Prehospital Emergency Care, 9Th Edition Detailed Lesson Plan 31 Page 1

MASTER TEACHING NOTES  Case Study Discussion  Teaching Tips Detailed Lesson Plan  Discussion Questions Chapter 31  Class Activities Head Trauma  Media Links 90–100 minutes  Knowledge Application  Critical Thinking Discussion

Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes I. Introduction Case Study Discussion 5 A. During this lesson, students will learn about assessment and care for a  What type of injury would present with a patient suffering from a head injury. delayed onset of signs and symptoms such B. Case Study as this? 1. Present Dispatch and Upon Arrival information from the chapter.  What are your immediate concerns for this 2. Discuss with students how they would proceed. patient?

II. Anatomy of the Skull and Brain—The Skull Teaching Tip 5 A. Contains and protects the brain and upper portion of the spinal cord Pass around an anatomical model of the skull B. Cranial skull to illustrate the basilar skull—a set of 1. Made of plates of large, flat bones structures that is often difficult for students to 2. Bones are fused together to form a helmet-like covering. visualize. C. Facial bones 1. 14 irregularly shaped bones 2. Cheek, nose, and jaw bones D. Basilar skull (floor of the skull) 1. Many separate pieces of bone 2. Weakest part of the skull 3. Spinal cord, nerves, and blood vessels perforate these bones 4. Many bony ridges that can cause injury to brain

III. Anatomy of the Skull and Brain—The Brain Discussion Questions 10 A. Cerebrospinal fluid  How can 1. Dense, serous substance surrounding brain you describe the location of intracranial 2. Protects brain and spinal cord against impact bleeding with respect to the meninges? 3. Clear and colorless  Why is 4. Circulates through skull and spinal column swelling or bleeding within the brain quickly 5. Is reabsorbed by circulatory system life threatening? 6. Combats infection and cleanses brain and spinal cord  What are PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 1 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes 7. Leakage through nose and ears is classic sign of basilar skull fracture the functions of the brain stem? B. The meninges (layers of tissue surrounding the brain) 1. Dura mater a. Outermost layer Knowledge Application b. Double layer of tough, fibrous tissue  Given 2. Arachnoid a description of the location of bleeding a. Between dura mater and pia mater within the cranium, students should be able b. Separated from pia mater by subarachnoid space (lattice of fibrous, to describe it using the correct terminology. spongy tissue)  Given 3. Pia mater a description of a region of the brain, a. Beneath arachnoid students should be able to describe the b. In contact with brain major functions of that area. C. Bleeding in the brain 1. Epidural bleeding Class Activity a. Occurs between dura mater and skull Assign groups of students to research and b. Usually involves brain’s outermost arteries present the anatomy and physiology of c. May have no permanent consequences if treated different parts of the brain. early 2. Subdural bleeding a. Occurs beneath dura b. Usually venous 3. Subarachnoid hemorrhage a. Occurs between arachnoid membrane and surface of brain b. Can be fatal within minutes D. Parts of the brain 1. Cerebrum a. Comprises three-fourths of brain’s volume b. Divided into right and left hemispheres c. Each hemisphere divided into four lobes i. Frontal lobe (anterior) ii. Parietal lobe (middle) iii. Occipital lobe (posterior) iv. Temporal lobe (side) d. Responsible for most conscious and sensory functions, emotions, and personality e. Not attached to inside of skull 2. Cerebellum (“little brain”) a. Found underneath cerebrum

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 2 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes b. Controls muscle movement and coordination c. Predicts when to stop movement d. Coordinates reflexes that maintain posture and equilibrium 3. Brain stem a. Most primitive and best-protected part of brain b. Tethered to skull by nerves and vessels c. Controls most automatic functions of the body (cardiac, respiratory, vasomotor or blood pressure, and so on) d. Made up of pons, midbrain, and medulla or medulla oblongata i. Medulla physically connects the brain to the spinal cord. ii. All messages between brain and spinal cord pass through the medulla.

