Suspected Spinal Injury Objectives At the completion of this unit, the EMS provider will be able to utilize assessment findings to formulate a field impression and implement a treatment plan for a patient with a suspected spinal injury. Prior to this unit, EMS providers should have an understanding of the anatomy of the spine and spinal cord, trauma assessment, and spinal immobilization. This presentation is to be used as an adjunct to the New York State Department of Health Bureau of EMS trauma curriculum update for the Suspected Spinal Injury protocol published in February of 2008. New York State Department of Health Bureau of Emergency Medical Services

Cervical Spine Injuries in Perspective 2.4% of blunt trauma patients experience some degree of musculoskeletal injury to the spine Approximately 20,000 spinal cord injuries a year in United States $1.25 million to care for a single patient with permanent SCI Cervical Spine Injuries in Perspective2.4% of blunt trauma patients experience some degree of musculoskeletal injury to the spine Injury ranges from sprain (i.e. whip lash) stable fractures (e.g. tear drop fracture) subluxations unstable fractures partial or complete spinal cord transection paralysis paraplegia (effecting two limbs) tetraplegia (effecting all four limbs) Approximately 20,000 spinal cord injuries a year in United States cost of lifetime medical care for spinal cord injury approximately $1.25 million dollars Occult spinal cord injury approximately 60% of patients present initially without spinal cord deficits weakness (paralysis) tingling or numbness (paresthesia)

Higher in men between ages of 16 – 30 Common causes: 15,000 – 20,000 SCI per year Higher in men between ages of 16 – 30 Common causes: Motor vehicle crashes – 2.1 million per year (48%) Falls (21%) Penetrating injuries (15%) Sports injuries (14%) Education in proper handling and transportation can decrease SCI

Historically Immobilization based on MOI – even if there were no signs and symptoms Lack of clear clinical guidelines EMS providers did poorly with full spinal immobilization Motor vehicles had fewer safety features Patients spent extended amounts of time in immobilization devices at E.D. Until recently EMS was taught to look at MOI as an indicator for spinal immobilization.

Why not board/collar and Xray everybody? Immobilization is uncomfortable: increased time immobilized = increased pain, risk of aspiration, vulnerable position, etc... >800,000 U.S. Patients receive cervical radiography each year Patient exposure to radiation >97% of x-rays are negative Cost exceeds $175,000,000 each year

Secondary Injury versus Primary Injury Spinal Injury that occurred at time of trauma Secondary Injury Spinal Injury that occurs after the trauma possibly secondary to mishandling of unstable fractures

Review of Anatomy & Physiology Spinal Column 32 - 34 separate, irregular bones Head (15-22 lbs) Balances on Top C-Spine Supported by Pelvis Ligaments and Muscles connect head to pelvis Injury to Ligaments may cause excess movement of vertebrae Vertebral Foramen - canal formed for cord

Vertebral foramen Spinous process Body

Anatomy & Physiology, cont. Cervical 7 Vertebrae Considered “Joint Above” when splinting Atlas (C1) and Axis (C2) Thoracic 12 Vertebrae Ribs connected forming rigid framework of thorax

Anatomy & Physiology, cont. Lumbar 5 Vertebrae (largest vertebral bodies) Flexible and Carries majority of body weight Sacrum 5 fused bones Considered “Joint Below” with pelvis when splinting

Anatomy & Physiology, cont. Coccyx 2-4 fused bones “Tailbone” Vertebral Structures Body Transverse Process Spinous Process Intervertebral Disks - fibrocartilage “shock absorber”

Cervical (7) Thoracic (12) Lumbar (5) Sacrum (5) Coccyx (4)

Anatomy & Physiology, cont. Central Nervous System (CNS) Brain Largest most complicated portion of CNS Continuous with spinal cord Responsible for all sensory and motor functions Spinal Cord Within the Vertebral Column Begins at Foramen Magnum and ends near L2 (cauda equina) Dural Sheath

Anatomy & Physiology, cont. CNS Cont. Ascending Nerve Tracts Carries impulses and sensory information from the body to the brain (I.e. touch, pressure, pain, tenderness, body movements, etc.) Descending Nerve Tracts Carries motor impulses from brain to body (e.g. muscle tone, sweat glands, muscle contraction, control of posture)

Anatomy & Physiology, cont. CNS Cont. Spinal Nerves 31 pairs originating from spinal cord Mixed Nerves - carry both sensory and motor functions Dermatones Topographical region of body surface innervated by one spinal nerve Example: C-7/T-1 motor = finger abduction and adduction, sensory = little finger

