Chapter 22 Spine Injuries

Overview Types of Spinal Injuries Patient Presentation Assessment Management Activity: Divide the class into groups of four to five students and have them answer the questions in the case “Head-On Collision.” Bring the class back together and have each group report on their responses. Suggested Responses: 1. The first priority with every trauma patient is to obtain and maintain a neutral in-line position of the cervical spine unless there is pain with movement or the EMT meets resistance. 2. The EMT should carefully assess and document the exact extent of paralysis and paresthesia the patient is experiencing, as well as perform repeated and ongoing assessments of the spinal cord injury. 3. Due to the mechanism of injury, the EMT should consider transporting this patient to a trauma center without the use of lights and siren. A cautious ride driven at slow speeds, with a minimum of movement, is in order.

Types of Spinal Injuries Without neurologic injury Consist only of ligament or bone injuries Patency of the spinal canal is not compromised Sensitive spinal cord is not traumatized Spinal injuries can consist of only ligament or bone injuries. If the patency of the spinal cord is not compromised and the sensitive cord is not traumatized, neurologic injury will not be present. A patient who has sustained a possible spinal injury should not be allowed to move. An EMT who suspects a spinal cord injury should treat the patient as though one exists.

Moving the Patient Watch this animation of how moving the patient with a spinal cord injury could cause further injury

Types of Spinal Injuries With neurologic injury Certain signs and symptoms indicate neurologic injury These result from an interruption in the normal message flow between the brain and the body The EMT should be aware that a patient who is walking around at the scene of an accident may have suffered a spinal cord injury. Certain signs and symptoms, which will be discussed later, are indicative of neurologic injury. These symptoms result from an interruption in the normal flow of messages between the brain and the body.

Types of Spinal Injuries Cervical Injury has the most extensive consequences Nearly 40% of cervical fractures have associated spinal cord injury Motor vehicle crashes account for a large number of cervical spine injuries Each segment of the spine has unique features that make it susceptible to particular types of injuries. Injury to the cervical spine has the most extensive consequences. Nearly 40% of cervical fractures have associated spinal cord injury. In the United States, car crashes account for a large number of cervical spine injuries.

Types of Spinal Injuries Thoracic Not injured as often as more mobile areas More likely to involve the spinal cord than other areas Often result from a direct blow to the back While the thoracic spine is not injured as often as the more mobile areas of the spine, when an injury occurs, it is more likely to involve the spinal cord. The reason is that the spinal cord is relatively narrow at this level. Thoracic spine injuries most often result from a direct blow to the back.

Types of Spinal Injuries Lumbar May not be as evident on examination as higher cord injuries Injuries usually caused by a flexion, extension, or rotational mechanism Injuries to the lumbar spinal cord may not be as evident on examination as higher spinal cord injuries. Presence of pain in the low back area can help the EMT determine if an injury to the area exists. These injuries are usually caused by a flexion/extension/rotational type of mechanism.

Types of Spinal Injuries Sacrococcygeal Injury to sacrum usually results from a direct blow Injury to coccyx usually results from a fall Spinal cord does not extend to coccyx Injury to the sacrum usually results from a direct blow. Injury to the coccyx, or tailbone, is usually the result of a fall. Because the spinal cord does not extend as far as the coccyx, injury to these fused bones does not cause spinal cord injury.

Patient Presentation Mechanism of injury First clue to the possibility of a spinal injury Consider these suspect: Any blow to the spine Any mechanism involving severe flexion, extension, or rotation of the spine Large majority of injuries result from collisions, violence, or falls The mechanism of injury is the EMT’s first clue to the possibility of a spinal cord injury. Any blow to the spine or any mechanism involving severe flexion, extension, or rotation of the spine should be considered suspect. The large majority of spinal cord injuries occur in males between the ages of 16 and 30 and are the result of motor vehicle collisions, violence, or falls.

Patient Presentation Mechanism of injury Motor vehicle crash Often causes flexion/extension injuries Force can cause motion beyond what is normally allowed Intrusion of normal anatomy into the narrow spinal canal causes cord injury The spinal column is designed to allow a certain amount of flexion, extension, and rotation. If force causes motion beyond that which is normally allowed, the spinal column may be damaged. When a disruption causes the normal anatomy of the spinal column to intrude into the narrow spinal cord, injury to the cord can occur. Forces in a motor vehicle crash often cause the neck to flex and extend forcefully beyond what is normally allowed.

