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Chapter 9
Spinal Trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Introduction to Spinal Injuries
Spinal Anatomy and Physiology
Pathophysiology of Spinal Injury
Assessment of the Spinal Injury
Patient
Management of the Spinal Injury
Patient
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Spinal Injuries
Annually 15,000 permanent spinal cord injuries
Commonly men 16–30 years old
Mechanism of Injury
–
–
–
–
Vehicle crashes: 48%
Falls: 21%
Penetrating trauma: 15%
Sports injury: 14%
25% of all spinal cord injuries occur from improper handling of
the spine and patient after injury.
– ASSUME based upon MOI that patients have a spinal injury.
– MANAGE ALL spinal injuries with immediate and continued care.
Lifelong care for spinal cord injury victim exceeds $1 million.
Best form of care is public safety and prevention programs.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (1 of 10)
33 bones comprise the spine.
Function:
– Skeletal support structure
– Major portion of axial skeleton
– Protective container for spinal cord
Vertebral Body:
– Major weight-bearing component
– Anterior to other vertebrae components
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (2 of 10)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (3 of 10)
Size of Vertebrae
– C-1 and C-2:
No vertebral body
Support head
Allow for turning of head
– Vertebral body size increases the more inferior
they become.
Lumbar spine strongest and largest
Bear weight of the body
– Sacral and coccyx vertebrae are fused.
No vertebral body
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (4 of 10)
Components of Vertebrae
– Spinal Canal
Opening in the vertebrae that the spinal cord passes
through
– Pedicles
Thick, bony structures that connect the vertebral body
to the spinous and transverse processes
– Laminae
Posterior bones of vertebrae that make up foramen
– Transverse Process
Bilateral projections from vertebrae
Muscle attachment and articulation location with ribs
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (5 of 10)
Components of Vertebrae
– Spinous Process
Posterior prominence on vertebrae
– Intervertebral Disk
Cartilaginous pad between vertebrae
Serves as shock absorber
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (6 of 10)
Vertebral Ligaments
– Anterior Longitudinal
Anterior surface of vertebral bodies
Provides major stability of the spinal column
Resists hyperextension
– Posterior Longitudinal
Posterior surface of vertebral bodies in spinal
canal
Prevents hyperflexion
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (7 of 10)
Cervical Spine
– 7 vertebrae
– Sole support for head
Head weighs 16–22 pounds
– C-1 (Atlas)
Supports head
Securely affixed to the occiput
Permits nodding
– C-2 (Axis)
Odontoid process (dens)
Projects upward
Provides pivot point so head can rotate
– C-7
Prominent spinous process (vertebra prominens)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (8 of 10)
Thoracic Spine
– 12 vertebrae
– 1st rib articulates with T-1
Attaches to transverse process and vertebral body
– Next nine ribs attach to the inferior and superior
portion of adjacent vertebral bodies
Limits rib movement and provides increased rigidity
– Larger and stronger than cervical spine
Larger muscles help to ensure that the body stays
erect
Supports movement of the thoracic cage during
respirations
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (9 of 10)
Lumbar Spine
– 5 vertebrae
– Bear forces of bending and lifting above
the pelvis
– Largest and thickest vertebral bodies and
intervertebral disks
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Vertebral Column (10 of 10)
Sacral Spine
– 5 fused vertebrae
– Form posterior plate of pelvis
– Help protect urinary and reproductive
organs
– Attach pelvis and lower extremities to
axial skeleton
Coccygeal Spine
– 3–5 fused vertebrae
– Residual elements of a tail
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Meninges
Layers
– Dura mater
– Arachnoid
– Pia mater
Cover entire spinal cord and peripheral
nerve roots that exit
Cerebrospinal fluid bathes spinal cord by
filling the subarachnoid space
– Exchange of nutrients and waste products
– Absorbs shocks of sudden movement
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Cord (1 of 4)
Function
– Transmits sensory input from body to the brain
– Conducts motor impulses from brain to muscles
and organs
– Reflex center
Intercepts sensory signals and initiates a reflex signal
Growth
– Fetus
Entire cord fills entire spinal foramen
– Adult
Base of brain to L-1 or L-2 level
Peripheral nerve roots pulled into spinal foramen at the
distal end (cauda equina)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Cord (2 of 4)
Blood Supply
– Paired spinal arteries
Branch off the vertebral, cervical, thoracic,
and lumbar arteries
Travel through intervertebral foramina
Split into anterior and posterior arteries
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Cord (3 of 4)
General Cord Anatomy
– Anterior Medial Fissure
Deep crease along the ventral surface of the spinal
cord that divides cord into left and right halves
– Posterior Medial Fissure
