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Lesson 7 b
- 1. Lesson 7B Disability —Part Two Central Nervous System Trauma: Injuries to the Spinal Cord
- 2. Spinal Trauma (1of 2) • In the United States, 15,000 to 20,000 spinal injuries occur annually • It is most common in ages 16 to 35 years • 80% of cases occur in males
- 3. Spinal Trauma (2of 2) • Causes include: – MVCs: 48% – Falls: 21% – Penetrating injuries: 15% – Sports injuries: 14% – Other: 2% • Improper assessment and management can result in permanent paralysis
- 4. Anatomy: Spinal Column (1of 2) • Cervical (7 vertebrae) • Thoracic (12 vertebrae) • Lumbar (5 vertebrae) • Sacrum (5 vertebrae) • Coccyx (4 vertebrae)
- 5.
- 6. Anatomy: Spinal Cord (1of 2) • The spinal cord fills the spinal canal – Leaves little room for swelling, hemorrhage, or bone injury • Contains motor and sensory tracts • The tracts form nerves that go to specific areas of the body – Sensory – Motor
- 7.
- 8. Anatomy: Spinal Cord Dermatomesand Sensation (1 of 2) • Sensory levels – Spinal cord • Nerves exit each vertebral level and detect sensation in specific areas of the body • Area that each nerve senses is called a “dermatome” • This creates a sensory map
- 9. Anatomy: Spinal Cord Dermatomesand Sensation (2 of 2)
- 10. Pathophysiology of CNSInjury • Primary injury – Damage that occurs at the moment of impact • Secondary injury – Damage that occurs subsequent to the initial impact • Systemic causes • Intrinsic causes – Prehospital management can often prevent or minimize the effects of secondary injury
- 11. Pathophysiology of CNSInjury: Secondary Injury • Systemic causes – Hypoxia – Hypotension – Anemia (blood loss) – Increased or decreased CO2 – Increased or decreased blood glucose • Intrinsic causes – Increased intracranial pressure (ICP) – Edema – Hematomas – Seizures
- 12. Patient Assessment: Primary Assessment •Determine the mechanism of injury and the need to consider possible spine injury • Is there: – Airway compromise? – Ventilatory compromise? – Adequate oxygenation? – Adequate circulation and perfusion?
- 13. Patient Assessment • Neurologicassessment for disability – The complete neurologic exam consists of six components: • Mental status (MS)* • Cranial nerves* • Motor function* • Sensory function* • Coordination • Reflexes *In most cases only the first four are completed in the prehospital setting
- 14. Patient Assessment: Mental Status(1 of 3) • A-V-P-U • Provides an initial impression – Alert – Responds to Verbal stimulus – Responds to Painful stimulus – Unresponsive
- 15. • Glasgow ComaScale – Use the modified GCS for pediatrics • The GCS should be scored after the correctible causes of altered mental status have been addressed Patient Assessment: Mental Status (2 of 3)
- 16.
- 17. Patient Assessment • Assessingfor symmetry of function (movement and sensation) is key – Asymmetry is abnormal until proven otherwise – In some people, asymmetry is a normal or baseline finding • Always ask, “Is this normal for you?”
