Chapter 25 Spinal Trauma - BrainSpewbrainspew.com/advanced/medic/slides/Chapter_025.pdf · zDescribe prehospital assessment of spinal cord injury zIdentify prehospital management

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Chapter 25Chapter 25Spinal TraumaSpinal Trauma

Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ObjectivesObjectivesDescribe incidence, morbidity, mortality related to spinal Describe incidence, morbidity, mortality related to spinal injuryinjury

Predict mechanisms of injury likely to cause spinal injuryPredict mechanisms of injury likely to cause spinal injury

Describe anatomy and physiology of spine and spinal Describe anatomy and physiology of spine and spinal cordcord

Outline assessment of a patient with suspected spine Outline assessment of a patient with suspected spine injuryinjury

Distinguish between types of spine injuryDistinguish between types of spine injury


ObjectivesObjectivesDescribe prehospital assessment of spinal cord injuryDescribe prehospital assessment of spinal cord injury

Identify prehospital management of the patient with Identify prehospital management of the patient with spinal injuriesspinal injuries

Distinguish between spinal shock, neurogenic shock, Distinguish between spinal shock, neurogenic shock, and autonomic hyperreflexia syndromeand autonomic hyperreflexia syndrome

Describe selected nontraumatic spinal conditions and Describe selected nontraumatic spinal conditions and the prehospital assessment and treatment of themthe prehospital assessment and treatment of them


Mosby, Inc. items and derived items © 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Sanders: Mosby's Paramedic Textbook, Revised 3rd Edition PowerPoint Lecture Notes

Chapter 25: Spinal Trauma

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ScenarioScenarioIt is 0300 and pouring rain when you reach the It is 0300 and pouring rain when you reach the crumpled car in the ditch. It appears to have rolled crumpled car in the ditch. It appears to have rolled several times. It is uprightseveral times. It is upright——and empty. Your flashlight and empty. Your flashlight beam glances over your patient, a 20beam glances over your patient, a 20--yearyear--old man old man who is lying in the nearby brush moaning. He is prone, who is lying in the nearby brush moaning. He is prone, smells strongly of sour beer, and repeats, smells strongly of sour beer, and repeats, ““My neck, My neck, my neck.my neck.”” There is severe tenderness over his lower There is severe tenderness over his lower CC--spine area. You quickly determine that he has rapid, spine area. You quickly determine that he has rapid, shallow respirations; a weak, slow radial pulse; and no shallow respirations; a weak, slow radial pulse; and no movement of his arms or legs.movement of his arms or legs.


DiscussionDiscussionWhat is your first challenge in the management of this What is your first challenge in the management of this patient?patient?

What concerns do you have about his respiratory status?What concerns do you have about his respiratory status?

Why is his pulse slow and weak?Why is his pulse slow and weak?

What drugs would be indicated on this call?What drugs would be indicated on this call?

How will you answer when he asks, How will you answer when he asks, ““Why canWhy can’’t I move my t I move my legs?legs?””


Spinal TraumaSpinal TraumaCausesCauses

MVC (48%)MVC (48%)Falls (21%)Falls (21%)Penetrating injuries (15%)Penetrating injuries (15%)Sports injury (14%)Sports injury (14%)

40% of victims with neurological deficit will 40% of victims with neurological deficit will have permanent injuryhave permanent injury



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Spinal Assessment CriteriaSpinal Assessment CriteriaAltered level of consciousnessAltered level of consciousness

Spinal pain or tendernessSpinal pain or tenderness

Neurological deficit or complaintNeurological deficit or complaint

Anatomical deformity of the spineAnatomical deformity of the spine

Alcohol or drugsAlcohol or drugs

Distracting injuryDistracting injury

Inability to communicateInability to communicate


Mechanism of InjuryMechanism of Injury

Classify mechanism of injury as:Classify mechanism of injury as:PositivePositiveNegativeNegativeUncertain Uncertain

Combine with clinical criteria for spinal injury Combine with clinical criteria for spinal injury to help identify situations in which spinal to help identify situations in which spinal immobilization is appropriateimmobilization is appropriate


Positive MOIPositive MOIForces highly suggestive of spinal cord injuryForces highly suggestive of spinal cord injury

Requires full spinal immobilizationRequires full spinal immobilization

ExamplesExamplesHighHigh--speed motor vehicle crashesspeed motor vehicle crashesFalls >3x patientFalls >3x patient’’s heights heightViolent injuries occurring near patientViolent injuries occurring near patient’’s spine s spine Sports injuriesSports injuriesOther highOther high--impact situationsimpact situations



