Spinal cord injury

Spinal cord injurySPINAL CORD INJURY (SCI)An insult to the spinal cord resulting in changed neurological functionMotorSensoryAutonomicMay be temporary or permanentInjuries tend to be physically, emotionally and financially devastating

CLASSIFICATIONTetraplegia: (quadriplegia)Cervical region injuryLoss of muscle strength to all four extremities Most critical: support respiratory functionParaplegiaInjury to the spinal cord in the ThoracicLumbarSacral segmentsT12 and L1 are the most common level

MECHANISM OF INJURYIn the United States:Automobile accidentsHigh speedEjection. rolloverFallsGreater than 4.5 meters/15 feet (or 3x height)Slip and fall: rare except in elderly Diving into shallow poolViolence BluntPenetratingSportsSITE OF INJURY AND NEUROLOGIC LEVEL

C5 Most common site of injuryT12 / L1 most common injuriesPRIMARY AND SECONDARYSPINAL CORD INJURYPrimary Spinal Cord Injury Initial physical damage to spinal cord or its structuresPhysical cord damage due to mechanical insult Neurons passing through injury site are physically disrupted and exhibit diminished myelin thickness

PRIMARY AND SECONDARY INJURYSecondary Spinal Cord injury:Progressive pathological responses to initial injuries Hemorrhage into cord compartmentsInflammatory response to initial insult (Biochemical cascade, progressive edema and cell necrosis)Hypoxia due to local and systemic hypoperfusion Systemic hypotension from other injuries (bleeding) or neurogenic shockCollectively damage intact neighboring tissueSymptoms: paralysis and loss of sensation to areas innervated below the general level of the injury

Mechanisms of Spinal InjuriesExtremes of motionHyperextensionHyperflexion: Kiss the ChestExcessive RotationLateral bendingAxial StressAxial loadingCompression common between T12 and L1DistractionCombinationDistraction/Rotation or compression/flexionOther MOIDirect, Blunt or Penetrating traumaElectrocution8Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of Spinal Injury (3 of 14) Spinal Column InjuresMovement of vertebrae from normal positionSubluxation or DislocationFracturesSpinous process and Transverse processVertebral bodyRuptured intervertebral disksCommon sites of injuryC-1/C-2: Delicate vertebraeC-7: Transition from flexible cervical spine to thoraxT-12/L-1: Different flexibility between thoracic and lumbar regions

10Spinal Cord InjuriesConcussionSimilar to cerebral concussionTemporary and transient disruption of cord functionContusionBruising of the cordTissue damage, vascular leakage and swellingCompressionSecondary to:displacement of the vertebraeherniation of intervertebral diskdisplacement of vertebral bone fragmentswelling from adjacent tissue

11Spinal Cord Injuries continuedLacerationCausesBony fragments driven into the vertebral foramenCord may be stretched to the point of tearingHemorrhage into cord tissue, swelling and disruption of impulsesHemorrhageAssociated with contusion, laceration, or stretching

12SPINAL CORD INJURY UNTIL PROVEN OTHERWISE IF:Significant mechanism of injuryhigh speed motor vehicle collisionFall from a heightDiving accidentElectrocutionDirect neck traumaHead or Neck pain associated with traumaMotor or sensory deficitsAltered Level of ConsciousnessDistracting Injury

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJSpinal Clearance Protocol

Primary and Secondary SurveysPrimary Survey Assess for life threatening injuries, if identified, stop immediately and address before moving onAirway with Spinal Cord PrecautionsBreathing and VentilationCirculationDisability mental statusExposure

Primary and Secondary SurveysSecondary Survey Complete head to toe and focused assessmentHistoryEverything else

Primary Survey

17AIRWAY AND SPINAL PROTECTIONAirway with simultaneous spinal protectionManually hold head/neck in lineInspect the airway using jaw thrust (if able)Tongue, secretions, blood, vomit, edema, foreign body, retropharyngeal hematomaGentle, frequent suction (avoid vagal stimulation and hypoxia)Quick check of head and neck for life threatening injury/bleeding

