Chapter LIJLDHR

8/13/2019 Chapter LIJLDHR

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Initial Assessment and Management

Committee on Trauma Presents

Spine andSpinal Cord

Trauma


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Case Scenario

38-year-old male is pulled from a

swimming pool.

BP: 80/62; Pulse: 58; RR: 28 GCS score: 15

Breathing is shallow.

He is not moving his arms or legs.

Discuss the patients diagnosis

and management.


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Objectives

Describe the evaluation of a patient with

suspected spinal injury.

Explain the appropriate management ofspinal injury.

Discuss appropriate patient disposition.


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Spinal Injury

When should you suspect a spine in jury?


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Spinal Injury

Mechanism of injury

Unconscious patient Neurologic deficit

Spine pain / tenderness

When should you suspect a spine in jury?


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Spinal Injury

How do I protect the spine dur ing evaluat ion

and transp ort?


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Spinal Injury

Immobilize entire patient on long spineboard with proper padding.

Apply semirigid collar.

How do I protect the spine dur ing evaluat ion

and transp ort?

Protection is priority;

detection is secondary.


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Drugs, alcohol, and other

injuries can mask spinal injury.

Spinal Injury Screening

Clinical

Normal neurologic exam and

Absence of spinal pain and tenderness

Caution


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If patient is

Conscious

Cooperative

Able to concentrate on c-spine

If noneck or spine pain or tenderness

If still nopain or tenderness with

voluntary movement

No further evaluation or x-ray necessary

Clear spin e and remove cervical col lar.


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Radiographic visualization of entire

spine

Plain films

CT scan of suspicious or poorly

visualized areas

Altered Consciousness or Symptoms


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How do I conf i rm a spine in jury?


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Clinical signs of neurological deficit

Radiological investigations

Plain X-ray / CT / MRI

Identify bony fracture / subluxation

Presume spinal instability

Early spine service consult

How do I conf i rm a spine in jury?


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Cervical Spine X-rays

Crosstable lateral film excludes 85% of

fractures

Addition of AP and odontoid viewsexcludes most fractures

Also may require

Swimmers view

CT scan for bony detail

MRI


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Cervical Spine X-rays

10% of patients with a c-spine fracture have

a second, associated noncontiguous

vertebral column fracture

Identify one abnormality? Look for another!

Radiographic screening of entire spine

required in this situation


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Spinal evaluation complicated by altered

sensorium

Remove spine board as soon as possible and

logroll patient

Pressure sores occur early in unconscious

or paralyzed patients

Pitfalls

Pitfalls


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Caution

At least 5% of patients with

spinal cord injuries worsen

neurologically at the hospital.

Caution


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Neurologic Status

How do I assess the patients neurologic status?


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Neurologic Status

Neurologic level

Most caudal level of motor / sensory function

Motor and sensory may not be the same

Sensory can vary on each side

Bony level

Site of vertebral column damage

How do I assess the patients neurologic status?


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Neurologic Status

Complete Injury

No motor or sensory function below

injury level

Incomplete Injury

Any motor or sensory preservation

below injury level

Sacral sparing may be only residual

function


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Effects of Spinal Cord Injury

Neurogenic shock

Spinal shock

Other consequences

Fasciculus cuneatus

Dorsal columnFasciculus gracilis

Lateral corticospinal tract

Spinothalamic


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Cardiovascular phenomenon due toloss of sympathetic tone

Associated with cervical / high thoracicspine injury

Hypotension and slow heart rate

Treatment includes fluid resuscitationand occasional atropine andvasopressors

Neurogenic ShockDirect Effects


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Neurologic, not hemodynamicphenomenon

Occurs shortly after cord injury

Variable duration

Flaccidity and loss of reflexes

Spinal ShockDirect Effects


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Inadequate ventilation

Abdominal evaluation compromised

Occult compartment syndrome

Other Consequences


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Management

How do I manage pat ients w i th spinal cord

in jury and l im i t secondary in jury?


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Management

Ensure adequate ventilation andoxygenation

Maintain blood pressure

Maintain perfusion of spinal cord

How do I manage pat ients w i th spinal cord

in jury and l im i t secondary in jury?


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Management

Assess for associated bleeding

Consider neurogenic shock

Monitor urinary output

Management of Hypotension

Stop

thebleeding!


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Management

Unstable fractures

Neurologic deficit

Whom do I trans fer?

Avoid transfer delay!

Caution


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Management

Provide respiratory

support as needed Exclude other life-

threatening injury

Properly immobilize

entire patient

Avoid hypothermia

Management of Patients Requiring Transfer


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Summary

Treat life-threatening injuries first

Properly immobilize entire patient

Obtain appropriate spine films

Document examination

Obtain neurosurgical / orthopaedic consult

Transfer unstable fracture / cord injury

Documents

Chapter LIJLDHR