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101 Cervical Tongs Or Halo Ring: Application for Use in Cervical Traction (Assist) 905

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101 Cervical Tongs Or Halo Ring: Application for Use in Cervical Traction (Assist) 905 Section Fourteen Traction Management PROCEDURE Cervical Tongs or Halo Ring : 101 Application for Use in Cervical Traction (Assist) Jennifer Massetti PURPOSE: Cervical tongs or a halo ring is inserted into the skull so that weighted traction can be applied to the cervical spine. Cervical traction decompresses the spinal cord and immobilizes and realigns the cervical spine. Realignment and immobilization of the cervical spine may decrease the severity of secondary spinal cord injury. Spinal realignment and immobilization allow spinal fractures and supportive structures to heal properly. PREREQUISITE NURSING fractures depends on the injury classifi cation and provider KNOWLEDGE or institutional preference. • Tongs consist of a body with one pin attached at each end • The nurse must be knowledgeable about the anatomy and ( Fig. 101-2 ). Tong pins are applied to the outer table of physiology of the spinal column, the anatomy of the cervi- the skull on both sides of the skull. Cervical tongs are cal vertebrae, the spinal cord, the cervical spinal nerves, available in a variety of types, such as Crutchfi eld, and the areas of peripheral innervation. In addition, it is Gardner-Wells, and Vinke tongs. important that the nurse understands the pathophysiology ❖ The shape, features, insertion site, and placement vary and manifestations of spinal cord injury, including ascend- slightly, but the purpose, principles, and care are the ing edema, spinal shock, and neurogenic shock. same. Preference of the physician, advanced practice • The nurse should observe the patient for signs of shock, nurse, or other healthcare professional is an important understand the phases of neurogenic and spinal shock, and deciding factor in choosing the specifi c device to be 2,11 know the appropriate interventions to implement. used. • The nurse needs to continuously monitor the patient for ❖ The insertion of Crutchfi eld and Vinke tongs necessi- changes in motor and sensory function during and after tates an incision to expose the skull. Two holes are the procedure. made in the outer table of the skull with a twist drill, • The nurse should continuously assess for changes in res- and the pins are inserted and tightened until there is a 2,11 piration during the procedure and continue to monitor fi rm fi t. while the patient is in traction. ❖ Gardner-Wells tongs are inserted by placing the razor- • Cervical spine traction is provided to realign, immobilize, sharp pin edges to the prepared areas of the scalp and and stabilize the cervical spine when it has become unsta- tightening the screws until the spring-loaded mecha- ble as a result of a cervical spine fracture or dislocation nism indicates that the correct pressure has been caused by trauma or disease, degenerative processes of achieved. To decrease the possibility of tong displace- the cervical vertebrae, or spinal surgery ( Fig. 101-1 ). 3,4 ment, all types of pins are well seated into the outer After initial medical stabilization of the patient and assess- table of the skull and angled inward. 2,6,11 ment and documentation of neurological function, cervi- ❖ Tongs are made of stainless steel or a graphite body cal skeletal traction with the tongs or halo ring can be with titanium pins. The graphite body with titanium applied to realign the cervical spine. Traction is used to pins is compatible with magnetic resonance imaging reduce cervical dislocation before the patient undergoes (MRI). surgery. Occasionally, an unstable cervical spinal injury • Traction can be applied with the use of a rope and may necessitate long-term cervical traction for a period of pulley system or a cable and alignment bracket. Weights weeks to attain realignment and immobilization to stabi- are added gradually and followed with radiographic lize the spine. The defi nitive method used to treat cervical imaging. The physician, advanced practice nurse, or other 904 101 Cervical Tongs or Halo Ring: Application for Use in Cervical Traction (Assist) 905 SAFE ZONE (a) a. Figure 101-1 Continuous traction provided by weight applied to Figure 101-3 Placement of halo pins and ring. The anterior a cervical external fi xation device via a rope and pulley system. pins are placed anterolaterally 1 cm above the orbital ridge. This (From McRae R: Practical fracture treatment, ed 2, Edinburgh, “safe zone” avoids the temporalis muscle laterally and an orbital 1989, Churchill Livingstone.) nerve plexus and frontal sinus medially. (From Batte M, Garfi n SR, Byrne TP, et al: The halo skeletal fi xator: Principles of applications and maintenance, Clin Orthop 239:14, 1989.) molded body jacket. The patient then is able to move while the head and neck remain immobile. A B EQUIPMENT • Tongs or halo ring • Insertion tray, including either the specifi c type of tongs to be used or the halo ring with insertion pins • Local anesthetic: lidocaine, 1% to 2% (with or without epinephrine, depending