AIRWAY WITH SPINAL STABILIZATIONOxygenOral-tracheal intubation with in-line stabilization is the preferred methodAny episode of hypoxia can lead to cord ischemia and further injuryPlan for: rigid C-collar (if able), head supports, long board, log roll patientMinimal movement/manipulation of spine!BREATHING/VENTILATIONAssess patients respiratory statusSpontaneous? Need for assistance?Rate and rhythmEqual chest rise and fallUse of accessory musclesVocalizationsSkin signsIs the patient tiring? AssistTrauma patient, look for: chest wall stability and penetrating injuriesThe higher the injury, the higher the risk for respiratory failure

CIRCULATIONBleeding? Control itSkin signs Hypovolemia: pale, cool, diaphoreticNeurogenic shock: warm, dry Palpate central pulsesHypovolemia: tachycardiaNeurogenic shock: bradycardia May be taking medication that affects heart rate, especially the elderlyCompare pulsesIntravenous access x 2Bradycardia may require atropine or pacing

22DISABILITYWhat is the patients mental status?Altered?Intoxicated?Distracting Injury?Significant Head or Neck Trauma?Check pupils

DISABILITY/MENTAL STATUS

DISABILITY/MENTAL STATUSAlertVerbalPainUnresponsiveEXPOSUREDont miss other injuries!Uncover the patient. Significant mechanism of injury means high risk for other trauma (thoracic, abdominal, pelvic, long bone fractures, head/brain trauma)Log Roll Patient. Palpate and inspect entire spine and paraspine for tenderness, deformity, bruising, step-offs and widening of the vertebral spacesSphincter tone and PriapismKeep warm. Recover. Patient may have no thermoregulationSECONDARY SURVEYPatient on the monitorFull set of vitals Full Head to ToeDont miss other injuries!Full HistoryMechanism is important!As much information as possible from the patient, the family, the paramedics Minimal movement of spine!Consider removing back board.BLOOD PRESSURECheck Blood pressure: any episodes of hypotension increase the risk of ischemic injury. Maintain a Mean Arterial Pressure of 85-90mmHgHypotension: 2 potential causesHypovolemiaIs the patient bleedingDont miss an injury. Patient needs fluids/bloodNeurogenic Shock lack of sympathetic innervation.May need dopamine and atropine. Caution not to fluid overload causing further cord edema and damage to brain and lungs

FULL NEUROLOGICAL ASSESSMENTWhat hurts? What can you feel/move?Check motor, sensory, proprioceptionWhat can you move?What can you feel?Distal to proximalPain point of pinPressure head of pinWhat toe am I moving and in which direction?Document using established scalesDermatomesAmerican Spinal Injury Association Neurological AssessmentUnresponsive patient: flaccid?Diaphragmatic breathing? Loss of grimace/withdrawal response? Sphincter tone? Priapism? Distended bladder/abdomen? Hypotension? Hypothermia?

American Spinal Injury AssociationScale to describe the extent of the injuryA = Complete: Complete loss of motor and sensory function in sacral segments S4-S5.B = Incomplete: Sensory function preserved preserved below site of injuryLoss of motor function below site of injuryC = Incomplete: Motor function is preserved below the site of injury More than half of key muscles below site of injury have a muscle strength less than 3.D = Incomplete: Motor function is preserved below site of injury At least half of key muscles below site of injury have a muscle strength of 3 or more.E = Normal: motor and sensory function are normal.

