Trauma – Spinal Cord Injury
Sameer D. Khatri, MD
Learning Objectives
• Correctly perform primary/secondary
surveys and recognize physical signs of
spinal cord injury
• Be aware of risk factors and understand
how to manage spinal cord injuries
• Recognize and treat neurogenic shock
• Understand clinical decision rules to
obtain radiographs for c-spine injuries
Introduction
• Spinal cord injury remains a devastating,
epidemic event in modern society, despite
early recognition, and treatment
• Injury usually leads to severe and
permanent disability
• TSCI effects young adults
disproportionately and is costly to society
Major Causes of TSCI in the U.S.
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Motor vehicle crashes: 47%
Falls: 23%
Violent acts like gunshot wounds: 14%
Sports related accidents: 9%
Other: 7%
Risk factors for TSCI
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Cervical spondylosis
Atlantoaxial instability
Congenital conditions like tethered cord
Osteoporosis
Spinal arthropathies like ankylosing
spondylitis or rheumatoid arthritis
Pathophysiology
• Injury to the bony vertebral column due to:
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Fracture
Dislocation
Ligamentous tears
Herniation or disruption of intervertebral disc
Initial Evaluation and Treatment
• Stabilize using ABCD prioritization
• Assume spine injury if:
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Head injury present
Unconscious or confused
Spinal cord pain present
Extremity weakness is present
Loss of sensation
• Use log-roll, backboard and rigid c-collar
Spinal and Neurogenic Shock
• Transient loss of spinal cord function can
follow TSCI
• Assume hypotension due to hemorrhage
• Consider neurogenic shock if:
• Hypotension not responding to fluids and/or
bradycardia
• Stabilizing BP may require pressors
• Stabilizing HR may require atropine or
pacing
Emergency Management
• Continue prioritizing care using ABCDs
• Continuous vital sign monitoring
• Be aware that 1/3 of cervical injuries require
intubation within 24 hours (Gardner, 1986)
• Address hypoxia
• Address hypotension
• Complete neurologic exam ASAP
• Asses for bladder distension and insert
urinary catheter ASAP
Imaging
• Plain films can be used to assess C-spine
• AP, lateral, and odontoid views (minimum)
• NEXUS Low-risk Criteria or Canadian Cspine rule –> imaging needed?
• CT usually done if C-spine plain films
inadequate or for lower spine injuries
NEXUS Low Risk Criteria
• C-spine imaging not necessary if:
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Absence of posterior midline cervical tenderness
Normal level of alertness
No evidence of intoxication
No abnormal neurologic findings
No painful distracting injuries
• Altered LOC defined as:
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Glasgow coma scale score below 15
Disorientation to person, place, time, or events
Inability to remember three objects at 5 minutes
Delayed or inappropriate response to external
stimuli
Canadian C-spine Rule
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Condition One – Perform imaging if:
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Condition Two – Assess low risk factors:
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Age 65 years or older
Dangerous mechanism of injury
Parasthesias in the extremities
Simple rear end MVA
Sitting position in ED
Ambulatory at any time
Delayed onset of neck pain
Absence of midline cervical spine tenderness
Condition Three
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Test active range of motion. If not able to rotate neck 45
degrees L&R. If able to do so, don’t need imaging.
Treatment
• Immediate surgical consultation is
recommended for all cases of TSCI
• Intensive medical care and continuous
monitoring required in the ICU setting to
minimize complications / disability
• Insufficient evidence to administer
steroids
Summary
• Injury to the spinal cord should be assumed
in any trauma situation
• Precautions using C-collars, backboards,
and log-rolling is advised to prevent
worsening injury
• C-spine can be ruled out with adequate plain
films and avoided altogether in certain using
clinical decision rules
• ABCDs scheme should be used to prioritize
care
References
1. Hansebout, Robert R., Kachur, Edward
Acute traumatic spinal cord injury.
UpToDate, Waltham, MA, 2012.
2. Gardner BP, Watt JW, Krishnan KR. The
artificial ventilation of acute spinal cord
damaged patients: a retrospective study of
forty-four patients. Paraplegia 1986; 24:208
3. American College of Surgeons, ATLS
Student Guide, 9th Edition, Sep 2012.
