Spinal Injury Management 2022.pdf

Spinal Injury Management Review of Spinal Anatomy Consists of 33 vertebrae articulating to form the vertebral column. It is the major structural component of the axial skeleton. The skeleton components are stabilized by ligaments and muscles. The allows for an erect posture, and the protection of...

Spinal Injury Management Review of Spinal Anatomy Consists of 33 vertebrae articulating to form the vertebral column. It is the major structural component of the axial skeleton. The skeleton components are stabilized by ligaments and muscles. The allows for an erect posture, and the protection of the delicate spinal cord, and allow for fluid movement. Anatomy of the Vertebrae Anatomy of the Vertebrae Traditional Spinal Assessment Criteria  Traditional criteria have focused on mechanism of injury (MOI) with spinal immobilization considerations for two specific patient groups:    Unconscious injury victims Any patient with a “motion” injury Covers all patients with a potential for spinal injury  Not always practical in the prehospital setting Prehospital Assessment  Prehospital assessment can be enhanced by applying clear, clinical criteria for evaluating spinal cord injury that includes the following signs and symptoms (in the absence of other injuries, altered mental status, or use of intoxicants) Mechanism of Injury or Nature of Injury   When determining mechanism of injury in a patient who may have spinal trauma, classify the MOI as:  Positive  Negative  Uncertain When combined with clinical criteria for spinal injury, can help identify situations in which spinal immobilization is appropriate Positive MOI Forces exerted on the patient are highly suggestive of spinal cord injury  Typically requires Spinal motion restriction  Examples:  High-speed motor vehicle crashes  Falls greater than three times the patient’s height  Violent situations occurring near the patient’s spine  Sports injuries  Other high-impact situations  Positive MOI  In the absence of signs and symptoms of SCI, some medical-direction agencies may recommend that a patient with a positive MOI not be immobilized  Recommendations will be based on the paramedic’s assessment when:  Patient history is reliable  There are no distraction injuries Negative MOI  Includes events where force or impact does not suggest a potential for spinal injury   In the absence of SCI signs and symptoms, does not require spinal immobilization Examples:    Dropping an object on the foot Twisting an ankle while running Isolated soft tissue injury Uncertain MOI  When the impact or force involved in the injury is unknown or uncertain, clinical criteria must be used to determine need for spinal immobilization  Examples:    Tripping or falling and hitting the head Falls from 2 to 4 feet Low-speed motor vehicle crashes (“fender benders”) Assessment of Uncertain MOI  Ensure that the patient is “reliable”   Reliable patients are calm, cooperative, sober, alert, and oriented Examples of “unreliable” patients:       Acute stress reactions from sudden stress of any type Brain injury Intoxicated Abnormal mental status Distracting injuries Problems communicating Axial Loading (Vertical Compression)   Results when direct forces are transmitted along the length of the spinal column May produce compression fracture or a crushed vertebral body without SCI  Most commonly occur at T12 to L2 Flexion, Hyperextension, and Hyperrotation  Extremes in flexion, hyperextension, or hyperrotation may result in:     Fracture Ligamentous injury Muscle injury Spinal cord injury is caused by impingement into the spinal canal by subluxation of one or more cervical vertebrae Distraction  May occur if the cervical spine is suddenly stopped while the weight and momentum of the body pull away from it  May result in tearing and laceration of the spinal cord Less Common Mechanisms of Spinal Injury    Blunt trauma Electrical injury Penetrating trauma Classifications of Spinal Injury        Sprains Strains Fractures Dislocations Sacral fractures Coccygeal fractures Cord injuries Spinal Injuries  All patients with suspected spinal trauma and signs and symptoms of SCI should be immobilized   Avoid unnecessary movement An unstable spine can only be ruled out by radiography or lack of any potential mechanism for the injury Assume Spinal Injury      Significant trauma and use of intoxicating substances Seizure activity Complaints of pain in the neck or arms (or paresthesia in the arms) Neck tenderness on examination Unconsciousness because of head injury     Significant injury above the clavicle A fall more than three times the patient's height A fall and fracture of both heels (associated with lumbar fractures) Injury from a highspeed motor vehicle crash Spinal Injury  Damage produced by injury forces can be