International Trauma Life Support, 6e Key Lecture Points Cover the anatomy of the spine briefly. Reinforce that any trauma patient who has an altered level of consciousness must be presumed to have a cervical spine injury until proven otherwise. Appropriate precautions must be taken. Stress that not only must the cervical spine be protected, but also the entire spine, including the lumbar and dorsal spine. Briefly discuss the signs, symptoms, and treatment of neurogenic shock. Stress documentation of the brief neurological exam (movement and sensation of hands and feet) before and after extrication or movement of the patient with a suspected spinal injury. Stress that full SMR includes cervical collar, head immobilizer, and appropriate strapping applied to the patient on a long spine board. Stress that cervical collars alone offer little to no protection of the cervical spine. ITLS teaches that SMR is manually maintained by a team member until the patient is secured to the long spine board. Emphasize that SMR on a long spineboard MANDATES airway protection by the rescuer due to the patient being prevented from protecting himself. Discuss the indications for rapid extrication (without using short boards or KED-type devices). Primary survey of the patient identifies a condition that requires immediate intervention that cannot be done in the entrapped area, such as: Airway obstruction that cannot be relieved by jaw thrust or finger sweep Cardiac or respiratory arrest Chest or airway injuries requiring ventilation or assisted ventilation Deep shock or bleeding that cannot be controlled Note that there are other situations that are so desperate that you may not have time to use any technique, and emergency rescue is warranted to pull the patient to safety. The need for emergency rescue is identified during the scene survey with circumstances that may immediately endanger the patient and the rescuers. Fire or immediate danger of fire Danger of explosion Rapidly rising water Structure in danger of collapse Continuing toxic exposure Mention that short backboard type SMR devices may be difficult to apply and ineffective in pregnant and very obese patients. Briefly clarify management of unusual circumstances, such as: Closed space rescue Water rescue Prone and standing patients Pediatrics Geriatrics Helmet removal (stress that studies have found that rescue scissors will not efficiently remove face masks) Obese patients Neck or face wounds Chapter 11 Spinal Trauma

Spinal Trauma Remember: SMR needs to be in an anatomical neutral position specific for each patient to be neutral for spinal cord and airway. Although texts often recommend age ranges (including ITLS), SMR is principle-driven. Appropriate padding should be used for all age groups and situations (elderly, American football shoulder pads, infants, obesity, etc).

Overview Spinal anatomy and physiology Spinal motion restriction (SMR) Mechanisms of injury indicating need Process of application Emergency Rescue and Rapid Extrication History and assessment indicating no need Special situations indicating need for alteration Neurogenic and hemorrhagic shock Spinal Trauma -

Spinal Trauma Devastating and life-threatening Skillfully assess mechanism of injury and patient Spinal motion restriction (SMR) ITLS recommendations are guidelines Based on careful evaluation of mechanism, reliable patient condition, special situations Know your local protocol Previous terms: traction and immobilization. This term more accurately reflects proper treatment and reality in field, because in certain patients, especially in prehospital environment, spine cannot be completely immobilized. No prospective randomized controlled clinical trials that compare methods of spinal motion restriction. No Class I evidence and no formal standards of care. Spinal Trauma -

Spinal Column IMAGE: Figure 11-1: Anatomy of spinal column (on page 162). IMAGE: Figure 11-2a: Vertebra viewed from above . Spinal cord passes through vertebral foramen (on page 162). IMAGE: Muscles attach to anterior column. Alignment is maintained by strong ligaments between vertebrae and by muscles that run along length of bony column from head to pelvis. NOTE: Differentiate spinal column from spinal cord. Bony tube composed of 33 vertebrae. Supports body in an upright position, allows use of our extremities, and protects delicate spinal cord. Column's 33 vertebrae are identified by their location: 7 cervical (the C-spine), 12 thoracic (the T-spine), 5 lumbar (the L-spine), and remainder fused together as posterior portion of pelvis (5 sacral and 4 coccygeal). Vertebrae are numbered in each section, from head down to pelvis. Third cervical vertebra from head is designated C-3, sixth is called C-6, and so forth. Thoracic vertebrae are T1–T12, and each attaches to one of 12 pairs of ribs. Lumbar vertebrae are numbered L1–L5, with L5 being last vertebra above pelvis. Vertebrae are each separated by a fibrous disc that acts as a shock absorber. Spinal column is aligned in a gentle S-curve that is most prominent at C5–C6 and T12–L1 levels in adults, making these areas most susceptible to injury. Spinal Trauma -

