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					Spinal Cord Injuries

Prepared by: Mrs Raheegehn Awni
          16/03/2012
INTRODUCTION
 Acute spinal cord injury primarily affects young,
  otherwise healthy males ( 18 to 35 years)
 A male to female ratio of 3 to 1.
 10-15 per million population in UK
The permanent paralysis experienced by these 800 or
  so patients a year leads to
major disability,
a shorter life expectancy
 significant economic costs.
Definition

 Spinal cord injury (SCI) is damage to the spinal cord
  that results in a loss of function such as mobility or
  feeling.

 In most SCI cases, the spinal cord is intact, but the
  damage to it results in loss of function.
( SCI )
 Associated with car accidents, sports injuries, and other
  violent impacts.
 The degree of paralysis is directly related to the level and
  severity of the injury.
 Injury below the first thoracic vertebra may produce
  paraplegia.
 Injuries above the first thoracic vertebra may cause
  quadriplegia.
 Advances in the management of spinal cord-injured patients
  have resulted in an improvement in overall survival and
  quality of life.
 The stability of the spine is dependent on the
  integrity of the anterior, middle and posterior
  columns.
Causes and Symptoms

 According to the National Spinal Cord Injury Association
  (NSCIA), spinal cord injuries are caused in the United States
  by motor vehicle accidents (44%),
 acts of violence (24%),
 falls (22%), sports (8%),
 and other causes (2%) such as abscesses, tumors, polio, spina
  bifida
SCI symptoms
 usually appear immediately after the injury.

 However, symptoms can develop slowly, if an infection or tumor
  is gradually increasing pressure on the spinal cord.

 weakness, poor coordination or paralysis, particularly below the
  level of the injury

 numbness, tingling, or loss of sensation

 loss of bowel or bladder control

 pain
NEUROGENIC SHOCK
• In acute spinal cord injury, shock may be neurogenic,
  haemorrhagic, or both.
• Following injuries at or above T6 there is significant loss of
  the sympathetic autonomic outflow.
• Consequently vasomotor tone is reduced and, if the lesion is
  high enough, sympathetic innervation of the heart ceases.
• This loss of sympathetic tone results in hypotension and also
  enhances vagal reflexes, causing profound bradycardia.
Spinal shock
 Spinal shock is defined as the complete loss of all neurological
  function, including reflexes, rectal tone and autonomic control
  below the level of spinal cord injury.
 Spinal shock is unrelated to hypovolaemia or neurogenic shock
  involves a 24- to 72-h period of complete loss of sensory,
  motor and segmental reflex activity with flaccid paralysis and
  areflexia below the level of the injury.
 Despite this profound paralysis, areas of the cord are still
  capable of a full recovery.
Diagnosis

 The possibility of SCI is usually suspected in anyone with
  significant trauma to the head and/or neck.
 Assume that such patients have a spine fracture until
  proven otherwise.
 x-rays of the spine
 CT scan (computed tomography), MRI (magnetic
  resonance imaging), and myelogram (x ray after injection
  of dye into the spinal canal).
ASSESSMENT AND MANAGEMENT OF
PATIENTS WITH SPINAL INJURY

 Reasons for missing significant spinal injuries are
  failing to consider injuries in patients who are either
  unconscious, intoxicated or have pre-existing risk
  factors (such as arthritis),
 Failing to examine patients adequately, and errors in
  the interpretation of radiographs

 Failing to examine patients adequately
AIRWAY WITH CERVICAL SPINE CONTROL
AND BREATHING
    During assessment of Airway, Breathing and Circulation,
     efforts must be made to protect the spinal cord from potential
     secondary injury.
    This is assisted by early immobilization of
     the whole spine.
SPINAL IMMOBILIZATION
 The majority of trauma patients will have been
  immobilized during the pre-hospital phase.
 The adequacy of immobilization and the position of
  and cervical collars.

 If none is in place, immobilization can be achieved by
  holding the head in the neutral position, or by the
  use of head blocks and tape.
• Patients who are agitated and moving around should not have
  their cervical spine immobilized in isolation.
• Long spine boards should be removed as soon as possible in a
  controlled way, usually as part of the log-roll.
• This will decrease the risk of pressure sore development in
  the spinally injured.
• Do not leave patients on long spine boards: remove
  them during the log-roll
The airway is the first priority
 A jaw thrust, clearing of oral secretions and insertion of oral or
  nasal airway may be all that is required initially to maintain the
  airway.
 Supplemental oxygen should be administered to prevent
  secondary damage from hypoxia.
 The whole spine must be maintained in neutral alignment after
  gentle controlled movement to a neutral position
 Attempts to bring the head into neutral alignment against
  palpable resistance or if the patient complains of pain should be
  abandoned and the head immobilized as it is found.
 Unconscious trauma patients should have orotracheal
  intubation.