IV. Head Injury—Scalp Injuries 5 A. The scalp may be contused, lacerated, abraded, or avulsed. B. Scalp injuries bleed heavily because of the rich supply of blood vessels. C. Underlying fascia (fibrous membrane) may be torn while the skin stays intact. D. Ruptured or depressed fascia can feel, on palpation, like a depressed skull fracture. E. If blood fills area between depressed skull fracture and scalp, skull will feel normal during palpation. V. Head Injury—Skull Injuries Discussion Questions 7 A. Linear skull fracture  What is a basilar skull fracture? 1. Resembles a line  What are the signs and symptoms of a 2. No gross deformity basilar skull fracture? 3. Can be diagnosed only through a radiograph B. Depressed skull fracture 1. Occurs when bone ends are pushed inward toward the brain 2. Depression can typically be palpated. 3. May pose harm if bone ends damage brain tissue C. Closed skull fracture—No open wound to scalp D. Open skull fracture 1. Open wound to scalp 2. Bacteria and other contaminants may infect brain through open wound 3. Cerebrospinal fluid may leak from open wound E. Basilar skull fracture 1. Often begins as linear temporal fracture that extends downward and into

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 3 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes the base of the skull 2. Often causes leakage of cerebrospinal fluid from ears, nose, or mouth 3. Patient often develops ecchymosis (bruise-type discoloration) around eyes and behind ears after several hours.

VI. Head Injury—Brain Injuries Teaching Tip 8 A. Injury to the skull can cause swelling of brain tissue or bleeding within the Take time to explain how increased skull. intracranial pressure affects cerebral blood B. Both conditions can cause increased pressure inside skull and decreased flow. perfusion of the brain. C. Effects of pressure inside skull and decreased perfusion Critical Thinking Discussion 1. Inadequate delivery of oxygen and glucose to brain tissues What happens to perfusion of the brain when 2. Inadequate removal of carbon dioxide and other waste from brain tissues brain tissue swells?

VII. Head Injury—Pathophysiology of Traumatic Brain Injury Discussion Questions 25 A. Closed head injury  How do intracranial hematomas 1. Scalp may be lacerated, but skull remains intact; no opening to the brain. develop? 2. Brain injury may still be extensive.  What conditions can lead to B. Open head injury secondary brain injury? 1. Involves break in skull and break in scalp 2. Involves direct local damage to tissue 3. Can also result in brain damage from infection, laceration, or puncture Weblinks C. Diffused axonal injury (DAI) Go to www.bradybooks.com and click on the 1. Results from shearing, tearing, or stretching of nerve fibers mykit link for Prehospital Emergency Care, 9th 2. Interferes with communication and transmission of nerve impulses edition to access web resources on traumatic throughout the brain brain injuries. 3. Most common in auto crashes and pedestrians struck by autos 4. Categorized as mild (concussion), moderate, or severe (involves brain stem) D. Concussion (temporary loss of brain’s ability to function) 1. Normally causes headache and some temporary disturbance in brain function 2. Presents with an altered mental status that progressively improves 3. Loss of consciousness will only occur immediately after impact. 4. Signs include confusion, brief memory loss, irritability, combativeness,

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 4 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes nausea and vomiting, and restlessness. E. Contusion (bruising and swelling of brain tissue) 1. Can accompany concussion 2. Causes bleeding into surrounding tissues 3. May cause increased intracranial pressure 4. Coup/contrecoup injury—Damage at and directly opposite the point of impact 5. Acceleration/deceleration injury—Head comes to a sudden stop but brain continues to move, resulting in bruising to brain. 6. Signs and symptoms i. All signs and symptoms of a concussion ii. Decreasing mental status or unresponsiveness iii. Paralysis iv. Unequal pupils v. Alteration of vital signs vi. Profound personality changes F. Subdural hematoma (collection of blood between dura mater and brain) 1. Due to low-pressure venous bleeding from veins torn during impact 2. Commonly associated with cerebral contusion 3. Formation of hematoma may cause pressure on the brain, resulting in cerebral injury. 4. Acute hematoma—Signs and symptoms begin almost immediately upon impact. 5. Occult hematoma—Signs and symptoms do not appear for days or weeks after impact. 6. Most common type of severe head injury; accounts for 33 percent of all severe head injuries 7. Those especially vulnerable to subdural hematoma a. Anyone over the age of 60 b. Anyone whose blood clots abnormally slowly (hemophiliacs, alcoholics, patients taking anticoagulant drugs) 8. Signs and symptoms a. Weakness or paralysis on one side of the body b. Deterioration in level of responsiveness c. Vomiting d. Dilation of one pupil e. Abnormal respirations or apnea

