Presentation on theme: "Suspected Spinal Injury"— Presentation transcript:
1Suspected Spinal Injury ObjectivesAt the completion of this unit, the EMS provider will be able to utilize assessment findings to formulate a field impression and implement a treatment plan for a patient with a suspected spinal injury. Prior to this unit, EMS providers should have an understanding of the anatomy of the spine and spinal cord, trauma assessment, and spinal immobilization.This presentation is to be used as an adjunct to the New York State Department of Health Bureau of EMS trauma curriculum update for the Suspected Spinal Injury protocol published in February of 2008.New York StateDepartment of HealthBureau of Emergency Medical Services
2Cervical Spine Injuries in Perspective 2.4% of blunt trauma patients experience some degree of musculoskeletal injury to the spineApproximately 20,000 spinal cord injuries a year in United States$1.25 million to care for a single patient with permanent SCICervical Spine Injuries in Perspective2.4% of blunt trauma patients experience some degree of musculoskeletal injury to the spineInjury ranges fromsprain (i.e. whip lash)stable fractures (e.g. tear drop fracture)subluxationsunstable fracturespartial or complete spinal cord transectionparalysisparaplegia (effecting two limbs)tetraplegia (effecting all four limbs)Approximately 20,000 spinal cord injuries a year in United Statescost of lifetime medical care for spinal cord injury approximately $1.25 million dollarsOccult spinal cord injuryapproximately 60% of patients present initially without spinal cord deficitsweakness (paralysis)tingling or numbness (paresthesia)
3Higher in men between ages of 16 – 30 Common causes: 15,000 – 20,000 SCI per yearHigher in men between ages of 16 – 30Common causes:Motor vehicle crashes – 2.1 million per year (48%)Falls (21%)Penetrating injuries (15%)Sports injuries (14%)Education in proper handling and transportation can decrease SCI
4HistoricallyImmobilization based on MOI – even if there were no signs and symptomsLack of clear clinical guidelinesEMS providers did poorly with full spinal immobilizationMotor vehicles had fewer safety featuresPatients spent extended amounts of time in immobilization devices at E.D.Until recently EMS was taught to look at MOI as an indicator for spinal immobilization.
5Why not board/collar and Xray everybody? Immobilization is uncomfortable: increased time immobilized = increased pain, risk of aspiration, vulnerable position, etc...>800,000 U.S. Patients receive cervical radiography each yearPatient exposure to radiation>97% of x-rays are negativeCost exceeds $175,000,000 each year
6Secondary Injury versus Primary Injury Spinal Injury that occurred at time of traumaSecondary InjurySpinal Injury that occurs after the traumapossibly secondary to mishandling of unstable fractures
7Review of Anatomy & Physiology Spinal Columnseparate, irregular bonesHead (15-22 lbs) Balances on Top C-SpineSupported by PelvisLigaments and Muscles connect head to pelvisInjury to Ligaments may cause excess movement of vertebraeVertebral Foramen - canal formed for cord
14Anatomy & Physiology, cont. Central Nervous System (CNS)BrainLargest most complicated portion of CNSContinuous with spinal cordResponsible for all sensory and motor functionsSpinal CordWithin the Vertebral ColumnBegins at Foramen Magnum and ends near L2 (cauda equina)Dural Sheath
15Anatomy & Physiology, cont. CNS Cont.Ascending Nerve TractsCarries impulses and sensory information from the body to the brain (I.e. touch, pressure, pain, tenderness, body movements, etc.)Descending Nerve TractsCarries motor impulses from brain to body (e.g. muscle tone, sweat glands, muscle contraction, control of posture)
16Anatomy & Physiology, cont. CNS Cont.Spinal Nerves31 pairs originating from spinal cordMixed Nerves - carry both sensory and motor functionsDermatonesTopographical region of body surface innervated by one spinal nerveExample: C-7/T-1 motor = finger abduction and adduction, sensory = little finger
17Pathophysiology of Spinal Injuries Mechanisms and Associated InjuriesHyperextensionCervical & Lumbar SpineDisk disruptionCompression of ligamentsFx with potential instability and bone displacementHyperflexionWedge FxStretching of ligamentsCompression Injury of cordDisk disruption with potential vertebrae dislocation
18Pathophysiology, cont. (Mechanisms and Common Injuries) RotationalMost commonly Cervical Spine but potentially in Lumbar SpineStretching and tearing of ligamentsRotational subluxation and dislocationFxCompressionMost likely between T12 and L2Compression fxRuptured disk
