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EMRG 1130 > Module 19- Spinal Injuries and Assessment > Flashcards

Module 19- Spinal Injuries and Assessment Flashcards

1
Q

Spinal injuries- mechanism of injury

A

Spinal injuries are classified by associated mechanism, location, and stability of the injury.

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2
Q

Vertebral fractures can occur…

A

with or without SCI

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3
Q

Stable fractures…

A

don’t involve the posterior column
- they poss less risk to the spinal cord

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4
Q

Unstable injuries…

A
  • involve the posterior column and include damage to the vertebrae and ligaments that protect the cord and nerve roots
  • Unstable injuries carry a higher risk of complicating SCI and progression of injury without appropriate treatment
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5
Q

What are flexion injuries?

A
  • Result from forward movement of head (usually from fast deceleration or a direct occipital blow)
  • Further down the spinal column, flexion forces are transmitted anteriorly through vertebral bodies
  • Results in anterior wedge fractures occur below this
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6
Q

What happens if a flexion injury occurs at C1-C2?

A

It can produce unstable dislocation with or without fracture

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7
Q

What are teardrop fractures?

A
  • Teardrop fractures are avulsion fractures of the anterior-inferior border of the vertebral body. These are hyperflexion injuries of significant force
  • These have potential for SCI
  • Can lead to unstable dislocation
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8
Q

What is rotation with flexion?

A
  • Only area mobile enough for it is C1-C2
  • Injuries are considered unstable due to its high cervical location and scant bony and soft-tissue support
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9
Q

When can rotation with flexion injuries occur?

A

Results from high acceleration forces

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10
Q

What ca a rotation with flexion injury produce?

A
  • Can produce stable dislocation in the cervical spine
  • In thoracolumbar spine, can fracture rather than dislocate
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11
Q

What is a vertical compression?

A
  • Transmitted through vertebral body and directed inferiorly through the skull or superiorly through the pelvis or feet
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12
Q

What can cause a vertical compression?

A
  • Can result from direct blow to the crown (parietal region) of the skull, or rapid deceleration from a fall via the feet, legs, and pelvis
  • Often produces a “burst” or compression fracture with or without SCI
  • May case disc herniation
  • SCI can occur if the vertebral body is shattered and bone embeds in the cord
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13
Q

What is hyperextension?

A
  • Hyperextension of the neck and head can result in fractures and ligaments
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14
Q

What can hyperextension cause?

A
  • Can be stable in flexion, but not in extension
  • May cause hangman’s (C2) fracture
  • Usually occurs in rapid declaration of skull, atlas, and axis as a unit
  • A teardrop fracture of the vertebral body can occur (anterior-inferior edge). Can be stable when the head is in flexion, but unstable in extension due to to loss of structural support
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15
Q

What are the two categories of spinal injuries?

A
  • Primary spinal cord injury: injury occurs at the moment of impact
  • Secondary cord injury
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16
Q

What causes primary spinal cord injury?

A
  • Injuries occur at the moment of impact
  • Often caused by penetration injury causing complete transection injury
  • Blunt injury produces compression if spinal cord
  • Hypoperfusion, tissue ischemia
  • Necrosis from prolonged ischemia, results in permanent function losses
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17
Q

What is included in a primary spinal cord injury?

A
  • Includes spinal cord concussion, contusion, and laceration
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18
Q

What is spinal cord concussion?

A
  • Temporary dysfunction of the spinal cord that lasts 24-48 hours occurs in 3-4% of SCIs
  • Considered an incomplete injury
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19
Q

What causes spinal cord concussion?

A
  • Caused by fractures, dislocation, or direct trauma
  • Edema, tissue damage
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20
Q

What is a cord laceration?

A
  • Occurs when a projectile or bone enters the spinal canal
  • Results in hemorrhage into cord tissue
  • Swelling
  • Disruption of some portion of the cord and its associated pathways
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21
Q

What is a secondary cord injury?

A
  • This injury occurs when multiple factors permit a progression of primary SCI
  • A cascade of inflammatory responses occurs
    Effects can be exacerbated by exposing neural elements (spinal cord and nerve roots) to further hypoxemia, hypoglycemia, and hypothermia
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22
Q

What are the classifications of spinal cord injuries?

A
  • Complete spinal cord injury
  • Incomplete spinal cord injury
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23
Q

What is a complete spinal cord injury?

A

Complete disruption of all tracts of cord, with permanent loss of all cord mediated functions below the level of transaction

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24
Q

What is a incomplete spinal cord injury?

A

Some degree of cord function remains

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25
Q

What is anterior cord syndrome?

A
  • Displacement of bony fragments into anterior cord
  • Flexion injuries or fractures
  • Paralysis below level of insult, with loss of sensation to pain, temp, and touch
26
Q

What is central cord syndrome?

