Spinal Injury


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Stephen Schutts, Master Sergeant, WA ANG
National Registry Emergency Medical Technician - Paramedic

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Spinal Injury

  1. 1. Assessment of Spinal Injury Stephen Schutts, Master Sergeant, WA ANG National Registry Emergency Medical Technician - Paramedic
  2. 2. Objectives <ul><li>Identify the anatomical levels of the spine. </li></ul><ul><li>Understand the function of the spinal cord/column. </li></ul><ul><li>View Types and Mechanisms of injury that can cause spine injury. </li></ul><ul><li>Discuss the difference between Spinal Column Injury vs Spinal Cord Injury. </li></ul><ul><li></li></ul>
  3. 3. Objectives <ul><li>Overview of Spinal Regions and Injuries </li></ul><ul><li>Step by step view of the EMS Spinal Immobilization Assessment Protocol </li></ul><ul><li>Discuss Common Treatment/Management Mistakes </li></ul><ul><li></li></ul>
  4. 4. Introduction <ul><li>Spinal injuries are devastating </li></ul><ul><li>Improper management can have horrible and permanent results </li></ul><ul><li>Appropriate use of spinal immobilization can mean the difference between a patient who fully recovers and one who must spent the rest of his/her life paralyzed </li></ul><ul><li></li></ul>
  5. 5. Mechanism based assessment (the current method) <ul><li>Low-speed fender bender </li></ul><ul><li>An elderly man trips over a lamp cord and falls </li></ul><ul><li>When in doubt back board ‘em </li></ul><ul><li></li></ul><ul><li>Are all 8 patients assumed to have spinal injuries? </li></ul><ul><li>Does this man have a spinal injury? Do all such falls cause spinal injuries? </li></ul><ul><li>Not necessarily, apply EMS Spinal Immobilization. </li></ul>
  6. 6. Anatomy & Physiology- General Structure & Function <ul><li>Spinal Column </li></ul><ul><li>Made up of 26 vertebrae stacked on top of one another </li></ul><ul><li>Divided into 5 areas; cervical, thoracic, lumbar, sacral, and coccyx </li></ul><ul><li></li></ul>
  7. 8. Anatomy & Physiology-“Long Bone” <ul><li>Think of the Spinal Column as on “Long Bone” with “Joints” at each end </li></ul><ul><ul><li>The Cervical spine makes up one “joint” </li></ul></ul><ul><ul><li>The Hip makes up the other </li></ul></ul><ul><ul><li>8 </li></ul></ul>
  8. 9. Anatomy & Physiology- Cervical Spine (7) <ul><li>“ Joint” at the superior end of the spinal “Long Bone” </li></ul><ul><li>Very flexible </li></ul><ul><ul><li>Allows flexion, extension, and rotation of the head </li></ul></ul><ul><li>The head acts as a weighted lever during acceleration/ deceleration </li></ul><ul><li>Common site of spinal injuries </li></ul><ul><li></li></ul>
  9. 11. C-1 “Atlas” C-2 “Axis” <ul><li>C-1 supports the full weight of the head </li></ul><ul><li>C-1 and C-2 allow head rotation and fine flexion and extension </li></ul><ul><li>11 </li></ul>
  10. 12. Anatomy & Physiology- Thoracic Spine (12) <ul><li>Much less flexible than C-Spine </li></ul><ul><ul><li>Stabilized by rib cage (especially down to T-10) </li></ul></ul><ul><li>Spinal canal narrow through T-Spine </li></ul><ul><ul><li>Spinal cord tightly fitted into narrow space </li></ul></ul><ul><ul><li>Spinal cord ends about T-12 or L-1 </li></ul></ul><ul><ul><li></li></ul></ul>
  11. 14. Anatomy & Physiology- Lumbosacral Spine <ul><li>5 Lumbar vertebrae plus sacrum and coccyx </li></ul><ul><li>More flexible than T-spine </li></ul><ul><li>More room in spinal canal </li></ul><ul><li>Spinal cord ends about T-12 or L-1 </li></ul><ul><ul><li>flexible nerve roots (Cauda equina) flow through LS spine </li></ul></ul><ul><ul><li></li></ul></ul>
