What is a classic example of an extension injury mechanism?
Rear-impact auto crash
Extremes of extension may cause?
Disk disruption, compression of interspinous ligaments,and fracture of the posterior vertebral elements
The result of a rotational spinal injury may include?
Stretching or tearing of ligaments
rotational subluxation or discoloration
Vertebral fracture
______ occurs as compressional stress is brought to bear along the axis of the spine.
Axial loading
What may occur when a person lifts a weight too great for the strength of the lumbar spine or when a person lands on their heels?
Axial loading
What are the most common sites of axial loading injuries?
Between T-12 and L-2
Cervical region
Axial loading injuries between T-12 and L-2 occur when?
For lifting injuries and heel-first falls
____ is the opposite of axial loading.
Distraction
The upper cervica region is most commonly affected by ______.
Distraction
What might hanging do to the victim?
Suspend the victim from the side of the head, causing injury from distraction and severe lateral bending direct at the C-1/C-2 region (causing hangman’s fracture)
The ___ region of the spinal column can be injured, and such injuries are usually related to ___ ___ trauma (i.e. failing on one’s tailbone).
coccygeal ; direct blunt
What forces may cause movement of the vertebrae from their normal position?
Subluxation (partial or complete dislocation) or dislocation
T or F. Trauma (especially axial loading) may damage the intervertebral disks and are always associated with injury to the spinal cord itself.
False - these injuries are to connective or skeletal tissue of the vertebral column and may or may not be associate with injury to the spinal cord itself
The ___ region accounts for over ___ of all spinal injuries, with the ___/___ (C-1/C-2) joint being most frequently involved.
cervical ; half ; atlas/axis
Why is C-7 also injured frequently?
Because it is located at the transition between the flexible cervical spine and the more rigid thoracic spine
The ___ area (L-5/S-1) is likewise injured because the ___ immobilizes the ___ spine.
lumbosacral ; pelvis ; sacral
The spinal cord ends at the ___/___ region.
L-1/L-2
What does a concussion of the cord cause?
Temporary and transient disruption of cord fuction
What is the resolution of a cord contusion and its associated S/S?
Likely to take longer than is the case with a concussion
When might spinal cord compression occur?
Secondary to the displacement of vertebra, through herniation of the intervertebral disk, from displacement of vertebral bone fragment, or from swelling of adjacent tissue.
What are cord lacerations likely to result in?
- Hemorrhage into the cord tissue
- Swelling due to the injury
- Disruption of some portions of the cord and their associated communication pathways
What is a cord transection?
Injury that partially or completely severs the spinal cord
What are the results of transection injuries below the beginning of the thoracic spine?
Incontinence
Paraplegia
What are the results of transection injuries to the cervical spine?
Quadriplegia
Incontinence
Partial/complete respiratory paralysis
What is the condition caused by bony fragments or pressure compressing the arteries that perfuse the anterior cord?
Anterior cord syndrome
What do anterior cord syndrome injuries usually involve?
Loss of motor function
Sensation to pain, light touch, and temperature below the injury site
What is an anterior cord syndrome patient likely to retain?
Motion
Positional
Vibration sensation
What are the S/S of spinal injury?
- Paralysis of the extremities
- Pain with and without movement
- tenderness along the spine
- Impaired breathing
- Spinal deformity
- Priapism
- Posturing
- Loss of bowel or bladder control
- Nerve impairment to extremities
What are the types of primary and secondary spinal cord injuries?
- Concussion
- Contusion
- Compression
- Laceration
- Hemorrhage
- Transection
What is the condition usually related to hyperextension of the cervical spine that results in motor weakness, usually in the upper extremities and possible bladder dysfunction?
Central cord syndrome
What is the conditional caused by partial cutting of one side of the spinal cord resulting in sensory and motor loss to that side of the body?
Brown-Sequard syndrome
Why is pain and temperature perception lost on the opposite (contralateral) side of the body in Brown-Sequard syndrome?
Because of the switching of the associated nerves that occurs as they enter the spinal cord
What condition occurs when nerve roots at the lower end of the spinal cord are compressed, interrupting sensation and movement?
Cauda equina syndrome
What results when injury to the spinal cord disrupts the brain’s ability to exercise control over the body?
Neurogenic (or spinal-vascular) shock
Lack of ___ tone permits the ___ and ___ to dilate, expanding the ___ space, resulting in a relative hypovolemia.
sympathetic ; arteries ; veins ; vascular
How does a patient in neurogenic shock present?
- Slow heart rate
- Low BP
- Shocklike symptoms (cool, moist, and pale skin) above the cord injury
- Warm, dry, flushed skin below the injury
- Priapism in male
What is the treatment for neurogenic shock?