A
  • Hyperextension injury to cervical area with hemorrhage and edema to central cervical segments
  • Rarely associated with fractures
  • Usually occurs with tears of anterior longitudinal ligament
  • Greater loss of function in the upper extremities than lower extremities
  • Prognosis is good with therapy
  • More commonly seen in elderly with severe spinal stenosis and/or spondylosis
27
Q

What is posterior cord syndrome?

A
  • Associated with extension injuries
  • Rare
  • Dysfunction of dorsal columns (Results in decreased sensation to light touch, vibration, and the ability to perceive the position and movement of one’s body)
28
Q

What is Brown-Sequard syndrome?

A
  • Associated with penetration trauma and complete damage to spinal cord tracts (hemisection of cord)
  • Motor loss on same side of injury below lesion level
  • Loss of sensation to light touch, proprioception, and vibration if dorsal column damaged
  • Damage of spinothalamic tracts causes loss of sensation of temperature and pain on the opposite side of the body.
29
Q

What is spinal shock syndrome?

A
  • temporary condition- swelling from trauma creates edema in spinal cord itself
  • Occurs immediately after spinal trauma
  • Swelling and edema of the cord within 30 mins can lead to disruption of nerve conduction distal to the injury
  • May present with variable degrees of acute spinal injury
  • Symptoms improve and resolve in hours or weeks
30
Q

What is neurogenic shock syndrome?

A
  • temporary loss of autonomic function that controls cardiovascular function
  • Marked hemodynamic and systemic reactions (hypotension, relative hypovolemia, bradycardia, warm red skin)
  • Hypotension due to absent or impared peripheral vascular tone
  • Blood pooling in enlarged vascular space
  • Absence of sweating
31
Q

What are the classic signs of neurogenic shock?

A
  • Hypotension
  • Bradycardia
  • Warm, flushed skin
  • Dry below the level of spinal lesion
32
Q

What is Spinal Cord Injury Without Radiographic Abnormalities?

A
  • Children have vertebrae that can dislocate and quickly relocate. Cord gets damaged but shows an aligned vertebral column
  • Cord can be transected or compressed
  • Only diagnosed in the ED. (MRI)
33
Q

Patient Assessment

A
  • Limiting progression of secondary SCI is a major goal
  • Have suspicion in an MOI that suggest possible SCI
  • Treat all patients who experience multiple trauma or those found unconscious after trauma as if a SCI exists
  • Any major trauma above clavicle level is considered an SCI risk
34
Q

What are the high risk mechanisms associated with SCI?

A
  • Motor vehicle collision velocity > 60km/h
  • Unrestrained occupant (mid/high speeds)
  • Vehicular damage intrusion of 30 cm or more
  • Fall from three times the patient’s height
  • Penetrating trauma near spine
  • Ejection from moving vehicle
  • Motorcycle collision . 30km/h with separation of rider from vehicle
  • Diving injury
  • Vehicle/ pedestrian or vehicle/bicycle collision . 10km/h
  • Other motor vehicle collisions (rollovers, death of another occupant in the same compartment, etc.)
35
Q

What is uncertain risk for spine injury?

A
  • Syncopal event in which the patient was seated or supine
  • Isolated minor head injury without positive mechanism for spine injury
  • Moderate to low velocity MVC
  • Patient involved in MVC with isolated injury with positive assessment for SCI
36
Q

What is the patient assessment for spinal injuries?

A
  • Determine the circumstances of the incident
  • Note the types of energy involved (degree of force, speed, trajectory, was there blunt or penetrating trauma?)
  • Determine if there was a torsion injury or any extreme motion of the neck
  • Note the height of fall
  • Note the exact injury time and any changes in patient presentation
  • In MVC, note restraints, positioning of pt, and degree of vehicle damages
  • Apply manual stabilization
  • Document suspected SCI noting area involved, sensation, dermatomes, motor function, and area of weakness
  • Communicate with the pt
    • If alert, ask them to hold still and tell them why
    • If unconscious, still communicate with the pt’s, they may hear you
37
Q

What is the scene assessment for SCI?

A
  • PPE, scene safety, need for ALS
  • Observe patient position, age, and gender
  • Determine if immediate life threats exist
  • Perform manual spinal stabilization
  • Determine LOC using AVPU initially
38
Q

What is the airway management for spinal injuries?

A
  • Open it; look in it
  • Suction or remove obstructions
  • Perform jaw thrust maneuver
  • Sterdous respiration= snoring
  • Consider use of OPA or NPA
    • An intact gag reflex= no OPA use
    • Basilar Skull Fracture= no NPA use
  • Orotracheal intubation if indicated
  • Log roll pt in case of vomiting
  • Follow up with suction
39
Q

What is the breathing management for spinal injuries?

