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Chapter11 spinal trauma
1. International Trauma Life Support
for Emergency Care Providers
CHAPTER
eighth edition
International Trauma Life Support for Emergency Care Providers, Eighth Edition
John Campbell • Alabama Chapter, American College of Emergency Physicians
Spinal Trauma and
Patient-Centered
Spinal Motion
Restriction
11
2. Spinal Trauma and Patient-Centered
Spinal Motion Restriction
Courtesy of Louis B. Mallory, MBA, REMT-P
Key Lecture Points
Cover the anatomy of the spine briefly.
Reinforce that any trauma patient who has an altered level of consciousness must be presumed to have a cervical spine injury until proven otherwise. Appropriate precautions must be taken.
Stress that not only must the cervical spine be protected, but also the entire spine, including the lumbar and dorsal spine.
Briefly discuss the signs, symptoms, and treatment of neurogenic shock.
Stress documentation of the brief neurological exam (movement and sensation of hands and feet) before and after extrication or movement of the patient with a suspected spinal injury.
Stress that full SMR includes cervical collar, head immobilizer, and appropriate strapping applied to the patient on a long spine board.
Stress that cervical collars alone offer little to no protection of the cervical spine. ITLS teaches that SMR is manually maintained by a team member until the patient is secured to the long spine board.
Emphasize that SMR on a long spineboard MANDATES airway protection by the rescuer due to the patient being prevented from protecting himself.
Discuss the indications for rapid extrication (without using short boards or KED-type devices). Primary survey of the patient identifies a condition that requires immediate intervention that cannot be done in the entrapped area, such as:
Airway obstruction that cannot be relieved by jaw thrust or finger sweep
Cardiac or respiratory arrest
Chest or airway injuries requiring ventilation or assisted ventilation
Deep shock or bleeding that cannot be controlled
Note that there are other situations that are so desperate that you may not have time to use any technique, and emergency rescue is warranted to pull the patient to safety. The need for emergency rescue is identified during the scene survey with circumstances that may immediately endanger the patient and the rescuers.
Fire or immediate danger of fire
Danger of explosion
Rapidly rising water
Structure in danger of collapse
Continuing toxic exposure
Mention that short backboard type SMR devices may be difficult to apply and ineffective in pregnant and very obese patients.
Briefly clarify management of unusual circumstances, such as:
Closed space rescue
Water rescue
Prone and standing patients
Pediatrics
Geriatrics
Helmet removal (stress that studies have found that rescue scissors will not efficiently remove face masks)
Obese patients
Neck or face wounds
Remember: SMR needs to be in an anatomically neutral position specific for each patient to be neutral for spinal cord and airway. Although texts often recommend age ranges (including ITLS), SMR is principle-driven. Appropriate padding should be used for all age groups and situations (elderly, American football shoulder pads, infants, obesity, etc).
Previous terms: traction and immobilization. This term more accurately reflects proper treatment and reality in field, because in certain patients, especially in prehospital environment, spine cannot be completely immobilized.
No prospective randomized controlled clinical trials that compare methods of spinal motion restriction. No Class I evidence and no formal standards of care.
IMAGE: Figure 11-1: Anatomy of spinal column.
IMAGE: Figure 11-2a: Vertebra viewed from above. Spinal cord passes through vertebral foramen (on page 162).
NOTE: Differentiate spinal column from spinal cord.
Bony tube composed of 33 vertebrae.
Supports body in an upright position, allows use of our extremities, and protects delicate spinal cord.
Column's 33 vertebrae are identified by their location: 7 cervical (the C-spine), 12 thoracic (the T-spine), 5 lumbar (the L-spine), and remainder fused together as posterior portion of pelvis (5 sacral and 4 coccygeal).
Vertebrae are numbered in each section, from head down to pelvis. Third cervical vertebra from head is designated C-3, sixth is called C-6, and so forth. Thoracic vertebrae are T1–T12, and each attaches to one of 12 pairs of ribs. Lumbar vertebrae are numbered L1–L5, with L5 being last vertebra above pelvis.
