spine trauma and management · treatment: bl 18g iv, 20mg ketamine iv, spine board, c-collar, he...
TRANSCRIPT
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Spine Trauma and ManagementC PT SA MUEL ROC K ER, A PA - C
LC DR A RI DOUC ET TE , PA - C
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DisclosuresCPT Rocker and LCDR Doucette have no financial interests to disclose with regard to this subject or the contents of the presentation.
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Importance
• 3% of blunt trauma patients sustain a spinal column injury
• 1% sustain a spinal cord injury
Non-deployed:
• 1/5 spinal column injuries has involved the cord
• 1/2 of those are complete
Deployed:
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Mechanisms of InjuryMechanical causes too numerous to list here, but may include• Rapid deceleration (e.g. MVC)
• Externally forced rotation (e.g. MVC, Machinery Acc)
• Blunt trauma (e.g. MV vs Ped, FFS)• Penetrating trauma (e.g. GSW, SW)
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Mechanisms
Non-deployed:• 1/2 from Motor Vehicle Accidents
• Risk factors: Speeding, ETOH, Unrestrained• Rollover Cervical spine injury• Falls, sports, violence
Deployed:• 2/3 Explosive• 17% GSW• 3% Falls• 66% Blunt, 28% Penetrating, 5% Combined
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Spinal Anatomy
A B RI EF REV I EW OF N ORMA L A N ATOMY:
3 3 B ON Y V ERTEB RAE:7 C ERVI C A L1 2 T HORAC I C5 LUMBA R5 SAC RA L (F US ED)4 COC C YG EA L (~ F US ED)
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Cervical Spine: C1-C3
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CraniocervicalLigaments: Internal
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Cervical Spine Injuries
Atlanto -occipital dislocation
Atlanto -axial dislocation
C1 Burst (Jefferson)
C1 Posterior Arch
C2 Pedicle (Hangman’s)
C2 Odontoid
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Atlanto-occipital dislocation
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Atlanto-occipital dislocation
Basion-posterior axial line interval (BAI)& Basion-dental interval (BDI)
If either exceeds 12mm, suggests A-O dislocation
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Atlanto-axial dislocation
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C1 Burst “Jefferson” fracture
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C1 Posterior Arch fracture
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C2 Pedicle “Hangman’s” fracture
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C2 Odontoid (“dens”) fracture
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CraniocervicalLigaments: External
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Flexion and Extension fractures
Anterior wedge - due forceful forward flexion. Typically stable
Flexion teardrop - also due to forceful forward flexion with compression. Unstable
Extension teardrop - severe abrupt extension avulses anterior corner of spine from rest of vertebral body. Unstable
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Burst fracturesVertical compression due to axial loading
Stable vs unstable
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Spinous process fractures
Clay shoveler’s fracture, stable
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Laminar fractures
Typically associate with other fractures
The other fracture determines stability
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Facet dislocations
Not necessarily a fracture, but…
Bilateral facet dislocation
Very unstable
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Facet dislocations
Not necessarily a fracture, but…
Unilateral facet dislocation
Stable
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General Vertebral Fracture Patterns
Anterior Wedge
Flexion or Extension teardrop
Spinous Process
Burst
Laminar
Facet
Ligamentous
Spinal Cord Injury With-Out Radiographic Abnormality (SCIWORA)
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Thoracic Vertebrae
Anterior Middle Posterior
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Thoracic Ligaments
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Lumbar Vertebrae
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Chance fracture
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Spinal Cord: Nerve Roots
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Spinal Cord: Protection
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Spinal Cord: Blood Supply
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Spinal Cord: Blood Supply
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Mechanisms of Spinal Cord Injury
• Vertebral column injury may result in spinal cord injury through:
• Transection• Compression• Contusion• Vascular Compromise
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TransectionPenetrating or blunt may transect all or part of the spinal cord
Either directly, or by displacing bony fragments into the spinal canal or through disk herniation
https://prod-images-static.radiopaedia.org/images/47636226/659df49efc3fea3fc2d05a9b526b6f_big_gallery.jpeghttps://www.researchgate.net/figure/MRI-sagittal-image-of-included-patient-with-complete-spinal-cord-transection-All_fig1_333294520
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Compression
OsteoarthritisSpondylolysis spondylolisthesisDisc Herniation
Trauma:• Edema• Hematoma• Fracture fragments
https://www.merckmanuals.com/-/media/manual/professional/images/spinal_cord_compression_slide_high.jpg