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Positive MOIPositive MOI

In absence of signs and symptoms of SCI, some In absence of signs and symptoms of SCI, some medical direction agencies may recommend that medical direction agencies may recommend that a patient with a positive MOI not be immobilizeda patient with a positive MOI not be immobilized

Based on assessment when:Based on assessment when:Patient history is reliablePatient history is reliableThere are no distraction injuriesThere are no distraction injuries


Negative MOINegative MOI

Force or impact suggests no potential for spinal Force or impact suggests no potential for spinal injuryinjury

If no SCI signs and symptoms, does not require If no SCI signs and symptoms, does not require spinal immobilizationspinal immobilization

Examples:Examples:Dropping an object on the footDropping an object on the footTwisting an ankle while runningTwisting an ankle while runningIsolated soft tissue injuryIsolated soft tissue injury


Uncertain MOIUncertain MOIImpact or force involved in injury is unknown or Impact or force involved in injury is unknown or uncertainuncertain

Clinical criteria used to determine need for Clinical criteria used to determine need for spinal immobilizationspinal immobilization

ExamplesExamplesTripping or falling and hitting headTripping or falling and hitting headFalls 2Falls 2--4 ft4 ftLowLow--speed motor vehicle crashes (speed motor vehicle crashes (““fender bendersfender benders””))



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Assessment of Uncertain MOIAssessment of Uncertain MOIEnsure patient is reliableEnsure patient is reliable

Calm, cooperative, sober, alert, and orientedCalm, cooperative, sober, alert, and oriented

Unreliable patientsUnreliable patientsAcute stress reactions Acute stress reactions Brain injuryBrain injuryIntoxicatedIntoxicatedAbnormal mental statusAbnormal mental statusDistracting injuriesDistracting injuriesProblems communicatingProblems communicating


Spinal ColumnSpinal Column

33 vertebrae33 vertebrae7 cervical7 cervical12 thoracic12 thoracic5 lumbar5 lumbar5 sacrum (fused)5 sacrum (fused)4 coccyx (fused)4 coccyx (fused)



Anterior spineAnterior spineVertebral bodiesVertebral bodiesIntervertebral disksIntervertebral disksAnterior and posterior Anterior and posterior longitudinal ligamentslongitudinal ligaments

•• Connect vertebral bodies Connect vertebral bodies anteriorly and inside canal anteriorly and inside canal



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Spinal ColumnSpinal ColumnVertebraVertebra

Solid bodySolid body•• Bears weight of Bears weight of

vertebral columnvertebral columnPosterior and anterior Posterior and anterior archarchPosterior spinous Posterior spinous processprocessTransverse process (in Transverse process (in some vertebrae)some vertebrae)



Spinal cord lies in Spinal cord lies in spinal canalspinal canal

Spinal nerve roots Spinal nerve roots pass out through pass out through vertebral foramen vertebral foramen


Adult SkullAdult Skull

Sits first cervical vertebra (C1) (atlas)Sits first cervical vertebra (C1) (atlas)

Second cervical vertebra (C2) (axis) and its Second cervical vertebra (C2) (axis) and its odontoid process allow head to move with odontoid process allow head to move with about 180about 180--degree range of motiondegree range of motion



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Adult SkullAdult Skull

Cervical spine susceptible to injury due to:Cervical spine susceptible to injury due to:Weight and position of head in relation to Weight and position of head in relation to Thin neck and cervical vertebraeThin neck and cervical vertebrae


Cervical Spine InjuryCervical Spine Injury


Spinal InjurySpinal InjuryCausesCauses

Axial loadingAxial loadingFlexion, hyperextension, hyperrotationFlexion, hyperextension, hyperrotationExcessive lateral bendingExcessive lateral bendingDistractionDistraction

Stable and unstable injuries based on:Stable and unstable injuries based on:Extent of disruption to spinal structuresExtent of disruption to spinal structuresRelative strength of structures remaining intactRelative strength of structures remaining intact



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Axial Loading Axial Loading

Direct forces transmitted along length of spinal Direct forces transmitted along length of spinal columncolumn

May produce compression fracture or a May produce compression fracture or a crushed vertebral body without SCIcrushed vertebral body without SCI

Commonly occur at T12 to L2Commonly occur at T12 to L2


Flexion, Hyperextension, Flexion, Hyperextension, HyperrotationHyperrotation

Extremes may result in:Extremes may result in:FractureFractureLigamentous injuryLigamentous injuryMuscle injuryMuscle injury

