Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Management of spinal trauma
1. Management of Spinal Trauma
Dr Nola McPherson
SCGH Registrar Education
April 2014
2. Spinal anatomy
Evaluating a patient with suspected spinal injury
Broad management principles of spinal injury
Hypovolaemic vs neurogenic vs spinal shock
Overview
3. Anatomy
Location of Spinal Injuries
55% in cervical region
(mobile & exposed)
15% in thoracic region
(less mobile & protected)
15% in thoracolumbar region
(fulcrum)
15% in lumbosacral region
4. Anatomy
Upper cervical region is wide from foramen magnum to
lower part C3
- 1/3 die at scene from apnoea
- those that survive are usually neurologically intact
when reach hospital
5. Anatomy
Below C3, diameter of spinal canal is smaller
- vertebral column injuries more likely to produce
spinal cord injuries
6. Anatomy
Most thoracic spine fractures are wedge compression
fractures without SC injury
If fracture-dislocation in thoracic spine region
– almost always complete spinal cord injury
because narrow thoracic canal
8. Anatomy
Multiple ascending and descending tracts in the spinal
cord (not going to cover all of these today!)
THREE are easily clinically assessable
lateral corticospinal tract (descending tract)
spinothalamic tract (ascending)
dorsal columns (ascending)
9. Anatomy
Corticospinal tract – controls motor power on SAME side
Spinothalamic tract – transmits pain & temp sensation from
OPPOSITE side
Dorsal columns – carries position sense (proprioception), vibration
sense and some light touch sensation from SAME side
18. Spinal Cord Syndromes
Different patterns of neurologic injury with the following syndromes:
Central Cord Syndrome
Anterior Cord Syndrome
Posterior Cord Syndrome
Inferior Cord Syndrome
Transverse Cord Syndrome
Brown-Sequard Syndrome
Cauda Equina Syndrome
Syringomyelia
19. Spinal Injury: Morphology
Spinal injuries can be described as:
1. Fractures
2. Fracture – dislocations
3. Spinal cord injury without radiographic abnormalities
4. Penetrating injuries
These injuries can be further categorized as stable or unstable
20. Spinal Injury: Signs and Symptoms
Pain (and bony tenderness on examination)
Tingling, numbness and weakness in peripheries
Loss of sensation or paralysis below level of injury
Impaired breathing – C3/4/5 (diaphragm)
Incontinence
Priapism
21. Spinal Trauma: Primary Survey
Activate trauma team, triage to trauma bay
Move patient off spinal board as soon as clinically safe to do so
Airway maintenance with C spine immobilisation
- definitive airway early if respiratory
compromise
(injury higher than C6 need intubation and
ventilation)
- maintain hard collar, sandbag/bolsters and
tape
Breathing and Ventilation
- 15L /min oxygen (NRB) + ventilatory support
- monitor RR, respiratory effort, cough
22. Circulation with haemorrhage control
- if hypotension – hypovolaemic vs neurogenic shock
- assume hypovolaemia 1st : search for source
blood loss + replace fluids
- if SC injury: guide fluid replacement with CVP
monitoring (controversial)
- inotropes may be required
- before IDC – perform rectal examination and
assess rectal sphincter tone and sensation
Spinal Trauma: Primary Survey
24. Adjuncts to Primary Survey
Full non invasive monitoring (consider invasive later)
ECG
Trauma Xray series – lateral cervical spine, chest, pelvis
Bedside FAST scan (?sources of bleeding)
NGT
IDC
25. Focused AMPLE Hx
Ask
mechanism?
does your neck or back hurt?
can you feel me touching your fingers and toes?
can you move your hands and feet?
Spinal Trauma: Secondary
Survey
26. Assess full spine
A. Log roll and palpate spine/paraspinal region
look for deformity/ crepitus/pain/contusions/
lacs/penetrating wounds
B. Assess for pain, paralysis and paraesthesia
location
neurological level
Spinal Trauma: Secondary
Survey
27. Spinal Trauma: Secondary
Survey
Test sensation
Test motor function
Test deep tendon reflexes
DOCUMENT carefully and REPEAT
Head to toe examination – assess for associated injuries
29. Disposition
EARLY discussion with spinal specialists
- best imaging technique based on suspected injury
- management options - ?steriods – give or not give
Transfer to spinal unit
30. Examination For SC Level
Sensory Examination
Best Motor Examination:
TABLE 1: Determining the level of Quadraplegia
TABLE 2: Determining the level of Paraplegia
32. Table 2: Examination For SC
Level
Action Nerve Root Level
Flexes hip Iliopsoas, L2
Extends knee Quadriceps L3-4
Flexes Knee Hamstrings L4-5, S1
Dorsiflexes big toe Extensor hallucis longus, L5
Plantar flexes ankle Gastrocnemius, S1
33. Phases of Injury
Primary spinal cord Injury
– initial trauma direct injury to SC due to fractures,
dislocations, haematomas, soft tissue swelling
Secondary spinal cord injury (later)
– due to ongoing mechanical instability or insults secondary
to hypoxia and hypotension
34. Spinal Trauma:
Management Principles
1. Immobiisation
2. Intravenous fluids
3. Medications
4. Early advise, prompt referral/transfer
ED acute care priority: avoid secondary spinal injury
35. Spinal Trauma:
Management Principles
Immobilisation: protect from further spinal injury
cervical collar
long spinal board, bolsters and tape
remove from spinal board as soon as possible
(ideally < 2hours, BEWARE pressure pts & decubitus
ulcers)
logroll maintaining neutral alignment of entire spine
(four or more helpers required with av 70kg patient)
36. After arriving at ED, at least 5% with spinal injury experience
new symptoms or worsening of preexisting symptoms as a
result of –
secondary spinal injury
(ischaemia & progression of spinal cord
oedema)
poor immobilisation technique
38. Spinal Trauma:
Management Principles
Medications
Corticosteriods - insufficient evidence for routine use
Aimed at reducing extent of permanent paralysis
Most trials have used high dose methylprednisolone
Improved motor neurological outcome up to one year post
injury if given within eight hours of injury
Given as bolus dose and then IV infusion for 24-48 hours
- 24 hour IVI if treatment commenced within 3 hours of injury
- 48 hours IVI if treatment commenced within 3-8 hours of injury
39. Spinal Trauma:
Management Principles
Early studies (NASCIS I & II)* showed no increased complications
or mortality if 24 or 48 hour IVI
More recent larger studies have raised concerns about
increased risk of sepsis due to immunosuppressive effects
CI: heavily contaminated open injuries, other heavily
contaminated injuries eg perforated bowel, sepsis
Consult with spinal specialist (use or not to use??)