further complicated by:     Patient's age Preexisting bone diseases Congenital spinal cord anomalies Spinal cord neurons do not regenerate to any great extent Assessment of Spinal Cord Injury Spinal cord trauma should be evaluated only after all life-threatening injuries have been assessed and treated. CLAPS D TICS D should be used. Priorities:     Scene survey Assessment of airway, breathing, and circulation Preservation of spinal cord function and avoiding secondary injury to the spinal cord Assessment of Spinal Cord Injury  Prevent secondary injury that could result from:     Unnecessary movement Hypoxemia Edema Shock Prehospital Goals  Maintain a high degree of suspicion for spinal injury Scene survey  Kinematics  History of the event  Provide early spinal immobilization  Manage Airway, breathing and circulation  Transport (SAFELY)  Neurological Examination  After managing life-threatening problems encountered in the initial assessment, perform a neurological exam    May be done at the scene or en route to the hospital if the patient requires rapid transport Document findings Components of neurological examination:   Motor and sensory findings Reflex responses Dermatomes  Each spinal nerve (except C1) has a specific cutaneous sensory distribution  Dermatome refers to skin surface area supplied by a single spinal nerve Figure 6-34 Dermatomes  Landmarks used for rapid sensory evaluation:  C2 to C4 dermatomes provide a collar of sensation around the neck and over the anterior chest to below the clavicles  T4 dermatome provides sensation to nipple line  T10 dermatome provides sensation to umbilicus  S1, S2, L4, L5, dermatome provides sensation to soles of feet Reflex Responses   Some are easily observed and may indicate autonomic injury Babinski's sign   May indicate neurologic injury Dorsiflexion of the great toe with or without fanning of toes Figure 23-5 Testing the Plantar Reflex Other Methods of Evaluation  Visual inspection may indicate presence of injury and its level     Transection of the cord above C3 often results in respiratory arrest Lesions that occur at C4 may result in paralysis of the diaphragm Transections at C5-C6 usually spare the diaphragm and permit diaphragmatic breathing Priapism in males may indicate lower spinal cord injuries or injury to the perineum Spinal Injury  Absence of neurological deficits does not rule out significant spinal injury     If a spinal injury is suspected, the patient's spine must be protected Patient's ability to walk should not be a factor in determining need for spinal precautions In fact many patients may have spinal cord injuries that are not even seen with X-Ray exams, common in as many of 65% of all children’s spinal injuries SCIWORA Spinal Cord Injury Without Radiographic Abnormality Spinal Immobilization Traditionally spinal immobilization has referred to the placement of a cervical collar, and immobilization on a rigid spinal board. Historically full spinal immobilization was applied to all patients, regardless of symptoms. This was done solely based on the mechanism of injury. The first notable study on the use of rigid spinal boards and cervical collars was conducted in the 1960’s. However, the finding were based on historical practice and informed opinion, not validate scientific evidence. Spinal Immobilization Since the 1960’s, multiple studies have been conducted on the subject of spinal immobilization. While the conclusions do vary, the most current evidence suggests that; A)The use of criteria or rules that indicate when spinal immobilization is required. This criteria or rules take into account a variety of factors including, mechanism of injury, signs, symptoms and preexisting comorbities. The most notable of these would be the NEXUS criteria, and the Canadian CSpine rule. Both the NEXUS criteria and the Canadian C-spine rules are validated, and are cited by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons Joint Commission in their official recommendations on the management of acute spinal cord injury. Spinal Immobilization B)The use of rigid spinal boards should be kept to a minimum, and used primary for extrication purposes. A C-Spine collar should be applied, and the patient secured to a rigid spinal board. Once the patient is secured in the truck, they are to be taken off the board. An exception to this would be a transport time of less than 30 minutes. If the patient is able to ambulate, they are free to do so once a C-spine collar has been placed. The overall notion that secondary injury to the cord due to transport is rare because the forces exerted during transport are weak compared to that required to injure the spinal cord may still hold true. Canadian C-Spine Rule NEXUS Criteria Rigid Spinal Boards The most current evidence suggests that the immobilization