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Contusion
Bony dislocationsSubluxationsFracture fragments
https://radiopaedia.org/images/51203318
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Vascular compromise
Causes ischemia
Suspected when discrepancy b/w clinically apparent neurologic deficit and the known level of spinal column injury
Important -Don’t miss
http://www.ajnr.org/content/36/5/825
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3 general clinical categories:
1. Patients with complete spinal cord syndromes
2. Patients with an incomplete spinal cord injury
3. Patients with a spine fracture but normal neurological function
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Thoracolumbar Spinal Trauma
BE.CONVDOCS.ORG/PARS_DOCS/REFS/113/112418/112418_HTML_4C6EB2ED.JPG
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Thoracolumbar Spinal Trauma
https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf
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Thoracolumbar Spinal Trauma
https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf
Spinal Shock◦ Transient◦ Decreased function ◦ Is complete when Bulbocavernosus reflex
returns
Neurogenic Shock◦ Circulatory collapse◦ Fluid resuscitation/pressers
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Thoracolumbar Spinal Trauma -The Role 1
ATLS/TCCC - Address life threats first
High index of suspicion given MOI
Stabilize and Evacuate
Hemodynamic Goals for Evacuation
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Thoracolumbar Spinal Trauma - The Role 2
ATLS/TCCC - Address life threats first
High index of suspicion given MOI
Plain Films Available
Stabilize and Monitor vs Evacuate
Hemodynamic Goals for Evacuation
HTTPS://MEDIA.DEFENSE.GOV/2017/MAY/19/2001749400/1088/820/0/170510-F-CH060-002.JPG
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Thoracolumbar Spinal Trauma -The Role 2
Stable Patterns
◦ Wedge Fractures◦ Transverse Process Fractures
https://www.uptodate.com/contents/images/RADIOL/83217/MildcompressionL2.jpg
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Thoracolumbar Spinal Trauma -The Role 2
https://www.uptodate.com/contents/images/RADIOL/83469/Xrayfraclumbartransproc.jpg
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Thoracolumbar Spinal Trauma - The Role 2
Radiographic Findings
Stable Patterns
◦ Wedge Fractures◦ Transverse Process Fractures
HTTPS://WWW.UPTODATE.COM/CONTENTS/IMAGE?IMAGEKEY=RADIOL%2F83140&TOPICKEY=EM%2F357&SOURCE=SEE_LINK&SP=0&SEARCH=
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Thoracolumbar Spinal Trauma -The Role 2
Radiographic Findings
Unstable Fracture Patterns◦ Burst Fracture◦ Shear Fractures◦ Translational distraction
https://www.uptodate.com/contents/images/RADIOL/83106/Verteburstfraclumbspine.jpg
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Thoracolumbar Spinal Trauma -The Role 2
Flexion Distraction Fracture◦ Be concerned for intrabdominal
process◦ High Likelihood for permanent
neurological injury
https://www.uptodate.com/contents/images/RADIOL/60907/Chancefraclumbarspine.jpg
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Thoracolumbar Spinal Trauma -The Role 2
Translational Spinal Fracture◦ Fracture dislocation◦ Shear Fracture
https://www.uptodate.com/contents/images/EM/61587/Thoraclmbrfraxdislctradg.jpg
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Thoracolumbar Spinal Trauma - The Role 2When to EVAC to higher level of care
When to sit on a patient
http://www.stripes.com/polopoly_fs/1.153264.1317334783!/image/2526600154.jpg_gen/derivatives/landscape_804/2526600154.jpg
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Thoracolumbar Spinal Trauma - Role 3
148 Beds (24 ICU Beds)
Up to 4 OR tables
Multiple specialties
CT Available
https://a57.foxnews.com/a57.foxnews.com/static.foxnews.com/foxnews.com/content/uploads/2018/11/640/320/1862/1048/louvre-istock.jpg?ve=1&tl=1?ve=1&tl=1
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Thoracolumbar Spinal Trauma -Role 3
Transverse Process Fracture
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Thoracolumbar Spinal Trauma -Role 3
Burst Fracture
No MRI in Role 3
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Thoracolumbar Spinal Trauma -Role 3CHANCE FRACTURE
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Thoracolumbar Spinal Trauma -Role 3WEDG E F RAC TURE
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Thoracolumbar Spinal Trauma - Role 3
Management
Medical
Handling
NonOP vs OP◦ Blunt◦ Penetrating
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Review questionsYou are the new role 1 PA. Shortly after you arrive 1st PLT Cco was hit with an IED. They are evacuating a 25YOM suffering a blast injury and was thrown 10 feet. The senior medic on the ground relays that the Pt is GCS 14 (1 off for confusion), BP of 90P, HR 110, resp 18. The pt has shrapnel wounds along the anterior BL LE that has achieved hemostasis with pressure dressings. Pt complains of excruciating LBP. The medic was concerned of ecchymoses and exquisite tenderness located at L3/4. But is otherwise neuro intact.|
Treatment: BL 18G IV, 20mg Ketamine IV, Spine Board, C-Collar,
He arrives to your aid station:
A - Patent
B- RR 20, 99 RA, Equal rise and fall of the chest, LCTAB
C - BP 100/60, HR 106. LE wounds hemostatic with pressure dressing
D - GCS 14 (1 off for confusion). Neuro Intact. Rectal tone was intact. Bogginess noted midline l spine around L3-4. TTP midline spine at that location.
