Provincial Reciprocity Attainment ProgramProvincial Reciprocity Attainment Program
Musculoskeletal
Skeletal System
The Skeletal System
Consists of: Bones Cartilage Ligaments
Connect Bone to Bone Tendons
Connect Muscle to Bone
Accounts for 20% of body weight
They are living tissue
Functions
Support Supports organs and against gravity
Protection Protects soft organs underneath
Movement Muscles attached provide movement
Storage Inner matrix has Ca salts, Fat in Yellow Bone
Marrow Blood Cell Formation
Hematopoesis in the Red Bone Marrow
Structure Types:
Compact Spongy
Classifications Long
Femur, Ulna, Radius, Tibia, Fibula Short
Tarsals and Carpals Flat
Cranial bones Irregular
Vertebrae
General Features of the Long Bone
Diaphysis
Epiphysis
Epiphyseal Plate
PeriosteumMedullary Cavity
Endosteum
Each bone has surface markings that make it unique
Contains 206 named bones
Two divisions Axial Skeleton Appendicular Skeleton
Divisions
Axial Skeleton 80 bones form the vertical axis Include:
Cranium Vertebrae Sternum Ribs
Divisions
Axial Skeleton
Skull 28 separate bones
Hyoid bone
Axial Skeleton
Vertebral column Consists of approximately 33 bones divided
into 5 regions 7 cervical vertebrae
C1 (Atlas) – Yes C2 (Axis) - No
12 thoracic vertebrae 5 lumbar vertebrae 1 sacral bone (5 fused vertebrae) 1 coccygeal bone (3-5 fused vertebrae)
Thoracic Cage
Protects vital organs in the thorax Prevents collapse of the thorax during
respiration 12 pairs of ribs Sternum
Manubrium Body Xiphoid process
126 Bones Consists of the bones of the upper and
lower extremities and their girdles Pectoral girdle
Comprised of the scapula and clavicle Attaches upper limbs to the axial skeleton
Appendicular Skeleton
Upper Extremity
Humerus Second largest
bone in the body Radius and Ulna Wrist
Pelvic Girdle
Attaches legs to trunk Consists of two hip bones (coxae) Acetabulum
Legs
Femur Longest bone in the body Head articulates with the acetabulum Articulates distally with patella
Tibia Larger than fibula and supports most
of leg's weight Distal end forms lateral malleolus,
forming medial side of ankle joint Fibula
Does not articulate with femur Does articulate with tibia Distal end forms lateral malleolus,
forming lateral aspect of ankle joint
Foot
Consists of tarsals, metatarsals, and phalanges
Talus articulates with tibia and fibula
Calcaneus
Every bone (except the hyoid bone) connects to at least one other bone
Three major classifications of joints Fibrous joints Cartilaginous joints Synovial joints
Biomechanics of Movement
Consist of two bones--united by fibrous tissue—that have little or no movement
Sutures (seams between flat bones)
Fibrous Joints
Unite two bones by means of hyaline cartilage (synchondroses) or fibrocartilage (symphyses)
Synchondroses Slight motion (between ribs and sternum)
Symphysis Slight motion, flexible (symphysis pubis)
Cartilaginous Joints
Synovial Joints
Contain synovial fluid Allow movement
between articulating bones
Account for most joints of appendicular skeleton
Plane or gliding joints Saddle joints Hinge joints Pivot joints Ball-and-socket joints Ellipsoid joints
Muscular System
Characteristics
Excitability The ability to receive and respond to stimulus
Contractility The ability to contract
Extensibility The ability to stretch (opposing pairs)
Elasticity The ability to recoil to original shape
Functions
Movement Posture Joint stability Heat Production
Types
Smooth Involuntary Found in the walls of organs Ex: Intestinal tract
Skeletal Voluntary
Cardiac Found only in cardiac muscle
Structure
As a whole each muscle may be made up of hundreds of muscle fibers
Fascia surrounds and separates each muscle
Each muscle is surrounded by a protective sheath called epimysium which divides the muscle into compartments
Each compartment contains a bundle of fibers called a fasciculus surrounded by a layer of tissue called perimysium
Each fiber in the fasciculus is surrounded by a layer of tissue called the endomysium
The coverings also contain blood vessels and nerves
Structure
Muscle Fibers Each fiber is a cylindrical cell The cell membrane is called the sacrolemma The cytoplasm is the sarcoplasm A special Endoplasmic Reticulum in the sarcoplasm
is called the sarcoplasmic reticulum The sarcolemma has multiple nuclei and
mitochondria (for energy production) Inward extensions of the sacrolemma are called T-
