4. TRAUMA EMERGENCIES
4.7 SPINAL COLUMN / CORD INJURIES
Spinal cord injury may be the result of direct blunt and/or penetrating trauma, compression forces (axial loading), abnormal motion (hyperflexion, hyperextension, hyperrotation, lateral bending and distraction, i.e., hanging). Most spinal injuries result from motor vehicle crashes, falls, firearms, and recreational activities.
Spinal injuries may be classified into sprains, strains, fractures, dislocations and actual cord injuries. Spinal cord injuries are classified as complete or incomplete and may be the result of pressure, contusion or laceration of the cord. One should assume the presence of spine injury and/or unstable spinal column in the following circumstances: grand mal seizure activity, significant trauma and use of intoxicating substances, complaint of pain and/or paresthesia, unconsciousness subsequent to head injury, injury above the clavicle, a significant fall, a fall resulting in apparent fracture of both heels, neck tenderness and/or deformity, injury due to high speed motor vehicle crash, or electrocution, and all non-extremity penetrating injuries.
Management of the patient with spinal column / cord injuries includes assessment of the patients airway, breathing and circulation. Priority must be given to preserving spinal cord function and avoiding secondary injury to the spinal cord. REMEMBER: Patients that may have a spinal column / cord injury may be difficult to assess as they may not present with pain or other signs and symptoms of injury. Therefore, treatment (spinal immobilization) is recommended based upon the mechanism of injury alone.
Hyperventilate the patient in suspected cases of herniation syndrome (e.g. - decorticate posturing; decerebrate posturing; fixed, dilated pupils, etc.).
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway using spinal precautions and assist ventilations as needed. Assume spinal injury and provide spinal immobilize accordingly.
3. Administer high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition.
4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness (AVPU/Glasgow Coma Scale), ABCs, disability and Vital Signs. Examine head for presence of lacerations, depressions, swelling, Battle’s Sign, Cerebrospinal Fluid (CSF) from ears/nose, and foreign (impaled) objects. Treat all life threatening conditions as they become identified.
5. When multiple patients are involved, they need to be appropriately triaged.
6. Obtain appropriate history related to event, mechanism of injury, including Past Medical History, Medications, Drug Allergies, Substance abuse. NOTE: Family and friends my be useful during the assessment to determine normal or abnormal mental status.
7. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
8. If the scene time and/or transport time will be prolonged, and a landing site is available, consider transport by air ambulance from the scene to an appropriate Trauma Center. See Air Ambulance protocol.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. Assure spinal stabilization/immobilization.* Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Hyperventilation with 100% oxygen at a rate no less than 24/ minute with BVM if associated with a significant closed head injury and signs of herniation syndrome.
5. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.)
6. Determine presence or absence of significant neurologic signs and symptoms: motor function, sensory function, reflex responses, visual inspection, bradycardia, priapism, hypotension, loss of sweating or shivering and loss of bladder/bowel control.
7. Activate ALS intercept, if deemed necessary and if available.
8. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
9. Initiate transport as soon as possible with or without ALS.
10. Notify receiving hospital of patient's status.
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. Assure spinal stabilization/immobilization.* Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.)
5. Determine presence or absence of significant neurologic signs and symptoms: motor function, sensory function, reflex responses, visual inspection, bradycardia, priapism, hypotension, loss of sweating or shivering and loss of bladder/bowel control.
6. Activate Paramedic intercept, if deemed necessary and if available.
7. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
8. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Hyperventilation with 100% oxygen at a rate no less than 24/ minute with BVM if associated with a significant closed head injury and signs of herniation syndrome.
c. Initiate IV Normal Saline (KVO). If hypotensive, administer a 250 cc - 500 cc bolus of Normal Saline and titrate IV to patient's hemodynamic status. CAUTION: DO NOT over-hydrate patient with suspected neurogenic shock.
d. PASG/MAST (optional).
9. Initiate transport as soon as possible with or without Paramedics.
10. Contact MEDICAL CONTROL. Medical Control may order:
a. Additional Normal Saline 250 cc - 500 cc bolus(es), wide open or titrated to patient's hemodynamic status.
11. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. Assure spinal stabilization/immobilization.* Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Hyperventilation with 100% oxygen at a rate no less than 24/ minute with BVM if associated with a significant closed head injury and signs of herniation syndrome.
5. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.)
6. Determine presence or absence of significant neurologic signs and symptoms: motor function, sensory function, reflex responses, visual inspection, bradycardia, priapism, hypotension, loss of sweating or shivering and loss of bladder/bowel control.
7. Patient care activities must not unnecessarily delay patient transport to an appropriate facility.
8. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Cardiac monitor/dysrhythmia recognition. Manage per protocol. NOTE: Bradydysrhythmias are commonly seen in high level spinal injuries.
c. Initiate IV Normal Saline (KVO). If hypotensive, administer a 250 cc - 500 cc bolus of Normal Saline and titrate IV to patient's hemodynamic status. CAUTION: DO NOT over-hydrate patient with suspected neurogenic shock.
d. PASG/MAST (optional).
9. Initiate transport as soon as possible.
10. Contact MEDICAL CONTROL. Medical Control may order:
a. Additional Normal Saline 250 cc-500 cc bolus(es), wide open or titrated to patient's hemodynamic status.
b. For suspected neurogenic shock (without hypovolemia):
- Dopamine (Intropin) 2-20 mg/kg/minute . Titrate to patient's hemodynamic status.
- If Dopamine infusion exceeds 20 mg/kg per minute to maintain blood pressure: Norepinephrine IV Infusion is recommended @ 0.5-30 mg/minute (for systolic BP less than 70).
c. Methylprednisolone (Solumedrol) 30 mg/kg IV infusion over thirty (30) minutes.
11. Notify receiving hospital.
*SPINAL STABILIZATION / IMMOBILIZATION SUMMARY
- Provide manual in-line immobilization
- Evaluate patient's responsiveness, ABCs, need for immediate resuscitation and check motor, sensory and circulation in all four extremities.
- Examine the patient's neck and apply cervical collar
- Immobilize the patient's torso to the selected immobilization device such that the torso cannot move up, down, left or right.
- Evaluate torso straps and adjust as needed.
- Place an appropriate amount of padding behind head if needed for adult patients and under the thorax for pediatric patients (age 7 yrs or under) to maintain in-line spinal immobilization.
- Immobilize the patient's head.
- Once patient is immobilized, secure patient's arms and legs to the board or immobilization device.
- Reevaluate patient's responsiveness, ABCs, need for immediate resuscitation and check motor, sensory and circulation in all four extremities.
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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