Module 19- Spinal Injuries and Assessment Flashcards
(60 cards)
1
Q
Spinal injuries- mechanism of injury
A
Spinal injuries are classified by associated mechanism, location, and stability of the injury.
2
Q
Vertebral fractures can occur…
A
with or without SCI
3
Q
Stable fractures…
A
don’t involve the posterior column
- they poss less risk to the spinal cord
4
Q
Unstable injuries…
A
- involve the posterior column and include damage to the vertebrae and ligaments that protect the cord and nerve roots
- Unstable injuries carry a higher risk of complicating SCI and progression of injury without appropriate treatment
5
Q
What are flexion injuries?
A
- Result from forward movement of head (usually from fast deceleration or a direct occipital blow)
- Further down the spinal column, flexion forces are transmitted anteriorly through vertebral bodies
- Results in anterior wedge fractures occur below this
6
Q
What happens if a flexion injury occurs at C1-C2?
A
It can produce unstable dislocation with or without fracture
7
Q
What are teardrop fractures?
A
- Teardrop fractures are avulsion fractures of the anterior-inferior border of the vertebral body. These are hyperflexion injuries of significant force
- These have potential for SCI
- Can lead to unstable dislocation
8
Q
What is rotation with flexion?
A
- Only area mobile enough for it is C1-C2
- Injuries are considered unstable due to its high cervical location and scant bony and soft-tissue support
9
Q
When can rotation with flexion injuries occur?
A
Results from high acceleration forces
10
Q
What ca a rotation with flexion injury produce?
A
- Can produce stable dislocation in the cervical spine
- In thoracolumbar spine, can fracture rather than dislocate
11
Q
What is a vertical compression?
A
- Transmitted through vertebral body and directed inferiorly through the skull or superiorly through the pelvis or feet
12
Q
What can cause a vertical compression?
A
- Can result from direct blow to the crown (parietal region) of the skull, or rapid deceleration from a fall via the feet, legs, and pelvis
- Often produces a “burst” or compression fracture with or without SCI
- May case disc herniation
- SCI can occur if the vertebral body is shattered and bone embeds in the cord
13
Q
What is hyperextension?
A
- Hyperextension of the neck and head can result in fractures and ligaments
14
Q
What can hyperextension cause?
A
- Can be stable in flexion, but not in extension
- May cause hangman’s (C2) fracture
- Usually occurs in rapid declaration of skull, atlas, and axis as a unit
- A teardrop fracture of the vertebral body can occur (anterior-inferior edge). Can be stable when the head is in flexion, but unstable in extension due to to loss of structural support
15
Q
What are the two categories of spinal injuries?
A
- Primary spinal cord injury: injury occurs at the moment of impact
- Secondary cord injury
16
Q
What causes primary spinal cord injury?
A
- Injuries occur at the moment of impact
- Often caused by penetration injury causing complete transection injury
- Blunt injury produces compression if spinal cord
- Hypoperfusion, tissue ischemia
- Necrosis from prolonged ischemia, results in permanent function losses
17
Q
What is included in a primary spinal cord injury?
A
- Includes spinal cord concussion, contusion, and laceration
18
Q
What is spinal cord concussion?
A
- Temporary dysfunction of the spinal cord that lasts 24-48 hours occurs in 3-4% of SCIs
- Considered an incomplete injury
19
Q
What causes spinal cord concussion?
A
- Caused by fractures, dislocation, or direct trauma
- Edema, tissue damage
20
Q
What is a cord laceration?
A
- Occurs when a projectile or bone enters the spinal canal
- Results in hemorrhage into cord tissue
- Swelling
- Disruption of some portion of the cord and its associated pathways
21
Q
What is a secondary cord injury?
A
- This injury occurs when multiple factors permit a progression of primary SCI
- A cascade of inflammatory responses occurs
Effects can be exacerbated by exposing neural elements (spinal cord and nerve roots) to further hypoxemia, hypoglycemia, and hypothermia
22
Q
What are the classifications of spinal cord injuries?
A
- Complete spinal cord injury
- Incomplete spinal cord injury
23
Q
What is a complete spinal cord injury?
A
Complete disruption of all tracts of cord, with permanent loss of all cord mediated functions below the level of transaction
24
Q
What is a incomplete spinal cord injury?
A
Some degree of cord function remains
25
What is anterior cord syndrome?
- Displacement of bony fragments into anterior cord
- Flexion injuries or fractures
- Paralysis below level of insult, with loss of sensation to pain, temp, and touch
26
What is central cord syndrome?
