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SPINAL INJURIES.ppt
- 1. SPINAL CODE INJURIES TRAUMA AND EMERGENCY
- 6. Epidemiology Spinal Trauma- 10,000 new cases each year, with over 200,000 spinal injury victims living in US 55% of spinal injuries occur in the C-spine 15% in the thoracic, lumbar, and sacral regions 10% of pts with c-spine injury have another vertebral fracture Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 7. Spinal Trauma Spinal trauma has a huge impact physically, financially, and emotionally on society Proper treatment can minimize further damage Immobilization equipment is easy to use, inexpensive, and readily available Our duty as EM physicians is to provide proper care and “Do No Harm” Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 8. Can we make an impact? “3-25% of cases of permanent neurologic impairment after spinal trauma have been attributed to injudicious manipulation by paramedical personnel, examining physicians, or radiology technicians.” Francisco de Assiss Aquino Gondim, MD, e-medicine- Spinal Cord Trauma Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 9. Prevention is key! With proper application of spinal precautions, we can positively impact patient outcomes Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 10. Pathophysiology of Acute Fractures Direct compression of neural elements by bone fragments, disc material, and ligaments leads to damage of the central and peripheral nervous system Blood vessel compression and disruption causes ischemia Massive cord swelling happens within minutes at the level of injury and leads to secondary ischemia Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 11. Cord Syndromes Central Cord Syndrome Anterior Cord Syndrome Posterior Spinal Cord Syndrome Brown Sequard Syndrome Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 12. Spinal vs. Neurogenic Shock Spinal Shock • Temporary phenomenon characterized by loss of all spinal cord function caudal to level of injury • Symptoms = Flaccid paralysis, Hypotonia, Areflexia, Priapism • Typical duration = 24-72 hours • Resolution = Return of Bulbocavernosus reflex • Outcome = Spastic paresis, hyper-reflexia Neurogenic Shock • Type of distributive shock characterized by loss of adrenergic tone due to sympathetic denervation • Classic Triad = Hypotension, Bradycardia, Hypothermia • Management = IVF, Vasopressor support, Atropine Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 13. Spinal Shock vs. Neurogenic Shock Spinal Shock- the flaccidity and loss of reflexes seen after spinal cord injury. The cord may appear destroyed but actually may regain function latter Neurogenic Shock- destruction of the descending sympathetic pathways of the spinal cord. Results is hypotension and bradycardia. Pts will require vasopressors and atropine as well as fluid. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 14. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 15. Management Immobilization Clinical C-spine Clearance • When to get images Thoracic and Lumbar Spinal Immobilization and Clearance Management of Cervical and Thoracolumbar fractures without spinal cord injury Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 16. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 17. Aims of Immobilization Prevent further damage - Protect the Cord Hold the spine in a comfortable, anatomically correct way Prevent movement of the spine Allow for safe concurrent management of other injuries Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 18. Options for Immobilization Anatomical Regions • Head • Neck • Body Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 19. Head Immobilization Manual - Hands, Legs Simple Assist Devices - Sandbags, Towels, Foam Pads Additional Devices - Straps Head/Neck immobilizer Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 20. Head Immobilization Cdang (Wikipedia) Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 21. Head Immobilization Study compared 3 methods during simulated vehicle motion, (Spine 1999;24) • Sandbags • Headband • Styrofoam wedges Wedges slightly better Key is body immobilization Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 22. Neck Immobilization Collars • Philadelphia • Stiffneck • Other options Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 23. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 24. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 25. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 26. Neck Immobilization Emrgmgmtca (Wikipedia) Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 27. Body Immobilization Backboards • Important for transporting patients and keeping them from possibly injuring themselves further Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 28. Back Boards Cdang (Wikipedia) Ryan.mco (Wikipedia) Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 29. Complications associated with Spinal Immobilization Pain Increased risk of pressure sores Aspiration and limited respiratory function • Increased risk of aspirating emesis while strapped on backboard • Marked pulmonary restrictive effect of appropriately applied entire body spinal immobilization devices Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 30. When to get an X-ray Patients involved in a traumatic event • with midline tenderness • With neurologic deficits • Altered level of consciousness • Patients who are intoxicated Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 31. C-spine X-ray Lateral View • Must see to the top of T1 for film to be adequate • May need swimmers view • Will see 90% of cervical spine fractures Odontoid view • Must include entire process and right and left c1 and c2 articulations Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 32. CT Scan More Sensitive If high suspicion for injury and have inadequate x-ray, CT is warranted Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 33. How do you clear a C-spine Injury? Two studies- NEXUS vs. Canadian C spine • Nexus Patients required to meet 5 criteria • No mid-line tenderness • No focal neurological deficit • Normal alertness • No