William W. Forgey, MD
Orthopedics part 4 - Head, Neck and Spine
Updated: Nov 13, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Head Lacerations of the scalp or face result in massive bleeding, the care of which is discussed on page 131. Internal head injuries range from insignificant to lethal. Check the level of responsiveness as per page 10. Urgent evacuation is necessary for anyone who exhibits any of the following: • Unconsciousness for more than 2 minutes • Debilitating headache • Loss of coordination or garbled speech • Persistent nausea and vomiting • Bruising behind the ears (sign of skull fracture) • Bruising around the eyes (sign of skull fracture) • Decrease in vision • Clear fluid draining from nose and/or ears (possible spinal fluid) • Seizures • Relapse into unconsciousness Suspect a neck injury in anyone with a head injury. On most trips it is prudent to seek medical care for anyone who has been knocked unconscious for even a brief moment. The patient can walk and assist in her own evacuation if there is no apparent spine injury. If the patient is not thinking clearly or has any of the above signs, immobilize the neck and entire spine. Initially this may have to be done on the ground, with the patient lying down and using hand traction to stabilize his head and neck. A head-injured patient will frequently vomit. To avoid aspirating this into his lungs, place him face down with his face turned to one side, or sit the patient up with his head elevated to 30 degrees. This position may also decrease some of the headache associated with head injury. While the patient is kept awake for neurological assessments of levels of responsiveness in civilization, if evacuation will take a long time (several days), allow the person to fall asleep. While the person is asleep the brain has its best chance to control its own swelling. While the use of pain and anti-nausea medication might alter the mental status and is avoided in urban first aid care, when you are responsible off the grid for long-term care, it makes sense to use these medications. It is best to use the mildest medication necessary for relief. Refer to pain management (page 31) and nausea management (page 24). If you detect improvement in the symptoms over the next 2 days, the prognosis is very good. If symptoms increase, rapidly return the patient to the grid if possible. If there is no grid, most everything you do will be of no additional help. In the past, large doses of steroid were given (such as dexamethasone, 16 to 24 mg per day, from the Rx Oral/Topical Medication Module). Recent studies indicate steroids cause more harm than good, although if all you have to offer is death in a deteriorating patient, going back to a widely used old protocol is all you have. Improved results from that therapy may show within 1 day or take up to 8 days. When this high a dose of dexamethasone is used, it will need to be gradually withdrawn (tapered) when concluding the treatment period in order to allow the adrenal glands to recover and produce the normal cortisol levels that have been suppressed by this therapy. When using low-dose dexamethasone (4 mg per day) less than 10 days, it can be stopped abruptly. But large doses used as indicated above must be tapered no matter how long they are used. Reduce high dose (16 to 24 mg) by halving the dose every few days, until down to 2 mg, then reduce by 0.5 to 1 mg every 5 to 7 days. A standard method of treating increased intracranial pressure is the use of hyperosmolar diuretics (such as mannitol) via intravenous infusion. This item is not in your suggested Off-Grid Medical Kit, but another item used is a “loop diuretic,” which is suggested. Use furosemide, 40 mg daily until consciousness improves, at which time it may be stopped abruptly. If only a milder diuretic is available, such as the hydrochlorothiazide, use 50 mg per day. It also may be stopped abruptly when symptoms improve. If the patient is conscious, you will need to insert a Foley catheter. Neck Examination of the neck is critical to helping preserve the spinal cord from injury if the neck is unstable. Without moving the neck, gently palpate along the spinous process to elicit point tenderness in the conscious patient. No point tenderness will generally mean no significant bone damage to the neck. In an unconscious patient with head trauma, treat as if the neck is fractured. Splint carefully for maximal immobilization. If the neck is at an odd angle, it should be straightened with gentle in-line traction, by pulling steadily and slowly on the head along the line in which you find the neck. Move the neck to a neutral position in a line with the spine. This is a maneuver taught by wilderness first aid classes. Practice before attempting. Patients should not be allowed to move, nor should they be lifted or transported without careful immobilization of the neck. The best technique for initial cervical immobilization is gentle but firm control by a person holding the patient's head. Remind the victim to remain still. Eventually this firm control might be replaced with a cervical collar, or a rolled Ensolite pad or other soft material. The SAM Splint can be molded into a cervical collar, as shown in figure 7-2.