of patients to a rigid spinal board causes more harm than good. The negative side effects and the potential adverse outcomes of immobilization on a rigid spinal board include, but are not limited too: A) B) C) D) Restricting respirations, especially in patients with underlying pulmonary diseases. Airway management is affected, and the risk of aspiration dramatically increases. Pressure ulcers can form is as little as 30 minutes. The average time a patient is immobilized is approximately 1 hour. Rigid spinal boards do not decrease pain, in fact most patient report pain increases. Spinal Motion Restriction (SMR) Standard BLS PCS Spinal Motion Restriction (SMR) Standard The paramedic shall: 1. Consider spinal motion restriction (SMR) for any patient with a potential spine or spinal cord injury, based on mechanism of injury, such as, a. any trauma associated with complaints of neck or back pain, b. sports accidents (impaction, falls), c. diving incidents and submersion injuries, d. explosions, other types of forceful acceleration/deceleration injuries, e. falls (e.g. stairs), f. pedestrians struck, g. electrocution, h. lightning strikes, or i. penetrating trauma to the head, neck or torso; Spinal Motion Restriction (SMR) Standard 2. if the patient meets the criteria listed in paragraph 1 above, determine if the patient exhibits ANY risk criteria, as follows, a. neck or back pain, b. spine tenderness, c. neurologic signs or symptoms, d. altered level of consciousness, e. suspected drug or alcohol intoxication, f. a distracting painful injury (any painful injury that may distract the patient from the pain of a spinal injury), g. anatomic deformity of the spine, Spinal Motion Restriction (SMR) Standard h. high-energy mechanism of injury, such as, i. fall from elevation greater than 3 feet/5 stairs, ii. axial load to the head (e.g. diving accidents), iii. high speed motor vehicle collisions (≥100 km/hr), rollover, ejection, iv. hit by bus or large truck, v. motorized/ATV recreational vehicles collision, or vi. bicyclist struck or collision, or i. age ≥65 years old including falls from standing height; Spinal Motion Restriction (SMR) Standard 3. if the patient meets the criteria of paragraph 1 above, but does not meet the criteria of paragraph 2 above, not apply SMR; 4. subject to paragraph 6 below, if the patient meets the requirements of paragraph 2 above, apply SMR using a cervical collar only*, attempt to minimize spinal movement, and secure the patient to the stretcher with stretcher straps (see Guideline below); *Note: Spinal boards or adjustable break-away stretchers may still be indicated for use to minimize spinal movement during extrication. Spinal Motion Restriction (SMR) Standard 5. if the patient has penetrating trauma to the head, neck or torso, determine if the patient exhibits ALL of the following, a. no spine tenderness. b. no neurologic signs or symptoms, c. no altered level of consciousness, d. no evidence of drug or alcohol intoxication, e. no distracting painful injury, and f. no anatomic deformity of the spine; and 6. notwithstanding paragraph 4 above, if the patient meets the criteria of paragraph 5, not apply SMR. SMR Guideline This standard does not allow the paramedic to “clear the spine” for blunt trauma patients. Rather, it identifies patients where the mechanism of injury in combination with and the absence of risk criteria mean a spine injury does not have to be considered. Using SMR does not mean the paramedic has “cleared” the spine for blunt trauma patients. The paramedic must at all times manage the patient to minimize spinal movement. In conjunction with the Documentation of Patient Care Standard, when possible, document the neurologic status before and after SMR on the Ambulance Call Report. Patient extrication and transport Patient with SMR may be placed in a semi-sitting or supine position, according to patient comfort/clinical condition. If patient is unresponsive/uncooperative, apply manual C-spine immobilization until appropriate SMR has been applied. Cervical collars should be placed on the patient prior to movement, if possible. Patients involved in an MVC, who remain in a vehicle with isolated neck or back pain and no neurologic signs or symptoms/indications of major trauma may be allowed to self-extricate using a stand, turn and pivot onto the stretcher. The paramedic should coach the patient to maintain neutral spinal alignment. Patient extrication and transport Patients who have had a spinal board or adjustable break-away stretcher applied by a first responder prior to the paramedic’s arrival should still be assessed for SMR as per the Standard. Unless otherwise required, SMR may be modified to meet this standard. Patients with SMR undergoing inter-facility transfers may have SMR modified as