Simulation Training Assessment Tool
(STAT)– Penetrating Neck Injury
Sameer D. Khatri, MD
Simulation Training Assessment Tool (STAT) – Spinal Cord Trauma
SCENARIO ALGORITHM
SET UP
• In situ—ED resuscitation bay
• Sim Man 3G w/ C-collar & backboard
• VS control by dedicated tech
PRE ARRIVAL
24 yo man discovered in ski slopes down
Does not remember accident
Can’t move legs, no sensation below T4
HR 90, BP 115/70, RR 22, SPO2 98%,
GCS 15
• Transient hypotension en route,
resolved with NS 500 cc bolus
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ARRIVAL
• Pt in full spinal precautions
• 18g x1 @ LUE
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PRIMARY SURVEY
A- Patent, can speak / follow commands
B- BS = bilat, RR 22
C- HR 54, BP 90/55
D- GCS 15
E- Superficial abrasions and contusions
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SECONDARY SURVEY
Spine – C collar, Extreme TTP at T6
Abdomen – Diffusely tender
Pelvis—Stable, no crepitus
Rectal—No rectal tone or sensation
GU—No perineal bruising ; priapism
LE – No sensation or motor strength (B)
LABS & IMAGES
• C-spine NL; Fracture of T6 and T7
• H/H 15/45
• CT Head – No bleed / No masses noted
DISPOSITION
• To OR with trauma team with
Neurosurgery consultation
Date:
Instructor(s):
Learner(s):
Learning Objectives:
1. Recognize and appropriately manage spinal cord trauma
2. Understand how to recognize and manage neurogenic shock
3. Consult Neuro Surgery or Ortho Spine Surgery for disposition
CRITICAL ACTIONS
MS
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SUSTAIN
IMPROVE
1° survey– recognize & treat
PC1
potential hemodynamic
instability
Recognize shock; initiate IVF,
PC1
order H/H, T&C
2° survey– careful log roll with
PC1
stable C-spine; perform full
spine exam
Full spine imaging
MK1
recommend: pan CT - Head to /2
L spine
BP falls to 80/50 and HR remains in 30s despite initiating pressor agents
Recognize hypotension and
MK1
bradycardia as neurogenic
shock
Initiate pressors: Norepi: 8-12 MK2
mcg/kg/min & titrate to effect
Atropine / pacing to counteract MK2
significant bradycardia
BP rises to 110/70 with vasopressors and HR rises to 60’s with atropine administration
Fentanyl 25mcg for pain
MK2
control
Consult neurosurgery for
SBPdisposition
4
Effective team leadership,
communication and synergy
TOTAL
C-3
Debriefing Notes
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A transient loss of spinal cord function can occur following
spinal column injury
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Clinicians must assume that hypotension following trauma
results from hemorrhage and treat as such
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Neurogenic shock from SCI may cause hypotension and
bradycardia
 Use of pressors my be necessary to stabilize BP
 Use of atropine or pacing may be needed for HR
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Secondary survey:
 Inspect entire body starting with head
 Palpate entire spine and paraspinal musculature for
tenderness, step-offs, or deformity
 Perform a focused but systematic neuro exam to
asses for symmetry in movements, priapism,
abnormal breathing pattern, symmetry of peripheral
strength, senasation, reflexes, sensory deficits,
bowel, or bladder incontinence
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Adequate plain xrays are essential to rule out c-spine
injuries
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AP, Lat, and odontoid views needed at minimum
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CT scan required if visualization is inadequate
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Use ABCs approach when reading plain film imaging
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NEXUS Low-risk Criteria (NLC); No radiographs if
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Absence of posterior midline cervical tenderness
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Normal level of alertness
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No evidence of intoxication
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No abnormal neurologic findings
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No painful distracting injuries
Altered LOC in NEXUS defined as:
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Glasgow coma scale below 15
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Disorientation to person, place, time, or events
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Inability to remember three objects at five minutes
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Delayed or inappropriate response to external simuli
Canadian C-spine Rule:
Condition One – Perform imaging if:
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Age 65 years or older
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Dangerous mechanism of injury (falls, high speed MVA,
axial load to head, ejection, collisions)
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Parasthesias in the extremities
Condition Two – Assess low risk factors:
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Simple rear end MVA
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SAmbulatory at any time
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itting position in ED
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Delayed onset of neck pain
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Absence of midline cervical spine tenderness
Condition Three
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Test active range of motion. If not able to rotate neck
45 degrees L&R. If able to do so, don’t need imaging.
Additional Instructor Notes
Case Synopsis
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25 yo male suffered a traumatic spinal cord injury after a ski related accident where he was found down. On arrival by first
responders, pt was found to have severe upper back pain but was still alert and oriented X 3 with a GCS of 15. He was
placed in C-collar and backboard and taken to the ED. En route, he was found to have transient hypotension and given a fluid
bolus which rapidly normalizing his pressures. Learner must continue through the ABCDs and the rest of the critical actions.
Consider telling the learner that the patient was not moving his lower extremities bilaterally.
Personnel and Roles
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Instructor—Introduces case, switches to “EMS” as case begins, provides ancillary data as requested and plays “Surgeon” at
the end of the case
Assistant (may be resident) —Acts voice of patient and manages monitor (tell Primary Learner that the assistant will be the
patient’s voice prior to entry). Can also substitute an actor who can respond to the questions asked
Primary learner (resident)—Is the responding doctor. May lead the Trauma Team response or act as sole provider, depending
on how your institution manages trauma
Secondary learners (residents)– Prompt primary learner to assign roles, e.g. Airway, Procedures, Nursing etc prior to
beginning case.
Props/Supply Checklist
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Sim Man w/ C-collar on and strapped onto a backboard (can substitute for a live actor)
Moulage as needed to simulate trauma sustained while skiing and running into a tree
Airway equipment– NRB, laryngoscope, ETT 8.0, suction, BMV, RSI drugs
Consideration for making Sim Man have priapism
Supporting Stimuli
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EMS Run Sheet– give to learner at start of case
Point of care labs– give to learner only if ordered, after credible time lapse
Imaging for C-spine, T- and/or L-spine– give to learner only if ordered, after credible time lapse
EMS Sheet
• 25 yo male found down while skiing the
slopes
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BP115/70
HR90
RR22
POX98% on RA
GCS15
Transient hypotension – responded with fluid
bolus