AMERICAN SPINAL INJURY ASSOCIATIOTIONScale for assessment of motor strength0 No contraction or movement1 Minimal movement2 Active movement, but not against gravity3 Active movement against gravity4 Active movement against resistance5 Active movement against full resistanceAMERICAN SPINAL INJURY ASSOCIATIONSensory ScaleBoth sides of the bodyDistal to proximalPain and Pressure0 Absent1 Impaired2 NormalNT Not testablePAIN CONTROLHypersensitivity above level of injuryTend to have extreme pain with even light pressureBalance needsPain relief Need to maintain adequate perfusion Need for ongoing neurological assessmentsOpioidspositioningAssisting with traction Devastating injury. Include the Patients Family REASSESSMENTSerial assessments are critical! Vital SignsMental statusWork of breathingFocal findings Motor, Sensory and ProprioceptionFull care of patient in spinal precautionsNausea and Vomiting!Radiology May require serial imagesGoal is best possible outcome for this patientSTUDIES X-RaysCheaperLess radiationDifficult to obtain 3 mandatory and adequate views Must visualize down to T1Computerized Tomography (CT)Easier, faster, see more Lots more radiation (especially for children)Cant see soft tissueMagnetic Resonance Imaging (MRI) Long delayRequires transport time Difficult to monitor patient in MRI machineSome patients unable to tolerate

36National Emergency X-Radiography Utilization Study Criteria

Canadian Criteria

Contoh kasusTn. D, usia 62 tahun, kedua tungkai tidak dapat digerakkan setelah jatuh terduduk 3 hari SMRS. Tidak bisa merasa pada tungkai tersebut, tidak menyadari BAB dan BAK, dan tidak bisa ereksi. Riwayat demam tidak ada, bengkak dan nyeri pada punggug tidak ada. Keluhan muncul setelah jatuh terduduk.

Motor skor : Kanan : 25 kiri : 25 total 50Sensori skor :Light touch dan pin prickKanan : 18 kiri : 18 total 36ASIA impairment scale A (complete)

PENATALAKSANAN SPINAL CORD INJURYPemberian terapiMP 30 mg/kgbb bolus, dilanjutkan 5.4 mg kg/bb selama 23 jam.

Perbaikan neurologi signifikan bia diberikan pada 3-8 jam setelah trauma.Mekanisme Kerja MetilprednisolonMenurunkan post traumatic SC edemaMenghambat post trauma LPMenghambat iskemik post traumaMembantu metabolisme aerob (reduksi laktat & meningkatkan ATP)Memperbaiki ca ekstrasel (menurunkan ca intrasel)Mengurangi neurofilamenMENURUT NASCISNASCIS I (USA, 1984)ProspektifMetil prednisolon (100 mg dan 1000 mg)

NASCIS III (1997)ProspektifMetilprednisolon, tirilazad NASCIS II (1990)Prospektif Metiprednisolon, naloxone, placebo

NASCIS I330 pasienT/100 mg bolus MP, kemudian 25 mg tiap 6 jam selama 10 hari1000 mg bolus MP, kemudian 250 mg tiap 6 jam selama 10 hari

Kesimpulan : tidak ada hasil signifikan dari kedua grup diatasAngka kejadian meningkat terhadap luka infeksi (dosis tinggi)NASCIS II 487 pasien dalam 1 tahunPasien yg meninggal dieksklusikanTotal 427 pasienT/ MP 30 mg/kgbb bolus, dilanjutkan 5.4 mg kg/bb selama 23 jam.Naloxone 5.4 mg//kgbb bolus, dilanjutkan 4.5 mg/kgbb selama 23 jamPlacebo NASCIS IIIProspektifTanpa placebo499 pasien. Total pasien 439 pasien setelah 1 tahun follow up.Diberikan dalam waktu < 8 jam setelah traumaT/MP 5.4 mg/kgbb/jam selama 24 jamMP 5.4 mg/kgbb/jam selama 48 jamTirilazad 2.5 mg/kgbb tiap 6 jam selama 48 jamMortalitas meningkat 6 kali pada grup yg 48 jam (respirasi) pneumonia dan sepsis.

Pasien tsb dibagi dalam 0-3 jam setelah trauma dan 3-8 jam setelah trauma.

Pada kelompok 0-3 jam tidak ada perbaikan neurologi.

Pada kelompok 3-8 jam terdapat perbaikan neurologi.