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Suspected Spinal Injury SuspectedSuspected SpinalSpinal InjuryInjury NewNew YorkYork StateState DepartmentDepartment ofof HealthHealth MLREMS Version -090308BureauBureau ofof EmergencyEmergency MedicalMedical ServicesServices1 LearningLearning OutcomeOutcome EMSEMS providersproviders needneed toto useuse appropriateappropriate clinicalclinical decisiondecision makingmaking toto applyapply spinalspinal immobilizationimmobilization toto thethe patientspatients whowho needneed itit basedbased onon MOI,MOI, physicalphysical findings,findings, andand patientpatient history.history. MLREMS Version -090308 2 LearningLearning OutcomeOutcome EMSEMS providersproviders needneed toto useuse appropriateappropriate clinicalclinical decisiondecision makingmaking toto applyapply spinalspinal immobilizationimmobilization toto thethe patientspatients whowho needneed itit basedbased onon MOI,MOI, physicalphysical findings,findings, andand patientpatient history.history. MLREMS Version -090308 3 ObjectivesObjectives DescribeDescribe thethe historyhistory andand rationalerationale forfor SpinalSpinal ImmobilizationImmobilization ReviewReview anatomyanatomy && pathophysiologypathophysiology ofof thethe spinespine ExplainExplain thethe newnew NYSNYS DOHDOH andand MLREMSMLREMS protocolsprotocols forfor SuspectedSuspected SpinalSpinal InjuryInjury GiveGive EMSEMS providersproviders thethe toolstools toto makemake anan appropriateappropriate decisiondecision onon spinalspinal immobilizationimmobilization MLREMS Version -090308 4 MLREMS Version -090308 5 MLREMS Version -090308 6 MLREMS Version -090308 7 CervicalCervical SpineSpine InjuriesInjuries inin PerspectivePerspective 2.4%2.4% ofof bluntblunt traumatrauma patientspatients experienceexperience somesome degreedegree ofof musculoskeletalmusculoskeletal injuryinjury toto thethe spinespine ApproximatelyApproximately 20,00020,000 spinalspinal cordcord injuriesinjuries aa yearyear inin UnitedUnited StatesStates $1.25$1.25 millionmillion toto carecare forfor aa singlesingle patientpatient withwith MLREMS Version -090308 permanentpermanent SCISCI 8 15,00015,000 –– 20,00020,000 SCISCI perper yearyear HigherHigher inin menmen betweenbetween agesages ofof 1616 –– 3030 CommonCommon causes:causes: Motor vehicle crashes – 2.1 million per year (48%) Falls (21%) Penetrating injuries (15%) Sports injuries (14%) EducationEducation inin properproper handlinghandling andand transportationtransportation cancan decreasedecrease SCISCI MLREMS Version -090308 9 HistoricallyHistorically ImmobilizationImmobilization basedbased onon MOIMOI –– eveneven ifif therethere werewere nono signssigns andand symptomssymptoms LackLack ofof clearclear clinicalclinical guidelinesguidelines EMSEMS providersproviders diddid poorlypoorly withwith fullfull spinalspinal immobilizationimmobilization MotorMotor vehiclesvehicles hadhad fewerfewer safetysafety featuresfeatures PatientsPatients spentspent extendedextended amountsamounts ofof timetime inin immobilizationimmobilization devicesdevices atat E.D.E.D. MLREMS Version -090308 10 WhyWhy notnot board/collarboard/collar andand XrayXray everybody?everybody? ImmobilizationImmobilization isis uncomfortable:uncomfortable: increasedincreased timetime immobilizedimmobilized == increasedincreased pain,pain, riskrisk ofof aspiration,aspiration, vulnerablevulnerable position,position, etc...etc... >800,000>800,000 U.S.U.S. PatientsPatients receivereceive cervicalcervical radiographyradiography eacheach yearyear PatientPatient exposureexposure toto radiationradiation >>97%97% ofof xx--raysrays areare negativenegative CostCost exceedsexceeds $175,000,000$175,000,000 eacheach yearyear MLREMS Version -090308 11 SecondarySecondary InjuryInjury versusversus PrimaryPrimary InjuryInjury PrimaryPrimary InjuryInjury ––SpinalSpinal InjuryInjury thatthat occurredoccurred atat timetime ofof traumatrauma SecondarySecondary InjuryInjury ––SpinalSpinal InjuryInjury thatthat occursoccurs afterafter thethe traumatrauma ––possiblypossibly secondarysecondary toto mishandlingmishandling ofof unstableunstable fracturesfractures MLREMS Version -090308 12 ReviewReview ofof AnatomyAnatomy && PhysiologyPhysiology SpinalSpinal ColumnColumn –– 3232 -- 3434 separate,separate, irregularirregular bonesbones –– HeadHead (15(15--2222 lbs)lbs) BalancesBalances onon TopTop CC--SpineSpine –– SupportedSupported byby PelvisPelvis –– LigamentsLigaments andand MusclesMuscles connectconnect headhead toto pelvispelvis –– InjuryInjury toto LigamentsLigaments maymay causecause excessexcess movementmovement ofof vertebraevertebrae –– VertebralVertebral ForamenForamen -- canalcanal formedformed forfor cordcord MLREMS Version -090308 13 Vertebral Spinous foramen process Body MLREMS Version -090308 14 AnatomyAnatomy && Physiology,Physiology, cont.cont. Cervical – 7 Vertebrae – Considered “Joint Above” when splinting – Atlas (C1) and Axis (C2) Thoracic – 12 Vertebrae – Ribs connected forming rigid framework of thorax MLREMS Version -090308 15 MLREMS Version -090308 16 AnatomyAnatomy && Physiology,Physiology, cont.cont. LumbarLumbar – 5 Vertebrae (largest vertebral bodies) – Flexible and Carries majority of body weight SacrumSacrum – 5 fused bones – Considered “Joint Below” with pelvis when splinting MLREMS Version -090308 17 AnatomyAnatomy && Physiology,Physiology, cont.cont. CoccyxCoccyx – 2-4 fused bones – “Tailbone” VertebralVertebral StructuresStructures – Body – Transverse Process – Spinous Process – Intervertebral Disks - fibrocartilage “shock absorber” MLREMS Version -090308 18 CervicalCervical (7)(7) ThoracicThoracic (12)(12) LumbarLumbar (5)(5) SacrumSacrum (5)(5) CoccyxCoccyx (4)(4) MLREMS Version -090308 19 AnatomyAnatomy && Physiology,Physiology, cont.cont. CentralCentral NervousNervous SystemSystem (CNS)(CNS) – Brain Largest most complicated portion of CNS Continuous with spinal cord Responsible for all sensory and motor functions – Spinal Cord Within the Vertebral Column Begins at Foramen Magnum and ends near L2 (cauda equina) Dural Sheath MLREMS Version -090308 20 AnatomyAnatomy && Physiology,Physiology, cont.cont. CNSCNS Cont.Cont. – Ascending Nerve Tracts Carries impulses and sensory information from the body to the brain (I.e. touch, pressure, pain, tenderness, body movements, etc.) – Descending Nerve Tracts Carries motor impulses from brain to body (e.g. muscle tone, sweat glands, muscle contraction, control of posture) MLREMS Version -090308 21 AnatomyAnatomy && Physiology,Physiology, cont.cont. CNSCNS Cont.Cont. – Spinal Nerves 31 pairs originating from spinal cord Mixed Nerves - carry both sensory and motor functions – Dermatones Topographical region of body surface innervated by one spinal nerve Example: C-7/T-1 motor = finger abduction and adduction, sensory = little finger MLREMS Version -090308 22 PathophysiologyPathophysiology ofof SpinalSpinal InjuriesInjuries MechanismsMechanisms andand AssociatedAssociated InjuriesInjuries –– HyperextensionHyperextension – Cervical & Lumbar Spine – Disk disruption – Compression of ligaments – Fx with potential instability and bone displacement –– HyperflexionHyperflexion – Cervical & Lumbar Spine – Wedge Fx – Stretching of ligaments – Compression Injury of cord – Disk disruption with potential vertebrae dislocation MLREMS Version -090308 23 Pathophysiology,Pathophysiology, cont.cont. (Mechanisms(Mechanisms andand CommonCommon Injuries)Injuries) –– RotationalRotational – Most commonly Cervical Spine but potentially in Lumbar Spine – Stretching and tearing of ligaments – Rotational subluxation and dislocation – Fx –– CompressionCompression – Most likely between T12 and L2 – Compression fx – Ruptured disk MLREMS Version -090308 24 Example of Wedge Fracture MLREMS Version -090308 25 Pathophysiology,Pathophysiology, cont.cont. (Mechanisms(Mechanisms andand CommonCommon Injuries)Injuries) –– DistractionDistraction – Most common in upper Cervical Spine – Stretching of cord without damage to spinal column –– PenetratingPenetrating – Forces directly to spinal column – Disruption of ligaments – Fx – Direct damage to cord MLREMS Version -090308 26 Pathophysiology,Pathophysiology, cont.cont. SpecificSpecific InjuriesInjuries – Fractures to vertebrae – Tearing of Ligaments, Tendons and/or Muscles – Dislocation or Subluxation of vertebrae – Disk herniation / rupture MLREMS Version -090308 27 Pathophysiology,Pathophysiology, cont.cont. (Specific(Specific Injuries)Injuries) –– CordCord InjuriesInjuries – Concussion - temporary or transient disruption of cord function – Contusion - Bruising of the cord with associated tissue damage, swelling and vascular leaking – Compression - Pressure on cord secondary to vertebrae displacement, disk herniation and/or associated swelling MLREMS Version -090308 28 Pathophysiology,Pathophysiology, cont.cont. (Specific(Specific Injuries)Injuries) ––CordCord InjuriesInjuries cont.cont. LacerationLaceration -- DirectDirect damagedamage toto cordcord withwith associatedassociated bleeding,bleeding, swellingswelling andand potentialpotential disruptiondisruption ofof cordcord HemorrhageHemorrhage -- OftenOften associatedassociated withwith aa contusion,contusion, lacerationlaceration oror stretchingstretching injuryinjury thatthat disruptsdisrupts bloodblood flow,flow, appliesapplies pressurepressure secondarysecondary toto bloodblood accumulation,accumulation, and/orand/or irritationirritation duedue toto bloodblood crossingcrossing bloodblood--brainbrain barrier.barrier. TransectionTransection -- PartialPartial oror completecomplete
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