- 18. Patient Assessment: Motor Function •Test upper extremities by having the patient: – Move the hands and arms – Squeeze your fingers • Test lower extremities by asking the patient to: – Wiggle the toes – Push and pull the feet against resistance
- 19. Patient Assessment: Sensory Function(1 of 3) • For a patient who is conscious with a suspected spinal cord injury (SCI): – Assess dermatomes to estimate the level of spine injury – Start at the head and work down to find the level of loss of sensation
- 20. • If lossof sensation is at: – Clavicles: C4–C5 injury – Nipples: T4 injury – Umbilicus: T10 injury – Pelvic rim: T12 injury Patient Assessment: Sensory Function (2 of 3)
- 21. • In anunconscious patient, assess for sensation with deep pain response – Sternal rub – Nailbed compression • Reflex response (from best to worst) – Purposeful withdrawal from pain – Nonpurposeful movement to pain – Flexion (decorticate posturing) – Extension (decerebrate posturing) – No response Patient Assessment: Sensory Function (3 of 3)
- 22. Spinal Injury (1of 2) • Trauma to the spine may result in: – Spinal column fracture – Spinal cord injury • Complete transection • Incomplete syndromes – Brown–Séquard – Anterior cord – Central cord – Both
- 23. Spinal Injury (2of 2) Anterior cord syndrome Central cord syndrome Brown-Séquard syndrome
- 24. Spinal Cord Injury:Clinical Findings (1 of 3) • Motor – Muscle weakness – Muscle paralysis • Sensory – Pain – Paresthesia (numbness) – Total loss of sensation • The extent and location of sensory and motor loss depend on the location and level of the injury
- 25. • High cervicalinjuries – Paralysis of diaphragm and intercostal muscles results in total loss of ability to breathe • Lower cervical injuries – Diaphragm still functions – Paralysis of intercostal muscles only Spinal Cord Injury: Clinical Findings (2 of 3)
- 26. • Cervical orhigh thoracic spinal cord injury may result in hypotension – Disruption of sympathetic nervous system results in unopposed parasympathetic tone • Vasodilation • Bradycardia • Warm, dry skin • However, the most likely cause of shock in any trauma patient is hemorrhage, which must be ruled out before calling it neurogenic “shock” Spinal Cord Injury: Clinical Findings (3 of 3)
- 27. CNS Injury Management •The overall goal is to prevent or recognize and treat secondary spinal cord injuries – Hypoxia – Hypotension – Hemorrhage • Spinal fractures, in most cases, can only be diagnosed and managed at the receiving hospital
- 28. CNS Injury Management: Overview •Prehospital setting – A-B-C-D-E approach – Spinal motion restriction – Initial resuscitation – Transport and destination decisions
- 29. CNS Injury Management: Airway(1 of 2) • Open it – Maintain spinal motion restriction (as appropriate for the mechanism of injury) – Jaw thrust • Clear it – Use suction as needed • Maintain it – GCS of 9 or more? – Able to maintain patency? • Consider airway management as necessary
- 30. • If activeairway management is required, monitor: – Oxygen saturation (95% or higher) – BP – End-tidal carbon dioxide (ETCO2) • Confirm proper tube placement – Use two methods: • Physiologic • Mechanical CNS Injury Management: Airway (2 of 2)
- 31. CNS Injury Management: Breathing •Provide oxygen (100%) – A single episode of hypoxia, O2 saturation < 90%, worsens outcome in patients with TBI • Assist ventilations (as needed) – Maintain normal ETCO2 at 35 to 40 mm Hg – Ventilation rates • Adults: 10 to 12 breaths per min • Pediatric: 12 to 20 breaths per min – No routine hyperventilation
- 32. CNS Injury Management: Circulation(1 of 2) • Control hemorrhage and prevent anemia: EVERY RBC COUNTS! • Maintain adequate BP and perfusion
- 33. • If BPis normal or elevated: – IV of LR/NS TKO • If BP is decreased: – IV of LR/NS bolus, with fluid titrated to maintain BP of 90 to 100 mm Hg • A single episode of hypotension, BP < 90 mm Hg, worsens outcome in patients with CNS injury CNS Injury Management: Circulation (2 of 2)
- 34. Spinal Immobilization Algorithm: BluntTrauma (1 of 5)
- 35. • Concerning mechanismof injury: – Violent impact to the head, neck, torso, or pelvis – Sudden acceleration, deceleration, or lateral bending forces to neck or torso – Falls – Ejection or fall from any motorized or human- powered transport device – Shallow-water diving incident Spinal Immobilization Algorithm: Blunt Trauma (2 of 5)
- 36. Spinal Immobilization Algorithm: BluntTrauma (3 of 5)