Neck injuries, when serious as described above, are best treated within the grid, but without the grid, you will need to move them onto a comfortable bed. Elevate the head to 30 degrees. Pad the neck with pillows on each side to discourage sideways movement and forward or rearward bending of the neck. The greatest challenge to be managed over the 8 weeks of healing is toilet activities. The neck must be provided adequate padding to prevent movement when the patient's position must change. Treat for pain and muscle spasm (see page 31 for pain management). Numbness, radiating pain, loss of nerve or muscle function possibly could have been prevented with surgery, but lacking on-grid care, the only thing you can do now is to try to relieve swelling around the spinal cord. Use the same treatments as indicated above for head injury with regard to use of dexamethasone, furosemide, or hydrochlorothiazide. To prevent neck injury, the cervical collar must be augmented with total body immobilization. Current techniques are being promoted that would avoid the use of cervical collars, as even attempting to put them on can cause more neck trauma than they prevent. Most cervical fractures are not unstable, so the collar adds to airway management difficulty and patient discomfort, and provides no benefit. If no point tenderness is claimed by the conscious victim, but generalized pain and spasm of the neck muscles are present, the victim may be suffering a severe sprain. A neck brace made from a towel or other rolled cloth can help with the long-term treatment and provides adequate support. Local warmth will help relax these muscles. Pain medication and muscle relaxants are useful in curing a neck sprain and spasm. It can take weeks for this injury to cease hurting Spine The neurological assessment of potential neck injury includes assessment of the entire spine. For a neurological check, ask the patient if there is numbness or tingling anywhere on the body. Assess grip strength on both sides as well as the ability to wiggle toes and flex the feet up and down. Check the entire spine by palpating along the spinous processes, looking for any point tenderness. If the above examination is questionable, or even if the trauma seems severe, both neck and spinal immobilization are in order. Having a rescuer maintain firm hand control of the victim's neck will be necessary until the patient has been placed upon a suitable rigid stretcher. Rigid stretchers are very difficult to improvise, and moving people upon them even more difficult. While Buck Tilton's Wilderness First Responder, 3rd edition (Globe Pequot Press, 2010) goes into great detail in describing this technique, these skills require practice. Ensure that the patient has been securely tied into the litter before you secure the head. If the body shifts while the head is tied down, any damage present in the neck could increase. When on the grid, this is the end of the neck/spine story. The patient remains fastened rigidly to a stretcher until the emergency department physician has taken tests and made the determination that she can be removed. This may take several agonizing hours. I say agonizing because even a normal person will hurt like crazy when attached to a rigid stretcher or backboard. It's almost a self-fulfilling prophecy. If patients don't have back trouble before being fastened down, they will now. A report in the Annals of Emergency Medicine titled “The Effect of Spinal Immobilization on Healthy Volunteers” placed 21 volunteers (who had never experienced any back problems) in standard backboard immobilization for 30 minutes and found that 100% had pain during that period, with 55% grading it moderate to severe, and after release 29% developed additional symptoms during the following 48 hours. Especially in a remote location, it is important to reassess the spine to ensure that continued immobilization is necessary, which is difficult even if healthy people develop back pain after a short time on the board. You will have to use common sense. Inability to move an extremity or loss of sensation, without an orthopedic injury in that limb, must cause a high suspicion of spinal cord injury. But if these signs and symptoms are not present and you become convinced that you are only dealing with a sore muscle problem in the back, not a broken or disrupted spine, then the spine may be cleared a term meaning let the patient out of the rigid support. Continued partial support with a soft foam pad around the neck, or even a back brace made of Ensolite foam wrapped around the patient, might make sense. Then again, it might not. It's a judgment call based upon the severity of the injury and resulting symptoms and, in general, how far off the grid you are. Point tenderness encountered when carefully palpating the spine indicates a possible fracture. If it is a fracture of the body of the vertebrae, this very painful condition can heal with only rest, although the healing process will take 8 weeks. This is a common fracture of elderly people due to osteoporosis and is encountered when they suddenly place a compression on the spine, usually while falling. These seldom are so bad that fragments compress the spinal cord. Fractures of the vertebral process where muscles attach can be stretch injuries or blows that can be very painful but not neurologically compromising. No numbness should result or endanger leg movement. Injuries causing instability of the back can result in complete paralysis below the injury. The only thing that can be done without proper X-ray evaluation is to pad the patient and prevent movement. This means feeding, toilet activities, and as much pain control as you can provide. There is no need to discuss here how tragic this injury can become without proper neurosurgical care. Eight weeks will tell the tale. Some pain relief can be attempted with the addition of oral steroid (decadron 4 mg twice daily) as discussed under head and neck injuries above.
Next week's Orthopedic post will focus on the collarbone and shoulder.