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 5 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes f. Possible increasing systolic blood pressure g. Decreasing pulse rate h. Headache i. Seizures j. Confusion k. Personality change (chronic subdural Discussion Question hematoma) What are the similarities and differences G. Epidural hematoma between subdural and epidural hematomas? 1. Arterial or venous bleeding pools between skull and dura 2. Bleeding is rapid, profuse, and severe and expands rapidly in a small space. 3. Rare; accounts for two percent of all severe head injuries 4. Extreme emergency 5. Most commonly results from low-velocity impact or from deceleration injury 6. Usually associated with a skull fracture, especially in temporal region 7. Signs and symptoms a. Loss of responsiveness; responsiveness returns (lucid interval) then rapidly deteriorates (occurs in only 20 percent of cases) Critical Thinking Discussion b. Decreasing mental status What is the explanation for Cushing’s reflex? (more common than above) c. Severe headache d. Fixed and dilated pupils e. Seizures f. Increasing systolic blood pressure and decreasing heart rate Discussion Question g. Vomiting What are indications of herniation? h. Apnea or abnormal breathing pattern i. Systolic hypertension and bradycardia (Cushing’s reflex) j. Posturing (withdrawal or flexion) 8. Needs immediate

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 6 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes surgical repair; prognosis is generally good. H. Laceration 1. Often occurs when an object penetrates the skull 2. Permanent injury; almost always results in bleeding 3. Can cause massive disruption of nervous system I. Brain herniation (compression of the brain) 1. Hematoma puts pressure on the brain, resulting in compression and pushing of brain downward and through foramen magnum (opening in base of skull) 2. Compression of brain stem destroys vital functions (heartbeat, respiration, blood pressure). 3. Signs and symptoms a. One dilated or sluggish pupil b. Weakness or paralysis c. Severe alteration in consciousness d. Abnormal posturing (nonpurposeful movement) e. Abnormal ventilation pattern f. Systolic hypertension and bradycardia (Cushing’s reflex) 4. May consider controlled hyperventilation IX. Head Injury—Assessment-Based Approach: Head Injury Knowledge Application 25 A. Scene size-up Given a variety of scenarios, students should 1. Always be alert for signs of head injury in a scene size-up. be able to identify and properly manage 2. Unresponsiveness or altered mental status should always suggest the patients with head injuries. possibility of head injury. 3. Never assume that mental status changes in a trauma victim are due to Critical Thinking Discussion drug or alcohol intoxication. How can EMTs’ actions help minimize B. Primary assessment secondary brain injury? 1. First step is manual in-line stabilization of the spine. 2. Establish an airway using a jaw-thrust maneuver. 3. Maintain airway and provide oxygen by nonrebreather mask. Video Clip 4. Assess patient’s mental status and keep in mind that it may Go to www.bradybooks.com and click on the change. mykit link for Prehospital Emergency Care, 9th PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 7 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes 5. Assess and record patient’s responsiveness accurately and in edition to access a video on applying a detail. cervical collar. a. Purposeful response—Patient tries to remove/move away from pain. Discussion Question b. Nonpurposeful response—Patient reacts What are flexion and extension posturing? inappropriately to pain. i. Flexion (decorticate) posturing (arms across chest, legs extended) indicates upper-level brain stem injury. ii. Extension (decerebrate) posturing (arms and legs extended, back sometimes arched) indicates lower-level brain stem injury. c. Unresponsive—Patient exhibits no response at all to verbal or painful stimuli. C. Secondary assessment 1. Physical exam a. Head—Using extreme care, palpate for deformities, depressions, lacerations, or penetrating objects. b. Eyes—Check pupils with a bright light for fixation or dilation; make sure eyes track normally; check for dark discoloration around eyes. c. Ears and nose—Check for leakage of blood or clear fluid; check for Battle’s sign (purplish discoloration behind ear). d. Motor/sensory assessment—Check patient’s ability to move fingers and toes; pinch extremities and check response. 2. Baseline vital signs—Check and record every five minutes. a. Pulse—If fast, suspect hemorrhage or early onset of hypoxia; if slow, suspect pressure inside skull or severe hypoxia. b. Respiration—If definite signs of brain herniation exist, begin positive pressure ventilation at a rate of 20 ventilations per minute; if these signs are not present, ventilate at a rate of 10–12 per minute. 3. History—Ask patient or bystanders: a. When and how did the incident occur? b. What is the patient’s chief complaint? c. Have symptoms changed since the incident? d. Did the patient lose consciousness at any time? Discussion Question e. Was he moved after the incident? What are some general signs and symptoms f. Is there any history of previous blows to the head? Can you of brain injury? provide any details?