- Hyperextension injury to cervical area with hemorrhage and edema to central cervical segments
- Rarely associated with fractures
- Usually occurs with tears of anterior longitudinal ligament
- Greater loss of function in the upper extremities than lower extremities
- Prognosis is good with therapy
- More commonly seen in elderly with severe spinal stenosis and/or spondylosis
27
What is posterior cord syndrome?
- Associated with extension injuries
- Rare
- Dysfunction of dorsal columns (Results in decreased sensation to light touch, vibration, and the ability to perceive the position and movement of one’s body)
28
What is Brown-Sequard syndrome?
- Associated with penetration trauma and complete damage to spinal cord tracts (hemisection of cord)
- Motor loss on same side of injury below lesion level
- Loss of sensation to light touch, proprioception, and vibration if dorsal column damaged
- Damage of spinothalamic tracts causes loss of sensation of temperature and pain on the opposite side of the body.
29
What is spinal shock syndrome?
- temporary condition- swelling from trauma creates edema in spinal cord itself
- Occurs immediately after spinal trauma
- Swelling and edema of the cord within 30 mins can lead to disruption of nerve conduction distal to the injury
- May present with variable degrees of acute spinal injury
- Symptoms improve and resolve in hours or weeks
30
What is neurogenic shock syndrome?
- temporary loss of autonomic function that controls cardiovascular function
- Marked hemodynamic and systemic reactions (hypotension, relative hypovolemia, bradycardia, warm red skin)
- Hypotension due to absent or impared peripheral vascular tone
- Blood pooling in enlarged vascular space
- Absence of sweating
31
What are the classic signs of neurogenic shock?
- Hypotension
- Bradycardia
- Warm, flushed skin
- Dry below the level of spinal lesion
32
What is Spinal Cord Injury Without Radiographic Abnormalities?
- Children have vertebrae that can dislocate and quickly relocate. Cord gets damaged but shows an aligned vertebral column
- Cord can be transected or compressed
- Only diagnosed in the ED. (MRI)
33
Patient Assessment
- Limiting progression of secondary SCI is a major goal
- Have suspicion in an MOI that suggest possible SCI
- Treat all patients who experience multiple trauma or those found unconscious after trauma as if a SCI exists
- Any major trauma above clavicle level is considered an SCI risk
34
What are the high risk mechanisms associated with SCI?
- Motor vehicle collision velocity > 60km/h
- Unrestrained occupant (mid/high speeds)
- Vehicular damage intrusion of 30 cm or more
- Fall from three times the patient’s height
- Penetrating trauma near spine
- Ejection from moving vehicle
- Motorcycle collision . 30km/h with separation of rider from vehicle
- Diving injury
- Vehicle/ pedestrian or vehicle/bicycle collision . 10km/h
- Other motor vehicle collisions (rollovers, death of another occupant in the same compartment, etc.)
35
What is uncertain risk for spine injury?
- Syncopal event in which the patient was seated or supine
- Isolated minor head injury without positive mechanism for spine injury
- Moderate to low velocity MVC
- Patient involved in MVC with isolated injury with positive assessment for SCI
36
What is the patient assessment for spinal injuries?
- Determine the circumstances of the incident
- Note the types of energy involved (degree of force, speed, trajectory, was there blunt or penetrating trauma?)
- Determine if there was a torsion injury or any extreme motion of the neck
- Note the height of fall
- Note the exact injury time and any changes in patient presentation
- In MVC, note restraints, positioning of pt, and degree of vehicle damages
- Apply manual stabilization
- Document suspected SCI noting area involved, sensation, dermatomes, motor function, and area of weakness
- Communicate with the pt
- If alert, ask them to hold still and tell them why
- If unconscious, still communicate with the pt's, they may hear you
37
What is the scene assessment for SCI?
- PPE, scene safety, need for ALS
- Observe patient position, age, and gender
- Determine if immediate life threats exist
- Perform manual spinal stabilization
- Determine LOC using AVPU initially
38
What is the airway management for spinal injuries?
- Open it; look in it
- Suction or remove obstructions
- Perform jaw thrust maneuver
- Sterdous respiration= snoring
- Consider use of OPA or NPA
- An intact gag reflex= no OPA use
- Basilar Skull Fracture= no NPA use
- Orotracheal intubation if indicated
- Log roll pt in case of vomiting
- Follow up with suction
39
What is the breathing management for spinal injuries?