Shallow longitudinal groove along the dorsal surface
– Gray Matter
Area of the CNS dominated by nerve cell bodies
Central portion of the spinal cord
– White Matter
Surrounds gray matter
Comprised of axons
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Cord (4 of 4)
General Cord Anatomy
– Axons
Transmit signals upward to the brain and
down to the body
Ascending tracts
Axons that transmit signals to the brain
Sensory tracts
Descending tracts
Axons that transmit signals to the body
Motor tracts
Voluntary and fine muscle movement
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (1 of 11)
31 pairs of nerves that originate along the
spinal cord from anterior and posterior nerve
roots
– Sensory and motor functions
– Travel through intervertebral foramina
1st pair exit between the skull and C-1
Remainder of pairs exit below the vertebrae
Each pair has 2 dorsal and 2 ventral roots
– Ventral roots: motor impulses from cord to body
– Dorsal roots: sensory impulses from body to
cord
– C-1 and Co-1 do not have dorsal roots
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (2 of 11)
Plexus
– Nerve roots that converge in a cluster of
nerves
Cervical plexus
5 cervical nerve roots
Innervates the neck
Produces the phrenic nerve
Peripheral nerve roots C-3 through C-5
Responsible for diaphragm control
“C3, 4, and 5 keep the diaphragm alive”
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (3 of 11)
Brachial Plexus
– C-5 through T-1
– Controls the upper extremity
Lumbar and Sacral Plexuses
– Innervation of the lower extremity
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (4 of 11)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (5 of 11)
Dermatomes
– Topographical region of the body surface
innervated by one nerve root
– Key locations
Collar region: C-3
Little finger: C-7
Nipple line: T-4
Umbilicus: T-10
Small toe: S-1
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (6 of 11)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (7 of 11)
Myotomes
– Muscle and tissue of the body innervated
by spinal nerve roots
– Key myotomes
Arm extension: C-5
Elbow extension: C-7
Small finger abduction: T-1
Knee extension: L-3
Ankle flexion: S-1
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (8 of 11)
Reflex Pathways
– Function
Speed body’s response to stressors
Reduce seriousness of injury
Body stabilization
– Occur in special neurons
Interneurons
Example
Touch hot stove.
Severe pain sends intense impulse to brain.
Strong signal triggers interneuron in the spinal cord to
direct a signal to the flexor muscle.
Limb withdraws without waiting for a signal from the brain.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (9 of 11)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (10 of 11)
Subdivision of ANS
– Parasympathetic, “Feed and Breed”
Controls rest and regeneration
Peripheral nerve roots from the sacral and
cranial nerves
Major Functions
Slows heart rate
Increases digestive system activity
Plays a role in sexual stimulation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Spinal Nerves (11 of 11)
Subdivision of ANS
– Sympathetic, “Fight or Flight”
Increases metabolic rate
Branches from nerves in the thoracic and lumbar
regions
Major Functions
Decreases organ and digestive system activity
Vasoconstriction
Release of epinephrine and norepinephrine
Systemic vascular resistance
Reduces venous blood volume
Increases peripheral vascular resistance
Increases heart rate
Increases cardiac output
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(1 of 14)
Mechanisms of Spinal Injury
– Extremes of Motion
Hyperextension
Hyperflexion: “Kiss the Chest”
Excessive rotation
Lateral bending
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(2 of 14)
Mechanisms of Spinal Injury
– Axial Stress
Axial loading
Compression common between T-12 and L-2
Distraction
Combination
Distraction/rotation or compression/flexion
– Other MOI
Direct, blunt, or penetrating trauma
Electrocution
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(3 of 14)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(4 of 14)
Column Injury
– Movement of vertebrae from normal position
– Subluxation or dislocation
– Fractures
Spinous process and transverse process
Pedicle and laminae
Vertebral body
– Ruptured intervertebral disks
– Common sites of injury
C-1/C-2: Delicate vertebrae
C-7: Transition from flexible cervical spine to thorax
T-12/L-1: Different flexibility between thoracic and
lumbar regions
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(5 of 14)
Cord Injury
– Concussion
Similar to cerebral concussion
Temporary and transient disruption of cord
function
– Contusion
Bruising of the cord
Tissue damage, vascular leakage, and
swelling
– Compression
Secondary to:
Displacement of the vertebrae
Herniation of intervertebral disk
Displacement of vertebral bone fragment
Swelling from adjacent tissue
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(6 of 14)
Cord Injury
– Laceration
Causes
Bony fragments driven into the vertebral foramen
Cord may be stretched to the point of tearing
Hemorrhage into cord tissue, swelling, and
disruption of impulses
– Hemorrhage
Associated with contusion, laceration, or
stretching
