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Acute Referral Procedure

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Pre-Hospital Care and Transfer of a Spinal Cord Injury:   

1.0 Introduction
2.0 Assessment
3.0 The Unconscious Patient
4.0 Handling the Patient with a Spinal Cord Injury
5.0 Transfer to A&E
6.0 References
Further Information

1.0 INTRODUCTION

People who sustain a spinal cord injury require specialised care and rehabilitation. The Queen Elizabeth National Spinal Injuries unit within the Southern General Hospital, Glasgow opened in 1992 and is the national unit for Scotland. The unit provides facilities for the acute care of these patients together with rehabilitation and life-long follow-up.

Pre-hospital care and the initial management of a patient with a suspected spinal cord injury can have major implications for the patient’s long-term management.(1) It is the intention of this booklet to assist these professionals in the initial assessment and stabilisation of the patient prior to transfer to the spinal injuries unit.

2.0 ASSESSMENT

Think Spinal Injury

Following an accident the potential for a spinal cord injury to exist must be considered. People may present with full movement and sensation of all four limbs. However they may have a vertebral fracture and if handled incorrectly the spinal cord may be damaged and the results could be devastating.

Spinal injuries should be suspected in all casualties who have been involved in:

1. Road traffic accident.

2. A fall or jump from a height.

3. An accident resulting in impact or crush injuries.

4. An accident resulting in multiple trauma.

5. An accident resulting in the casualty losing consciousness.

6. Penetrating trauma to the neck and/or trunk eg. stab wounds, gunshot wounds.

and, if

7. Following injury the patient complains of back or neck pain and appears to be guarding their back or neck.

8. The patient complains of any sensory changes or loss such as numbness or tingling.

A description of the accident can give an indication of the potential injuries.

A full but quick examination of the patient is essential in order to identify and stabilise possible injuries. This is known as the primary survey. In the primary survey due to the risk of anoxic damage and damage from under perfusion airway, breathing and circulation must take priority over cord or potential cord injuries. However, although airway, breathing and circulation are a priority in any initial assessment, a suspected spinal injury can be considered concurrently.

Airway(3,4)

As soon as it is feasible the patient should be placed into the neutral supine position. Airway obstruction leads to hypoxia which will eventually lead to cord deterioration. The largest group of patients who present with a significant airway compromise are usually those with an impaired conscious level.

Observation:

• Look for evidence of breathing difficulties, obstruction or aspiration.

• Listen for noisy breathing, stridor or gurgling - evidence of airway compromise.

• Feel for air exchange, deformity or foreign bodies in the mouth or throat.

Action:

• Clear airway of any obstruction, use a gloved finger to scoop the inside of the mouth.

• Remove any foreign bodies from the mouth or throat.

• Oral suctioning may be necessary.

• To protect a threatened airway do not hyperextend the neck instead use the jaw thrust or chin lift technique.

• Guedel airways can be used to keep the airway open. Naso-pharyngeal airways must be used with caution particularly in patients with head injuries eg base of skull fracture.

Breathing (3, 4)

Assessment of the breathing involves looking for adequacy of ventilation and oxygenation. These may be impaired not only in head and spinal injuries due to hypoventilation but, also in life threatening chest injuries eg pneumothorax, haemothorax.

Observation:

Look for:

• Presence, rate & depth of respirations.

• Shallow or abdominal breathing

• Asymmetry of the chest.

• Paradoxical breathing in cervical injuries.

Action:

• Continuously monitor oxygen saturation levels.

• Maintain SaO2 at 95% or above.

• Administer high flow oxygen via an oxygen mask with a re-breathe bag (this is especially important where chest injuries are suspected).

The risk of deteriorating respiratory function is extremely high in all patients due to:

• Fatigue of innovated muscles.

• Chest trauma.

• Ascension of spinal cord lesion.

• Retained secretions.