Pathophysiology of Spinal Injuries Mechanisms and Associated Injuries Hyperextension Cervical & Lumbar Spine Disk disruption Compression of ligaments Fx with potential instability and bone displacement Hyperflexion Wedge Fx Stretching of ligaments Compression Injury of cord Disk disruption with potential vertebrae dislocation

Pathophysiology, cont. (Mechanisms and Common Injuries) Rotational Most commonly Cervical Spine but potentially in Lumbar Spine Stretching and tearing of ligaments Rotational subluxation and dislocation Fx Compression Most likely between T12 and L2 Compression fx Ruptured disk

Pathophysiology, cont. (Mechanisms and Common Injuries) Distraction Most common in upper Cervical Spine Stretching of cord without damage to spinal column Penetrating Forces directly to spinal column Disruption of ligaments Fx Direct damage to cord

Pathophysiology, cont. Specific Injuries Fractures to vertebrae Tearing of Ligaments, Tendons and/or Muscles Dislocation or Subluxation of vertebrae Disk herniation / rupture

Pathophysiology, cont. (Specific Injuries) Cord Injuries Concussion - temporary or transient disruption of cord function Contusion - Bruising of the cord with associated tissue damage, swelling and vascular leaking Compression - Pressure on cord secondary to vertebrae displacement, disk herniation and/or associated swelling

Pathophysiology, cont. (Specific Injuries) Cord Injuries cont. Laceration - Direct damage to cord with associated bleeding, swelling and potential disruption of cord Hemorrhage - Often associated with a contusion, laceration or stretching injury that disrupts blood flow, applies pressure secondary to blood accumulation, and/or irritation due to blood crossing blood-brain barrier. Transection - Partial or complete severing of cord

Pathophysiology, cont. (Specific Injuries) Spinal Shock Temporary insult affecting body below level of the injury Flaccidity and decreased sensation Hypotension Loss of bladder and/or bowel control Priapism Loss of temperature control Often transient if no significant damage to cord

Pathophysiology, cont. (Specific Injuries) Neurogenic Shock Injury disrupts brain’s control over body lack of sympathetic tone Arterial and vein dilation causing relative hypovolemia Decreased cardiac output Decrease release of epinephrine Decreased BP Decreased HR Decreased Vasoconstriction

Signs and Symptoms of Spinal Cord Injury Paralysis Paresthesias Paresis (weakness) Shock Priapism Pain Tenderness Painful Movement Deformity Soft Tissue Injury in area of spine (Bruise, Laceration, etc.)

General Assessment Scene Size Up Initial Assessment Including manual stabilization/immobilization of the c-spine Focused History and Physical Exam - Trauma Reevaluate Mechanism of Injury (MOI) Suspected Spinal Injury Protocol

Positive MOI - Forces or impact suggest a potential spinal injury Sports Injuries Other High Impact Situations Consideration to special pt. Population pediatrics geriatrics history of Down’s spino bifoda etc. High Speed MVC Falls Greater than 3x pt.’s body height Axial Loading Violent situations near the spine Stabbing Gun shots etc.

High Risk MOIs Axial load (i.e., diving injury, spearing tackle) High speed motorized vehicle crashes or rollover Falls greater than standing height The presence of one of these MOIs does not always require treatment, but providers should be more suspicious of spinal injury, and immobilize if they are at all worried about the possibility of spinal injury High Risk Mechanisms of injury have been identified as being more likely than other types of blunt trauma to lead to possible spinal injury. A patient with one of these MOIs does not require treatment, but providers need to more suspicious of injury. High risk mechanisms of injury associated with unstable spinal injuries include, but are not limited to:  Axial load (i.e. diving injury, spearing tackle)  High speed motorized vehicle crashes or rollover  Falls greater than standing height in relationship to the patient’s feet. For example, a 6 foot tall person falls five feet off a step ladder they would not have a high risk MOI.

