外科急诊创伤之脊椎损伤

Spinal Cord InjuriesL.Barnes,BS,CCEMT-P,NREMT-Pn“Among all neurologic disorders,the cost to society of automotive SCI is exceeded only by the cost of mental retardation.nNational Institutes of Healthn33 bones comprise the spinenFunctionnSkeletal support structurenMajor portion of axial skeletonnProtective container for spinal cordnVertebral BodynMajor weight-bearing componentnAnterior to other vertebrae componentsSpinal Anatomy and PhysiologyVertebral ColumnnSize of VertebraenC-1&C-2nNo vertebral bodynSupport headnAllow for turning of headnVertebral body size increase the more inferior they becomenLumbar spine has strongest and largestnBear weight of the bodynSacral&Coccyx vertebrae are fusednNo vertebral bodySpinal Anatomy and PhysiologyVertebral ColumnnComponents of VertebraenSpinal CanalnOpening in the vertebrae that the spinal cord passes throughnPediclesnThick,bony structures that connect the vertebral body to the spinous and transverse processesnLaminaenPosterior bones of vertebrae that make up foramennTransverse ProcessnBilateral projections from vertebraenMuscle attachment and articulation location with ribsSpinal Anatomy and PhysiologyVertebral ColumnnComponents of VertebraenSpinous ProcessnPosterior prominence on vertebraenIntervertebral DisksnCartilagenous pad between vertebraenServes as shock absorberSpinal Anatomy and PhysiologyVertebral Column(continued)nVertebral LigamentsnAnterior LongitudinalnAnterior surface of vertebral bodiesnProvides major stability of the spinal columnnResists hyperextensionnPosterior LongitudinalnPoster surface of vertebral bodies in spinal canalnPrevents hyperflexionSpinal Anatomy and PhysiologyVertebral ColumnnCervical Spinen7 vertebraenSole support for headnHead weighs 16-22 poundsnC-1(Atlas)nSupports HeadnSecurely affixed to the occiputnPermits noddingnC-2(Axis)nOdontoid Process(Dens)nProjects upwardnProvides pivot point so head can rotatenC-7nProminent spinous process(vertebra prominens)Spinal Anatomy and PhysiologyDivisions of the Vertebral ColumnnThoracic Spinen12 vertebraen1st rib articulates with T-1nAttaches to transverse process and vertebral bodynNext nine ribs attach to the inferior and superior portion of adjacent vertebral bodiesnLimits rib movement and provides increased rigiditynLarger and stronger than cervical spinenLarger muscles help to ensure that the body stays erectnSupports movement of the thoracic cage during respirationsSpinal Anatomy and PhysiologyDivisions of the Vertebral ColumnnLumbar Spinen5 vertebraenBear forces of bending and lifting above the pelvisnLargest and thickest vertebral bodies and intervertebral disksSpinal Anatomy and PhysiologyDivisions of the Vertebral ColumnnSacral Spinen5 fused vertebraenForm posterior plate of pelvisnHelp protect urinary and reproductive organsnAttaches pelvis and lower extremities to axial skeletonnCoccygeal Spinen3-5 fused vertebraenResidual elements of a tailSpinal Anatomy and PhysiologyDivisions of the Vertebral ColumnnLayersnDura maternArachnoidnPia maternCover entire spinal cord and peripheral nerve roots that exitnCSF bathes spinal cord by filling the subarachnoid spacenExchange of nutrients and waste productsnAbsorbs shocks of sudden movementSpinal Anatomy and PhysiologySpinal MeningesnFunctionnTransmits sensory input from body to the brainnConducts motor impulses from brain to muscles and organsnReflex CenternIntercepts sensory signals and initiates a reflex signalnGrowthnFetusnEntire cord fills entire spinal foramennAdultnBase of brain to L-1 or L-2 levelnPeripheral nerve roots pulled into spinal foramen at the distal end(Cauda Equina)Spinal Anatomy and PhysiologySpinal CordnBlood SupplynPaired spinal arteriesnBranch off the vertebral,cervical,thoracic,and lumbar arteriesnTravel through intervertebral foraminanSplit into anterior and posterior arteriesSpinal Anatomy and PhysiologySpinal CordnGeneral Cord AnatomynAnterior Medial FissurenDeep crease along the ventral surface of the spinal cord that