tubules
Structure
Muscle Fibers
SACROMERE
Nerve & Blood Supply
Have an abundant supply Before a muscle can contract it needs a
stimulus This requires ATP Blood supply deliver O2 and nutrients to
produce this and remove the waste products One Artery and One Vein accompany each
nerve
Contraction
Stimulated by specialized nerve cells called motor neurons
The motor neuron and muscle(s) is called a motor unit
Where the axon of the neuron meets the muscle is called the neuromuscular junction
Between the two is a small depression in the muscle membrane called the synaptic cleft
Contraction
ACh is contained within the synaptic vesicles of the axon
Receptors for ACh are in the sacrolemma The combination results in a stimulus for
contraction (an impulse) which travels along the sacrolemma into the T-tubules where a physiological change occurs causing a contraction
The enzyme acetylcholinesterase deactivates the ACh at the synaptic cleft
Sacromere Contraction
In a relaxed muscle fiber myosin receptor sites on the actin are inactive
Heads on the myosin are also inactive and are bound to ATP
Ca is stored in the sarcoplasmic reticulum and has a low concentration in the sarcoplasm
An impulse into the T-tubule cause release of Ca from the SR into the sarcoplasm
This rapid influx changes configuration of troponin on the actin fibers which exposes receptor sites
Sacromere Contraction
Simultaneously ATP is broken down to ADP which gives energy to the myosin
This energy allows it to interact with the actin The myosin heads bind forming cross-bridges and
rotate pulling the actin towards the center of the myosin (Power stroke)
This pulls the Z line closer together shortening the sacromere
This does not shorten the myofilament New ATP on myosin reverse the reaction This is the “Sliding Filament Theory”
Sacromere Contraction
When the stimulation ceases, Ca is actively transported into the SR
This causes the receptor sites to close and ceasing the contraction
Follows the All-or-none Principle, which is basically: A sufficient stimulus is need to cause a contraction
(threshold stimulus) A greater stimulus will not produce greater contraction Not enough will elicit no response (sub-threshold
stimulus)
Whole Muscle Contraction
Does not follow All-or-none Varies due to work load Increase contraction is achieved by motor unit
summation and wave summation A single stimulus causes a twitch (lab setting) 3 stages of contraction
lag phase contraction relaxation
Whole Muscle Contraction
A stimulus given during relaxation phase will cause stronger contraction, and continues to build to form a smooth contraction called tetany (multiple wave summation)
Treppe (staircase) shows an increase in force with a stimulus of same intensity
Muscle tone is the continued state of partial contractions of the muscles (needed for posture and temp)
If movement occurs it is an isotonic contraction If there is no movement then it is isometric
Energy Sources
Initial Source ATP for the cross-bridge and active transport Last only 6 seconds
Second Source Creatine Phospate is used to instantaneously
give its energy to ADP to synthesis ATP If ATP is in excess it will convert to Creatine
phosphate to store for later use Lasts only 10 seconds
Energy Sources
Third Stage Muscles use fatty acids and glucose for energy Fatty acids found in blood Glucose is a derivative of the glycogen found in the muscle If oxygen available then the fats and glucose are broken
down with aerobic metabolism (20 times more production)
Fatty Acids or glucose + O2 → CO2 + H20 + ATP If oxygen is not available then glucose is the primary
source of energy (anaerobic metabolism – happens at a faster rate)
Glucose → lactic acid + ATP
Energy Sources Oxygen storage
Red fibers have myoglobin which has iron to bind with O2 White Fibers do not contain myoglobin
Lactic Acid Excessive lactic acid is send to the liver when O2 is available and
converted and stored as glycogen
Oxygen Debt After strenuous exercise using anaerobic metabolism, ATP and creatine
phosphate have to be replaced, this requires O2 Is the additional O2 needed to do this after exercise
Musculoskeletal Injury
Injury to Muscle
Can occur due to: Overexertion where fibers are broken With trauma muscles can be bruised,
crushed, cut, or even torn even without a break in the skin.