Other High Risk Factors Associated with Spinal Injury Trisomy 21 (Down Syndrome, mongolism) Risk of Atlanto-Axial Instability (AAI) Age Greater than 55 Risk of degenerative arthritis of cervical spine Degenerative Bone Disease (including ostegenesis imperfecta, or “fragile bones”) Risk of “pathological” (disease-related) fractures Spinal Tumors Patients with these risk factors have been shown to be more likely to have a spinal injury, with a lower mechanism of injury. Providers should be more cautious when considering the situation including the patient’s history, mechanism of injury, complaints and history to make the decision regarding immobilization. For example, Down Syndrome patients may have atlantoaxial instability, or AAI. This effects the integrity of the cervical spine and may make these patients more susceptible to spinal cord injury. This is important when evaluating the patient for the need for spinal immobilization.

Negative MOI Forces or impact involved does not suggest a potential spinal injury Dropping rock on foot Twisting ankle while running Isolated soft tissue injury

Uncertain MOI Unclear or uncertainty regarding the impact or forces Trip and fall hitting head Fall from 2-4 feet Low speed MVC with minor damage

MOI, cont. When using the Suspected Spinal Injury protocol, a positive mechanism of injury is not considered means to necessitate full immobilization … BUT… should be used as a historical component that may heighten a provider’s suspicion for a spinal cord injury.

Current Practice Widespread spinal immobilization of all adult and pediatric trauma patients.

Spinal Immobilization Education Identify All Patients at Risk for Spinal Injury based on Mechanism of Injury and Patient Assessment Shift from current thinking of immobilization based on mechanism of injury alone.

History of Spinal Immobilization Maine Selective Spinal Immobilization Early Leaders in Out – of – Hospital Selective Spinal Immobilization National Emergency X-Radiography Utilization Study (NEXUS) History of Selective Spinal Immobilization Maine Selective Spinal Immobilization Early Leaders in Out – of – Hospital Selective Spinal Immobilization National Emergency X – Radiography Utilization Study (NEXUS)

Spinal Immobilization Protocols in New York State The following groups of patient should be immobilized: The following groups of patient should be immobilized!

Major Trauma Protocol All Adult and Pediatric Trauma Patients who meet the Major Trauma Protocols (T 6–7) Certain Adult and Pediatric Patients with Blunt Head and Neck Trauma i.e. Based on Mechanism of Injury (T 8) Major Trauma All adult and pediatric trauma patients who meet the Major Trauma Protocols (T-6) Certain adult and pediatric patients with blunt head and neck trauma as outlined below (T-8) Spinal Immobilization indicated for the following adult and pediatric patients based on Mechanism of Injury (*included in Major Trauma Protocol) Violent Impact of the Head, Neck or Trunk Motor Vehicle Crash High Speed Rollover* Ejection* Falls Moving Vehicle at any speed Height greater than 3 feet or 5 stairs Mechanism consistent with potential axial loading / cervical compression ex. brick falling on head of patient wearing hard hat

Consider Spinal Immobilization Not Meeting Major Trauma Protocol but patient has one or more: Altered Mental Status Patient Complaint of Neck Pain Weakness, Tingling or Numbness Pain on Palpation of Posterior Midline Neck Spinal Immobilization indicated for the following adult and pediatric trauma patients based on Physical Findings Altered Mental States Verbal or less on AVPU Assessment 14 or less on the Glascow Coma Scale Patient complaints Neck Pain Presence of the following in the trunk or extremities Weakness Tingling Numbness Findings on Physical Examination Pain on Palpation of posterior midline neck or along spine Palpable Deformity in the posterior midline neck or along spine Paralysis Paresthesia

Consider Spinal Immobilization High Risk Patients Not Meeting Major Trauma Protocol but patient has one or more: Altered Mental Status Evidence of Intoxication Distracting Injury Inability to Communicate Acute Stress Reaction Elderly Age Greater than 65 years Spinal Immobilization indicated for the following adult and pediatric patients who are defined as High Risk Patients Elderly Age Greater than 65 years Evidence of Intoxication Distracting Injury Inability to Communicate

What is an Altered Level of Consciousness? Verbal or less on the AVPU Scale Glascow Coma Scale of 14 or Less Short Term Memory Deficit What is considered an Altered Level of Consciousness? Verbal or less on the AVPU Scale Disoriented to Person or Place or Time Glascow Coma Scale of 14 or Less Short Term Memory Deficit Inability to remember Five (5) Items in Five (5) Minutes

What is Intoxication? Patients who have either A History of Recent Alcohol Ingestion or Ingestion of Other Intoxicants Evidence of Intoxication on Physical Examination What is considered Intoxication? Patients who have either A History of Recent Alcohol Ingestion or Intoxication Evidence of Intoxication on Physical Examination Smell of Alcoholic Beverages on the Breath Slurred Speech Positive Lateral Nystagmus (movement of eyes side to side –rapidly)