Spinal cord injury when impingement into spinal Spinal cord injury when impingement into spinal canal by subluxation of one or more cervical canal by subluxation of one or more cervical vertebraevertebrae


Lateral BendingLateral Bending

Excessive lateral bendingExcessive lateral bendingDislocations and bony fractures of cervical and Dislocations and bony fractures of cervical and thoracic spinethoracic spineSudden lateral impact moves torso sidewaysSudden lateral impact moves torso sideways

Head remains in place until pulled along by Head remains in place until pulled along by cervical attachmentscervical attachments



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DistractionDistraction

Cervical spine suddenly stops while weight Cervical spine suddenly stops while weight and momentum of body pull away from itand momentum of body pull away from it

May result in tearing and laceration of spinal cordMay result in tearing and laceration of spinal cord


Less Common Mechanisms Less Common Mechanisms

Other mechanisms of spine injuryOther mechanisms of spine injuryBlunt traumaBlunt traumaElectrical injuryElectrical injuryPenetrating traumaPenetrating trauma


Classifications of Spinal InjuryClassifications of Spinal Injury

SprainsSprainsStrainsStrainsFracturesFracturesDislocationsDislocationsSacral fracturesSacral fracturesCoccygeal fracturesCoccygeal fracturesCord injuriesCord injuries



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Spinal Injuries Spinal Injuries

Immobilize patients with:Immobilize patients with:Suspected spinal traumaSuspected spinal trauma

OROR

Signs and symptoms of SCISigns and symptoms of SCI•• Avoid unnecessary movement Avoid unnecessary movement

Unstable spine can be ruled out only by Unstable spine can be ruled out only by radiography or lack of any mechanism for radiography or lack of any mechanism for injury injury


Assume Spinal InjuryAssume Spinal Injury

Significant trauma and Significant trauma and use of intoxicating use of intoxicating substancessubstancesSeizure activitySeizure activityPain or paresthesia in Pain or paresthesia in neck or armsneck or armsNeck tendernessNeck tendernessUnconsciousness Unconsciousness because of head injurybecause of head injury

Significant injury above Significant injury above clavicleclavicleFall more than three times Fall more than three times patient's heightpatient's heightFall and fracture of both Fall and fracture of both heels heels Injury from a highInjury from a high--speed speed motor vehicle crashmotor vehicle crash


Spinal InjurySpinal Injury

Damage further complicated by:Damage further complicated by:Patient's agePatient's agePreexisting bone diseasesPreexisting bone diseasesCongenital spinal cord anomalies Congenital spinal cord anomalies

Spinal cord neurons do not regenerate to any Spinal cord neurons do not regenerate to any great extentgreat extent



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Hyperflexion Sprains and StrainsHyperflexion Sprains and Strains

Hyperflexion sprainsHyperflexion sprainsPosterior ligamentous complex tears Posterior ligamentous complex tears

Hyperextension strains (whiplash)Hyperextension strains (whiplash)LowLow--velocity, rearvelocity, rear--end automobile collisionsend automobile collisions

Local painLocal painSpasms of neck musclesSpasms of neck musclesNonradiating, aching soreness of neck or backNonradiating, aching soreness of neck or backTreat as cord injury until cleared by xTreat as cord injury until cleared by x--rayray


Fractures and DislocationsFractures and Dislocations

Most frequently injured spinal regionsMost frequently injured spinal regionsC5C5--C7C7C1C1--C2C2T12T12--L2L2

WedgeWedge--shaped compression fractures and shaped compression fractures and "teardrop" fractures or dislocations common"teardrop" fractures or dislocations common


WedgeWedge--Shaped FracturesShaped FracturesHyperflexion injuryHyperflexion injury

Compressive force to Compressive force to anterior vertebral body anterior vertebral body stretches posterior ligament stretches posterior ligament complex complex

Industrial accidents, fallsIndustrial accidents, fallsMiddle or lower cervical Middle or lower cervical segments or at T12 and L1segments or at T12 and L1

Generally stable Generally stable



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Teardrop Fractures and DislocationsTeardrop Fractures and Dislocations

Extremely unstable Extremely unstable

Severe hyperflexion and Severe hyperflexion and compression forcescompression forces

Motor vehicle crashesMotor vehicle crashes


Sacral and Coccygeal FracturesSacral and Coccygeal Fractures

Most serious spinal injuries in cervical, Most serious spinal injuries in cervical, thoracic, and lumbar regionsthoracic, and lumbar regions