Injured muscles tend to be: Swollen, tender and painful, weak
Classification of MS Injuries
Injuries that result from traumatic forces include: Fractures Sprains Strains Dislocations
Complications
Hemorrhage Instability Loss of tissue Simple laceration and contamination Interruption of blood supply Nerve damage Long-term disability
Ligaments BONE to BONE
Tendons MUSCLE to BONE
Sprain is an injury to a ligament Strains are injuries to tendons or muscles Dislocations are bones of a joint that are separated
from normal position of use
Sprains, Strains and Dislocations
Sprains
A partial tearing of a ligament caused by a sudden twisting or stretching of a joint beyond its normal range of motion Ankle and knees are most common
Sprains are graded by severity: First degree
Ligaments are stretched but not torn Can put weight on the ankle
Second degree Ligament is partially torn, pain and swelling are greater Painful with weight
Third degree Cannot handle weight
Strains
An injury to the muscle or its tendon from overexertion or overextension
Commonly occur in the back and arms (welcome to EMS)
May be accompanied by significant loss of function
Severe strains may cause an avulsion of the bone from the attachment site
Dislocations
Occur when the normal articulating ends of two or more bones are displaced Luxation (a complete dislocation) Subluxation (Incomplete dislocation)
Suspect a joint dislocation if deformity or does not move with normal range of function
All dislocations can result in damage and instability
Due to limited diagnostic equipment, field diagnosis is not necessary
They are all treated as fractures until proven otherwise
Treatment
Treatment
Most BONE, JOINT, and MUSCLE injuries will benefit from RICE:
Rest
Ice
Compression
Elevation
Direct Force Indirect Force Twisting Forces Muscle Contractions Pathological
Common MOI’s
Any break in the continuity of the bone Open Fracture
An open wound leading to the break The bone may or may not be exposed
Closed Fracture No wound in the are of the break
Simple Single fracture of the bone
Complex Multiple fractures of the bone
Fractures
Swelling Discoloration Deformity Pain
On palpation or movement
Crepitus Loss of function
Decreased ROM False movement
Decreased of absent sensory perception or circulation distal to the injury
Signs and Symptoms
Types of Fractures
Epiphyseal Fracture (Growth plate)
Assessment
Scene Assessment Primary survey
Rule out life threatening injuries and treat first remember distracting injuries
Identify Six P’s of MS assessment
Stabilize Expose
Compare to uninjured extremity Assess CMS Splint Reassess CMS
Pain management (Call for ALS if required)
Six P’s of MS Assessment
Pain Pain on palpation Pain on movement
Pallor Pale skin or poor capillary refill
Paresthesia Pins and needles sensation
Pulses Diminished or absent
Paralysis Pressure
Splinting
The goal of splinting is Immobilization of injured body part
Helps alleviate pain Decreases tissue injury, bleeding and
contamination of an open wound Simplifies and facilitates transport
Splinting
Splint joints above and below the fracture Cover open wounds to reduce
contamination Check CMS before and after Immobilize joints in position found (ensure
good vascular supply) Cold applied to reduce swelling and pain
(heat is used later for healing)
Rigid Splints
Cannot be changed in shape Require the body part to be positioned
to fit Board splints Cardboard splints
Can be padded to accommodate anatomical shape and comfort
Soft or Formable Splints
Can be molded into various shapes to accommodate injured part Pillows Blankets Slings and swathes Vacuum splints Wire ladder spliints Flexible aluminum splints (SAM splints) Inflatable splints
Traction Splints
Specifically designed for Mid-Shaft femur fractures
Provide enough traction to stabilize and align a fracture
Upper-Extremity Injuries
Shoulder Injury
Common in the older adult because of weaker bone structure Frequently results from a fall on an
outstretched arm
Shoulder Injury
Anterior fracture or dislocation Patient often positioned with the affected arm or
shoulder close to the chest Lateral aspect of the shoulder appears flat instead
of rounded Deep depression between the head of the humerus
and the acromion laterally (“hollow shoulder”) Posterior fracture or dislocation
Patient may be positioned with the arm above the head
Shoulder Injury – Management
Assessment of neurovascular status