Vertebrae are each separated by a fibrous disc that acts as a shock absorber.
Spinal column is aligned in a gentle S-curve that is most prominent at C5–C6 and T12–L1 levels in adults, making these areas most susceptible to injury.
IMAGE: Figure 11-3: Spinal nerves.
IMAGE: Figure 11-2b: Vertebra with spinal cord viewed from top.
IMAGE: Figure 11-4: Relationship of spinal cord to vertebrae.
Extension of brain stem down to level of first lumbar vertebra and at that point separates into nerves.
Cord is 10 to 13 mm in diameter and is suspended in middle of vertebral foremen.
Cord is soft and flexible like a cotton rope, and is surrounded and bathed by cerebrospinal fluid along its entire length.
Fluid and flexibility provide some protection to cord from injury.
Composed of specific bundles of nerve tracts that are arranged in a predictable manner.
Spinal cord passes down vertebral canal and gives off pairs of nerve roots that exit at each vertebral level.
Roots lie next to intervertebral discs and lateral part of vertebrae, making nerve roots susceptible to injury when trauma occurs in these areas.
Nerve roots carry sensory signals from body to spinal cord and then to brain.
Roots also carry signals from brain to specific muscles, causing them to move.
Signals pass back and forth rapidly, and some are strong enough to cause actions on their own, called reflexes.
Strong signals also can overwhelm spinal cord's ability to keep signals moving separately to brain.
Integrity of spinal-cord function is tested by motor, sensory, and reflex functions.
Level of sensory loss is most accurate for predicting level of spinal-cord injury.
Muscle strength is another function that is easy to assess in conscious patient.
Reflexes are helpful for distinguishing complete from partial spinal-cord injuries, but are best left for hospital assessment.
Spinal cord is also an integrating center for autonomic nervous system, which assists in controlling heart rate, blood vessel tone, and blood flow to skin.
Injury to this component of spinal cord results in neurogenic shock (commonly called spinal shock), which is discussed later.
IMAGE: Table 11-1: Mechanism of Blunt Spinal Injury
Hyperextension
Excessive posterior movement of the head or neck
Hyperflexion
Excessive anterior movement of head onto chest
Compression
Weight of head or pelvis driven into stationary neck or torso
Rotation
Excessive rotation of the torso or head and neck, moving one side of the spinal column against the other
Lateral Stress
Direct lateral force on spinal column, typically shearing one level of cord from another
Distraction
Excessive stretching of column and cord
Spinal-cord injury occurs throughout the world with an annual incidence of 15 to 40 cases per million.
The majority of demographic and epidemiological data related to traumatic spinal-cord injury has been collected in North America and Europe. Data collected by the Model Spinal Cord Care Systems and are published by the National Spinal Cord Injury Statistical Center
In the United States, the incidence of spinal injury is about 40 per million persons per year, with approximately 250,000 living survivors of spinal-cord injury in the United States in 2010.
The male-to-female ratio of individuals with spinal-cord injury in the United States is 4:1.
More than 50% of all cases of spinal-cord injuries occur in persons aged 16–30 years. Greater mortality is reported in older patients with spinal injury.
Motor-vehicle collisions account for 56% of them.
Among children so injured, 67% of those injured in a motor-vehicle collision were not wearing a seatbelt.
Under age 8, the relatively large size of the head makes the upper end of the cervical cord the most common site of injury, which can be devastating.
In the cervical spine region, it is much more common to have cord injury, with almost 40% of column injuries having cord damage.
NOTE: Paresthesia (tingling or burning feeling to skin)
Spinal-cord injury results in a defective signal-conducting function, presenting as a loss of motor function and reflexes, loss or change in sensation, or neurogenic shock. The delicate structure of the spinal cord's nerve tracts makes it very sensitive to any form of trauma.
Primary spinal-cord injury occurs at the time of the trauma itself. Primary spinal-cord injury results from the cord being cut, torn, or crushed or by its blood supply being cut off. The damage is usually irreversible despite the best trauma care.