- 37. • Distracting injuries –Any injury that may impair the patient’s ability to appreciate other injuries, including: • Long-bone fracture • Suspected visceral injury • Large laceration, degloving, or crush injury • Large burns • Any other injury that produces acute functional impairment Spinal Immobilization Algorithm: Blunt Trauma (4 of 5)
- 38. • Inability tocommunicate – Speech or hearing impaired – Speaks a foreign language – Small children Spinal Immobilization Algorithm: Blunt Trauma (5 of 5)
- 39. Spinal Immobilization Algorithm: PenetratingTrauma (1 of 2)
- 40. • Unstable spinalfractures from penetrating trauma are extremely rare • Life-threatening conditions take priority Spinal Immobilization Algorithm: Penetrating Trauma (2 of 2)
- 41. CNS Injury Management: SpinalCord • Prevent secondary injury – Maintain adequate oxygenation – Maintain adequate perfusion (BP) • Steroids for spinal cord injury – No longer recommended
- 42. CNS Injury Management •Transport and destination – Minimal on-scene time – Supine position – Appropriate receiving facility – Frequent reassessment
- 43. Expose • Component ofthe primary assessment • Allows visualization of all body areas and identification of hidden injuries • Remove clothing only as appropriate – Driven by MOI/kinematics and patient complaints – If suspected criminal activity, consider evidence preservation – Maintain patient privacy • Prevent body heat loss
- 44. Summary (1 of2) • Identify the mechanism of injury • Perform primary assessment – Identify and treat life-threatening conditions first • Key determination is if initial findings are changing and in which direction (better or worse) • Neurogenic “shock” may occur in patients with spinal cord injury – Hemorrhagic shock is still the most common cause of shock overall and must be ruled out
- 45. • Evaluate needfor spinal immobilization – When in doubt, immobilize • Treatment key: minimize secondary injury of the spinal cord – Correct or prevent hypoxemia – Correct or prevent hypotension • Transport to an appropriate facility Summary (2 of 2)
- 46.
Editor's Notes
- #2 Instructor Notes Lesson 7B will provide participants with an overview on assessing for disabilities and managing injuries to the spinal cord.
- #3 Instructor Notes Expand on the following points: In the United States, 15,000 to 20,000 spinal injuries occur annually. Spinal trauma is most common in ages 16 to 35 years. 80% of cases occur in males.
- #4 Instructor Notes Expand on the following points: Causes of spinal trauma include: MVCs: 48% Falls: 21% Penetrating injuries: 15% Sports injuries: 14% Other: 2% Improper assessment and management can result in permanent paralysis. Failure to suspect and appropriately manage the injury, both in the prehospital and hospital setting, can cause permanent damage to the spinal cord. It is estimated that as many as 10% to 15% of spinal cord injuries occur after the patient gets into medical hands.
- #5 Instructor Notes Expand on the following points: The spinal column is composed of 33 vertebrae stacked on top of one another. The individual vertebrae are stacked in an S-like shape. Ligaments and muscles maintain the spine in a normal anatomic position with normal curvatures. Injuries occur when the spinal column is stressed beyond its normal movement limits. The spinal column is divided into five individual regions for reference. Cervical (7 vertebrae) Thoracic (12 vertebrae) Lumbar (5 vertebrae) Sacrum (5 fused vertebrae) Coccyx (4 fused vertebrae) A breakdown of spinal injury by location shows: 55% cervical 15% thoracic 15% thoracolumbar junction 15% in the lumbosacral regions
- #6 Instructor Notes Expand on the following points: A vertebra is essentially a ring of bone comprised of: Body — Bears most of the weight of the vertebral column and torso superior to it Neural arches — Two curved sides formed by the pedicle and the lamina Spinous process — Serves as the points of attachment for the muscles and ligaments Vertebral foramen — Or the spinal canal, through which the spinal cord passes The spinal cord is protected somewhat from injury by the bony vertebrae surrounding it.
- #7 Instructor Notes Expand on the following points: The spinal cord fills the spinal canal, leaving little room for swelling, hemorrhage, or bone injury. The spinal cord contains the motor and sensory tracts. The motor and sensory tracts form nerves that go to specific areas of the body.
- #8 Instructor Notes Expand on the following points: The figure on this slide illustrates the spinal cord tracts: the spinothalamic tract, the pyramidal tract, and the posterior columns.