Spinal Cord Spinal Trauma - IMAGE: Spinal nerves. IMAGE: Figure 11-2b: Vertebra with spinal cord viewed from top (on page 162). IMAGE: Figure 11-4: Relationship of spinal cord to vertebrae (on page 163). Extension of brain stem down to level of first lumbar vertebra and at that point separates into nerves. Cord is 10 to 13 mm in diameter and is suspended in middle of vertebral foremen. Cord is soft and flexible like a cotton rope, and is surrounded and bathed by cerebrospinal fluid along its entire length. Fluid and flexibility provide some protection to cord from injury. Composed of specific bundles of nerve tracts that are arranged in a predictable manner. Spinal cord passes down vertebral canal and gives off pairs of nerve roots that exit at each vertebral level. Roots lie next to intervertebral discs and lateral part of vertebrae, making nerve roots susceptible to injury when trauma occurs in these areas. Nerve roots carry sensory signals from body to spinal cord and then to brain. Roots also carry signals from brain to specific muscles, causing them to move. Signals pass back and forth rapidly, and some are strong enough to cause actions on their own, called reflexes. Strong signals also can overwhelm spinal cord's ability to keep signals moving separately to brain. Integrity of spinal-cord function is tested by motor, sensory, and reflex functions. Level of sensory loss is most accurate for predicting level of spinal-cord injury. Muscle strength is another function that is easy to assess in conscious patient. Reflexes are helpful for distinguishing complete from partial spinal-cord injuries, but are best left for hospital assessment. Spinal cord is also an integrating center for autonomic nervous system, which assists in controlling heart rate, blood vessel tone, and blood flow to skin. Injury to this component of spinal cord results in neurogenic shock (commonly called spinal shock), which is discussed later. Spinal Trauma -

Spinal Injury Mechanism Hyperextension Hyperflexion Compression Rotation Lateral stress or distraction Less common NOTE: These mechanisms and their subsequent injuries are illustrated in Table 11-1 (on page 165). Spinal Trauma -

Blunt Spinal-Column Injury Requires significant force Unless preexisting weakness or defect in bone Higher risk: elderly, severe arthritis Sudden movement of head or trunk Frequently injured in more than one place Spinal cord involvement Column injuries with cord injury: 14% Cervical region : 40% In cervical spine region it is much more common to have cord injury, with almost 40% of column injuries having cord damage. Spinal Trauma -

Blunt Spinal-Column Injury Signs and symptoms Pain most common symptom Frequently masked by other injures Back pain with or without movement of back Tenderness along spinal column Obvious deformity or wounds Paralysis Weakness Paresthesia NOTE: Paresthesia (tingling or burning feeling to skin). Spinal Trauma -

Blunt Spinal-Cord Injury New cord injuries each year MVC (including pedestrian) Falls Penetrating Recreational activities Young adults most common Under 8 years, usually high cervical Elderly New cord injuries each year (U.S.): MVC (including pedestrian) 48% Falls 23% Penetrating 14% Recreational activities 9% Young adults most common: Under 8 years, usually high cervical Elderly: 11% Spinal Trauma -

Blunt Spinal-Cord Injury Primary damage At time of force Cut, torn, crushed, cut off blood supply Usually irreversible Secondary damage After time of force Hypotension, generalized hypoxia, blood vessel injury, swelling, compression from hemorrhage Good prehospital care may help prevent Spinal Trauma -

Spinal Injury 2 NOTE: ANIMATION. Box emphasizes column displacement, and line represents cord displacement. NOTE: The “2” represents the second cervical vertebrae. Spinal Trauma -

Neurogenic Shock Cervical or thoracic cord injury Signs and symptoms High-space shock Malfunction of autonomic nervous system Signs and symptoms Hypotension Normal skin color and temperature Inappropriately slow heart rate Diagnosis of exclusion May have both neurogenic and hemorrhagic NOTE: See also Chapter 8 for high-space shock. In healthy patient, blood pressure maintained by controlled release of catecholamines (epinephrine and norepinephrine) from adrenal glands. Sensors in aortic and carotid arteries monitor blood pressure. Catecholamines cause constriction of blood vessels, increase heart rate and strength of heart contraction, and stimulate sweat glands. Brain and spinal cord signal adrenal glands to release catecholamines to keep blood pressure in normal range. In pure hemorrhagic shock, these sensors detect hypovolemic state and compensate by constricting blood vessels and speeding heart rate. High levels of catecholamines cause pale skin, tachycardia, and sweating. Mechanism of shock from spinal-cord injury is just opposite. There is no significant blood loss, but injury to spinal cord destroys ability of brain to regulate release of catecholamines from adrenals (the spinal cord cable is out), so no catecholamines are released. When levels of catecholamines drop, blood vessels dilate, causing blood to pool. This drop in preload causes blood pressure to fall. Brain cannot correct this because it cannot get message to adrenal glands. Patient with neurogenic shock cannot show signs of pale skin, tachycardia, and sweating because cord injury prevents release of catecholamines. Spinal Trauma -

