Spinal Cord Injuries

Every year in the United States, 11,000 to 15,000 new spinal cord injuries (SCIs) occur.¹ Motor vehicle crashes account for 41.3% in those patients younger than 44 years.² Falls, by patients over 45 years of age, are responsible for 27% of SCIs in this population.² Other causes of SCI include violence (15%) and sports (8%) along with vascular disorders, tumors, infections, spondylosis, and developmental disorders.² Extreme sports, which often epitomize the ultimate in risk-taking behavior, increase the incidence of SCI in males between the ages of 15 and 30 years.²

Mechanisms of Injury

Trauma may cause injury to the vertebral column, spinal nerves, or spinal cord. Blood supply may be impaired, causing damage to many other structures. Cord trauma may be caused through fracture or dislocation of the vertebrae. Transection or disruption of the cord or other extradural processes can also cause injury.

• Rapid acceleration-deceleration forces cause the vertebral column to be moved beyond its usual range of motion. Injuries can be the result of hyperextension, hyperflexion, rotation, and axial loading (Table 37-1).³

• Most SCIs result from blunt trauma; penetrating injuries from bullets affect the cord and column. Less frequently, stab wounds lacerate the cord or nerve roots.

• Concurrent injuries may include injuries to the head, chest, abdomen, and long bones.

• Rib fractures and other chest injuries often occur with thoracic vertebral trauma.

• Lumbar and pelvic fractures may occur simultaneously.

• Axial loading, resulting from a blow to the head or from jumping or falling from a height, results in a specific pattern of injury with compression along the lumbar spine and fractures to the calcaneus.

• SCI should always be suspected in trauma patients who are intoxicated, demonstrate altered level of consciousness, or have distracting injuries such as open fractures.

• SCI is frequently associated with near drowning or diving incidents. In these situations, consider alcohol or drug use, seizure disorder, and unknown depth of water.

TABLE 37-1 MECHANISMS OF INJURY TO THE VERTEBRAL COLUMN

Because of the flexibility of their spines, pediatric patients under 8 years of age may experience a phenomenon called SCIWORA (spinal cord injury without radiographic abnormality). However, this term is becoming outdated since magnetic resonance imaging on children with SCIWORA has demonstrated various spinal cord injuries, including ligament damage, spinal cord hemorrhage, and complete cord transection.

Consequences of Spinal Cord Injury

Spinal cord injuries may be primary or secondary. Primary cord injury occurs at the time of injury as a result of an initial mechanism (Table 37-1). Secondary injury is a progressive, pathologic response that may be caused by hypoperfusion and hypoxia of the spinal cord from:

• Respiratory depression or failure

• Systemic hypotension and shock

• Hemorrhagic shock from multiple injuries

• Neurogenic shock

• Cord injury or ischemia leading to neurologic deficits

Respiratory Depression or Failure

Spinal cord injuries, particularly injury to the upper cervical region, can result in alterations in respiratory function. The degree of respiratory impairment results in part from the level of injury, as noted in Table 37-2. Additional considerations related to respiratory function include the following:

• Concurrent lung injury (pneumothorax, pulmonary contusion)

• Medical history of respiratory dysfunction (chronic obstructive pulmonary disease)

• Associated head injury

• Presence of intoxication

TABLE 37-2 CERVICAL SPINE INJURIES AND RESPIRATORY IMPAIRMENT

Shock

Shock in the patient with SCI may be hemorrhagic (lose of intravascular volume), neurogenic (loss of sympathetic outflow), or spinal (loss of reflexes).

• Hemorrhagic shock—as in any trauma patient, hemorrhagic hypovolemic shock can lead to inadequate perfusion of vital organs. Hypoperfusion of the spinal cord is a common cause of secondary injury in the patient with SCI.

In acute SCI, shock may be neurogenic, hemorrhagic, or both. Bleeding must be ruled out as a cause of hypotension before a diagnosis of neurogenic shock is made.

• Neurogenic shock can occur with an injury at the level of T6 or higher. Descending sympathetic paths are affected, resulting in loss of vasomotor tone and sympathetic stimulation.

• Peripheral vasodilation results in maldistribution of blood volume; blood volume is maintained but the vascular bed is enlarged.

• Classic signs of neurogenic shock are:

Hypotension

Bradycardia

Peripheral vasodilation

• Additional signs may include hypothermia and loss of sweating below the level of injury.

• This loss of sympathetic outflow prevents reflex tachycardia and vasoconstriction; expected signs of hypovolemic (hemorrhagic) shock may be absent, making its diagnosis difficult.

• Spinal shock is the temporary loss of motor, sensory, and reflex function below the level of damage.

• Onset is usually immediate but may occur up to several days after the injury and last for days to weeks.

• The level of the damage will determine the intensity and duration of the spinal shock.

• Clinical presentation includes flaccid paralysis, areflexia, and loss of bowel and bladder function.

