lesson 7 b
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Lesson 7BDisability — Part TwoCentral Nervous System
Trauma:Injuries to the Spinal Cord
Spinal Trauma (1 of 2)
• In the United States, 15,000 to 20,000 spinal injuries occur annually
• It is most common in ages 16 to 35 years• 80% of cases occur in males
Spinal Trauma (2 of 2)
• Causes include:– MVCs: 48%– Falls: 21%– Penetrating injuries: 15%– Sports injuries: 14%– Other: 2%
• Improper assessment and management can result in permanent paralysis
Anatomy: Spinal Column(1 of 2)
• Cervical (7 vertebrae)• Thoracic (12 vertebrae)• Lumbar (5 vertebrae)• Sacrum (5 vertebrae)• Coccyx (4 vertebrae)
Anatomy: Spinal Column(2 of 2)
Anatomy: Spinal Cord(1 of 2)
• The spinal cord fills the spinal canal– Leaves little room for swelling, hemorrhage,
or bone injury • Contains motor and sensory tracts• The tracts form nerves that go to
specific areas of the body– Sensory– Motor
Anatomy: Spinal Cord(2 of 2)
Anatomy: Spinal CordDermatomes and Sensation (1 of 2)
• Sensory levels– Spinal cord
• Nerves exit each vertebral level and detect sensation in specific areas of the body
• Area that each nerve senses is called a “dermatome”
• This creates a sensory map
Anatomy: Spinal CordDermatomes and Sensation (2 of 2)
Pathophysiology of CNS Injury
• Primary injury– Damage that occurs at the moment of impact
• Secondary injury– Damage that occurs subsequent to the initial
impact• Systemic causes• Intrinsic causes
– Prehospital management can often prevent or minimize the effects of secondary injury
Pathophysiology of CNS Injury: Secondary Injury
• Systemic causes– Hypoxia– Hypotension– Anemia (blood loss)– Increased or
decreased CO2
– Increased or decreased blood glucose
• Intrinsic causes– Increased
intracranial pressure (ICP)
– Edema– Hematomas– Seizures
Patient Assessment:Primary Assessment
• Determine the mechanism of injury and the need to consider possible spine injury
• Is there: – Airway compromise?– Ventilatory compromise?– Adequate oxygenation?– Adequate circulation and perfusion?
Patient Assessment
• Neurologic assessment for disability– The complete neurologic exam consists of six
components:• Mental status (MS)*• Cranial nerves*• Motor function*• Sensory function*• Coordination• Reflexes
*In most cases only the first four are completed in the prehospital setting
Patient Assessment: MentalStatus (1 of 3)
• A-V-P-U• Provides an initial impression
– Alert– Responds to Verbal stimulus– Responds to Painful stimulus– Unresponsive
• Glasgow Coma Scale – Use the modified GCS for pediatrics
• The GCS should be scored after the correctible causes of altered mental status have been addressed
Patient Assessment: MentalStatus (2 of 3)
Patient Assessment: MentalStatus (3 of 3)
Patient Assessment
• Assessing for symmetry of function (movement and sensation) is key– Asymmetry is abnormal until proven otherwise– In some people, asymmetry is a normal or
baseline finding• Always ask, “Is this normal for you?”
Patient Assessment: MotorFunction
• Test upper extremities by having the patient:– Move the hands and arms– Squeeze your fingers
• Test lower extremities by asking the patient to:– Wiggle the toes– Push and pull the feet against resistance
Patient Assessment: SensoryFunction (1 of 3)
• For a patient who is conscious with a suspected spinal cord injury (SCI):– Assess dermatomes to estimate the level of
spine injury– Start at the head and work down to find the
level of loss of sensation
• If loss of sensation is at:– Clavicles: C4–C5 injury– Nipples: T4 injury– Umbilicus: T10 injury– Pelvic rim: T12 injury
Patient Assessment: SensoryFunction (2 of 3)
• In an unconscious patient, assess for sensation with deep pain response– Sternal rub– Nailbed compression
• Reflex response (from best to worst)– Purposeful withdrawal from pain– Nonpurposeful movement to pain– Flexion (decorticate posturing)– Extension (decerebrate posturing)– No response
Patient Assessment: SensoryFunction (3 of 3)
Spinal Injury (1 of 2)
• Trauma to the spine may result in:– Spinal column fracture– Spinal cord injury
• Complete transection• Incomplete syndromes
– Brown–Séquard– Anterior cord– Central cord
– Both
Spinal Injury (2 of 2)
Anterior cord syndrome Central cord syndrome
Brown-Séquard syndrome
Spinal Cord Injury: ClinicalFindings (1 of 3)
• Motor– Muscle weakness– Muscle paralysis
• Sensory– Pain– Paresthesia (numbness)– Total loss of sensation
• The extent and location of sensory and motor loss depend on the location and level of the injury
• High cervical injuries– Paralysis of diaphragm and intercostal
muscles results in total loss of ability to breathe
• Lower cervical injuries– Diaphragm still functions– Paralysis of intercostal muscles only
Spinal Cord Injury: ClinicalFindings (2 of 3)
• Cervical or high thoracic spinal cord injury may result in hypotension– Disruption of sympathetic nervous system results
in unopposed parasympathetic tone• Vasodilation• Bradycardia• Warm, dry skin
• However, the most likely cause of shock in any trauma patient is hemorrhage, which must be ruled out before calling it neurogenic “shock”
Spinal Cord Injury: ClinicalFindings (3 of 3)
CNS Injury Management
• The overall goal is to prevent or recognize and treat secondary spinal cord injuries– Hypoxia– Hypotension– Hemorrhage
• Spinal fractures, in most cases, can only be diagnosed and managed at the receiving hospital
CNS Injury Management:Overview
• Prehospital setting– A-B-C-D-E approach– Spinal motion restriction– Initial resuscitation– Transport and destination decisions
CNS Injury Management:Airway (1 of 2)
• Open it– Maintain spinal motion restriction (as
appropriate for the mechanism of injury)– Jaw thrust
• Clear it– Use suction as needed
• Maintain it– GCS of 9 or more? – Able to maintain patency?
