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SPINE TRAUMA Moderator: Dr.Bhalla

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Presentation on theme: "SPINE TRAUMA Moderator: Dr.Bhalla"— Presentation transcript:

1 SPINE TRAUMA Moderator: Dr.Bhalla www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com

2 Spinalcord anatomy Spinal cord is 18 inches lying in the vertebral column Extends from foramen magnum to L1-L2 vertebra Spinal cord has 31segments 8cervical, 12thoracic, 5lumbar, 5sacral and 1coccygeal C3-C5-Phrenic nerve C5-T1-motor to upper limb T1-T5-sympathetic supply to heart L2-S2- motor supply to lower extremities

3 Blood supply 1 anterior spinal artery 2 posterior spinal artery Radicular branches Artery of adamkiewicz

4 Anatomy Ascending tracts Desending tracts

5 Incidence Affects 10000 a year Age group-16-30 years Male: female=4:1 Automobile accidents are the most common cause in person <65 years Falls are the most common cause in person>65years

6 Causes Motor vehicle collision 47% Fall from height 23% Penetrating injuries 14%(gun shot, bullet injuries)

7 Mechanisms of injury Distraction-hyperextension of spine as in hangings Compression-caused by axial loadings as in falls Torsional-high energy motor vehicle collisions Penetrating-stab or gunshot wounds

8 Sites of spinal cord injury M/C junction between flexible and inflexible segments Mid-thoracic injuries are less common because of the rotational stabilisation provided by rib cage and intercostal musculature So injuries are much common above and below the thoracic vertebra --lower cervical and upper thoracic

9 Pathophysiology of SCI Primary injury Spinal vascular disruption may result in diminished arterial supply or venous drainage Cellular edema will lead to increased pressure within the spinal canal, with compromise to blood flow

10 Pathophysiology of SCI

11 Secondary injury Hypotension Hypotension Hypoxia Hypoxia Anemia Anemia During intubation During intubation

12 Degree of Injury Complete transection Complete transection Total paralysis and loss of sensory and motor function although arms or rarely completely paralyzed Incomplete (partial transection) Incomplete (partial transection) Mixed loss of voluntary motor activity and sensation

13 Complete transection High cervical Low cervical High thoracic Low thoracic lumbar Acute phase Subacute phase Chronic phase

14 Complete transection of SC High cervical lesions Resp insufficiency Resp insufficiency Quadriplegia Quadriplegia Horners syndrome Horners syndrome Hypotension – no tachycardia (T1-T5) Hypotension – no tachycardia (T1-T5) Temperature regulation is altered Temperature regulation is altered GI- ileus, abd distension GI- ileus, abd distension GU- bladder bowel incontinence GU- bladder bowel incontinence Blood -DVT Blood -DVT

15 Complete transection of SC… Low cervical No diaphragmatic involvement No diaphragmatic involvement High thoracic (above T7) Paraparesis Paraparesis Autonomic invol. Autonomic invol. Low thoracic and lumbar Bladder and bowel invol. Bladder and bowel invol. Autonomic sys. Spared Autonomic sys. Spared

16 Acute phase Spinal shock Spinal shock Loss spinal reflexes causes flaccid paralysis Resp difficulty Bladder bowel involved Fever –loss of perspiration 3-6 Weeks Neurogenic shock Neurogenic shock Loss of vasomotor tone Hypotension without tachycardia Close monitoring of HR Typically 3 days- 3 weeks

17 Sub acute phase Flaccidity of spinal shock is replaced by spasticity Usually returns in 3 weeks Hyperreflexia and increased muscular tone are noted with extensor plantor response

18 Autonomic Dysreflexia It is characterised by massive firing of sympathetic neurons after distention, stimulation or manipulation of bladder and bowel Cutaneous stimulation with painful or cold stimuli can lead to massive sympathetic firing Mediated at brain stem level

19 Autonomic Dysreflexia An acute emergency Occurs only after spinal shock has resolved The increase in ICP and blood pressure can lead to cerebral hemorrhage Classic signs Classic signs pounding headache marked hypertension diaphoresis (particularly of the forehead) BradycardiaFlushingPiloerection nausea and nasal congestion

20 Mass reflex Occurs after spinal cord transection Mild noxious stimuli may trigger, withdrawal, defecation, sweating Advantages Elicit voiding and defecation Control of micturition and defecation

21 Incomplete cord patterns Anterior cord syndrome Anterior cord syndrome Posterior cord syndrome Posterior cord syndrome Brown-Sequard syndrome Brown-Sequard syndrome Cauda equina syndrome Cauda equina syndrome

22 Anterior cord syndrome Compression of the ant. Cord Compression of the ant. Cord motor paralysis at lesion and below motor paralysis at lesion and below Pain and loss of temperature sensation below site. Pain and loss of temperature sensation below site. Touch, position, vibration and motion remain intact. Touch, position, vibration and motion remain intact.

23 Posterior cord syndrome Assoc with cervical hyperextension injuries Dorsal area of cord is damaged resulting in loss of proprioception Pain, temperature sensation and motor function remain intact.

24 Brown-Sequard syndrome Partial transection of cord BSS may be caused by a spinal cord tumor, penetrating injuries to spinal cord Paralysis and loss of vibration sense on same side of the body loss of pain and temparature (hemianesthesia) on the opposite side.