Secondary spinal-cord injury occurs from hypotension, generalized hypoxia, injury to blood vessels, swelling, compression of the cord from surrounding hemorrhage or injury to the cord from movement of a damaged and unstable spinal column. Emergency efforts are directed at preventing secondary spinal-cord injury through attention to the ABCs, medications, and careful packaging of the patient.
NOTE: See also Chapter 8 for high-space shock.
In healthy patient, blood pressure maintained by controlled release of catecholamines (epinephrine and norepinephrine) from adrenal glands.
Sensors in aortic and carotid arteries monitor blood pressure. Catecholamines cause constriction of blood vessels, increase heart rate and strength of heart contraction, and stimulate sweat glands. Brain and spinal cord signal adrenal glands to release catecholamines to keep blood pressure in normal range. In pure hemorrhagic shock, these sensors detect hypovolemic state and compensate by constricting blood vessels and speeding heart rate. High levels of catecholamines cause pale skin, tachycardia, and sweating.
Mechanism of shock from spinal-cord injury is just opposite.
There is no significant blood loss, but injury to spinal cord destroys ability of brain to regulate release of catecholamines from adrenals (the spinal cord cable is out), so no catecholamines are released. When levels of catecholamines drop, blood vessels dilate, causing blood to pool. This drop in preload causes blood pressure to fall. Brain cannot correct this because it cannot get message to adrenal glands.
Patient with neurogenic shock cannot show signs of pale skin, tachycardia, and sweating because cord injury prevents release of catecholamines.
NOTE: More detailed neurological exam in Chapters 2 and 10.
Document these findings later in written report. Not only does this pre-extrication neurological exam alert you to any spinal injury, it also provides documentation on whether or not there was loss of function before extrication was begun.
NOTE: SMR and Rapid Extrication are covered in skill stations. Give basic principles and foundations.
Document details of any situation requiring emergency rescue or Rapid Extrication.
Modification to SMR:
Immediate danger of death.
Critical degree of ongoing danger that requires an intervention within 1 or 2 minutes.
Emergency rescue: Immediate environmental threat of life
Fire or immediate danger of fire or explosion.
Hostile environment, gunfire, or other weapons.
Danger of being carried away by rapidly moving water.
Structure in immediate danger of collapse.
Continuing immediately life-threatening toxic exposure.
Rapid extrication: Medical condition or situation that requires an intervention within 1 or 2 minutes
Airway obstruction that cannot be relieved by modified jaw thrust or finger sweep.
Cardiac or respiratory arrest.
Chest or airway injuries requiring ventilation or assisted ventilation.
Deep shock or bleeding that cannot be controlled.
IMAGE: Figure 11-5: Neutral alignment
Proper padding is often required to obtain and maintain neutral alignment of patient's cervical spine when you perform spinal motion restriction.
A truly neutral cervical-spine position for an adult is usually obtained with use of 1 to 2 inches of occipital padding on a long backboard. This slightly elevates head and brings neck into a neutral position that tends to make patient more comfortable and also makes endotracheal intubation easier if needed. This is accomplished with head pad on a cervical motion-restriction device or padding that is used with many backboard devices.
Elderly patients whose necks have a natural flexed posture will require more padding.
Children, because their heads are proportionately larger, usually require padding under shoulders to prevent neck flexion on backboard.
IMAGE: Figure 11-6b: Miller board splint
IMAGE: Figure 11-6c: Pediatric SMR
IMAGE: Figure 11-6d: Kendricks Extrication Device (KED)
IMAGE: Figure 11-6e: Wood short spine board
A wide range of devices that provide spinal motion restriction (SMR) for injured patients is available in the marketplace.
No device has yet been proven to excel over all others, and no device will ever be produced that can be used to provide SMR for all patients.
No device is better than the crew using it. Training with the available tools is the most critical factor in providing good patient care.
The head and airway are in a fixed position, which can produce airway compromise and aspiration if the patient vomits.
The patient will be uncomfortable and will often complain of head and low back pain that is directly related to being strapped onto the hard backboard.
Obese patients and those with congestive heart failure can suffer life-threatening hypoxia.