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(7 of 14)
Transection Cord Injury
– Injury that partially or completely severs
the spinal cord
Complete
Cervical Spine
Quadriplegia
Incontinence
Respiratory paralysis
Below T-1
Incontinence
Paraplegia
Incomplete
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(8 of 14)
Incomplete Transection Cord Injury
– Anterior Cord Syndrome
Anterior vascular disruption
Loss of motor function and sensation of pain, light
touch, and temperature below injury site
Retain motor, positional, and vibration sensation
– Central Cord Syndrome
Hyperextension of cervical spine
Motor weakness affecting upper extremities
Bladder dysfunction
– Brown-Sequard’s Syndrome
Penetrating injury that affects one side of the cord
Ipsilateral sensory and motor loss
Contralateral pain and temperature sensation loss
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(9 of 14)
General Signs and Symptoms
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Extremity paralysis
Pain with and without movement
Tenderness along spine
Impaired breathing
Spinal deformity
Priapism
Posturing
Loss of bowel or bladder control
Nerve impairment to extremities
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(10 of 14)
Spinal Shock
– Temporary insult to the cord
– Affects body below the level of injury
– Affected area
Flaccid
Without feeling
Loss of movement (flaccid paralysis)
Frequent loss of bowel and bladder control
Priapism
Hypotension secondary to vasodilation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(11 of 14)
Neurogenic Shock
– Spinal-Vascular Shock
– Occurs when injury to the spinal cord disrupts
the brain’s ability to control the body
Loss of sympathetic tone
Dilation of arteries and veins
Expands vascular space
Results in relative hypotension
Reduced cardiac preload
Reduction of the strength of contraction
Frank-Starling reflex
ANS loses sympathetic control over adrenal medulla
Unable to control release of epinephrine and
norepinephrine
Loss of positive inotropic and chronotropic effects
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(12 of 14)
Neurogenic Shock
– Signs and Symptoms
Bradycardia
Hypotension
Cool, moist, and pale skin above the injury
Warm, dry, and flushed skin below the injury
Male: priapism
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(13 of 14)
Autonomic Hyperreflexia Syndrome
– Associated with the body’s resolution of the
effects of spinal shock
– Commonly associated with injuries at or above
T-6
– Presentation
Sudden hypertension
Bradycardia
Pounding headache
Blurred vision
Sweating and flushing of skin above the point of injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
(14 of 14)
Other Causes of Neurologic
Dysfunction
– Any injury that affects the nerve
impulse’s path of travel
Swelling
Dislocation
Fracture
Compartment syndrome
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Spinal Injury
Patient (1 of 4)
Scene Size-up
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Evaluate MOI.
Consider spinal clearance protocol.
Determine type of spinal trauma.
Maintain suspicion with sports injuries.
If unclear about MOI, take spinal
precautions.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Spinal Injury
Patient (2 of 4)
Initial Assessment
– Consider spinal clearance protocol.
– Consider spinal precautions.
Head injury
Intoxicated patients
Injuries above the shoulders
Distracting injuries
– Maintain manual stabilization.
Vest style versus rapid extrication
Maintain neutral alignment
Increase of pain or resistance, restrict movement in
position found
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Spinal Injury
Patient (3 of 4)
Initial Assessment
– ABCs.
– Suction.
– Consider oral or digital intubation if
required.
Maintain in-line manual c-spine control.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Spinal Injury
Patient (4 of 4)
Rapid Trauma Assessment
– Focused versus rapid assessment
– Rapid Assessment
Suspected or likely spinal cord/column injury
Multi-system trauma patient
Evaluate for
Neck
Deformity, pain, crepitus, warmth, tenderness
Bilateral extremities
Finger abduction/adduction
Push, pull, grips
Motor and sensory function
Dermatome and myotome evaluation
Babinski’s sign test
Hold-up position
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Babinski’s Sign Test
Stroke lateral aspect of the bottom of
the foot.
Evaluate for movement of the toes.
– Fanning and flexing (lifting)
Positive sign
Injury along the pyramidal (descending spinal) tract
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Spinal Injury Patient
Vital Signs
– Body temperature
Above and below site of injury
– Pulse
– Blood pressure
– Respirations
Ongoing Assessment
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Recheck elements of initial assessment.
Recheck vital signs.
Recheck interventions.
Recheck any neurological deviations.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Clearance Protocol
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Integrity Terminology
Stabilize is a word commonly used to describe
protecting the spinal cord from possible injury (or
further injury) when vertebral column integrity is
disrupted.
