Module 19- Spinal Injuries and Assessment Flashcards
Spinal injuries- mechanism of injury
Spinal injuries are classified by associated mechanism, location, and stability of the injury.
Vertebral fractures can occur…
with or without SCI
Stable fractures…
don’t involve the posterior column
- they poss less risk to the spinal cord
Unstable injuries…
- 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
What are flexion injuries?
- 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
What happens if a flexion injury occurs at C1-C2?
It can produce unstable dislocation with or without fracture
What are teardrop fractures?
- 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
What is rotation with flexion?
- 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
When can rotation with flexion injuries occur?
Results from high acceleration forces
What ca a rotation with flexion injury produce?
- Can produce stable dislocation in the cervical spine
- In thoracolumbar spine, can fracture rather than dislocate
What is a vertical compression?
- Transmitted through vertebral body and directed inferiorly through the skull or superiorly through the pelvis or feet
What can cause a vertical compression?
- 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
What is hyperextension?
- Hyperextension of the neck and head can result in fractures and ligaments
What can hyperextension cause?
- 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
What are the two categories of spinal injuries?
- Primary spinal cord injury: injury occurs at the moment of impact
- Secondary cord injury
What causes primary spinal cord injury?
- 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
What is included in a primary spinal cord injury?
- Includes spinal cord concussion, contusion, and laceration
What is spinal cord concussion?
- Temporary dysfunction of the spinal cord that lasts 24-48 hours occurs in 3-4% of SCIs
- Considered an incomplete injury
What causes spinal cord concussion?
- Caused by fractures, dislocation, or direct trauma
- Edema, tissue damage
What is a cord laceration?
- 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
What is a secondary cord injury?
- 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
What are the classifications of spinal cord injuries?
- Complete spinal cord injury
- Incomplete spinal cord injury
What is a complete spinal cord injury?
Complete disruption of all tracts of cord, with permanent loss of all cord mediated functions below the level of transaction
What is a incomplete spinal cord injury?
Some degree of cord function remains
What is anterior cord syndrome?
- 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
What is central cord syndrome?
- 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
What is posterior cord syndrome?
- 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)
What is Brown-Sequard syndrome?
- 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.
What is spinal shock syndrome?
- 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
What is neurogenic shock syndrome?
- 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
What are the classic signs of neurogenic shock?
- Hypotension
- Bradycardia
- Warm, flushed skin
- Dry below the level of spinal lesion
What is Spinal Cord Injury Without Radiographic Abnormalities?
- 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)
Patient Assessment
- 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
What are the high risk mechanisms associated with SCI?
- 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.)
What is uncertain risk for spine injury?
- 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
What is the patient assessment for spinal injuries?
- 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
What is the scene assessment for SCI?
- 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
What is the airway management for spinal injuries?
- 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
What is the breathing management for spinal injuries?
- 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
What is the assessment for circulation for spinal injuries?
- 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
What are the transport decisions?
- 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)
What is the focused history & physical examination for spinal injuries?
- 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
Placement on backboard
- 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
What backboards can we use fir spinal injuries?
- Fracture board
- Scoop method: use of the scoop stretcher to lessen motion to patient
- Back raft: low profile air mattress
Detailed physical examination for spinal injuries:
- 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
What muscle group does C3-C5 control?
Diaphragm
What muscle group does C5 control?
Elbow flexors: biceps, brachilis, brachioradialis
What muscle group does C6 control?
wrist extensors
What muscle group does C7 control?
Elbow extensors; triceps
What muscle group does C8 control?
Finger flexors: flexor digitorum profundus to middle finger
What muscle group does T1 control?
Hand intrinsics: interossei, small finger abductors
What muscle group does T2-T7 control?
Intercostal muscles
What muscle group does L2 control?
Hip flexors: iliopsoas
What muscle group does L3 control?
Knee extensors: quadriceps
What muscle group does L4 control?
Ankle dorsiflexors: tibialis anterior
What muscle group does L4 control?
Ankle dorsiflexors: tibialis anterior
What muscle group does L5 control?
Long toe extensors: extesnor halluces longus
What muscle group does S1 control?
Ankle plantar flexors (gastrocnemius soleus)
What muscle group does S4-S5 control?
Anus, bowel, bladder
What is the ongoing assessment for spinal injuries?
- 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
