Spinal Trauma

BAGUS RAHMAT SANTOSO, NS., M.KEP

Overview
Spinal anatomy and physiology
Spinal Motion Restriction (SMR)
 Mechanisms of injury indicating need
 Process of application
 Emergency Rescue and Rapid Extrication
 History and assessment indicating no need
 Special situation
Neurogenic and Hemorrhagic Shock
Spinal Trauma
Devastating and life-threatening
Spinal Motion Restriction (SMR)
 BTLS Recommendation are guidelines
 Based on careful evaluation of mechanism, reliable patient
condition, special situations
Spinal column
Spinal Cord
Spinal injury mechanism
 Hyperextension
 Hyperflexion
 Compression
 Rotation
 Lateral Stress or Distraction (Less
Common)
Blunt Spinal-Column Injury
Requires significant force
 Unless preexisting weakness or defect in
bone  Higher risk: elderly, severe
arthritis
 Sudden movement of head
 Frequently injured in more than one place
Blunt Spinal-Column Injury
Signs and symptoms
 Pain most common symptom
 Frequently masked by other injuries
 Back pain with or without movement of back
 Tenderness along spinal column
 Obvious deformity or wounds
 Paralysis
 Weakness
 Paresthesia
Blunt Spinal-Cord Injury
 MVC (Including pedestarian)
 Falls
 Penetrating
 Recreational Activities
 Young adult most common
 Under 8 years, usually high cervical
 Elderly
Spinal Injury
Neurogenic Shock
Cervical or thoracic cord injury
 High-space shock
 Malfunction of autonomic nervous system
Sign and symptoms
 Hypotension
 Normal skin colour and temperature
 Inappropriately slow heart rate
Diagnosis of exclusion
 May have both neurogenic and hemorrhagic
Assessment
BTLS Primary and Secondary Survey
Motor and sensory function
 Concious
 Motor: Move fingers and toes
 Sensation: abnormal is suspicious
 Unconscius
 Motor: Pinch fingers and toes
 Sensation: pinch finger and toes
 Flaccid paralysis, no reflexes or withdrawal means injury
Clues to spinal injury
Mechanism
 Blunt trauma above clavicle
 Diving accident
 Motor vehicle or bicycle accident
 Fall
 Stabbing or impalement near spinal column
 Shooting or blast injury to torso
 Any violent injury with forces acting on spine
Clues to spinal injury
Patient complaints
 Neck or back pain
 Numbness
 Tingling
 Los of movement
 Weakness
Clues to spinal injury
Sign revealed during assessment
 Pain on movement of back or spinal column
 Obvious deformity of back or spinal column
 Guarding againts movement of back
 Loss of sensation
 Weal or flaccid muscles
 Loss of control of bladder or bowels
 Erection of penis (priapism)
 Neurogenic shock
Complication of SMR
Airway compromise and aspiration
 Head and airway are in fixed position
 Head and low back pain
Directly related to being on hard backboard
 Life-threatening hypoxia
 Obese
Congestive heart failure
 Pressure sore
 Uneven skin pressure
 SMR

Apply when most likely benefit.

Avoid if not necessary
SMR Indicated
 Positive mechanisms
 High-speed MVC
 Fall > 3 times patient’s height
 Diving accidents
 Penetrating wound in or near spinal column
 Sports injuries to head or neck
 Unconscious trauma patient
SMR Indicated
Potential mechanism with at least one:
 Altered mental status
 Evidence of intoxication
 A distracting painful injury
 Exp: long bone extremity fracture
 Neurologic deficit
 Spinal pain or tenderness
SMR Decision
Reliable Patient Unreliable patient
 Calm  Acute stress reaction
 Cooperative  Head/brain injury
 Sober  Altered mental status
 Alert  Intoxication with drugs and/or
alcohol
 No distracting injuries
 Distracting injuries
SMR Not Indicated
 No high-risk mechanism of injury
 No alteration of mental status
 No distracting injuries
 Not intoxicated
 No pain or tenderness along spine
 No neurological deficits
Management
Spinal motion restriction (SMR)
 Minimize movement to avoid aggravating injury
 No specific device proven more effective
 SMR Success depends on application process

Modification required
 Immediate danger of death
 Critical degree of ongoing danger that requires an intervention
within 1-2 minutes
Management
Emergency rescue
 Reserved for immediate (within seconds) environmental threat to
life of victim or rescuer
 Move to save area in manner that minimizes risk

Rapid extrication
 Considered for medical conditions or situations that requires fast
intervention to prevent death
 One or two minutes, but not seconds
Neutral alignment
Always monitor airway and breathing
Log roll
Single unit: spinal-column, head,
pelvis
 Patient lying prone or supine
Modification required
 Paint arm, leg, chest
 Roll into uninjured side
 Unstable fractures pelvis
 Scoop stretcher
 Lift carefully by four or more
rescuers
Special SMR Situations
Combative patient
 Children
 Altered mental status
 Under influence
Special SMR Situations
Require side transport
 Airway
 Unconscious patient who are not
intubated
 Pregnant
 20 weeks or more
 Vacuum board best
Special SMR Situantions
Closed-space rescue
 Safety is first priority
 In line with long axis

Water emergencies
 Backboard floated under
 Secure then remove
Special SMR Situantions
PEDIATRIC ELDERLY
Special SMR Situations
Prone, Seated or Standing
 Minimize movement into supine position
Special SMR Situations
Protective gear
 Motorcycle helmet: removal
 Poorly fitted to patient
 Significant neck flexion
 Full face and open face
 Note:
 Remove to evaluate and manage airway
Special SMR Situations
Protective gear
 Remove athletic helmet when
 Face mask not removed timely
 Airway cannot be controlled
 Does not hold head securely
 Note:
 Cut chin strap: do not unhook
Special SMR Situations
Neck wounds
 Caution: cervical collar
 May prevent Ongoing Exam
 Compromised airway with
subcutaneous air, expanding
hematomas, or mandible
fracture
 Note:
 May be needed to avoid
cervical collar; use manual
stabilization, head cushion
devices, blanket rolls
Diagnostik
 Spinal X-Ray
 CT-Scan  Abnormalitas tulang
 MRI  Kerusakan pada medulla spinalis, edema, cedera kompresi,
hematom ekstradural spinal
 Laktat  Perfusion Monitoring
 AGD  Hipoksia
Emergency Management in ER
 Prevent continuous spinal injury  Supinasi
 Aspirasi  Suction
 OPA / ET Tube
 Monitoring Ventilation
 SP02
 AGD
 Pasang Iv Line
 Resusitasi cairan  Kristaloid = Nadi radialis teraba
 Hipotensi  Syok Neurogenik  Vasopressor  MAP
 Kateter  Urine Output
Emergency Management in ER
 NGT  distensi ileus dan penurunan peristaltic
 Prevent hipotermia
 Sedasi  Pasien Gelisah
 Profilaksis tetanus, analgetik, dan antibiotic sesuai indikasi
 Summary
Unstable or incomplete spinal damage is not completely
predictable
 Unconscious trauma or dangerous mechanism affecting
head, neck should have SMR
 Uncertain mechanisms may not require SMR
 Special cases may require special techniques
 Maintain neutral alignment specific for patient
 Be prepared to manage airway compromise