  12. 16. Anatomy & Physiology- Spinal Cord <ul><li>Bundles of nerve fibers originating in the brain </li></ul><ul><li>Bundles or tracts travel in right and left pairs </li></ul><ul><li>Spinal Tract pairs crossover midline at various specific levels </li></ul><ul><ul><li>always in specific anatomical areas </li></ul></ul><ul><ul><li>understanding of the structure of these tracts helps in assessing spinal cord injuries </li></ul></ul><ul><ul><li></li></ul></ul>
  13. 18. Mechanism of Injury <ul><li>Physical manner and forces involved in producing injuries or potential injuries </li></ul><ul><li>Valuable tool in determining if the a particular set of circumstances could have caused a spinal injury </li></ul><ul><li>Mechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents) </li></ul><ul><li></li></ul>
  14. 19. Hyperflexion
  15. 20. Hyperextension
  16. 21. Hyperotation
  17. 22. Axial Loading
  18. 23. Axial Distraction
  19. 24. Sudden/Extreme Lateral Bending <ul><li>Excessive/abnormal lateral movement of the spine </li></ul><ul><li>Can affect any portion of the spine </li></ul><ul><li>Example: T-bone MVAs </li></ul><ul><li></li></ul>
  20. 25. Spinal Column Injury <ul><li>Bony spinal injuries may or may not be associated with spinal cord injury </li></ul><ul><li>These bony injuries include: </li></ul><ul><ul><li>Compression fractures of the vertebrae </li></ul></ul><ul><ul><li>Comminuted fractures of the vertebrae </li></ul></ul><ul><ul><li>Subluxation (partial dislocation) of the vertebrae </li></ul></ul><ul><li>Other injuries may include: </li></ul><ul><ul><li>Sprains- over-stretching or tearing of ligaments </li></ul></ul><ul><ul><li>Strains- over-stretching or tearing of the muscles </li></ul></ul><ul><ul><li></li></ul></ul>
  21. 26. Spinal Cord Injury <ul><li>Cutting, compression, or stretching of the spinal cord </li></ul><ul><li>Causing loss of distal function, sensation, or motion </li></ul><ul><li>Caused by: </li></ul><ul><ul><li>Unstable or sharp bony fragments pushing on the cord, or </li></ul></ul><ul><ul><li>Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia </li></ul></ul><ul><ul><li></li></ul></ul>
  22. 27. Primary Spinal Cord Injury <ul><li>Immediate and irreversible loss of sensation and motion </li></ul><ul><li>Cutting, compression, or stretching of the spinal cord </li></ul><ul><li>Occurs at the time of impact/injury </li></ul><ul><li></li></ul>
  23. 28. Secondary Spinal Cord Injury <ul><li>Injury Delayed </li></ul><ul><li>Occurs later due to swelling, ischemia, or movement of sharp or unstable bone fragments </li></ul><ul><li>May be avoided if spine immobilized during extrication, packaging, treatment, and transport </li></ul><ul><li></li></ul>
  24. 29. Incomplete Spinal Cord Injury <ul><li>Complete injury to specific spinal tracts with reduced function distally </li></ul><ul><li>Other tracts continue to function normally with distal function intact </li></ul><ul><li></li></ul>
  25. 30. Spinal Region Overview <ul><li>Cervical Spine Injuries </li></ul><ul><li>Thoracic Spine Injuries </li></ul><ul><li>Lumbosacral Spine Injuries </li></ul><ul><li>Spinal Injury Summary </li></ul><ul><li></li></ul>
  26. 31. Cervical Spine Injuries <ul><li>C-spine very flexible </li></ul><ul><li>Most frequently injured area of spine </li></ul><ul><li>Most injuries at C-5/C-6 level </li></ul><ul><li></li></ul>
