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.

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

• 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

• 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

• Exposure/Environment
  • Increased risk of hyperthermia due to peripheral vasodilation
  • Look for other injuries
    • Fractures – Basilar skull fracture?
    • Scalp laceration
    • Burns

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)