Division 3

Trauma Emergencies

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 24 Spinal Trauma

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics
Introduction to Spinal Injuries Spinal Anatomy and Physiology Pathophysiology of Spinal Injury Assessment of the Spinal Injury Patient Management of the Spinal Injury Patient

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Spinal Injuries

Annually 15,000 permanent spinal cord injuries Commonly men 1630 years old Mechanism of Injury
Vehicle crashes: 48% Falls: 21% Penetrating trauma: 15% Sports injury: 14%

25% of all spinal cord injuries occur from improper handling of the spine and patient after injury.
ASSUME based upon MOI that patients have a spinal injury. MANAGE ALL spinal injuries with immediate and continued care.

Lifelong care for spinal cord injury victim exceeds $1 million. Best form of care is public safety and prevention programs.

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Spinal Anatomy and Physiology Vertebral Column (1 of 10)

33 bones comprise the spine. Function:
Skeletal support structure Major portion of axial skeleton Protective container for spinal cord

Vertebral Body:
Major weight-bearing component Anterior to other vertebrae components
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Spinal Anatomy and Physiology Vertebral Column (2 of 10)

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Spinal Anatomy and Physiology Vertebral Column (3 of 10)

Size of Vertebrae
C-1 and C-2:
No vertebral body Support head Allow for turning of head

Vertebral body size increases the more inferior they become.

Lumbar spine strongest and largest
Bear weight of the body

Sacral and coccyx vertebrae are fused.

No vertebral body
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Spinal Anatomy and Physiology Vertebral Column (4 of 10)

Components of Vertebrae
Spinal Canal
Opening in the vertebrae that the spinal cord passes through

Pedicles
Thick, bony structures that connect the vertebral body to the spinous and transverse processes

Laminae
Posterior bones of vertebrae that make up foramen

Transverse Process
Bilateral projections from vertebrae Muscle attachment and articulation location with ribs
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Spinal Anatomy and Physiology Vertebral Column (5 of 10)

Components of Vertebrae
Spinous Process
Posterior prominence on vertebrae

Intervertebral Disk
Cartilaginous pad between vertebrae Serves as shock absorber

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Spinal Anatomy and Physiology Vertebral Column (6 of 10)

Vertebral Ligaments
Anterior Longitudinal
Anterior surface of vertebral bodies Provides major stability of the spinal column Resists hyperextension

Posterior Longitudinal
Posterior surface of vertebral bodies in spinal canal Prevents hyperflexion

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Spinal Anatomy and Physiology Vertebral Column (7 of 10)

Cervical Spine
7 vertebrae Sole support for head
Head weighs 1622 pounds

C-1 (Atlas)
Supports head Securely affixed to the occiput Permits nodding

C-2 (Axis)
Odontoid process (dens)
Projects upward Provides pivot point so head can rotate

C-7
Prominent spinous process (vertebra prominens)
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Spinal Anatomy and Physiology Vertebral Column (8 of 10)

Thoracic Spine
12 vertebrae 1st rib articulates with T-1
Attaches to transverse process and vertebral body

Next nine ribs attach to the inferior and superior portion of adjacent vertebral bodies
Limits rib movement and provides increased rigidity

Larger and stronger than cervical spine

Larger muscles help to ensure that the body stays erect Supports movement of the thoracic cage during respirations
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Spinal Anatomy and Physiology Vertebral Column (9 of 10)

Lumbar Spine
5 vertebrae Bear forces of bending and lifting above the pelvis Largest and thickest vertebral bodies and intervertebral disks

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Spinal Anatomy and Physiology Vertebral Column (10 of 10)

Sacral Spine
5 fused vertebrae Form posterior plate of pelvis Help protect urinary and reproductive organs Attach pelvis and lower extremities to axial skeleton

Coccygeal Spine
35 fused vertebrae Residual elements of a tail
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Spinal Anatomy and Physiology Spinal Meninges

