1. Cervical spinal injury– initial assessment and guidelines (Prehospital care guidelines) Sang Ryong JEON, M.D., Ph.D. Dept.of Neurological Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Korea

5. Why appropriate management in acute C-spine injury or SCI is important?

6. Well treated: Having ShE & EF Feeding Teeth cleaning Bathing and Hair washing Dressing – some Some cooking and kitchen work Writing – some with minimal aids Transfers – some, sliding board Push wheelchair up incline (5%) Car – some using hand-controls 2 segment upward aggravation: Talking Swallowing Breathing

7. Why appropriate management? motor recovery after SCI ASIA A (no motor, no sensory) : 80%  A, 10%  B, 10%  C can not go ASIA D (=abnormal but useful motor function ) can not walk, can not use hands ASIA B (no motor, some sensory) :15%~40%  C, 40%  D ASIA C : 60~80%  D So, when we do not keep mean BP, O 2 saturation, the initial incomplet SCI ASIA B would change to complete SCI ASIA A.

8. Why appropriate management? Historically, up to 25% of SCI may be aggravated after the initial insult, either during transport or early in the course of treatment. So, immobilization of the injured spine, keeping BP, and O 2 saturation are the keys to preventing such catastrophic decline. Spinal cord injury (SCI)—Prehospital management, M Bernhard, A Gries, P Kremer, BW. B¨ottiger Resuscitation 66 (2005) 127–139

9. Agenda 1.Initial assessment of traumatic SCI at the scene 2.Initial management 3. Prehospital immobilization 4. Intubation during immobilization 5.Cardiovascular support 6. Transport

10. Strategy in management of Acute SCI Initial assessment at the scene Keep V/S from the field to the hospital Prehospital Immobilization & transportation Medically stabilization Radiological assessment Reduction (close or open) Rigid fixation (internal or external) Rehabilitation Prehospital management of SCI

11. Epidemiology in SCI Epidemiology in SCI 40% quadriplegia, 60%paraplegia 40% complete injury

12. Epidemiology in SCI Epidemiology in SCI Spinal cord injury (SCI) occurs...... predominantly, in blunt injury the M/C injuries -contusive & compressive forces at the cervical level (C1-T1) (55%) thoracic (T1 - T11) thoracolumbar (T11-L2) lumbosacral (L2 -S5) injuries, each 15%

13. Worldwide, an estimated annual incidence ; 15-40 cases/million(US) over 10,000 new injuries occur annually. predominantly occurs in young, healthy individuals —mostly between 15 & 34 years The male to female ratio is 2:1 ∼ 4:1. The causes of traumatic SCI are… The cervical spine Edward C. Benzel. – 5th ed. P 557

14. SCI-associated injuries SCI occurs in 5–10% of severe TBI 10–30% of multiple body trauma up to 30% of Abdominal and thoracic trauma 25–50% of SCI have an associated head Injury.

15. we have to suspect combined spine injury. In multiple injury patients.

16. Abdominal bleeding or TBI in pts suffering from multiple trauma cause higher mortality rates than SCI. Therefore, in severely injured pts, prehosipital treatment priorities should be established based on their principal life threatening injuries, vital signs, and the injury mechanisms, according to established (ATLS) principles. but the subsequent management of SCI must be born in mind all the time.

17. Primary survey (ABCDE) on scene Airway and Cervical spine protection Breathing and Ventilation Circulation with control of external hemorrhage, Disability: Brief neurologic evaluation Exposure/Environment: completely undress the patient, but prevent hypothermia ATLS 8th

18. Prehospital management of SCI -Airway management Check continous pulse oximetry, O 2 administration if needed via face mask, rigid cervical collar; intubation of the trachea, Ix : if saturation persistently <90%, hypoventilation (under 10/min ) Chirurgia (2012) 107 (No5):564-570, GCS < 9 method of intubation open cervical collar under manual in-line stabilisation

19. Airway management -prehospital solutions Other methods… Laryngeal mask and the Combitube –not recommended greater pressure on the cervical vertebrae, only be used when routine intubation is not possible. An accepted in-hospital standard in SCI - fiberoptic tracheal intubation, but this technique is not often used in the prehospital setting

20. Patient immobilisation The patient should be immobilized in Neutral spine position at the scene During transport by using a rigid cervical collar, Sandbags on either side of the head, Rigid backboard with straps Pads or inflatable bean bag boards should be utilized to reduce pressure on the occiput and sacrum J NEUROTRAUMA 28:1341–1361 (August 2011)

21. Patient immobilisation

22. Papoose infant spinal immobilizer

23. Patient immobilization Disadvantages increase risk of respiratory compromise increase back and neck pain risk of pressure sores, raise intracranial pressure time consuming and expensive. increase the risk of dropping the patient injuring Emergency Medical Services (EMS) personnel Prehopital and Disaster Meidicine 2014, vol29,No4, 399-402

24. Patient immobilization Selective immobilization (= spinal clearance) is also important Emergency paramedical personnel can be trained to apply the clearance protocol.

25. Prehospital selective immobilization protocols (spinal clearance protocols) patients who are at very low risk of SCI, and therefore could be transported without spinal immobilization. Nexus (National Emergency X-Radiography Utilization Study) criteria the Canadian C-spine Rule (CCR)

26. 1. Correction of hypotension in SCI : ASAP Keep mean a BP 85- 90mmHg in first 7 days avoid episodes of hypotension (systolic BP below 90mmHg ) Prehospital management of SCI -Cardiovascular support Ropper AE, et al. Pract Neurol 2015;15:266–272. M Bernhard, et al Resuscitation 66 (2005) 127–139

27. Prehospital management of SCI -Cardiovascular support 2. Hypovolemic shock (multiple trauma): systolic blood pressure <100 mmHg; tachycardia Trendelenburg position fluid resuscitation Maintenance of mean arterial BP >90 mmHg; avoid episodes of hypotension (sBP <90 mmHg) 3. Neurogenic shock (SCI above T5 level): due to sympathectomy effect below injury level systolic blood pressure <70 mmHg; bradycardia Trendelenburg position i.v. administration of atropine, dopamine, arterenol

28. Transportation and trauma centre V/S stable patient: nearest level 1 centre (where spine care is possible). Hemodynamically unstable patient: nearest trauma centre; ->second-line transportation after hemodynamic stabilization to a level 1 trauma centre for SCI Transportation to the level 1 trauma center ( definitive spine care center): should occur within 24 h of injury. it is associated with patient’s outcomes. J NEUROTRAUMA 28:1341–1361 (August 2011) Prehospital management of SCI -Transportation

29. Summary In prehospital Mx of C-spine injury Initial assessment at the scene: ABCDE Keep V/S from the field to the hospital mean aBP 85- 90mmHg normal O 2 saturation Immobilization and Clearance by NEXUS criterior Intubation by “manual in line stabilization” Transportation to level 1 trauma center within 24Hr

30. Thank you for your attention..