Alexander ch40 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 40
Spine Injuries

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely injured patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Describe the structure and function of the spinal column,
spinal cord, and spinal nerves.
3. Use scene size-up, understanding of mechanisms of
injury, patient assessment, and patient history to develop
an index of suspicion for spine injuries.
4. Describe the incidence of neurologic deficit in patients
with injury to the spinal column.
5. Explain the threat to ventilation associated with injuries to
the spinal cord at the cervical level.
Objectives (1 of 4)

6. Anticipate the presence of other injuries in patients
with mechanisms of injury that can produce spine injury.
7. Differentiate between the concepts of spinal-column
injury and spinal-cord injury.
8. Give examples of forces that would produce each of
the following mechanisms of spine injury: compression,
distraction, extension, flexion, lateral bending,
penetration, and rotation.
9. Describe the concepts of complete and incomplete
spinal-cord injury.
Objectives (2 of 4)

10.Differentiate between the concepts of spinal shock and
neurogenic hypotension.
11.Recognize signs and symptoms of spinal-cord and
spinal-column injuries.
12.Given a series of scenarios, demonstrate the assessment
and management of patients suspected of having an
injury to the spine.
13.Demonstrate spinal motion restriction skills associated
with airway management, patient repositioning, and
patient extrication.
Objectives (3 of 4)

14.Describe the purpose and process of reassessing
patients with suspected injury to the spine.
15.Discuss current trends and controversies in the
assessment and management of patients with suspected
spine injuries.
Objectives (4 of 4)

Introduction (1 of 3)
• Individuals between the ages of 16 and 35 sustain
spine injury more frequently because they engage
more frequently in high-risk activities.
• Common causes
– Motor vehicle crashes (MVCs)
– Falls
– Penetrating injury
– Sports injuries
– Others

• Spinal-cord injuries can lead to permanent
disability; sometimes patient paralyzed.
• When potential for spinal-column injury exists,
restrict motion of spine, first manually, then assess
to determine need for continued spinal motion
restriction.
• Consider MOI and assess signs and symptoms.

• Cervical spine delicate; more prone to injury.
• Risk factor for injury of cervical spine is injury to
head or face.
• Not all patients with head, face, and neck trauma
have a spinal-column or spinal-cord injury.

Think About It
• Given this MOI, what types of injuries might the
pilot have sustained?
• The patient was ambulatory on the scene. What
does that tell Ashley and Sarah about the potential
for significant injury?

Figure 40-1
The central and peripheral nervous systems.

Anatomy and Physiology Review
(1 of 12)
• Central nervous system and peripheral nervous
system communicate with each other.
• Motor neurons
– Exit spinal cord from anterior surface
• Sensory neurons
– Enter the spinal cord from its posterior surface

(2 of 12)
• Gray matter and white matter
– Allow nervous signals to be transmitted up and down
spinal cord, between brain and peripheral nervous
system
• Spinal cord completely severed, communication
from point in cord downward ceases

(3 of 12)
• Central nervous system
– Brain and spinal cord
• Peripheral nervous system
– All nervous tissue outside central nervous system
• Efferent neurons
– Originate in the brain or spinal cord and travel to
effector cells

(4 of 12)
• Afferent neurons
– Sense stimuli throughout body; initiate signals that
travel toward brain or spinal cord
• Efferent portion
– Divided into autonomic and voluntary divisions
• Autonomic nervous system
– Sympathetic and parasympathetic divisions

(5 of 12)
• When signal is disrupted to and from brain, bodily
function affected.
• Nerves do not have ability to regenerate; when
injury occurs, results permanent.
• Brain and spinal cord are protected by skull and
spinal column.
– When significant forces are applied, the brain and
spinal cord are more susceptible to injury.

Figure 40-2
The spinal column.

(6 of 12)
• The spinal column
– Extends from base of skull to pelvis
– 33 vertebrae
– Separated from others by fibrous intervertebral disk
– Hole through center (vertebral foramen)
 Houses and protects spinal cord

(7 of 12)
• The spinal column (continued)
– Cervical spine (C-1 through C-7)
– Thoracic spine (T1 through T12)
– Lumbar spine (L1 through L5)
– Sacral spine
– Coccyx

(8 of 12)
• The spinal column (continued)
– Muscles and ligaments support and hold spine in
position; allow for movement.
– Cervical-spine injuries are more prevalent.
 Weight of head causes hyperflexion, hyperextension, rotation
when forces applied to body

(9 of 12)
• The spinal cord
– Begins at base of brainstem; continues through each
vertebral foramen to L2.
– Each vertebral disk has nerve roots that extend from
the spinal cord through neural foramina.
– Muscle function results from nerve impulses.

