chapter 7, spine and spinal cord trauma
DESCRIPTION
Chapter 7, Spine and Spinal Cord TraumaTRANSCRIPT
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ObjectivesEvaluate for suspected spinal injury.Appropriately manage spinal injury.Determine appropriate patient disposition.
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Key QuestionsWhen 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 patients neurologic status?
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More Key QuestionsHow do I identify and treat neurogenic and spinal shock?How do I treat the patient with spinal cord injury and limit secondary injury?
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Unconscious patient Neurologic deficitSpine pain / tenderness
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Spinal Injury ScreeningIf patient is ConsciousCooperative Able to concentrate on c-spine
If no neck or spine pain or tendernessIf still no pain or tenderness with voluntary movement No further evaluation or x-ray necessaryRemove c-collar
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Spinal Injury Screening Radiographic: Normal x-raysClinical Normal neurologic exam and Absence of spinal pain and tendernessDrugs, alcohol, and other injuries may mask spinal injury
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Spine Injury ScreeningAltered SensoriumRadiographic visualization of entire spinePlain films CT scan of suspicious or poorly visualized areas
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C-spine X-raysCrosstable lateral film excludes 85% of fracturesAddition of AP and odontoid views exclude most fracturesAlso may require Swimmers viewCT scan for bony detail MRI
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C-spine X-rays10% of patients with a c-spine fracture have a 2nd, associated noncontiguous vertebral column fractureIdentify 1 abnormality? Look for another!Radiographic screening of entire spine required in this situation
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How do I protect the spine?Immobilize entire patient on long spine board with proper paddingApply semirigid cervical collarProtection is priority; detection is secondary
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How do I protect the spine?Spinal evaluation complicated by altered sensoriumRemove spine board as soon as possible and logroll patientPressure sores occur early in unconscious or paralyzed patients
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At least 5% of patientsWith spinal cord injuries Worsen neurologically at hospital.
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Assess neurologic status?Neurologic levelMost caudal level of motor / sensory functionMotor and sensory may not be same Sensory may vary on each side Bony level: Site of vertebral column damage
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Assess neurologic status Complete: No motor or sensory function below injury levelIncomplete:Any motor or sensory preservation below injury level Sacral sparing may be only residual function
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Injury effect on assessment / management?Inadequate ventilationAbdominal evaluation compromisedOccult compartment syndrome
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Identify / treat neurogenic shock?Associated with cervical / high thoracic spine injuryHypotension and slow heart rate Treatment: Fluid Resuscitation and occasional atropine and vasopressors
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Identify spinal shock?Neurologic, not hemodynamic phenomenonOccurs shortly after cord injury Variable duration Flaccidity and loss of reflexes
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Treat / prevent secondary injury?Ensure adequate ventilation and oxygenationMaintain blood pressureAtropine as needed for bradycardiaMethylprednisolone
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Assess for associated bleeding Consider neurogenic shock Monitor urinary output
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Blunt injury only Start within 8 hours of injury30 mg / kg over 15 minutes5.4 mg / kg over next 23 hours if started within 3 hours of injury48 hours if started within 3 to 8 hours after injury
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Management Provide respiratory support as needed Properly immobilize entire patientAvoid transfer delay!
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Who do I transfer?Unstable fractures Neurologic deficitAvoid transfer delay!
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Treat life-threatening injuries first Immobilize Appropriate spine films Document examination Neurosurgical / orthopedic consultTransfer unstable fracture / cord injury