Application of a sling and swathe
Application of a cold pack
Splinting may need to be improvised to hold the injury in place
Humerus Injury
Common in older adults and children Often difficult to stabilize Associated complications
Radial nerve damage may be present if a fracture occurs in the middle or distal portion of the humeral shaft
Fracture of the humeral neck may cause axillary nerve damage
Internal hemorrhage into the joint
Humerus Injury – Management
Assessment of neurovascular status
Traction if there is vascular compromise
Application of a rigid splint and sling and swathe or splinting the extremity with the arm extended
Application of a cold pack
Elbow Injury
Common in children and athletes Especially dangerous in children May lead to ischemic contracture with serious
deformity of the forearm and a claw-like hand Usually involves falling on an outstretched arm
or flexed elbow Associated complications
Laceration of the brachial artery Radial nerve damage
Elbow Injury – Management
Assessment of neurovascular status
Splinting in the position found with a pillow, rigid splint, or sling and swathe
Application of a cold pack
Radius, Ulnar, or Wrist Injury
Usually result from a fall on an outstretched arm
Wrist injuries may involve the distal radius, ulnar, or any of the eight carpal bones Common injury is Colles' fracture
Forearm injuries are common in both children and adults
Radius, Ulnar, or Wrist Injury – Management
Assessment of neurovascular status
Splinting in the position found with rigid or formable splints or sling and swathe
Application of a cold pack and elevation
Hand (Metacarpal) Injury
Frequently results from: Contact sports Violence (fighting) Crushing in industrial context
A common injury is boxer's fracture Results from direct trauma to a closed fist
fracturing the fifth metacarpal bone Injuries may be associated with hematomas
and open wounds
Hand Injury – Management
Assessment of neurovascular status Splinting with rigid or formable splint in
position of function Application of a cold pack and elevation
Finger (Phalangeal) Injury
May be immobilized with foam-filled aluminum splints or tongue depressors or by taping injured finger to adjacent one (“buddy splinting”)
Finger injuries are common Should not be considered trivial
Serious injuries include: Thumb metacarpal fractures Any open fracture Markedly comminuted metacarpal or proximal phalanx
fracture
Finger Injury – Management
Assess neurovascular status Splint Apply cold pack and elevate
Lower-Extremity Injuries
Compared with upper-extremity injuries, lower-extremity injuries are: Associated with greater wounding forces and
more significant blood loss than upper-extremity injuries
More difficult to manage in the patient with multiple injuries
May be life threatening Femur fracture Pelvic fracture
Pelvic Fracture
Blunt or penetrating injury to the pelvis may result in: Fracture Severe hemorrhage Associated injury to the urinary bladder and urethra
Deformity may be difficult to see Suspect injury to the pelvis based on:
Mechanism of injury Presence of tenderness on palpation of the iliac crests
Pelvic Fracture
Management High-concentration oxygen administration Treatment for shock Full body immobilization on a long spine
board (adequately padded for comfort) Regular monitoring of vital signs
Hip Injury
Commonly occurs in older adults because of a fall Also occurs in younger patients from major
trauma If the hip is fractured at the femoral head and
neck, the affected leg is usually shortened and externally rotated
Dislocations of the hip are usually evidenced by a shortened and rotated leg
Hip Injury – Management
Assessment of neurovascular status Splinting with a long spine board and
generously padding patient for comfort during transport
Slight flexion of the knee or padding beneath the knee may improve comfort
Frequent monitoring of vital signs
Femur Injury
Usually results from major trauma (motor vehicle crashes and pedestrian accidents)
Fairly common result of child abuse Fractures are usually evident from the powerful
thigh muscles producing overriding of the bone fragments
Patient generally has a shortened leg that is externally rotated and mid-thigh swelling from hemorrhage
Bleeding may be life-threatening
Femur Injury – Management
High-concentration oxygen administration
Treatment for shock Assessment of neurovascular status Application of a traction splint Regular monitoring of vital signs
