Module 3: Trauma and Spinal Injury

Learning Outcomes

1. Explain the mechanism of injury

2. Describe the basics of trauma management

 Primary survey
 Resuscitation
 Secondary survey

3. Discuss common conditions associated with trauma (pneumothorax, haemothorax,

flail chest etc. ) and their management
4. Discuss haemorrhagic shock and its management
5. Define spinal cord injury (SCI)
6. Identify the causes and risk factors of SCI
7. Describe the pathophysiology of SCI
8. Describe the signs and symptoms of SCI
9. Describe the complications of SCI
10. Describe the management of a patient with SCI

FOR EXAM:

Spinal Cord Injury Trauma

n Mechanism of injury n Types of injuries
n Risk factors n Clinical assessment
n Diagnostic tests n Complications
n Pathophysiology n Causes
n Treatment n Management
n Nursing care

n Complications
 1. Trauma – Overview & Initial Management

Definition of Trauma

Trauma occurs when external energy (mechanical, thermal, chemical, electrical, radiant or
hypoxic) is transferred to the body, resulting in tissue injury

Mechanisms of Injury (MOI)

n The extent of a patient’s injuries depends on the Mechanisms of Injury.

n Mechanisms of Injury are the exchange of forces between environment and person that
result in injury.
n The transfer of kinetic energy, or energy of motion (shock wave) to tissues results in injury.

There are many different types of energy agents, including:

 Mechanical/Kinetic: blunt or penetrating trauma

 Thermal: injury due to burns (heat or cold)
 Chemical: acids/alkalis exposure
 Electrical: electrocution
 Radiant: radiation exposure
 Oxygen deprivation: drowning, smoke inhalation

MOI provides clues to injury pattern and severity

Types of Traumatic Injury

1. Blunt Trauma

 Compression
 Shear
 Overpressure

2. Vehicle collusion

 Frontal impact collisions

 Lateral impact collisions
 Rear impact collisions
 Off-centre or rotational collisions
 Rollover

3. Open Vehicles
Initial Assessment and Management of the Trauma Patient

Preparation

 Team assembly
 Equipment check
 Triage by acuity

Trauma Management Sequence

1. Primary survey
2. Resuscitation
3. Secondary survey
4. Monitoring and evaluation
5. Transfer to definitive care (ICU, ward, theatre)

 Triage

 Sort patients by level of acuity

 Primary survey

 Designed to identify injuries that are immediately life threatening and to treat
them as they are identified

 Resuscitation

 Rapid procedures and treatment to treat injuries found in primary survey before
completing the secondary survey

 Secondary survey

 Full history and physical exam to evaluate for

 Monitoring and evaluation

 Transfer to definitive care

 ICU, ward, operating theatre, another facility

 n Primary Survey (ABCDE)

A – Airway with Cervical Spine Protection

 Loss of airway can cause death in <3 minutes

 Maintain cervical spine immobilisation
 Assess airway patency, RR, SpO₂, mental status
 Interventions: suction, jaw thrust, oxygen, intubation, cricothyrotomy

B – Breathing and Ventilation

Life-threatening injuries:

 Tension pneumothorax
 Haemothorax
 Flail chest
 Open pneumothorax

Management includes oxygen therapy, needle decompression and chest tube insertion

C – Circulation

 Assume haemorrhagic shock until proven otherwise

 Signs: hypotension, tachycardia, delayed capillary refill, decreased urine output
 Management: IV access, fluids, blood products, haemorrhage control

D – Disability

 Glasgow Coma Scale

 Pupillary assessment
 Motor and sensory function
 Rectal tone

E – Exposure

 Remove clothing
 Inspect entire body
 Log roll with spinal precautions
 Prevent hypothermia (hypothermia worsens coagulopathy)
Trauma Assessment Framework (ABCDE)

Primary Survey

Purpose: identify and treat life-threatening injuries immediately.