 In conscious patients with signs of a high spinal cord injury
  (for example, weakness in arms and legs, neurogenic shock
  or diaphragmatic breathing) early intubation and
  ventilation should be considered.

 Intubation is not contraindicated in the presence of spinal
  injury.
 The ideal technique is intubation with cervical spine control.
 Oral suction, laryngoscopy and intubation may precipitate
  severe bradycardia from unopposed vagal stimulation in
  patients with autonomic disruption from cervical or high
  thoracic spinal cord injury.
 Atropine should be immediately available.
CIRCULATION

The most common sources of occult haemorrhage are:

• chest injuries (often associated with thoracic spine
  fractures)

• intra-abdominal haemorrhage

• retroperitoneal haemorrhage
• pelvic fractures and long-bone fractures.
 Once occult sources of haemorrhage have been excluded, initial treatment of
    neurogenic shock involves cautious fluid resuscitation.

 Excessive fluid administration may precipitate pulmonary oedema.

 The therapeutic goals for neurogenic shock are adequate
    perfusion with a systolic blood pressure of 90-100 mmHg), a heart rate of 60-
    100 beats per minute, urine output above 30 ml/h, and normothermia.

      Patients with persisting bradycardia should be given atropine
      0.5-1 mg intravenously, this being repeated if necessary until the heart rate is
    acceptable.
THE LOG-ROLL

 A log-roll should be performed at the end of the primary
  survey.
 This allows assessment of the back and spinal column and the
  removal of the long spine board if one is present.
 Before the log-roll is commenced, mechanical stabilization
  of the cervical spine should be removed and replaced by
  manual in-line immobilization by the log-roll team leader.
 At the same time, the neck can be checked for any
  deformity, tenderness, bogginess or spasm.
 To examine the remainder of the vertebral column the
  patient must be 'log-rolled'.
 This technique requires at least five people.
 One person is responsible for maintaining the in-line
  stabilization of the head and neck and coordination of the
  log-roll (the team leader).
 A second person holds the patient's shoulder with one hand
  and places the other hand on the pelvis.
 The third person holds the pelvis with one hand and places
  the other hand under
 the patient's opposite thigh.
 The fourth person places both arms under the opposite
  lower leg and supports it during the roll.
   The fifth person is responsible for examining the back,
    conducting a rectal and perineal examination, observing
    pressure areas, and clearing debris.
 Further staff will be needed to assist with the removal of a
  long spine board.
 The team leader must give clear audible instructions and
  indicate in advance what these will be:
 'The instruction will be ready, steady, move'.
The examination of the back
includes looking for evidence of bruising or swelling,
 palpation over the spinous processes for deformity, swelling,
 wounds or increased tenderness down the
 whole length of the spine.
Local tenderness at any point should be used to guide
 radiographic examination.
 Patients with altered level of consciousness or other
  distracting injuries may not have any features on examination
  of the back to suggest spinal injury, and may be unable to
  cooperate with neurological examination.
 Despite these, spinal injury cannot be absolutely excluded
  until a full neurological and radiological examination has
  been completed.
   These patients will require spinal immobilization until they
    regain consciousness.
Signs of spinal injury in the unconscious patient

• Diaphragmatic breathing
• Neurogenic shock (hypotension and bradycardia)
• Flaccid areflexia (spinal shock)
• Flexed posture of the upper limbs (loss of extensor
   innervation distal to C5)
• Response to pain above the clavicles only
• Priapism (the erection may be incomplete)
Trauma in women

 Trauma in women includes accidental injury to the pregnant
  woman and to the fotus, and to the gynaecological organs in
  association with major trauma to the abdomen and pelvis.
 Also included is deliberate injury, encompassing domestic
  violence.
 When managing trauma in any female patient aged between
  10 and 60 years, the
 possibility of pregnancy must be considered.
 Not one, but two lives may be at risk and
 initial assessment and ongoing monitoring must include the
  fetus.
 Outcome for the fetus is dependent upon successful
  management of the mother.
 A multidisciplinary approach is demanded, with early
  involvement of an obstetrician
 A neonatal paediatrician if appropriate, in addition to the
  usual members of the trauma response team
 In most cases these injuries are slight
 and are the result of falls or direct blows to the abdomen.
Complications associated with pregnancy occur in over 8% of
  women admitted to hospital.
The risk of foetomaternal transfusion must be considered in all
  cases beyond 11 weeks'
complications
   slight injury:
    premature labor,
   Placental abruption
   injury to the fetus.
   In a minority of cases, life-threatening maternal and fetal
    injury will occur.
    For example, trauma remains the most common cause of
    non-obstetric death.
MECHANISMS OF INJURY