(10 of 12)
• The spinal cord (continued)
– Nervous impulses travel to diaphragm by way of
phrenic nerves.
– Injury to spinal cord in high cervical spine region may
result in injury to phrenic nerves and cause failure of
diaphragm to contract; life-threatening ventilatory
insufficiency.

(11 of 12)
– Reflexes
 Defense mechanisms that assist us in preventing injury to
ourselves
 Action that results from nervous stimulation within spinal cord,
not the brain
– Nerve roots of spinal cord allow reflex actions to take
place.

(12 of 12)
– Ascending spinal tracts
 Carry impulses from body to brain
 Carry sensations such as:
– light touch, pressure, pain, temperature, and vibration
– Descending spinal tracts
 Carry motor impulses from brain to body
 Control muscle activity and tone

Mechanisms of Spine Injury
• Not all injury to spinal column results in injury to
spinal cord.
• Take steps to restrict movement of the spine so
that movement does not worsen any injury.

Mechanisms of Spine Injury (2 of 8)
• Compression
• Hyperflexion
• Hyperextension
• Rotation
• Lateral bending
• Distraction
• Penetration

• Spinal-column injury versus spinal-cord injury
– Spinal-column injury
 Damage to musculoskeletal structures—vertebrae or ligaments
of spine
– Spinal-cord injury
 Damage to spinal cord itself; patient will present with
neurologic dysfunction.

• Spinal-column injury versus spinal-cord injury
(continued)
– Primary injury
 Result of compression or shearing of cord; direct result of MOI
– Secondary injury
 Occurs after initial injury; swelling, ischemia, movement of
bone into or against spinal cord
– Spinal-cord concussion
 Temporary disruption of normal spinal-cord function distal to
site of injury

• Complete spinal-cord injury
– Total disruption of spinal cord
– Total loss of neurologic function distal to injury site
– Swelling also occurs.
 As swelling subsides, some neurologic function returns.

• Incomplete spinal-cord injury
– Injury involving portion of spinal cord
– Anterior-cord syndrome
– Central-cord syndrome
– Brown-Sequard syndrome

Figure 40-4
Incomplete spine injuries: (A) Central-cord syndrome results from injury to the central
region of the spinal cord. (B) Anterior-cord syndrome results from injury to the anterior cord.
(C) Brown-Séquard syndrome results from injury to one side of the cord, either right or left.

Table 40-1
Types of Incomplete Spine Injuries
Type of Injury Mechanism of Injury Signs and Symptoms
Anterior-cord
syndrome
Bone fragment introduction
or pressure to blood vessels
of the anterior cord
Loss of motor function and pain,
temperature, and light touch
sensation at and below the level of
injury. Normal vibration and position
senses.
Central-cord
syndrome
Usually occurs with hyperextension of
the
cervical spine
Weakness to upper extremities, while
lower extremities maintain strength.
Variable sensory changes.
Brown-Séquard
syndrome
Penetrating injury causing
hemitransection of one side
of the cord
Loss of motor function and vibration
and position sense on the affected
side of the body with loss of pain and
temperature sensation on the other
side.
Source: NAEMT/ACS (National Association of Emergency Medical Technicians Prehospital Trauma Life Support
Committee in Cooperation with American College of Surgeons Committee on Trauma). 2014. Prehospital Trauma Life
Support. 8th ed. Burlington, MA: Jones and Bartlett Learning.

• Spinal shock
– Concussion-like injury to spinal cord; causes
neurologic deficits below level of injury
– Loss of muscle tone or paralysis below level of injury
– Both smooth and skeletal muscle tone is lost.
 Loss of bowel or bladder control
 Hypothermia (possible)

• Spinal shock (continued)
– If enough vasculature affected, hypotension occurs
(neurogenic hypotension).
– Neurogenic shock:
 Neurogenic hypotension from spinal shock
 Dilation results in relative hypovolemia and patient becomes
hypotensive.
 Compensation is lost due to spinal injury.

Table 40-2
Comparison of Neurogenic and Hypovolemic
Shock*
Neurogenic Shock Hypovolemic Shock
Skin condition Pale and cool above the level of
injury, flushed and warm below the
level of injury
Skin of the entire body is pale
and cool
Heart rate Remains within normal range Tachycardia
*The difference in signs and symptoms of the neurogenic shock patient is due to the loss of sympathetic
stimulation, which is a compensatory mechanism for hypovolemic states.