On a rigid board, there is uneven skin pressure that can result in pressure sores.
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Lifting the patient and the board can cause injuries to rescue personnel.
Patients with penetrating trauma to the chest or abdomen are critical load-and-go patients. The extra time it takes to perform SMR can have a devastating effect on survival. When you have a patient with a gunshot or stab wound of the trunk that is not in proximity to the spine and no symptoms of spinal injury, you should carefully but quickly load the patient on the stretcher and transport immediately.
Similarly, isolated gunshot wounds to the head may not require SMR.
SMR should be applied appropriately to those who will most likely benefit, and it should be avoided if not necessary.
The widely held belief is that injured patients must have SMR performed until an injury can be ruled out.
However, as mentioned above, there are no Class I studies to confirm this, and some countries do not perform SMR.
One study has been done comparing the EMS systems of a country that performs no SMR (Malaysia) and one that consistently performs SMR (the United States). The study concluded that prehospital SMR had little or no effect on neurological outcome in patients with blunt spinal trauma.
This is not to condemn SMR, but to remind us that what we are doing is based on logic and not actually based on scientific evidence.
SMR is not required if there is no mechanism of injury that would damage the spine (foot crushed by a car).
If the mechanism is a high-risk event, SMR is performed regardless of other clinical findings. High-risk situations include high-speed motor-vehicle collisions, falls of greater than three times the patient's height, penetrating wounds into or near the spinal column, sports injuries to the head or neck, diving accidents, and any trauma situation in which the patient remains unconscious.
If the danger of spinal injury is uncertain (ground-level fall, low-speed “fender bender”), the rescuer should manually stabilize the spine and then assess the patient for signs of spinal injury.
IMAGE: Figure 11-8: Decision Tree for SMR
Studies have resulted in a clinical pathway referred to as the Maine Protocol for Spinal Motion Restriction, which was published in 1994 by Peter Goth, MD (Figure 11-8).
This protocol is supported by the National Association of EMS Physicians. (See Table 11-3 for NAEMSP's position paper on spinal motion restriction.)
You must assess the mechanism of injury, interview and examine the patient, then use this information to determine which patients need SMR. From the scene size-up, history, and assessment come the clues that identify the patients who do not need SMR.
The patient must be reliable enough to understand the EMS provider and answer the questions accurately, so children and patients with altered mental status or acute stress reactions are excluded.
The patient is assessed for evidence of intoxication or distracting injuries that may not allow the patient to clearly feel the pain associated with a spinal injury.
The patient is asked if he has pain in the area of the spinal column.
If no pain is present in the neck or back, and no other injuries are so painful as to distract the patient from comprehending back or neck pain, the rescuer then carefully examines the spinal column and performs a neurological exam.
If there is any tenderness on palpation of the spinal column area or if the patient complains of midline pain when asked to move his back, SMR is performed. SMR is also performed if there are alterations in the motor or sensory exam.
If the patient has no high-risk mechanism of injury, no alteration of mental status, no distracting injuries, is not intoxicated, has no pain or tenderness along the spine, and has no neurological deficits, the patient may be treated and transported without SMR.
This protocol has proven effective in research studies but, like all medical protocols, must be approved for local use by medical direction and followed up with a quality assurance program.
IMAGE: Figure 11-9: Controlling airway
SMR in any manner, the patient loses some of her ability to maintain her own airway.
The rescuer must then assume this responsibility until the patient has a controlled airway or has the spinal column cleared in the emergency department and is released from the motion-restricting equipment.
Nasotracheal, orotracheal, or cricothyroid intubations all induce some bony movement.
The risk of dying with an uncontrolled airway is greater than the risk of inducing spinal-cord damage using a careful approach to intubation.
IMAGE: Figure 11-10: Closed space rescue
Closed-Space Rescues
Safety of the rescuer is of prime importance in all closed-space rescues. Asphyxia, toxic gases, and structure collapse are dangers of closed-space rescue and may require the use of emergency rescue.
Never enter a closed space unless you are properly trained, equipped (air pack, safety line, and so on), and sure of scene safety.
