Potential Spinal Trauma

Question 1

Potential Spinal Trauma - Definition

Answer 1

Potential injury to spinal column as a result of any force applied to the head, neck or spine

Question 2

Goal of Care

Answer 2

Protect against further injury; transport

Question 3

Overview

Answer 3

Safe management of potential spinal trauma is a basic expectation of pre-hospital care
The fragility of pts w/ spinal inj and the risk of worsening the inj are legitimate concerns.
Spinal trauma accompanies approximately 12% of serious trauma and may be present in lesser degrees w/ even minor trauma
The cervical spine is the most often inj segment

Question 4

Nexus Rules

Answer 4

Simplified Nexus Rules - as taught in ITLS and outlined in the Evolving Practices in Trauma Care on-line course describe pt in whome gentle care but no specified Spinal Motion Restriction (SMR) devises/techniques are required. Previously BCEHS used Canadian C-spine Rules (CCR) to define thses pts; however, the NEXUS criteria are now being utilized for C-spine inj clearnace

Pts w/ suspected thoracic and lumbar spine injs are usually assessed by mechanism and signs and symptoms; their management is outlined in the Evolving Practices in Trauma Care course

Question 5

Patients at Higher Risk for Spinal Trauma

Answer 5

1. Elderly pts, who are prone to spinal inj due to loss of soft tissue mobility, spinal fragility and pre-existing spinal cord narrowin. This is particularly common w/ falls from standing height to the face/frontal region in this group
2. Special situationis such as falls w/ axial load
3. Penetrating trauma usually requires rapid transport. Delays caused by spinal immobilization increase mortality
4. Pts w/ ALOC or intoxication that confounds assessment and makes pt cooperation difficult
5. Pts of any age w/ spinal mobility issues including prior fracture and conditon such as ankylosing spondylitis or rheumatoid arthritis
6. Pt w/ painful distracting injs

Question 6

Guiding Principles - Basic Principles of Immobilization

Answer 6

1. Follow fundamental trauma principles including minimizing scen times.
   Immobilization may range from simple stabilization in the mutlti-trauma pt requiring immediate rapid transport, to the quick and efficient full immobilization of the pt w/ an isolated spinal cord inj
2. Appropriate gentle handling of pts w/ potential spinal trauma
3. Awareness of risks of spinal immobilization including airway compromise, respiratory restriction, pressure ulcers, decreased cardiac output, vomiting/aspiration, increased intracranial pressure, pain, increased scene time and more complicated ER management
4. Spinal immobilzation of uncooperative pts can be difficult to achieve and standard immobilization alone may not be enough. Attempts to maintain spinal immobilization may need to be individualized and must be well documented
5. Document details of the inj and examination focusing on motor and sensory changes, parasthesias, along w/ signs of spinal tenderness/pain, or conditions that would preclude a physical examination

Question 7

Isolated Spinal Cord Injury

Answer 7

Isolated spinal cord inj - may be known or highly suspected in pts in the absence of major multi-system trauma. This is seen most in the setting of sports, recreation or work based inj.
High cervical lesions may prevent further damage or conversion of a recoverable situation to a permanent one as well as ensuring breathing mechanics and reducing chances of pressure related inj
Signs of other injury and internal bleeding may be masked so scene times must be as short as possible

A focused neurological exam including motor, and ligt and sharp touch sensation can help receiving physicians evaluate evolving injury

Question 8

Neurogenic Shock

Answer 8

Neurogenic shock - may be present - hypotension coupled w/ bradycardia may be part of the injury pattern
Treat in accordance w/ the treatment guideline for shock. Severe bradycardia w/ hypoperfusion may be treated in consultation w/ CliniCAll. Target BP 120 systolic or great if clear signs of acute neurologic deficit

Question 9

Poly Trauma

Answer 9

For poly trauma pts. aim for a target SBP of 90, however, if you are concerned about concomitant spine and brain injs, call CliniCall for further BP target goals

Question 10

Nexus Criteria

Answer 10

1. Is there midline tenderness?
2. Is there an altered LOC?
   - Must be alert and oriented x 4
3. Are there new focal neurological deficits?
4. Are they intoxicated?
   - Judgment and pain sensations must be intact
5. Is there a major distracting injury?
   - Significant enough to interfere w/ their ability to assess pain response when palpating spine

No to ALL FIVE questions - SMR is not warranted

Question 11

Intervention Guidelines - EMR/PCP/ACP

Answer 11

EMR
SMR

PCP/ACP
Treat nausea/vomiting
- Dimenhydrinate

Correct hypoperfusion- hypotension

• NS 500mL up to 2L - reassess BP/lungs every 500
• Target BP is 70-90 systolic (or to mentation) if suspected SPINAL COLUMN trauma
• Target BP of 120 systolic if suspected CORD inj

Question 12

Further Care

Answer 12

Vasopressors to target BP