Patient may say, Patient may say, ““I broke my tailboneI broke my tailbone””Moderate pain from mobile coccyxModerate pain from mobile coccyx


Sacral and Coccygeal FracturesSacral and Coccygeal Fractures

Fractures of S1 and S2 fairly commonFractures of S1 and S2 fairly commonMay compromise sacral nerves May compromise sacral nerves May result in loss of perianal sensory motor May result in loss of perianal sensory motor function and in bladder and sphincter disturbancesfunction and in bladder and sphincter disturbances

Sacrococcygeal joint may be injured from Sacrococcygeal joint may be injured from direct blows and fallsdirect blows and falls



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Classification of Cord InjuriesClassification of Cord Injuries

Primary injuriesPrimary injuriesOccur at time of impactOccur at time of impact

Secondary injuriesSecondary injuriesOccur later due to:Occur later due to:

•• SwellingSwelling•• IschemiaIschemia•• Movement of bony fragmentsMovement of bony fragments


Cord InjuriesCord InjuriesConcussedConcussed

ContusedContused

CompressedCompressed

LaceratedLacerated

Severity of injuries depends on:Severity of injuries depends on:Amount and type of force Amount and type of force Duration of injuryDuration of injury


Cord LesionsCord Lesions

Lesions (transections) of spinal cord are Lesions (transections) of spinal cord are classified as:classified as:

CompleteCompleteIncompleteIncomplete



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Complete Cord LesionsComplete Cord LesionsUsually spinal fracture or dislocationUsually spinal fracture or dislocation

Absence of pain, pressure, and joint sensationAbsence of pain, pressure, and joint sensation

Complete motor paralysis below injury Complete motor paralysis below injury

QuadriplegiaQuadriplegia•• Injury at cervical levelInjury at cervical level•• Loss of all function below injury site Loss of all function below injury site

Paraplegia Paraplegia •• Thoracic or lumbar level injuryThoracic or lumbar level injury•• Loss of lower trunk functionLoss of lower trunk function


Complete Cord LesionsComplete Cord Lesions

Autonomic dysfunction may occur with Autonomic dysfunction may occur with complete cord lesions complete cord lesions

Manifestations of autonomic dysfunctionManifestations of autonomic dysfunctionBradycardia Bradycardia HypotensionHypotensionPriapismPriapismLoss of sweating and shiveringLoss of sweating and shiveringPoikilothermy Poikilothermy Loss of bowel and bladder controlLoss of bowel and bladder control


Incomplete LesionsIncomplete LesionsCentral cord syndromeCentral cord syndrome

Seen with hyperextension or flexion cervical Seen with hyperextension or flexion cervical injuriesinjuriesGreater motor impairment of upper than lower Greater motor impairment of upper than lower extremitiesextremities

Signs and symptomsSigns and symptomsParalysis of armsParalysis of armsSacral sparingSacral sparing



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Incomplete LesionsIncomplete LesionsAnterior cord syndromeAnterior cord syndrome

Usually flexion injuriesUsually flexion injuriesPressure on anterior spinal cord by ruptured Pressure on anterior spinal cord by ruptured intervertebral diskintervertebral disk

•• Fragments of vertebral body extruded into spinal canalFragments of vertebral body extruded into spinal canal

Signs and symptomsSigns and symptomsDecreased sensation of pain and temperature Decreased sensation of pain and temperature below lesionbelow lesionIntact light touch and position sensationIntact light touch and position sensationParalysisParalysis


Incomplete LesionsIncomplete LesionsBrownBrown--SSééquard syndromequard syndrome

Hemitransection of spinal cordHemitransection of spinal cord•• Ruptured intervertebral diskRuptured intervertebral disk•• Encroachment on spinal cord by a fragment of vertebral Encroachment on spinal cord by a fragment of vertebral

bodybody

Pressure on half spinal cord results in:Pressure on half spinal cord results in:•• Weakness of upper and lower extremities on ipsilateral Weakness of upper and lower extremities on ipsilateral

sideside•• Loss of pain and temperature on contralateral sideLoss of pain and temperature on contralateral side


Pharmacological TherapyPharmacological Therapy

Use in incomplete cord injury is very Use in incomplete cord injury is very controversialcontroversial

GlucocorticoidsGlucocorticoidsNaloxoneNaloxoneCalcium channel blockersCalcium channel blockersMethylprednisolone (SoluMethylprednisolone (Solu--Medrol)Medrol)