Patient Presentation Mechanism of injury Falls Falls from any height can cause injury to the spine Compression fractures are seen in patients who experience a direct blow to a vertebra Axial loading can cause spinal injuries Falls from any height can cause injury to either the spine or the vertebrae. Compression fractures, a crushing injury to an individual bone, are often seen in patients who have experienced a direct blow to a vertebra. Victims who fall from a height and land on their feet, a phenomenon known as axial loading, may experience spinal injuries. The force of the fall is transmitted from the feet through the legs to the spine.

Patient Presentation Mechanism of injury Firearms Recreation Create a penetrating injury that can damage the spinal cord or a vertebra Recreation High school football results in 20–30 permanent spinal cord injuries every year Mechanism of injury varies with each situation The number of injuries related to firearms has become significant. A gunshot or knife can cause injury to a vertebra or spinal cord. Because it is difficult to discern the direction of the internal travel of a bullet, any patient who has suffered a gunshot wound to the torso should be treated for a potential spinal injury. While recreational sports are generally a safe way to exercise, they can result in spinal injuries. Each year in the United States, high school football results in 20 to 30 permanent spinal cord injuries. Depending on the sport, the mechanism of spinal injury will vary with each situation.

Patient Presentation Mechanism of injury Associated injuries Suspect spinal injury when significant trauma is sustained by a body part close to the spine Head and face—assume cervical spine injury with trauma above clavicles Chest—assume thoracic spine injury Abdomen—assume lumbar spine injury Because the spine is near to many other body parts, an injury to another part can also cause injury to the spine. The EMT should suspect spinal injury if significant trauma is sustained by any part of the body that is close to the spine. With trauma to the head and face, the EMT should assume there is cervical spine injury. With trauma to the chest, the EMT should assume there is thoracic spine injury. With trauma to the abdomen, she should assume lumbar spine injury.

Patient Presentation Signs and symptoms Determine whether the patient has signs or symptoms of possible spinal injury Patient may not have symptoms of spinal injury even though the mechanism is likely to cause one After considering the mechanism of injury, the EMT should determine whether the patient has signs or symptoms of possible spinal injury. The EMT must be mindful of those patients who may not have signs or symptoms of a spinal injury but have a mechanism to suggest such an injury is possible. If in doubt, the EMT should assume the patient has a spinal injury and treat the patient accordingly.

Patient Presentation Limitations Patients with certain conditions may not be able to notice or describe symptoms of spinal injury Intoxication Altered mental status Distracting injury Some patients may not be able to notice or describe symptoms of spinal injury if they are present. Patients who are intoxicated may not feel severe pain and therefore cannot be relied upon to describe the symptoms. The same applies to patients with an altered mental status. The presence of another painful injury may distract a patient from the symptoms of a spinal injury.

Patient Presentation Neck or back pain Patient does not always feel pain in the back or neck If present, treat the patient as if a spinal injury exists Some patients with a spinal cord injury will not feel pain in the back or neck. If pain is present, the patient should be treated for spinal cord injury. If the patient has no neck or back pain, but has tenderness upon palpation of the neck or back, the EMT should assume that spinal injury exists.

Stop and Review Describe different types of spinal injuries. Injuries to the cervical, thoracic, lumbar, and sacrococcygeal spine can occur with or without neurologic injury.

Patient Presentation Neurologic abnormality Respiratory failure Caused by damage to C3, C4, C5 Diaphragm is necessary for effective breathing Neurologic abnormalities may be seen in a patient with a spinal cord injury. The cervical nerves C3, C4, and C5 must be intact for the diaphragm to function. When the nerve supply to the diaphragm is cut off, the patient’s breathing efforts become ineffective and respiratory failure can ensue. This is evidenced by the patient being short of breath, having obvious respiratory difficulty, or experiencing apnea.

Patient Presentation Neurologic abnormality Neurogenic shock Vasodilation Patient appears flushed Heart rate remains normal Hypotension An injury to the spinal cord can disrupt the nerves controlling blood vessel constriction. Thus, blood vessels below the area of the injury may dilate. When blood vessels dilate, the heart rate normally increases in order to maintain a normal blood pressure. With a spinal cord injury, the patient’s heart rate may not increase despite a falling blood pressure. The combination of flushed skin with hypotension and bradycardia is called neurogenic shock, and it indicates a serious spinal cord injury.