Layers
Dura mater Arachnoid Pia mater

Cover entire spinal cord and peripheral nerve roots that exit Cerebrospinal fluid bathes spinal cord by filling the subarachnoid space
Exchange of nutrients and waste products Absorbs shocks of sudden movement
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Spinal Anatomy and Physiology Spinal Cord (1 of 4)

Function
Transmits sensory input from body to the brain Conducts motor impulses from brain to muscles and organs Reflex center
Intercepts sensory signals and initiates a reflex signal

Growth
Fetus
Entire cord fills entire spinal foramen

Adult
Base of brain to L-1 or L-2 level Peripheral nerve roots pulled into spinal foramen at the distal end (cauda equina)
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Spinal Anatomy and Physiology Spinal Cord (2 of 4)

Blood Supply
Paired spinal arteries
Branch off the vertebral, cervical, thoracic, and lumbar arteries Travel through intervertebral foramina
Split into anterior and posterior arteries

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Spinal Anatomy and Physiology Spinal Cord (3 of 4)

General Cord Anatomy
Anterior Medial Fissure
Deep crease along the ventral surface of the spinal cord that divides cord into left and right halves

Posterior Medial Fissure

Shallow longitudinal groove along the dorsal surface

Gray Matter
Area of the CNS dominated by nerve cell bodies Central portion of the spinal cord

White Matter
Surrounds gray matter Comprised of axons
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Spinal Anatomy and Physiology Spinal Cord (4 of 4)

General Cord Anatomy
Axons
Transmit signals upward to the brain and down to the body Ascending tracts
Axons that transmit signals to the brain Sensory tracts

Descending tracts
Axons that transmit signals to the body Motor tracts Voluntary and fine muscle movement
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Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Spinal Anatomy and Physiology Spinal Nerves (1 of 11)

31 pairs of nerves that originate along the spinal cord from anterior and posterior nerve roots
Sensory and motor functions Travel through intervertebral foramina

1st pair exit between the skull and C-1 Remainder of pairs exit below the vertebrae Each pair has 2 dorsal and 2 ventral roots
Ventral roots: motor impulses from cord to body Dorsal roots: sensory impulses from body to cord C-1 and Co-1 do not have dorsal roots
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Spinal Anatomy and Physiology Spinal Nerves (2 of 11)

Plexus
Nerve roots that converge in a cluster of nerves
Cervical plexus
5 cervical nerve roots Innervates the neck Produces the phrenic nerve Peripheral nerve roots C-3 through C-5 Responsible for diaphragm control C3, 4, and 5 keep the diaphragm alive

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Spinal Anatomy and Physiology Spinal Nerves (3 of 11)

Brachial Plexus
C-5 through T-1 Controls the upper extremity

Lumbar and Sacral Plexuses

Innervation of the lower extremity

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Spinal Anatomy and Physiology Spinal Nerves (4 of 11)

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Spinal Anatomy and Physiology Spinal Nerves (5 of 11)

Dermatomes
Topographical region of the body surface innervated by one nerve root Key locations
Collar region: C-3 Little finger: C-7 Nipple line: T-4 Umbilicus: T-10 Small toe: S-1
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Spinal Anatomy and Physiology Spinal Nerves (6 of 11)

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Spinal Anatomy and Physiology Spinal Nerves (7 of 11)

Myotomes
Muscle and tissue of the body innervated by spinal nerve roots Key myotomes
Arm extension: C-5 Elbow extension: C-7 Small finger abduction: T-1 Knee extension: L-3 Ankle flexion: S-1
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Spinal Anatomy and Physiology Spinal Nerves (8 of 11)

Reflex Pathways
Function
Speed bodys response to stressors Reduce seriousness of injury Body stabilization

Occur in special neurons

Interneurons Example
Touch hot stove. Severe pain sends intense impulse to brain. Strong signal triggers interneuron in the spinal cord to direct a signal to the flexor muscle. Limb withdraws without waiting for a signal from the brain.
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Spinal Anatomy and Physiology Spinal Nerves (9 of 11)