  27. 32. Thoracic Spine Injuries <ul><li>T-spine less flexible </li></ul><ul><li>Narrow spinal canal </li></ul><ul><li>Cord injury occurs with minimal displacement </li></ul><ul><li>Common mechanisms </li></ul><ul><li>Any cord damage usually complete at this level </li></ul><ul><li>Most T-spine injuries occur at T-9/T-10 </li></ul><ul><li></li></ul>
  28. 33. Lumbosacral Spine Injuries <ul><li>LS spine flexible nerve roots in roomy spinal canal </li></ul><ul><li>May have bony injury w/o cord or nerve root damage </li></ul><ul><li>Secondary injury still possible </li></ul><ul><li>Neurological injury rare w/ isolated sacral injuries </li></ul><ul><li></li></ul>
  29. 34. Assessment Overview <ul><li>Decision to apply spinal immobilization in past based was solely on mechanism of injury </li></ul><ul><li>Utilize EMS Spinal Immobilization Algorithm to determine when spinal immobilization is NOT needed </li></ul><ul><li></li></ul>
  30. 35. Spinal Immobilization Algorithm <ul><li>Patient Mentation : </li></ul><ul><li>Decreased Level of Consciousness? </li></ul><ul><li>No Yes ----------------------------Immobilize </li></ul><ul><li>ETOH/Drug Impairment? </li></ul><ul><li>No Yes ----------------------------Immobilize </li></ul><ul><li>Subjective Assessment : </li></ul><ul><li>Cervical/Thoracic/Lumbar Spinal pain? </li></ul><ul><li>No Yes ----------------------------Immobilize </li></ul><ul><li>Numbness/Tingling/Burning/Weakness? </li></ul><ul><li>No Yes -----------------------------Immobilize </li></ul><ul><li>Objective Assessment: </li></ul><ul><li>Cervical/Thoracic/Lumbar Deformity or Tenderness? </li></ul><ul><li>No Yes -----------------------------Immobilize </li></ul><ul><li>Other Severe Injury? </li></ul><ul><li>No Yes -----------------------------Immobilize </li></ul><ul><li>Other Severe Injury? </li></ul><ul><li>No Yes -----------------------------Immobilize </li></ul><ul><li>Pain w/Cervical Range of Motion? </li></ul><ul><li>No Yes -----------------------------Immobilize </li></ul><ul><li> MAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONS </li></ul><ul><li></li></ul>
  31. 36. Principles of Treatment <ul><li>Protect spinal cord from secondary injury </li></ul><ul><li>We have little or no effect on primary injury </li></ul><ul><li>Focus on prevention of secondary injury </li></ul><ul><li></li></ul>
  32. 37. Complete Spinal Immobilization <ul><li>Must act as if whole spine unstable </li></ul><ul><li>Immobilize entire spine </li></ul><ul><li>To do this we must immobilize the head, neck, shoulders/chest, and pelvis /hips </li></ul><ul><li></li></ul>
  33. 38. Common Treatment/Management Mistakes <ul><li>Improperly sized C-Collar </li></ul><ul><li>Spine not supported due to improper positioning on backboard </li></ul><ul><li>Inadequate strapping allows excessive movement </li></ul><ul><li>Movement possible due to little or no padding to shim the body </li></ul><ul><li>C-spine movement by inadequate or improperly applied head immobilization device </li></ul><ul><li>C-spine hyperextension due to improperly applied C-collar or head immobilization device </li></ul><ul><li></li></ul>
  34. 39. Common Treatment/Management Mistakes (cont.) <ul><li>Readjusting torso straps after immobilization of the head, causing misalignment of the spine </li></ul><ul><li>Securing head to backboard prior to securing shoulders, torso, hips, and legs </li></ul><ul><li></li></ul>
  35. 40. Any Questions???