EMS World

SEP 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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44 SEPTEMBER 2018 | EMSWORLD.com CONTINUING EDUCATION Y ou arrive on scene at a shopping mall with a BLS crew to find a 78-year-old woman lying at the bottom of a staircase. A bystander says he saw the woman lose her balance and fall backward down the stairs. As you approach, the woman complains of numb- ness in her hands and feet and says she hasn't been able to move. She also com- plains of feeling light-headed. You direct your partner to hold manual c-spine stabilization while you perform a rapid trauma exam and check vitals. The trauma exam is significant for a contusion over the occiput and point tenderness over the cervical spine. She has diminished sen- sation in her distal upper and lower extremi- ties. Her grip strength is diminished, and she is unable to move either foot or wiggle her toes. Her skin is warm and pink. Vital signs are significant for blood pressure of 60/30, heart rate of 52, and respirations of 22. While you direct the BLS crew to apply a cervical collar and package the patient for transport, you wonder what is causing her hypotension and bradycardia. Spinal Cord Injury Spinal cord injur y (SCI) is devastating to patients. Given the lifelong disability associated with these injuries and fear that neurological injury may be exacer- bated during transport, immobilization of the spine using cervical collars and back- boards has long been ingrained into EMS training and protocols. However, recent research highlighting the potential harms and uncer tain benefit of backboards has triggered a shift from the historical "backboard everyone" approach to a more selective protocol of spinal protection. 1 With this more nuanced approach, it has become even more important for EMS providers to understand the mechanisms and management of spinal cord injury. SCI can be caused by a variety of trau- matic mechanisms. Motor vehicle colli- sions are the most common, accounting for 48% of all SCIs.² Falls account for 16% and are the most common cause in patients over 60. 2,3 Violence and sport- ing accidents are other common causes. 2 Injury to the spinal cord can occur as a result of vertebral fractures or dislocation, direct damage to the cord from penetrat- ing trauma (e.g., shootings or stabbings), or tearing of the ligaments that support the spine. 4 Unstable fractures are of par- ticular concern to EMS because they have the potential to cause or worsen SCI if the spine is not protected during transport. 5 While unstable fractures can occur after blunt trauma, they are exceedingly rare in patients with penetrating injuries. 6 Spinal fractures can also result in bleeding with- in the epidural space of the spinal cord, much like how there can be an epidural hematoma in the brain. Bleeding within the epidural space of the spinal cord can result in neurological deficits similar to those observed in direct SCI. Patients on anticoagulants are at increased risk for spinal epidural hematoma after trauma. After the initial insult to the spinal cord, a series of changes at the cellular level result in additional damage to neurons in the spinal cord. These cellular insults, termed the secondary mechanisms of SCI, can be exacerbated by hypoxemia or hypotension. 3,7 Early identification and treatment of hypotension and hypoxemia in patients with SCI is therefore impor- tant to avoid secondary damage to the spinal cord. The majority of SCIs occur at the level of the cervical spine. 7 The cervical spine is vulnerable to injury because there are few surrounding structures to provide support. In addition, the joints between cervical vertebrae require less force to dislocate than the joints in the thoracic and lum- ber spine. 3 Because the cervical spine is inherently less stable and more likely to be injured than the thoracic or lumbar, it is particularly important to immobilize. Many disorders of the spine can pre- dispose patients to SCI after traumatic injur y. Osteoporosis increases the risk for SCI and may reduce the mechanism required to produce it. 4 Rheumatoid arthritis can cause destruction of the cervical joints, predisposing patients to severe SCI from low-mechanism injuries. 8 A variety of other degenerative spinal con- This CE activity is approved by EMS World, an organization accredited by the Commission on Accreditation for Pre-Hospital Continuing Education (CAPCE), for 1 CEU upon successful completion of the post-test available at EMSWorldCE.com . Test costs $6.95. Questions? E-mail editor@EMSWorld.com. • Identify patterns of neurological deficits in spinal cord injury • Describe the management of spinal cord injury • Recognize neurogenic shock • Describe the pathophysiology and management of neurogenic shock OBJECTIVES Spinal Cord Injury and Neurogenic Shock Recognize and treat shock in SCI patients before it causes further damage By Alexander J. Ordoobadi, NREMT-I, and Sean M. Kivlehan, MD, MPH, NREMT-P Sean M. Kivlehan is a Featured Speaker at EMS World Expo, Oct. 29-Nov. 2, 2018, Nashville, TN emsworldexpo.com

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