divides cord into left&right halvesnPosterior Medial FissurenShallow longitudinal groove along the dorsal surfacenGray MatternArea of the CNS dominated by nerve cell bodiesnCentral portion of the spinal cordnWhite MatternSurrounds gray matter.nComprised of axonsSpinal Anatomy and PhysiologySpinal CordnGeneral Cord AnatomynAxonsnTransmit signals upward to the brain and down to the bodynAscending TractsnAxons that transmit signals to the brainnSensory TractsnDescending TractsnAxons that transmit signals to the bodynMotor tractsnVoluntary and fine muscle movementSpinal Anatomy and PhysiologySpinal Cordn31 pairs of nerves that originate along the spinal cord from anterior and posterior nerve rootsnSensory&motor functionsnTravel through intervertebral foraminan1st pair exit between the skull and C-1nRemainder of pairs exit below the vertebraenEach pair has 2 dorsal and 2 ventral rootsnVentral roots:motor impulses from cord to bodynDorsal roots:sensory impulses from body to cordnC-1&Co-1 do not have dorsal rootsSpinal Anatomy and PhysiologySpinal NervesSpinal Anatomy and PhysiologySpinal Nerves(continued)nnPlexusPlexusnnNerve roots that converge in a cluster of Nerve roots that converge in a cluster of nervesnervesnnCervical PlexusCervical Plexusnn5 cervical nerve roots5 cervical nerve rootsnnInnervates the neckInnervates the necknnProduces the phrenic nerveProduces the phrenic nervennPeripheral nerve roots C-3 thru C-5Peripheral nerve roots C-3 thru C-5nnResponsible for diaphragm controlResponsible for diaphragm controlnn“C3,4&5 keeps the diaphragm alive“C3,4&5 keeps the diaphragm aliveSpinal Anatomy and PhysiologySpinal NervesnnBrachial PlexusBrachial PlexusnnC-5 thru T-1C-5 thru T-1nnControls the upper extremityControls the upper extremitynnLumbar&Sacral PlexusLumbar&Sacral PlexusnnInnervation of the lower extremityInnervation of the lower extremitynReflex PathwaysnFunctionnSpeeds bodys response to stressorsnReduces seriousness of injurynBody stabilizationnOccur in special neuronsnInterneuronsnExamplenTouch hot stovenSevere pain sends intense impulse to brainnStrong signal triggers interneuron in the spinal cord to direct a signal to the flexor musclenLimb withdraws without waiting for a signal from the brainSpinal Anatomy and PhysiologySpinal NervesnSubdivision of ANSnParasympathetic“Feed&BreednControls rest and regenerationnPeripheral nerve roots from the sacral and cranial nervesnMajor FunctionsnSlows heart ratenIncrease digestive system activitynPlays a role in sexual stimulationSpinal Anatomy and PhysiologySpinal NervesnSubdivision of ANS nSympathetic“Fight or FlightnIncreases metabolic ratenBranches from nerves in the thoracic and lumbar regionsnMajor FunctionsnDecrease organ and digestive system activitynVasoconstrictionnRelease of epinephrine and norepinephrinenSystemic vascular resistancenReduce venous blood volumenIncrease peripheral vascular resistancenIncreases heart ratenIncrease cardiac outputSpinal Anatomy and PhysiologySpinal NervesnColumn InjurynMovement of vertebrae from normal positionnSubluxation or DislocationnFracturesnSpinous process and Transverse processnPedicle and LaminaenVertebral bodynRuptured intervertebral disksnCommon sites of injurynC-1/C-2:Delicate vertebraenC-7:Transition from flexible cervical spine to thoraxnT-12/L-1:Different flexibility between thoracic and lumbar regionsPathophysiology of Spinal InjurynCord InjurynConcussionnSimilar to cerebral concussionnTemporary and transient disruption of cord functionnContusionnBruising of the cordnTissue damage,vascular leakage and swellingnCompressionnSecondary to:ndisplacement of the vertebraenherniation of interverterbral diskndisplacement of vertebral bone fragmentnswelling from adjacent tissuePathophysiology of Spinal InjurynCord InjurynLacerationnCausesnBony fragments driven into the vertebral foramennCord may be stretched to the point of tearingnHemorrhage into cord tissue,swelling and disruption of impulsesnHemorrhagenAssociated with contusion,laceration,or