intoxication • No painful, distracting injury Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 34. Methylprednisolone Controversial treatment modality for blunt spinal cord trauma National Acute Spinal Cord Injury Studies (NASCIS) Subsequent studies • Pointillart (2000) • Matsumoto (2001) Mechanism of Action • Inhibition of free radical induced lipid peroxidation Current recommended regimen • Methylprednisolone prescribed as a bolus intravenous infusion of 30 mg/kg of body weight over 15 min within 8 hours of acute closed spinal cord injury • Followed 45 min later by an infusion of 5.4 mg/kg of body weight per hour for 23 hours Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 35. Summary Spinal immobilization can reduce the likelihood of neurological deterioration in patients with unstable c-spine injuries following trauma Immobilization of the entire spinal column is necessary in patients until a spinal cord/column injury has been excluded or until the appropriate treatment has been initiated Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 36. Summary A combination of rigid cervical collar with supportive blocks on a rigid backboard with straps is effective at achieving safe, effective spinal immobilization for transport Spinal immobilization devices are effective but can result in patient morbidity. They should be used for safe extrication and transport, but should be removed as soon as definitive evaluation is accomplished or treatment initiated Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 37. Summary Methylprednisolone therapy for acute spinal cord injury is controversial with only benefit when administered within 8 hours of injury Current Methyprednisolone regimen: • Methylprednisolone bolus intravenous infusion of 30 mg/kg of body weight over 15 min within 8 hours of acute closed spinal cord injury • Followed 45 min later by an infusion of 5.4 mg/kg of body weight per hour for 23 hours Appropriate classification of SCI patients within ED to ensure prompt evaluation and treatment Communication between ED staff and residents is key to limiting errors and providing appropriate care Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
- 38. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
Editor's Notes
- Spinal Shock vs. Neurogenic Shock Spinal Shock = Spinal shock refers to a phenomenon that occurs immediately after a spinal cord injury (within min) where the patient experiences a physiological loss of all spinal cord function caudal to the level of the injury. Characterized by flaccid paralysis, hypotonia, areflexia. Priapism in males. Spinal shock is thought to be caused by the loss of potassium within the injured cells of the cord and accumulation of the potassium in the extracellular space, resulting in reduced axonal transmission. As potassium levels wear off, spinal shock wears off. Typically lasts 24-72 hours post injury Resolution of loss of as bulbocavernosus reflex (anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley) indicates the end of spinal shock. Typically, clinical manifestations may normalize but are more often replaced by a spastic paresis and hyper-reflexia. Neurogenic Shock = A type of distributive shock characterized by loss of adrenergic tone due to sympathetic denervation. Typically occurs in patients with partial or complete cord injury at T6 level or above. Injury at this level causes sympathetic denervation and a loss of alpha adrenergic tone, causing vasodilitation of arterial/venous vessels. Leads to loss of systemic resistance and hypotension. In addition, loss of sympathetic innervation to the heart (T1-T4) results in unopposed parasympathetic innervation via the vagus nerve that results in bradycardia. Symptoms = Classic triad (Hypotension, Bradycardia, Hypothermia), Warm/dry extremities, peripheral vasodiliation, venous pooling, decreased cardiac output. Treatment – Fluid hydration followed by: BP Phenylephrine, epinephrine, Consider dopamine/dobutamine HR Atropine, Consider pacing if necessary Transient Paralysis/Spinal Shock Spinal shock is a clinical condition characterized by a physiological loss of all spinal cord function caudal to the level or the injury with flaccid paralysis, anesthesia, absent bowel/bladder control and loss of reflex activity. Priapism may be present in males. Altered physiological state may last several hours to several weeks. Loss of function is thought to be secondary loss of potassium within the injured cells in the cord and the accumulation of potassium witin the extracellular space, resulting in decreased axonal transmission. As potassium levels normalize between the intra/extracellular spaces, the spinal shock wears off and clinical manifestations may normalize but are usually replaced by a spastic paresis reflecting morphologic injury ot the spinal cord. Transient paralysis with complete recovery is most often described in younger patients with athletic injuries. Cauda Equina Syndrome/Conus medullaris/Concussion The cauda equina is comprised entirely of lumbar, sacral and coccygeal nerve roots and injury produces a peripheral nerve injury pattern rather than direct injury to spinal cord. Clinical features Variable motor/sensory lesions in lower extremities Bowel/bladder dysfunction Saddle anesthesia Prognosis = Good 2/2 peripheral nerve ability to regenerate Conus medullaris syndrome - is a sacral cord injury with or without involvement of the lumbar nerve roots. This syndrome is characterized by areflexia in the bladder, bowel, and to a lesser degree, lower limbs. Motor and sensory loss in the lower limbs is variable. Cauda equina syndrome involves injury to the lumbosacral nerve roots and is characterized by an areflexic bowel and/or bladder, with variable motor and sensory loss in the lower limbs. Because this syndrome is a nerve root injury rather than a true SCI, the affected limbs are areflexic. This injury is usually caused by a central lumbar disk herniation. A spinal cord concussion is characterized by a transient neurologic deficit localized to the spinal cord that fully recovers without any apparent structural damage.
