2. • The term ‘spinal cord injury’ refers to damage to the
spinal cord resulting from trauma (e.g. a car crash) or
from disease or degeneration (e.g. cancer)
• Every year, around the world, between 250 000 and
500 000 people suffer a spinal cord injury (SCI).
• The majority of spinal cord injuries are due to
preventable causes such as road traffic crashes, falls
or violence.
3.
4. TREAT AS SCI UNTIL PROVEN OTHERWISE:
1. All victims of significant trauma
2. Trauma patients with loss of consciousness
3. Minor trauma patients with complaints referable to
the spine or spinal cord
4. Associated findings suggestive of SCI:
a) Abdominal Breathing
b) Priapism
10. PATHOPHYSIOLOGY
• PRIMARY INJURY:
Initial traumatic force that
directly damages neurons,
glia and blood vessels and
disrupts the cord architecture
• SECONDARY INJURY:
Complex cascade of cellular
and micro-environmental
changes that results in
ongoing, profound damage to
the cord. Onset is rapid and
persists for several days and
months.
12. MANAGEMENT IN THE FIELD
o Follow ATLS Protocol:
-Airway maintenance with restriction of cervical motion
-Breathing and ventilation
-Circulation and hemorrhage control
-Disability
-Exposure/ Enviromental control
o During the Primary Survey , life-threatening conditions are identified and treated.
13. TRANSPORT OF THE PATIENT
● REMOVE THE HELMET
ACCORDING TO PROTOCOL
● STABILIZE THE CERVICAL SPINE
● LOG ROLL THE PATIENT ONTO A
SPINAL BOARD
22. RED FLAGS TO LOOK FOR
22
● Spine pain and tenderness
● Restricted Motion
● Neurological Deficit
● Step – off
● Mute plantars
● Look out for spinal shock
23. SPINAL SHOCK
● Transient loss of ALL neurological function below the level of SCI
● FLACCID PARALYSIS and AREFLEXIA
● Loss of bulbocavernosus reflex.
● May resolve within 72 hours but often persists 1 -2 weeks
● A poor prognostic sign
● When the shock resolves, there will be spasticity below the level of injury and
return of the BCR
23
24. Initial Clinical Evaluation
• Involves a thorough systemic evaluation based
on the advanced trauma life support (ATLS)
guidelines.
• After patient has been resuscitated and
stabilized, attention may then be directed to a
focused spine injury evaluation.
26. INITIAL MANAGEMENT IN THE HOSPITAL
1. Immobilization
2. BP maintenance
3. Oxygenation
4. NG tube to suction
5. Catheterization
6. DVT prophylaxis
7. Temperature Regulation
8. Check electrolytes
9. More detailed neuro-evaluation
10. Radiological Evaluation
27. MANAGEMENT OF BLOOD
PRESSURE
● Keep systolic blood pressure >90mmHg
● Give pressors, if necessary
- Dopamine is the agent of choice
- Avoid Phenylephrine
● Fluids as necessary to replace losses
● Military anti-shock trousers (If available)
MAINTAIN OXYGENATION
• Keep oxygen saturation >90%
• If no indication for intubation: Use NC
or Face mask
• Intubation: For airway compromise or
hypoapnea
• Caution with uncleared C-spine:
- Use chin lift (not jaw thrust) with neck
extension
- Avoid tracheostomy
cricothyroidotomy
28. Neurological Level of Injury
● Most caudal segment of the spinal
cord that has normal sensory and
motor function on both sides of the
body
● The neurological level of injury is
determined primarily by clinical
examination.
● Frequently, there is discrepancy
between the neurological and bony
level of injury
29. SENSORY
LEVEL
ASSESSMENT
DERMATOME:
● Area of skin innervated
by the sensory axons
within a particular
segmental nerve root.
● The most caudal intact
dermatome is
considered the sensory
level
30.
31. MOTOR
LEVEL
ASSESSMENT
MYOTOME:
● A group of muscles that a single spinal
nerve innervates.
● The key muscles should be tested on
both sides for strength and graded on a
six point scale
● The motor level is the most caudal level
with grade 3 or higher (and all levels
above being normal)
32.
33. COMPLETENESS OF LESION
● INCOMPLETE LESION:
DEFINITION: Any residual motor or sensory function more than 3
segments below the level of the injury.
SIGNS:
- Sensation or voluntary movement in the LEs in the presence of a thoracic
or cervical cord injury
- Sacral sparing
-An injury does not classify as incomplete with preserved sacral reflexes
alone (e.g bulbocavernosus)
34.
35. RADIOLOGY
CT Scan Spine with 3D reconstruction
OR X-ray Spine
+/- MRI of the suspected segment
50. Uh-oh
A 28 year old female presents with history of RTA and complaint of inability to
move all four of her limbs. She is also breathing rapidly. Treatment was provided
on the scene.
51. - What will your approach be?
- What will be your initial step?
- How will you examine the back?
- Which investigations will you go for?
Phenylephrine is non-inotropic and there might be possible reflex increase in vagal tone -> causing bradycardia MAST: immobilizes lower spine, compensates for lost muscles tones in cord injuries (prevents muscle pooling)
In SCI hypoapnea maybe due to paralyzed intercostal muscles or paralyzed diaphragm (phrenic nerve C3,4,5) May also be due to depressed LOC in TBI
Sacral sparing: preserved sensations around the anus, voluntary rectal contraction or voluntary toe flexing?
