Armando Hasudungan
Biology and Medicine videos

Spine and Spinal Cord Trauma

Overview Devastatingly disabling injury. Can be missed as ambulant patients may have an  unstable vertebral injury. Up to 10% of unconscious patients have a significant vertebral injury. Most common cause of spinal injuries include MVA, Falls and pedestrian on roads. Ask yourself: Complete vs incomplete spinal injury Complete Incomplete Incomplete transverse spinal cord syndrome Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown‐sequard syndrome – hemicord lesion Effects of autonomic system Cardiovascular‐ loss of vasomotor tone and any compensatory tachycardia Gastrointestinal‐ passive aspiration due to sphincter tone loss, and paralytic ileus Urinary‐ bladder denervation resulting in over distension Thermoregulatory‐ loss of any compensatory  mechanisms such as vasoconstriction and shivering and  sweating Spinal shock or neurogenic shock? Spinal shock is transient cessation of all distal  […]

Overview Devastatingly disabling injury. Can be missed as ambulant patients may have an  unstable vertebral injury. Up to 10% of unconscious patients have a significant vertebral injury. Most common cause of spinal injuries include MVA, Falls and pedestrian on roads. Ask yourself:

  1. Complete vs incomplete spinal injury
    • Complete
    • Incomplete
      • Incomplete transverse spinal cord syndrome
      • Central cord syndrome
      • Anterior cord syndrome
      • Posterior cord syndrome
      • Brown‐sequard syndrome – hemicord lesion
  2. Effects of autonomic system
    • Cardiovascular‐ loss of vasomotor tone and any compensatory tachycardia
    • Gastrointestinal‐ passive aspiration due to sphincter tone loss, and paralytic ileus
    • Urinary‐ bladder denervation resulting in over distension
    • Thermoregulatory‐ loss of any compensatory  mechanisms such as vasoconstriction and shivering and  sweating
  3. Spinal shock or neurogenic shock?
    • Spinal shock is transient cessation of all distal  cord function lasting weeks to months‐ both  somatic and autonomic function are lost (flaccid  areflexia)
    • Neurogenic shock is autonomic loss (usually resulting from injury above T6) resulting in  hypotension and bradycardia and peripheral  dilation below the spinal lesion.
Neurogenic Shock Triad Hypotension, bradycardia, peripheral dilation

 

Autonomic Dysreflexia

PAMD

  • Preparation
  • Assessment – Primary Survey
  • Management
  • Assessment – Secondary Survey
  • Dislocation

Preparation

  • Staff
  • Equipment

Assessment – Primary Survey – ABCDE

  • Airway – Patent and Protected
    • Foreign bodies
    • Facial, mandibular, or tracheal/laryngeal fractures
    • Inspect the spine for any gross deformities or ecchymosis. Palpate the spine noting any focal tenderness
Remember If the patient is able to communicate verbally, the airway is usually patent
  • Breathing – Look, listen, feel
    • Look at chest – is it rising?
    • Listen to breath sounds from mouth and auscultate chest
    • Feel for chest movement and breath
    • Identify any life-threatening conditions affecting thorax
      • Tension pneumothorax
      • Flail Chest
      • Massive haemothorax
Side note Ventilation may be reduced for a number of reasons, (1) diaphragm fatigue, (2) Progressively ascending spinal cord damage from primary damage or secondary ascending spinal cord oedema encroaching on C3-C5, (3) These same segments may be involved from primary injury and diaphragm may be partially paralysed and (4) Consequence of co-existing chest trauma
  • Circulation
    • HR, BP, Capillary refill, skin colour
    • 2 large IV insertion
    • Look for signs of shock or unstable rhythm
    • Hypotensive trauma victims should be considered as intravascularly volume depleted and bleeding until proven otherwise
  • Disability
    • GCS
    • Pupils – equal and reactive
    • Neurological examination – motor, sensory, reflex
    • Suspect C-spine injury until ruled out
    • Check for signs of ↑ICP – Cushing’s response (bradycardia, hypertension, irregular respirations)
    • Check Bulbocavernosus reflex – negative sign suggests complete spinal cord injury
Remember Cauda Equina Syndrome can occur with any spinal cord injury below T10 vertebrae. Look for incontinence, anterior thigh pain, quadriceps weakness, abnormal sacral sensation, decreased rectal tone, and variable reflexes
  • Exposure/Environment
    • Increased risk of hyperthermia due to peripheral vasodilation
    • Look for other injuries
      • Fractures – Basilar skull fracture?
      • Scalp laceration
      • Burns
INVESTIGATIONS
Bedside Laboratory Imaging
Blood sugar FBC X-Ray – Neck, Thorax, Pelvis
ECG EUC Head CT scan (non-contrast)
VBG Cross match C-spine CT
FAST Urinalysis MRI – ligament injury suspected
Serum lactate

Management 

  • Airway – Patent and Protected
    • Insertion of nasogastric tube important to minimise likelihood of aspiration
    • Ensure oxygen delivery to brain through intubation and prevent hypercarbia
      • Intubate if GCS < 9, patient is hypoxic, injury at or above C4
    • C-Spine support
  • Breathing – Look, listen, feel
    • Consider diaphragm issues (injury at C3, C4, C5)
    • Identify and treat life threatening chest injury
    • In the absence of major airway obstruction and flail chest, the presence of paradoxical breathing is considered highly suggestive of cervical spine injury
  • Circulation
    • Rule out hemorrhagic shock → maintain MAP >70
    • Look for signs of shock or unstable rhythm
    • If hypotensive – IV fluids
    • If seizure/risk – benzodiazepines, phenytoin, phenobarbital
  • Disability
    • GCS
    • Pupils – equal and reactive
    • Neurological examination – motor and sensory
    • Spinal immobilisation until spinal cord or unstable vertebral injury has been excluded on physical examination and investigations
  • Exposure/Environment
    • Increased risk of hyperthermia due to peripheral vasodilation
      • Warm IV fluids
      • Warm blankets
    • Look for other injuries

Assessment – Secondary Survey (Head to Toe)

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