- Methylprednisolone in management of acute spinal cord injury: High dose methylprednisolone (Solumedrol) is recommended on the basis of the National acute spinal cord injury studies and is the only effective neuroprotective agent to be tested in controlled multicenter clinical trials Methylprednisolone is hypothesized to work through inhibition of free radical induced lipid peroxidation and reducing intracellular calcium overload and tissue lactate levels, improving microcirculation and inhibiting post-traumatic cord ischemia. National Acute Spinal Cord Injury Studies NASCIS I – First study conducted in 1979, NASCIS results published in 1984 Comparison: 100 mg bolus followed by 25 mg q 6 hrs for 10 days 1000 mg bolus followed by 250 mg q 6 hrs for 10 days. Prospective, RCT, double-blinded, multicenter trial in 330 patients. Primary outcome measures = Sensory and Motor assessment at 6 weeks, 6 months and 1 year after the SCI No statistical difference between the two groups with respect to either modality at all time points. Adverse events: 4-fold increase in wound infections in high dose group. Trends towards increased sepsis, pulmonary embolis and death in high dose group. NASCIS II Subsequent animal studies suggested that only higher doses of MP have a neuroprotective effect after SCI, prompting the NASCIS II study conducted in 1985 with results published in 1990. Prospective RCT, double blinded, multicenter trial Patients randomized to one of 3 treatment arms: MPSS 30 mg/kg bolus followed by 5.4 mg/kg/hr infusion for 23 hours Naloxone 5.4 mg/kg bolus followed by infusion for 23 hours (Note – naloxone had shown promise in previous animal exp) Placebo infusion N = 487 patients who arrived to hospital within 12 hours Exclusion criteria = Patients with isolated peripheral nerve injury, pregnant women and patients with other serious injuries Primary outcome measures = Neurologic outcome (6 weeks, 6 months and 1 yr), Mortality Neurologic outcome was an assessment of motor and sensory function. Motor = 14 muscle groups (power 0-5) for total score of 0-70 points Sensory = pinprick and tactile sensation in 29 dermatomes (graded between 1-3) Total score ranged between 29-87 points. No difference between the three groups in initial analysis Complications Increases in wound infection, GI bleeding, Pulmonary embolism in steroid group Post-hoc analysis Examination of patients (subgroup = 62) treated with MPSS within 8 hours of injury found a benefit with improvement in motor scores at 6 months and 1 year. Motor scores demonstrated improvement of 17.2 points compared with 12.0 points in the control group Sensory scores also demonstrated improvement in steroid group at 6 months but effect disappeared by 1 year Most improvement in motor scores was observed in patients with incomplete spinal cord injury. NASCIS III Third study conducted in 1991, published in 1997 Prospective RCT, Double blinded multi-center trial of MP in 499 patients Only patients presenting within 8 hours were included. Exclusion criteria = pregnancy and patients with serious illness Treatment arms: All patients administered bolus of 30 mg/kg and then were randomized to one of three arms MP 5.4 mg/kg/hr infusion for 23 hours MP 5.4 mg/kg/hr infusion for 47 hours Trilizad mesylate 2.5 mg/kg bolus q 6 hrs for 48 hrs Trilazad has same lipid peroxidation effect as MP but lacks glucocorticoid effect Results Randomization did not generate equal treatment groups Patients receiving trilizad mesylate demonstrated significantly worse motor function than pts receiving MP Among MP groups, no significant difference in outcomes Post analysis of patients receiving treatment before 3 hours compared with before 8 hours demonstrated a statistically significant difference in motor score in patients receiving 48 hours of infusion compared with 24 hours. Difference was noted at 6 weeks and 6 months but was less apparent at 1 yr. No sensory improvement was noted. Complications: 2-fold increase in severe pneumonia, 4-fold increase in severe sepsis and 6-fold increase in mortality 2/2 respiratory complications in 48 hr group compared with 24 hour group infusion. Other Clinical Studies to evaluate MP in treatment of Acute SCI