per the Standard in consultation with the sending physician. This may involve removal of a spinal board. SMR and agitated patients Patients who are markedly agitated, combative or confused may not be able to follow commands and cooperate with minimizing spinal movement. There may be rare circumstances in which attempts to apply SMR using a C-collar, spinal board or adjustable break-away stretcher leads to an increase in patient agitation that constitutes a safety hazard to both the patient and the paramedic. In these situations, the paramedic shall apply SMR to the best of his/her ability and secure the patient to the stretcher with stretcher straps. In conjunction with the Documentation of Patient Care Standard, the paramedic shall clearly document the circumstances of the safety hazard and his/her resulting inability to apply SMR to the patient. Use of spinal boards Spinal boards or adjustable break-away stretchers should be considered primarily as extrication/patient lifting devices. The goal should be to remove the patient from these devices as soon as it is safe to do so. If sufficient personnel are present, the patient should be log rolled from the extrication device to the stretcher during loading of the patient or shortly after loading into the ambulance. Spinal boards or adjustable break- away stretchers may remain in place if the paramedic deems it safer/more comfortable for the patient in consideration of short transport times (<30 min) . Recall that patients with suspected pelvic fractures should be secured on a spinal board or adjustable break-away stretcher as per the Blunt/Penetrating Injury Standard. Spinal Stabilization Techniques  Beginning in the primary assessment, and immediately on recognizing a possible or potential spine injury, manually protect the patient's head and neck  Head and neck must be maintained in line with the long axis of the body and this must be maintained until a collar is applied and the person is secured onto a rigid back board Manual In-line Immobilization  Contraindications for moving the patient's head to an in-line position:       Resistance to movement Neck muscle spasm Increased pain Presence or increase in neurological deficits during movement Compromise of the airway or ventilation Severe misalignment of the head away from the midline of the shoulders and body axis (rare) Manual In-line Immobilization  Should be applied without traction, applying only enough tension to relieve the weight of the head from the cervical spine Manual In-line Immobilization From the Side Figure 23-6 Manual In-line Immobilization From the Front Figure 23-7 Manual In-line Immobilization With a Supine Patient Figure 23-8 Log-Roll Supine Patient Rescuer 1 at head, rescuers 2 and 3 at midthorax and knees. Figure 23-9 A Log-Roll Supine Patient Maintain immobilization and roll to ground in one move. Figure 23-9 B Log-Roll Supine Patient Rescuer 4 positions spine board. Figure 23-9 C Log-Roll Supine Patient In one move, rescuers log-roll and center patient on spine board. Figure 23-9 D Log-Roll – Prone Patient Rescuer 1 provides in-line stabilization, prepares for rotation. Figure 23-10 A Log-Roll – Prone Patient In one move, patient is rotated away from prone position. Figure 23-10 B Log-Roll – Prone Patient In one move, rescuers log-roll and center patient on spine board. Figure 23-10 C Rigid Cervical Collars      Available in many sizes (or are adjustable) Choosing the appropriate size reduces flexion or hyperextension Must not inhibit patient's ability to open his or her mouth or to clear his or her airway in case of vomiting Must not obstruct airway passages or ventilations Should be applied only after the head has been brought into a neutral in-line position Rigid Cervical Collars Come in a variety of sizes depending on the manufacturer. Most collars are adjustable one size for adults and children. Rescuer 1 maintains in-line stabilization Rescuer 2 positions and secures collar Rescuer 1 maintains support until patient secured to board Short Spine Boards     Used to splint the cervical and thoracic spine Vary in design and are available from many equipment manufacturers Generally used to provide spinal immobilization in situations in which the patient is in a sitting position or a confined space After short spine board immobilization, the patient is transferred to a long spine board for extrication, or taken off completely. Short Spine Trauma Devices The Yates Spec Pak KED Kendrick extrication device Figure 23-12 KED Application In order to ensure that the device in placed correctly, there is a specific order of application that must be followed. Once the cervical collar is applied and manual C-spine is maintained. The order is as follows: Middle strap Bottom strap Leg straps Head straps Top strap To remember use the mnemonic device “My baby looks hot tonight”. 