20Pathophysiology, cont. (Mechanisms and Common Injuries) DistractionMost common in upper Cervical SpineStretching of cord without damage to spinal columnPenetratingForces directly to spinal columnDisruption of ligamentsFxDirect damage to cord
21Pathophysiology, cont. Specific Injuries Fractures to vertebrae Tearing of Ligaments, Tendons and/or MusclesDislocation or Subluxation of vertebraeDisk herniation / rupture
22Pathophysiology, cont. (Specific Injuries) Cord InjuriesConcussion - temporary or transient disruption of cord functionContusion - Bruising of the cord with associated tissue damage, swelling and vascular leakingCompression - Pressure on cord secondary to vertebrae displacement, disk herniation and/or associated swelling
23Pathophysiology, cont. (Specific Injuries) Cord Injuries cont.Laceration - Direct damage to cord with associated bleeding, swelling and potential disruption of cordHemorrhage - Often associated with a contusion, laceration or stretching injury that disrupts blood flow, applies pressure secondary to blood accumulation, and/or irritation due to blood crossing blood-brain barrier.Transection - Partial or complete severing of cord
24Pathophysiology, cont. (Specific Injuries) Spinal ShockTemporary insult affecting body below level of the injuryFlaccidity and decreased sensationHypotensionLoss of bladder and/or bowel controlPriapismLoss of temperature controlOften transient if no significant damage to cord
25Pathophysiology, cont. (Specific Injuries) Neurogenic ShockInjury disrupts brain’s control over bodylack of sympathetic toneArterial and vein dilation causing relative hypovolemiaDecreased cardiac outputDecrease release of epinephrineDecreased BPDecreased HRDecreased Vasoconstriction
26Signs and Symptoms of Spinal Cord Injury ParalysisParesthesiasParesis (weakness)ShockPriapismPainTendernessPainful MovementDeformitySoft Tissue Injury in area of spine (Bruise, Laceration, etc.)
27General Assessment Scene Size Up Initial Assessment Including manual stabilization/immobilization of the c-spineFocused History and Physical Exam - TraumaReevaluate Mechanism of Injury (MOI)Suspected Spinal Injury Protocol
28Positive MOI - Forces or impact suggest a potential spinal injury Sports InjuriesOther High Impact SituationsConsideration to special pt. Populationpediatricsgeriatricshistory of Down’sspino bifodaetc.High Speed MVCFalls Greater than 3x pt.’s body heightAxial LoadingViolent situations near the spineStabbingGun shotsetc.
29High Risk MOIs Axial load (i.e., diving injury, spearing tackle) High speed motorized vehicle crashes or rolloverFalls greater than standing heightThe presence of one of these MOIs does not always require treatment, but providers should be more suspicious of spinal injury, and immobilize if they are at all worried about the possibility of spinal injuryHigh Risk Mechanisms of injury have been identified as being more likely than other types of blunt trauma to lead to possible spinal injury. A patient with one of these MOIs does not require treatment, but providers need to more suspicious of injury.High risk mechanisms of injury associated with unstable spinal injuries include, but are not limited to: Axial load (i.e. diving injury, spearing tackle) High speed motorized vehicle crashes or rollover Falls greater than standing height in relationship to the patient’s feet. For example, a 6 foot tall person falls five feet off a step ladder they would not have a high risk MOI.
30Other High Risk Factors Associated with Spinal Injury Trisomy 21 (Down Syndrome, mongolism)Risk of Atlanto-Axial Instability (AAI)Age Greater than 55Risk of degenerative arthritis of cervical spineDegenerative Bone Disease (including ostegenesis imperfecta, or “fragile bones”)Risk of “pathological” (disease-related) fracturesSpinal TumorsPatients with these risk factors have been shown to be more likely to have a spinal injury, with a lower mechanism of injury. Providers should be more cautious when considering the situation including the patient’s history, mechanism of injury, complaints and history to make the decision regarding immobilization.For example, Down Syndrome patients may have atlantoaxial instability, or AAI. This effects the integrity of the cervical spine and may make these patients more susceptible to spinal cord injury. This is important when evaluating the patient for the need for spinal immobilization.
