spinal injury in sport Flashcards
The challenges of transitioning to SMR concepts “Spinal Motion Restriction” included:
geographic variations *
medico-legal issues
* health policies
* resistance to change * risk tolerance
* historical and cultural perspectives.
As sideline healthcare professionals our goals are to
provide the best appropriate care possible
- be familiar with current literature findings
- adapt skill sets
- embrace change for the sake of athlete health and safety.
T/F “First Aid Providers” should not use immobilization devices because their benefit has not been proven.
T
Is For first aid providers, the routine application of cervical cervical is recommended.
no
what first aid provider are recommend to do in a suspected cervical spine injury
t is recommended to manually support the person’s head in a position limiting angular movement until more advanced care arrive”
in special circumstance what can be use for extrication by trained HCP
traditional immobilization
correct application of cervical collar would require
require training, regular practice and the ability of the first aid provider to distinguish between high risk and low risk injuries
Long backboard use has been shown to cause and lead to the following:
Agitation and anxiety
* Altered physical examination
* Delay in treatment, time consuming to apply
* Increased cranial pressure (collar)
* Painful (>30 min)
* Pressure sores (usually less than 1 hour)
* Airway and Respiratory compromise, risk of aspiration
* Unnecessary radiographs
* Expensive to buy, maintain, train
* Does not usually achieve neutral spinal alignment …
It is the position of International Trauma Life Support that
- Spinal motion restriction (SMR) is not indicated in every trauma
patient. - The long spine board and other rigid devices are primarily
extrication devices designed to move a patient to a transport stretcher. Having the patient remain on the board for prolonged periods can produce discomfort, pressure sores and respiratory compromise. - In order to minimize these negative occurrences, patients should be removed from the long spine board as soon as it is safe and practical to do so. 4. Maintenance of in-line spinal alignment when moving the patient and appropriately securing them to the transport stretcher remain important components of SMR.
- SMR should be applied appropriately to those patients who have indicators that they may have sustained or are at high risk for spinal injuries, or who cannot be adequately
assessed clinically for the presence of such injuries. Providers should apply the appropriate guideline in these situations and apply a rigid cervical collar and other rigid devices as clinically appropriate. - Spinal Motion Restriction onto a long board is not indicated in penetrating wounds of the torso, head or neck unless there is clinical evidence of a spinal injury
the spine board is an excellent _ device
extraction
Overall, _% of the patients developed pain within the 30-minute observation period, and _% graded their pain as moderate or severe. Of these, _% developed additional symptoms over the next 48 hours.”
100, 55, 29
t/f.The prolonged immobilization is often unnecessary and adds to the burden of already overtaxed emergency medical services systems and crowded emergency departments.
T
Canadian C-spine rule
- any high-risk factor
age >/= 65
dangerous mechanism
paresthesias in extremity
-> if no move to step 2, if yes immobilize - low-risk factor
- simple rear end MVC
- ambulatory at any time
- delayed onset of neck pain
- absence of middling
c-spine tenderness
-> if yes move to #3, if no immobilize - able to actively rotate neck 45º left and right
-> if unable immobilize
what are some dangerous mechanism of C-spine rule
fall from elevation >/+ 3 feet/5 stairs
axial load to head
high speed MVC
motorized recreational vehicle
bycile struck or collision
what are simple rear end MVC exclude of C-spine rule
pushed into oncoming traffic
hit by bus/large truc
rollover
hit by high speed vehicule
Sports Medicine Responder ROLE
BETTER SPINAL ASSESSMENT & SCREENING IN THE FIELD TO PREVENT UNNECESSARY HOSPITAL TRANSFERS.
❑APPROPRIATE SPINAL MOTION RESTRICTION PRINCIPLES WITH SUSPECTED SPINAL INJURED ATHLETES.
❑EXPERTISE WITH PROTECTIVE SPORTS EQUIPMENT REMOVAL BEFORE TRANSPORT TO A MEDICAL FACILITY.
C1-C2 do _% rotation
C3-C6 do _% rotation
58
24
C3 spinal cord occupied _ % of canal
Lumbar spinal cord occupies _ % of canal
95
65
C3 have _mm clearance of cord in canal
3
C2-C5 have which nerve involvement
phrenic
The spine can normally withstand forces of up to _ ft-lbs of energy. Contact sports can cause forces in excess of this.
