prehospital care 10th edition chapter 32

elderly patients may suffer fractures much more easily with less force applied to the spine:

C1 and C2 dislocations may be more common in elderly patients who suffer from rheumatoid arthritis and may be more common in down syndrome patients because of abnormal development of the odontoid (second cervical vertebra)

tools to remove face mask:

FM extractor, trainers angel, knives, pruning shears and PVC pipe cutter

indications for spinal immobilization based on assessment findings:the following as indications for spinal immobilization in blunt or penetrating trauma based on thorough assessment:

Glasgow coma scale of <15 any suspected traumatic brain injury any condition in which the patient has an altered mental status signs of acute stress reaction (ASR) that may mask any pain the patient is experiencing any pain or tenderness along the vertebral column any paralysis (partial or complete), weakness, numbness, or tingling, prickling sensation priapism deformity along the vertebral column incontinence of bowel or bladder a patient who has sustained a significant MOI and is under the influence of alcohol or drugs, cannot communicated effectively or understand, or has a painful distracting injury if any of the above indications are found during the assessment you must provide complete spinal immobilization, this is true even if the moi doesn't seem sever enough to produce a spinal injury

even though face masks are typically screwed in:

a screwdriver is not recommended to take off the face mask unscrewing the clips causes excessive movement of the head especially if the screws have been in place for some time and are rusted DuraShears, Emt shears and a seatbelt cutter are also not recommended because these tools take too much time to cut the plastic clips a simple pruning tool for gardening is sometimes the best device to use

immobilizing a seated patient:

a short spinal immobilization device will be used, this will minimize the movement and aggravation of potential spine injury while the patient is being transferred to a long board for complete immobilization

although a patient complaining of pain to the spinal column likely has:

a vertebral fracture or injury pain does not indicate a spinal cord injury conversely a loss of motor or sensory function indicates a spinal cord injury however it does not imply a vertebral fracture or injury in either case- pain/ tenderness along the spinal column or loss or motor/sensory function-the patient would be considered to have a spinal injury and must be completely immobilized

suspicion of injury to the spine or spinal cord is based primarily on the assessment findings and sets the standard for subsequent emergency care for the patient:

all assessment and care must be conducted with extreme caution to avoid excessive movement and manipulation of the body in line stabilization must be maintained throughout the entire patient contact

neurogenic hypo-tension from spinal shock:

also called spinal-vascular shock or neurogenic shock results from injury to the spinal cord that interrupts the nerve impulses to the arteries when the arteries lose there nerve impulses from the brain and spinal cord they relax and dilate this vasodilation causes a relative hypovelemia within the circulatory system, there is more space than blood to fill arteries, the patient becomes hypotensive with spinal shock sympathetic nerve impulses to the adrenal glands are lost which prevents the release of epinephrine and nonepinephrine this causes vessel dilation (red skin) and a lack of sweat gland stimulation (causing skin to reamin dry)

gunshot wounds to the head, neck, chest, abdomen, back, or pelvis should

always cause suspicion of injury to the vertebrae or spinal cord, even if the entrance and exit wounds are closely aligned and appear to indicate a clean straight through wound the bullet could have ricocheted and caused an injury to the vertebrae or spinal cord also exploding fragments from other bones could have injured the spine

brown-sequard syndrome:

an injury to a hemisection to the right or left half of the spinal cord disrupts the spinal tracts on only one side of the cord the patient expeirences motor and sensory losses below the injury site but a sitinctive feature is that the effects differ on two sides of the body the patient may lose motor function and light touch sensation on one side but lose pain sensation on the opposite side

you should first assess the patient wearing a helmet in the following areas:

assess the patients airway and breathing assess the fit of the helmet and the likelihood of movement of the patients head within the helmet determine you ability to gain access to the patients airway if intervention should be necessary to assist his breathing

the face mask of the helmet should be removed:

at the earliest possible point but before transportation the face mask should be removed, but before transportation the face mask should be removed ant time a spinal injury is suspected, regardless of the mental status and airway or respiratory status of the patient

the most common causes of spine injury:

automobile crashes shallow water diving accidents motorcycle crashes falls are common causes of spine injury

common mechanisms of spinal injuries:

automobile crashes: make up close to half 48% or all spinal injuries gunshot wounds and recreational activities such as diving an football are the next most frequent cases do not be complacent in management of any patient with a significant mechanism of injury for spinal trauma or one who displays any signs or symptoms of spinal column or cord injury

likely mechanisms of injury:

be especially alert to the possibility of spine injury when called to any of the following scenes since all of them are likely to produce the mechanisms that may result in spinal injury: motorcycle crashes motor vehicle crashes pedestrian vehicle collisions falls blunt trauma penetrating trauma to the head neck or torso sporting injuries hangings diving or other water-related accidents gunshot wounds to the head, neck, chest, abdomen, back, pelvis unresponsive trauma patient electrical injuries

obtain a history from the responsive patient:

because of the seriousness of a spine injury try to take this history as the physical exam is being conducted questions: does your neck or back hurt? where does it hurt? can you move your hands or feet? do you have any pain or muscle spasms along your back or to the back of your neck ? do you have any numbness or tingling sensations in either of your arms or legs? was the onset of pain associated with a fall or other injury? did you move or did someone move you before our arrival? were you up walking around before our arrival? assess for allergies, medications, past medical history and the last intake of food or drink remember to ask about the events prior to the onset of signs or symptoms because the may provide evidence of or classify the MOI if the patients is unresponsive obtain the history from bystanders at the scene, try to determine the patients mental status before you arrival if the patient was moving any extremities, or if the patient was moved prior to your arrival

cervical spine immobilization collars should be applied:

by two rescuers one stabilizes the neck manually in the neutral position while the other applies the collar placement of the cervical collar should never obstruct the patients airway

injured vertebrae that are still aligned but unstable :

can become unstable at any moment and damage or sever the spinal cord conduct a thorough assessment to determine if spine injury is suspected and the need for complete spinal immobilization

posterior exam:

carefully log roll the patient with in-line stabilization to assess the posterior body palpate the area of the spine very gently evidence of deformity, tenderness, contusions, lacerations, punctures, or swelling to the spine or around the spine should heighten your suspicion that a spinal column injury exists muscle spasms along the spinal column are a protective reflex and a common indication that a spine injury has occurred

the motor tracts:

carry impulses down the spinal cord and out to the muscles motor tracts are tested by having the patient move the motor tract on the right side of the spinal cord carry the impulses that allow the patient to move on the right side of the body the motor tracts on the left side of the body allow movement on the left side of the body

the pain tracts:

carry impulses from pain receptors up tot the spinal cord to the brain the pain tracts are tested by applying pain to the patient upon entering the spinal cord a pain tract crosses over and carries the impulse up the opposite side of the cord, thus pain applied to the right side of the body is actually carries up the left side of the spinal cord to test the right pain tract, you must apply pain to the left side of the body to test the left pain tract apply pain to the right side of the body

light touch tracts:

carry light touch impulses from sensory receptors up the spinal cord to the brain these are test by applying light touch to the patient the light touch sensation if carried up the same side of the spinal cord as the side where the touch is applied since light touch ans pain are carried by different tracts it is possible for the patient to be unable to feel light touch but able to feel the pain of a pinch this finding may be present if the spinal cord is partially but not completely injured

treatment for spinal shock is much the same as for any other shock:

cervical spinal stabilization must be applied and the patient must be kept warm and completely immobilized

the basic tools you will use in immobilizing the patients are:

cervical spine immobilization collars, long backboards, and both rigid and vest type short backboards

pulse assessment:

check for the presence and strength of the radial pulses for the upper extremities the pedal pulses for the lower extremities

the nervou system has two major functions:

communication and control it enables the individual to be aware of and react to his environment it also coordinates the responses of the body to changes in the environment and keeps body systems working together

the spinal cord:

composed of nervous tissue exits the brain through an opening at the base of the skull the cord is surrounded by a sheath of protective membranes and a cushioning layer or cerebrospinal fluid the cord narrows as it goes filling 95 percent of the spinal column "canal" in the cervical vertebrae (neck) but only 60 percent in the lumbar area (lower back) all nerves to the trunk and extremities originate from the spinal cord, the spinal cord carries messages from the brain to the various parts of the body through nerve bundles studying the spinal cord tracts to understand where they are located ans what impulses studying the pinal cord tracts to understand whwere they are located and what impulses are carried by them will help you better understand assessment findings associated with incomplete spinal cord injuries also knowing that various tracts within the spinal cord carry different impulses will reinforce and help you better understand the steps in the neurological assessment

the spine is quite strong and flexible but is particularly susceptible to injury from the following mechanisms:

compression: when the weight of the body is driven against the head, this is common in falls, diving accidents, motor vehicle crashes, or other accidents where a person impacts an object head first flexion: when there is severe forward movement of the head in which the chin meets the chest or when the torso is excessively curled forward extension:when there is severe backward movement of the head in which the neck is stretched or when the torso is severely arched backward rotation: when 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: when the vertebrae and spinal cord are stretched and pulled apart this is common in hangings penetration: when there is injury from gunshots, stabbings, or other types of penetrating trauma that involve the cranium or spinal column you must suspect spine injury in any case that may involve one or more of these mechanisms even if the patient appears to move normally

secondary assessment of a spinal injury:

continue manual in line stabilization and reassess the patients mental status conduct a physical exam then assess vital signs and gather a history

special considerations to be aware of when using a short spinal device:

do any assessment of the back, scapula, arms, or clavicles before you apply the board angle the board to fit between the arms of the rescuer who is stabilizing the patients head without jarring the rescuers arms push the spine board as far down in the seat as possible , if you dont the board may shift compressing the cervical spine never place a chin cup or chin strap on the patient, they will prevent the patient from opening his mouth if he needs to vomit when applying the first strap to the torso take care not to apply the strap too tightly which could impair breathing or abdominal injury always tighten the torso and leg straps before securing the patients head to the device, this prevents accidental movements of the cervical spine never allow buckles to be placed mid sternum where they would interfere with proper hand placement if CPR becomes necessary never pad between the cervical collar and the board: doing so creates a pivot point that may cause hyper extension of the cervical spine when the head is secured assess pulses and motor sensory function before and after applying the device

full body spinal immobilization devices

exist to provide stabilization and immobilization of the head, neck, torso, pelvis, and extremities generally long back boards are used to immobilize patients in a lying or standing position they may also be used in conjunction with short backboards for proper immobilization of a patient, padding, straps, and cravats are also used with the long backboard

when you encounter a supine or prone patient with a suspected spine injury:

first ensure that all life-threatening situations have been managed, establish and maintain in-line manual stabilization and apply cervical spine immobilization collar then immobilize the patient to a long backboard

motor function assessment: upper extremities:

flex you arms (bend the elbows) across your chest (test mf at C6) extend your arms (straighten the arms to the side of the body) (tests mf at C7) spread your fingers out on both hands and dont let me squeeze them together (tests mf at T1) hold out both atms and dont let me push your hand down (done while you support hand under wrist) ( tests mf at C7)

for vest type devices:

follow all of the manufactures instructions regarding application and use of the device

cervical spine immobilization collar:

following your assessment of the neck apply the cervical spine immobilization collar the cervical collar is only an adjunct to a full spinal immobilization it does not provide complete immobilization by itself do not release manual in-line spinal stabilization until the patient is fully immobilized on a backboard this will be done after the secondary assessment

the mental status of a patient with a spine injury may range :

from completely alert and oriented to unresponsive based on the assessment findings categorize the patient as either a high or low priority for emergency care or transport

the skeletal system:

gives the body its framework supports and protects vital organs and permits motion the skeleton is flexible enough to absorb and protect against impact and stress the parts of the skeletal system that protect the most important parts of the nervous system are the skull and spinal column

test for light touch perception:

have the patient again close his eyes lightly touch the patients 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 what hand and which finger im touching you would repeat the test on one of the toes on each foot: same questioning as fingers

test for pain perception:

have the patient close his eyes with the sharp end of the wooden Q-tip stick poke one of the 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 then on each foot

whenever a patient is placed onto a backboard:

he must be secured to the board with backboard straps and some type of head immobilizer straps or cravats should be placed next to the patient to keep the patient from sliding up and down or laterally on the board place straps across the chest and under the armpits in a manner that does not interfere with the patients breathing place the straps across the pelvis and above the patients knees deceleration straps are another important adjunct to immobilization these straps are fastened across the patients shoulders and prevent the patients torso from sliding up the backboard and compressing the cervical spine when the ambulance slows or stops during transport

the patients pulse and skin color, temperature and condition may appear normal in spite of injury to the vertebrae:

however an injury to the spinal cord can interrupt the transmission of impulses from the brain to the heart and blood vessels that control blood pressure you may find the radial pulse weak or absent because of a reduced blood pressure the skin may be warm and dry below the site of the spinal cord injury and cool, pale, and moist above the site of injury

there are only two circumstances in which the helmet should be removed:

if it does not adequately secure the head because its too large for the patient or if you cannot gain access to the airway if the helmet is removed, padding must be added behind the head to ensure that the head and shoulder pads are kept in a neutral in-line position