Immobilize refers to the “splinting” of the head,
neck, and torso to limit any transmission of motion
to the spine.
Spinal motion restriction (SMR) is now suggested
as a more accurate description of modern spinal
injury care. However, this phrase could be
misunderstood to indicate a more limited
“immobilization” of the spine than is currently
practiced.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (1 of 7)
Spinal Alignment
– Move patient to a neutral, in-line position.
Position of function.
– Hips and knees should be slightly flexed for maximum
comfort and minimum stress on muscles, joints, and
spine.
Place a rolled blanket under the knees.
– ALWAYS support the head and neck.
– Contraindications to neutral position:
Movement causes a noticeable increase in pain.
Noticeable resistance met during procedure.
Increase in neurological deficits occurs during movement.
Gross deformity of spine.
– LESS MOVEMENT IS BEST.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (2 of 7)
Manual Cervical Immobilization
– Seated Patient
Approach from front.
Assign a caregiver to hold GENTLE manual traction.
Reduce axial loading.
Evaluate posterior cervical spine.
Position patient’s head slowly to a neutral, in-line
position.
– Supine Patient
Assign a caregiver to hold GENTLE manual traction.
Adult
Lift head off ground 1–2”: neutral, in-line position.
Child
Position head at ground level: avoid flexion.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (3 of 7)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (4 of 7)
Cervical Collar Application
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Apply the C-collar as soon as possible.
Assess neck prior to placing.
C-collar limits some movement and reduces axial loading.
DOES NOT completely prevent movement of the neck.
Size and Apply according to the manufacturer’s
recommendation.
Collar should fit snugly.
Collar should NOT impede respirations.
Head should continue to be in neutral position.
SIZE IT, SIZE IT, SIZE IT!!!
– DO NOT RELEASE manual control until the patient is fully
secured in a spinal restriction device.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (5 of 7)
Standing Takedown
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Minimum 3 rescuers.
Have patient remain immobile.
Rescuer provides manual stabilization from behind.
Assess neck.
Size and place c-collar.
Position board behind patient.
Grasp board under patient’s shoulders.
Lower board to ground.
Secure patient.
COMMUNICATE WITH PARTNERS AND PATIENT.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (6 of 7)
Helmet Removal
– When to remove:
Helmet does not immobilize the patient’s head within.
Cannot securely immobilize the helmet to the long
spine board.
Helmet prevents airway care.
Helmet prevents assessment of anticipated injuries.
Present or anticipated airway or breathing problems.
Removal will not cause further injury.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (7 of 7)
Helmet Removal
– Technique:
2 Rescuers.
Have a plan.
Remove face mask and chin strap.
Immobilize head.
Slide one hand under back of neck and head.
Other hand supports anterior neck and jaw.
Remove helmet.
Gently rock head to clear occiput.
All actions should be slow and deliberate.
– TRANSPORT HELMET with patient.
– COMMUNICATION is the KEY.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Movement of the
Spinal Injury Patient (1 of 2)
Any movement MUST be coordinated.
Move patient as a unit.
NO LATERAL PUSHING.
– Move patient up and down to prevent lateral
bending.
Rescuer at the head “CALLS” all moves.
ALL MOVES MUST be slowly executed and
well coordinated.
Consider the final positioning of the patient
prior to beginning move.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Movement of the
Spinal Injury Patient (2 of 2)
Types of Moves
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Log roll
Straddle slide
Rope-Sling slide
Orthopedic stretcher
Vest-type immobilization
Rapid extrication
Final patient positioning
Long spine board
Full-body vacuum mattress
Diving injury immobilization
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (1 of 3)
Medications and Spinal Cord Injury
– Steroids if neuro-deficit is identified
Reduce the body’s response to injury
Reduce swelling and pressure on cord
Administered within 1st 8 hours of injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (2 of 3)
Medications and Neurogenic Shock
– Fluid Challenge
Isotonic solution: 20 mL/kg
250 mL initially
Monitor response and repeat as needed
– PASG
Controversial
Research shows no positive outcome
– Dopamine
2–20 mcg/kg/min titrated to blood pressure
– Atropine
0.5–1.0 mg q 3–5 min (maximum of 2.0 mg)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient (3 of 3)
Medications and the Combative
Patient
– Consider sedatives to reduce anxiety and
calm patient.
Prevents spinal injury aggravation
– Medications:
Meperidine (Demerol)
Diazepam (Valium)
Consider paralytics with airway control
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Introduction to Spinal Injuries
Spinal Anatomy and Physiology
Pathophysiology of Spinal Injury
Assessment of the Spinal Injury
Patient
Management of the Spinal Injury
Patient
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