spinal
- 1. Paramedic Care: Principles & Practice Volume 5 Trauma Emergencies
- 3. 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
- 4. Introduction to Spinal Injuries
- 5. Introduction to Spinal Injuries Annually 10,000 permanent spinal cord injuries Commonly men 15–24 years old Mechanism of Injury – Vehicle crashes: 50% – Falls: 25% – Sports injury: 10%
- 6. Introduction to Spinal Injuries Spinal Injuries are sometimes missed in the pre-hospital setting Lifelong care for spinal cord injury victims exceeds $1 million Best form of care is public safety and prevention programs
- 7. Spinal Anatomy and Physiology
- 9. Vertebral Column Components of Vertebrae – Spinal Canal – Pedicles – Laminae – Transverse Process – Spinous Process – Intervertebral Disk
- 10. Disc
- 12. Blood Supply to the Spine Primarily supplied by the anterior spinal artery and the two posterior spinal arteries – Arise from the vertebral artery
- 13. Divisions of the Spinal Column Cervical Spine – 7 vertebrae – Sole support for head – C-1 (Atlas) Atlanto-occipital joint Most frequent site of injury – C-2 (Axis)- strongest of cervical vertebrae Odontoid process (dens) Projects upward Provides pivot point so head can rotate – C-7 Prominent spinous process (vertebra prominens)
- 14. Axis and Allies
- 15. C-1
- 16. C-2
- 17. Atlas and Axis Relationship © Ralph T. Hutchings
- 18. Cervical Spine © Ralph T. Hutchings
- 19. Vertebral Column Thoracic Spine – 12 vertebrae – 1st rib articulates with T-1 Demifacets – 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
- 20. Ribs & Vertebrae
- 21. Vertebral Column Lumbar Spine – 5 vertebrae – Bear forces of bending and lifting above the pelvis – Largest and thickest vertebral bodies and intervertebral disks – The anterior parts of the vertebral bodies are higher than the posterior part Contributes to the normal curvature (lordosis)
- 22. Lumbar Vertebrae © Ralph T. Hutchings
- 23. Oh Lordy
- 24. Vertebral Column Sacral Spine – 5 fused vertebrae Sacral promontory – Form posterior plate of pelvis – Attach pelvis and lower extremities to axial skeleton Coccygeal Spine – 3–5 fused vertebrae – Residual elements of a tail
- 25. I did not steal this picture
- 26. Sacral-Coccygeal Spine © Ralph T. Hutchings
- 27. Spinal Cord Function – Sensory – Motor – Reflex 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)
- 28. Cauda Equina
- 29. Spinal Cord Blood Supply – Paired spinal arteries Branch off the vertebral, cervical, thoracic, and lumbar arteries Travel through intervertebral foramina Split into anterior and posterior arteries
- 30. Spinal Cord 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
- 31. Spinal Cord © Ralph T. Hutchings
- 32. Spinal Cord 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
- 34. 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
- 35. Spinal Meninges
- 36. Spinal Nerves 31 pairs of nerves that originate along the spinal cord from anterior and posterior nerve roots – Sensory and motor functions – Travel through intervertebral foramina Each pair has 2 dorsal and 2 ventral roots – Ventral roots: motor impulses – Dorsal roots: sensory impulses – C-1 does not have dorsal roots
- 37. This is getting on my nerves. © Ralph T. Hutchings
- 38. Why is this so comPLEXUS ?
- 39. Cervical Plexus
- 40. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Spinal Nerves 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”
- 41. Brachial Plexus
- 42. Spinal Nerves Brachial Plexus – C-5 through T-1 – Controls the upper extremity Lumbar and Sacral Plexuses – Innervation of the lower extremity
- 43. Lumbar and Sacral Plexus
- 44. Spinal Nerves
- 45. Spinal Nerves 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
- 46. Dermatomes
- 47. Spinal Nerves 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
- 48. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e © 2009 by Pearson Education, Inc. Upper Saddle River, NJ
- 49. Spinal Anatomy and Physiology - Spinal Nerves Reflex Pathways – Function Speed body’s response to stressors Reduce seriousness of injury Body stabilization – Occur in special neurons Interneurons
- 50. Spinal Nerves 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
- 51. Spinal Nerves 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
- 52. Pathophysiology of Spinal Injury
- 53. Pathophysiology of Spinal Injury Mechanisms of Spinal Injury – Extremes of Motion Hyperextension Hyperflexion: “Kiss the Chest” Excessive rotation Lateral bending
- 54. Mechanisms of Spinal Injury
- 56. Hyperextension
- 57. Lateral Bending
- 58. Axial Loading
- 60. Pathophysiology of Spinal Injury 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
- 61. Results of Trauma to Spine Column Injury – Movement of vertebrae from normal position Subluxation or dislocation – Fractures – 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
- 62. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma Emergencies, 3/e © 2009 by Pearson Education, Inc. Upper Saddle River, NJ
- 63. Dislocation
- 64. Subluxation
- 65. Results of Trauma to Spine Cord Injury – Primary and secondary injuries to the spinal cord Concussion Contusion Compression Laceration Hemorrhage Transection
- 66. Results of Trauma to Spine Concussion – A temporary and transient disruption of cord function Contusion – Bruising of the cord If blood crosses the blood-brain barrier, significant edema may result Compression
- 67. Results of Trauma to Spine Compression – May occur secondary to: Displacement of a vertebra Herniation of an intervertebral disk Displacement of a vertebral bone fragment Swelling of adjacent tissue © Photo Researchers, Inc.