stretchingPathophysiology of Spinal InjuryClassificationnClassify as one of cord syndromesnIncomplete cord syndromes may have variable neurologic findingsnSCI syndromesnConcussionnCompleten T6nhypotension with acute SCI T6 may present with autonomic dysfunctionnhigh incidence of associated injuryNeurogenic ShocknUsually does not occur below SCI T6nShock below T6 should be considered hemorrhagic until proven otherwisenCharacterized by severe autonomic dysfunctionnHypotensionnRelative bradycardianPeripheral vasodilationnhypothermiaNuerogenic Shock TriadnDecreased BPnDecreased HRnPeripheral vasodilationnResulting from autonomic dysfunction and interruption of sympathetic NS control in acute SCISpinal ShocknComplete loss of neurological function ReflexesnRectal tonenFlaccid reflexes below specific levelnSpinal ShocknTemporary insult to the cordnAffects body below the level of injurynAffected areanFlaccidnWithout feelingnLoss of movement(Flaccid paralysis)nFrequent loss of bowel&bladder controlnPriapismnHypotension secondary to vasodilationnScene Size-upnEvaluate MOInDetermine type of spinal traumanMaintain suspicion with sports injuriesnIf unclear about MOI take spinal precautionsAssessment of the Spinal Injury Patient(continued)nInitial AssessmentnConsider spinal precautionsnHead injurynIntoxicated patientsnInjuries above the shouldersnDistracting injuriesnMaintain manual stabilizationnVest style versus rapid extricationnMaintain neutral alignmentnIncrease of pain or resistance,restrict movement in position foundAssessment of the Spinal Injury PatientnInitial AssessmentnABCsnSuctionnConsider Oral or Digital Intubation if requirednMaintain in-line manual c-spine controlAssessment of the Spinal Injury PatientnRapid Trauma AssessmentnFocused versus Rapid AssessmentnRapid AssessmentnSuspected or likely spinal cord/column injurynMulti-system trauma patientnEvaluate fornNecknDeformity,Pain,Crepitus,Warmth,TendernessnBilateral ExtremitiesnFinger Abduction/AdductionnPush,Pull,GripsnMotor&Sensory FunctionnDermatome&Myotome evaluationnBabinski Sign TestnHold-Up PositionAssessment of the Spinal Injury PatientBabinskis Sign TestnStroke lateral aspect of the bottom of the footnEvaluate for movement of the toesnFanning and Flexing(lifting)nPositive signnInjury along the pyramidal(descending spinal)tractnVital SignsnBody TemperaturenAbove&Below site of injurynPulsenBlood PressurenRespirationsnOngoing AssessmentnRecheck elements of initial assessmentnRecheck vital signsnRecheck interventionsnRecheck any neurological deviationsAssessment of the Spinal Injury PatientnSpinal AlignmentnMove patient to a neutral,in-line positionnPosition of functionnHips and knees should be slightly flexed for maximum comfort and minimum stress on muscles,joints,&spinenPlace a rolled blanket under the kneesnALWAYS support the head and necknContraindications to neutral positionnMovement causes a noticeable increase in painnNoticeable resistance met during procedurenIncrease in neurological deficits occurs during movementnGross deformity of spinenLESS MOVEMENT IS BESTManagement of the Spinal Injury PatientnManual Cervical ImmobilizationnSeated PatientnApproach from frontnAssign a care giver to hold GENTLE manual tractionnReduce axial loadingnEvaluate posterior cervical spinenPosition patients head slowly to a neutral,in-line positionnSupine PatientnAssign a care giver to hold GENTLE manual tractionnAdultnLift head off ground 1-2:Neutral,in-line positionnChildnPosition head at ground level:Avoid flexionManagement of the Spinal Injury PatientnCervical Collar ApplicationnApply the c-collar as soon as possiblenAssess neck prior to placingnC-Collar limits some movement and reduces axial loadingnDOES NOT completely prevent movement of the necknSize and Apply according to the Manufacturers RecommendationnCollar should fit snugnCollar should NOT impede respirationsnHead should continue to be in neutral positionnSIZE IT,SIZE IT,SIZE IT!nDO NOT RELEASE manual control until