Spinal cord injury
SPINAL CORD INJURY (SCI)
• An insult to the spinal cord resulting in changed neurological function – Motor – Sensory – Autonomic
• May be temporary or permanent • Injuries tend to be physically, emotionally and financially devastating
CLASSIFICATION
• Tetraplegia: (quadriplegia) – Cervical region injury – Loss of muscle strength to all four extremities – Most critical: support respiratory function
• Paraplegia – Injury to the spinal cord in the • Thoracic • Lumbar • Sacral segments
– T12 and L1 are the most common level
MECHANISM OF INJURY • In the United States: • Automobile accidents
– High speed – Ejection. rollover • Falls
– Greater than 4.5 meters/15 feet (or 3x height) – Slip and fall: rare except in elderly – Diving into shallow pool • Violence
– Blunt – Penetrating • Sports
SITE OF INJURY AND NEUROLOGIC LEVEL C5 Most common site of injury
T12 / L1 most common injuries
PRIMARY AND SECONDARY SPINAL CORD INJURY
• Primary Spinal Cord Injury – Initial physical damage to spinal cord or its structures – Physical cord damage due to mechanical insult – Neurons passing through injury site are physically disrupted and exhibit diminished myelin thickness
PRIMARY AND SECONDARY INJURY • Secondary Spinal Cord injury: – Progressive pathological responses to initial injuries • Hemorrhage into cord compartments • Inflammatory response to initial insult (Biochemical cascade, progressive edema and cell necrosis) • Hypoxia due to local and systemic hypoperfusion • Systemic hypotension from other injuries (bleeding) or neurogenic shock – Collectively damage intact neighboring tissue – Symptoms: paralysis and loss of sensation to areas innervated below the general level of the injury
Mechanisms of Spinal Injuries • Extremes of motion – Hyperextension – Hyperflexion: “Kiss the Chest” – Excessive Rotation – Lateral bending • Axial Stress – Axial loading • Compression common between T12 and L1 – Distraction – Combination • Distraction/Rotation or compression/flexion • Other MOI – Direct, Blunt or Penetrating trauma – Electrocution
Pathophysiology of Spinal Injury (3 of 14)
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson
Spinal Column Injures Movement of vertebrae from normal position Subluxation or Dislocation Fractures • Spinous process and Transverse process • Vertebral body • Ruptured intervertebral disks Common sites of injury • C-1/C-2: Delicate vertebrae • C-7: Transition from flexible cervical spine to thorax • T-12/L-1: Different flexibility between thoracic and lumbar regions
Spinal Cord Injuries Concussion • Similar to cerebral concussion • Temporary and transient disruption of cord function Contusion • Bruising of the cord • Tissue damage, vascular leakage and swelling Compression • Secondary to: displacement of the vertebrae herniation of intervertebral disk displacement of vertebral bone fragment swelling from adjacent tissue
Spinal Cord Injuries continued… Laceration
• Causes
Bony fragments driven into the vertebral foramen Cord may be stretched to the point of tearing
• Hemorrhage into cord tissue, swelling and disruption of impulses
Hemorrhage
• Associated with contusion, laceration, or stretching
SPINAL CORD INJURY UNTIL PROVEN OTHERWISE IF:
• Significant mechanism of injury – high speed motor vehicle collision – Fall from a height – Diving accident – Electrocution – Direct neck trauma
• • • •
Head or Neck pain associated with trauma Motor or sensory deficits Altered Level of Consciousness Distracting Injury
Spinal Clearance Protocol
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson
Primary and Secondary Surveys
• Primary Survey – Assess for life threatening injuries, if identified, stop immediately and address before moving on – Airway with Spinal Cord Precautions – Breathing and Ventilation – Circulation – Disability – mental status – Exposure
Primary and Secondary Surveys
• Secondary Survey – Complete head to toe and focused assessment – History – Everything else
Primary Survey
AIRWAY AND SPINAL PROTECTION
• Airway with simultaneous spinal protection – Manually hold head/neck in line
• Inspect the airway using jaw thrust (if able) • Tongue, secretions, blood, vomit, edema, foreign body, retropharyngeal hematoma • Gentle, frequent suction (avoid vagal stimulation and hypoxia)
AIRWAY WITH SPINAL STABILIZATION
• Oxygen • Oral-tracheal intubation with in-line stabilization is the preferred method • Any episode of hypoxia can lead to cord ischemia and further injury • Plan for: rigid C-collar (if able), head supports, long board, log roll patient • Minimal movement/manipulation of spine!
