ch 32: spinal cord injury

Helmets

-First, assess the patient wearing the helmet. ▪Assess the patient's mental status. ▪Assess the patient's airway and breathing. ▪Assess the fit of the helmet and the likelihood of movement. ▪Determine your ability to gain access to the patient's airway. -Leave the helmet in place if: ▪The helmet fits well, and there is little or no movement. ▪No impending airway problems. ▪Helmet removal would cause further injury. ▪You can provide SMR with the helmet on. ▪It doesn't interfere with your ability to reassess airway and breathing. -Remove the helmet if it: ▪Interferes with your ability to assess or reassess airway and breathing. ▪Interferes with your ability to adequately manage the airway. ▪Does not fit well. ▪Interferes with spine motion restriction. ▪Patient is in cardiac arrest. -Helmet Removal ▪Two basic types of helmets: -Sports helmets -Motorcycle helmets ▪Face masks on football helmets can be removed by cutting the plastic clips. ▪Motorcycle helmets generally cover the full face and prevent access to the airway.

Tools for SMR

-Full Body Spinal Restriction Devices -Long Rigid Backboards ▪There are many hazards and harmful effects associated with placing a patient on a long rigid backboard. -Alternative Long Devices for Spine Motion Restriction ▪Vacuum mattress & scoop stretcher. -Short Spine Motion Restriction Devices ▪K.E.D. is most common. ▪These devices are rarely used. ▪Some EMS systems might make it part of their S MR protocol, so you need to be familiar with the proper use of this device -Other SMR Equipment ▪Head stabilization device and straps.

Spinal cord tracts

-Motor tracts carry impulses to the same side of the body. -Pain tracts carry impulses from the opposite side of the body. -Light touch tracts carry impulses from the same side of the body. Because light touch and pain are carried by different tracts, the patient might not feel light touch but can feel the pain of a pinch. This finding can be present if the spinal cord is partially injured.

SMR in Infants and Children

-Pad from the shoulders to the heels of an infant or child, if necessary, to maintain neutral in-line stabilization. -Make sure the cervical collar fits before applying it to an infant or child.

Assessment-Based Approach: Spinal Injury

-Primary Assessment ▪With mechanism of injury consistent with potential for spine injury: -Immediately provide in-line manual stabilization of the spine. -Use jaw-thrust maneuver to open airway. -Follow local protocols for spine motion restriction. ▪Perform manual stabilization of the spine based on mechanism of injury. ▪Maintain manual stabilization until a thorough assessment does not reveal indications for motion restriction, OR spine motion restriction has been accomplished. ▪Provide spine motion restriction on patients with positive mechanism of injury who: -Have an altered mental status -Have painful distracting injuries -Cannot effectively communicate with you ▪High-priority patients -Unresponsive -Responsive but unable to obey commands -Abnormal respiratory pattern -Obvious signs of spine injury -Secondary Assessment ▪Maintain in-line spinal stabilization. ▪Conduct a physical exam. ▪After assessing the neck, apply a cervical collar. ▪Assess pulses and motor and sensory function. -Say to the patient, "bend your arms at the elbows and place them across your chest." This flexion tests motor function at C6. -Say to the patient, "Straighten your arms, then bring them to either side of your body". This extension tests motor function at C7. -Say to the patient, "Spread your fingers out on both hands and don't let me squeeze them together." This abduction tests motor function at T1. -Support the patient's hand under the wrist and say to the patient, "Hold out both arms and don't let me push your hand down." This test assesses motor function at C7. -Place your hands on the top of the patient's feet and say to the patient, "Pull up against my hands with your feet." This plantar flexion tests motor function at the level of L5. -Place your hands under the patient's feet and say to the patient, "Push down against my hands with your feet." This dorsiflexion tests motor function at S1 and S2. -Assess pain and light touch in hands and feet. A cotton swab with a wooden stick can be used for checking both pain and light touch. Break the stick in half and use the jagged broken end to test for pain. Have the patient close his eyes. With the sharp end of the swab's wooden stick, poke one of his hands. When the patient grimaces, moans, or responds in some other way, ask, "Where does it hurt?" Repeat the test on the other hand and on each foot. -Have the patient again close his eyes. Lightly touch the patient's fingers on one hand, then the other. As you perform this test for light touch to the fingers, ask: •"Can you feel me touching your finger?" •"Can you tell me which hand and which finger I'm touching?" ▪Posterior exam - Log roll the patient with spine motion restriction maintained to assess the posterior body. Palpate the area of the spine gently. ▪Baseline Vital Signs -If the brain or spinal cord is damaged, vital signs might reflect neurogenic hypotension. -If the hypotension is severe and the patient has tachycardia, suspect bleeding as the cause of shock. ▪Signs and Symptoms: -Tenderness along the spine -Pain associated with movement -Pain independent of palpation or movement -Deformity of the spine on palpation -Soft tissue injuries -Numbness, tingling, weakness; loss of sensation or motor function -Loss of bladder or bowel control -Priapism -Impaired breathing ▪Assessment findings that are indications for spine motion restriction -GCS <15 -Suspected traumatic brain injury -Altered mental status -Pain or tenderness of spinal column -Paralysis, weakness, numbness, tingling