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Spinal Anatomy and Physiology Spinal Nerves (10 of 11)

Subdivision of ANS
Parasympathetic, Feed and Breed
Controls rest and regeneration Peripheral nerve roots from the sacral and cranial nerves Major Functions
Slows heart rate Increases digestive system activity Plays a role in sexual stimulation

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Spinal Anatomy and Physiology Spinal Nerves (11 of 11)

Subdivision of ANS
Sympathetic, Fight or Flight
Increases metabolic rate Branches from nerves in the thoracic and lumbar regions Major Functions
Decreases organ and digestive system activity Vasoconstriction Release of epinephrine and norepinephrine Systemic vascular resistance Reduces venous blood volume Increases peripheral vascular resistance Increases heart rate Increases cardiac output

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Pathophysiology of Spinal Injury

(1 of 14)

Mechanisms of Spinal Injury

Extremes of Motion
Hyperextension Hyperflexion: Kiss the Chest Excessive rotation Lateral bending

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Pathophysiology of Spinal Injury

(2 of 14)

Mechanisms of Spinal Injury

Axial Stress
Axial loading
Compression common between T-12 and L-2

Distraction Combination
Distraction/rotation or compression/flexion

Other MOI
Direct, blunt, or penetrating trauma Electrocution
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Pathophysiology of Spinal Injury

(3 of 14)

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of Spinal Injury

(4 of 14)

Column Injury
Movement of vertebrae from normal position Subluxation or dislocation Fractures
Spinous process and transverse process Pedicle and laminae Vertebral body

Ruptured intervertebral disks Common sites of injury

C-1/C-2: Delicate vertebrae C-7: Transition from flexible cervical spine to thorax T-12/L-1: Different flexibility between thoracic and lumbar regions
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Pathophysiology of Spinal Injury

(5 of 14)

Cord Injury

Concussion
Similar to cerebral concussion Temporary and transient disruption of cord function Bruising of the cord Tissue damage, vascular leakage, and swelling

Contusion

Compression

Secondary to:
Displacement of the vertebrae Herniation of intervertebral disk Displacement of vertebral bone fragment Swelling from adjacent tissue
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Pathophysiology of Spinal Injury

(6 of 14)

Cord Injury
Laceration
Causes
Bony fragments driven into the vertebral foramen Cord may be stretched to the point of tearing

Hemorrhage into cord tissue, swelling, and disruption of impulses

Hemorrhage
Associated with contusion, laceration, or stretching
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Pathophysiology of Spinal Injury

(7 of 14)

Transection Cord Injury

Injury that partially or completely severs the spinal cord
Complete
Cervical Spine Quadriplegia Incontinence Respiratory paralysis Below T-1 Incontinence Paraplegia

Incomplete
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Pathophysiology of Spinal Injury

(8 of 14)

Incomplete Transection Cord Injury

Anterior Cord Syndrome
Anterior vascular disruption Loss of motor function and sensation of pain, light touch, and temperature below injury site Retain motor, positional, and vibration sensation

Central Cord Syndrome

Hyperextension of cervical spine Motor weakness affecting upper extremities Bladder dysfunction

Brown-Sequards Syndrome
Penetrating injury that affects one side of the cord Ipsilateral sensory and motor loss Contralateral pain and temperature sensation loss
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Pathophysiology of Spinal Injury

(9 of 14)

General Signs and Symptoms

Extremity paralysis Pain with and without movement Tenderness along spine Impaired breathing Spinal deformity Priapism Posturing Loss of bowel or bladder control Nerve impairment to extremities
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Pathophysiology of Spinal Injury

(10 of 14)

Spinal Shock
Temporary insult to the cord Affects body below the level of injury Affected area
Flaccid Without feeling Loss of movement (flaccid paralysis) Frequent loss of bowel and bladder control Priapism Hypotension secondary to vasodilation
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Pathophysiology of Spinal Injury

(11 of 14)