the patient is fully secured in a spinal restriction deviceManagement of the Spinal Injury PatientnStanding TakedownnMinimum 3 rescuersnHave patient remain immobilenRescuer provides manual stabilization from behindnAssess necknSize and place c-collarnPosition board behind patientnGrasp board under patients shouldersnLower board to groundnSecure patientCOMMUNICATE WITH PARTNERS AND PATIENTManagement of the Spinal Injury PatientnHelmet RemovalnWhen to removenHelmet does not immobilize the patients head withinnCannot securely immobilize the helmet to the long spine boardnHelmet prevents airway carenHelmet prevents assessment of anticipated injuriesnPresent or Anticipated airway or breathing problemsnRemoval will not cause further injuryManagement of the Spinal Injury PatientnFootball helmetsnMust remove shoulder pads if helmet removednExcessive extensionnMotorcycle helmetsnMust be removed or sufficient padding under bodynExcessive flexionnHelmet RemovalnTechniquen2 RescuersnHave a plannRemove face mask and chin strapnImmobilize head nSlide one hand under back of neck and headnOther hand supports anterior neck and jawnRemove helmetnGently rock head to clear occiputnAll actions should be slow and deliberatenTRANSPORT HELMET with patientnCOMMUNICATION is the KEYManagement of the Spinal Injury PatientnAny movement MUST be coordinatednMove patient as a unitnNO LATERAL PUSHINGnMove patient up and down to prevent lateral bendingnRescuer at the head“CALLS all movesnALL MOVES MUST be slowly executed and well coordinatednConsider the final positioning of the patient prior to beginning moveMovement of the Spinal Injury PatientnTypes of movesnLog RollnStraddle SlidenRope-Sling SlidenOrthopedic StretchernVest-Type ImmobilizationnRapid ExtricationnFinal Patient PositioningnLong Spine BoardnDiving Injury ImmobilizationMovement of the Spinal Injury PatientnMedications&Spinal Cord injurynSteroidsnReduce the bodys response to injurynReduce swelling&pressure on cordnAdministered within 1st 8 hours of injurynTypes of MedicationsnMethylprednisolone(Solu-Medrol)nReduce capillary dilation and permeabilitynLoading dose:30 mg/kg over 15 minutesnMaintenance:5.4 mg/kg/hr over 23 hrsnDexamethasone(Decadron,Hexadrol)nReduce capillary dilation and permeabilityn5x more potent than Solu-Medroln4-24 mg(occasionally up to 100 mg)Management of the Spinal Injury PatientnMedications&Neurogenic ShocknFluid ChallengenIsotonic Solution:20 ml/kgn250 ml initiallynMonitor response and repeat as needednPASGnControversialnResearch shows no positive outcomenDopaminen2-20 mcg/kg/min titrated to blood pressurenAtropinen0.5-1.0 mg q 3-5 min(maximum of 2.0 mg)Management of the Spinal Injury PatientnMedications&the Combative PatientnConsider sedatives to reduce anxiety and calm patientnPrevents spinal injury aggravationnMedicationsnMeperidine(Demerol)nDiazepam(Valium)nConsider paralyticsManagement of the Spinal Injury PatientNeck TraumanFew emergencies pose as great a challenge as neck traumanairwaynvasculaturenneurologicalngastrointestinalnVasculature of the NecknCarotid ArteriesnArise fromnRIGHT:Brachiocephalic ArterynLEFT:Aorta ArterynSplitnInternal&External Carotid ArteriesnUpper border of the LarynxnCarotid Bodies&Sinuses locatednBodies:Monitor CO2 and O2 levelsnSinuses:Monitor Blood PressureAnatomy&Physiology of the Neck(continued)nJugular VeinsnExternalnSuperficial,lateral to the tracheanInternalnSheath with the carotid artery and vagus nerveAnatomy&Physiology of the NecknAirway StructuresnLarynxnEpiglottisnThyroid&Cricoid CartilagenTracheanPosterior border is anterior border of esophagusAnatomy&Physiology of the NecknOther StructuresnCervical SpinenMusculoskeletal FunctionnExternal Skeletal support of the head and necknAttachment point for spinal column ligamentsnAttachment point for tendons to move head and shouldersnNervous FunctionnSpinal Cord contained withinnPeripheral NervenExit between vertebraeAnatomy&Physiology of the NecknOther StructuresnEsophagusnCranial