31Negative MOIForces or impact involved does not suggest a potential spinal injuryDropping rock on footTwisting ankle while runningIsolated soft tissue injury
32Uncertain MOI Unclear or uncertainty regarding the impact or forces Trip and fall hitting headFall from 2-4 feetLow speed MVC with minor damage
33MOI, cont.When using the Suspected Spinal Injury protocol, a positive mechanism of injuryis not considered means to necessitate fullimmobilization …BUT…should be used as a historical componentthat may heighten a provider’s suspicion for a spinal cord injury.
34Current PracticeWidespread spinal immobilization of all adult and pediatric trauma patients.
35Spinal Immobilization Education Identify All Patients at Risk for Spinal Injury based on Mechanism of Injury and Patient AssessmentShift from current thinking of immobilization based on mechanism of injury alone.
36History of Spinal Immobilization Maine Selective Spinal ImmobilizationEarly Leaders in Out – of – Hospital Selective Spinal ImmobilizationNational Emergency X-Radiography Utilization Study (NEXUS)History of Selective Spinal ImmobilizationMaine Selective Spinal ImmobilizationEarly Leaders in Out – of – Hospital Selective Spinal ImmobilizationNational Emergency X – Radiography Utilization Study (NEXUS)
37Spinal Immobilization Protocols in New York State The following groups of patient should be immobilized:The following groups of patient should be immobilized!
38Major Trauma ProtocolAll Adult and Pediatric Trauma Patients who meet the Major Trauma Protocols (T 6–7)Certain Adult and Pediatric Patients with Blunt Head and Neck Trauma i.e. Based on Mechanism of Injury (T 8)Major TraumaAll adult and pediatric trauma patients who meet the Major Trauma Protocols (T-6)Certain adult and pediatric patients with blunt head and neck trauma as outlined below (T-8)Spinal Immobilization indicated for the following adult and pediatric patients based on Mechanism of Injury (*included in Major Trauma Protocol)Violent Impact of the Head, Neck or TrunkMotor Vehicle CrashHigh SpeedRollover*Ejection*FallsMoving Vehicle at any speedHeight greater than 3 feet or 5 stairsMechanism consistent with potential axial loading / cervical compressionex. brick falling on head of patient wearing hard hat
39Consider Spinal Immobilization Not Meeting Major Trauma Protocol but patient has one or more:Altered Mental StatusPatient Complaint of Neck PainWeakness, Tingling or NumbnessPain on Palpation of Posterior Midline NeckSpinal Immobilization indicated for the following adult and pediatric trauma patients based on Physical FindingsAltered Mental StatesVerbal or less on AVPU Assessment14 or less on the Glascow Coma ScalePatient complaintsNeck PainPresence of the following in the trunk or extremitiesWeaknessTinglingNumbnessFindings on Physical ExaminationPain on Palpation of posterior midline neck or along spinePalpable Deformity in the posterior midline neck or along spineParalysisParesthesia
40Consider Spinal Immobilization High Risk PatientsNot Meeting Major Trauma Protocol but patient has one or more:Altered Mental StatusEvidence of IntoxicationDistracting InjuryInability to CommunicateAcute Stress ReactionElderlyAge Greater than 65 yearsSpinal Immobilization indicated for the following adult and pediatric patients who are defined as High Risk PatientsElderlyAge Greater than 65 yearsEvidence of IntoxicationDistracting InjuryInability to Communicate
41What is an Altered Level of Consciousness? Verbal or less on the AVPU ScaleGlascow Coma Scale of 14 or LessShort Term Memory DeficitWhat is considered an Altered Level of Consciousness?Verbal or less on the AVPU ScaleDisoriented to Person or Place or TimeGlascow Coma Scale of 14 or LessShort Term Memory DeficitInability to remember Five (5) Items in Five (5) Minutes
42What is Intoxication? Patients who have either A History of Recent Alcohol Ingestion or Ingestion of Other IntoxicantsEvidence of Intoxication on Physical ExaminationWhat is considered Intoxication?Patients who have eitherA History of Recent Alcohol Ingestion or IntoxicationEvidence of Intoxication on Physical ExaminationSmell of Alcoholic Beverages on the BreathSlurred SpeechPositive Lateral Nystagmus(movement of eyes side to side –rapidly)
43What is a Distracting Painful Injury?? Painful Injury or Serious Illness that would Mask the Symptoms Associated with Spinal Cord InjuryWhat is a Distracting Painful Injury?Painful Injury that would mask the symptoms associated with Spinal Cord InjuryPainParenesthesia (Tingling)Paralysis (Weakness)Examples of Distracting Painful InjuryLimb Injuries such asAny Long FractureCrush InjuryDegloving InjuryInternal Organ Injuryaka Injury meeting Major Trauma ProtocolLarge LacerationsAny Injury that produces an Acute Functional ImpairmentInability to Move an ExtremityInability to Feel an ExtremitySevere Exacerbations of Medical ConditionsChest PainCardiac RelatedShortness of BreathRespiratory Distress/FailureSevere Abdominal Pain