BREATHING/VENTILATION • Assess patient’s respiratory status
– Spontaneous? Need for assistance? – Rate and rhythm – Equal chest rise and fall – Use of accessory muscles – Vocalizations – Skin signs – Is the patient tiring? Assist – Trauma patient, look for: chest wall stability and penetrating injuries • The higher the injury, the higher the risk for respiratory failure
CIRCULATION • Bleeding? Control it • Skin signs
– Hypovolemia: pale, cool, diaphoretic – Neurogenic shock: warm, dry • Palpate central pulses • Hypovolemia: tachycardia • Neurogenic shock: bradycardia • May be taking medication that affects heart rate, especially the elderly • Compare pulses • Intravenous access x 2 • Bradycardia may require atropine or pacing
DISABILITY
• • • • • •
What is the patient’s mental status? Altered? Intoxicated? Distracting Injury? Significant Head or Neck Trauma? Check pupils
DISABILITY/MENTAL STATUS
DISABILITY/MENTAL STATUS
• • • •
Alert Verbal Pain Unresponsive
EXPOSURE • Don’t miss other injuries! • Uncover the patient. Significant mechanism of injury means high risk for other trauma (thoracic, abdominal, pelvic, long bone fractures, head/brain trauma) • Log Roll Patient. Palpate and inspect entire spine and paraspine for tenderness, deformity, bruising, step-offs and widening of the vertebral spaces • Sphincter tone and Priapism • Keep warm. Recover. Patient may have no thermoregulation
SECONDARY SURVEY
• Patient on the monitor • Full set of vitals • Full Head to Toe – Don’t miss other injuries!
• Full History – Mechanism is important! – As much information as possible from the patient, the family, the paramedics
Minimal movement of spine! Consider removing back board.
BLOOD PRESSURE • Check Blood pressure: any episodes of hypotension increase the risk of ischemic injury. • Maintain a Mean Arterial Pressure of 8590mmHg • Hypotension: 2 potential causes 1. Hypovolemia • Is the patient bleeding • Don’t miss an injury. • Patient needs fluids/blood 2. Neurogenic Shock • lack of sympathetic innervation. • May need dopamine and atropine. • Caution not to fluid overload causing further cord edema and damage to brain and lungs
FULL NEUROLOGICAL ASSESSMENT • What hurts? What can you feel/move? • Check motor, sensory, proprioception – What can you move? – What can you feel? • Distal to proximal • Pain – point of pin • Pressure – head of pin – What toe am I moving and in which direction? Document using established scales Dermatomes American Spinal Injury Association
Neurological Assessment • Unresponsive patient:
– flaccid? – Diaphragmatic breathing? – Loss of grimace/withdrawal response? – Sphincter tone? – Priapism? – Distended bladder/abdomen? – Hypotension? – Hypothermia?
American Spinal Injury Association
Scale to describe the extent of the injury •
A = Complete: – Complete loss of motor and sensory function in sacral segments S4-S5.
•
B = Incomplete: – Sensory function preserved preserved below site of injury – Loss of motor function below site of injury
•
C = Incomplete: – Motor function is preserved below the site of injury – More than half of key muscles below site of injury have a muscle strength less than 3.
•
D = Incomplete: – Motor function is preserved below site of injury – At least half of key muscles below site of injury have a muscle strength of 3 or more.
•
E = Normal: motor and sensory function are normal.