More research needed
Analgesia
* National Acute Spinal Cord Injury Study I & II
40. Spinal Trauma:
Management Principles
Transfer
Promptly after consultation with spinal specialist
If injury above C6 (can result in partial or complete loss of
respiratory function) – intubate before transfer
42. Hypovolaemic vs Neurogenic Shock
Hypovolaemic Shock Neurogenic Shock
Increase HR Decreased HR
Decreased BP Decreased BP
Cool extremities Warm extremities
43. American Spinal Injury Association
(ASIA) Classification
Allows classification of spinal cord injury (standardizing
terminology worldwide)
Based on
- severity of neurological deficit
A=complete to E=normal
- neurological level
most caudal segment with normal function
44.
45. Neurogenic Shock
Neurogenic Shock
Mechanism
impairment of descending sympathetic pathways in the
cervical or upper thoracic spinal cord (usually above T6)
Loss of sympathetic vasomotor tone
- peripheral vasodilation (visceral and lower extremity
b/v) pooling of blood
HYPOTENSION
46. Neurogenic Shock
Loss of sympathetic innervation to heart (usually lesion
above T1)
bradycardia (or at least failure of tachycardic
response to hypovolaemia)
47. Neurogenic Shock
Management:
1. Hypotension
1. crystalloid (250mL boluses) and IVI
– may not improve BP despite massive infusion
(beware fluid overload and pulmonary oedema)
2. vasopressors eg noradrenaline, dopamine
- after trial of volume replacement
Maintain organ perfusion: mentation, UO>0.5mL/kg/hr,
MAP >65mmHg, warm peripheries
Consider CVP monitoring
48. Neurogenic Shock
2. Bradycardia
1. atropine (0.6mg IV boluses, up to max 3mg)
2. avoid overzealous vagal stimulation with suction/NGT
and ETT placement
49. Spinal Shock
Spinal Shock
= transient loss of muscle tone and loss of reflexes
(flaccid areflexia) below the level of spinal cord injury
Not true shock
Spinal cord (temporarily) nonfunctional but not destroyed
No ANS or somatic reflexes
First to return is bulbocavernosus and Babinski reflexes
Duration variable (hours to weeks)
Resolves with improvement in soft tissue swelling
50. Take Home Messages
Over half of spinal cord injuries occur in the cervical spine
region (most vulnerable and mobile region)
C spine immobilisation in trauma = spinal board (initially),
hard collar, sandbags/bolster and tape
Consider early intubation and ventilation with injuries
higher than C6 (altered LOC, regurgitation, cervical
haematomas) – hypoxaemia is late sign of deterioration
Follow ATLS ‘A B C D E’ algorithm in spinal trauma – aim is
to limit secondary spinal cord injury
51. Take Home Messages
Neurogenic shock is a triad of hypotension, bradycardia
and peripheral vasodilation
In trauma patients, neurogenic shock is a diagnosis of
exclusion
Watch over zealous fluid treatment – if hypotension not
improving with fluid resuscitation, consider neurogenic
shock
EARLY discussion with spinal specialist the use of
noradrenaline (for hypotension) and steroids (remains
controversial) in spinal trauma
53. References
Fildes J, et al. Advanced Trauma Life Support Student Course
Manual (9th edition), American College of Surgeons 2012.
Image of Vertebral Column taken from:
http://upload.wikimedia.org/wikipedia/commons/5/54/
Gray_111_-_Vertebral_column-coloured.png
Image of Major Tracts in Spinal Cord taken
from:http://www.dontbeasalmon.net/archives/2012/01/week-
222-spinal.html
54. References
Image of Dermatomes taken
from:http://commons.wikimedia.org/wiki/File:Dermatomes_and
_cutaneous_nerves_-_anterior.svg
Image of Myotomes taken from:
https://www.pinterest.com/pin/174162710563226309/
Image of Tetraplegia/paraplegia spinal levels taken from:
http://quizlet.com/23549824/spinal-cord-injury-med-surg-
exam-2-flash-cards/
55. References
Trauma Spinal Injury taken from:
https://www.lifeinthefastlane.com/trauma-tribulation-016/
ASIA Impairment Scale taken from:
http://www.asia-spinalinjury.org/elearning/
ISNCSCI_ASIA_ISCOS_low.pdf
BrackenMB.Steroidsforacutespinalcordinjury.CochraneDatabas
eofSystematicReviews2012,Issue1.Art.No.:CD001046. DOI:
10.1002/14651858.CD001046.pub2.
56. References
Cameron P, Jelinek G, Kelly AM, Murray L, Brown A. Textbook of
Adult Emergency Medicine. 3rd Edition. Churchill Livingston
Elsevier 2009.