44Distracting Injury or Circumstances Painful InjuryObvious DeformitySignificant BleedingImpaled ObjectAny painful injury that may distract the patient’s attention from another, potentially more serious (cervical spine) injuryInability to Communicate Clearly (small child, confused or intoxicated adult)Emotional DistressPresence or Exacerbation of Existing Medical ConditionsWhat is a Distracting Injury or Circumstance?Painful Injury that would mask the symptoms associated with Spinal Cord InjuryPain from obvious fracturesImpaled ObjectsLarge Laceration or Other significant bleedingExamples of Difficulties with Patient CommunicationVery Young PatientDevelopmentally Disable PersonsLanguage BarrierPhysical BarriersHearing ImpairmentEmotional DistressExcited, Distraught, Unable to FocusInjured Child or Family MemberHorrific AccidentAnxietyA patient with a medical complaint may not be able to participate fully in the exam.
45Fundamental Principle Patient CommunicationPatients with CommunicationDifficultiesAcute Stress ReactionFundamental PrinciplePatient CommunicationInability to communicate with the patient would have EMS provider err on the side of caution and immobilize the cervical spineExamples of Difficulties with Patient CommunicationLanguage BarrierPhysical BarriersHearing ImpairmentAcute Stress ReactionAcute Stress Reaction (ASR) results in an inability to communicate effectively
46What is Acute Stress Reaction? A “fight or flight”response that canoverride any painfrom an injuryWhat is Acute Stress Reaction?A “fight or flight” response that can override any pain from an injurysubjective appearance of “panic” or “alarm”associated signs of fight or flight responseincreased respiratory rate – tachypneaelevated heart rate – tachycardiaelevated blood pressure – hypertension
47Key PointIf there is ANY DOUBT, then SUSPECT that a SPINE INJURY is Present and Treat Accordingly
48Termination of Immobilization Once spinal immobilization has been initiated, it must be completed.An extrication or cervical collarstarts the immobilization processManual Stabilization does NOTstart the immobilization processOnce spinal immobilization has been initiated, it must be completed. An extrication or cervical collar starts the immobilization process, manual stabilization does not
49Documentation Negligence Either an omission or a commission of an act Documentation of rationale toImmobilizeNot ImmobilizeDocumentationNegligenceEither an omission or a commission of an actDocumentation of rationale toImmobilizeNot Immobilize
50Routine Prehospital Care Documentation Mechanism Of InjuryPatient Chief ComplaintPhysical Examination FindingInitial AssessmentRapid Trauma ExaminationDetailed Trauma ExaminationRoutine Prehospital care documentation includingmechanism of injurypatient complaintsphysical examination findingsinitial assessmentrapid trauma examinationdetailed trauma examination
51Documentation of Rationale to Not Immobilize Mechanism Of Injury is MinorPhysical Examination (Positives)Physical Examination (Negatives)Absence of signs of spine injuryAbsence of distracting injuryPatient was not one of the identified high risk patientsDocumentation of rationale to not immobilizeMechanism Of Injury is Minori.e. does not meet major trauma criteriawas not a violent impact to head, neck or trunkphysical examination did not findAltered mental statusI.e. Patient Awake and AlertGlascow Coma Scale of 15Evidence of intoxicationAbsence of numbness (paraesthesia) or weakness (paralysis)absence of signs of spine injurycervical spine tendernesspain of the cervical spine on palpationdeformity of the cervical spineabsence of distracting injurypatient was not one of the identified high risk patientselderly (>65)
56Friday Night Lights 16 year old male football player Made a spear tackle during the game and remains downAssessment finds tenderness to the posterior of the neckShould the patient be immobilized? Why or Why not?EMS Standby at JV Football GameAfter a play, the crew is motioned onto the field to aid a player that hasn’t gotten upThe coach and trainer are talking to a prone patient. The patient is CAOx3 but reports that he doesn’t remember how he got injured.The coach reports that the patient had made a “spear tackle.”The patient assessment finds no life threats, normal vital signs, good sensation, motion, and pulses in all extremities. There is mild tenderness on palpation to the posterior of the neck.The patient SHOULD be immobilized based on the Mechanism of Injury – Axial Loading and Physical Findings – tenderness in the neck.Either alone would be an indication for immobilization.
