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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

TABLE 55-1

Glasgow Coma Scale

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 ...

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