Patient Presentation Neurologic abnormality Paralysis Paresthesia Quadriplegia/paraplegia High spinal cord injury can cause respiratory failure Paresthesia Numbness or tingling below level of injury Other 1. The inability to move, called paralysis, is the most well known and easily recognized complication of spinal cord injury. The patient who is unable to move or feel his arms and legs should be assumed to have a spinal cord injury. A patient who has lost the use of both arms and legs has quadriplegia. A patient who has lost use of his legs alone has paraplegia. Because a high spinal cord injury can cause respiratory failure, the EMT should carefully monitor the patient for signs of respiratory decompensation. 2. The patient with a spinal cord injury may describe an area of numbness or tingling below the level of injury. The term used to describe this sensory problem is paresthesia. 3. Other signs of spinal cord injury include an inability to control bowel function and presence of a painful penile erection, called priapism.

Assessment Assess for hazards Mechanism of injury Initial assessment The patient with a spinal cord injury may require ventilatory assistance Assessment of the patient determines whether spinal injury is suspected. The purpose of the initial assessment is to find and treat any life threatening problems. Any patient with a spinal cord injury or an injury that may have caused spinal cord damage may require ventilator assistance.

Assessment Focused history and physical exam Vital signs History Hypotension without tachycardia Flushed, warm skin History Mechanism of injury The patient’s neurologic status The focused trauma assessment should be geared toward finding any evidence of spinal injury or any other injury sustained during the incident. The EMT should use an organized head-to-toe approach to assessment, as described in Chapter 14. In terms of vital signs, the patient with a spinal cord injury can undergo generalized vasodilation below the level of the injury, which may result in neurogenic shock. As described previously, the symptoms of this are flushed, warm skin and hypotension without tachycardia. A description of the mechanism of injury, along with a history obtained by the EMT, can be helpful to the hospital staff. The patient’s neurologic status immediately after the incident is often useful to the staff, since it can reveal the type of injury sustained.

Management Save the patient Protect the cord Address the ABCs Perform all treatment with protection of the cord in mind Position the patient with the head in a neutral position and maintain in-line immobilization of the head and spine The priorities in managing a patient with a potential spinal injury are threefold: save the patient’s life, protect the spinal cord, and deliver the patient to definitive care. Preserving the patient’s life is best accomplished by following the ABCs, that is, addressing airway, breathing, and circulation problems, in that order. If the EMT suspects a spinal cord injury, all treatment should be performed with protection of the cord in mind. The EMT should immediately position the patient with the head in a neutral position and maintain in-line immobilization of the head and spine during all phases of treatment.

Management Cervical spine immobilization device Semi-rigid device that fits around patient’s neck to discourage movement A rolled-up towel can be used Ensure manual stabilization even after the collar has been applied The best way to keep a patient’s head and neck in line is to manually stabilize them. However, the EMT often cannot maintain stabilization manually for a long period of time because of other tasks that need to be done. Several devices allow the EMT to maintain spinal stabilization. The cervical spine immobilization device, sometimes called a cervical collar, is a semi-rigid device that is designed to fit around the patient’s neck snugly enough to discourage movement. The EMT measures the patient to determine the correct size of collar to use. One EMT holds the patient’s head in line with the spine while another secures the collar around the neck. If a proper cervical collar is not available, the EMT can improvise by wrapping a rolled-up towel around a patient’s neck and shoulders, or the EMT can maintain manual stabilization throughout transport. Because the cervical collar is just an aid and does not definitively immobilize the spine, the EMT must ensure manual stabilization even after the collar has been applied, until the patient has been secured in a more definitive fashion.

Management

Cervical Collar Watch this clip demonstrating application of the cervical collar

Management Short immobilization device Used if a patient is seated and has a suspected spinal injury Apply cervical collar first Secure the torso, then the head Transfer patient to a long spine board A short immobilization device is used if a patient is seated and has a suspected spinal injury, as would be the case in a motor vehicle crash. The purpose of the short immobilization device is to maintain in-line immobilization of the head, neck, and back while the patient is extricated from the site and transported. The EMT first places a cervical spine immobilization device on the patient to stabilize the patient’s neck. Then the short immobilization device is applied. In doing this, the torso is secured first, followed by the head. Once secured in the short immobilization device, the EMT should place the patient on a long spine board.

