Spinal injury MASTER MOTIVATION: Many trauma patients sustain spinal column injuries including potentially unstable fractures. Recognition and appropriate patient handling will minimise any spinal cord damage and subsequent neurological injury. There are approximately 500 new spinal cord injuries in the UK each year, principally affecting young adults. Whilst relatively uncommon, the significance of spinal cord injury is that the central nervous system once damaged cannot regenerate. © BASICS Education March 2019

High index of suspicion If you do not recognise and manage the potential spinal injury . . . the patient may live to regret it

Consider spinal injury in the following High energy mechanism of injury Diving accidents Falls from a height (>10 ft or 2 x patient’s height) Serious injury above the clavicle Multiple trauma victims Road traffic collisions Horse riding accidents Altered level of consciousness Presence of drugs / alcohol Certain mechanisms of injury and injury patterns are associated with spinal column injury and should raise awareness, these are: • Falls from height, particularly two times the patients own height • High speed vehicle accidents with rapid deceleration, roll over, ejection Significant head injury (5-10% incidence of cervical spine injuries in unconscious trauma patients). The commonest mechanism of injury is unexpected impact or deceleration such as: • Diving into shallow water, ejection from a horse or motorcycle, collapse of a rugby scrum • Ejection from a car is associated with a 1 in 14 risk of spinal injury. (This compares with the risk of 1 in 483 if the patient is restrained).

Indicators of spinal injury: Neurological deficit Paralysis / loss of power Altered sensation Diaphragmatic breathing Neurogenic shock Priapism Urinary incontinence / loss of anal tone Decreased range of movement Pain & / or tenderness of the spine midline

Scene assessment Mechanisms of injury Surrounding incident area Damage to structures involved intrusion Casualty position Recognition As has been stressed previously an assessment of the mechanism of injury should be made both from the scene and then from an assessment of the patient. The injury patterns referred to above should raise the suspicion of spinal column damage.

Spinal injury - patient assessment History / Mechanisms Airway & Cervical spine consideration Breathing (low cervical / high thoracic injury?) Circulation (neurogenic shock?) Disability: signs & symptoms, AVPU Neurological deficit (motor / sensory function?) Exposure: other fractures / wounds Airway Manual in line stabilisation initially provides the best method of immobilisation and should be maintained without interruption during extrication and until collar, head blocks and straps can be applied. The airway takes precedence over cervical spine control. The collar may need to be removed to allow airway access though manual in-line stabilisation should be maintained during the intervention. Caution is needed when inserting an airway in a patient with a potential spinal cord injury. Damage to the patient’s sympathetic nervous system can leave the patient with unopposed parasympathetic (vagal) activity, which is heightened by hypoxia and hypovolaemia – Airway manoeuvres can result in profound bradycardia or even cardiac arrest. Specific measures: Keep intervention to a minimum to provide a satisfactory airway. If suction and/or airway adjuncts are required to secure vascular access be prepared to treat with a small dose of atropine 500 mcg IV.10. Breathing Thoracic vertebral fractures tend to be stable unless there is an associated sternal fracture or multiple rib fractures. The reverse of this is that patients with sternal fractures are at increased risk of thoracic spine damage and spinal cord injury. In high spinal injuries the breathing pattern may be diaphragmatic Circulation – Neurogenic Shock. Loss of sympathetic activity causes a loss in vascular tone leading to pooling of blood in the peripheral circulation. This leads to hypotension. This would normally lead to a rise in heart rate but because the nervous system has been damaged this does not take place. Patients thus have a low blood pressure and a low pulse rate. This is known as Neurogenic shock. It should be remembered that shock in the patient with multiple injuries must never be attributed solely to spinal cord injury: hypovolaemic shock must be excluded. Specific Measures: In those patients who exhibit signs of neurogenic shock care should be taken not to tip them feet down. Fluid replacement should be kept to a minimum, guided by maintaining a radial pulse. This will ensure adequate perfusion, without over-resuscitation resulting in side effects such as pulmonary oedema. Disability Signs of spinal injury can very quickly be assessed at this stage. You should record: • Spinal pain or tenderness • Paraesthesia (pins and needles) • Inability to move a limb or part of a limb These are coarse signs but enough to confirm the need for immobilisation and can be done without moving the patient.

Recognition of spinal injury REMEMBER A normal neurological examination does NOT rule out the possibility of a spinal cord injury

Objectives of treatment Support vital functions Prevent further damage Neutral alignment of the C- Spine prevents secondary hypoxic damage Injuries to the spinal cord may, like head injuries, be primary cord injuries or secondary cord injuries. In the case of primary cord injury there is little that can be done about the primary injury. The injury has resulted from the forces transmitted during the accident. However the spinal cord is at risk of further injury through inappropriate handling. A mechanical insult from pressure applied to it as a result of disruption to the vertical column from unstable fractures or fracture dislocations. In all trauma patients it is safest to assume an injury to the vertical column and immobilise the patient appropriately until the specialist advice and investigation in hospital have ruled this out. The main causes of secondary cord injury are hypoxia, whether from obstructed airway or ventilatory embarrassment, hypovolaemia due to associated injury and movement induced deterioration (for example causing impairment of the vascular supply of the spinal cord)

