Chapter 7

 Evaluate for suspected spinal injury  Appropriately manage spinal injury  Determine appropriate patient disposition

 When do I suspect spine injury?  How do I confirm the presence or absence of a significant spine injury?  How do I protect the spine during evaluation and transport?  How do I assess the patient’s neurologic status? How do I identify and treat neurogenic and spinal shock?  How do I limit secondary injury?

 Mechanism of injury  Unconscious patient  Neurologic deficit  Spine pain/ tenderness

Presence of paraplegia/quadriplegia Presume spinal instability Identify bony fracture/subluxation Early neurosurgical/orthopaedic consult Conscious patient

 If patient is ◦ Conscious ◦ Cooperative ◦ Able to concentrate on c-spine ◦ Not under the influence ◦ No distracting injury  Check ◦ No neck or spine pain or tenderness (midline) ◦ No pain or tenderness with voluntary movement ◦ No focal neurologic deficits ◦ No further evaluation necessary ◦ Remove c-collar NEXUS (National Emergency X-Radiography Utilization Study) criteria Or Canadian C-spine Rules

 Radiographic: if required ◦ Altered sensorium ◦ Suspicion on exam ◦ Abnormal exam  Radiographic visualization of entire spine ◦ Multiple views: lateral, AP, oblique, odontoid ◦ Consider CT scan or MRI  If injury noted, radiographic screening of entire spine required as 10% will have another spine fracture elsewhere

 Immobilize on long board with proper padding  Apply semi-rigid collar  Protection is priority  At least 5% of patients with spinal cord injuries worsen neurologically at hospital

 Neurologic level ◦ Most caudal level of motor/sensory function ◦ Motor and sensory may not be the same ◦ Sensory may vary on each side

 Complete: no motor or sensory function below injury level  Incomplete: Some motor or sensory preservation below injury level  Sacral sparing

 Inadequate ventilation  Abdominal examination compromised  Occult compartment syndrome

 Associated with cervical/high thoracic spine injury  Hypotension and slow heart rate  Treatment: fluid resuscitation and occasional atropine and vasopressors

 Neurologic, not hemodynamic phenomenon  Occurs shortly after cord injury  Variable duration  Flaccidity and loss of reflexes  Treatment: ventilate, maintain BP, atropine as required for bradycardia, steroids  Consider internal bleeding in the hypotensive patient.

 Unstable fractures  Neurologic deficit  Avoid transfer delay!

 Treat life-threatening injuries first  Properly immobilize entire patient  Appropriate spine films  Document examination  Neurosurgical/ortho consult  Transfer unstable fracture/cord injury