PHTLS5E9

7/27/2019 PHTLS5E9

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Spinal Trauma

Lesson

9

Prehospital Trauma Life Support

Copyright © 2003, Elsevier Science (USA). All rights reserved.

PROVIDER COURSE

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Spinal Trauma

• Significant kinetic energy can produce injuryto the spine and/or spinal cord

• Potential for these injuries must be

recognized

• Failure in assessment and management can

result in permanent paralysis

• Spinal injuries have a substantial lifelong

financial impact on the victim


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Spinal Trauma

• As many as 15,000 to 20,000 spinal injuriesoccur annually

• The most common age is 16 to 35 years old

• Causes: – MVCs

– Falls

– Penetrating injuries

– Sports injuries


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Anatomy

Spinousprocess

Vertebral

foramen

Body


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Anatomy

• Cervical (7)

• Thoracic (12)

• Lumbar (5)• Sacrum (5)

• Coccyx (4)


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You are called to a public pool for a16-year-old male who sustained an

injury while diving. Upon your arrival he

has been removed from the pool.


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Primary Survey

A - PatentB - Rapid and shallow

C - Slow heart rate, weak radial pulse,

warm extremities

D - GCS score 15, loss of motor and

sensory function in extremities

E - No other obvious injuries

What is the life-threatening problem?


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Sensory Assessment

Nipple line = T4

Umbilical line = T10


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Ventilatory Impairment

• High cervical injuries - loss of total ability to

breathe

• Lower cervical injuries - diaphragm still

functions, loss of intercostal muscles


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Neurogenic Shock

• Hypotension associated with cervical or high

thoracic spinal cord injury

• Disruption of sympathetic nervous system

– Vasodilation below injury

– Heart—bradycardia

Failing to consider hypovolemia as a

cause of shock


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How would you manage this patient?


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A 28-year-old male has been shot in the

neck by his girlfriend.


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Primary Survey

A - PatentB - Fast, BS equal

C - Copious external hemorrhage from neck wound,

radial pulse fast and weak

D - GCS score 15, no neurologic deficits in extremities

E - Expanding hematoma to left side of neck

When is spinal immobilization indicated for

penetrating trauma?


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• Unstable spinal fractures from penetrating trauma are

extremely rare

• Life-threatening conditions take priority

Copyright © 2003, Elsevier Science (USA). All rights reserved. 9-16

Penetrating trauma

Neurological deficit/complaint?

No Yes

IMMOBILIZE IMMOBILIZATION

NOT INDICATED

Rapid transport Rapid transport

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You are called to a nightclub where a

35-year-old female has fallen down a flight of

stairs. Your patient denies neck and back

pain but complains of severe left ankle pain.

You smell alcohol on her breath.


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Primary Survey

A - PatentB - Normal, BS clear

C - Minor bleeding from small scalp laceration,

normal radial pulse

D - Slurred speech, GCS score 15

E - Grossly deformed left ankle

When is spinal immobilization indicated for blunt

trauma?


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Blunt trauma

Altered level of consciousness (GCS,15)

No Yes

IMMOBILIZE

Rapid transport

Spinal pain or tenderness?

or

Neurologic deficit or complaint?

or Anatomic deformity of spine?

No Yes

IMMOBILIZE

Rapid transport

Concerning

mechanism of

injury?

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Concerning Mechanism of Injury

• Violent impact to the head, neck, torso, or

pelvis

• Sudden acceleration, deceleration, or lateral

bending forces to neck or torso

• Any fall

• Ejection or fall from any motorized or human-

powered transport device• Shallow-water diving incident


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Distracting Injuries

• Any injury that may have the potential toimpair the patient’s ability to appreciate other

injuries

– Long bone fracture

– Suspected visceral injury

– Large laceration, degloving, or crush injury

– Large burns

– Any other injury that produces acute functionalimpairment


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Inability to Communicate

• Speech or hearing impaired

• Foreign language speaking

• Small children


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Presence of:

Evidence of alcohol/drugs

or

Distracting injury

or

Inability to communicate

When in doubt, immobilize!


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Concerning Mechanism Of Injury

No Yes

IMMOBILIZE

IMMOBILIZATION

NOT INDICATED

Rapid transport

Transport

No Yes

IMMOBILIZATION NOT

INDICATED

Transport

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You are called to the scene of a multi-vehicle crash

on a highway. After your patient’s vehicle was rear -

ended it was propelled into the vehicle in front of it.

The vehicle has moderate damage. The driver was

unrestrained and the windshield is spider-webbed.

On the basis of kinematics, why should spinal

injury be suspected?


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Primary Survey

A - PatentB - Normal, BS clear

C - Normal radial pulse

D - GCS score 15E - Abrasion on forehead

What are the indications for rapid extrication?


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Rapid Extrication

Indications:• Threat to life identified in primary survey

• External threat to patient or rescuers

Using rapid extrication when not indicated

Not using rapid extrication when indicated


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The patient is complaining of neck pain.

What role does a cervical collar play in spinal

immobilization?

How is spinal immobilization performed?


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Cervical Collar

• Adjunct only: DOES NOT IMMOBILIZE!

• Apply after returning head to neutral inline

position unless contraindicated

• Must be rigid and properly sized

• Should not impair opening of mouth


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Spinal Immobilization

• Manual stabilization in neutral inline position• Assess neurologic function

• Apply cervical collar

• Secure torso• Apply padding where needed

• Secure head

• Secure extremities

• Reassess primary survey/neurologic function


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Spinal Immobilization

Over reliance on cervical collar

Immobilizing only the head, or the

head before the torsoFailing to immobilize the entire spine

Failing to use interim device when

indicated


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9-32

Prehospital Trauma Life Support

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