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Assessment of Spinal Cord Injury Assessment of Spinal Cord Injury

After lifeAfter life--threatening injuries have been threatening injuries have been assessed and treatedassessed and treated

Priorities:Priorities:Scene surveyScene surveyAssess airway, breathing, and circulationAssess airway, breathing, and circulationPreserve spinal cord functionPreserve spinal cord functionAvoid secondary injury to spinal cordAvoid secondary injury to spinal cord


Assessment of Spinal Cord InjuryAssessment of Spinal Cord Injury

Prevent secondary injury from:Prevent secondary injury from:Unnecessary movementUnnecessary movementHypoxemiaHypoxemiaEdemaEdemaShock Shock


Prehospital GoalsPrehospital GoalsSuspect spinal injury:Suspect spinal injury:

Scene surveyScene surveyKinematicsKinematicsHistory of eventHistory of event

Early spinal immobilizationEarly spinal immobilization

Oxygen Oxygen

Correct volume deficitsCorrect volume deficits



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Neurological ExaminationNeurological Examination

Neurological examNeurological examAt scene or en routeAt scene or en routeDocument findingsDocument findingsMotor and sensory findingsMotor and sensory findingsReflex responsesReflex responses


DermatomesDermatomesSpinal nerves (except Spinal nerves (except C1) have specific C1) have specific cutaneous sensory cutaneous sensory distributiondistribution

DermatomeDermatome is skin is skin surface area supplied surface area supplied by a single spinal nerveby a single spinal nerve


DermatomesDermatomesLandmarks for sensory Landmarks for sensory evaluationevaluation

C2 to C4: Around the C2 to C4: Around the neck and over anterior neck and over anterior chest to below clavicleschest to below claviclesT4: Nipple lineT4: Nipple lineT10: UmbilicusT10: UmbilicusS1: Soles of feetS1: Soles of feet



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Reflex ResponsesReflex ResponsesSeldom evaluated Seldom evaluated prehospitalprehospital

Some indicate autonomic Some indicate autonomic injuryinjury

Babinski's signBabinski's signPlantar reflexPlantar reflexDorsiflexion of great toe Dorsiflexion of great toe with or without fanning of with or without fanning of toestoes


Other Methods of EvaluationOther Methods of Evaluation

Visual inspectionVisual inspectionCord transection above C3 often results in Cord transection above C3 often results in respiratory arrestrespiratory arrestC4 lesions may cause paralysis of diaphragmC4 lesions may cause paralysis of diaphragmTransections at C5Transections at C5--C6 spare diaphragmC6 spare diaphragm

•• Permit diaphragmatic breathingPermit diaphragmatic breathing


Spinal InjurySpinal Injury

Absence of neurological deficits Absence of neurological deficits does notdoes not rule rule out spinal injuryout spinal injury

Ability to walk should Ability to walk should notnot be a factor in be a factor in determining need for spinal precautionsdetermining need for spinal precautions



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Spinal ImmobilizationSpinal ImmobilizationPrimary goalPrimary goal

Prevent further injuryPrevent further injury

Treat spine as a long bone with a joint at either end Treat spine as a long bone with a joint at either end (the head and pelvis)(the head and pelvis)

Use complete spinal immobilizationUse complete spinal immobilization

Begins at initial assessmentBegins at initial assessment

Maintain until spine is immobilized on a long Maintain until spine is immobilized on a long backboardbackboard


Spinal Immobilization TechniquesSpinal Immobilization Techniques

When a possible or When a possible or potential spine injury potential spine injury recognized, manually recognized, manually protect head and neckprotect head and neck

Maintain in line with long Maintain in line with long axis of bodyaxis of body


Manual InManual In--Line Immobilization from the FrontLine Immobilization from the Front



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Log RollLog Roll——Prone PatientProne PatientIn one move, patient is rotated away from prone position.