Circulation (3,4)

Neurogenic shock is the response to sudden loss of sympathetic control. Lack of vasomotor control results in significant hypotension. Bradycardia occurs as a result of unopposed effects of the vagus nerve.

The detection of internal haemorrhage is difficult in the spinal cord injured as they already have a significant low BP and also with a lack of sensation below the level of the injury the patient is unaware and cannot alert to a potential problem. Therefore it is vital that a thorough search for haemorrhage is made.

Shock in the multiple trauma patient must not be considered to be caused solely by spinal shock. As haemorrhage is likely aggressive fluid administration is instigated until proven otherwise. This involves screening for haemorrhage into the pelvis abdomen and chest.

Generally speaking patients suffering from haemorrhagic shock present:

• Hypotensive.

• Tachycardic with thready pulse.

• Colour poor.

• Skin cold and clammy.

When a patient has a normal pulse but is hypotensive then spinal plus trauma injury should be suspected.

The patient suffering solely from spinal shock will present:

• Hypotensive.

• Bradycardic with pulse of good volume.

• Colour good.

• Peripherally warm and dry.

In the casualty who has an isolated spinal cord injury, fluid administration should be done with care.

Observation:

• Monitor BP.

Action:

• Maintain a systolic BP of 90-100mmHg.

• Administer IV fluids.

N.B. Do not over infuse. This may precipitate cardiac failure and pulmonary oedema.

Observation:

• Bradycardia

Action

• If heart rate drops below and remains below 40 beats per minute, give Atropine 300-600 micrograms, may be given as IV bolus.

• N.B. An abnormal vasovagal response can occur through stimulation such as rapid changes in body positioning - logrolling too quickly, tracheal suctioning, passing an N.G. tube etc.

Neurological Status (2)

Examine for both Sensation and Motor Power.

Examine by:

1. Light Touch.

2. Blunt pin (pain).

Record level of normal sensation by drawing a line on the patient’s skin.

Note levels:

C4 Shoulders

C6 Thumbs

T10 Umbilicus

T12 Groin

L3 Front of knee

L5 Big toe

S1 Little toe

S3 Genitalia

Motor Power Key Levels

C4 Shrug shoulder

C5 Bend elbow

C6 Push wrist backwards

C8 Open and close hands

T1-T12 Look for intercostal muscles

L1- L5 Look for abdominal muscles

L1-L2 Bend hip

L3 Straighten knee

L4 Pull foot up

L5-S1 Push foot down

3.0 THE UNCONSCIOUS PATIENT

Think Spinal Injury

• Airway:

Consider the need for intubation.

• Breathing:

Look for paradoxical breathing.

• Circulation:

Hypotension & bradycardia (slow pulse) - usually means spinal cord injury (quadriplegia/tetraplegia).

• Flaccid Limbs.

• Loss of Reflexes.

• Loss of response to pain.

• Erection (priaprism) in the male.

4.0 HANDLING THE PATIENT WITH A SPINAL CORD INJURY

Pre-hospital personnel must immobilise suspected spinal cord injury patients before their transport to the A&E department.

Following an accident it is important to place the patient as soon as it is feasible into a neutral supine position keeping the spine in alignment at all times to avoid further pressure or damage on the cord.

There are many devices such as the Kendrick extrication device which ensures that the spine is kept still during extraction from vehicles etc.

In suspected cervical injuries the neck should be immobilised using a stiff neck collar(5).

To ensure that total immobilisation of the spine is maintained when the patient is moved there are 2 techniques which can be applied.

1. Logroll.

Spinal Lift (2,6)

Skin

The risk of developing pressure sores following spinal cord injury is extremely high due to:

• Lack of sensation, the patient is unaware that there may be a problem.

• Lack of muscle activity below the level of injury.

• Poor capillary perfusion reducing tissue oxygenation.

Observation:

• Check all pressure areas for signs of skin breakdown.

Action:

• Remove any objects from patient’s clothing (may cause pressure).