on the preference of the phy- C sician, advanced practice nurse, or other healthcare Figure 101-2 All three types of cervical tongs consist of a stain- professional) less steel body and a pin with a sharp tip attached to each end. • Needles (18- and 23-gauge) A, Crutchfi eld tongs are placed about 5 inches apart in line with • Sterile and nonsterile gloves the long axis of the cervical spine. B, Vinke tongs are placed on the parietal bones, near the widest transverse diameter of the • Gowns, masks, and eye shields skull. C, Gardner-Wells tongs are inserted slightly above the • Antiseptic solution patient ’ s ears. • Sterile sponges • Sterile drill and bits (for insertion of Crutchfi eld and Vinke tongs) healthcare professional uses serial radiographs of the cer- • Rope and traction assembly for the bed (if a RotoRest vical spine to assist in determining the optimal amount of Delta Kinetic Therapy™ bed is used, a cable and bracket traction (measured in pounds) needed to reduce a fracture alignment system is needed; see Procedure 99 ) and provide optimal alignment. Excessive traction may • S and C hooks (to attach to the distal end of the rope for result in stretching of the spinal cord and subsequent weight application) damage. 2–4 • Weights to attach to the traction • Cervical traction also may be applied with a halo ring • Torque wrench for the halo apparatus as well as the halo device. This is a stainless steel or graphite ring that is vest if this is the defi nitive treatment attached to the skull by four stabilizing pins (two anterior Additional equipment, to have available as needed, includes and two posterolateral; Fig. 101-3 ). Skull pins can be the following: made of stainless steel, titanium, or ceramic material.1,2,5,7 • Hair clippers Pins are threaded through holes in the ring, screwed into • Emergency equipment the outer table of the skull, and locked into place. Traction can be applied to the ring device with the use of a rope PATIENT AND FAMILY EDUCATION and pulley system or a cable and bracket alignment system. Weights are added gradually. After alignment of • Explain the procedure and the reason for cervical traction. the cervical spine is achieved, the spine can be immobi- Clarify or reinforce information as needed by the patient lized by attaching the ring to a body vest or a custom or family. Discuss use of any special equipment, such as 906 Unit III Neurologic System a special bed, that may be needed. Rationale: Patient and • Inspect the scalp for abrasions, lacerations, or sites of family anxiety is decreased. infection. Rationale: Any potential sites of infection that • Explain the patient ’ s role in assisting with insertion of the may contraindicate the insertion of a cervical fi xation tongs. Rationale: Explanation elicits patient cooperation device into the infected area are identifi ed. and facilitates insertion. The nonintubated patient should • Assess the level of pain or discomfort and anxiety. Ratio- be communicating with the team during traction if he or nale: Assessment establishes data for decision making she feels any changes in sensation, new or worsening pain, regarding the need for analgesia or anxiolytics for comfort or new or worsening change in motor function. and cooperation during the insertion procedure. • Explain that the procedure can be uncomfortable when • Assess for any allergies to an antiseptic agent, local anes- the incisions are made but that an anesthetic will be thetic, or analgesia and anxiolytics. Rationale: Review of administered by the physician, advanced practice nurse, medication allergies before administration of a new medi- or other healthcare professional. Rationale: This informa- cation decreases the chances of an allergic reaction. tion prepares the patient for what to expect. Patient Preparation PATIENT ASSESSMENT AND • Ensure that the patient and family understand prepro- PREPARATION cedural teaching. Answer questions as they arise, and reinforce information as needed. Rationale: Understand- Patient Assessment ing of previously taught information is evaluated and • Conduct a complete neurological assessment that includes reinforced. evaluation of cranial nerve function, motor strength of • Verify that the patient is the correct patient using two major muscles, sensation (assessment of light touch, pain, identifi ers. Rationale: Before performing a procedure, the and proprioception, noting highest dermatome level), and nurse should ensure the correct identifi cation of the patient deep tendon refl exes (biceps, triceps, patella, and Achil- for the intended intervention. les) and superfi cial refl exes (abdominal and anal wink). • Ensure that informed consent has been obtained. Ratio- Rationale: Baseline data are provided for comparison of nale: Informed consent protects the rights of the patient postinsertion assessments to determine the presence of and makes a competent decision possible for the patient. neurological compromise or extension of spinal cord • Perform a preprocedure verifi cation and time out, if non- injury. emergent. A time out (per institutional practice) should be • Assess the patient ’ s vital signs.
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