1 3 2 4 Rapid Extrication  Steps may vary depending on:   Size and make of the vehicle Patient’s location inside the vehicle Rapid Extrication  Rescuer 1 maintains inline stabilization Figure 23-14 A Rapid Extrication  Rescuer 2 supports midthorax as rescuer 3 frees lower extremities Figure 23-14 B Rapid Extrication  Patient lowered onto long spine board Figure 23-14 C Rapid Extrication  Patient centered and secured on spine board Figure 23-14 D Long Spine Board  Available in a variety of types including:     Plastic and synthetic spine boards Metal alloy spine boards Vacuum mattress splints Split litters (scoop stretchers) that must be used with a long spine board Long Spine Board -Supine Patient Immobilizing the torso to a long spine board must always precede immobilization of the head  Torso must not be allowed to move up, down, or to either side  Long Spine Board -Supine Patient  Place straps at the:     Shoulders or chest Around the midtorso Across the iliac crests to prevent movement of the lower torso After immobilization of torso, immobilize head and neck in neutral, in-line position Long Spine Board - Supine Patient  Children have proportionally larger heads than adults  May require padding under the torso to allow the head to lie in a neutral position on the board Figure 23-15 B Long Spine Board -Supine Patient  Secure the head to the device by placing commercial “head immobilzers” or towel rolls on both sides of the head and securing with:   Included straps 2- to 3-inch tape strips Figure 23-16 Long Spine Board -Supine Patient    Secure upper forehead across supraorbital ridge Secure lower portion of head across the anterior portion of the rigid cervical collar Secure patient’s legs with two or more straps applied above and below the knees Figure 23-16 Long Spine Board-Standing Patient  Rescuer 1 maintains manual in-line stabilization while rescuer 2 and 3 support patient  In one organized move, patient is lowered to ground on long spine board for further immobilization Figure 23-17 Immobilizing Pediatric Patients  Prehospital care should include:     Manual in-line immobilization Rigid cervical collar Long spinal immobilization device for extrication only. Immobilization devices available from various equipment manufacturers  If unavailable, adult long spine boards may be used for full spinal immobilization Figure 23-18 Helmet Issues  Purpose of helmets is to protect the head and brain, not the neck  Leaves the cervical spine vulnerable to injury Types of Helmets  Full-face or openface designs   Used in motorcycling, bicycling, rollerblading, and other activities Helmets designed for sports such as football and hockey Helmet Removal  When determining the need to remove a helmet consider:  Athletic trainers may have special equipment (and training) to remove face-pieces from sports helmets    Allows easier access to the patient’s airway Sports garb (e.g., shoulder pads) could further compromise the cervical spine if only the helmet were removed Firm fit of a helmet may provide firm support for patient’s head Helmet Removal Helmet removal should be completed unless it is causing extreme pain or discomfort to the patient.  A helmet may be left on as long as it does not hinder access to the airway, or assessment of the head or face. A helmet should only be left on in rare circumstances.  Helmet Removal  Immobilize helmet and head in in-line position Figure 23-19 A Helmet Removal  Spread side of helmet away from head and ears Figure 23-19 B Helmet Removal  Rotate helmet to clear nose and remove from head in straight line Figure 23-19 C Helmet Removal  After helmet removed, apply in-line immobilization and rigid cervical collar Figure 23-19 D Spinal Immobilization in Diving Accidents   Most diving accidents involve injury to the patient's head, neck, and spine If the patient is still in the water when EMS arrives:   Ensure scene and personal safety Only rescuers trained in water rescue should enter the water Spinal Immobilization in Diving Accidents  A supine patient should be floated to a shallow area without unnecessary movement of the spine  A prone patient should be approached from the top of the head   The patient should be carefully turned to a supine position and airway and breathing should be quickly assessed Rescue breathing may be initiated in the water Spinal Immobilization in Diving Accidents Second rescuer slides a long spine board or other rigid device under the patient's body  First rescuer continues to support the patient's head and neck without flexion or extension  Apply rigid cervical collar  Maintain manual in-line immobilization  Spinal immobilization device should be floated to edge of water and lifted out  Completely immobilize patient on long spine board 