Chapter 27: Vertebral Column & Spinal Cord Trauma

IMMEDIATE MANAGEMENT OF THE PATIENT WITH SUSPECTED SPINAL INJURY

SUSPECT SPINAL CORD INJURY

Patients with blunt trauma, particularly those with head injury, severe mechanism, or neurologic complaints should be assumed to have spinal column injuries until proven otherwise. These injuries are major causes of morbidity and mortality in the trauma patient, and thorough assessment as well as a high clinical suspicion beginning in the prehospital setting is essential. These are also potentially unstable injuries, so the utmost care must be taken to prevent additional harm to these patients in both prehospital and emergency department (ED) settings. As with any traumatic injury, patients with suspected spinal cord injury should be evaluated and stabilized using advanced trauma life support procedures.

Immobilization

Immobilization of patients with suspected spinal cord injury may prevent further injury, especially during prehospital transport. However, immobilization can also cause morbidity. Discretion should be used in selecting patients for spine immobilization, and it is appropriate in patients with spinal tenderness or deformity, neurologic deficits, or patients with altered level of consciousness, intoxication, or distracting injury. Immobilization may involve the use of a longboard with the patient in a rigid cervical collar with lateral rolls and tape across the forehead for stabilization of lateral rotation. Prolonged immobilization on hard surfaces should be avoided in the ED, and upon arrival, the patient should be removed from the longboard as soon as possible using logroll technique, maintaining in-line stabilization (see below). Careful immobilization should be maintained throughout resuscitation procedures, physical examination, and diagnostic evaluation.

A. Supine Position

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

B. Lateral Position

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

C. 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 verbally directing the team during 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 ED, 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 ...