central cord syndrome:

if the central portion of the spinal cord is injured the patient may present with weakness or paralysis and loss of pain sensation to the upper extremities while the lower extremities have a good function opposite of complete spinal cord injury where there is loss of function below site of injury the medial inner aspects of the motor and pain tracts control the upper extremities whereas the lateral outer portions of the tracts control the lower extremities in CCS the midial or middle portion of spinal cord is injured causing a dysfunction in the inner tracts that control upper extremity motor and sensory function more commonly seen in elderly patients

you must consider the patient a high priority for emergency care and prompt transportation to the highest level trauma center based on your destination protocols if:

if the patient is unresponsive is responsive but unable to obey commands displays an abnormal respiratory pattern or obvious signs of spine injury such as numbness or paralysis

regardless of the lack of obvious trauma or patient complaints, you must adopt a high index of suspicion and initiate:

immediate manual in-line spinal stabilization if the scene size-up has suggested a mechanism of injury that could cause spine injury manual stabilization must not be released until the patient is securely strapped to a backboard with his head and neck immobilized or until a thorough assessment is conducted and the findings do not indicate spinal injury, you must follow your local protocols regarding spinal immobilization in the case of an altered mental status the patient is considered unreliable and you should always assume a spinal cord injury and completely immobilize that patient any patients with injuries above the clavicles (head,face,neck) should be assumed to have cervical spine injury whenever spine injury is suspected you must open the airway using jaw-thrust manuever instead of the head-tilt chin lift manuever do not turn the patients head to the side to facilitate drainage of fluids from the airway instead suction any secretions blood or vomitus from the patients mouth be prepared to provide ppv with supplemental oxygen

with any gunshot wound to the body:

immediately establish manual in line spinal stabilization and take the necessary spinal precautions during your emergency care until a more thorough assessment can be conducted

both vest-type and rigid short boards should be used only to:

immobilize the patient while moving him from a sitting position then immediately to a long board short devices cannot adequately immobilize the patient because they cant immobilize the surrounding joints of the head, torso, and legs

assessing pulse and motor and sensory function:

in the responsive patient assess pms of each extremity while the assessment of pulses is being performed maintain manual spine stabilization

spine injury may produce catastrophic permanent damage three major complications of spine injury are these:

inadequate breathing effort paralysis inadequate circulation

with the blood pooling in the periphery and lack or circulating hormones the patients physical signs are different from those with classic hypovlemic shock:

instead of pale, moist skin as would develop in hypovelmia the spinal shock patients skin will be warm and dry and may appear pink or red in spinal shock in which sympathetic impulses are impaired the patients pulse is typically 60-80 beats per minute this differs from sympathetic stimulation in hypovolemia

physical exam of spinal injury:

instruct the patient not to move and be still do not attempt to unbutton or unzip clothing to expose the patient reduce unnecessary movement by cutting away clothing conduct a physical exam inspect and palpate the head, neck, chest and abdomen, pelvis, extremities, and posterior body for evidence of trauma

spinal cord injury:

involves damage to the nervous tissue that is enclosed inside the hollow center of the bony spinal column: the spinal cord if the spinal cord is injured a disruption in one or more of the motor or sensory tracts is likely thus a patient with a spinal cord injury would experience loss of motor or sensory function or both

spinal shock:

is a temporary concussion like insult to the spinal cord that causes effect below the level of the injury such an injury usually occurs high in the cervical region below level of injury there is: a loss of muscle tone (flaccid muscles) the patient is unable to feel sensations (anesthetic effect) ans the patient is unable to move the extremities or any voluntary muscles (paralysis) the patient will typically lose control of bladder and bowel a male patient may have an involuntary erection of the penis called priapism the vessels below the site of injury may dilate leading to decreased blood pressue (neurogenic hypotension) temperature regulation is also disrupted by loss of vessel tone spinal shock usually resolves within 24 hours after the incidents but may last for several days this patient should be managed as one with a spine injury even if the dysfunction begins to resolve while you are managing the patient

spinal column injury:

is an injury to one or more vertebrae that is the portion of the spine composed of bone whether it is a fracture or dislocation a spinal column injury is a bone injury if a patient has an injury to the spinal column it will produce a complaint of pain or tenderness somewhere along the spine remember , pain is what the patient complains of, and tenderness is pain elicited on palpation you must gently palpate the length of the spine feeling for any gross abnormalities while also checking for tenderness

if at any point the patient complains or tenderness along the length of the spinal column:

it is an indication of potential injury the patient must receive complete spinal immobilization

in some EMS protocols spinal immobilization is based on physical assessment findings and not soley on MOI:

it is imperative for you to recognize that a patients lack of pain in the spinal column or his ability to walk to move his extremities, and to feel sensations does not rule out the possibility of spinal column or incomplete spinal cord injury

an important factor to consider in the patient with a possible spine injury is the mental status if the mental status is altered:

it may be an indication of a head injury, alcohol intoxication, drug influence, shock, hypoxia, or other causes an altered mental status does not allow the patient to respond adequately to questions or physical assessment or provide complaints of pain, numbness, tingling, paralysis, or other signs or neurological dysfunction in the case of an altered mental status the patient is considered unreliable and you should always assume a spinal cord injury and completely immobilize the patient

four rescuer log-roll immobilization procedure:

move the patient onto the spine board by log-rolling the patient: one at head,1-3 actually move the patient,as the patine is rolled onto his side, his posterior body should be carefully assessed if this has not been done during the primary assessment position the long spine board under the patient by sliding the board under the patient during the log roll : place patient on board by command of person holding in-line, use a slide, proper lift, log roll, or scoop stretcher to position the patient on the backboard so that movement is as limited as possible place padding in the spaces between the patient and the board immobilize the patients torso to the board with staps: tight enough to prevent shifting but not impair breathing immobilize the patients head to the board with a commercial head/cervical immobilization device or through the use on blanket rolls and tape: never place padding behind the neck itself secure the patients legs to the board with the straps proceed with

rapid extrication:

moving a patient before immobilizing him to a long backboard or even a short spinal device three situations in which rapid extrication is permissible: the scene is not safe: threat of fire or explosion, chemical spills or gunfire the patients condition is so unstable that you need to move and transport him immediately the patient blocks your access to a second more seriously injured patient benefit of rapid transport outweighs the risk of movement during extrication requires constant cervical spine stabilization and good communication among the EMTs moving the patient the patient is brought into alignment with manual in-line stabilization and a cervical spine immobilization collar is applied a long backboard is positioned next to him the patient is quickly transferred to the long backboard while manual in-line spina stabilization in maintained

any patient with a gunshot wound to the neck; the anterior, lateral, or posterior chest chest; the abdomen; the pelvis:

must be assessed for spinal injury

the nervous system consists of:

nerve centers and nerves that branch off from the centers and lead to tissues and organs most nerve centers are i the brain and spinal cord

baseline vital signs:

obtain and record a set of baseline vital signs if the brain or spinal cord is damaged the baseline vital signs may reflect neurogenic hypotension the blood pressure will be low and the heart rate normal or bradycardic the hypotension associated with spinal shock is usually not severe but mild with a systolic blood pressure no lower than 80 mmHg hypovelemia and spinal cord injury can be both present in the same patient; therefore be cautious in your assessment since the spinal cord injury may prevent the typical signs of hypovolemic shock from occurring

incomplete spinal cord injury:

occurs when the spinal cord is injured- but not completely through all of the three major tracts (motor, light touch and pain tracts) that means some tracts are spared and retain function because some tracts are injured and some are not the patient may present with conflicting or confusing signs of spinal cord injury

immobilizing a standing patient:

one EMT should immediately take normal manual in-line stabilization measures while another EMT applies a cervical collar position the long board behind the patient:examine the back carefully two EMTs should stand on either side to support him: each should place one arm under the patients armpit and grasp the highest reachable handhold on the long board, the EMTs other hands should be holding the patients elbows to steady and support him, the third EMT maintains in-line manual stabilization the EMTs at the sides of the patient should each place a leg behind the board: they should then slowly tip the board backward and begin lowering it to the ground while the third EMT maintains stabilization, be sure to inform the patient what you are going to do before you tip the board backward once the board is lying level on the ground, one EMT maintains manual stabilization while the others perform the necessary assessment and care proceed with care

the spinal column:

or vertebral column is the principal support system of the body the ribs originate from it to the thoracic cavity and the rest of the skeleton is directly or indirectly attached to the spine made up of 33 irregularly shaped bones called vertebrae the body of a vertebra is the bulky portion that faces anteriorly in the spinal column the posterior aspect of a vetebra is the spinous process, this can be felt as the bony projections along the spinal column lying one on top of the other to form a strong flexible column the vertebrae are bound firmly together by strong ligaments between each two vertebrae is a fluid-filled pad of tough elastic cartilage called a disk that acts as a shock absorber

