1) The document outlines trauma management protocols, with a focus on spinal cord injuries. It describes the ABCDE approach for initial assessment and management of major trauma patients. 2) It provides details on mechanisms of spinal cord trauma, pre-hospital preparation, secondary evaluations, considerations for special populations, and principles for management during the first 72 hours after injury. 3) The document emphasizes the importance of spine immobilization during transport and stresses that spinal injuries often occur alongside other traumatic injuries, so management must consider the whole clinical picture.

1. March 28,2017 1
Dr. Abhishek Neupane
Medical Officer
Medical Department , SIRC

2. Trauma management protocol (ABCDE)
INTRODUCTION
In physical medicine, major trauma is
injury or damage to a biological
organism caused by physical harm
from an external source.
Major trauma is also injury that can
potentially lead to serious long-term
outcomes like chronic pain and
disabilities.

3. Mechanisms of Trauma (leading to SCI)
• Road Traffic Accidents
• Falls
• Natural disasters like earthquake
• Sports injury
• Violence/war
• Carrying heavy loads

4. Preparedness(at hospital setup)
• Pre-arrival preparation and
Trauma Team- a
multidisciplinary group of
healthcare workers who
collectively work together
on the assessment and
treatment of those who are
severely injured along with
availability of equippments
required(ALS).

5. Primary Evaluation and Management
(at the site of injury)
• Triage ie classification of
patients on priority basis-
(including other severe
injuries check for suspicious
spinal injuries and handle it
accordingly)

6. Management Protocol after proper
assesment(ABCDE/CABDE)
A)Airway
- Assessment
Talk to the patient!
Protect Cervical Spine
Give Oxygen
Assess Airway: look,
Listen and
Feel
- Intubation IF REQUIRED(at hosp setup)
Further steps if airway is obstructed
(cricothyrotomy may be considered)

7. B-Breathing and ventilation
• Oxygenation if required and if available
• Management: oxygen/assisted ventilation(artificial
respiration)/decompression of tension pneumothorax/draining
of haemo/ pneumothorax
• Asses Chest movement-Further steps if required

8. C-Circulation
• Blood pressure/heart rate(pulse) monitoring, exclude the state of
shock
• Check for Hemorrhage-sites of Hemorrhage, Shock, Hypovolumia and
Resuscitation/Management-
• consider Blood Transfusion or start IV fluids if possible
-Detection of site of Hemorrhage
-Causes of Hemorhhage from different sites -
Head/chest/Abdomen/Pelvis/ limbs
• (if ventillation and proper circulation is not noticed go for CPR
protocol)

9. Consider Nonhemorrhagic causes of shock
This occurs secondary to sympathetic denervation, resulting in
arteriolar dilation and pooling of blood in the venous compartment,
and interruption of cardiac sympathetic innervation (T1–T4) with
unopposed vagal activity promotes bradycardia and reduced
myocardial contractility.
Neurogenic shock is suggested by decreased blood pressure and
systemic vascular resistance with a variable heart rate response.
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10. D-Disability and neurologic evaluation
-assessment for neurological disability from Brain(GCS) or spinal cord
E-Exposure and environmental control
-Undress the patient and look for hidden injuries

11. • Go for Available Diagnostic studies(if possible)
- Portable radiographs
- Ultrasound (FAST exam)
- Emergency computed tomography (CT)
- Diagnostic peritoneal tap or lavage
- Electrocardiogram
- Laboratory tests

12. Secondary evaluation
Physical examination
- Head and face
- Neck
- Chest
- Abdomen
- Rectum and genitourinary
- Musculoskeletal
- Neurologic
- Skin

13. • Additional imaging(if possible for
hosp setup)
- Plain radiographs
- Computed tomography, including
total body CT

14. Pitfalls and pearls(what may be obscured during
assessment and management)
Esophageal intubations
Hemorrhagic shock
Cardiac tamponade
Thoracoabdominal injury
Penetrating bowel injury
Open book pelvic fractures
Ocular injuries
Elder patients
Analgesia and sedation

15. Consider following
• -Paediatric Trauma
-Trauma in Pregnancy
-Trauma in old age
At the extremes of age, or in the presence of a
preexisting spine deformity, provide patient
care in the position of greatest comfort while
maintaining immobilization.