Assessment ITLS Primary and Secondary Surveys Motor and sensory function Conscious Motor: move fingers and toes Sensation: abnormal is suspicious Unconscious Motor: pinch fingers and toes Sensation: pinch fingers and toes Flaccid paralysis, no reflexes or withdrawal means injury NOTE: More detailed neurological exam in Chapters 2 and 10. Document these findings later in written report. Not only does this pre-extrication neurological exam alert you to any spinal injury, it also provides documentation on whether or not there was loss of function before extrication was begun. Spinal Trauma -

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

Clues to Spinal Injury Patient complaints Neck or back pain Numbness Tingling Loss of movement Weakness Spinal Trauma -

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

Complications of SMR Airway compromise and aspiration Head and airway are in fixed position Head and low back pain Directly related to being on hard backboard Life-threatening hypoxia Obese Congestive heart failure Pressure sores Uneven skin pressure Spinal Trauma -

Apply when most likely benefit. SMR Apply when most likely benefit. Avoid if not necessary. Spinal Trauma -

SMR Indicated Positive mechanisms High-speed MVC Falls >3 times patient’s height Axial load Diving accidents Penetrating wound in or near spinal column Sports injuries to head or neck Unconscious trauma patient Spinal Trauma -

SMR Indicated Potential mechanism with at least one: Altered mental status Evidence of intoxication A distracting painful injury e.g., long bone extremity fracture Neurologic deficit Spinal pain or tenderness Spinal Trauma -

SMR Decision Reliable patient Unreliable patient Calm Cooperative Sober Alert No distracting injuries Acute stress reaction Head/brain injury Altered mental status Intoxication with drugs and/or alcohol Distracting injuries Spinal Trauma -

SMR Not Indicated No high-risk mechanism of injury No alteration of mental status No distracting injuries Not intoxicated No pain or tenderness along spine No neurological deficits Spinal Trauma -

Management Spinal motion restriction (SMR) Modification required Minimize movement to avoid aggravating injury No specific device proven more effective SMR success depends on application process Modification required Immediate danger of death Critical degree of ongoing danger that requires an intervention within 1–2 minutes SMR and Rapid Extrication are covered in skill stations. Give basic principles and foundations. Document details of any situation requiring emergency rescue or Rapid Extrication. Immediate danger of death: Fire or immediate danger of fire or explosion. Hostile environment, gunfire, or other weapons. Danger of being carried away by rapidly moving water. Structure in immediate danger of collapse. Continuing immediately life-threatening toxic exposure. Critical degree of ongoing danger that requires an intervention within 1 or 2 minutes: Airway obstruction that cannot be relieved by modified jaw thrust or finger sweep. Cardiac or respiratory arrest. Chest or airway injuries requiring ventilation or assisted ventilation. Deep shock or bleeding that cannot be controlled. Spinal Trauma -

Management Emergency rescue Rapid extrication Reserved for immediate (within seconds) environmental threat to life of victim or rescuer Move to safe area in manner that minimizes risk Rapid extrication Considered for medical conditions or situations that require fast intervention to prevent death One or two minutes, but not seconds SMR and Rapid Extrication are covered in skill stations. Give basic principles and foundations. Document details of any situation requiring emergency rescue or rapid extrication. Immediate danger of death: Fire or immediate danger of fire or explosion. Hostile environment, gunfire, or other weapons. Danger of being carried away by rapidly moving water. Structure in immediate danger of collapse. Continuing immediately life-threatening toxic exposure. Critical degree of ongoing danger that requires an intervention within 1 or 2 minutes: Airway obstruction that cannot be relieved by modified jaw thrust or finger sweep. Cardiac or respiratory arrest. Chest or airway injuries requiring ventilation or assisted ventilation. Deep shock or bleeding that cannot be controlled. Spinal Trauma -

Neutral Alignment Always monitor airway and breathing Proper padding is often required to obtain and maintain neutral alignment of patient’s cervical spine when you perform spinal motion restriction. A truly neutral cervical-spine position for an adult is usually obtained with use of 1 to 2 inches of occipital padding on a long backboard. This slightly elevates head and brings neck into a neutral position that tends to make patient more comfortable and also makes endotracheal intubation easier if needed. This is accomplished with head pad on a cervical motion-restriction device or padding that is used with many backboard devices. Elderly patients whose necks have a natural flexed posture will require more padding. Children, because their heads are proportionately larger, usually require padding under shoulders to prevent neck flexion on backboard. Spinal Trauma -

Log Roll Single unit: spinal-column, head, pelvis Patients lying prone or supine Modification required Painful arm, leg, chest Roll onto uninjured side Unstable fractured pelvis Scoop stretcher Lift carefully by four or more rescuers Spinal Trauma -

Special SMR Situations Combative patient Children Altered mental status Under influence IMAGE: Reeves sleeve. Spinal Trauma -

