Traumatic Spinal Injury part 4

SCI and potential injury raise several potential considerations:

The spinal cord runs down the spinal canal to the level of the second lumbar vertebra in adults. The amount of space in the spinal canal in the upper neck is relatively large, and risk of secondary injury in this area can be reduced if good immobilisation is applied. In the thoracic area the spinal cord is wide and the spinal canal relatively narrow, meaning injury in this area is more likely to disrupt and damage the spinal cord.

Following a SCI a patient may have related signs and symptoms such as:

  • Abnormal or diaphragmatic breathing
  • Hypotension with bradycardia
  • Warm peripheries or vasodilation in the presence of low blood pressure
  • Flaccid muscles with absent reflexes
  • Priapism

Assess for sensory and motor function by asking if the patient can feel a light touch on the skin or if they are able to gently move all their limbs. If assessing sensation, gently palpate along the mid-axilla line rather than on the chest. C2 – C4 all supply sensation to the nipple line and can confuse trying to identify the level of SCI. As a reference of sensation for the patient, the forehead can be used as a guide to what normal sensation is.

If a patient has an isolated penetrating wound to the limb or head, they will not require immobilisation. If the patient has a penetrating injury to the torso or neck, consider the trajectory of the penetrating object and whether it may have passed through the spinal cord. Review the injury and symptoms of the patient.

If a patient is unconscious following a traumatic incident, it is important to treat them with a presumed SCI as they are unable to tell you what happened, their symptoms, any pain, etc.

Immobilising the patient will help reduce any further secondary SCI, however there are hazards that may present with immobilisation, such as:

  • Compromised airway
  • Increased ICP
  • Increased risk of aspiration
  • Restricted ventilation
  • Dysphagia
  • Skin Ulceration
  • Further pain being caused due to the discomfort of immobilisation

Cauda Equina Syndrome (CES)

CES is caused by the compression of the nerves in the spinal canal below the end of the spinal cord. It can occur in patients with trauma, a herniated disc, chronic or acute lower back pain, and patients with tumours or infections. Most cases are of sudden onset and progress rapidly within hours or days. It is however possible that CES can develop slowly and may not always present with pain.

Symptoms of CES include:

  • Loss of bladder and/or bowel control, causing incontinence
  • Reduced sensation in the perineal area
  • New onset of sexual dysfunction
  • Neurological deficit in the lower limbs

Neurogenic shock

Neurogenic shock is a consequence of SCI that can manifest as hypotension, bradycardia, and temperature dysregulation. It is associated with cervical and high thoracic spine injury. Due to the SCI, autonomic dysregulation can occur between the brain and body. This dysregulation is due to a loss of sympathetic tone and unopposed parasympathetic response.

For example, a patient with a complete SCI at C7 would have a significant amount of tissue and organ mass unregulated by the brain. Due to this severed link, the body cannot react effectively to changing needs. If blood pressure was to drop, then there would be no signals warning the brain, and the brain couldn’t instruct blood vessel constriction and increase of heart rate. If the body was getting cold, there would be no signal to warn the brain and no action to find something warm or start shivering. Likewise, if the body was getting hot and the patient wasn’t aware of their rise in temperature.

A patient with neurogenic shock may present with individual symptoms or a mixture of hypotension, bradycardia, or hypothermia/hyperthermia. Other symptoms relating to these may include dizziness, loss of consciousness, lethargy, nausea/vomiting, faint pulse, hypoxia/cyanosis.

Treating neurogenic shock requires working through the primary survey and managing any deficits you come across. Hypotension requires fluid therapy, hypothermia requires patient warming, hyperthermia requires patient cooling.

Patient management

Following the Primary survey:

Catastrophic Haemorrhage: Stemming any catastrophic haemorrhage is vital to maintain any homeostatic stability of the patient.

Airway with C-spine consideration: Manage airway with a stepwise approach if there are any deficits. C-spine and spinal care will be of great consideration where a SCI is suspected. Effective management of immobilisation and extrication to reduce any further secondary SCI.

Breathing: Management of breathing may be required if there is neurological deficit or Cervical SCI. The patient may require assistance with their respirations, or they may be in respiratory arrest.

Circulation: Review further haemorrhage control where there may be internal concerns. Apply pelvic binder, TXA for major head injury and bleeding concerns following your ambulance service guidelines. Query if there are any signs of neurologic shock and treat where possible.

Disability: Maintain patients’ temperature and cover to avoid heat loss, review blood glucose levels and treat any unusual findings, review GCS level, review any seizure activity and treat if required.

Evacuate: Consider early evacuation of the patient to further care, request specialist support if needed and available. Review your extrication plan, request further assistance/specialist services if needed to help protect the patient from secondary SCI during extrication. If there is an immediate life-threatening concern you cannot treat in their current position, or an immediate danger to the patient, an emergency/rapid extrication may be needed. Where possible in this situation, try to maintain some immobilisation of the patient to allow some SCI protection.