- #9 Instructor Notes Expand on the following points: In the spinal cord, nerves exit each vertebral level and detect sensation in specific areas of the body. The area that each nerve senses is called a dermatome. Dermatomes allow the body areas to be mapped out for each spinal level. Three landmarks to keep in mind are: The clavicles, which are the C4–C5 dermatome The nipple level, which is the T4 dermatome The umbilicus level, which is the T10 dermatome
- #10 Instructor Notes Expand on the following points: This figure illustrates the dermatome map. The dermatome map shows the relationship between areas of touch sensation on the skin and the spinal nerves that correspond to these areas. Loss of sensation in a specific area may indicate injury to the corresponding spinal nerve.
- #11 Instructor Notes Expand on the following points: Primary injury is the injury that occurs at the moment of traumatic event. It is a direct injury to the brain or spinal cord. Secondary injury occurs after the primary injury. It is due to systemic problems or intracranial/intraspinal causes. Secondary injury can worsen the patient’s outcome, but the prehospital care provider can often make a huge difference in patient outcome by recognizing and correcting secondary problems.
- #12 Instructor Notes Expand on the following points: The systemic causes of secondary injury include: Hypoxia, which increases brain cell death and edema Hypotension and anemia due to blood loss which impair oxygen delivery to the brain. Altered carbon dioxide (CO2) levels lead to cerebral vasoconstriction or vasodilation, each of which may impair perfusion of the brain. Increased or decreased blood glucose The brain is dependent on a constant supply of glucose. Brain cells cannot function without it. Increased glucose is also associated with worse neurologic outcome. The intrinsic causes of secondary injury include: Increased intracranial pressure leads to impaired circulation, tissue hypoxia, and cell death. Edema and hematomas both put pressure on sensitive nerve tissue, which leads to impaired circulation, hypoxia of tissue, and cell death. Seizures cause injury to brain cells and must be controlled.
- #13 Instructor Notes Expand on the following points: During the primary assessment: Determine the mechanism of injury and the need to consider possible spine injury. Is there airway compromise? Is there ventilatory compromise? Is there adequate oxygenation? Are the circulation and perfusion adequate?
- #14 Instructor Notes Expand on the following points: The complete neurologic exam consists of six components: Mental status (MS) Cranial nerves (applicable cranial nerves only) Motor function Sensory function Coordination Reflexes In most cases, only the first four are completed in the prehospital setting.
- #15 Instructor Notes Expand on the following points: The AVPU method of evaluating mental status provides a inital impression of how injured the patient may be. Alert Responds to Verbal stimulus Responds to Painful stimulus Unresponsive
- #16 Instructor Notes Expand on the following points: The GCS is a more detailed method for evaluating a patient’s mental status and functioning and for following changes in neurologic function over time. A normal GCS score is 15; the lowest score is 3. The GCS score should be reported by the three individual components: E, V, and M. The GCS is modified for infants to allow for scoring of preverbal children. Of particular importance is the fact that the GCS should not be scored until the patient has been resuscitated (hypoxia and hypotension are corrected) and other reversible causes of altered mentation such as hypoglycemia have also been addressed.
- #17 Instructor Notes Expand on the following points: This figure lists the scoring criteria of the Glasgow Coma Scale.
- #18 Instructor Notes Expand on the following points: Assessing for symmetry of function (movement and sensation) is key during the patient assessment. Asymmetry is abnormal until proven otherwise. In some people, asymmetry is a normal or baseline finding. Always ask, “Is this normal for you?”
- #19 Instructor Notes Expand on the following points: To evaluate the patient’s motor function, test the patient’s upper and lower extremities. Test the upper extremities by having the patient: Move the hands and arms Squeeze your fingers Test the lower extremities by asking the patient to: Wiggle the toes Push and pull the feet against resistance that you provide with your hands.
- #20 Instructor Notes Expand on the following points: For a patient who is conscious with a suspected spinal cord injury (SCI): Assess the dermatomes to estimate the level of spinal injury. Start at the patient’s head and work down to find the level where the loss of sensation begins.