Knee and Patella Injury
Fractures to the knee and fractures and dislocations of the patella commonly result from: Motor vehicle crashes Pedestrian accidents Contact sports Falls on a flexed knee
The relationship of the popliteal artery to the knee joint may lead to vascular injury, particularly with posterior dislocations
Knee and Patella Injury – Management
Assessment of neurovascular status Splinting in the position found with rigid or
formable splint that effectively immobilizes the hip and ankle
Application of a cold pack and elevation, if possible
Tibia and Fibula Injury
May result from direct or indirect trauma or twisting injury
If associated with the knee, popliteal vascular injury should be suspected
Management Assessment of neurovascular status Splinting with a rigid or formable splint Application of a cold pack and elevation
Foot and Ankle Injury
Fractures and dislocations of the foot and ankle may result from: Crush injury Fall from a height Violent rotary force
Patient usually complains of point tenderness and is hesitant to bear weight on the extremity
Foot and Ankle Injury – Management
Assessment of neurovascular status Application of a formable splint, such
as a pillow, blanket, or air splint Application of a cold pack Elevation
Phalanx Injury
Often caused by “stubbing” the toe on an immovable object
Usually managed by buddy taping the toe to an adjacent toe for support and immobilization
Management Assessment of neurovascular status Buddy splinting Application of cold pack Elevation
Management
As a rule, fractures and dislocated joints should be immobilized in the position of injury and the patient transported to the emergency department for realignment (reduction)
If transport is delayed or prolonged and circulation is impaired, an attempt to reposition a grossly deformed fracture or dislocated joint should be made
The elbow should never be manipulated in the prehospital setting
Method
Handle the injury carefully Apply gentle, firm traction in the
direction of the long axis of the extremity
If there is obvious resistance to alignment, splint the extremity without repositioning
Realignment Guidelines
Only one attempt at realignment should be made in the prehospital setting
Only if there is severe neurovascular compromise (e.g., extremely weak or absent distal pulses)
May consult OLMC Manipulation (if indicated) should be
performed as soon as possible after the injury
Realignment Guidelines
Should be avoided in the presence of other severe injuries
If not contraindicated by other injuries, consider use of analgesics for the realignment procedure
Assess and document pulse, sensation, and motor function before and after manipulating any injured extremity or joint
Spinal Injuries
Hyperextension Flexion Compression Lateral Distraction Penetration Flexion-Rotation
Common MOI’s
Traditional Spinal Assessment Criteria
Traditional criteria have focused on mechanism of injury (MOI) with spinal immobilization considerations for two specific patient groups: Unconscious accident victims Any patients with a “motion” injury
Covers all patients with a potential for spinal injury Not always practical in the prehospital setting
Prehospital Assessment
Prehospital assessment can be enhanced by applying clear, clinical criteria for evaluating spinal cord injury that includes the following signs and symptoms (in the absence of other injuries, altered mental status, or use of intoxicants):
Pain Tenderness Painful with or without movement Deformity Cuts/bruises over spinal area Paralysis Paresthesias Weakness Priaprism (usually a total transection of the cord) SOB with very little Chest Expansion Incontinence
MOI or Nature of Injury
When determining mechanism of injury in a patient who may have spinal trauma, classify the MOI as: Positive Negative Uncertain
When combined with clinical criteria for spinal injury, can help identify situations in which spinal immobilization is appropriate
Positive MOI
Forces exerted on the patient are highly suggestive of spinal cord injury
Always require full spinal immobilization Examples:
High-speed motor vehicle crashes Falls greater than three times the patient’s height Violent situations occurring near the patient’s spine Sports injuries Other high-impact situations
Positive MOI