- Assess rate, depth, symmetry
- Injuries may affect phrenic nerve (C3-C5), which can paralyze the diaphragm causing abdominal breathing and accessory neck muscle usage
- Lower C-spine or upper T-spine injury can paralyze intercostal muscles
- Oxygen via non-rebreather if resp are adequate
- Any inadequate respiration patterns will require breathing assistance
Assisted breathing
- BVM device with 12-15 l/min oxygen at 10-12 breaths per minute (adult)
- If head injury is suspected use PCO2 monitoring to maintain CO2 levels at 34-45 mm Hg
40
What is the assessment for circulation for spinal injuries?
- Compare radial and carotid pulses (check rate, quality, regularity and equality)
- Check skin color, temp, and moisture
- No pulse: initiate CPR
- Volume resuscitation: may be needed (multisystem trauma, hypovolemic shock)
- Pure neurologic shock rarely needs fluid; may need vasolytic drugs (atropine) and vasopressors (dopamine) to reverse vagal stimulation and alpha receptor blockade
41
What are the transport decisions?
- Early decision: complete focused history and physical examination on scene or transport immediately and treat en route
- Unstable or potentially unstable= transport ASAP to appropriate hospital (perhaps by air, if distance is great and time is short)
42
What is the focused history & physical examination for spinal injuries?
- Accurate H&P is critical in SCI injury
- Reliability of patient a factor (distracting injury and emotion, Intoxication or drug use, Acute stress reaction)
- If unreliable, err on the side of safety and immobilize
- Baseline vitals, assess pupils, use SAMPLE and DCAP-BTLS
- Distal PMS check to all extremities (pulse, motor, and sensory check)
- Use AVPU and GCS for responsiveness evaluation and trends
43
Placement on backboard
- Perform a back assessment before securing the patient on backboard
- Patient can be log rolled to visualize the neck and back
- Look for pain, deformity, or step off
- Try to minimize the number of times the patient must be moved
- Palpate each individual vertebrae and allow time for the patient to respond
- Protect any limbs that may be paralyzed or weak
- Absence of pain or tenderness along spine, normal neurologic examination, and low risk MOI may eliminate immobilization need.
- Skin breakdown is a problem with any time spent on a backboard
- Some devices are made for seated patients
44
What backboards can we use fir spinal injuries?
- Fracture board
- Scoop method: use of the scoop stretcher to lessen motion to patient
- Back raft: low profile air mattress
45
Detailed physical examination for spinal injuries:
- Head to toe examination
- Done to any patient with significant MOI
- May be done en route to hospital
- Special attention to head, face, and spine
- Evaluate chest and abdomen for internal and external injury (palpate all quadrants and pelvis, assess for priapism)
- Continually monitor cardiovascular system for shock
- Neurogenic, spinal and hypovolemic shock are all possible
- Palapte all extremities for deformity, contusions, abrasions, punctures, lacerations, and edema
- Notice any posturing
46
What muscle group does C3-C5 control?
Diaphragm
47
What muscle group does C5 control?
Elbow flexors: biceps, brachilis, brachioradialis
48
What muscle group does C6 control?
wrist extensors
49
What muscle group does C7 control?
Elbow extensors; triceps
50
What muscle group does C8 control?
Finger flexors: flexor digitorum profundus to middle finger
51
What muscle group does T1 control?
Hand intrinsics: interossei, small finger abductors
52
What muscle group does T2-T7 control?
Intercostal muscles
53
What muscle group does L2 control?
Hip flexors: iliopsoas
54
What muscle group does L3 control?
Knee extensors: quadriceps
55
What muscle group does L4 control?
Ankle dorsiflexors: tibialis anterior
56
What muscle group does L4 control?
Ankle dorsiflexors: tibialis anterior
57
What muscle group does L5 control?
Long toe extensors: extesnor halluces longus
58
What muscle group does S1 control?
Ankle plantar flexors (gastrocnemius soleus)
59
What muscle group does S4-S5 control?
Anus, bowel, bladder
60
What is the ongoing assessment for spinal injuries?
- Monitor vitals every 5 mins in unstable pt’s
- Stable pt’s should have vital monitored every 15 mins
- Pay special attention to the cardiovascular status of patient
- Monitor hypotension with a normal to slow pulse and warm skin= possible neurogenic shock
- May also show flaccid paralysis and complete sensation loss below injury level
- Hypovolemic shock= tachycardia and pale, cool, clammy skin
- Check oxygen flow and spinal immobilization for effectiveness often