- #21 Instructor Notes Expand on the following points: If loss of sensation is at: The clavicles, then the patient may have a C4–C5 injury The nipples, then the patient may have a T4 injury The umbilicus, then the patient may have a T10 injury The pelvic rim, then the patient may have a T12 injury
- #22 Instructor Notes Expand on the following points: To test the sensory function in an unconscious patient, assess for sensation by trying to elicit a deep pain response Perform a sternal rub Compress the patient’s nailbed Rate the reflex response (from best to worst) Purposeful withdrawal from pain Nonpurposeful movement to pain Flexion (decorticate posturing) Extension (decerebrate posturing) No response
- #23 Instructor Notes Expand on the following points: Just as in brain trauma, secondary injuries in the spine occur after the initial impact from complications such as edema, ischemia, hypoxia, hypotension, or inadvertent movement of bony fragments from a spinal column fracture. Trauma to the spine may result in: Spinal column fracture Spinal cord injury Complete transection Incomplete syndromes Brown–Séquard Anterior cord Central cord Both spinal column fracture and spinal cord injury
- #24 Instructor Notes Expand on the following points: The figures on this slide illustrate three types of incomplete spinal cord injuries. Anterior cord syndrome is a result of bony fragments or pressure on the spinal arteries. Central cord syndrome usually occurs with hyperextension of the cervical area. Brown-Séquard syndrome is caused by penetrating injury and involves hemitransection of the spinal cord, involving only one side of the cord.
- #25 Instructor Notes Expand on the following points: Damage to the spinal cord should be suspected whenever the patient complains of or there are findings of any combination of sensory or motor abnormalities. Motor abnormalities include: Muscle weakness Muscle paralysis Sensory abnormalities include: Pain Paresthesia (numbness) Total loss of sensation The extent and location of sensory and motor loss depend on the location and level of the injury.
- #26 Instructor Notes Expand on the following points: High cervical injuries should be suspected when the patient experiences: Paralysis of the diaphragm and intercostal muscles resulting in a total loss of the ability to breathe Lower cervical injuries should be suspected when the patient experiences: A still functioning diaphragm and paralysis of the intercostal muscles only
- #27 Instructor Notes Expand on the following points: Neurogenic “shock” can result from spinal cord injury. Damage to the spinal cord interrupts the normal sympathetic system stimulus to the vascular system, resulting in unopposed parasympathetic tone. For example, a cervical or high thoracic spinal cord injury This results in the dilation of blood vessels (vasodilation), a slow heart rate (bradycardia), and warm, dry skin. The dilation of blood vessels leads to decreased blood pressure (BP). However, the most likely cause of shock in any trauma patient is hemorrhage, which must be ruled out before calling it neurogenic “shock.”
- #28 Instructor Notes Expand on the following points: The overall goal of CNS injury management is to prevent or recognize and treat secondary spinal cord injuries. Prevent and recognize: Hypoxia Hypotension Hemorrhage Spinal fractures, in most cases, can only be diagnosed and managed at the receiving hospital.
- #29 Instructor Notes Expand on the following points: In the prehospital setting, the approach to CNS injury management includes: The A-B-C-D-E approach Spinal motion restriction Initial resuscitation Transport and destination decisions These management steps will be discussed in subsequent slides.
- #30 Instructor Notes Expand on the following points: Essential airway maneuvers are the mainstay of good patient care. Complex airway maneuvers should only be provided after essential airway maneuvers have been accomplished and only when the need dictates that they be performed. When managing the patient’s airway, remember: Open it. Maintain spinal motion restriction (as appropriate for the mechanism of injury). Jaw thrust Clear it. Use suction as needed. Maintain it. Does the patient have a GCS of 9 or more? Is the patient able to maintain airway patency? Consider airway management as necessary.
- #31 Instructor Notes Expand on the following points: If active airway management is required, monitor the patient’s: Oxygen saturation (95% or higher) BP End-tidal carbon dioxide (ETCO2) Confirm proper tube placement Use two methods: Physiologic Mechanical
- #32 Instructor Notes Expand on the following points: When managing the patient’s breathing: Provide oxygen (100%). A single episode of hypoxia, with an oxygen saturation rate of < 90%, worsens the outcome in patients with TBI. Assist ventilations as needed: Maintain normal ETCO2 at 35 to 40 mm Hg. Ventilation rates: Adults: 10 to 12 breaths/min Pediatric: 12 to 20 breaths/min No routine hyperventilation
- #33 Instructor Notes Expand on the following points: When managing the patient’s circulation, control any hemorrhage and prevent anemia. Remember, every red blood cell (RBC) counts! Maintain adequate BP and perfusion.