the ambulatory patient

1.Instruct the patient to hold his head and neck in a neutral in-line position and not to move it. When approaching the patient, do so from directly in front of them so that they remain focused forward and don't move their head and neck to the side to look at you. Immediately instruct the patient as you approach them to bring their head and neck in an in-line position by lining up their nose with their umbilicus and not to bend, rotate, extend, or flex their head or neck; they should bring their feet and toes together and in line with their umbilicus and nose. 2.Assess the patient for pain or tenderness. Ask them if they have any pain anywhere, especially in their neck or along their vertebral column. Palpate the posterior vertebral column gently. Determine if the patient has any tenderness or if you feel any abnormality to the bony structure. 3.Assess motor and sensory function in the upper extremities. Have the patient maintain self-restriction, and continue to look forward with their arms at their sides. Test motor and sensory function in both upper extremities following the neurologic assessment steps previously covered in the Physical Exam section. Ask the patient if they have any abnormal sensations such as tingling or numbness in the extremities or upper body. 4.Assess motor and sensory function in the lower extremities. Test motor and sensory function in both lower extremities, following the neurologic assessment steps. Ask the patient if they have any abnormal sensations such as tingling or numbness in the lower extremities or lower body. 5.The patient should be instructed to relax and allowed to freely move if they meet the following criteria; patient is reliable (GCS 15, no distracting injury, can communicate, not intoxicated or under influence of drugs); the patient has no pain, tenderness, or abnormality in the vertebral column; and the patient has no motor or sensory deficits or abnormal sensations; the spine has been "cleared"; and there is no need for any further spine motion restriction procedures. If the patient is to be transported, they could be placed directly on the stretcher mattress in a comfortable position.

Ferno Kendrick Extrication Device (K.E.D)

After a Cervical Collar has been Applied, Slip the K.E.D. behind the Patient and Center it (Position the short spinal device behind the patient. Examine the back carefully. Be careful that the EMT who is holding in-line spinal stabilization does not move excessively or move the patient as the device is positioned.) Properly Align the Device. Then Wrap the Vest around the Patient's Torso (You should slide the board behind the patient and as far into the seat as you can. The top of the board should be level with the top of the patient's head, and the bottom of the board should not extend past the coccyx. The body flaps should fit snugly under the patient's armpits.) When the Device is Tucked Well up into the Armpits, Secure the Chest Straps (Secure the device to the patient's torso. Make sure the straps are tight enough to prevent movement of the device, laterally and vertically.) Secure the Leg Straps (If the device has straps that circle the legs, apply and tighten these after the chest straps are applied.) Secure the Patient's Head with the Velcro Head Straps (Pad behind the patient's head to ensure neutral alignment of the head and neck with the rest of the spine. Secure the patient's head to the device. Maintain manual in-line spinal stabilization, even though the head is secured to the device. Securing the head is the last step in the application of the device.) Tie the hands together and pivot the patient onto the backboard while maintaining manual in-line spinal stabilization. Position a long backboard under or next to the patient's buttocks and rotate them until their back is in line with the backboard. If it is not possible to get a long backboard next to the patient, lift the patient under their arms and legs and lower them onto the long board. Release manual in-line spinal stabilization only when the patient is completely secured to the backboard. Assess pulses and motor and sensory function and record your findings on the prehospital care report.

Extrication from a Car Seat

Car seats involved in crashes may have lost integrity of the structure and might not provide protection for the child if another crash were to occur. Transfer the child to a backboard. In children less than 8 years of age, if any MOI suggests possible spinal injury, it is prudent to provide spinal motion restriction appropriate for the young child. EMT #1 Stabilizes the Car Seat in an Upright Position and Applies Manual Stabilization to the Child's Head and Neck EMT #2 prepares equipment, then loosens or cuts the seat straps and raises the front guard. A Cervical Collar is Applied to the Child as EMT #1 Maintains Manual Stabilization of the Head and Neck As EMT #1 Maintains Manual Stabilization, EMT #2 Places the Child Safety Seat on the Center of a Backboard and Slowly Tilts it into Supine Position. The EMTs are careful not to let the child slide out of the safety seat. For a child with a large head, place a towel under the area where the shoulders will eventually be placed on the board to prevent the child's head from tilting forward. EMT #1 Maintains Manual Stabilization and Calls for a Coordinated Long Axis Move Onto the Backboard EMT #1 Maintains Manual Stabilization as the Move Onto the Board is Completed with the Child's Shoulders over the Folded Towel EMT #1 Maintains Manual Stabilization as EMT #2 Places Rolled Towels or Blankets on Both Sides of the Child EMT #1 Maintains Manual Stabilization as EMT #2 Straps or Tapes the Child to the Board at the Level of the Upper Chest, Pelvis, and Lower Legs. Do Not Strap Across The Abdomen. EMT #1 Maintains Manual Stabilization as EMT #2 Places Rolled Towels on Both Sides of the Head & Then tapes the head securely in place across the forehead and cervical collar. Do not tape across the chin to avoid pressure on the neck.