Special SMR Situations Require side transport Airway Unconscious patients who are not intubated Pregnant 20 weeks or more Vacuum board best NOTE: Notice that body is maintained in a straight line. Spinal Trauma -

Special SMR Situations Closed-space rescue Safety is first priority In line with long axis Water emergencies Backboard floated under Secure then remove Courtesy of Roy Alson, MD Spinal Trauma -

Special SMR Situations Pediatric Elderly NOTE: Most car seat manufacturers recommend only transporting child in safety seat if there is no visible sign of damage to safety seat. Children who are involved in an MVC while restrained in a child safety seat but have no apparent injuries may be packaged in safety seat for transport to hospital. Using towel or blanket rolls, cloth tape, and a little reassurance, you can secure child in safety seat and then belt seat into ambulance. When child is in a car seat that is damaged, or in a built-in child-restraint seat that cannot be removed, child must be removed for SMR. Children in such situations will have to be carefully extricated onto a backboard or another pediatric SMR device, using manual stabilization. Elderly patients: Require flexibility in packaging techniques. Many elderly patients have arthritic changes of spine and very thin skin. Such patients will be very uncomfortable when placed on a backboard. Some arthritic spines are so rigid that patient cannot be laid straight on board, and some elderly patients have rigid flexion of neck that will result in a large gap between head and board. Make use of towels, blankets, and pillows to pad elderly patient and prevent movement and discomfort on backboard. Spinal Trauma -

Special SMR Situations Prone, seated or standing Minimize movement into supine position Prone patients are log-rolled onto a backboard, with careful coordination of head and chest rescuers. Seated patients may be stabilized using short backboards or their commercial adaptations. Used appropriately, short backboards provide initial stabilization of cervical and thoracic spine and then facilitate movement of patient onto a long backboard. Standing patients may be placed against long board while upright and then strapped in place. The board is then gently lowered to supine position. Spinal Trauma -

Special SMR Situations Protective gear Motorcycle helmet: removal Poorly fitted to patient Significant neck flexion Full face and open face Note: Remove to evaluate and manage airway NOTE: This skill is covered in skill stations. Motorcycle helmets often removed in prehospital setting. Removal technique is modified to accommodate different design. Motorcycle helmets are often designed with a continuous solid face guard that limits airway access. These helmets are not custom designed and frequently are poorly fitted, and their large size usually produces significant neck flexion if left in place when patient is positioned on a backboard. Motorcycle helmets will make it difficult to stabilize neck in a neutral position, may obstruct access to airway, and may hide injuries to head or neck. Helmet should be removed in prehospital setting, using techniques described in Chapter 12. Spinal Trauma -

Special SMR Situations Protective gear Remove athletic helmet when: Face mask not removed timely Airway cannot be controlled Does not hold head securely Helmet prevents stabilization Note: Cut chin strap; do not unhook Football and ice hockey helmets are custom fitted to individual. Unless special circumstances exist, such as respiratory distress coupled with an inability to access airway, helmet should not be removed in prehospital setting. Athletic helmet design will generally allow easy airway access once face guard is removed. Best method to remove face guard is with screwdriver (cordless screwdriver is best), but sometimes screw slot strips out and face guard will have to be cut off. Excellent device made specifically for cutting off four face guard mounting strips exists (Face Mask Extractor by Collins Sports Medicine), but at this time it is extremely expensive. Next best choice is to use anvil pruning shears. Rescue scissors have been advocated in past, but studies have found them to be unsuitable for this task. Unhooking chin strap may cause movement of spine. It is better to cut chin strap. Spinal Trauma -

Special SMR Situations Protective gear Shoulder pad: removal With helmet removal Neutral alignment inability Unable to secure to board Access to chest needed Note: Cut axillary straps and laces on front, open from core outward, slide out from under Athlete wearing shoulder pads has neck in neutral position when on backboard with helmet in place. If helmet removed, padding must be inserted under head to keep neck from extending. Most shoulder pads removed by cutting axillary straps and laces on front of appliance, opening appliance from core outward (like a clam shell), and sliding appliance out from under athlete. Spinal Trauma -

Special SMR Situations Neck wounds Caution: cervical collar May prevent Ongoing Exam Compromised airway with subcutaneous air, expanding hematomas, or mandible fracture Note: May be needed to avoid cervical collar; use manual stabilization, head cushion devices, blanket rolls Spinal Trauma -

Summary Unstable or incomplete spinal damage is not completely predictable. Unconscious trauma or dangerous mechanism affecting head, neck, trunk should have SMR. Uncertain mechanisms may not require SMR. Special cases may require special techniques. Maintain neutral alignment specific for patient. Be prepared to manage airway compromise. Spinal Trauma -

Discussion © Bob Krist/CORBIS Spinal Trauma -