A
  • Assess rate, depth, symmetry
  • Injuries may affect phrenic nerve (C3-C5), which can paralyze the diaphragm causing abdominal breathing and accessory neck muscle usage
  • Lower C-spine or upper T-spine injury can paralyze intercostal muscles
  • Oxygen via non-rebreather if resp are adequate
  • Any inadequate respiration patterns will require breathing assistance

Assisted breathing
- BVM device with 12-15 l/min oxygen at 10-12 breaths per minute (adult)
- If head injury is suspected use PCO2 monitoring to maintain CO2 levels at 34-45 mm Hg

40
Q

What is the assessment for circulation for spinal injuries?

A
  • Compare radial and carotid pulses (check rate, quality, regularity and equality)
  • Check skin color, temp, and moisture
  • No pulse: initiate CPR
  • Volume resuscitation: may be needed (multisystem trauma, hypovolemic shock)
  • Pure neurologic shock rarely needs fluid; may need vasolytic drugs (atropine) and vasopressors (dopamine) to reverse vagal stimulation and alpha receptor blockade
41
Q

What are the transport decisions?

A
  • Early decision: complete focused history and physical examination on scene or transport immediately and treat en route
  • Unstable or potentially unstable= transport ASAP to appropriate hospital (perhaps by air, if distance is great and time is short)
42
Q

What is the focused history & physical examination for spinal injuries?

A
  • Accurate H&P is critical in SCI injury
  • Reliability of patient a factor (distracting injury and emotion, Intoxication or drug use, Acute stress reaction)
  • If unreliable, err on the side of safety and immobilize
  • Baseline vitals, assess pupils, use SAMPLE and DCAP-BTLS
  • Distal PMS check to all extremities (pulse, motor, and sensory check)
  • Use AVPU and GCS for responsiveness evaluation and trends
43
Q

Placement on backboard

A
  • Perform a back assessment before securing the patient on backboard
  • Patient can be log rolled to visualize the neck and back
  • Look for pain, deformity, or step off
  • Try to minimize the number of times the patient must be moved
  • Palpate each individual vertebrae and allow time for the patient to respond
  • Protect any limbs that may be paralyzed or weak
  • Absence of pain or tenderness along spine, normal neurologic examination, and low risk MOI may eliminate immobilization need.
  • Skin breakdown is a problem with any time spent on a backboard
  • Some devices are made for seated patients
44
Q

What backboards can we use fir spinal injuries?

A
  • Fracture board
  • Scoop method: use of the scoop stretcher to lessen motion to patient
  • Back raft: low profile air mattress
45
Q

Detailed physical examination for spinal injuries:

A
  • Head to toe examination
  • Done to any patient with significant MOI
  • May be done en route to hospital
  • Special attention to head, face, and spine
  • Evaluate chest and abdomen for internal and external injury (palpate all quadrants and pelvis, assess for priapism)
  • Continually monitor cardiovascular system for shock
  • Neurogenic, spinal and hypovolemic shock are all possible
  • Palapte all extremities for deformity, contusions, abrasions, punctures, lacerations, and edema
  • Notice any posturing
46
Q

What muscle group does C3-C5 control?

A

Diaphragm

47
Q

What muscle group does C5 control?

A

Elbow flexors: biceps, brachilis, brachioradialis

48
Q

What muscle group does C6 control?

A

wrist extensors

49
Q

What muscle group does C7 control?

A

Elbow extensors; triceps

50
Q

What muscle group does C8 control?

A

Finger flexors: flexor digitorum profundus to middle finger

51
Q

What muscle group does T1 control?

A

Hand intrinsics: interossei, small finger abductors

52
Q

What muscle group does T2-T7 control?

A

Intercostal muscles

53
Q

What muscle group does L2 control?

A

Hip flexors: iliopsoas

54
Q

What muscle group does L3 control?

A

Knee extensors: quadriceps

55
Q

What muscle group does L4 control?

A

Ankle dorsiflexors: tibialis anterior

56
Q

What muscle group does L4 control?

A

Ankle dorsiflexors: tibialis anterior

57
Q

What muscle group does L5 control?

A

Long toe extensors: extesnor halluces longus

58
Q

What muscle group does S1 control?

A

Ankle plantar flexors (gastrocnemius soleus)

59
Q

What muscle group does S4-S5 control?

A

Anus, bowel, bladder

60
Q

What is the ongoing assessment for spinal injuries?

A
  • Monitor vitals every 5 mins in unstable pt’s
  • Stable pt’s should have vital monitored every 15 mins
  • Pay special attention to the cardiovascular status of patient
  • Monitor hypotension with a normal to slow pulse and warm skin= possible neurogenic shock
  • May also show flaccid paralysis and complete sensation loss below injury level
  • Hypovolemic shock= tachycardia and pale, cool, clammy skin
  • Check oxygen flow and spinal immobilization for effectiveness often

EMRG 1130 (13 decks)

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