Spinal Trauma - Emergency Medicine PDF

Spinal Trauma RADWA MUHAMMAD ASHOUR LECTURER OF EMERGENCY MEDICINE  Why should we suspect spinal injury early? ❑ For early spinal immobilization with airway management. ❑ The neck is the most common site of cord injury → If immobilization is n...

Spinal Trauma RADWA MUHAMMAD ASHOUR LECTURER OF EMERGENCY MEDICINE  Why should we suspect spinal injury early? ❑ For early spinal immobilization with airway management. ❑ The neck is the most common site of cord injury → If immobilization is not achieved with unstable injuries → additional cord or nerve root damage can be produced.  When to suspect spinal injury? ❑ Major trauma. ❑ Minor trauma with spinal pain and/ or neurological symptoms/ signs. ❑ Altered consciousness after injury if there is “Flaccid areflexia - ↓ anal tone on PRE - Diaphragmatic breathing - An ability to flex (C5), but not to extend (C7), the elbow - Response to painful stimulus above, but not below, the clavicle - Hypotension with bradycardia – Priapism”  When to suspect spinal injury? ❑ Dangerous mechanism of injury “MVA with patient ejection, with death of occupant, or with rollover - Pedestrian or bicyclist without helmet - FFH {> 3ft ( 5ft (>2y)} - Head struck by high impact object” ❑ Pre- existing spinal disease “e.g., rheumatoid arthritis, ankylosing spondylitis, severe osteoarthritis, osteoporosis, steroid therapy”  Approach to possible spinal injury? A. Airway Management and Spinal Immobilization: ✔Perform manual immobilization rapidly (without traction): Keep the head and neck in the neutral position by placing both hands around the neck and interlocking them behind, with the forearms preventing head movement.  Approach to possible spinal injury? A. Airway Management and Spinal Immobilization: ✔Maintain manual stabilization/ support: 1. Use sandbags or blocks placed on either side of the head and tape, or straps applied to the forehead and chin to prevent rotation.  Approach to possible spinal injury? A. Airway Management and Spinal Immobilization: ✔Maintain manual stabilization/ support: 2. Use Cervical collar: avoid overtighten the cervical collar – use Stifneck or Miami J collar “better than hard collar”.  Approach to possible spinal injury? A. Airway Management and Spinal Immobilization: ✔Ensure airway patency: 1. Why? Hypoxia compromises an injured cord. 2. Initially in an unconscious patient, jaw thrust - suction to the upper airway can be used – adjuncts as OPA or NPA maybe used. 3. If ETT is needed: must be performed by an expert in advanced anesthetic techniques (usually RSI), with an assistant controlling the head/ neck to limit cervical spine movement.  Approach to possible spinal injury? B. Breathing and ventilation: ✔Look regularly: for diaphragmatic breathing - use of accessory muscles of respiration. ✔Confirm adequate oxygenation and ventilation: using pulse oximetry and regular ABG analysis. ✔Ventilation can deteriorate due to cord oedema/ ischaemia → Tracheal intubation and controlled ventilation may be required.  Approach to possible spinal injury? C. Circulation: ✔Monitor ECG – BP - HR. ✔Insert a urinary catheter: monitor UOP and prevent bladder distension. ✔NG tube “If there is no craniofacial injury”: prevent gastric distension (ileus is common after cord injury) → ↓ the risk of aspiration. ✔Abdominal distension may occur without signs of peritonism → Consider the need for FAST or CT scan.  Approach to possible spinal injury? C. Circulation: ✔Neurogenic shock: ❑ Pathophysiology: 1. Interruption of the cord sympathetic system “cord injury above T6” → loss of vasomotor tone → VD → ↑ venous pooling → ↓ BP. 2. If T1-4 injury → loss of sympathetic innervation to heart with unopposed vagal tone → bradycardia or loss of reflex tachycardia.  Approach to possible spinal injury? C. Circulation: ✔Neurogenic shock: ❑ Presentation: 1. Flaccidity and areflexia. 2. Triad of warm “VD” – bradycardia – hypotension. 3. Hypothermia “↑ heat loss”.  Approach to possible spinal injury? C. Circulation: ✔Neurogenic shock: ❑ Treatment: 1. Exclude and treat other causes of hypotension (e.g., blood loss, tension pneumothorax). 2. IV fluid usually corrects relative hypovolaemia. 3. Consider inotropes if ↓ COP despite adequate volume replacement and correction of bradycardia by atropine.  Approach to possible spinal injury? D. Disability: ✔The level of injury: a) Refers to the point where the spinal cord is injured. b) Marks a border between areas of the body that are affected and not affected by the spinal cord injury.  Approach to possible spinal injury? D. Disability: ✔Sensory Level: defined as the most caudal segment of the spinal cord with normal sensory function in both sides of the body. ✔The sensation: is usually assessed by light pain “Pinprick test” and touch “lightly touching the area with a piece of cotton-wool”.  Approach to possible spinal injury? D. Disability: ✔Motor Level: defined as the lowest cord segment for which the key muscle has a strength grade of 3, as long as the strength of key muscles representing more superior Level Muscle supplied Level Muscle supplied segments is normal. C5 Shoulder abductor (deltoid) L2 Hip flexors (iliopsoas) Elbow Flexion (Biceps) C6 Wrist extensors (extensor carpi radialis) L3 Knee extensors (quadriceps) C7 Elbow extensor (triceps) L4 Ankle dorsiflexors (tibialis anterior) C8 Middle finger flexor (flexor digitorum L5 Big toe extensor (extensor hallucis longus) profundus) T1 Little finger abductor (abductor digiti minimi) S1 Ankle plantar flexors (soleus, gastrocnemius) Muscle force is graded between 0-5:  Approach to possible spinal injury? D. Disability: ✔Types of spinal cord injury: A: Complete: No muscle movement, light touch, pin prick, or pressure feelings are present in or around your anus. B: Sensory Incomplete: Feeling is present in or around your anus. There might be a few muscle movements preserved below your neurological level of injury but only in the first adjacent segments.  Approach to possible spinal injury? D. Disability: ✔Types of spinal cord injury: C: Motor Incomplete: You can move some muscles well below your neurological level of injury, but many are not strong enough to lift against gravity. D: Motor Incomplete: Muscle strength in most muscles below your neurological level of injury are strong enough to lift against gravity. E: NORMAL.  Central Cord Syndrome The most common incomplete spinal cord lesion. Hyperextension injury. Presentation: Weakness UL > LL – may loss of pain & temperature UL > LL.  Anterior Cord Syndrome Flexion or extension injury with injury of anterior spinal artery. Presentation: Paralysis and loss of pain and temperature sensation  Posterior Cord Syndrome Presentation: loss of vibration and proprioception sensation  Brown-Sequard Syndrome Hemisection of the cord usually with penetrating trauma Presentation: ipsilateral loss of motor and vibration sensation – contralateral loss of pain and temperature sensation.  Approach to possible spinal injury? D. Disability: ✔Spinal shock: 1. Transient depression of all spinal cord function below level of partial or complete spinal cord injury. 2. Function usually return within 24-48 h.  Approach to possible spinal injury? E. Exposure: ✔Log roll the patient using adequate method. ✔Consider using 6+ lift and slide maneuver.  When to obtain cervical spine imaging? ✔Cervical Spine imaging is required if any: (NEXUS Criteria)