Pre-hospital spinal injury management Ensure ABC Manual C spine control Neutral alignment If no resistance / pain High flow oxygen Analgesia if necessary Immobilisation The main goal of the emergency care provider is to prevent additional cord damage, which may result in further deterioration of the spinal cord. Both cost and damages can be reduced by having obvious and defined treatment goals along with greater focus and more training on these types of injuries. Treatment goals: Treatment by pre-hospital and in-hospital personnel is directed towards stabilization of existing injuries, prevention of secondary cord injury and safe transportation to an appropriate facility. This is accomplished by restraining the spine in the neutral position. By restricting movement, the internal area of the canal and the diameter of the cord remain constant, reducing the chance for secondary injury. In-hospital providers work toward the same goal by continuing the motion restriction established in the pre-hospital setting, initiating care on patients who have by-passed the pre-hospital care system.

Spinal immobilisation If it is possible that a spinal injury exists appropriate spinal immobilisation must be undertaken Collar? Scoop Neil Robertson stretcher KED When necessary airway takes priority over C-Spine Spinal immobilisation is particularly important in the pre-hospital environment because it is there that failure to recognise that the potential spinal damage may result in avoidable death or permanent disability. Spinal injury should be suspected in all patients who have suffered blunt trauma, especially with injury above the clavicles. There is a four-fold increase in risk of cervical spine injury if there is a clinically significant head injury. Those patients who should receive immobilisation are those who have: • Injury above the clavicles • Pre-existing disease of the spine (history from the patient) • Neurological signs or symptoms related to spinal injury • Altered level of consciousness at the time of assessment Intoxication Pain or tenderness of the spine Other injuries, the pain of which may distract them from their spinal symptoms A mechanism of injury which gives suspicion of possible injury for example high velocity car crash, fall of greater than twice the patient’s height, ejection from vehicle

No immobilisation required? Low likelihood given mechanism No midline neck or back pain / midline spinal tenderness No palpable ‘step’ No neurological symptoms & signs No reduction in LOC Alert and orientated No alcohol / drugs No distracting injury No relevant medical history Ankylosing Spondylitis, Rheumatoid Arthritis etc There is no doubt that collars are overused. By using some of the criteria below, some patients will be able to avoid the discomfort, waiting time in A&E and exposure to X-rays that an unnecessarily applied collar can bring about. Evidence based guidelines suggest that spinal immobilisation may not be required for car occupants when the following circumstances co-exist: • The impact was low velocity • The is minimal damage to car • The patient normally fit • There is no complaint of neck pain • There is no spasm in the neck • There is no spinal tenderness This will occasionally bring the carer and patient into conflict, for example with the confused, intoxicated, or head injured patient. Important considerations in this respect are that the patient receives oxygen, as the confusion may be hypoxic in origin. At the least manual in-line stabilisation should be attempted but manual restraint or attempts at full immobilisation of a combative patient are not advocated and may only cause further harm. It is essential that accurate patient notes are recorded reflecting the difficulty the practitioner has experienced in dealing with this challenging patient.

Documentation is essential What spinal care was given Any neurological deficit Condition at handover

Cervical collars Have been shown to raise intracranial pressure Have not been shown to restrict movement significantly Once secure on the scoop the collar may be loosened Document Include in handover

Longboards & pressure sores Extrication device only Pressure sores may develop after 30 minutes. After 1-2 hours major ischaemia will occur 60% occur at heels 26% on the sacral area Also on occiput / elbows Document your long board time The patient should not spend longer than 30 minutes in total on the board as this can lead to pressure sores – particularly in the case of a spinally injured patient. In the case of a longer hospital transfer or A&E assessment, the patient can be extricated on a long board, and then transferred by scoop stretcher to a vacuum mattress.

Transportation Patient & equipment are reassessed before leaving scene Journey < 30 mins on scoop or Neil Robertson stretcher Journey > 30 mins on vacuum mattress

Special considerations This slide can be used to discuss the special problems associated with the management of a spinal injured patient in the following: Children & babies ‘Walking’ spinal injured casualty

Spinal injury Questions?

Summary <C>AcBCDE priorities take precedence History of incident & mechanisms of injury are crucial A high index of suspicion maintained by all personnel Attempt to return neck to neutral alignment Controlled handling of patient is essential If spinal immobilisation - all equipment must be used Extrication based on the clinical condition of the patient Summary ABC’s still apply as priority to patients with suspected spinal injuries. The spinally injured patient presents specific problems during intervention. In-line stabilisation should be maintained from the point of first contact with a patient who could have a spinal injury, until immobilisation has been achieved by approved methods or it is judged that immobilisation is not necessary. If in doubt, immobilise. Not all patients who have collapsed or been involved in RTAs need collars. Clinical factors as well as mechanism of injury should be assessed when deciding the need for full spinal immobilisation. Collars have no place on their own, as they do not provide adequate immobilisation.

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