These include:
• Road traffic accidents
• Motorcycle and bicycle accidents
• Burn injury
• Intentional injury
• Falls
• Exposure to blast
Blunt impact

 Road traffic accidents (RTAs) still predominate among blunt
  impact trauma cases, and deaths from head and intra-
  abdominal injury are the leading cause of non-obstetric
  mortality.
 Invariably this also results in fetal death; maternal death
  remains the most common cause of fetal death, followed by
  placental abruption.
Domestic violence

 Is typically characterized by direct blows to the abdomen.
 Falls are another common cause of maternal and fetal injury.
 Seat belts have been shown to reduce maternal mortality,
  though poorly applied or designed restraints may increase
  fetal mortality
   belt placed above the pregnant uterus reduce the risk of
    injury to the fetus, particularly due to placental abruption.

   The abdominal wall musculature, the pregnant uterus and
    amniotic fluid all afford some protection to both mother and
    fetus by absorbing applied forces.
   However, acceleration, deceleration and shearing forces or
    direct blows applied to the abdominal wall in later pregnancy
    may result in placental abruption, with or without
    disseminated intravascular coagulation, ruptured uterus and
    direct injury to the fetus.
 Farmer et a/.12 have shown that the
 extent of maternal injury does not necessarily correlate with
  the degree of fetal injury.
 Lethal fetal injury associated with placental disruption or
  direct injury may occur in the
 face or minimal maternal injury.
Penetrating injury
• penetration by vehicular parts or debris from the
   environment (fences or railings);

• stab injury by knives or related objects;

• In the UK, the usual pattern of injury is by stabbing or
   penetration by objects in RTAs, or following falls.
  During the first trimester, patterns of injury in thepregnant
  and non-pregnant woman are similar, provided that the
  injury track does not extend into the pelvis.
 In later pregnancy the uterus acts a shield for the mother,
  but the fetus is at particular hazard.
 The uterine musculature and the amniotic fluid
  effectively retard missile velocity, reducing energy
  transfer and wounding potential, with outcome for the
  fetus being determined by the structures injured.

 Penetration of the umbilical cord or placenta may result
  in abruption and haemorrhage, which may be
  catastrophic for both fetus and mother.
 Operative intervention is recommended in all cases of
  penetrating injury in the
 pregnant woman.
 At laparotomy, the uterus must be carefully assessed for
  evidence of
penetration and the viability of the fetus assessed.
 Evidence of uterine penetration is
 widely regarded as an indication for immediate Caesarean
  section.
In early pregnancy (less than 28 weeks), operative delivery of
  the fetus is associated with risk of fetal death, and it
may be appropriate in carefully selected cases to preserve the
  pregnancy.
Burn injury

 Burn injury caused by flame or hot liquid in the first
  trimester differs little from a similar
injury in the non-pregnant patient.
Beyond the first trimester an increasing percentage of maternal
  cardiac output is diverted to the uterine and placental
  circulation, reducing maternal compensation in the face of
  sudden loss of circulating volume.
INITIAL ASSESSMENT AND MANAGEMENT
 and optimal care of the mother is the best immediate
  management possible for the fetus.
 The following management pathway is
recommended If advanced notification is given, the following
  information should be obtained:
  The number of weeks' gestation
• Mechanism of injury
• Obvious injuries sustained
• Vital signs at scene
• Treatment given.
Initial assessment and resuscitation
 maternal
 A logical and sequential approach is vital.
 While the general approach should not
 differ, pregnancy dictates some modifications.
AIRWAY AND CERVICAL SPINE CONTROL


The increased risk of airway compromise in the face of altered
   conscious level which may result from silent regurgitation of
   gastric contents should be recognized. Facial and oral
   swelling may make intubation technically difficult.
In particular, neck swelling may mask
normal landmarks, including the cricothyroid membrane.
 The need to secure and protect the airway must be
  anticipated.
 Intubation must be performed by a skilled anaesthetist
 Cricothyroid pressure is essential until the airway is
  definitively protected, and collar
 and tape should be replaced by manual in-line stabilization for
  the duration of the procedure.
BREATHING AND VENTILATION