In the absence of signs and symptoms of SCI, some medical-direction agencies may recommend that a patient with a positive MOI not be immobilized Recommendations will be based on the
paramedic’s assessment when: Patient history is reliable There are no distraction injuries
Negative MOI
Includes events where force or impact does not suggest a potential for spinal injury In the absence of SCI signs and symptoms, does
not require spinal immobilization Examples:
Dropping an object on the foot Twisting an ankle while running Isolated soft tissue injury
Uncertain MOI
When the impact or force involved in the injury is unknown or uncertain, clinical criteria must be used to determine need for spinal immobilization
Examples: Tripping or falling and hitting the head Falls from 2 to 4 feet Low-speed motor vehicle crashes (“fender
benders”)
Assessment of Uncertain MOI
Ensure that the patient is “reliable” Reliable patients are calm, cooperative, sober, alert,
and oriented Examples of “unreliable” patients:
Acute stress reactions from sudden stress of any type Brain injury Intoxicated Abnormal mental status Distracting injuries Problems communicating
Spinal Injury
Frequent causes of spinal trauma: Axial loading Extremes of flexion, hyperextension, or hyperrotation Excessive lateral bending Distraction
May result in stable and unstable injuries based on: Extent of disruption to spinal structures Relative strength of the structures remaining intact
Axial Loading (Vertical Compression)
Results when direct forces are transmitted along the length of the spinal column
May produce compression fracture or a crushed vertebral body without SCI Most commonly occur at T12 to L2
Flexion, Hyperextension, and Hyperrotation
Extremes in flexion, hyperextension, or hyperrotation may result in: Fracture Ligamentous injury Muscle injury
Spinal cord injury is caused by impingement into the spinal canal by subluxation of one or more cervical vertebrae
Lateral Bending
Excessive lateral bending may result in dislocations and bony fractures of cervical and thoracic spine Occurs as a sudden lateral impact moves
the torso sideways Initially, head tends to remain in place
until pulled along by the cervical attachments
Distraction
May occur if the cervical spine is suddenly stopped while the weight and momentum of the body pull away from it May result in tearing and laceration of the
spinal cord
Less Common Mechanisms of Spinal Injury
Blunt trauma Electrical injury Penetrating trauma
Classifications of Spinal Injury
Sprains Strains Fractures Dislocations Sacral fractures Coccygeal fractures Cord injuries
Spinal Injuries
All patients with suspected spinal trauma and signs and symptoms of SCI should be immobilized Avoid unnecessary movement
An unstable spine can only be ruled out by radiography or lack of any potential mechanism for the injury
Assume Spinal Injury:
Significant trauma and use of intoxicating substances
Seizure activity Complaints of pain in the
neck or arms (or paresthesia in the arms)
Neck tenderness on examination
Unconsciousness because of head injury
Significant injury above the clavicle
A fall more than three times the patient's height
A fall and fracture of both heels (associated with lumbar fractures)
Injury from a high-speed motor vehicle crash
Spinal Injury
Damage produced by injury forces can be further complicated by: Patient's age Preexisting bone diseases Congenital spinal cord anomalies
Spinal cord neurons do not regenerate to any great extent
Hyperflexion Sprains and Strains
Hyperflexion sprains Occur when the posterior ligamentous
complex tears at least partially Hyperextension strains (whiplash)
Common in low-velocity, rear-end automobile collisions
Signs and symptoms Management
Fractures and Dislocations
Most frequently injured spinal regions in descending order: C5-C7 C1-C2 T12-L2
Of these, the most common are wedge-shaped compression fractures and "teardrop" fractures or dislocations
Sacral and Coccygeal Fractures
Most serious spinal injuries occur in the cervical, thoracic, and lumbar regions
Patients frequently complain that they have “broken their tailbone” Experience moderate pain from the mobile
coccyx
Sacral and Coccygeal Fractures
Fractures through the foramina of S1 and S2 are fairly common and may compromise several sacral nerve elements May result in loss of perianal sensory motor
function and in bladder and sphincter disturbances
Sacrococcygeal joint may also be injured because of direct blows and falls
Classification of Cord Injuries