• Consider airway management as necessary
• If active airway management is required, monitor:– Oxygen saturation (95% or higher)– BP – End-tidal carbon dioxide (ETCO2)
• Confirm proper tube placement– Use two methods:
• Physiologic• Mechanical
CNS Injury Management:Airway (2 of 2)
CNS Injury Management:Breathing
• Provide oxygen (100%)– A single episode of hypoxia, O2 saturation
< 90%, worsens outcome in patients with TBI• Assist ventilations (as needed)
– Maintain normal ETCO2 at 35 to 40 mm Hg– Ventilation rates
• Adults: 10 to 12 breaths per min• Pediatric: 12 to 20 breaths per min
– No routine hyperventilation
CNS Injury Management:Circulation (1 of 2)
• Control hemorrhage and prevent anemia:EVERY RBC COUNTS!
• Maintain adequate BP and perfusion
• If BP is normal or elevated:– IV of LR/NS TKO
• If BP is decreased:– IV of LR/NS bolus, with fluid titrated to
maintain BP of 90 to 100 mm Hg • A single episode of hypotension,
BP < 90 mm Hg, worsens outcome in patients with CNS injury
CNS Injury Management:Circulation (2 of 2)
Spinal ImmobilizationAlgorithm: Blunt Trauma (1 of 5)
• Concerning mechanism of injury:– Violent impact to the head, neck, torso, or
pelvis– Sudden acceleration, deceleration, or lateral
bending forces to neck or torso– Falls– Ejection or fall from any motorized or human-
powered transport device– Shallow-water diving incident
Spinal ImmobilizationAlgorithm: Blunt Trauma (2 of 5)
Spinal ImmobilizationAlgorithm: Blunt Trauma (3 of 5)
• Distracting injuries– Any injury that may impair the patient’s ability
to appreciate other injuries, including: • Long-bone fracture• Suspected visceral injury• Large laceration, degloving, or crush injury• Large burns• Any other injury that produces acute functional
impairment
Spinal ImmobilizationAlgorithm: Blunt Trauma (4 of 5)
• Inability to communicate– Speech or hearing impaired– Speaks a foreign language– Small children
Spinal ImmobilizationAlgorithm: Blunt Trauma (5 of 5)
Spinal Immobilization Algorithm:Penetrating Trauma (1 of 2)
• Unstable spinal fractures from penetrating trauma are extremely rare
• Life-threatening conditions take priority
Spinal Immobilization Algorithm:Penetrating Trauma (2 of 2)
CNS Injury Management:Spinal Cord
• Prevent secondary injury– Maintain adequate oxygenation– Maintain adequate perfusion (BP)
• Steroids for spinal cord injury– No longer recommended
CNS Injury Management
• Transport and destination– Minimal on-scene time– Supine position– Appropriate receiving facility– Frequent reassessment
Expose
• Component of the primary assessment• Allows visualization of all body areas and
identification of hidden injuries• Remove clothing only as appropriate
– Driven by MOI/kinematics and patient complaints
– If suspected criminal activity, consider evidence preservation
– Maintain patient privacy• Prevent body heat loss
Summary (1 of 2)
• Identify the mechanism of injury• Perform primary assessment
– Identify and treat life-threatening conditions first
• Key determination is if initial findings are changing and in which direction (better or worse)
• Neurogenic “shock” may occur in patients with spinal cord injury– Hemorrhagic shock is still the most common
cause of shock overall and must be ruled out
• Evaluate need for spinal immobilization– When in doubt, immobilize
• Treatment key: minimize secondary injury of the spinal cord– Correct or prevent hypoxemia– Correct or prevent hypotension
• Transport to an appropriate facility
Summary (2 of 2)
Questions?
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