AMERICAN SPINAL INJURY ASSOCIATIOTION
Scale for assessment of motor strength • 0 No contraction or movement • 1 Minimal movement • 2 Active movement, but not against gravity • 3 Active movement against gravity • 4 Active movement against resistance • 5 Active movement against full resistance
AMERICAN SPINAL INJURY ASSOCIATION
• Sensory Scale – Both sides of the body – Distal to proximal – Pain and Pressure • • • •
0 Absent 1 Impaired 2 Normal NT Not testable
PAIN CONTROL • Hypersensitivity above level of injury – Tend to have extreme pain with even light pressure
• Balance needs – Pain relief – Need to maintain adequate perfusion – Need for ongoing neurological assessments • Opioids • positioning • Assisting with traction
Devastating injury. Include the Patient’s Family
REASSESSMENT
Serial assessments are critical! • • • • • • • •
Vital Signs Mental status Work of breathing Focal findings –Motor, Sensory and Proprioception Full care of patient in spinal precautions Nausea and Vomiting! Radiology – May require serial images Goal is best possible outcome for this patient
STUDIES •
•
•
X-Rays – Cheaper – Less radiation – Difficult to obtain 3 mandatory and adequate views – Must visualize down to T1 Computerized Tomography (CT) – Easier, faster, see more – Lots more radiation (especially for children) – Can’t see soft tissue Magnetic Resonance Imaging (MRI) – Long delay – Requires transport time – Difficult to monitor patient in MRI machine – Some patients unable to tolerate
National Emergency X-Radiography Utilization Study Criteria
Canadian Criteria
Contoh kasus • Tn. D, usia 62 tahun, kedua tungkai tidak dapat digerakkan setelah jatuh terduduk 3 hari SMRS. Tidak bisa merasa pada tungkai tersebut, tidak menyadari BAB dan BAK, dan tidak bisa ereksi. Riwayat demam tidak ada, bengkak dan nyeri pada punggug tidak ada. Keluhan muncul setelah jatuh terduduk.
• Motor skor : – Kanan : 25 kiri : 25 total 50 • Sensori skor : – Light touch dan pin prick • Kanan : 18 kiri : 18 total 36 • ASIA impairment scale A (complete)
PENATALAKSANAN SPINAL CORD INJURY
Pemberian terapi • MP 30 mg/kgbb bolus, dilanjutkan 5.4 mg kg/bb selama 23 jam. • Perbaikan neurologi signifikan bia diberikan pada 3-8 jam setelah trauma.
Mekanisme Kerja Metilprednisolon • Menurunkan post traumatic SC edema • Menghambat post trauma LP • Menghambat iskemik post trauma • Membantu metabolisme aerob (reduksi laktat & meningkatkan ATP) • Memperbaiki ca ekstrasel (menurunkan ca intrasel) • Mengurangi neurofilamen
MENURUT NASCIS •
NASCIS I (USA, 1984) • Prospektif • Metil prednisolon • NASCIS II (1990) (100 mg dan • Prospektif 1000 mg) • Metiprednisolon, naloxone, placebo • NASCIS III (1997) • Prospektif • Metilprednisolon , tirilazad
NASCIS I
• 330 pasien • T/ – 100 mg bolus MP, kemudian 25 mg tiap 6 jam selama 10 hari – 1000 mg bolus MP, kemudian 250 mg tiap 6 jam selama 10 hari Kesimpulan : tidak ada hasil signifikan dari kedua grup diatas Angka kejadian meningkat terhadap luka infeksi (dosis tinggi)
NASCIS II • • • •
487 pasien dalam 1 tahun Pasien yg meninggal dieksklusikan Total 427 pasien T/ – MP 30 mg/kgbb bolus, dilanjutkan 5.4 mg kg/bb selama 23 jam. – Naloxone 5.4 mg//kgbb bolus, dilanjutkan 4.5 mg/kgbb selama 23 jam – Placebo
NASCIS III • Prospektif • Tanpa placebo • 499 pasien. Total pasien 439 pasien setelah 1 tahun follow up. • Diberikan dalam waktu < 8 jam setelah trauma • T/ – MP 5.4 mg/kgbb/jam selama 24 jam – MP 5.4 mg/kgbb/jam selama 48 jam – Tirilazad 2.5 mg/kgbb tiap 6 jam selama 48 jam
• Mortalitas meningkat 6 kali pada grup yg 48 jam (respirasi) pneumonia dan sepsis. • Pasien tsb dibagi dalam 0-3 jam setelah trauma dan 3-8 jam setelah trauma. • Pada kelompok 0-3 jam tidak ada perbaikan neurologi. • Pada kelompok 3-8 jam terdapat perbaikan neurologi.