1000
are burner/stinger spinal
Not spinal, but unilateral peripheral nerve (compressive or tensile).
what is neurogenic shock
Secondary to spinal cord injury:
* *
Lesion to vaso-regulatory fibers which
produce loss of sympathetic tone to vessels (vaso-dilation) below level of lesion.
s/s neurogenic shock
S/S: skin warm / dry Pulse will be slow
BP will be low
* Produces relative hypovolemia
… may cause hypo-perfusion
what is spinal shock
Lasts variable time period after spinal cord injury
* Loss of all sensory/motor fcn, flaccidity, paralysis
* Loss of reflexes below level of spinal injury
* Usually caused by penetrating type or bony #
* Severity depends am’t bleeding into tissues
* Damage / disruption of spinal cord blood supply
can result in local cord tissue ischemia
what are burner
Are not “spinals”, but peripheral nerve injuries
s/s burner/stinger
-burning that usually begins in the shoulder and radiates “unilaterally” into the arm and hand.
-weakness, numbness or both are occasionally associated with in a C5-C6 nerve root distribution.
-recovery usually occurs in minutes, but some S/S can last for for days/ weeks if recurrent condition
MOI of stinger/burner
- Compressive mechanism when head and neck are forcibly
moved into postero-lateral direction toward symptomatic upper limb. - Tensile mechanism occurs when involved arm and neck are forced in opposite directions.
Both mechanism are more of a cervical radiculopathy that a brachial plexopathy. (as the cervical nerves are more fragile)
differentiation of burner stinger
burners are usually unilateral, spinals lesion involve both arms Mechanism of injury is paramount to proper diagnosis
what are some specific MOI of spinal injury
AXIAL LOADING (most common in sport) EXCESSIVE FLEXION
EXCESSIVE EXTENSION
EXCESSIVE ROTATION
EXCESSIVE SIDEBENDING DISTRACTION
assessment of spinal
- Approach athlete from the front,
- ask athlete not to move, 3. stabilize the head manually.
- Proceed slowly right after the injury as the athletes response to stress may release endorphins blocking pain. Stress can also lead to making poor decision makings.
what are the X-ray spinal criteria
Meet all low-risk criteria
1. No posterior midline cervical-spine tenderness
2. No evidence of intoxication
3. A normal level of alertness 4. No focal neurologic deficit
5. No painful distracting injuries
-> yes = no radiography, no= radiography
what is the most common cause of shooting pain immediately after a traumatic event
Pressure on the spinal cord or spinal nerves due to a spinal fracture
what are you testing for sensation and why
Evaluate perception of light touch (soft touch) and pain (pin prick) as these two sensations are carried in different spinal tracts.
* Ascending nerve tracts for pain cross-over in spinal cord, those for light touch do not.
why do check the sensation of dorm of hand or foot with spinal injury
Check on dorsum of hand or foot to see if they can distinguish between these sensations.
* If they can’t, it is a possible sign of partial cord injury.
T/F Full dermatome/myotome assessment best left for field clinic or hospital
T
palpation for spine injury
Palpate firmly along the spine, sharp pain is typical of a fractured vertebrae.
* Clinically significant pain would be felt within a 1” swath over SP. (ie: 1⁄2” width on either side).
limb strength for spinal
Examine and gently compare strength in each hand, they should be equal.
* Perform same gentle test for feet.
* A noticeable difference in strength between sides may be due to pressure from a fractured vertebrae.
when do you AROM of c-spine
f cervical was suspect and all above tests negative, have athlete slowly and actively rotate head left and right.
* They should be able to rotate at least 45° without difficulty.
* Stop if pain or symptoms appear.
at which step of spinal eval a spinal is highly unlikely
when you are at the point where you test RROM
can test RROM with a spinal eval
If cervical was suspect and all above tests negative including active range of motion, gently test athletes’ isometric neck strength.
* They should be able to exert (pain free) some pressure into the examiners hands.
delayed symptom in spinal injury are usually from
spinal cord edema and secondary hypoxia
when can you rule out a spinal
Usually…if an athlete is awake and cooperative, with
* No spine pain,
* No spine tenderness with palpation,
* No shooting pains,
* No noticeable weakness in their hands or feet,
* Able to distinguish between light touch and pin prick pain
They do NOT have an unstable spine.
