Download Paramedic Care: Principles & Practice Volume 4

Paramedic Care:
Principles & Practice
Volume 4
Trauma Emergencies
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 9
Spinal Trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Spinal Injuries
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Spinal Injuries
Annually 10,000 permanent spinal cord
injuries
Commonly men 15–24 years old
Mechanism of Injury
– Vehicle crashes: 50%
– Falls: 25%
– Sports injury: 10%
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Spinal Injuries
Spinal Injuries are sometimes missed in the
pre-hospital setting
Lifelong care for spinal cord injury victims
exceeds $1 million
Best form of care is public safety and
prevention programs
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and Physiology
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and
Physiology
Vertebral Column
– 33 bones comprise
the spine
– Function:
Skeletal support
structure
Major portion of axial
skeleton
Protective container
for spinal cord
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vertebral Column
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
Bears weight of the body
– Sacral and coccyx vertebrae are fused
No vertebral body
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vertebral Column
Components of
Vertebrae
–
–
–
–
–
–
Spinal Canal
Pedicles
Laminae
Transverse Process
Spinous Process
Intervertebral Disk
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vertebral Column
Vertebral
Ligaments
– Anterior
Longitudinal
Provides major
stability of the spinal
column
Resists
hyperextension
– Posterior
Longitudinal
Prevents
hyperflexion
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Supply to the Spine
Primarily supplied by the anterior spinal artery
and the two posterior spinal arteries
– Arise from the vertebral artery
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Divisions of the Spinal Column
Cervical Spine
– 7 vertebrae
– Sole support for head
– C-1 (Atlas)
Atlanto-occipital joint
Most frequent site of injury
– C-2 (Axis)- strongest of cervical vertebrae
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cervical Spine
© Ralph T. Hutchings
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Atlas and Axis Relationship
© Ralph T. Hutchings
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vertebral Column
Thoracic Spine
– 12 vertebrae
– 1st rib articulates with T-1
Demifacets
– 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vertebral Column
Lumbar Spine
– 5 vertebrae
– Bear forces of bending and lifting above the pelvis
– Largest and thickest vertebral bodies and
intervertebral disks
– The anterior parts of the vertebral bodies are
higher than the posterior part
Contributes to the normal curvature (lordosis)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Lumbar Vertebrae
© Ralph T. Hutchings
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vertebral Column
Sacral Spine
– 5 fused vertebrae
Sacral promontory
– Form posterior plate of pelvis
– 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Sacral-Coccygeal Spine
© Ralph T. Hutchings
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord
© Ralph T. Hutchings
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Meninges
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
31 pairs of nerves that originate along the
spinal cord from anterior and posterior nerve
roots
– Sensory and motor functions
– Travel through intervertebral foramina
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
© Ralph T. Hutchings
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Dermatomes
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Anatomy and
Physiology - Spinal Nerves
Reflex Pathways
– Function
Speed body’s
response to stressors
Reduce seriousness
of injury
Body stabilization
– Occur in special
neurons
Interneurons
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Nerves
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Spinal Injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Spinal Injury
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Mechanisms of Spinal Injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Spinal Injury
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Column Injury
– Movement of vertebrae from normal position
Subluxation or dislocation
– Fractures
– 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Cord Injury
– Primary and secondary injuries to the spinal cord
Concussion
Contusion
Compression
Laceration
Hemorrhage
Transection
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Concussion
– A temporary and transient disruption of cord
function
Contusion
– Bruising of the cord
If blood crosses the blood-brain barrier, significant edema
may result
Compression
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Compression
– May occur
secondary to:
Displacement of a
vertebra
Herniation of an
intervertebral disk
Displacement of a
vertebral bone
fragment
Swelling of adjacent
tissue
© Photo Researchers, Inc.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Laceration
– Causes
Bony fragments driven into the vertebral foramen
Cord may be stretched to the point of tearing
Hemorrhage
– Associated with contusion, laceration, or stretching
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Transection Cord Injury
– Injury that partially or completely severs the
spinal cord
Complete
Cervical Spine
Quadriplegia
Incontinence
Respiratory paralysis
Below T-1
Incontinence
Paraplegia
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord Syndromes
Signs and
symptoms seen
following a spinal
cord injury are
directly related to:
– Level of the spinal
cord affected
– Degree of damage
that results from the
injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord Syndromes
The signs and symptoms of a complete
transaction occur in phases
– Acute phase
– Subacute phase
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Cord Syndromes
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-Séquard’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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
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
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Neurogenic Shock (cont.)
– 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
Transient Syndromes
– Most often result from sporting events
“Stinger”
Painful electrical sensations radiating through one of the arms
Not a cord injury
– Transient quadriplegia
Results from a more serious, but temporary, injury to the
cervical spinal cord
Usually lasts less than 15 minutes
May take up to 48 hours to resolve
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Results of Trauma to Spine
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pediatric Spinal Injury
Anatomical Considerations
– Flexibility
– Large head size
Children are at risk for the same sort of
injuries as adults
– Harder to detect due to anatomical considerations
SCIWORA
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Spinal Injury Patient
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Spinal Injury Patient
Scene Size-up
–
–
–
–
Evaluate MOI
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Spinal Injury Patient
Initial Assessment
– Take 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Spinal Injury Patient
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Spinal Injury Patient
Rapid Trauma Assessment
– Focused versus rapid assessment
Suspected or likely spinal cord/column injury
Multi-system trauma patient
– Rapid Assessment
Neck
Deformity, pain, crepitus, warmth, tenderness
Bilateral extremities
Finger abduction/adduction
Push, pull, grips
Motor and sensory function
Dermatome and myotome evaluation
Hold-up position
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Clearance Protocol
Spinal clearance protocols are based upon a
protocol used in emergency departments
There are several derivations of these
protocols, but all have common features
Always use the protocol mandated by your
EMS system medical director
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Clearance Protocol
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Spinal Injury Patient
Ongoing
Assessment
– Recheck elements
of initial assessment
– Recheck vital signs
– Recheck
interventions
– Recheck any
neurological
deviations
© Craig Jackson/In the Dark Photography
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
Spinal Alignment
–
–
–
–
Move patient to a neutral, in-line position
Hips and knees should be slightly flexed
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
Manual Cervical Immobilization
– Seated Patient
Approach from front
Assign a caregiver to hold gentle manual traction
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cervical Stabilization
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
Cervical Collar Application
– 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
– 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Spinal Motion Restriction
Click here to view an animation on c-spine.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
Standing Takedown
–
–
–
–
–
–
–
–
–
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Movement of the
Spinal Injury Patient
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
Consider the final positioning of the patient
prior to beginning move
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Movement of the
Spinal Injury Patient
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
Medications and Spinal Cord Injury
– Steroids
Routine use of steroids for the treatment of spinal injury is
no longer recommended
If Used
Reduce the body’s response to injury
Reduce swelling and pressure on cord
Administered within first 8 hours of injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the
Spinal Injury Patient
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 Emergencies, 3/e
© 2009 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 Emergencies, 3/e
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