Manual InManual In--Line Immobilization from the FrontLine Immobilization from the Front


Log RollLog Roll——Supine PatientSupine PatientRescuer 1 at head, rescuers 2 and 3 at midthorax and knees



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Log RollLog Roll——Supine PatientSupine PatientRescuer 4 manages spine board


Log RollLog Roll——Supine PatientSupine PatientMaintain immobilization and roll in one move


Log RollLog Roll——Supine PatientSupine PatientIn one move, rescuers log-roll and center patient on spine board



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Log RollLog Roll——Prone PatientProne PatientRescuer 1 provides in-line stabilization; prepares for rotation


Log RollLog Roll——Prone PatientProne PatientIn one move, rescuers log-roll and center patient on spine board


Rigid Cervical CollarRigid Cervical Collar

Protects cervical spine from compressionProtects cervical spine from compressionReduces movement and some range of motion of Reduces movement and some range of motion of headheadDoes not provide adequate spinal immobilizationDoes not provide adequate spinal immobilization

Use with manual inUse with manual in--line stabilization or line stabilization or immobilization by a suitable deviceimmobilization by a suitable device



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Rigid Cervical CollarsRigid Cervical CollarsMany sizes (or are adjustable)Many sizes (or are adjustable)

Appropriate size reduces flexion or hyperextension Appropriate size reduces flexion or hyperextension

Must not:Must not:Inhibit ability to open mouth or clear airway Inhibit ability to open mouth or clear airway Obstruct airway or ventilationsObstruct airway or ventilations

Apply after head is in neutral inApply after head is in neutral in--line positionline position


Cervical Collar ApplicationCervical Collar Application

Rescuer 1 maintains inRescuer 1 maintains in--line stabilizationline stabilization

Rescuer 2 positions and Rescuer 2 positions and secures collarsecures collar

Rescuer 1 maintains Rescuer 1 maintains support until patient has support until patient has been secured to boardbeen secured to board


Short Spine BoardsShort Spine BoardsSplint cervical and thoracic spineSplint cervical and thoracic spine

Vary in designVary in design

Spinal immobilization for patient in a sitting Spinal immobilization for patient in a sitting position or a confined spaceposition or a confined space

After short spine board has been applied, After short spine board has been applied, patient is transferred to a long spine boardpatient is transferred to a long spine board



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KED ApplicationKED Application


Rapid ExtricationRapid Extrication

Steps vary depending on:Steps vary depending on:Size and make of vehicleSize and make of vehiclePatientPatient’’s location inside vehicles location inside vehicle


Rapid ExtricationRapid ExtricationRescuer 1 maintains inRescuer 1 maintains in--line stabilizationline stabilization



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Rapid ExtricationRapid ExtricationRescuer 2 supports Rescuer 2 supports midthorax as rescuer 3 midthorax as rescuer 3 frees lower extremitiesfrees lower extremities


Rapid ExtricationRapid ExtricationPatient lowered onto Patient lowered onto long spine boardlong spine board


Rapid ExtricationRapid Extrication

Patient centered and Patient centered and secured on spine boardsecured on spine board



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Rapid ExtricationRapid Extrication——2 Rescuers2 Rescuers


Rapid ExtricationRapid Extrication——2 Rescuers2 Rescuers


Long Spine BoardLong Spine Board

Available in a variety of types:Available in a variety of types:Plastic and synthetic spine boardsPlastic and synthetic spine boardsMetal alloy spine boardsMetal alloy spine boardsVacuum mattress splintsVacuum mattress splintsSplit litters (scoop stretchers) that must be used Split litters (scoop stretchers) that must be used with a long spine boardwith a long spine board



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Long Spine BoardLong Spine Board——Supine PatientSupine Patient

Immobilize torso to a long spine board before Immobilize torso to a long spine board before immobilization of head immobilization of head

Torso must not be allowed to move up, down, Torso must not be allowed to move up, down, or to either sideor to either side



Place straps at:Place straps at:Shoulders or chest Shoulders or chest Around midtorsoAround midtorsoAcross iliac crests to prevent movement of lower Across iliac crests to prevent movement of lower torsotorso

After immobilization of torso, immobilize After immobilization of torso, immobilize head and neckhead and neck



Padding added as Padding added as needed before securing needed before securing headhead

Padding (if needed) Padding (if needed) should be firm and should be firm and extend full length and extend full length and width of the torso from width of the torso from the buttocks to the top the buttocks to the top of the shouldersof the shoulders



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Children have Children have proportionally larger proportionally larger headsheads

May require padding May require padding under the torso to allow under the torso to allow head to lie in a neutral head to lie in a neutral positionposition


Long Spine BoardLong Spine Board——Supine PatientSupine PatientSecure head to device



Secure forehead across Secure forehead across supraorbital ridgesupraorbital ridge

Secure lower head Secure lower head across front of cervical across front of cervical collarcollar

Secure legs with two or Secure legs with two or more straps above and more straps above and below kneesbelow knees