special considerations when immobilizing children and infants:

pad from the shoulders to the heels of an infant or a child, if necessary to maintain a neutral in-line immobilization the larger head of infant or young child usually up until 8 years of age causes the head and neck to flex with supine use padding behind the shoulders and upper back to eliminate flexion and maintain neutral alignment of head, neck, and spine make sure the cervical collar fits properly before applying it to an infant or child if you dont have a collar that fits,immobilize the neck with a rolled towel, tape the towel to the backboard and manually support the patients head in a neutral in-line position an improperly fitted collar will do more harm than good

reassessment:

perform a reassessment every 5 min en route to the hospital ensure that the airway is clear and breathing is adequate reassess and record vital signs look for any changes in the pulse, skin condition or blood pressure because a spine injury is rarely and isolated injury look for digns of shock remember that a decreasing level of responsiveness is an early sign of head injury while a rising systolic and decreasing heart rate are a late sign of head injury if the patient has further complaints repeat those necessary parts of the physical exam be aware of complaints of tingling, numbness, loss of sensation or paralysis anywhere in the body reevaluate any airway adjuncts, ppv devices, mask seal, oxygen therapy , splints, and immobilization devices record your findings in the PCR and communicate them to the emergency department

if the patient is unresponsive:

pinch the foot and hand to determine a sensory response compare the sensory function and strength in the upper and lower extremities it is more common for spine injuries to cause paralysis to all four extremities or to only the lower half of the body loss of function confined to one side is more typical of a brain injury or stroke conflicting or partial loss of motor or sensory function may be an indication of an incomplete spinal cord injury

motor function assessment: lower extermities

push downs against my hands with your feet (place your hands under the feet) (tests mf at S1 and S2) pull up against my hands with the tops of your feet (tests motor function at the level of L5)

you should leave a footballers helmet on unless it is absolutely necessary to remove it:

removing the helmet while leaving the shoulder pads on will cause the head to drop and hyper-extend the neck

the skull:

resting at the top of the spinal column the skull contains the brain the skull has two parts the cranium and the face

anterior cord syndrome:

results from injury if the sensory and motor tracts located in the anterior potion of the cord the patient will present with the loss of sensation to pain and loss of motor function below the site of cord injury however the patient will retain the ability to feel light touch

complete spinal cord injury:

results when an area of the spinal cord has been completely transected (cut crossways) either physically or physiologically the injury having severed the motor and sensory tracts prevents any motor impulses from passing down from the brain to the body or sensory impulses from the body to the brain through the injured area of the cord therefore there is a total loss of motor sensory function below the level of the injury the patient presents with the inability to move or feel sensations of pain, light touch, ad crude pressure below the level of injury the patient will also likely present with a loss of bowel and bladder control because autonomic function is blocked when a patient presents with complete loss of motor and sensory function distal to the cord injury the patient may instead be experiencing spinal shock

cervical spine immobilization collars:

should be used any time you suspect injury to the spine never use a soft collar it permits too much movement the cervical collar by itself does not immobilize the patient the purpose of the colalr is not to prevent the head from moving buth rather prevent the head from moving in relation to the spine and reduce compression of the cervical spine during movement and transport of the patient even if you believe the injury is only to the neck area the cervical collar is not enough, the entire spine must be stabilized and then immobilized after a collar is applied, in-line manual stabilization must be maintained until the patient is fully secured to a backboard sizing of the collar to the patient is based on the design of the device be sure to use a collar of the proper size for the patient: too small will not restrain the patients head adequately, too large may cause extension of the patients neck and aggravate the spine injury

any time you get abnormal motor function or sensation results from your assessment findings that conflict with classical findings:

suspect incomplete cord injury

techniques for removal of motorcycle and sports helmets:

take the patients eyeglasses of before you attempt to remove the helmet one rescuer should stabilize the helmet by placing hands on each side of the helmet with fingers on the mandible to prevent movement a second rescuer should loosed the chin strap the second rescuer should place one hand anteriorly on the mandible at the angle of the jaw and the other at the back of the head the rescuer holding the helmet should pull the sides of the helmet apart (to provide clearance for the ears) gently slip the helmet halfway off the patients head and then stop the rescuer who is maintaining stabilization of the neck should reposition sliding his hand under the patients head to keep the head from falling back after the helmet is completely removed the first rescuer should remove the helmet completely the patient should then be immobilized as described earlier