The only general rules that can be applied to these rescues are to prevent gross spinal movement and to move patients in line with the long axis of the body (Figure 11-10).
IMAGE: Scan 11.1: Water rescue
Water Emergencies
You can perform water rescues by moving the patient in line.
The backboard is floated under the patient, and the patient is then secured and removed from the water.
Safety of both rescuers and patients is of paramount importance. If you are not trained in water rescue, do not attempt to rescue victims in hazardous situations such as deep or swift water.
Prone patients are log-rolled onto a backboard, with careful coordination of head and chest rescuers.
Seated patients may be stabilized using short backboards or their commercial adaptations. Used appropriately, short backboards provide initial stabilization of cervical and thoracic spine and then facilitate movement of patient onto a long backboard.
NOTE: Most car seat manufacturers recommend only transporting child in safety seat if there is no visible sign of damage to safety seat.
Children who are involved in an MVC while restrained in a child safety seat but have no apparent injuries may be packaged in safety seat for transport to hospital. Using towel or blanket rolls, cloth tape, and a little reassurance, you can secure child in safety seat and then belt seat into ambulance.
When child is in a car seat that is damaged, or in a built-in child-restraint seat that cannot be removed, child must be removed for SMR. Children in such situations will have to be carefully extricated onto a backboard or another pediatric SMR device, using manual stabilization.
Elderly patients require flexibility in packaging techniques.
Many elderly patients have arthritic changes of spine and very thin skin. Such patients will be very uncomfortable when placed on a backboard.
Some arthritic spines are so rigid that patient cannot be laid straight on board, and some elderly patients have rigid flexion of neck that will result in a large gap between head and board.
Make use of towels, blankets, and pillows to pad elderly patient and prevent movement and discomfort on backboard.
IMAGE: Figure 11-14a: Face guard
IMAGE: Figure 11-14b: Pruning sheers
Football and ice hockey helmets are custom fitted to individuals. Unless special circumstances exist, such as respiratory distress coupled with an inability to access airway, helmet should not be removed in prehospital setting.
Athletic helmet design will generally allow easy airway access once face guard is removed.
Best method to remove face guard is with screwdriver (cordless screwdriver is best), but sometimes screw slot strips out and face guard will have to be cut off.
Excellent device made specifically for cutting off four face guard mounting strips exists (Face Mask Extractor by Collins Sports Medicine), but at this time it is extremely expensive.
Next best choice is to use anvil pruning shears.
Rescue scissors have been advocated in past, but studies have found them to be unsuitable for this task.
Unhooking chin strap may cause movement of spine. It is better to cut chin strap.
IMAGE: Figure 11-15a: Neutral alignment with helmet and shoulder pads.
IMAGE: Figure 11-15b: Shoulder pads without helmet.
Athlete wearing shoulder pads has neck in neutral position when on backboard with helmet in place.
If helmet removed, padding must be inserted under head to keep neck from extending.
Most shoulder pads removed by cutting axillary straps and laces on front of appliance, opening appliance from core outward (like a clam shell), and sliding appliance out from under athlete.
IMAGE: Figure 11-16: Motorcycle helmet
NOTE: This skill is covered in skill stations.
Motorcycle helmets often removed in prehospital setting.
Removal technique is modified to accommodate different design.
Motorcycle helmets are often designed with a continuous solid face guard that limits airway access.
These helmets are not custom designed and frequently are poorly fitted, and their large size usually produces significant neck flexion if left in place when patient is positioned on a backboard.
Motorcycle helmets will make it difficult to stabilize neck in a neutral position, may obstruct access to airway, and may hide injuries to head or neck.
Helmet should be removed in prehospital setting, using techniques described in Chapter 12.
Cervical collars will prevent continued examination of the wound site and could compromise the airway in wounds with expanding hematomas or subcutaneous air.
If the mandible is fractured, the collar might again cause airway compromise.
It may be wise to avoid collars and use instead manual stabilization and head cushion devices or blanket rolls for cervical motion restriction.
Remember with penetrating neck wounds, unless spinal involvement, SMR is usually not needed.