25 Approach to patient ABC Associated injuries Spinal shock

26 Airway management Suspected cervical spine injury Respiratory distress No respiratory distress ABC History ABC History Clinical exam Investigations

27 Signs and Symptoms Neck or back pain Penetrating injury of neck or back Tenderness to palpation of spine Loss of strength in extremities Loss of feeling in extremities ParalysisIncontinence SCIWORA (spinal cord injury without radiological abnormality) common in pediatric age group

28 How to exclude Cervical Spine Injuries NEXUS CRITERIA Normal mental status Not intoxicated Normal neurological examination No tenderness to palpation of C spine No pain with active range of motion

29 Imaging X-ray cervical spine AP view AP view Lateral view Lateral view Odontoid view Odontoid view CT scan MRI

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31 Lateral view Anterior vertebral margins Posterior vertebral margins Spinolaminar junction lines

32 cervical spine injuries cervical spine injuries

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34 MANAGEMENT A-AirwayB-BreathingC-Circulation To prevent secondary spinal cord injuries Hypotension Hypotension Hypoxia Hypoxia Anemia Anemia

35 Cervical spine immobilization Patients neck should be immobilized at the earliest until complete evaluation has been made to exclude cervical spine injury Soft collars unsatisfactory as they permit 75%neck movement unsatisfactory as they permit 75%neck movement Rigid collar They reduce flexion extention to 70% reduces rotational movements by 54% They reduce flexion extention to 70% reduces rotational movements by 54%

36 Cervical spine immobilization… The best method of immobilization is Secure the patient in a hard board from head to feet Secure the patient in a hard board from head to feet With sand bags placed on either side of head With sand bags placed on either side of head Rigid collar around neck Rigid collar around neck This method reduces neck movement to 5% of normal

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38 Spinal Immobilization Transfer patient to long spine board as soon as feasible Logroll in unison Stabilize head and neck with sandbags or rolled blankets

39 Airway control Clear the airway Maintain adequate oxygenation Initial maneuver of maintaining airway patency should not displace the cervical spine Acceptable maneuvers include: Lifting the chin (5mm) Lifting the chin (5mm) Forward displacement of mandible Forward displacement of mandible Placement of appropriate sized oral or nasal airways Placement of appropriate sized oral or nasal airways

40 Indications of tracheal intubation GCS<8 Loss of protective airway reflex Hemorrhage into the airway Pao2<60mmhgPaco2>45mmhgSeizures Actual or impending airway obstruction

41 Airway control Blind nasal vs orotracheal Safest method is debatable Depends on anesthesiologist opinion with which he is well versed Advanced trauma and life support (1993) Nasotracheal in a spontaneously breathing Nasotracheal in a spontaneously breathing Orotracheal in a apneic patient Orotracheal in a apneic patient

42 Orotracheal intubation Safest and surest method of intubating the trachea It is the best method to secure the in an emergency setting Manual in line stabilisation (MILS) technique should be used

43 MILS technique It is the continuous immobilization of the neck during tracheal intubation that is important for reducing the incidence of secondary SCI

44 Orotracheal intubation… Preoxygenation for 3 minutes Administration of a Intravenous induction agent Application of cricoid pressure by the assistant Administration of rapidly acting neuromuscular blocking drug Laryngoscopy and Intubation of trachea

45 Elevation of laryngoscpe results in extention of atlanto occipital joint (2002) Canadian Journal of Anesthesia 49:733-744 (2002) Edward Crosby, MD et al

46 Difficulties Cervical collar-reduces mouth opening Cricoid pressure-distorts the view MILS

47 Collar tape Sand bags MILSOptimal position Kj heath et al Anesthesia 1994

48 To improve the success rate Remove the anterior part of collar Gum elastic bougie Nolan et al Nolan et al Anesthesia 1993 Anesthesia 1993 Mccoy laryngoscopy D A Gabbott et al D A Gabbott et al Anesthesia 1996 Anesthesia 1996

49 Nasotracheal intubation Sucessful in 90% of patients Requires multiple attempts Contraindication Base of skull fracture and mid-facial injuries Base of skull fracture and mid-facial injuries Apnea ApneaDisadvantages Bleeding can occur in the airway making other methods of securing the airway difficult Bleeding can occur in the airway making other methods of securing the airway difficult Aspiration Aspiration Vomitting Vomitting

50 Role of intubating LMA in emergency setting Can be used safely for intubation Provides a means for ventilation in case of failed tracheal intubation Adv-will allow tracheal intubation in patient in patient with rigid cervical collar komotsu et al BJA;2004,93(5) 655-659 Does not require a, secretion free or a blood free airway

51 ILMA -Disadvantages Risk of aspiration in trauma patients LMA can exert high pressures while insertion insufflation and while in situ this increases the risk of posterior displacement of spine Anesthesia-Analgesia 1999,89:1296-1300 Anesthesia-Analgesia 1999,89:1296-1300 Eventhough there is posterior movement of C- spine clinically this not significant Textbook of laryngeal mask anesthesia by Brimacombe Textbook of laryngeal mask anesthesia by Brimacombe

52 other methods Fibroptic intubation Lightwand Retrograde intubation Bullard laryngoscopy Cricothyroidotomy Surgical airway

53 www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com


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