Chapter 27. Vertebral Column & Spinal Cord Trauma

Suspect Spinal Cord Injury

Patients with blunt trauma, particularly those with head injury, severe mechanism, or neurologic complaints should be assumed to have spine injuries until proven otherwise. Such injuries are major causes of morbidity and mortality in the trauma patient, so thorough assessment beginning in the prehospital setting is essential. The potential instability of such injuries necessitates that the utmost care be taken not to render additional harm to these patients.

Immobilization

Immobilization of the spine is essential to prevent further injury to the spinal cord. From the field, or when transferred, the patient should be on a long spine board, in a rigid cervical collar (Philadelphia) with lateral rolls and tape across the forehead. Upon arrival, logroll the patient off this board and onto the examination bed, maintaining in-line stabilization (see below). Careful immobilization should be maintained throughout resuscitation procedures, physical examination, and diagnostic evaluation.

Supine Position

The optimal position for examination and in-line immobilization is supine. Once in the emergency department, the patient's rigid collar should be changed to a semirigid collar (Miami-J). Remember to limit the amount of time the patient is kept on any hard surface to minimize discomfort and avoid pressure injury.

Lateral Position

If the patient cannot lie supine for any reason (eg, vomiting), the lateral position with careful in-line cervical stabilization is acceptable.

Technique for Moving the Patient

If the patient must be moved, in-line spinal stabilization should be maintained and the head and trunk rolled as one unit (logroll). Proper technique requires three individuals. The first individual stands at the head of the bed and is responsible for maintaining cervical spine immobilization and controlling the turn. The two remaining individuals stand to one side of the patient and are in charge of maintaining thoracic and lumbar spine immobilization.

Establish Airway and Maintain Ventilation

As with all patients in the emergency department, initial assessment should focus on airway and breathing. However, when vertebral or spinal injury is suspected, neck alignment and immobility must be maintained during all attempts to establish adequate ventilation.

In the patient with apnea or overt respiratory failure, a definitive airway should be established immediately. Whenever possible, rapid sequence intubation is the preferred as the least traumatic and most efficient method of achieving intubation (see Chapter 10). Designate an assistant to maintain cervical spine immobilization during intubation, and minimize neck extension induced by direct laryngoscopy. Airway adjuncts such as a fiberoptic bronchoscope or videolaryngoscope, in the hands of an experienced user may further minimize neck movement. Nasotracheal intubation is an option only in the spontaneously breathing patient.

Spontaneously breathing patients with cervical spinal cord injuries can have loss of diaphragmatic and/or intercostal muscle innervation, which may cause them to tire ...