16. “Spinal cord injury often does not exist in
isolation. Other traumatic and medical
conditions of the patient must be
considered when selecting management
strategies. As with all trauma patients,
the acute management of a patient with
SCI requires rapid restoration of the airway,
breathing, and circulation”

17. Post injury disabilities- signs of SCI
(spinal cord injury)
Weakness / paralysis
Loss/impaired sensation
Change of tone
Bladder dysfunction
Bowel dysfunction
Blood pressure dysfunction
Thermo-regulation dysfunction
Sexual dysfunction

18. For any suspected cases of SCI
• Consider Immobilization of spine:
-If the immobilization is indicated then the whole spine must be
immobilized.
-Immobilization should be maintained until the individual reaches
hospital.

20. Transportation
A major obstacle to transporting injured patients to health facilities in
resource limited settings is the lack of adequate prehospital systems.
Long transportation time, lack of appropriate airway, cervical spine and
monitoring equipment makes concurrent airway management and spine
immobilization difficult.
In settings where no specialized transport equipment such as backboard exits,
use of blanket or tarpaulin is reasonable alternative.

21. Before a patient with a spinal cord injury is
transported from one facility to another, the following protocol should be
completed to ensure that the patient’s condition is sufficiently stabilized:
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1)Spine immobilization is adequate and secure.
2)The airway is clear and can be maintained
during transfer;consider intubation prior to
transfer if PaCO2 is elevated or if ventilatory
failure is likely to develop during a prolonged
transfer.
3)A chest tube is in place for any pneumoor
hemothorax, especially if air transport is
considered.
4)Supplemental oxygen is being administered
and ventilation (spontaneous or assisted) is
adequate.
5)IV (intravenous fluid) is patent and infusing at
the desired rate.
6)Hemodynamic parameters have been
stabilized and can be monitored during
transport.
7)When indicated, nasogastric tube is in situ,
draining freely, and connected to low suction.
Indwelling urinary catheter is in situ and
draining freely.

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8) Skin is protected from injury due to excessive pressure, especially over bony
prominences,
such as the sacrum, that contact the support surface, and any apparatus or debris that
could cause pressure sores is cleared away.
9)Neurological level and completeness of injury,as determined from a motor and sensory
examination according to the International Standards Neurological Classification of
SCI /AIS Scoring are documented immediately prior to transferring the patient.
10)All imaging and other records accompany the
patient.

23. Management at Hospital:
Immediate care : Principles for “FIRST 72 HOURS”
Transfer the patient with a potential spinal injury as soon
as possible off the backboard into a firm padded surface
while maintaining spinal alignment.

24. .
Altered mental status.
Evidence of intoxication.
Suspected extremity fracture or distracting
injury.
Focal neurological deficit.
Spinal pain or tenderness.
Emergency medical service (EMS) providers should use the
following five clinical criteria to determine the potential risk of
cervical spinal injury in a trauma patient:

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In cases of confirmed spinal or spinal cord
injury, maintain spine immobilization until
definitive treatment

26. Neuroprotection:
Pharmacologic Neuroprotection in Patients
with Spinal Cord Injury
No clinical evidence exists to definitively
recommend the use of any neuroprotective
pharmacologic agent, including steroids, in
the treatment of acute spinal cord injury to
improve functional recovery.
-Methylprednisolone.
-GM-1: ganglioside GM-1
-Gacyclidine.
-Tirilazad and naloxone.
-Other promising pharmaceutical agentscurrently undergoing investigation include a tetracycline
derivative, minocycline (phase II investigationin Calgary, Canada), and erythropoietin, the
hormonethat regulates erythropoiesis.
July 24, 2018 26

27. Take home message:
Most of the spinal injuries are
flared up while transportation
that lacks proper immobilization
(consider ABCDE before referral)

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Thank you