Assessment and Management (1 of 6)
• Scene size-up
– Ensure scene is safe.
– Assess MOI.
 Maintain high index of suspicion when MOI indicates potential
spine injury.
 For MVCs, assess vehicle for indications.

Table 40-3
Mechanisms of Injury Indicating the Potential for
Spine Injury
• Motor vehicle collisions
• Motorcycle or bicycle crashes
• Falls
• Blunt trauma to the head, neck, or back
• Penetrating trauma to the head, neck, or torso
• Pedestrians struck by a vehicle
• Sports-related injuries of the neck and back
• Hangings
• Diving accidents
• Blunt trauma with altered level of responsiveness

Figure 40-5
Manual stabilization of the head and neck.

• Primary assessment
– If MOI suggests spine injury, perform manual
stabilization of head and neck by grasping either side
of head with gloved hands.
– Instruct patient to remain still; do not allow him to
move.

• Primary assessment (continued)
– Maintain manual stabilization of head and neck until
cervical collar applied and patient positioned properly,
or it is determined spinal motion restriction is not
indicated.
– If ambulatory, have patient stand still during manual
stabilization.
 Ensure adequacy of airway, breathing, and circulation.

• Primary assessment (continued)
– If you must manually open patient’s airway, use
modified-jaw-thrust maneuver.
– Level of responsiveness
 Alterations may indicate head injury, intoxication, shock,
hypoxia.
– Determine critically injured or noncritically injured.
– Make transport decision.

• Secondary assessment
– Perform while maintaining manual stabilization of head
and neck.
– Perform rapid trauma exam.
– During head-to-toe exam, assess neurologic, motor,
sensory function in all four extremities.
 In male patients, presence of persistent erection of penis
(priapism) indicative of spine injury.
– Record baseline vital signs and history.

• Secondary assessment (continued)
– Spinal motion restriction
 Size/apply c-collar.
 Maintain manual stabilization until completely secured to
stretcher.
 Process different for seated or lying patient.
– Reassessment
 Motor function and sensation in all four extremities
 Document changes.

Scan 40-1 (1 of 12)
Assessing Neurologic, Motor, and Sensory Function
1. Assess flexion.

Scan 40-1 (2 of 12)
2. Assess extension.

Scan 40-1 (3 of 12)
3. Assess finger abduction.

Scan 40-1 (4 of 12)
4. Assess finger adduction.

Scan 40-1 (5 of 12)
5. Assess the wrist and hand.

Scan 40-1 (6 of 12)
6. Assess plantar flexion.

Scan 40-1 (7 of 12)
7. Assess dorsiflexion.

Scan 40-1 (8 of 12)
8. Assess pain response in the hand.

Scan 40-1 (9 of 12)
9. Assess pain response in the foot.

Scan 40-1 (10 of 12)
10. Assess light touch response in the hand.

Scan 40-1 (11 of 12)
11. Assess light touch response in the foot.

Scan 40-1 (12 of 12)
12. Assess flexion of the great toe on the same foot.

Think About It
• Should Ashley and Sarah classify this patient as
critical or noncritical? What factors would support
their decision?
• Combining the information from the scene size-up
with the patient’s initial information, what injuries
should Ashley and Sarah suspect?
• How should Ashley and Sarah integrate
assessment, management, and preparation for
transport in this situation?

• Spinal motion restriction
– Not all injured patients require spinal motion restriction.
– Incorporate specific criteria and adhere to them strictly.
– Consider MOIs that are positive indications for spinal
motion restriction and signs and symptoms.

• Spinal motion restriction (continued)
– Assess level of responsiveness.
 If altered or there is a communication barrier, perform spinal
motion restriction.
– Ask patient if neck or back hurts.
 If pain, perform spinal motion restriction.
– Palpate entire spine; ask if tender.
 If tender, perform spinal motion restriction.
– Assess for motor and sensory deficit.
 If deficit, perform spinal motion restriction.

Figure 40-6
Spinal motion restriction decision protocol.

Figure 40-6 (continued)
Spinal motion restriction decision protocol.

• Spinal motion restriction (continued)
– Distracting injury may make less sensitive to presence
of other symptoms.
– Err on the side of caution if unable to determine need
for spinal motion restriction.
– Follow your protocol.

