Spinal Injury Flashcards
Pitfalls of spinal immobilisation:
NO EVIDENCE to demonstrate a reduction in neurological injury, even when unstable # present
—> Doesn’t actually immobilise the spine!
HARMS:
Increased pain/ distress
Hides neck/ injuries
Interferes with intubation
Increases ICP (collar)
Aspiration
Restricts ventilation
May force into unfavourable position
Creates false positive midline tenderness
Pressure sores
APPROACH:
- Add or change to in-line manual/ sandbags ASAP
- Remove backboard ASAP
- Aim to clear ASAP
Cspine immobilisation methods:
Hard collar
Soft (Philly) collar
Sandbags
Blocks
Strapping
In-line manual stabilisation
Vac Pac
Algorithmic approach to clearing Cspine:
Canadian C spine tool:
Any HIGH risk features?
-Sixty five, fast drive, sensory deprived?
Any LOW risk features?
-Slow wreck, slow neck. Sitting down, walking round. Cspine fine? Range the spine!
Able to rotate 45deg?
-Look both ways? Then hit the road!
Age 16+ only
NEXUS C Spine tool:
more like what we do naturally:
Clear if no:
Reduced consciousness
Intoxication
Distracting injury
Midline tenderness
Focal defecit
OKAY FOR KIDS!
Compare NEXUS and Canadian C Spine rules:
Both are very sensitive
Both determine imaging vs no imaging but NOT xray vs CT..
However, CANADIAN has better diagnostic accuracy
NEXUS is still good, just not quite as good.
It is easier
It can be used in kids!!
It doesn’t exclude elderly, but sensitivity drops ++ after age 65 (so maybe it should..)
Features of SPINAL shock:
Reversible loss of motor, sensory and autonomic cord function below level of injury
Cannot determine whether sacral sparing is present during spinal shock (will be absent).
SNS loss, PNS predominance
- Flaccid, paralysis
- Absent reflexes
- Anaesthesia
- Urinary retention, fecal incontinence
- Ileus
- Loss of thermoregulation
….will either see this recover over 3 weeks, or persist, in which case not spinal shock but permanent deficit
At what spinal level is there a risk of neurogenic shock?
T6 and above
(Usually higher thoracic)
The higher the injury, the more profound the shock.
Features of NEUROGENIC shock:
T6 or higher
Vasodilatory, vasoplegic shock. Sympathetic loss with unopposed vagal.
Brady, warm and flushed, priapism
- Careful filling
- Noradrenaline
- Atropine
Important deficits in SCI at various spinal levels:
C3- Neck movement
C5- Diaphragm
T6 - Neurogenic shock
T1- Arms
L5- Legs
Neurological assessment of spinal cord injury:
- Motor, reflexes, sensation (MUST INCLUDE pain, temp, proprio)
- Anal sensation/ tone
- Perianal sensation/ tone
- Priapism
- Bulbocavernosis reflex
True levels can not be determined until 72 hours*
1- Cord Syndrome?
2- Sensory Level Left&Right
–> Pinprick + light touch
–> Level = where normal
3- Motor Level Left&Right
–> Level = where *grade 3** at least (against gravity).
4- Neurological level
–> Where BOTH normal sensation + grade 3 motor exist bilaterally
5- ‘Completeness’
–> If there is sacral sparing= incomplete.
APPROACH to suspected SCI:
- ATLS
–> Haemorrhage may be masked: no PR rise - Treat bradycardia with atropine
- Treat neurogenic shock with norad to MAP >85
- Intubate C5 or higher (or compromised/ FVC <15ml/kg). Avoid sux >72h
- Assess for evidence of SCI
–> Motor, sensory, reflexes
–> Bradycardia, loss of sweat, Horner’s
–> Perianal/ anal, bilbucavernosis
–> Priapism - Assess motor, sensory and neuro levels and for cord syndromes
- Assess completeness
- CT +/- MRI
-
Secondary prevention
–> Normophysiology
–>MAP > 70
–> NO STEROIDS in ED - Art line, NGT, IDC, pressure care
For COMPLETE TRANSECTION cord syndrome:
- Clinical features
- Peculiar causes
- Flaccid paralysis
- No reflexes
- No sensation
Transverse myelitis
Infarct
Stab
For BROWN-SEQUARD (hemisection) cord syndrome:
- Clinical features
- Peculiar causes
- Ipsilateral loss of motor and PROPRIO
- Contralateral pain and temp loss
Light touch is preserved!
Unilateral compression
For CENTRAL cord syndrome:
- Clinical features
- Peculiar causes
think: WEAK HANDS
- Motor > sensory
- Upper limbs > lower limbs
- Distal > proximal
- Bladder
Elderly with hyperextension
Syringomyelia
Canal stenosis