signs and symptoms of spine injury:

tenderness in the area of the injury, specifically along the spinal column pain associated with movement fromt he spine injury that may be localized, ask the patient to pinpoint the location, do not ask the patient to move or try to elicit a pain response, do not move the patient to test for pain pain independent of movement or palpation along the spinal column or in the lower legs, such pain is generally intermittent instead of constant and may occur anywhere along the spinal column from the base of the head to the extreme lower back, if the lower spinal column is injured the patient may complain of pain to the legs obvious deformity of the spine upon palpation this is a rare assessment finding soft tissue injuries, from head and neck associated with cervical spine injury, from shoulders, posterior thorax, or abdomen associated with thoracic or lumbar spine injury lower extremity trauma is associated with lumbar and sacral spine injury numbess weakness tingling or loss of sensation or motor function in any of the arms or legs loss of sensation or paralysis below the suspected level of injury or in the upper or lower extremities, paralysis of the extremities is a reliable sign of spine injury loss of bowel or bladder control (incontinence) pripism, a persistent erection of the penis resulting from injury to the spinal nerves to the genitals, it occurs soon after injury and is a classocal sign of cervical spine injury impaired breathing especially breathing that involves little or no chest movement and only slight abdominal movement , thi is an indication that the patient is breathing with the diaphragm alone , diaphragmatic breathing is indicative of cervical spine injury, if injury to the nerve that controls the diaphragm occurs, you may see either no breathing effort or an attempt to breathe using only only abdominal muscles

the rapid extrication techniques require:

the EMTs to improvise at the scene based on the type of car, location of roof support posts, console between the srats, size of patient if time, resources and patient condition permit removal of roof will allow for much better access to the patient and for an easier removal

ligaments:

the bony framework of the body is held together by ligaments tough, fibrous connective tissue

the structural divisions of the nervous system:

the central nervous system which consists of the brain and spinal cord the peripheral nervous system which consists of nerves located outside the brain and spinal cord

the spinal column which surronds and protects the spinal cord is divided into five parts:

the 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 the thoracic spine: the 12 vertebrae directly below the cervical vertebrae that compose the upper back the lumbar spine: the next 5 that for the lower back the sacral spine: the next five vertebrae that are fused together and form the rigid posterior portion of the pelvis the coccyx- the four fused vertebrae that form the lower end of the spine

suspect spine injury with any serious blunt injury to the head, neck, chest, abdomen, back, or pelvis- and even to the legs or arms -

the energy of the impact can travel up the extremity to the spinal column

you should leave the helmet in place if you assessment reveals the following:

the helmet fits well and there is little to no movement of the patients head inside the helmet there are no impending airway or breathing problems removal of the helmet would cause further injury to the patient you can properly immobilize the spine with the helmet in place the helmet dosent interfere with your ability to assess and reassess airway and breathing

you should remove the helmet if your assessment reveals the following:

the helmet interferes with your ability to assess and reassess airway and breathing the helmet interferes with your ability to adequately manage the airway or breathing the helmet does not fit well and allows excessive movement of the head inside the helmet the helmet interferes with proper spinal immobilization the patient is in cardiac arrest

short spinal immobilization devices:

the most common short spine device is the commercially made vest-type device with supplied straps for the head, chest, and legs both vest-type and rigid device provide stabilization and immobilization to the head,neck,and torso they require a significant amount of time to apply and are most commonly used to immobilize non-critical sitting patients with suspected spine injuries, not critical patients who require rapid transport it is very important to be completely familiar with the proper use of these devices to avoid further injury to the patient

there are three main types of tracts within the spinal cord that are tested in assessment to determine if spinal cord injuries exist:

the motor tract the pain tract the light touch tracts

the functional divisions of the nervous system are:

the voluntary nervous system: which influences the activity of the voluntary muscles and movements throughout the body the autonomic nervous system: which is automatic an influences the activities of the involuntary muscles and glands, the autonomic system is partly independent of the rest of the nervous system, the sympathetic and parasympathetic nervous system are included in the autonomic nervous system

spinal cord damage from a cervical spine injury can block nerve impulses traveling from the brain to the diaphragm and intercostal muscles which are necessary for adequate respiration

there may be very little movement of the chest and only slight movement of the abdominal muscles or you may not excessive abdominal movement

the three most common types of incomplete spinal cord injury result in distinctive patterns of signs and symptoms (syndromes):

they are central cord syndrome and anterior cord syndrome and brown sequard syndrome