Neurologic Deficits

Neurologic deficits can be the result of both primary and secondary injury; they may be permanent or transient. Familiarity with the anatomic landmarks for the body’s dermatomes (Fig. 37-1 and Table 37-3) will help the emergency nurse identify the level of SCI and anticipate complications related to the level of injury.

Fig. 37-1 Sensory dermatomes.

(From Marx, J. A. [2010]. Rosen’s emergency medicine: Concept and clinical practice [7th ed.]. Philadelphia, PA: Mosby Elsevier.)

TABLE 37-3 ANATOMIC LANDMARKS AND DERMATOME LEVELS

ANATOMIC LANDMARK	DERMATOME LEVEL	MOTOR FUNCTION PRESENT
Top of shoulder	C5	Flexion and extension of arms
Nipple line	T4	Respiratory muscles function
Umbilicus	T10	None
Great toe	L4 S4	Flexion of foot, extension of toes Positive sphincter tone

Data from Emergency Nurses Association. (2007). Trauma nursing core course provider manual (6th ed.). Des Plaines, IL: Author.

Helmet Removal

There are many different styles of helmets that offer varying degrees of protection to the head while participating in a wide variety of sports. When the helmet is in place, airway management is limited at best and it is difficult to maintain spinal immobilization. Removal of a helmet requires two or three trained staff members working as a team. See Figure 37-2 for the steps in removing a helmet.

Fig. 37-2 Helmet removal.

(From Sanders, M. [2000]. Mosby’s paramedic textbook [2nd ed.]. St. Louis, MO: Mosby.)

General Assessment

• Ensure that spinal immobilization is maintained throughout the assessment process to minimize the potential for further injury. Table 37-5 lists considerations while applying spinal immobilization.

• Assessment and treatment of airway, breathing, and circulation problems take precedence over other assessments.

• Airway management is often complex and difficult because the spine must be maintained in neutral alignment at all times.

• Evaluate breathing by assessing respiratory rate, rhythm, and depth.

• Determine if the patient can take a deep breath and cough.

• Increased work of breathing or use of abdominal muscles may indicate deterioration of the patient’s condition.

• Patients with SCI may appear to breathe well initially but tend to decompensate over time. Continued reassessment is necessary.

• Circulatory assessment includes measurement of blood pressure and heart rate. Hypotension may be neurogenic or hemorrhagic in origin.

• Search for occult signs of hemorrhage in the chest, abdomen, or retroperitoneal areas.

• Pelvic or long bone fractures may be a source of blood loss.

• Check skin signs, such as color, temperature, and moisture, as an indication of perfusion.

• Assess level of consciousness; concurrent head injury is common.

• Perform secondary assessment as for any trauma patient (see Chapter 35, Assessment and Stabilization of the Trauma Patient).

• Logroll patient, maintaining spinal alignment, to examine the patient’s back.

• Check for point tenderness, ecchymosis, and open wounds.

• Assess sphincter tone and the presence of “anal wink” (contraction of the sphincter in response to proximal pinprick).

• Determine patient’s body temperature; with SCI, the patient’s body temperature may be that of the ambient environment (poikilothermy).

• Observe for priapism in males (indicates vasodilation of blood vessels and strongly indicative of neurogenic shock).

TABLE 37-5 CONSIDERATIONS WHILE APPLYING SPINAL IMMOBILIZATION

• Spinal immobilization requires a team approach. A leader who will direct the process must be identified beforehand. • Assess the patient’s motor and sensory status prior to immobilization. • The leader maintains in-line stabilization (not traction) with both hands on either side of the patient’s head, stabilizing the head and neck in a neutral, vertical position. The patient’s nose should be in line with his or her umbilicus. • Remove earrings, necklaces, other sharp objects, and bulky clothing that could cause soft tissue pressure injury. • Following the manufacturer’s recommendations for sizing, apply the collar to fit between the point of the chin and the suprasternal notch, resting on the clavicles and supporting the lower jaw. • Check motor and sensory status after application of the collar. • At the leader’s direction, gently logroll the patient onto a long board while the team leader maintains head and neck stabilization. • Secure the patient to the long board using straps at the chest, hips, and knees. Straps should be snug but not restrict chest wall or abdominal movement. • The patient’s head is then secured using head blocks (not sandbags) and tape. Manual stabilization may then be released. • Recheck motor and sensory status. • Follow the institution’s policy for removal of spinal immobilization, especially in the elderly patient, as soon as feasible. Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Workplace Violence and Disruptive Behavior Alcohol Abuse Hematologic and Immunologic Emergencies Sepsis Triage Chest Trauma Stay updated, free articles. Join our Telegram channel Join Tags: Sheehys Manual of Emergency Care Aug 9, 2016 | Posted by admin in EMERGENCY MEDICINE | Comments Off on Spinal Cord and Neck Trauma Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access