57Motorcycle Accident 35 year old female Single vehicle accident in the rainLaid the motorcycle down to avoid striking another carPain to left elbow & shoulderNo other unusual findingsShould the patient be immobilized? Why or Why not?Respond for report of a motorcyclist downArrive to find a 35 year old woman sitting on the curb, CAOx3 near her damaged motorcycle. The road is wet from a light rain. She reports she was riding at about 35 mph and had to avoid a vehicle that entered the road from a parking lot. She laid the motorcycle down to avoid the collision. The patient was wearing a helmet and “leathers”She complains that she has some pain in her left elbow and shoulder, but otherwise she feels fine. Patient assessment finds bruising near left elbow, but no other abnormalities. Good sensation, movement and circulation in all extremities. No pain in neck or back. No signs of intoxication.The mechanism of injury does not meet the threshold of high speed motor vehicle crash.The physical findings do not indicate a suspected spinal injuryThe patient is not high risk.EMS providers may immobilize this patient based on provider concern, but it is not required by protocol.
58Two Cars, Two Drivers Driver # 1 Driver # 2 Ambulatory, Agitated, 50 year old maleRear ended by driver # 2 at a stoplightDriver # 2Belted and still in vehicle 19 year old femaleCouldn’t stop in time, struck other vehicleShould either patient be immobilized?Why or Why not?EMS responds and is first on the scene of the MVC at an intersection.Vehicle # 1 is midsized sedan with crumpled trunk, but no other damage. Windshield is intact. Airbags did not deploy. The driver is walking around the scene inspecting the damage and glaring menacingly at the other driver and holding a bloody handkerchief to his nose.Vehicle # 2 is a minivan with damage to the grill, umber and front fenders. The front air bags did deploy. The driver is still in the vehicle with her seat belt on and she is on her cell phone visibly crying.Does either driver fall into mechanism?Driver # 1- Maybe – What is a violent mechanism? Why is his nose bleeding? The driver reports that he hit himself in the nose with his hand because we was about to call someone on his phone when she hit him.- This is not a violent mechanism. Striking the steering wheel would be.Would it matter if he was un-belted and struck the wheel or windshield? Its not clear and more information is needed. But if there is doubt, providers should immobilize him.Driver # 2 –No.Physical AssessmentDriver #1 Alert and oriented, bleeding from the nose, complains that his left shoulder hurts him, but no other complaints. Neck is not tender and no deformities are noted. Vital signs are slightly elevated, but not worrisome. He exhibits no signs of intoxication during the exam. Should he be immobilized? No – the nose should not be categorized as a distracting injury and nothing else on the patient assessment seems to indicate the need to immobilize.Driver # 2 Alert and Oriented, but very upset. Complains of burning on her face and keeps repeating that she just didn’t see him in time to stop. The vital signs are normal except the heart rate of 120. Once you get her to get off the phone, she states that nothing hurts except her face. There is not pain on palpation during the physical exam of the neck. No injuries are found and circulation motor and sensation are normal.High Risk PatientNeither driver seems to be a high risk patientAny doubt?Either patient may be immobilized if EMS crews are unsure, Regardless of the decision, EMS providers need to document their justification to follow a specific path of care.
59QA/QI Regional review of PCRs. Agency increased review of all PCRs where spinal immobilization was not used.On-going education of providersRegions should develop a useful tool to complete enhanced review of PCRs for those patients that had and did not receive spinal immobilization.Agencies should increase their review of these patients as well. The agency Medical Director should be involved with this increased review.Statistical data at both the agency and regional level could help with future protocol revisions.
60First, do no harmGood Medical Care requires good clinical judgment; this can not be defined or legislated, but must be employed.When in doubt, decide in favor of the patient and immobilize the spine.