Central Cord Syndrome

results from injury to the central cord -The medial portion of the motor and pain tracts control the upper extremities. -The lateral portions of the tracts control the lower extremities. -In central cord syndrome, the medial portion of the spinal cord is injured. In central cord syndrome, the patient presents with a loss of motor function or weakness and loss of pain sensation to the upper extremities while motor and sensory functions remain normal in the lower extremities.

Brown-Séquard syndrome

results from injury to the right or left half of the cord -The injury affects only one side of the cord. -Loss of motor and light touch sensation on the affected side. -Loss of pain sensation on the side opposite the injury. In Brown-Séquard syndrome, the patient loses motor function and light touch sensation on one side of the body while retaining pain sensation on that same side. On the opposite side of the body, the patient retains motor function and light touch sensation while losing pain sensation.

anterior cord syndrome

syndrome results from injury to the anterior cord -Loss of function in motor and pain tracts, but not in light touch tracts. -The patient experiences paralysis and inability to feel pain below the level of injury, but can detect light touch. In anterior cord syndrome, the patient loses the ability to feel pain and crude touch below the site of injury and likely experiences the loss of motor function below the injury site. However, the patient retains the ability to feel light touch above and below the site of injury.

SMR techniques vary widely; they might include any of the following:

•Application of a soft cervical collar and the patient secured to the ambulance mattress. •Application of a rigid cervical collar and the patient secured to the ambulance stretcher. •Application of a cervical collar and the patient secured in a vacuum mattress and then placed on the stretcher. •Application of a cervical collar and the patient lifted and moved to the stretcher using a scoop stretcher. After the patient is moved to the stretcher, the scoop stretcher is removed. •Application of a cervical collar and the patient lifted and moved to the stretcher using a backboard. After the patient is moved to the stretcher, they are removed from the backboard and placed directly on the stretcher mattress. •Application of a cervical collar and vest-type device applied to the patient for extrication. The patient is secured to the backboard with the vest-type device in place. The backboard, holding the patient, is placed on the stretcher. •Application of a cervical collar and the patient placed on and strapped to a long backboard, the head secured by a head-stabilization device. The backboard, holding the patient, is placed on the stretcher.

The spine is particularly susceptible to injury from:

•Compression. The weight of the body is driven against the head. This is common in falls, diving accidents, motor vehicle crashes, or other accidents in which a person impacts an object headfirst. •Flexion. There is severe forward movement of the head in which the chin meets the chest, or the torso is excessively curled forward. •Extension. There is severe backward movement of the head in which the neck is stretched, or the torso is severely arched backward. •Rotation. There is lateral movement of the head or spine beyond its normal rotation. •Lateral bending. When the body or neck is bent severely from the side. •Distraction. The vertebrae and spinal cord are stretched and pulled apart. This is common in hangings. •Penetration. There is injury from gunshots, stabbings, or other types of penetrating trauma that involve the cranium or spinal column.

The following spinal motion restriction teaching points summarize the new approach to emergency care of patients with suspected spinal injury in the prehospital setting:

•Do not use mechanism of injury as the sole criteria for spinal motion restriction. Assessment findings should guide SMR. •Differentiate between stable and unstable cervical column injuries. •Differentiate the multisystem, multitrauma victim from the patient with moderate, low kinetic energy trauma, who likely does not require SMR. •Emphasize the complete assessment of the patient before deciding on SMR. •Omit SMR altogether for those patients who meet the "clearance" criteria. •Victims of penetrating trauma should not be provided spinal motion restriction unless neurologic deficits are present. •There is a lack of evidence and potential harm in using an unpadded backboard; therefore, avoid its use. •Stable spinal injuries need little in terms of field stabilization; •application of a cervical collar and securing the patient to the stretcher mattress is usually all that is necessary. •The use of a vacuum mattress alternative method of SMR. •The SMR method should conform to the patient. You should not make the patient conform to the SMR device. •When performing SMR, allow patients to be comfortably secured in a variety of positions such as sitting, reclining, or on their sides.

