campbell, international trauma life support, 6th ed. © 2008 pearson education, inc., upper saddle...

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

International Trauma Life Support

International Trauma Life Support

for Prehospital Care ProvidersSixth Edition

for Prehospital Care ProvidersSixth Edition

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Chapter 11Spinal TraumaChapter 11Spinal Trauma

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Spinal TraumaSpinal Trauma

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Overview

Spinal anatomy and physiology

Spinal motion restriction (SMR)• Mechanisms of injury indicating need• Process of application• Emergency Rescue and Rapid Extrication• History and assessment indicating no need• Special situations indicating need for alteration

Neurogenic and hemorrhagic shock

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Spinal Trauma

Devastating and life-threatening• Skillfully assess mechanism of injury and patient

Spinal motion restriction (SMR)• ITLS recommendations are guidelines

• Based on careful evaluation of mechanism, reliable patient condition, special situations

• Know your local protocol

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Spinal Column

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Spinal Cord

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Spinal Injury

Mechanism

• Hyperextension

• Hyperflexion

• Compression

• Rotation

• Lateral stress or distraction• Less common

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Blunt Spinal-Column Injury

Requires significant force• Unless preexisting weakness or defect in bone

• Higher risk: elderly, severe arthritis

• Sudden movement of head or trunk• Frequently injured in more than one place

Spinal cord involvement• Column injuries with cord injury: 14%• Cervical region : 40%

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Blunt Spinal-Column Injury

Signs and symptoms• Pain most common symptom

• Frequently masked by other injures• Back pain with or without movement of back• Tenderness along spinal column

• Obvious deformity or wounds• Paralysis • Weakness• Paresthesia

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Blunt Spinal-Cord Injury

New cord injuries each year• MVC (including pedestrian)• Falls• Penetrating • Recreational activities

Young adults most common• Under 8 years, usually high cervical• Elderly

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Blunt Spinal-Cord Injury

Primary damage• At time of force• Cut, torn, crushed, cut off blood supply• Usually irreversible

Secondary damage• After time of force• Hypotension, generalized hypoxia, blood vessel

injury, swelling, compression from hemorrhage• Good prehospital care may help prevent

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Spinal Injury

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Neurogenic Shock

Cervical or thoracic cord injury• High-space shock• Malfunction of autonomic nervous system

Signs and symptoms• Hypotension • Normal skin color and temperature • Inappropriately slow heart rate

Diagnosis of exclusion• May have both neurogenic and hemorrhagic

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Assessment

ITLS Primary and Secondary Surveys

Motor and sensory function

• Conscious• Motor: move fingers and toes• Sensation: abnormal is suspicious

• Unconscious• Motor: pinch fingers and toes• Sensation: pinch fingers and toes

– Flaccid paralysis, no reflexes or withdrawal means injury

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Clues to Spinal Injury

Mechanism• Blunt trauma above clavicle

• Diving accident

• Motor vehicle or bicycle accident

• Fall

• Stabbing or impalement near spinal column

• Shooting or blast injury to torso

• Any violent injury with forces acting on spine

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Clues to Spinal Injury

Patient complaints

• Neck or back pain

• Numbness

• Tingling

• Loss of movement

• Weakness

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Clues to Spinal Injury

Signs revealed during assessment• Pain on movement of back or spinal column• Obvious deformity of back or spinal column• Guarding against movement of back• Loss of sensation• Weak or flaccid muscles• Loss of control of bladder or bowels• Erection of penis (priapism)• Neurogenic shock

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Complications of SMR

Airway compromise and aspiration• Head and airway are in fixed position

Head and low back pain • Directly related to being on hard backboard

Life-threatening hypoxia• Obese• Congestive heart failure

Pressure sores• Uneven skin pressure

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

SMR

19

Apply when most likely benefit.Apply when most likely benefit.

Spinal Trauma -

Avoid if not necessary.Avoid if not necessary.

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

SMR Indicated

Positive mechanisms• High-speed MVC

• Falls >3 times patient’s height

• Axial load

• Diving accidents

• Penetrating wound in or near spinal column

• Sports injuries to head or neck

• Unconscious trauma patient

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

SMR Indicated

Potential mechanism with at least one:

• Altered mental status

• Evidence of intoxication

• A distracting painful injury • e.g., long bone extremity fracture

• Neurologic deficit

• Spinal pain or tenderness

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

SMR Decision

Reliable patient• Calm

• Cooperative

• Sober

• Alert

• No distracting injuries

Unreliable patient

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• Acute stress reaction

• Head/brain injury

• Altered mental status

• Intoxication with drugs and/or alcohol

• Distracting injuries

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

SMR Not Indicated

No high-risk mechanism of injury

No alteration of mental status

No distracting injuries

Not intoxicated

No pain or tenderness along spine

No neurological deficits

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Management

Spinal motion restriction (SMR)• Minimize movement to avoid aggravating injury• No specific device proven more effective• SMR success depends on application process

Modification required• Immediate danger of death • Critical degree of ongoing danger that requires

an intervention within 1–2 minutes

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Management

Emergency rescue• Reserved for immediate (within seconds)

environmental threat to life of victim or rescuer• Move to safe area in manner that minimizes risk

Rapid extrication• Considered for medical conditions or situations

that require fast intervention to prevent death• One or two minutes, but not seconds

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Neutral Alignment

Always monitor airway and breathing

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Log Roll

Single unit: spinal-column, head, pelvis• Patients lying prone or supine

Modification required

• Painful arm, leg, chest • Roll onto uninjured side

• Unstable fractured pelvis• Scoop stretcher• Lift carefully by four or more rescuers

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Combative patient

• Children

• Altered mental status

• Under influence

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Require side transport

• Airway• Unconscious patients

who are not intubated

• Pregnant• 20 weeks or more• Vacuum board best

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Closed-space rescue• Safety is first priority• In line with long axis

Water emergencies• Backboard floated under• Secure then remove

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Courtesy of Roy Alson, MD

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Pediatric Elderly

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Prone, seated or standing• Minimize movement into supine position

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Protective gear

• Motorcycle helmet: removal• Poorly fitted to patient• Significant neck flexion• Full face and open face

• Note:• Remove to evaluate and manage airway

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Protective gear

• Remove athletic helmet when:• Face mask not removed timely• Airway cannot be controlled• Does not hold head securely• Helmet prevents stabilization

• Note:• Cut chin strap; do not unhook

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Protective gear

• Shoulder pad: removal• With helmet removal• Neutral alignment inability• Unable to secure to board • Access to chest needed

• Note:• Cut axillary straps and laces on front,

open from core outward, slide out from under

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Special SMR Situations

Neck wounds

• Caution: cervical collar • May prevent Ongoing Exam• Compromised airway

with subcutaneous air, expanding hematomas, or mandible fracture

• Note:• May be needed to avoid cervical collar; use manual

stabilization, head cushion devices, blanket rolls

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Summary

Unstable or incomplete spinal damage is not completely predictable.

• Unconscious trauma or dangerous mechanism affecting head, neck, trunk should have SMR.

• Uncertain mechanisms may not require SMR.

• Special cases may require special techniques.

• Maintain neutral alignment specific for patient.

• Be prepared to manage airway compromise.

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Discussion

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© Bob Krist/CORBIS