- 68. Results of Trauma to Spine Laceration – Causes Bony fragments driven into the vertebral foramen Cord may be stretched to the point of tearing Hemorrhage – Associated with contusion, laceration, or stretching
- 69. Results of Trauma to Spine Transection Cord Injury – Injury that partially or completely severs the spinal cord Complete Cervical Spine Quadriplegia Incontinence Respiratory paralysis Below T-1 Incontinence Paraplegia
- 70. Spinal Cord Syndromes Signs and symptoms seen following a spinal cord injury are directly related to: – Level of the spinal cord affected – Degree of damage that results from the injury
- 71. Spinal Cord Syndromes The signs and symptoms of a complete transaction occur in phases – Acute phase – Subacute phase
- 72. Spinal Cord Syndromes the strange ones 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-Séquard’s Syndrome – Penetrating injury that affects one side of the cord – Ipsilateral sensory and motor loss – Contralateral pain and temperature sensation loss
- 73. Results of Trauma to Spine 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
- 74. Results of Trauma to Spine Neurogenic Shock – Spinal-Vascular Shock – Occurs when injury to the spinal cord disrupts the brain’s ability to control the body Loss of sympathetic tone ANS loses sympathetic control over adrenal medulla Unable to control release of epinephrine and norepinephrine Loss of positive inotropic and chronotropic effects
- 75. Results of Trauma to Spine Neurogenic Shock (cont.) – Signs and Symptoms Bradycardia Hypotension Cool, moist, and pale skin above the injury Warm, dry, and flushed skin below the injury Male: priapism
- 76. Results of Trauma to Spine Autonomic Hyperreflexia Syndrome – Associated with the body’s 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
- 77. Results of Trauma to Spine Transient Syndromes – Most often result from sporting events “Stinger” Painful electrical sensations radiating through one of the arms Not a cord injury – Transient quadriplegia Results from a more serious, but temporary, injury to the cervical spinal cord Usually lasts less than 15 minutes May take up to 48 hours to resolve
- 78. Results of Trauma to Spine Other Causes of Neurologic Dysfunction – Any injury that affects the nerve impulse’s path of travel Swelling Dislocation Fracture Compartment syndrome
- 79. Pediatric Spinal Injury Anatomical Considerations – Flexibility – Large head size Children are at risk for the same sort of injuries as adults – Harder to detect due to anatomical considerations SCIWORA
- 80. Assessment of the Spinal Injury Patient
- 81. Assessment of the Spinal Injury Patient Scene Size-up – Evaluate MOI – Determine type of spinal trauma – Maintain suspicion with sports injuries – If unclear about MOI, take spinal precautions
- 82. Assessment of the Spinal Injury Patient Initial Assessment – Take 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
- 83. Assessment of the Spinal Injury Patient Initial Assessment – ABCs – Suction – Consider oral or digital intubation if required Maintain in-line manual c-spine control
- 84. Assessment of the Spinal Injury Patient Rapid Trauma Assessment – Focused versus rapid assessment Suspected or likely spinal cord/column injury Multi-system trauma patient – Rapid Assessment Neck Deformity, pain, crepitus, warmth, tenderness Bilateral extremities Finger abduction/adduction Push, pull, grips Motor and sensory function Dermatome and myotome evaluation Hold-up position
- 85. Spinal Clearance Protocol Spinal clearance protocols are based upon a protocol used in emergency departments There are several derivations of these protocols, but all have common features Always use the protocol mandated by your EMS system medical director
- 87. Assessment of the Spinal Injury Patient Vital Signs – Body temperature Above and below site of injury – Pulse – Blood pressure – Respirations
- 88. Assessment of the Spinal Injury Patient Ongoing Assessment – Recheck elements of initial assessment – Recheck vital signs – Recheck interventions – Recheck any neurological deviations © Craig Jackson/In the Dark Photography
- 89. 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.
- 90. Management of the Spinal Injury Patient
- 91. Management of the Spinal Injury Patient Spinal Alignment – Move patient to a neutral, in-line position – Hips and knees should be slightly flexed – 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
- 92. Management of the Spinal Injury Patient Manual Cervical Immobilization – Seated Patient Approach from front Assign a caregiver to hold gentle manual traction Position patient’s head slowly to a neutral, in-line position – Supine Patient Assign a caregiver to hold GENTLE manual traction Adult Lift head off ground 1–2”: neutral, in-line position Child Position head at ground level: avoid flexion
- 94. Special SMR Situations Pediatric Elderly Courtesy of Louis B. Mallory, MBA, REMT-P ©2012 Pearson
- 95. Management of the Spinal Injury Patient 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 manufacturer’s recommendation – Do not release manual control until the patient is fully secured in a spinal restriction device
- 97. Special SMR Situations Prone, seated or standing • Minimize movement into supine position Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P
- 98. Management of the Spinal Injury Patient 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 patient’s shoulders – Lower board to ground – Secure patient
- 99. Special SMR Situations Protective gear – Shoulder pad: removal With helmet removal Neutral alignment inability Unable to secure to board Access to chest needed – Note: Cut axillary straps and laces on front, open from core outward, slide out from under Courtesy of Bob Page, NREMT-P © Pearson
- 100. Management of the Spinal Injury Patient 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
- 101. Movement of the Spinal Injury Patient 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 Consider the final positioning of the patient prior to beginning move
- 102. Movement of the Spinal Injury Patient 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
- 103. Maine Protocol for SMR (Reprinted by permission of Peter Goth, MD)
- 104. Management of the Spinal Injury Patient Medications and Spinal Cord Injury – Steroids Routine use of steroids for the treatment of spinal injury is no longer recommended If Used Reduce the body’s response to injury Reduce swelling and pressure on cord Administered within first 8 hours of injury
- 105. Management of the Spinal Injury Patient 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 2–20 mcg/kg/min titrated to blood pressure – Atropine 0.5–1.0 mg q 3–5 min (maximum of 2.0 mg)
- 106. Management of the Spinal Injury Patient 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
- 107. 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