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Long Spine BoardLong Spine Board——Standing PatientStanding PatientRescuer 1 maintains manual inRescuer 1 maintains manual in--line stabilization; rescuers 2 and 3 support patient;line stabilization; rescuers 2 and 3 support patient;

Patient is lowered onto long spine board for further immobilizatPatient is lowered onto long spine board for further immobilizationion


Immobilizing Pediatric PatientsImmobilizing Pediatric Patients

Prehospital carePrehospital careManual inManual in--line line immobilizationimmobilizationRigid cervical collarRigid cervical collarSpinal immobilization Spinal immobilization device device

Adult long spine Adult long spine boards may be usedboards may be used


Manual InManual In--Line ImmobilizationLine Immobilization

Apply without tractionApply without traction

Use only enough tension to relieve weight Use only enough tension to relieve weight of head from cervical spineof head from cervical spine



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Manual InManual In--Line ImmobilizationLine ImmobilizationDo notDo not move head to inmove head to in--line position if:line position if:

Resistance to movementResistance to movementNeck muscle spasmNeck muscle spasmIncreased painIncreased painPresence or increase in neurological deficits Presence or increase in neurological deficits during movement during movement Compromise of airway or ventilationCompromise of airway or ventilationSevere misalignment of headSevere misalignment of head


HelmetsHelmets

Helmets protect head and brain, not neckHelmets protect head and brain, not neckLeaves cervical spine vulnerable to injuryLeaves cervical spine vulnerable to injury


Types of HelmetsTypes of Helmets

FullFull--face or openface or open--face designsface designsMotorcycling, bicycling, rollerblading, and other Motorcycling, bicycling, rollerblading, and other activitiesactivities

Helmets designed for sports such as football Helmets designed for sports such as football and motocrossand motocross



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Helmet RemovalHelmet Removal

If helmet removal is needed:If helmet removal is needed:Athletic trainers may have special equipment to Athletic trainers may have special equipment to remove faceremove face--pieces pieces Easier access to airwayEasier access to airwaySports gear (shoulder pads) could compromise Sports gear (shoulder pads) could compromise spine if helmet is spine if helmet is



Helmet removal is controversial Helmet removal is controversial Guided by medical directionGuided by medical direction

FullFull--face helmets are removed in the fieldface helmets are removed in the fieldPermits access to airwayPermits access to airwayAllows assessment for hidden bleeding or injuriesAllows assessment for hidden bleeding or injuries



Immobilize helmet and Immobilize helmet and head in inhead in in--line positionline position



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Spread side of helmet Spread side of helmet away from head and away from head and earsears


Helmet Removal Helmet Removal

Rotate helmet to clear Rotate helmet to clear nose and remove from nose and remove from head in straight linehead in straight line



After removal of helmet, After removal of helmet, apply inapply in--line line immobilization and rigid immobilization and rigid cervical collarcervical collar



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Spinal Immobilization in Diving AccidentsSpinal Immobilization in Diving Accidents

Most diving accidents cause injury to head, Most diving accidents cause injury to head, neck, and spineneck, and spine

Patient in water:Patient in water:Ensure scene and personal safetyEnsure scene and personal safetyRescuers trained in water rescue should enter Rescuers trained in water rescue should enter waterwater



Float supine patient to shallow area:Float supine patient to shallow area:No unnecessary movement of spineNo unnecessary movement of spine

Approach prone patient from top of head:Approach prone patient from top of head:Carefully turn supine and assess airway and Carefully turn supine and assess airway and breathingbreathingRescue breathing may be initiated in waterRescue breathing may be initiated in water



Rescuer 2 slides long spine board or rigid device under Rescuer 2 slides long spine board or rigid device under patientpatient

Rescuer 1 supports head and neck without flexion or extensionRescuer 1 supports head and neck without flexion or extensionRigid cervical collar is appliedRigid cervical collar is appliedMaintain manual inMaintain manual in--line immobilizationline immobilization

Float immobilization device to edge of water and lift outFloat immobilization device to edge of water and lift out

Immobilize patient on long spine boardImmobilize patient on long spine board



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Extrication of a Diving Accident VictimExtrication of a Diving Accident Victim


Spinal ShockSpinal ShockTemporary loss of spinal cord function distal Temporary loss of spinal cord function distal to injuryto injury

Flaccid paralysisFlaccid paralysisLoss of autonomic functionLoss of autonomic function

Avoid secondary injury Avoid secondary injury OxygenOxygenTrendelenburgTrendelenburgIV crystalloidsIV crystalloids