• Logroll patient to ensure there is nothing that could cause pressure - objects in back pockets etc.

• Heels vulnerable when lying flat on back. If feasible place a small pillow or rolled up towel underneath the ankles to keep heels pressure free.

• Pressure relief must be carried out 2 hourly.

• If properly secured on a vacuum mattress the whole unit can be moved from side to side without compromising the spine.

• Protect risk areas at all times. Pressure sores often occur within the first few hours following injury.

Temperature

During neurogenic shock due to the passively dilated blood vessels the body loses heat. As patients are unable to shiver below the level of injury they cannot generate heat and hypothermia can occur.

Observation:

• Monitor temperature.

Action

• Prevent hypothermia by covering patient with sheet, space blanket then blankets.

Note: Be aware of the risk of fire when using oxygen therapy and space blankets.

If there is any delay (ie. more than 4 hours) between time of accident and arrival to the A & E department, consider the following:

Paralytic Ileus

Paralytic ileus is common in neurogenic shock. There is a risk of vomiting/aspiration.

Observation:

• Listen to abdomen for presence of bowel sounds.

• Observe for abdominal distention.

Action:

• Nil - by - mouth.

• Pass naso-gastric tube - free drainage. N.B. Passing a N-G tube is contra-indicated in those casualties who have a suspected head injury (base of skull fracture).

Bladder

During neurogenic shock bladder control is lost. Urinary retention can occur.

Observation:

• Avoid overdistention of the bladder.

Action:

• Insert foley catheter, urine volume should be monitored hourly. This also gives a good indication for fluid replacement.

• If the patient has priapsim or has pelvic injuries, do not attempt urethral catheterisation, there may be urethral trauma.

• Medical team pass supra-pubic catheter in this instance.

5.0 TRANSFER TO THE A & E DEPARTMENT

The spinal unit recommends a vacuum mattress for transportation of all levels of injury. If this is not available then use a spinal board.

Skull traction may be left in place. The weights can be removed for transfer and position maintained by hand with the added stabilisation of a rigid collar, sand bags at either side of the head and tape across the forehead. Immobilisation straps across the patient should allow easy access and must not impede chest and abdominal movements.

The patient will require pressure relief at 2 hourly intervals as previously mentioned. If this cannot be carried out by the transferring team then transfer by air should be considered. There are practically no contra-indications to transfer by air except patients with chest injuries who may require intercostal drainage.

Speed of transfer

Recent advice suggests that a properly immobilised spinal injured patient can be transferred at normal speeds appropriate for the road. Sudden acceleration and deceleration should be avoided – note advantage of police escort.

6.0 REFERENCES

1. Spinal Injuries Association. 1997. A

Charter for Support: The Spinal Injuries Association recommendations regarding NHS treatment of people confirmed, suspected or potentially experiencing spinal cord injury. Spinal Injuries Association. London.

2. American College of Surgeons. 1997.

Advanced Trauma Life Support Manual. Chicago.

3. Zedjdlik Cynthia Perry. 1992.

Management of Spinal Cord Injury. 2nd. edition. Jones and Bartlett. Boston.

4. Grundy D, Swain A. 1992. ABC of Spinal

Cord Injury 2nd. edition. British Medical Journal Publishing Group. London.

5. Laerdal. Stiffneck Extrication Collars.

Laerdal Medical Ltd. Kent.

6. Edward Benzel, David Doezema. Early

Care Chapter 78 - Spinal Cord Injury Part II. 1996.

For further information and advice please contact:

The Queen Elizabeth National Spinal Injuries Unit                               Southern General Hospital Division                                                   1345 Govan Road, Glasgow G51 4TF

Telephone: 0141-201 2533 (Edenhall Ward)

0141-201 2550 (Night Answerphone)

Facsimile: 0141-201 2991

E-mail: spinalunit@sgh.scot.nhs.uk

Copyright 2009 The Queen Elizabeth National Spinal Injuries Unit

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