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 8 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes 4. Signs and symptoms a. Altered mental status, from disorientation to unresponsiveness that doesn’t improve, or that gets worse b. Irregular breathing pattern (severe) c. Cushing’s reflex (increasing blood pressure and decreasing pulse) (severe) d. Obvious signs of injury—Contusions, lacerations, hematomas to scalp; deformity to skull e. Visible damage to skull f. Pain, tenderness, or swelling at injury site g. Blood or cerebrospinal fluid from ears or nose h. Discoloration around eyes in absence of trauma to eyes (very late) i. Absent motor or sensory function j. Nausea and/or vomiting k. Unequal pupil size with altered mental status l. Diplopia (double vision) m. Possible seizures n. Nonpurposeful response to painful stimuli o. Retrograde amnesia (no memory of what led up to incident) p. Anterograde amnesia (no memory of what happened after incident) D. Emergency medical care 1. Take Standard Precautions. 2. Take manual in-line spine stabilization. 3. Maintain a patient airway, adequate breathing, and oxygenation. a. Use a jaw-thrust to open airway. b. Remove any foreign bodies from the mouth; suction blood and mucus. c. Protect against aspiration by having suction available and by being prepared to roll secured patient to clear airway. d. If breathing is adequate, administer oxygen by nonrebreather mask at 15 lpm. e. If breathing is inadequate, administer positive pressure ventilation with supplemental oxygen at 10–12 per minute with SpO2 reading at 95 percent or greater.

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 9 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes f. Consider controlled hyperventilation if signs of brain herniation are present. 4. Monitor airway, breathing, pulse, and mental status for deterioration. 5. Control bleeding. a. Do not apply pressure to open or depressed skull injury. b. Dress and bandage open head wounds. c. Do not attempt to stop flow of blood or cerebrospinal fluid from ears or nose; cover loosely with sterile gauze dressing. d. For other wounds, use gentle, continuous direct pressure with sterile gauze only as needed to control bleeding. e. Never try to remove a penetrating object; immobilize in place and dress wound. 6. Provide emergency care for seizures. 7. Transport immediately. E. Reassessment 1. Recheck patient’s airway and mental status. 2. Repeat reassessment every five minutes. X. Head Injury—Summary: Assessment and Care Class Activity 5 A. Review possible assessment findings and emergency care Give students 20 to 30 minutes to review the for head injuries. lecture and their textbooks. Divide the class B. Review Figures 31-18 and 31-19. into two teams. Read aloud the In Review questions from the text. The team to ring its bell first gets an opportunity to answer. If the students on the team are correct, they get a point. If they are incorrect, the other team gets an opportunity to answer. XI. Follow-Up Case Study Follow-Up Discussion 10 A. Answer student questions.  Based on Mike’s presentation, what type of B. Case Study Follow-Up injury do you suspect? 1. Review the case study from the beginning of the chapter.  What factors do you believe made a 2. Remind students of some of the answers that were given to the difference in Mike’s good outcome? discussion questions. 3. Ask students if they would respond the same way after discussing the chapter material. Follow up with questions to determine why students Class Activity Alternatively, assign each question to a group PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 31 PAGE 10 Chapter 31 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. Minutes Content Outline Master Teaching Notes would or would not change their answers. of students and give them several minutes to C. Follow-Up Assignments generate answers to present to the rest of the 1. Review Chapter 31 Summary. class for discussion. 2. Complete Chapter 31 In Review questions. 3. Complete Chapter 31 Critical Thinking. Teaching Tips D. Assessments  Answers to In Review and Critical Thinking 1. Handouts questions are in the appendix to the 2. Chapter 31 quiz Instructor’s Wraparound Edition. Advise students to review the questions again as they study the chapter.  The Instructor’s Resource Package contains handouts that assess student learning and reinforce important information in each chapter. This can be found under mykit at www.bradybooks.com.

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