Neurogenic HypotensionNeurogenic HypotensionBlockade of vasoregulatory fibers, motor fibers, and Blockade of vasoregulatory fibers, motor fibers, and sensory fiberssensory fibers

RareRare

Hypotension Hypotension

BradycardiaBradycardia

Warm, dry skinWarm, dry skin



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Autonomic Hyperreflexia SyndromeAutonomic Hyperreflexia Syndrome

Chronic SCI with injuries at T6 or aboveChronic SCI with injuries at T6 or above

Distended bladder or rectum initiatesDistended bladder or rectum initiatesHypertensionHypertensionHAHABlurred visionBlurred visionSweatingSweatingNauseaNauseaBradycardiaBradycardia


Low Back Pain (LBP)Low Back Pain (LBP)

Affected areaAffected areaBetween lower rib cage and gluteal musclesBetween lower rib cage and gluteal musclesMay radiate to thighsMay radiate to thighs

Risk factorsRisk factorsRepetitive liftingRepetitive liftingVibrations from machineryVibrations from machineryOsteoporosisOsteoporosis


Low Back PainLow Back Pain——CausesCauses

TumorsTumors

Disk prolapseDisk prolapse

BursitisBursitis

SynovitisSynovitis

Degenerative joint Degenerative joint diseasedisease

Abnormal joint diseaseAbnormal joint disease

Inflammation from Inflammation from infectioninfection

FracturesFractures

Ligament strainsLigament strains



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Degenerative Disk DiseaseDegenerative Disk Disease

Common >50 y/oCommon >50 y/o

CausesCausesAlterations in tissue of intervertebral disks that Alterations in tissue of intervertebral disks that occur with agingoccur with agingNarrowing of disk results in variable segmental Narrowing of disk results in variable segmental instability and occasional low back paininstability and occasional low back pain


SpondylosisSpondylosis

Defect of lamina or vertebral archDefect of lamina or vertebral archUsually lumbar spine between superior and inferior Usually lumbar spine between superior and inferior articulating facetsarticulating facetsRotational stress fractures common at affected siteRotational stress fractures common at affected siteHeredity significant factor Heredity significant factor


Herniated Intervertebral DiskHerniated Intervertebral DiskTear in posterior rim of capsule encloses gelatinous Tear in posterior rim of capsule encloses gelatinous center of diskcenter of disk

Rupture of disk by:Rupture of disk by:TraumaTraumaDegenerative disk diseaseDegenerative disk diseaseImproper lifting (most common)Improper lifting (most common)

Disks commonly affected:Disks commonly affected:L5L5--S1 and L4S1 and L4--L5L5Occasionally C5Occasionally C5--C6 and C6C6 and C6--C7C7



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Spinal Cord TumorsSpinal Cord TumorsMay develop from:May develop from:

Cord compressionCord compressionDegenerative changes in bones and jointsDegenerative changes in bones and jointsInterruption in cordInterruption in cord’’s blood supplys blood supply

Classified by cell type, growth rate, and Classified by cell type, growth rate, and structure of originstructure of origin


Spinal Cord TumorsSpinal Cord TumorsSigns and symptoms depend on tumor type and Signs and symptoms depend on tumor type and locationlocation

May include:May include:Temperature dysfunctionTemperature dysfunctionSensory changesSensory changesOther abnormalitiesOther abnormalitiesParesisParesisSpasticitySpasticityPainPainBilateral or asymmetric motor dysfunctionBilateral or asymmetric motor dysfunction


Nontraumatic Spinal ConditionsNontraumatic Spinal Conditions

Assessment and management are based on:Assessment and management are based on:PatientPatient’’s chief complaints chief complaintPhysical examinationPhysical examinationEvaluation of associated risk factorsEvaluation of associated risk factors

Common signs and symptomsCommon signs and symptoms

Care must be taken to decrease pain and discomfortCare must be taken to decrease pain and discomfortFull spinal immobilization is not required unless condition is tFull spinal immobilization is not required unless condition is the he result of traumaresult of trauma



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ConclusionConclusionEducation in injury prevention, prehospital Education in injury prevention, prehospital

assessment, and proper handling and assessment, and proper handling and transportation of patients with spinal injury transportation of patients with spinal injury

can decrease mortality and morbidity.can decrease mortality and morbidity.


Questions ?Questions ?



Documents

Chapter 25 Spinal Trauma - BrainSpewbrainspew.com/advanced/medic/slides/Chapter_025.pdf · zDescribe prehospital assessment of spinal cord injury zIdentify prehospital management