Neurogenic Shock
Spinal-Vascular Shock Occurs when injury to the spinal cord disrupts the brains ability to control the body
Loss of sympathetic tone
Dilation of arteries and veins Expands vascular space Results in relative hypotension Reduced cardiac preload Reduction of the strength of contraction Frank-Starling reflex

ANS loses sympathetic control over adrenal medulla

Unable to control release of epinephrine and norepinephrine Loss of positive inotropic and chronotropic effects
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Pathophysiology of Spinal Injury

(12 of 14)

Neurogenic Shock
Signs and Symptoms
Bradycardia Hypotension Cool, moist, and pale skin above the injury Warm, dry, and flushed skin below the injury Male: priapism

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Pathophysiology of Spinal Injury

(13 of 14)

Autonomic Hyperreflexia Syndrome

Associated with the bodys resolution of the effects of spinal shock Commonly associated with injuries at or above T-6 Presentation
Sudden hypertension Bradycardia Pounding headache Blurred vision Sweating and flushing of skin above the point of injury
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Pathophysiology of Spinal Injury

(14 of 14)

Other Causes of Neurologic Dysfunction

Any injury that affects the nerve impulses path of travel
Swelling Dislocation Fracture Compartment syndrome

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Assessment of the Spinal Injury Patient (1 of 4)

Scene Size-up
Evaluate MOI. Consider spinal clearance protocol. Determine type of spinal trauma. Maintain suspicion with sports injuries. If unclear about MOI, take spinal precautions.

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Assessment of the Spinal Injury Patient (2 of 4)

Initial Assessment
Consider spinal clearance protocol. Consider spinal precautions.
Head injury Intoxicated patients Injuries above the shoulders Distracting injuries

Maintain manual stabilization.

Vest style versus rapid extrication Maintain neutral alignment Increase of pain or resistance, restrict movement in position found
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Assessment of the Spinal Injury Patient (3 of 4)

Initial Assessment
ABCs. Suction. Consider oral or digital intubation if required.
Maintain in-line manual c-spine control.

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Assessment of the Spinal Injury Patient (4 of 4)

Rapid Trauma Assessment
Focused versus rapid assessment Rapid Assessment
Suspected or likely spinal cord/column injury Multi-system trauma patient Evaluate for
Neck Deformity, pain, crepitus, warmth, tenderness Bilateral extremities Finger abduction/adduction Push, pull, grips Motor and sensory function Dermatome and myotome evaluation Babinskis sign test Hold-up position Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

Babinskis Sign Test

Stroke lateral aspect of the bottom of the foot. Evaluate for movement of the toes.
Fanning and flexing (lifting)
Positive sign
Injury along the pyramidal (descending spinal) tract

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Assessment of the Spinal Injury Patient

Vital Signs
Body temperature
Above and below site of injury

Pulse Blood pressure Respirations

Ongoing Assessment
Recheck elements of initial assessment. Recheck vital signs. Recheck interventions. Recheck any neurological deviations.
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Spinal Clearance Protocol

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Spinal Integrity Terminology

Stabilize is a word commonly used to describe protecting the spinal cord from possible injury (or further injury) when vertebral column integrity is disrupted. Immobilize refers to the splinting of the head, neck, and torso to limit any transmission of motion to the spine. Spinal motion restriction (SMR) is now suggested as a more accurate description of modern spinal injury care. However, this phrase could be misunderstood to indicate a more limited immobilization of the spine than is currently practiced.
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Management of the Spinal Injury Patient (1 of 7)

Spinal Alignment
Move patient to a neutral, in-line position.
Position of function.

Hips and knees should be slightly flexed for maximum comfort and minimum stress on muscles, joints, and spine.
Place a rolled blanket under the knees.

ALWAYS support the head and neck. Contraindications to neutral position:

Movement causes a noticeable increase in pain. Noticeable resistance met during procedure. Increase in neurological deficits occurs during movement. Gross deformity of spine.