      The normal physiological hyperventilation associated with
       advanced pregnancy should be recognized; it may be
       necessary to hyperventilate artificially if ventilatory support
       is required.
     Swelling of the soft tissues of the neck and upper chest may
       mask tracheal
      deviation.
    If a chest drain is required, the presence of a high diaphragm
       should be considered.
CIRCULATION AND HAEMORRHAGE
CONTROL

 Inferior vena caval compression must be avoided from the
  outset by one of the following:
• elevation of the right hip with a wedge;
 log-rolling into the left lateral position; or
manual displacement of the uterus to left.
 Always relieve inferior vena caval compression
Following vascular access, blood should be taken for a
  Kleihauer-Betke test.

    In the pregnant patient, the end-point of fluid
     resuscitation should be
    the maintenance of a normal or near-normal systolic
     blood pressure
 If surgical intervention is judged necessary in order to
  control maternal haemorrhage in any cavity, this should not
  be deferred because of the pregnancy.
 Ongoing maternal haemorrhage will lead to fetal hypoxia and
  fetal death. Controlling maternal haemorrhage is the best
  means of ensuring fetal survival
DISABILITY

   If the level of consciousness is altered, the possibility of
    eclampsia or severe pre-eclampsia
   must be considered.
   EXPOSURE AND ENVIRONMENT
   Neither the mother nor foetus can be properly assessed
    without full exposure. The patient
   must be undressed in a warm environment, and hypothermia
    avoided.
 Following initial assessment and stabilization of the mother,
  attention should now be
 turned to an initial assessment of the foetus. Although best
  performed by an obstetrician,
 this assessment should be within the competence of any
  member of the attending trauma
 team.
resuscitation: the foetus

 A detailed obstetric assessment of the maternal abdomen and
  pelvis should only commence
 following stabilization of the mother, and should include the
  following stages.
MATURITY AND PLACENTAL
INTEGRITY/POSITION
 A detailed obstetric history (if available) and a clinical
  assessment of fundal height should
 give an accurate estimate of foetal viability (over 24 weeks'
  gestation). Gestational age,
 foetal viability and placental position can also be confirmed
  using pelvic ultrasound. This
 investigation may also be used to diagnose placental
  abruption and intrauterinehaemorrhage.
   ASSESSMENT OF UTERINE INTEGRITY
   The uterus should be examined per abdomen. Signs of
    premature contractions, tenderness
   or rigidity, or extrauterine foetal parts are sought and their
    presence demands immediate
   obstetric consultation and consideration of urgent surgical
    intervention. Digital or
   speculum examination of the vagina requires special
    expertise and should be performed by
   an obstetrician.
   Vaginal examination may reveal bleeding or amniotic fluid
    loss. Additional
   findings include the condition of the cervical os and the
    presence of pelvic fracture. Vaginal
   examination in the injured pregnant woman is fraught with
    hazard, and injudicious or
   clumsy examination may precipitate catastrophic bleeding
    from unsuspected placenta
   praevia or may reveal a previously concealed placental
    abruption. Consequently, such
   examinations are usually best performed by an obstetrician -
    this having the additional
DISTRESS

 The normal foetal heart rate is 120-160 beats/min and is
  best assessed using Doppler
 ultrasound. This examination is only useful once the uterus
  has risen above the pelvic brim
 (after the 12th week). Bradycardia of less than 100 beats/min
  is a clear sign of foetal distress.
 If the mother is conscious and able to report foetal
  movements, a cardiotocogram can be
 utilized to monitor foetal heart rate during uterine
  contractions. The presence of any of the
 signs of foetal distress or decompensation summarized in
  Table 14.1 should prompt
 immediate skilled assessment by an obstetrician
decompensation

   • Bradycardia of <100 beats/min or abnormal foetal baseline
    heart rate
   • Repeated decelerations in response to uterine contractions
   • Absence of acceleration in response to foetal movements
   • Increasing uterine activity
   • Positive Kleihauer-Betke test
 Traumatic foetomaternal haemorrhage can be detected by
  the Kleihauer-Betke test
 women with a positive Kleihauer-Betke test, anti-D
  immunoglobulin should be
 administered to prevent rhesu isoimmunization.
 risks to mother and foetus.
   Thank you

				
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