* The athlete must also have no distracting injury, or spinal shock signs in order to consider a suspected spinal rule out valid.
can head strap could be crossed
no
is thorax always need to be secure with extrication
not always necessary with short duration extrication
type of cervical stabilization device
Mechanical blocks with velcro (ie: Ferno CID)
* Blanket sausage roll
* Two towel rolls
* Two pool noodle rolls
* Disposable head stabilizers
where do you place head strap and collar strap
Head Strap: across supra-orbital ridge
* Collar Strap: across collar (just below collar chin support)
which type of strap is not used in aquatic rescue milieu
There is no “chin strap” as used in aquatic rescue milieu
what are the 2 techniques of scoop stretcher
double clam shell
single clam shell
*Spinal board now used mostly for_
*Spinal board now used mostly for extrication (removal from playing surface/danger)
what do you need to avoid with cervical collar
Avoid techniques that cause cervical distraction -cervical collars that are too tall
which other technique do you need to avoid for cervical distraction
Avoid techniques where head and torso not stabilized at same time:
-standing take-down
-four-point take down
-SMR stabilization for extrication/transport
why do we avoid over-size collar
internal decapitation
why do we avoid too tight cervical collar
internal jugular compression
T/F cervical collar fully immobilize
F , Does not fully immobilize: flexion by 90%, other ranges by 50%
collar may have more disadvantage than merit why
impede pulse check, mouth opening, airway maintenance, airway access, vessel compression, etc…
collar may be applied in which position
spine, seated, standing
how do you prepare cervical collar
Stored flat in protective case
* Prepared before use
* Pre-form anterior portion (careful)
* Pre-form posterior portion segments
(bend distal segment for small neck)
how do you measure cervical collar
Measure from trap to bottom of chin * Choose 1 size smaller than measured
how do apply for sitting and standing cervical collar
Pre-form anterior/posterior portions of collar
* Hold anterior collar preformed in one hand
* Place over neck/under chin
Align collar with center of sternum
* Align Velcro and secure comfortably
* NOT TOO TIGHT- may compress internal jugular
Mouth should be able to open 2-3 finger widths NOT TOO TALL – may cause cervical distraction
application of cervical collar supine
Measure from trap to bottom of chin
* Choose 1 size smaller than measured
* Fold over Velcro strap
* Slide posterior portion under neck/head
* Extend anterior portion around and under chin
* Align Velcro strap and secure comfortably
around anterior neck.
* NOT TOO TIGHT- may compress internal jugular
Mouth should be able to open 2-3 finger widths
* NOT TOO TALL – may cause cervical distraction
which supine extrication option is better
supine scoop. least amount of movement
which supine extrication require less rescuers
supine log roll
advantage/disadvantage of supine log roll
More movement than
lift & slide (L&S) Requires fewer rescuers. LR-5, LR-4. LR-2
which technique between supine log roll or supine life & slide is better
supine lift and slide
which technique of extrication do we use with an athlete supin in tight space or on uneven surface
Supine Straddle-Lift & Slide
when do you use single clam scoop stretcher
on ice surface -> attach at head, close halves
when do you use double clamp scoop stretcher
on turf or grass
how to use scoop stretcher double clam
Athlete collared, measure scoop length allowing 2-3” space at each end, separate in 2 halves.
Place one half at a time. R2,R3,R4 perform minimal “unweighing” roll. Attach head then feet. Occiput support/padding or foam roll craddle
how to do prone log roll (4 or 7 person)
Prone to supine in 2-steps
Torso brought to sideline, head now in neutral Short “pause”, ready for roll to supine
Option: 3 more people to assist 2nd part of roll
* useful with heavy athletes
R1- on knees, slightly to side towards roll
R2,R3,R4 -lunge position on board
R1- rotates head slower than torso to arrive neutral Pause when on side to ensure minimal movement Option: R5,R6,R7 may assist during downward roll
T/F take down with board has been discontinued
T
how to do standing take down (2-person)
Ask athlete not to move head
R1 -Stabilize from front with trap/head hold
R2 -Retrieves collar and stabilizes from back with trap head hold
R1 -Measures and applies collar, asks R2 to slowly release head/trap hold
R1 & R2 assists athlete to seated position using a cross hip/trunk hold (not arm)
Slowly guide athlete to stretcher or down to floor.
Stretcher: sit to stretcher, assist seated pivot, place trunk on upright stretcher, recline back Floor: R1- Apply ant (thorax), Post (spine) support and assist to supine, R2 helps guide thorax
R2- Applies trap/head support towards end of descent, applies head hold once supine
Head is “_” stabilized first, but _stabilized last
manually
mechanically
technique to re-positioning on board
PHTLS: lateral then vertical ITLS: V-slide