it is important to note that a patient can have a spinal cord injury without spinal column damage:

this specific condition is referred to as spinal cord injury without radio-logic abnormality or SCIWORA

injuries to the spine have potential for severity because within the spinal column is the spinal cord:

this structure carries nerve impulses from most of the body to the brain and back to the body a single spinal cord injury can affect several organs and body functions

if the patient has other injuries especially extremity fractures the pain associated with these injuries may distract from any pain or tenderness the patient is experiencing to the spinal column "distracting injuries" :

thus the patient does not complain of pain to the spinal column allowing the EMT who is not prudent to miss the possible spinal injury

assessment approach for spine injury:

upon arrival scan scene closely for evidence of MOI that could cause damage to the vertebrae or spinal cord look up, down and around the patient for signs that an injury has occurred even though there may be no overt signs of trauma to the patient a spine injury may nevertheless exist in such a situation open the airway using head tilt chin lift maneuver or failing to provide proper manual in line stabilization may produce catastrophic permanent injury or even be lethal to the patient these dire results can be avoided if you perform a thorough assessment of the patient many times a patient with a stable spine injury does not exhibit signs and symptoms consistent with injury to the spine improper movement by either the patient or the emt can easily cause the stable injury to become unstable, resulting in permanent neurological damage or even death you must maintain proper in-line stabilization even if the patient has moved prior to your arrival

when treating infants and children:

use a rigid board appropriate for the child's size

the following are general steps to follow for using a vest type device:

use manual in-line spinal stabilization and apply a cervical collar: assess pms in all 4 extremities position the short spinal deice behind the patient: examine the back carefully , the top of board should be level with top of head, and the bottom of the board should not extend past the coccyx secure the device to the patients torso: make sure straps are tight enough to prevent movement of the device laterally or vertically, if the device has straps that circle the legs apply and tighten these after the chest straps are applied pad behind the patients head to ensure neutral alignment of the head and neck with the remainder of the spine: excessive padding = neck to flex forward, to little =extension of head and neck secure the patients head to the device: maintain in-line stabilization even though the head is secured to the device, securing the head is the last step in the application of the device position a long backboard under or next to the patients buttocks and rotate him until his back is in line with the backboard : lower the patient onto the backboard while maintaining manual in-line spinal stabilization if it is not possible to get a long backboard next to the patient, lift the patient under his arms and legs and lower him onto the long board follow the guidelines for immobilizing a patient to a long backboard: release manual in-line stabilization when the patient is completely secured to the backboard, assess pms and record your findings in the PCR proceed with care

injuries associated with spine injury:

watch for evidence of trauma to the head, posterior cervical region, anterior neck , chest, abdomen, back and pelvis injuries to these areas also frequently cause spine injury

emergency medical care of spinal injury:

when in doubt immobilize the patient take necessary standard precautions establish and maintain in-line spinal stabilization immediately upon making contact with the patient: make sure head is in a neutral position, in line position, this manual stabilization must be maintained until the patient is completely immobilized to the backboard when performing the primary assessment open and maintain the airway with the jaw thrust maneuver assess the pulse, motor function and sensation in all extremities assess the cervical region and the neck before applying the cervical spine immobilization collar apply cervical spine immobilization collar immobilize the patient to a long backboard once the patient is immobilized reassess, record, and document the pulses and motor sensory function in all extremities transport to the hospital

primary assessment:

when performing a primary assessment the general impression may not lead you to suspect a spine injury since the signs and symptoms may not be apparent

posterior portion of the cord:

where the tracts for light touch are located

the patient who has suffered any spinal cord injury:

whether complete or incomplete requires complete immobilization

it is important to note that only 14 to 15 percent of patients who have spinal column fractures or dislocations:

will have a spinal cord injury that results in neurological deficits (motor and sensory dysfunction) this means that 85 to 86 percent of patients who actually have a spinal fracture or dislocation will not present with a neurological deficit when you arrive on scene and find the patient walking about it does not mean the patient did not suffer a spinal injury improper management of this patient however can convert a spinal column injury into a spinal cord injury the result could be permanent paralysis

extrication from a car seat:

you cannot use that car seat to stabilize the child for transport car seats involved in crashes may have lost the integrity of the structure and may not provide protection to the child if another crash were to occur transfer the child to a backboard

it is your job as an EMTto recognize such injuries that could damage the spinal column or spinal cord and provide appropriate emergency care:

you must be aware that improper movement and handling of the patient in such situations can lead to permanent disability or even death