LESS MOVEMENT IS BEST.

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Management of the Spinal Injury Patient (2 of 7)

Manual Cervical Immobilization
Seated Patient
Approach from front. Assign a caregiver to hold GENTLE manual traction.
Reduce axial loading. Evaluate posterior cervical spine.

Position patients head slowly to a neutral, in-line position.

Supine Patient
Assign a caregiver to hold GENTLE manual traction. Adult
Lift head off ground 12: neutral, in-line position.

Child
Position head at ground level: avoid flexion.

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Management of the Spinal Injury Patient (3 of 7)

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of the Spinal Injury Patient (4 of 7)

Cervical Collar Application
Apply the C-collar as soon as possible. Assess neck prior to placing. C-collar limits some movement and reduces axial loading. DOES NOT completely prevent movement of the neck. Size and Apply according to the manufacturers recommendation.
Collar should fit snugly. Collar should NOT impede respirations. Head should continue to be in neutral position. SIZE IT, SIZE IT, SIZE IT!!!

DO NOT RELEASE manual control until the patient is fully secured in a spinal restriction device.
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Management of the Spinal Injury Patient (5 of 7)

Standing Takedown
Minimum 3 rescuers. Have patient remain immobile. Rescuer provides manual stabilization from behind. Assess neck. Size and place c-collar. Position board behind patient. Grasp board under patients shoulders. Lower board to ground. Secure patient.

COMMUNICATE WITH PARTNERS AND PATIENT.

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Management of the Spinal Injury Patient (6 of 7)

Helmet Removal
When to remove:
Helmet does not immobilize the patients head within. Cannot securely immobilize the helmet to the long spine board. Helmet prevents airway care. Helmet prevents assessment of anticipated injuries. Present or anticipated airway or breathing problems. Removal will not cause further injury.

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Management of the Spinal Injury Patient (7 of 7)

Helmet Removal
Technique:
2 Rescuers. Have a plan. Remove face mask and chin strap. Immobilize head.
Slide one hand under back of neck and head. Other hand supports anterior neck and jaw.

Remove helmet.
Gently rock head to clear occiput.

All actions should be slow and deliberate.

TRANSPORT HELMET with patient. COMMUNICATION is the KEY.

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Movement of the Spinal Injury Patient (1 of 2)

Any movement MUST be coordinated. Move patient as a unit. NO LATERAL PUSHING.
Move patient up and down to prevent lateral bending.

Rescuer at the head CALLS all moves. ALL MOVES MUST be slowly executed and well coordinated. Consider the final positioning of the patient prior to beginning move.
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Movement of the Spinal Injury Patient (2 of 2)

Types of Moves
Log roll Straddle slide Rope-Sling slide Orthopedic stretcher Vest-type immobilization Rapid extrication Final patient positioning Long spine board Full-body vacuum mattress Diving injury immobilization
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Management of the Spinal Injury Patient (1 of 3)

Medications and Spinal Cord Injury
Steroids if neuro-deficit is identified
Reduce the bodys response to injury Reduce swelling and pressure on cord Administered within 1st 8 hours of injury

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Management of the Spinal Injury Patient (2 of 3)

Medications and Neurogenic Shock
Fluid Challenge
Isotonic solution: 20 mL/kg
250 mL initially Monitor response and repeat as needed

PASG
Controversial
Research shows no positive outcome

Dopamine
220 mcg/kg/min titrated to blood pressure

Atropine
0.51.0 mg q 35 min (maximum of 2.0 mg)
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Management of the Spinal Injury Patient (3 of 3)

Medications and the Combative Patient
Consider sedatives to reduce anxiety and calm patient.
Prevents spinal injury aggravation

Medications:
Meperidine (Demerol) Diazepam (Valium) Consider paralytics with airway control
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Summary
Introduction to Spinal Injuries Spinal Anatomy and Physiology Pathophysiology of Spinal Injury Assessment of the Spinal Injury Patient Management of the Spinal Injury Patient

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