexes right arm to pain, left arm Motor – flexes right arm to pain, left arm
straightens to painstraightens to pain
Repeat VS: 88/50, P-62, R-28 irregularRepeat VS: 88/50, P-62, R-28 irregular
9595
Case Scenario #6Case Scenario #6
Treatment/interventionsTreatment/interventions– C-spine control – spinal motion restrictionC-spine control – spinal motion restriction– Open and secure airway Open and secure airway
Modified jaw thrustModified jaw thrust
– Support ventilations 20 breaths per minuteSupport ventilations 20 breaths per minute
– IV-OIV-O22-monitor (what should be enroute?)-monitor (what should be enroute?)
– Rapid transport once extricatedRapid transport once extricated– Is there a need for helicopter service in Is there a need for helicopter service in
your town/your location?your town/your location?
9696
Case Scenario # 6Case Scenario # 6
GCS – 2-1-3; Total 6GCS – 2-1-3; Total 6
Pt had intracerebral hematoma and Pt had intracerebral hematoma and bilateral pneumo/hemothoraxbilateral pneumo/hemothorax
Chest tube placed in ED for chest Chest tube placed in ED for chest injuriesinjuries
Remains on ventilator in ICCURemains on ventilator in ICCU
Unable to do brain surgery due to Unable to do brain surgery due to location of bleedlocation of bleed
9797
New Recommendations of the AANNew Recommendations of the AANAmerican Academy of Neurology statesAmerican Academy of Neurology states
1.1. Any athlete who is suspected to have Any athlete who is suspected to have suffered a concussion suffered a concussion • Remove from participation until Remove from participation until
evaluated by a physician with training evaluated by a physician with training in the evaluation and management of in the evaluation and management of sports concussionssports concussions
2. No athlete should be allowed to 2. No athlete should be allowed to participate in sports if he or she is still participate in sports if he or she is still experiencing symptoms from a experiencing symptoms from a concussionconcussion
9898
AAN Recommendations cont’dAAN Recommendations cont’d
3. Following a concussion, a neurologist or 3. Following a concussion, a neurologist or physician with proper training should be physician with proper training should be consulted prior to clearing the athlete for consulted prior to clearing the athlete for return to participationreturn to participation
4. A certified athletic trainer should be present 4. A certified athletic trainer should be present at all sporting events, including practices, at all sporting events, including practices, where athletes are at risk for concussionwhere athletes are at risk for concussion
5. Education efforts should be maximized to 5. Education efforts should be maximized to improve the understanding of concussion by improve the understanding of concussion by all athletes, parents, and coachesall athletes, parents, and coaches
9999
TBITBIPrevention is the most effective Prevention is the most effective treatmenttreatment– Use of restraints in vehiclesUse of restraints in vehicles
Shoulder/lapShoulder/lapCar seatsCar seats
– Use of helmetsUse of helmets– Following guidelines when players Following guidelines when players
can return to play following can return to play following concussionconcussion
100100
Hands-on PracticeHands-on Practice
All participants to measure a peer for All participants to measure a peer for cervical collar placementcervical collar placement
Practice in groups of 3 standing Practice in groups of 3 standing backboard take-downbackboard take-down– Have 4Have 4thth person role play a patient person role play a patient
101101
BibliographyBibliography
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices Third Edition. Brady. 2009.Campbell, J.E. International Trauma Life Support for Prehospital Care Providers, 6th Edition. Brady. 2008.
Region X SOP March 2007; amended January 1, Region X SOP March 2007; amended January 1, 20082008
102102
Internet Reference SitesInternet Reference Siteshttp://www.answers.com/topic/intracranial-http://www.answers.com/topic/intracranial-pressurepressurehttp://www.bmj.com/content/338/bmj.b1683.fullhttp://www.bmj.com/content/338/bmj.b1683.fullhttp://faculty.washington.edu/chudler/facts.htmlhttp://faculty.washington.edu/chudler/facts.html
www.link-intl.com/gulfspine/Anatomy.htmlwww.link-intl.com/gulfspine/Anatomy.htmlhttp://neuropathology.neoucom.edu/chapter14/http://neuropathology.neoucom.edu/chapter14/chapter14CSF.htmlchapter14CSF.html http://www.spinal-cord.org/at-risk-activities.htmhttp://www.spinal-cord.org/at-risk-activities.htmhttp://www.spinalinjury.net/html/_spinal_cord_101http://www.spinalinjury.net/html/_spinal_cord_101.html.html