Spinal Column

▪33 vertebrae in five divisions. ▪Vertebrae bound together by ligaments. ▪Vertebrae are separated by disks. The spinal column is divided into five parts: •Cervical spine. The first seven vertebrae that form the neck. The cervical vertebrae are the most mobile and delicate; injury to the cervical spine is the most common cause of spinal cord injury. •Thoracic spine. The 12 vertebrae directly below the cervical vertebrae that compose the upper back. •Lumbar spine. The next five vertebrae that form the lower back. •Sacral spine (sacrum). The next five vertebrae that are fused together and form the rigid posterior portion of the pelvis. •Coccyx (tailbone). The four fused vertebrae that form the lower end of the spine.

Placing a supine patient on a long backboard

▪Apply cervical collar ▪Log roll patient ▪Position board ▪Position patient on board ▪Secure the torso ▪Secure the head and legs

SMR for Seated Patient Using a Vest-Type

▪Assess the back, scapula, arms, or clavicles before you apply the board ▪Never use a chin cup or strap ▪Always tighten the torso and leg straps before securing the patient's head ▪Never pad between the cervical collar and the board

Cervical Collars

▪Cervical collar can increase intracranial pressure. ▪Cervical collar can cause pressure sores. ▪Increase in difficulty in managing the airway with a cervical collar.

Indications for Spine Motion Restriction

▪Follow local protocol. ▪Use criteria to "clear the spine". ▪Must be a reliable patient. ▪Unreliable patients with a qualifying MOI must be provided with spine motion restriction. ▪SMR is necessary for: -An unreliable patient -Patient with a neurologic deficit -Pain or tenderness near vertebral column -Distracting injury A reliable patient is one who: •Has a Glasgow Coma Scale score of 15 (the maximum score) •Does not have a head injury •Is not intoxicated or under the influence of drugs •Does not have a distracting injury (long bone fracture, large laceration, or other injury that causes more pain than the vertebral column, if injured) •Can communicate effectively to understand your questions and provide appropriate responses (does not have communication barriers such as hearing loss, deafness, or a language barrier). ▪SMR not necessary for: -Reliable patient who communicates -No spinal pain or tenderness -No abnormal neurologic findings No distracting injury orintoxication

Incomplete spinal cord injury

▪Injury does not involve all three tracts. ▪Some, but not all, signs of spinal injury are present. ▪The pattern of lost functions is reflected in different syndromes.

SMR and Self-Extrication from a Vehicle

▪Instruct patient to hold his head and neck in a neutral in-line position ▪Assess for pain or tenderness ▪Assess motor and sensory function ▪Apply cervical collar ▪Instruct patient to pivot his legs and body ▪Instruct the patient to stand straight up ▪Have the patient rotate 180 degrees and then sit directly back onto the stretcher. ▪Have the patient lift his legs onto the stretcher and then lie back into a supine position. ▪Secure the patient to the stretcher. Instruct the patient to maintain constant self-restriction and rotate 180 degrees until his back faces the stretcher. Have the second EMT, who should now be positioned on the opposite side of the stretcher as the patient, prevent the stretcher from moving and guide the patient back onto the stretcher mattress.

SMR for a Supine or Prone Patient with the Backboard as a Movement Device Only

▪Logroll the patient onto the backboard. ▪Secure the patient to the backboard. ▪Move the patient to the stretcher. ▪Place the backboard onto the stretcher. ▪Instruct the patient to keep his toes, nose and umbilicus lined up.

Spinal Shock, loss of sympathetic control

▪Neurogenic hypotension -Vasodilation of arterioles. -Diminished release of epinephrine and norepinephrine. -The skin is warm and dry, and the pulse rate is normal. A male patient might have an involuntary erection of the penis called priapism. Treatment for spinal shock is much the same as for any other shock. Spinal motion restriction must be applied, and the patient must be kept warm because of the increased heat loss from the peripheral vasodilation.

Rapid Extrication (Rapid Rollout)

▪Three situations in which such movement is permissible: -The scene is not safe. -The patient's condition is so unstable that you need to move and transport them immediately. -The patient blocks your access to a second, more seriously injured patient. In rapid extrication, the patient is brought into alignment with manual in-line spinal stabilization and a cervical collar is applied. This is best achieved from behind or to the side of the patient. Perform a primary assessment and a rapid physical exam. Then, apply a cervical collar. Support the Patient's Thorax. Rotate the Patient until Her Back is Facing the Open Car Door. Bring the Patient's Legs and Feet up Onto the Car Seat. A long backboard is positioned next to the patient. Bring the Board in Line with the Patient and against the Buttocks. Stabilize the Cot under the Board. Begin to Lower the Patient Onto the Board If the Structural Features of the Vehicle, Time, Resources, and the Patient's Condition Permit, It May be Worthwhile to Remove the Roof Before Performing a Rapid Extrication

Complete spinal cord injury

▪Transection of the cord; loss of motor, sensory, and autonomic function below the site of injury.