Scan 40-2 (1 of 3)
Sizing a Cervical Collar
1. To size a cervical collar, first draw an imaginary line across the top of the shoulders
and the bottom of the chin. Use your fingers to measure the distance from the shoulder
to the chin.

Scan 40-2 (2 of 3)
2. Check the collar you select. The distance between the sizing post (black fastener) and
lower edge of the rigid plastic should match that of the number of stacked fingers previously
measured against the patient’s neck.

Scan 40-2 (3 of 3)
3. Assemble and preform the collar.

Scan 40-3 (1 of 3)
Applying a Cervical Collar to a Seated Patient
1. After selecting the proper size, slide the cervical collar up the chest wall. The chin must
cover the central fastener in the chin piece.

Scan 40-3 (2 of 3)
2. Bring the collar around the neck and secure the Velcro. Recheck the position of the
patient’s head and collar for proper alignment. Make sure that the patient’s chin covers
the central fastener of the chin piece.

Scan 40-3 (3 of 3)
3. If the chin is not covering the fastener of the chin piece, readjust the collar by tightening
the Velcro until a proper sizing is obtained. If additional tightening will cause hyperextension
of the patient’s head, select the next smaller size.

Spinal Trauma Management
• Current trends
– Decrease or eliminate use of both short and long
backboards as treatment for suspected spine injury.
– Long backboard limited to:
 Blunt trauma and altered level of responsiveness
 Spinal pain or tenderness
 Neurologic complaint
 Anatomic deformity to spine
 High-energy MOI and drug or alcohol intoxication, inability to
communicate, or distracting injury

Spinal Trauma Management (2 of 8)
• Spinal motion restriction for supine and prone
patients
– Perform manual stabilization of the head and neck.
– Size and apply a cervical collar.
– Position the patient on a transfer device such as a
scoop stretcher.
– Transfer the patient onto a stretcher, remove the
transfer device, and secure him to the stretcher using
the stretcher straps.

• Spinal motion restriction for seated patient
– Perform manual stabilization of the head and neck.
– Size and apply a cervical collar.
– While maintaining manual stabilization have the patient
stand and rotate. Then direct the patient to sit on the
stretcher. Use a transfer device if necessary.
– Holding manual stabilization, secure the patient to the
stretcher with the stretcher straps.

Figure 40-8
(A) (B)
(A) Maintain manual stabilization of the head and neck of a seated patient while positioning
her on the stretcher. (© Acadian Ambulance Service, Inc.) (B) After positioning the patient,
secure the patient with the stretcher straps. (© Acadian Ambulance Service, Inc.)

• Spinal motion restriction and rapid extrication
– Procedure for rapid extrication
 Stabilize manually.
 Other rescuers rotate the patient's body in small increments
until the patient's back is facing the transfer device.
 Gently recline patient onto transfer device.
 Slide patient along with device onto stretcher.
 Remove transfer device and secure patient.

• Special considerations—helmet removal
– If helmet fits well, allows for access to airway, and you
can properly immobilize patient using padding beneath
torso, leave helmet in place.
– If helmet does not fit well enough, access to airway not
possible, or you cannot properly immobilize patient with
helmet in place, remove helmet.

• Removal of full-face motorcycle helmets
– EMT 1 grasps face mask portion of helmet; maintains
manual stabilization of head and neck.
– EMT 2 removes or cuts chin strap, gently grasps
mandible with one hand, and supports the posterior
neck with the other.
– Remove helmet slowly and gently.
– EMT 2 hands over manual stabilization to EMT 1.

• Removal of open-face helmets
– EMT 1 performs manual stabilization of head and neck.
– EMT 2 removes or cuts chin strap.
– EMT 2 removes helmet while EMT 1 maintains manual
stabilization of head and neck.
– EMT 2 sizes and applies rigid cervical collar while
EMT 1 maintains manual stabilization of head and
neck.

• Immobilizing infants and children
– Use same procedure for immobilizing infants and
children as with adults.
– Use appropriately sized cervical collar.
– Apply padding beneath torso so neck in neutral
position.

Chapter Summary
• If significant MOI present, or if patient exhibits
signs and symptoms of spine injury, apply spinal
motion restriction.
• Vital that you manage patient appropriately.
Always follow protocols.
• Inappropriate spinal motion restriction can lead to
additional injury or permanent disability.
• The care you provide to spine-injured patients will
reduce likelihood of worsening patient’s condition
and reduce possibility of devastating, lifelong
disability.

Alexander ch40 lecture

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