Bolus of isotonic solution 20 mL/kg (200 mL initially)
Atropine - 0.5 to 1 mg every 3 to 5 minutes
Dopamine - 2 to 20 mcg/kg
What is the condition associated with the body’s adjustment ot the effects of neurogenic shock; presentation includes sudden hypertension, bradycardia, pounding headache, blurred vision, and sweating/flushing of the skin above point of injury?
Autonomic hyperreflexia syndrome
Autonomic hyperreflexia syndrome is most commonly associated with injuries at or above ___.
T-6
You should test ___ and ___ function for the lower extremities by (1) placing your hand against the ball of the patient’s foot and have him push firmly against it (plantar flexion, S-1, S-2) then (2) place your hand on top of the toes and have the patient ___ the toes and foot upwards (___, L-5)
motor ; sensory ; pull ; dorsiflexion
How to you test for Bainski’s sign?
Stroke the lateral aspect of the bottom of the foot and watch for movement of the toes and great toe
Fanning of the toes and ___ (lifting) of the great toe is a positive sign and suggest injury along the ___ (descinding spinal) tracts.
dorsiflexion ; pyramidal
What might a patient with midcervical spine injury present with?
“Hold-up” position - patient’s arms rise to a position above the shoulders and head because the injury paralyzes the adductor and extensor muscles while the patient maintains control over the abductors and flexors
What is the study that proposed, validated, and is used by emergency physicians to determine which patients need spinal x-rays and which do not?
National Emergency X-Radiography Utilization Study (NEXUS)
What three conditions must be met to discontinue spinal precautions?
- Patient is alert and fully oriented; not intoxicated or under the influence of drugs (including alcohol); has GCS of 15; and not significantly affected by the “fight-or-flight” response
- Patient is free of significant distracting injuries or symptoms such as a fracture, joint injury, abdominal pain, or dyspnea
- Patient is free of any S/S of spinal injury
When should a helmet be removed?
- Helmet does not immobilize the patient’s head within
- Cannot securely immobilize the helmet to the long spine board
- Helmet prevents airway care
- Helmet prevent assessment of anticipated injuries
- There are (or you anticipate) airway/breathing problems
- Helmet removal will not cause further injury
Routine use of ___ for spinal injury is no longer recommended.
steroids
How is hypovolemia frequently treated?
- Fluid challenge
- Followed by careful use of vasopressor such as dopamine
- Slow heart rate treated with atropine to reduce any parasympathetic stimulation
The most common sites of axial loading for lifting injuries and heel-first falls are located between:
T-12 and L-2
During a trauma assessment you notice that a patient has no sensation below the lower border of the rib cage. This would suggest spinal pathology between which vertebral areas?
T-4 and T-10
Which of the following vital signs would most likely indicate a potential spinal cord injury?
Hypotension, bradycardia, and shallow respirations
For which of the following patients would the anticholinergic agent atropine be best suited. A patient:
with an injury to the upper spinal cord
The primary management objective in a patient with a suspected spinal cord injury is to:
maintain the patient in a neutral, in-line position
Priapism is defined as:
A sustained erection of the penis
Which of the following statements regarding cervical collars is true?
They serve as an adjunct to full cervical immobilization
All of the following are S/S of spinal shock except:
a. priapism
b. hypertension
c. loss of bladder control
d. flaccid paralysis
b. hypertension
Which of the following best defines spinal shock?
temporary insult to the cord that affects the body below the level of the injury
When a neuromuscular blocker is to be given to a patient, a(n) ___ should be administered first.
sedative/hypnotic
Feed or breed is which system?
Parasympathetic
Fight or flight is which system?
Sympathetic
C1 is also known as?
Atlas
Which part of the spine allows for wide range of motion for head to move and pivot?
C1
C2 is also known as?
Axis
What is the odondoid process?
Rises through C1 to keep spine in line
What does C6/7 control?
Fingers and hands
Biceps
What does C3 and above control?
Respiratory
What does C4 control?
Diaphragm - results in paralysis
If paralyzed waist down, break might have occurred where?
T10
If paralyzed waist up, break might have occurred where?
T4
Where is T4 located?
Nipple line
Where is T10 located?
Umbilicus
Which shock usually resolves within 24 hours?
Neurogenic shock
What is the presentation for neurogenic hypotension?
BP between 80-100
Warm, dry skin, bradycardia
What is the proper way to secure a patient to back board?
Torso
Head
Legs
Arms
What is methylprednisolone used for?
To reduce edema and inflammation within spine