E-Placed in “blizzard blanket”
Do you evac patient or sit on patient if this is your only patient?
Your EMEDS is located approx. 26 km away (40 min drive) air or ground evac?
Its been two hours since the pt was evaced from POI on a spine board. What should you do?
What should you ensure about his blood pressure?
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Review questionsThe Role 1 PA relays that the Pt is GCS 14 (1 off for confusion), BP of 100/60, HR 110, resp 18. The pt has shrapnel wounds along the anterior BL LE that has achieved hemostasis with pressure dressings. Pt complains of excruciating LBP. The PA was concerned of ecchymoses and exquisite tenderness located at L3/4 and paresthesia's noted in the L3 distribution of the left side. But is otherwise neuro intact.
Treatment: BL 18G IV, 25mg Ketamine IV, Spine Board, C-Collar, Blizzard blanket
He arrives to your role 2:
A - Patent
B- RR 26, 90 RA, Equal rise and fall of the chest, decreased lung sounds left side. JVD noted.
C - BP 100/60, HR 115. LE wounds hemostatic with pressure dressing
D - GCS 14 (1 off for confusion). CN II-XII grossly intact, EOMI sans diplopia Neuro intact.. Rectal tone was intact. Bogginess noted midline l spine around L3-4. TTP midline spine at that location.
E-Placed in “blizzard blanket” What do you want to do next to address low SPO2?
After Pt is stabilized?
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Review questionsYOU S HOOT A C HEST X RAY ,C , T, L S P I N E PELV I C F I L MS
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Review questions
C-Spine and T spine films are clear. You notice this on L Spine films
What are you concerned of?
Do you Evac?
Should you consult a Neurosurgeon?
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Review questions
WHAT I F YOU P I C K ED UP ON THI S ?
WHAT A RE YOU WORRI ED A B OUT ?
WHO EL S E S HOUL D I N VOLV E I N THE PAT I EN T ’S C A RE?
WOUL D YOU F I N D A N YTHI N G ON FA ST EX A M?
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Bibliography
Cervical Spine Collar Clearance in the Obtunded Adult Blunt Trauma Patient - Practice Management Guideline. https://www.east.org/education/practice-management-guidelines/cervical-spine-collar-clearance-in-the-obtunded-adult-blunt-trauma-patient. Accessed 27 Dec. 2019.
Cervical Spine Injuries Following Trauma - Practice Management Guideline. https://www.east.org/education/practice-management-guidelines/cervical-spine-injuries-following-trauma. Accessed 27 Dec. 2019.
Eisen, Andrew. “Anatomy and Localization of Spinal Cord Disorders.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord-disorders. Accessed 26 Dec. 2019.
Hansebout, Robert, and Edward Kachur. “Acute Traumatic Spinal Cord Injury.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury. Accessed 26 Dec. 2019.
Hoffman, J. R., et al. “Validity of a Set of Clinical Criteria to Rule out Injury to the Cervical Spine in Patients with Blun t Trauma. National Emergency X-Radiography Utilization Study Group.” The New England Journal of Medicine, vol. 343, no. 2, July 2000, pp. 94-99, doi:10.1056/NEJM200007133430203.
Kaji, Amy. “Evaluation and Initial Management of Cervical Spinal Column Injuries in Adults.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/evaluation-and-initial-management-of-cervical-spinal-column-injuries-in-adults. Accessed 26 Dec. 2019.
Kaji, Amy, and Robert Hockberger. “Spinal Column Injuries in Adults: Definitions, Mechanisms, and Radiographs.” UpToDate, edited by TW Post, UpToDate Inc, https://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs. Accessed 26 Dec. 2019.
Netter, Frank H. Atlas of Human Anatomy. Philadelphia, PA: Saunders/Elsevier, 2006. Print.
Stiell, I. G., et al. “The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients.” JAMA, vol. 286, no. 15, Oct. 2001, pp. 1841-48, doi:10.1001/jama.286.15.1841.
Weingart, Scott. “Cervical Spine Injuries in the ED.” EMCrit Project, 25 Dec. 2011, https://emcrit.org/emcrit/cervical-spine-injuries-i/.
CDR Chris Neal, Col Randall McCafferty, LTC Brett Freedman, MAJ Melvin Helgson. “Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting” 05 Aug 2015, https://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/Spinal_Injury_-_Cervical_and_Thoracolumbar_Aug_2016_ID15.pdf
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Questions?