NervesnCN-IX(Glossopharyngeal)nCarotid Bodies&Carotid SinusesnCN-XnSpeech,swallowing,cardiac,respiratory&visceral functionnThoracic DuctnDelivers lymph to the venous systemAnatomy&Physiology of the Neck(continued)nGlandsnThyroidnRate of cellular metabolismnSystemic levels of calciumnBrachial PlexusnNetwork of nerves in lower neck and should that control arm and hand functionAnatomy&Physiology of the NeckCommonnMost common traumatic injuries to neck sprains and strainsNeck InjurynBlood Vessel TraumanBlunt traumanSerious hematomanLacerationnSerious exsanguinationnEntraining of air embolismnCover with occlusive dressingnAirway TraumanTracheal rupture or dissection from larynxnAirway swelling&compromiseNeck InjurynCervical Spine TraumanVertebral fracturenParesthesia,anaesthesia,paresis or paralysis beneath the level of the injurynNeurogenic shock may occurnOther Neck TraumanSubcutaneous emphysemanTension pneumothoraxnTraumatic asphyxianPenetrating TraumanEsophagus or TracheanVagus nerve disruptionnTachycardia&GI disturbancesnThyroid&Parathyroid glandsnHigh vascularnScene Size-upnInitial AssessmentnAirway,Breathing,CirculationnRapid Trauma AssessmentnHead,Face,NecknGlasgow Coma Scale ScorenVital SignsnFocused History&Physical ExamnDetailed AssessmentnOngoing AssessmentAssessment ofHead,Facial&Neck InjuriesnA single penetrating wound is capable of great harm seemingly inocuous wounds may not manifest clear Sx potentially lethal injuries may be overlooked or discountednairway occlusionnexsanguinationnMuskuloskeletalnc spinencervical m.ntendons,ligamnetsnlaryngeal N.nCN(IX-XII)nVasculaturencarotid A.ncommonninternalnexternalnvertebral A.nveinsnvertebralnbrachiocephalicnjugularAnterior and lateral most exposednVisceralnthoracic ductsnesophagusnpharynxnlarynxntracheanGlandularnthyroidnparathyroidnsubmandibularnparotidZone 1nsubclavian vesselsnbrachiocephalic veinsncommon carotid arterynjugular veinnaortic archntracheanesophagusnLung apicesnc spinenspinal cordnCN rootsThoracic inlet to cricoid cartilageZone 2nCarotid and vertebral arteriesnjugular veinsnpharynxnlarynxntracheanesophagusnc spinenspinal cordCricoid cartilage to angle of mandibleZone 3nSalivary glandsnparotid glandnesophagusntracheanc spinenCarotid arteriesnjugular veinsnCN IX-XIIAngle of mandible to base of skullPenetratingnknives 50%nguns 45%nshotgun 5%nGSW greatest injuriesndeeper penetrationncavitationnsuck debrisnbullet and bone fragmentsBluntnMVCsnsports relatedn“clothesline tacklenstrangulationnmanipulationnshoulder belt compressionDirect ForcenShearingnexcessive rotation/hyperextensionndistention and stretchingnintraoral injurynbasilar skull fxImpact Anterior NecknCrush larynx or trachea;cricoid ringncompress esophagus against spinal columnnsudden increased intratracheal pressure against closed glottis(seatbelt),crush bruise(clothesline tackle)nrapid acceleration/deceleration results in tracheal injuryStrangulationnHangingnligature suffocationnmanual chokingnpostural asphyxiationnchildren with neck over object and body weight produces compressionHangingnSignificant c spine/SCI occur only with fall body heightnsimple asphyxia rarely cause deathnc spine disruption subsequent to strangulationPathophysiology of HangingnVenous obstructionnHypoxianCerebral stagnationnArterial spasmsnDecreased cerebral blood flownVagal collapse nIncreased parasympathetic toneStatisticsn5-10%trauma neck injuriesncervical injuries initially missed mortality 15%nZone 1 injuries associated with increased morbidity and mortalitynHxnMOInquestion patient and bystandersnclarify eventsndrug/ETOH abusenestablish time of injurynbaseline conditionnblood loss/LOCMVCnSeatbelt usenpatient locationnairbag deploymentnmagnitude of vehicle damagePenetratingnWeapon usedncaliber gunnsize knifeHangingnSuspension timendrop heightnligaturenHx drug/ETOH usenHx suicide attemptsnPain-OPQRSTCV manifestationsnBleedingnSx associated with CVAAerodigestivenDyspneanhoarsenessndysphoniandysphagiaCNSnParasthesianweaknessnplegianpares