International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Spinal Trauma...

International Trauma Life Supportfor Emergency Care Providers

CHAPTER

seventh edition

Spinal Trauma

11

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Spinal Trauma

Courtesy of Louis B. Mallory, MBA, REMT-P


Overview

Spinal anatomy and physiology

Spinal motion restriction (SMR)– Mechanisms of injury indicating need– Process of application– Emergency Rescue and Rapid Extrication– History and assessment indicating no need– Special situations indicating need for alteration

Neurogenic and hemorrhagic shock


Spinal Trauma

Devastating and life-threatening– Skillfully assess mechanism of injury and

patient

Spinal motion restriction (SMR)– ITLS recommendations are guidelines

– Based on careful evaluation of mechanism, reliable patient condition, special situations

– Know your local protocol


Spinal Column


Spinal Cord


Spinal Injury


Incidence Spinal Injury

Model Spinal Cord Care System– US 40 per million persons per year– 250,000 living survivors– 4:1 male to female ratio– 50% are 16-30 years old

Children– MVC leading cause

Over 65% not wearing a seatbelt– Cervical cord most common site


Blunt Spinal-Column Injury

Requires significant force– Unless preexisting weakness or defect in bone

Higher risk: elderly, severe arthritis

– Sudden movement of head or trunk– Frequently injured in more than one place

Spinal cord involvement– Column injuries with cord injury:14%– Cervical region: 40%


Blunt Spinal-Column Injury

Signs and symptoms– Pain most common symptom

Frequently masked by other injures Back pain with or without movement of back Tenderness along spinal column

– Obvious deformity or wounds– Paralysis – Weakness– Paresthesia


Blunt Spinal-Cord Injury

Primary damage– At time of force– Cut, torn, crushed, cut off blood supply– Usually irreversible

Secondary damage– After time of force– Hypotension, generalized hypoxia, blood vessel

injury, swelling, compression from hemorrhage– Good prehospital care may help prevent


Spinal Injury

Courtesy of John Campbell


Neurogenic Shock

Cervical or thoracic cord injury– High-space shock– Malfunction of autonomic nervous system

Signs and symptoms– Hypotension – Normal skin color and temperature – Inappropriately slow heart rate

Diagnosis of exclusion– May have both neurogenic and hemorrhagic


Assessment

ITLS Primary and Secondary Surveys

Motor and sensory function– Conscious

Motor: move fingers and toes Sensation: abnormal is suspicious

– Unconscious Motor: pinch fingers and toes Sensation: pinch fingers and toes

– Flaccid paralysis, no reflexes or withdrawal means injury



Clues to Spinal Injury

Mechanism– Blunt trauma above clavicle– Diving accident– Motor vehicle or bicycle accident– Fall– Stabbing or impalement near spinal column– Shooting or blast injury to torso– Any violent injury with forces acting on spine



Patient complaints– Neck or back pain

– Numbness or tingling

– Loss of movement or weakness



Signs revealed during assessment– Pain on movement of back or spinal column– Obvious deformity of back or spinal column– Guarding against movement of back– Loss of sensation– Weak or flaccid muscles– Loss of control of bladder or bowels– Erection of penis (priapism)– Neurogenic shock


Management

Spinal motion restriction (SMR)– Minimize movement to avoid aggravating injury– No specific device proven more effective– SMR success depends on application process

Modification required– Immediate danger of death – Critical degree of ongoing danger that requires

an intervention within 1–2 minutes


Management

Emergency rescue– Reserved for immediate (within seconds)

environmental threat to life of victim or rescuer– Move to safe area in manner that minimizes

risk

Rapid extrication– Considered for medical conditions or situations

that require fast intervention to prevent death One or two minutes, but not seconds


Neutral Alignment

Technique may vary however the

principle is the same


Log Roll

Single unit: spinal-column, head, pelvis– Patients lying prone or supine

Modification required– Painful arm, leg, chest

Roll onto uninjured side

– Unstable fractured pelvis Scoop stretcher Lift carefully by four or more rescuers



SMR Devices

© Pearson


Complications of SMR

Airway compromise and aspiration– Head and airway are in fixed position

Head and low back pain – Directly related to being on hard backboard

Life-threatening hypoxia– Obese– Congestive heart failure

Pressure sores– Uneven skin pressure


Complications of SMR

Injury to rescue personnel– Lifting and transferring patient to and with the

SMR

Delayed scene time – Penetrating to chest or abdomen

Not in proximity to spine No symptoms of spinal injury

SMR should be applied to those who will benefit and avoided if not necessary


Controversy with SMR

General belief SMR should be done until injury ruled out

– Maine Protocol

No solid evidence (Class 1)– Malaysia/USA study – SMR done based on logic not science


SMR Situations

Low-risk situation– SMR not required

High-risk situation– SMR performed

Uncertain situation– Manually stabilize– Assess for signs of spinal injury– Determine if SMR is required


Maine Protocol for SMR

(Reprinted by permission of Peter Goth, MD)


SMR Decision

Reliable patient•Calm•Cooperative•Sober•Alert•No distracting injuries

Unreliable patient•Acute stress reaction•Head/brain injury•Altered mental status•Intoxication with drugs and/or alcohol•Distracting injuries


Airway Intervention

– Patient loses some ability to maintain their airway

– Rescuer assume responsibility

– Airway manipulation causes spinal column movement

– Risk versus benefit

(Courtesy of Stanley Cooper, EMT-P)


Special SMR Situations

Closed-space rescue– Safety is first priority– In line with long axis

Courtesy of Roy Alson, MD



Water emergencies– Backboard floated under– Secure then remove



Prone, seated or standing• Minimize movement into supine position

Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P



Protective gear

– Remove athletic helmet when: Face mask not removed timely Airway cannot be controlled Does not hold head securely Helmet prevents stabilization

– Note: Cut chin strap; do not unhook

(Courtesy of Jeff Hinshaw, MS, PA-C, NREMT-P)

(Courtesy of Jeff Hinshaw, MS, PA-C, NREMT-P)



Protective gear

– Shoulder pad: removal With helmet removal Neutral alignment inability Unable to secure to board Access to chest needed

– Note: Cut axillary straps and laces on front,

open from core outward, slide out from under

Courtesy of Bob Page, NREMT-P

© Pearson



Protective gear

– Motorcycle helmet: removal Poorly fitted to patient Significant neck flexion Full face and open face

– Note: Remove to evaluate and manage airway

(Courtesy of Bob Page, NREMT-P)



Neck wounds– Caution: cervical collar

May prevent Ongoing Exam Compromised airway

with subcutaneous air, expanding hematomas, or mandible fracture

– Note: May be needed to avoid cervical collar; use manual

stabilization, head cushion devices, blanket rolls

© corepics


Summary

Unstable or incomplete spinal damage is not completely predictable.– Unconscious trauma or dangerous mechanism

affecting head, neck, trunk should have SMR.

– Uncertain mechanisms may not require SMR.

– Special cases may require special techniques.

– Maintain neutral alignment specific for patient.

– Be prepared to manage airway compromise.

International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Spinal Trauma...

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