EMS World

SEP 2018

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46 SEPTEMBER 2018 | EMSWORLD.com CONTINUING EDUCATION ing the patient to plantar-flex their feet. Sensory deficits and motor weakness or paralysis are highly suspicious for SCI. It also is helpful to ascertain whether the patient was ambulatory on scene prior to EMS arrival, since the ability to ambulate decreases the likelihood of SCI. Assessment of the patient with sus- pected spine injury can be hindered by painful distracting injuries and altered mental status. Painful distracting injuries can make detection of point spine ten- derness difficult. Altered mental status, whether caused by head injury or intoxica- tion, prevents accurate identification of neurological deficits, making it difficult to rule out SCI in these patients. Since both head injuries and alcohol use are asso- ciated with cervical spine injuries, there should be heightened suspicion for SCI in these patients. 7 Managing Complications Approaches to spinal protection var y widely, and EMS providers should follow their local protocols. However, there are some principles that guide the general approach to spinal protection. Given the potential harms of back- boards, many EMS agencies have cur- tailed their use. Some restrict the use of backboards to patients at high risk for SCI, since the benefit of spinal immobilization in these patients may outweigh the risks. Other agencies do not use backboards for any patients. Backboards generally should not be used for patients with pen- etrating trauma. 6,13 Spinal protection can be achieved without the use of a backboard by using the "cot and collar" method. This involves applying a cervical collar and securing the patient to the ambulance cot with seat belts. With this method the cot acts as a padded backboard, with the seat belts preventing excessive movement of the spine. 1 Towel rolls or head blocks can be used to further secure the cervical spine. If the cot and collar method is used, the patient must be safely moved from where they are found to the ambulance cot. The first step upon arriving on scene is to apply a cervical collar to the patient and initiate manual c-spine stabilization. Patients who are alert, able to follow instructions, and able to ambulate may be allowed to self-extricate and sit down on the cot. Studies of simulated extrica- tions have demonstrated that allowing patients to self-extricate after being given clear instructions to avoid unnecessary movement of the head is associated with less movement of the cervical spine than conventional extrication methods. 14,15 If patients are unable to self-extricate, a scoop stretcher or backboard can be used to help move them to the cot. The scoop stretcher may be favored for patients found lying supine because its applica- tion causes less movement of the spine than application of a backboard. 16 In addition to protecting the spine, EMS providers should evaluate for and treat any compromise to airway or breathing. As discussed above, any SCI above the level of C5 can impair ventilations by causing paralysis of the diaphragm. Neurogenic shock is a form of distribu- tive shock that occurs in 20% of cases of cervical SCI. 17 It is caused by disruption of sympathetic output from the spinal cord. The loss of sympathetic tone results in a loss of peripheral vasoconstriction, leading to hypotension and warm skin. Without sympathetic innervation to the heart, there is unopposed vagal activ- ity, leading to bradycardia. Together, the cardinal signs of neurogenic shock are hypotension, bradycardia, and warm skin in patients with suspected SCI. It is important to understand the dis- tinction between neurogenic shock and spinal shock, since the terms are often confused. Spinal shock refers to flac- cid paralysis and loss of spinal reflexes that occurs after SCI. 18 Spinal shock is a temporary state, and spinal reflexes and motor function may return once spinal shock resolves. Although patients with spinal shock may also develop neurogenic shock, the terms are not interchangeable. Types of Shock in Trauma EMS providers must initially consider the full range of possible causes of shock in trauma before concluding their patient is suffering from neurogenic shock. Hypo- volemic shock is the most common cause of shock in trauma. The body responds to hypovolemic shock by activating the sympathetic nervous system, resulting in increased heart rate and vasoconstriction. Patients with hypovolemic shock there- fore present with varying degrees of pale, cool skin, tachycardia, and hypotension. Obstructive shock can be present if there is cardiac tamponade or tension pneumothorax and would present with signs of tension pneumothorax (e.g., diminished lung sounds and JVD) and/or signs of cardiac tamponade (e.g., JVD and decreased heart sounds) in addition to hypotension and tachycardia. Neurogenic shock presents differently from hypovo- lemic and obstructive shock. Because sympathetic tone is lost in neurogenic shock, there will be vasodilation and bradycardia. The vasodilation results in warm, well-perfused skin in addition to hypotension. Because hemorrhage is the most com- mon cause of shock in trauma, suspect it whenever neurogenic shock is considered. Patients with SCI have high rates of inter- nal injuries because the forces required to cause SCI are often powerful enough to SCI PEARLS AND PITFALLS • Burning, numbness, or tingling may be the initial presenting symptom of SCI. The presence of any of these symptoms should raise suspicion for SCI even in the absence of motor or sensory deficits. • Rheumatoid arthritis, ankylosing spondylitis, and osteoporosis can lead to vertebral fractures after low-mechanism trauma. Have an elevated index of suspicion for vertebral fractures and SCI in patients with degenerative conditions that affect the spine. • Spinal cord injury does not always present with bilateral motor and sensory deficits. Patients with Brown-Séquard syndrome or other forms of incomplete SCI may have weakness or sensory deficits on only one side of the body. Patients with central cord syndrome may have weakness in the bilateral upper extremities but intact strength in the lower extremities.

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