Primary injuries - occur at time of impact
Secondary injuries - occur after the initial injury and can include: Swelling Ischemia Movement of bony fragments
Cord Injuries
The spinal cord can be concussed, contused, compressed, and lacerated
Severity of these injuries depends on: Amount and type of forced that produced
them Duration of the injury
Cord Lesions
Lesions (transections) of the spinal cord are classified as complete or incomplete
Complete Cord Lesions
Usually associated with spinal fracture or dislocation Total absence of pain, pressure, and joint sensation
and complete motor paralysis below the level of injury
Results in: Quadriplegia
Injury at the cervical level Loss of all function below injury site
Paraplegia Injury at the thoracic or lumbar level Loss of lower trunk only
Complete Cord Lesions
Autonomic dysfunction may be associated with complete cord lesions
Manifestations of autonomic dysfunction: Bradycardia Hypotension Priapism Loss of sweating and shivering Poikilothermy (look it up!) Loss of bowel and bladder control
Incomplete Lesions
Central cord syndrome Commonly seen with hyperextension or
flexion cervical injuries Characterized by greater motor impairment
of the upper than lower extremities Signs and symptoms
Paralysis of the arms Sacral sparing
Incomplete Lesions
Anterior cord syndrome Usually seen in flexion injuries Caused by:
Pressure on the anterior aspect of the spinal cord by a ruptured intervertebral disk
Fragments of the vertebral body extruded posteriorly into the spinal canal
Signs and symptoms Decreased sensation of pain and temperature below level
of lesion Intact light touch and position sensation Paralysis
Incomplete Lesions
Brown-Sequard syndrome A hemi-transection of the spinal cord May result from:
A ruptured intervertebral disk Encroachment on the spinal cord by a fragment of
vertebral body, often after knife or missile injuries
In the classic presentation, pressure on half the spinal cord results in:
Weakness of the upper and lower extremities on ipsilateral side
Loss of pain and temperature on contralateral side
Assessment
Priorities: Scene survey Assessment of airway, breathing, and
circulation Preservation of spinal cord function and
avoiding secondary injury to the spinal cord
Assessment
Prevent secondary injury that could result from: Unnecessary movement Hypoxemia Edema Shock
Prehospital Goals
Maintain a high degree of suspicion for spinal injury Scene survey Kinematics History of the event
Provide early spinal immobilization Oxygen administration Rapidly correct any volume deficits
Neurological Examination
After managing life-threatening problems encountered in the initial assessment, perform a neurological exam May be done at the scene or en route to the
hospital if the patient requires rapid transport Document findings
Components of neurological examination: Motor and sensory findings Reflex responses
Dermatomes
Dermatomes correspond to spinal nerves The following landmarks may be useful for a quick
sensory evaluation in the prehospital setting: C2 to C4 dermatomes provide a collar of sensation around
the neck and over the anterior chest to below the clavicles T4 dermatome provides sensation to the nipple line T10 dermatome provides sensation to the umbilicus S1 dermatome provides sensation to soles of the feet
Other Methods of Evaluation
Visual inspection may indicate presence of injury and its level Transection of the cord above C3 often
results in respiratory arrest Lesions that occur at C4 may result in
paralysis of the diaphragm Transections at C5-C6 usually spare the
diaphragm and permit diaphragmatic breathing
Spinal Injury
Absence of neurological deficits does not rule out significant spinal injury If a spinal injury is suspected, the patient's
spine must be protected Patient's ability to walk should not be a
factor in determining need for spinal precautions
Spinal Immobilization
Primary goal is to prevent further injury Treat the spine as a long bone with a joint at
either end (the head and pelvis) Always use “complete” spinal immobilization
Spinal immobilization begins in the initial assessment Must be maintained until the spine is completely
immobilized on a long backboard
Spinal Stabilization Techniques
Immediately on recognizing a possible or potential spine injury, manually protect the patient's head and neck Head and neck must be maintained in line
