Avoid hypoxia (SpO2 below 90), hypotension and routine hyperventilation — each worsens brain injury.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A patient with a severe head injury has a systolic pressure of 136 and no suspected spinal injury. Which positioning supports cerebral venous drainage?
Answer: A. Raising the head about 30 degrees, with the head midline and nothing constricting the neck, helps venous blood leave the skull and lowers intracranial pressure when perfusion is adequate. Leg elevation and head-down tilt raise venous pressure in the head and can worsen swelling. If spinal precautions are needed, the whole board can be tilted instead.
Question 2 of 5
A 3-year-old needs spinal motion restriction on a flat board after a fall. Which adjustment keeps the cervical spine neutral?
Answer: A. A young child's occiput is proportionally large, so lying flat pushes the neck into flexion. Padding under the shoulders and torso brings the spine back to neutral. Padding under the head worsens the flexion, the head is secured after the torso to avoid pivoting, and children can sustain cord injury even without a visible fracture.
Question 3 of 5
An older patient with long-standing arthritis of the neck has fallen. Restricting spinal motion in this patient requires that you:
Answer: A. A neck fused or angled by arthritis has no neutral position to return to, and forcing one compresses a cord already sitting in a narrowed canal — so the head is supported and padded where it lies. A tight collar on a deformed neck creates pressure points and levers the spine, and leaving the head unsupported abandons the restriction altogether.
Question 4 of 5
A patient in a crash is intoxicated and has an obviously fractured femur, but denies neck pain. Regarding spinal motion restriction, you should:
Answer: A. Selective spinal motion restriction depends on a patient who can be examined, and intoxication plus a painful distracting injury both destroy the reliability of a denial of neck pain. Waiting for sobriety is not an option in the field, and vehicle damage is a mechanism clue rather than a substitute for an assessment you cannot perform.
Question 5 of 5
A patient with a severe head injury is wearing a rigid cervical collar that fits tightly. Concern about that collar is justified because it can:
Answer: A. The jugular veins drain the skull through the soft tissue the collar compresses, and obstructing that outflow adds directly to intracranial pressure — which is why fit is checked and the head of the stretcher is raised where injuries allow. A collar does not restrict inspired oxygen, and pupils remain visible whatever the collar is doing to the neck.
Keep the streak going with more questions like these, each with a full rationale.
What is head & spinal trauma?
The exam checks recognition of rising intracranial pressure, the ventilation and perfusion targets, and selective spinal motion restriction.
Key points to remember
- Avoid hypoxia (SpO2 below 90), hypotension and routine hyperventilation — each worsens brain injury.
- Ventilate to an ETCO2 of about 35–40; mild hyperventilation only for active herniation signs.
- Cushing's triad: rising blood pressure with a wide pulse pressure, bradycardia, irregular respirations.
- Herniation signs: a blown pupil, posturing, or a falling GCS.
- Neurogenic shock: hypotension with a normal or slow heart rate and warm, dry skin below the injury.
Field priorities
- Serial GCS and pupils — the trend matters more than one number.
- Spinal motion restriction by criteria (altered, intoxicated, deficit, spine pain, distracting injury).
- A long board is an extrication tool, not a transport device.
Coaching the patient
- Spinal shock is a temporary loss of cord function; neurogenic shock is the hemodynamic picture.
Red flags: act now
- GCS drop of 2 or more
- Unequal pupil with decreasing responsiveness
- Lucid interval then decline (epidural hematoma)
Head & Spinal Trauma: FAQs
What are the priority actions for Head & Spinal Trauma in the field?
Serial GCS and pupils — the trend matters more than one number. Spinal motion restriction by criteria (altered, intoxicated, deficit, spine pain, distracting injury). A long board is an extrication tool, not a transport device.
What findings in Head & Spinal Trauma change your plan or your transport decision?
GCS drop of 2 or more. Unequal pupil with decreasing responsiveness. Lucid interval then decline (epidural hematoma).
What do I need to know about Head & Spinal Trauma for the NREMT?
Avoid hypoxia (SpO2 below 90), hypotension and routine hyperventilation — each worsens brain injury. Ventilate to an ETCO2 of about 35–40; mild hyperventilation only for active herniation signs. Cushing's triad: rising blood pressure with a wide pulse pressure, bradycardia, irregular respirations. Herniation signs: a blown pupil, posturing, or a falling GCS.
What should the crew communicate or document for Head & Spinal Trauma?
Spinal shock is a temporary loss of cord function; neurogenic shock is the hemodynamic picture.
