Prehospital Academy Lesson 33.2
Trauma: Spinal Injuries
This lesson focuses on the prehospital assessment and management of spinal injuries for EMTs. Injuries to the spinal column and/or spinal cord are among the most critical traumatic emergencies, carrying the potential for permanent disability or death. A thorough understanding of spinal anatomy, physiology, and pathophysiology, coupled with proper assessment and immobilization techniques, is paramount in mitigating further damage.
Anatomy and Physiology of the Spinal Column and Cord
The spinal column (vertebral column) provides structural support for the body, protects the spinal cord, and allows for flexibility and movement.
Spinal Column: Composed of 33 vertebrae divided into five regions:
Cervical (C1-C7): Neck region, most mobile, supports the head.
Thoracic (T1-T12): Upper back, attaches to ribs, relatively stable.
Lumbar (L1-L5): Lower back, bears most of the body's weight.
Sacral (S1-S5): Fused vertebrae forming the posterior wall of the pelvis.
Coccygeal (4 fused vertebrae): Tailbone.
Intervertebral Discs: Act as shock absorbers between vertebrae.
Spinal Cord: A long, cylindrical bundle of nervous tissue that extends from the brainstem down to the lumbar region. It is a vital pathway for nerve impulses between the brain and the body.
Sensory Nerves: Carry information from the body to the brain.
Motor Nerves: Carry information from the brain to the muscles and glands.
Meninges & CSF: The spinal cord is also protected by meninges and cerebrospinal fluid.
Injury to the spinal column can result in direct damage to the spinal cord or compromise its function by compression, stretching, or laceration.
Mechanisms and Types of Spinal Injuries
Spinal injuries typically result from significant kinetic energy transfer or specific trauma mechanisms.
Common Mechanisms of Injury:
Flexion: Forward movement of the head (e.g., head-on collisions, falls onto the head).
Extension: Backward movement of the head (e.g., rear-end collisions, falls with impact to the chin).
Compression: Forces applied along the axis of the spine (e.g., falls from a height landing on feet or buttocks, diving into shallow water).
Rotation: Twisting forces (e.g., sports injuries, side-impact collisions).
Lateral Bending: Side impact forces.
Distraction: Stretching of the spine (e.g., hangings, child abuse).
Types of Spinal Injuries:
Fractures/Dislocations of Vertebrae: Can lead to instability of the spinal column and potential spinal cord impingement.
Spinal Cord Concussion: Temporary loss of function.
Spinal Cord Contusion: Bruising of the spinal cord.
Spinal Cord Laceration/Transection: Partial or complete severing of the spinal cord, often resulting in permanent loss of function below the injury site.
Signs and Symptoms of Spinal Cord Injury
The presentation depends on the level and severity of the injury.
Pain: Localized pain or tenderness along the spine, or radiating pain.
Motor Deficits: Weakness, paralysis, loss of voluntary movement below the injury.
Sensory Deficits: Numbness, tingling, loss of sensation (touch, pain, temperature) below the injury.
Respiratory Compromise: Especially with high cervical injuries (C3-C5), affecting the diaphragm (phrenic nerve).
Neurogenic Shock (Common with T6 and above injuries):
Hypotension (due to vasodilation).
Bradycardia (due to loss of sympathetic tone).
Warm, dry skin (blood pooling peripherally).
Priapism: Persistent erection in males (spinal cord injury often affects autonomic nervous system).
Incontinence: Loss of bladder or bowel control.
Deformity: Visible deformity of the spine.
Prehospital Care for Spinal Injuries
The primary goal is to prevent further injury to the spinal cord through meticulous immobilization and supportive care.
Scene Safety: Ensure the scene is safe before approaching the patient.
Manual In-Line Stabilization: Immediately establish and maintain manual in-line spinal stabilization upon contact with the patient. This must be maintained until the patient is fully secured to a long backboard or vacuum mattress.
Primary Assessment (ABCs):
Airway: Ensure a patent airway. Use a jaw-thrust maneuver if cervical spine injury is suspected. Avoid head-tilt/chin-lift.
Breathing: Administer high-flow oxygen. Monitor for respiratory compromise, especially with cervical injuries. Be prepared to assist ventilations.
Circulation: Assess for signs of shock. Treat neurogenic shock if present with fluid resuscitation (advanced providers) and vasopressors per protocol.
Rapid Extrication/Packaging: Carefully extricate and immobilize the patient onto a long backboard or vacuum mattress using appropriate devices (head immobilizer, c-collar, straps).
Secondary Assessment: Perform a detailed head-to-toe assessment, paying close attention to motor and sensory function in all four extremities.
Monitor & Reassess: Continuously monitor vital signs and neurological status. Document any changes.
Rapid Transport: Transport to an appropriate trauma center.
Critical Thinking Questions
You are called to a motor vehicle collision where the driver complains of neck pain and numbness in both legs. What is your immediate priority upon arrival, and why?
Explain the physiological reason why a patient with a high cervical spinal cord injury (e.g., C3-C5) might experience significant respiratory distress.
Describe the key components of neurogenic shock and how they differ from hypovolemic shock.
A patient with suspected spinal injury has a severely angulated lower extremity fracture. How would you prioritize and manage both injuries in the prehospital setting?
Discuss the importance of proper manual in-line stabilization and thorough immobilization techniques to prevent secondary spinal cord injury.