What is a Distracting Painful Injury?? Painful Injury or Serious Illness that would Mask the Symptoms Associated with Spinal Cord Injury What is a Distracting Painful Injury? Painful Injury that would mask the symptoms associated with Spinal Cord Injury Pain Parenesthesia (Tingling) Paralysis (Weakness) Examples of Distracting Painful Injury Limb Injuries such as Any Long Fracture Crush Injury Degloving Injury Internal Organ Injury aka Injury meeting Major Trauma Protocol Large Lacerations Any Injury that produces an Acute Functional Impairment Inability to Move an Extremity Inability to Feel an Extremity Severe Exacerbations of Medical Conditions Chest Pain Cardiac Related Shortness of Breath Respiratory Distress/Failure Severe Abdominal Pain

Distracting Injury or Circumstances Painful Injury Obvious Deformity Significant Bleeding Impaled Object Any painful injury that may distract the patient’s attention from another, potentially more serious (cervical spine) injury Inability to Communicate Clearly (small child, confused or intoxicated adult) Emotional Distress Presence or Exacerbation of Existing Medical Conditions What is a Distracting Injury or Circumstance? Painful Injury that would mask the symptoms associated with Spinal Cord Injury Pain from obvious fractures Impaled Objects Large Laceration or Other significant bleeding Examples of Difficulties with Patient Communication Very Young Patient Developmentally Disable Persons Language Barrier Physical Barriers Hearing Impairment Emotional Distress Excited, Distraught, Unable to Focus Injured Child or Family Member Horrific Accident Anxiety A patient with a medical complaint may not be able to participate fully in the exam.

Fundamental Principle Patient Communication Patients with Communication Difficulties Acute Stress Reaction Fundamental Principle Patient Communication Inability to communicate with the patient would have EMS provider err on the side of caution and immobilize the cervical spine Examples of Difficulties with Patient Communication Language Barrier Physical Barriers Hearing Impairment Acute Stress Reaction Acute Stress Reaction (ASR) results in an inability to communicate effectively

What is Acute Stress Reaction? A “fight or flight” response that can override any pain from an injury What is Acute Stress Reaction? A “fight or flight” response that can override any pain from an injury subjective appearance of “panic” or “alarm” associated signs of fight or flight response increased respiratory rate – tachypnea elevated heart rate – tachycardia elevated blood pressure – hypertension

Key Point If there is ANY DOUBT, then SUSPECT that a SPINE INJURY is Present and Treat Accordingly

Termination of Immobilization Once spinal immobilization has been initiated, it must be completed. An extrication or cervical collar starts the immobilization process Manual Stabilization does NOT start the immobilization process Once spinal immobilization has been initiated, it must be completed. An extrication or cervical collar starts the immobilization process, manual stabilization does not

Documentation Negligence Either an omission or a commission of an act Documentation of rationale to Immobilize Not Immobilize Documentation Negligence Either an omission or a commission of an act Documentation of rationale to Immobilize Not Immobilize

Routine Prehospital Care Documentation Mechanism Of Injury Patient Chief Complaint Physical Examination Finding Initial Assessment Rapid Trauma Examination Detailed Trauma Examination Routine Prehospital care documentation including mechanism of injury patient complaints physical examination findings initial assessment rapid trauma examination detailed trauma examination

Documentation of Rationale to Not Immobilize Mechanism Of Injury is Minor Physical Examination (Positives) Physical Examination (Negatives) Absence of signs of spine injury Absence of distracting injury Patient was not one of the identified high risk patients Documentation of rationale to not immobilize Mechanism Of Injury is Minor i.e. does not meet major trauma criteria was not a violent impact to head, neck or trunk physical examination did not find Altered mental status I.e. Patient Awake and Alert Glascow Coma Scale of 15 Evidence of intoxication Absence of numbness (paraesthesia) or weakness (paralysis) absence of signs of spine injury cervical spine tenderness pain of the cervical spine on palpation deformity of the cervical spine absence of distracting injury patient was not one of the identified high risk patients elderly (>65)

New NYS BLS Protocol Suspected Spinal Injury (not meeting major trauma criteria)

Review this first section of the protocol, which outlines the major components of the protocol.

Review these two boxes from the protocol.

