Trauma: skull, brain, vascular trauma, spinal cord, nerve trauma Flashcards
When should cord injury be assumed?
- Significant falls (>3m)
- Decceleration injuries
- Blunt trauma to head / neck / back
When can cauda equina syndrome occur?
With any spinal cord injury below T10.
Types of spinal cord injuries?
- Complete / incompete transection
- Cord oedema
- Spinal shock
Hx in ?spinal trauma?
- AMPLE
- ?neck pain / paralysis / paresthesia
Exam in ?spinal trauma workup?
- ABCDE
- Abdo: ecchymosis, tenderness
- Total neuro
- Spine: maintain neutral position, palpate C spine; logroll, then palpate Tspine and L spine, assess rectal tone
- Extremities: cap refill, suspect thoracolumbar injury with calcaneal #
What should be assessed for when palpating spine in examination?
- Tenderness
- Muscle spasm
- Bone deformities
- Step off and spinal process malalignment
Imaging in ?spinal injury?
- Full C spine X ray series for trauma (AP, lateral, odontoid)
- Thoracolumbar Xrays (AP and lateral)
- Consider CT, MRI
What are the indications for thoracolumbar X-rays?
- Pt w/ C spine injury
- Unconscious pts
- Pts w/ neurological sx/signs
- pts with palpable deformities on log roll
- pts w/ back pain
- pts w/ bilateral calcaneal #
When can C spine be cleared?
Can clear C spine if:
- no posterior midline cervical tenderness
- no evidence of intoxication
- oriented to P/P/T/E
- no focal neurological deficits
- no painful distracting injuries (e.g. long bone #)
Mx of spinal cord injury?
- Immobilise
- ABCs
- Treat shock
- Insert NGT and Foley catheter
- High dose steroids
- Complete imaging of spine
- Continually reassess high cord injuries (oedema can travel up cord)
- Watch for resp insufficiency if C cord injury
- Warm blanket, volume infusion, ?vasopressors
Sequelae of acute phase SCI?
- Spinal shock
- Neurogenic shock
What is spinal shock?
Absence of all voluntary and reflex activity below level of injury (decreased reflexes, no sensation, flaccid paralysis below level of injury)
What is neurogenic shock?
Loss of vasomotor tone, SNS tone. Occurs w/in 30min of SCI at level T6 or above.
Watch for: hypotension (no SNS), bradycardia (unopposed PNS), poikilothermia (no SNS so no shunting of blood from extremities to core)
What are the high dose steroids used in SCI?
-Methylprednisolone 30mg/kg bolus
Then 5.4mg/kg/h drip within 6-8h or injury.
What are the types of spinal #?
- Compression # (58%)
- Burst # (17%)
- Flexion distraction injury (6%)
- Fracture dislocation (6%)
Features of spinal compression #?
- Produced by flexion
- Posterior ligament complex remain intact
- Stable but produce kyphotic deformity
What is the posterior ligament complex?
- Supraspinous and interspinous ligaments
- Ligamentum flavum
- Intervetebral joint capsule
What are the features of spinal burst #?
Stable: anterior and middle columns parted with bone retropulsed nearby
Unstable: same + posterior column disruption (usually ligamentous)
What are the hallmarks of burst fracture on Xray?
Pedicle widening on AP XR
What is flexion distraction injury?
Hyperflexion and distraction of posterior elements (middle and posterior columns fail in distraction)
Classic = chance: horizontal fracture through posterior arch, pedicles, posterior vertebral body
What is fracture dislocation?
Anterior and cranial dislocation of superior vertebral body --> 3 column failure. 3 types: -flexion rotation -flexion distraction -shear/hyperextension