Short Immobilization Device Watch this clip to see how the short immobilization device is used

Management Rapid extrication Used when the patient must be removed quickly Provide manual stabilization Keep the spine in line Rapid extrication must be used when the patient must be removed quickly because of the severity of the patient’s injuries, because the EMT needs to gain access to other victims, or because of dangers at the scene. In these situations, the EMT should provide manual stabilization to keep the spine in line while the patient is quickly rotated and lowered onto a long spine board. Rapid extrication is not the optimal method and should never be done simply because it is easier or quicker.

Management Long spine board Used for patients found standing or lying down Supine patient Holding head and neck, roll patient to supine position Check PMS functions Apply a collar Move patient onto the long spine board If the patient is found standing or lying down, a long spine board may be used for immobilization. Not all patients found lying will be in the supine position, and great care must be taken when moving the patient into a supine position to maintain in-line cervical immobilization. The EMT gains control of the cervical spine by holding the head and neck and rolling the patient into the supine position. In this position, the patient’s pulses and motor and sensory functions should be checked in all four extremities, the collar should be applied, and the patient should be moved onto the long spine board with the help of several assistants. The EMT secures the patient’s head to the board only after securing the torso and legs.

Log Roll Watch this video demonstrating the log roll procedure

Management Long spine board Standing patient Perform standing takedown maneuver Requires no movement on the patient’s part Upon arrival on the scene, the EMT will often encounter patients who are standing. An example of this situation is a motor vehicle crash in which less seriously injured patients have gotten out of their cars and are walking around when the EMT arrives. If spinal injury is suspected, patients should be immobilized. The standing takedown maneuver is used to accomplish this. This technique, which requires no movement on the patient’s part, is an easy and safe way to have the standing patient lie down without compromising the spine.

Management Special considerations Helmets Helmet may remain in place if it allows assessment and management of patient’s airway, breathing, and immobilization Typical sports helmet—fairly easy access Motorcycle helmet—management of airway difficult EMT must not compromise spine during removal Since some spinal injuries occur during recreational sports, the patient may be wearing a helmet when the EMT arrives. The helmet may remain in place if it does not impede the EMT’s assessment and management of the patient’s airway and breathing and if it allows the EMT to immobilize the patient’s head and neck. A helmet that prevents the EMT from doing these functions must be removed. The typical sports helmet usually affords easy access to the airway. A full-face motorcycle helmet, on the other hand, makes assessment of the patient and management of the airway difficult. During helmet removal, the EMT must not compromise the spine.

Management

Management Special considerations Pediatric Geriatric Use pediatric immobilization boards Use long spine board with pad from shoulders to heels Geriatric Use padding for excess spinal curvature (scoliosis, kyphosis) Anatomic considerations in both the pediatric and geriatric populations require adjustment in immobilization technique, such as the use of padding or specialized spinal immobilization equipment for pediatrics. Because the head of a child is relatively larger than that of an adult, the child’s neck is forced into a flexed position when lying flat. Pediatric immobilization boards are made specifically for smaller children to help resolve the problem of flexion. Alternatively, the EMT can use a long spine board and place padding under the child’s shoulders to the heels to solve the problem. Some geriatric patients have excess curvature of the spine. This is called scoliosis when the curvature is lateral and kyphosis when the curvature is in the anterior-posterior dimension. The best way to provide immobilization to these patients is to use padding to fill the gaps after the patient is placed on the board.

Management

Transport Establish prompt transport Follow local protocols regarding the facility Provide ongoing assessment Document and advise staff of any changes in patient condition The EMT should be very careful with loading the ambulance and transporting to minimize movement of the patient who has a potential spinal injury. The last priority in patient management is getting the patient to the hospital in a reasonable amount of time. Keep in mind that some treatments for spinal injuries are time dependent. The EMT should follow local protocols regarding the appropriate way to accomplish the transport. The EMT should also provide an ongoing assessment of patients with potential spinal cord injuries. Document and advise the hospital staff of any change in the patient’s status.

Stop and Review Describe how to apply a cervical collar. Describe when rapid extrication from a vehicle is indicated. While one EMT maintains stabilization of the patient’s head, a second EMT measures the patient’s neck to determine the correct size of cervical collar. The second EMT slides the posterior portion in the void behind the neck and slides the anterior portion up the chest until it captures the chin. The second EMT then fastens the Velcro securely. If a proper cervical collar is not available, the EMT can improvise by wrapping a rolled-up towel around a patient’s neck and shoulders. Rapid extrication from a vehicle is indicated when the patient’s injuries are severe, when the EMTs need to gain access to another patient or patients, and when the scene is inherently dangerous.