with the long axis of the body
Rigid Cervical Collars
Designed to limit (not stop) motion of the head and neck
Available in many sizes (or are adjustable) Choosing the appropriate size reduces flexion or
hyperextension Must not inhibit patient's ability to open his or her
mouth or to clear his or her airway in case of vomiting
Must not obstruct airway passages or ventilations Should be applied only after the head has been
brought into a neutral in-line position
To measure the collar Check the distance from the angle of the
jaw to the top of the Trapezius muscle with your hand
Match the appropriate finger width to the C-collar and select appropriate size
C-Collars
Short Spine Boards
Used to splint the cervical and thoracic spine
Vary in design and are available from many equipment manufacturers
Generally used to provide spinal immobilization in situations in which the patient is in a sitting position or a confined space
After short spine board immobilization, the patient is transferred to a long spine board for complete spinal immobilization
Rapid Extrication
Steps may vary depending on: Size and make of the vehicle Patient’s location inside the vehicle
Procedure
Long Spine Board
Available in a variety of types including: Plastic and synthetic spine boards Metal alloy spine boards Vacuum mattress splints Split litters (scoop stretchers) that must be
used with a long spine board
Long Spine Board - Supine Patient
Immobilizing the torso to a long spine board must always precede immobilization of the head
Torso must not be allowed to move up, down, or to either side
Place straps at the: Shoulders or chest Around the mid-torso Across the iliac crests to prevent movement of the lower
torso
After immobilization of torso, immobilize head and neck in a neutral, in-line position
Long Spine Board - Supine Patient
Noncompressible padding should be added as needed before securing the head
Padding (if needed) should be firm and extend the full length and width of the torso from the buttocks to the top of the shoulders
Long Spine Board - Supine Patient
Children have proportionally larger heads than adults May require padding under the torso to
allow the head to lie in a neutral position on the board
Long Spine Board - Supine Patient
Secure the head to the device by placing commercial pads or rolled blankets on both sides of the head and securing with: Included straps 2 to 3 inch tape strips
You must be comfortable with both types!
Tape
When apply tape, use a minimum of 3 complete wraps while apply gentle but firm traction on the tape
Use a continuous loop (do not break at each section) Order of taping
Secure thoracic cage Hands/arms free for the conscious patient Hands/arms secured for the unconscious patient
Secure pelvis Secure lower extremities (thighs and lower limbs) Secure head
Straps
Need a minimum of 3 straps (4 or more is preferred) Straps should be applied in same order as tape Use cross over technique
Right shoulder to left hip Left shoulder to right hip
Standing Take Down
Used to immobilize the standing patient Should be done in a quick efficient
manor
Techniques… Two person Three person
Immobilizing Pediatric Patients
Prehospital care should include: Manual in-line immobilization Rigid cervical collar Long spinal immobilization device
Immobilization devices available from various equipment manufacturers If unavailable, adult long spine boards may be used
for full spinal immobilization
Helmet Issues
Purpose of helmets is to protect the head and brain, not the neck Leaves the cervical spine vulnerable to injury
Types of helmets Full-face or open-face designs
Used in motorcycling, bicycling, rollerblading, and other activities
Helmets designed for sports such as football and motor-cross
Helmet Issues
When determining the need to remove a helmet consider: Athletic trainers may have special equipment (and
training) to remove face-pieces from sports helmets Allows easier access to the patient’s airway
Sports garb (e.g., shoulder pads) could further compromise the cervical spine if only the helmet were removed
Firm fit of a helmet may provide firm support for patient’s head
Helmet Removal
Removing a helmet from an injured patient in the prehospital setting (vs. in-hospital removal) is controversial If the patient’s airway cannot be
adequately accessed or secured, or if the helmet hinders emergency care procedures, the helmet should be removed in the field