Flow Chart

Friday Night Lights 16 year old male football player Made a spear tackle during the game and remains down Assessment finds tenderness to the posterior of the neck Should the patient be immobilized? Why or Why not? EMS Standby at JV Football Game After a play, the crew is motioned onto the field to aid a player that hasn’t gotten up The coach and trainer are talking to a prone patient. The patient is CAOx3 but reports that he doesn’t remember how he got injured. The coach reports that the patient had made a “spear tackle.” The patient assessment finds no life threats, normal vital signs, good sensation, motion, and pulses in all extremities. There is mild tenderness on palpation to the posterior of the neck. The patient SHOULD be immobilized based on the Mechanism of Injury – Axial Loading and Physical Findings – tenderness in the neck. Either alone would be an indication for immobilization.

Motorcycle Accident 35 year old female Single vehicle accident in the rain Laid the motorcycle down to avoid striking another car Pain to left elbow & shoulder No other unusual findings Should the patient be immobilized? Why or Why not? Respond for report of a motorcyclist down Arrive to find a 35 year old woman sitting on the curb, CAOx3 near her damaged motorcycle. The road is wet from a light rain. She reports she was riding at about 35 mph and had to avoid a vehicle that entered the road from a parking lot. She laid the motorcycle down to avoid the collision. The patient was wearing a helmet and “leathers” She complains that she has some pain in her left elbow and shoulder, but otherwise she feels fine. Patient assessment finds bruising near left elbow, but no other abnormalities. Good sensation, movement and circulation in all extremities. No pain in neck or back. No signs of intoxication. The mechanism of injury does not meet the threshold of high speed motor vehicle crash. The physical findings do not indicate a suspected spinal injury The patient is not high risk. EMS providers may immobilize this patient based on provider concern, but it is not required by protocol.

Two Cars, Two Drivers Driver # 1 Driver # 2 Ambulatory, Agitated, 50 year old male Rear ended by driver # 2 at a stoplight Driver # 2 Belted and still in vehicle 19 year old female Couldn’t stop in time, struck other vehicle Should either patient be immobilized? Why or Why not? EMS responds and is first on the scene of the MVC at an intersection. Vehicle # 1 is midsized sedan with crumpled trunk, but no other damage. Windshield is intact. Airbags did not deploy. The driver is walking around the scene inspecting the damage and glaring menacingly at the other driver and holding a bloody handkerchief to his nose. Vehicle # 2 is a minivan with damage to the grill, umber and front fenders. The front air bags did deploy. The driver is still in the vehicle with her seat belt on and she is on her cell phone visibly crying. Does either driver fall into mechanism? Driver # 1- Maybe – What is a violent mechanism? Why is his nose bleeding? The driver reports that he hit himself in the nose with his hand because we was about to call someone on his phone when she hit him.- This is not a violent mechanism. Striking the steering wheel would be. Would it matter if he was un-belted and struck the wheel or windshield? Its not clear and more information is needed. But if there is doubt, providers should immobilize him. Driver # 2 –No. Physical Assessment Driver #1 Alert and oriented, bleeding from the nose, complains that his left shoulder hurts him, but no other complaints. Neck is not tender and no deformities are noted. Vital signs are slightly elevated, but not worrisome. He exhibits no signs of intoxication during the exam. Should he be immobilized? No – the nose should not be categorized as a distracting injury and nothing else on the patient assessment seems to indicate the need to immobilize. Driver # 2 Alert and Oriented, but very upset. Complains of burning on her face and keeps repeating that she just didn’t see him in time to stop. The vital signs are normal except the heart rate of 120. Once you get her to get off the phone, she states that nothing hurts except her face. There is not pain on palpation during the physical exam of the neck. No injuries are found and circulation motor and sensation are normal. High Risk Patient Neither driver seems to be a high risk patient Any doubt? Either patient may be immobilized if EMS crews are unsure, Regardless of the decision, EMS providers need to document their justification to follow a specific path of care.

QA/QI Regional review of PCRs. Agency increased review of all PCRs where spinal immobilization was not used. On-going education of providers Regions should develop a useful tool to complete enhanced review of PCRs for those patients that had and did not receive spinal immobilization. Agencies should increase their review of these patients as well. The agency Medical Director should be involved with this increased review. Statistical data at both the agency and regional level could help with future protocol revisions.

First, do no harm Good Medical Care requires good clinical judgment; this can not be defined or legislated, but must be employed. When in doubt, decide in favor of the patient and immobilize the spine.