- #34 Instructor Notes Expand on the following points: If the patient’s BP is normal or elevated: Start intravenous (IV) therapy of lactated Ringer’s (LR) or normal saline (NS) to keep vein open (TKO). If the patient’s BP is decreased: Start an IV of LR/NS bolus, and titrate fluid to maintain BP of 90 to 100 mm Hg. A single episode of hypotension, BP < 90 mm Hg, worsens the outcome in patients with CNS injury.
- #35 Instructor Notes Expand on the following points: Considerations for spinal immobilization need to be based on the specific assessment of the patient that follows an established algorithm. This section of spinal immobilization algorithm focuses on the level of consciousness in a patient with suspected blunt trauma to the CNS. Neurologic deficit includes any patient with a GCS score less than 15.
- #36 Instructor Notes Expand on the following points: Consider the mechanism of injury (MOI) when determining the need for spinal immobilization. MOIs that indicate a need for spinal immobilization include: Violent impact to the head, neck, torso, or pelvis Sudden acceleration, deceleration, or lateral bending forces to neck or torso Falls Ejection or fall from any motorized or human-powered transport device Shallow-water diving incident
- #37 Instructor Notes Expand on the following points: This section of spinal immobilization algorithm focuses on the patient’s MOI.
- #38 Instructor Notes Expand on the following points: When assessing the patient, beware of distracting injuries. Distracting injuries are any injury that may impair the patient’s ability to appreciate other injuries, including: Long-bone fracture Suspected visceral injury Large laceration, degloving, or crush injury Large burns Any other injury that produces acute functional impairment
- #39 Instructor Notes Expand on the following points: An inability to communicate, including the following, can impair the assessment of a patient: Speech or hearing impaired Speaks a foreign language Small children
- #40 Instructor Notes Expand on the following points: This section of the spinal immobilization algorithm focuses on the patient with penetrating trauma.
- #41 Instructor Notes Expand on the following points: Unstable spinal fractures from penetrating trauma are extremely rare. Life-threatening conditions take priority. Airway compromise or gross hemorrhage should always be the first priorities for any trauma patient.
- #42 Instructor Notes Expand on the following points: CNS injury management of the spinal cord includes: Preventing a secondary injury Maintain adequate oxygenation. Maintain adequate perfusion (BP). Steroids for spinal cord injury are no longer recommended.
- #43 Instructor Notes Expand on the following points: Transport and destination considerations include: Minimize the on-scene time. The supine position is preferred to maximize cerebral perfusion pressure (CPP). Although elevating the head of patient’s bed may moderately decrease intracranial pressure, it is generally associated with a fall in mean arterial pressure (MAP) and CPP. An appropriate receiving facility should have a functioning computed tomography (CT) scanner and prompt availability of neurosurgeon. Frequent reassessment should be performed. Includes primary assessment, including GCS and pupils
- #44 Instructor Notes Expand on the following points: Expose is a component of the primary assessment. It allows visualization of all body areas and identification of hidden injuries. Remove the patient’s clothing only as appropriate. This component is driven by the MOI/kinematics and patient complaints. If there is suspected criminal activity, consider evidence preservation tactics. Maintain the patient’s privacy. Prevent body heat loss in the patient.
- #45 Instructor Notes Expand on the following points: Identify the mechanism of injury. Perform a primary assessment. Identify and treat life-threatening conditions first. A key determination is if initial findings are changing and in which direction (better or worse). Neurogenic “shock” may occur in patients with spinal cord injury. Hemorrhagic shock is still the most common cause of shock overall and must be ruled out.
- #46 Instructor Notes Expand on the following points: Evaluate the need for spinal immobilization. When in doubt, immobilize. The treatment key is minimize the potential for secondary injury of the spinal cord. Correct or prevent hypoxemia. Correct or prevent hypotension. Transport the patient to an appropriate facility.
- #47 Instructor Notes Allow time for a question and answer session to answer any questions about the topics presented in the lesson.