Airway and Protection of Spinal Cord

 Why first in the algorithm?

o Loss of airway can result in death in < 3 minutes
o Prolonged hypoxia = Inadequate perfusion, end-organ damage
 Airway assessment
o Vital signs = RR, O2 sat
o Mental status = Agitation, somnolent, coma
o Airway patency = Secretions, stridor, obstruction
o Traumatic injury above the clavicles
o Ventilation status = Accessory muscle use, retractions, wheezing
 Clinical signs and symptoms
o Patients who are speaking normally = do not have a need for immediate
airway management
o Hoarse or weak voice may indicate a subtle tracheal or laryngeal injury
o Noisy Respirations frequently indicates an obstructed respiratory pattern

Airway interventions

 Maintenance of Airway Patency

 Suction of secretions
 Chin lift/Jaw thrust
 Nasopharyngealairway
 Definitive airway (intubation)

 Airway support

 Oxygen (NRBM, Bag valve mask)

 Definitive airway

 Definitive Airway

 Endotracheal intubation
 In-line cervical stabilization

 Surgical cricothyroidotomy

 1. Breathing and Ventilation

n Identify Life Threatening Injuries

Tension pneumothorax

 Air trapping in the pleural space between the lung and chest wall
 Sufficient pressure builds up and pressure to compress the lungs and shift the
mediastinum
 Physical exam

- Absent breath sounds

- Air hunger
- Distended neck veins
- Tracheal shift

Treatment

 Needle decompression
 2nd Intercostal space, midclavicular line
 Tube thoracostomy
 5th Intercostal space, anterior axillary line
Haemothorax (blood)

 Blood collecting in the pleural space and is common after penetrating and blunt
chest trauma
 Source of bleeding = Lung, chest wall (intercostal arteries), heart, great vessels
(aorta), diaphragm
 Physical exam

- Absent or diminished breath sounds

- Dullness to percussion over chest
- Hemodynamic instability

 Treatment = Chest tube

 Thoracostomy

Flail Chest

 Direct injury to the chest resulting in an unstable segment of the chest wall that
moves separately from remainder of thoracic cage
 Typically results from two or more fractures on 2 or more ribs
 Typically accompanied by a pulmonary contusion
 Physical exam = Paradoxical movement of chest segment (does not expand)
 Treatment = Improve abnormalities in gas exchange

- Early intubation for patients with respiratory distress

- Avoidance of overaggressive fluid resuscitation

Open pneumothorax

 Sucking chest wound

 Large defect of chest wall
- Leads to rapid equilibration of atmospheric and intrathoracic pressure
- Impairs oxygenation and ventilation
 Initial treatment

- Three-sided occlusive dressing

- Provides a flutter valve effect
- Chest tube placement remote to site of wound
- Avoid complete dressing, will create a tension pneumothorax
 2. Circulation

n Shock

 Impaired tissue perfusion

 Tissue oxygenation is inadequate to meet metabolic demand
 Prolonged shock state leads to multiorgan system failure and cell death

Clinical signs of shock

 Altered mental status

 Tachycardia (HR > 100) = Most common sign
 Arterial hypotension (SBP < 120)
 Inadequate tissue perfusion

- Pale skin color

- Cool clammy skin
- Delayed cap refill (> 3 seconds)
- Altered LOC
- Decreased urine output (< 0.5 mL/kg/hr)

Types of shock in trauma

 Hemorrhagic

- Assume hemorrhagic shock in all trauma patients until proven

otherwise
- Results from internal or external bleeding

 Obstructive

- Cardiac tamponade
- Tension pneumothorax

 Neurogenic

- Spinal cord injury

Sources of bleeding

- Chest
- Abdomen
- Pelvis
- Bilateral femur fractures
Emergency nursing treatment

- Two large IV lines

- Cardiac monitor
- Blood pressure monitoring

General treatment:

- Stop bleeding (apply direct pressure)

- Close open book pelvic fractures
- Restore circulation volume (administer normal saline, blood peoducts)

3. Disability

Baseline neurologic exam (GCS)

- Pupillary exam (dilated pupil)

- AVPU scale (alert, verbal, pain, unresponsive
- Neurological exam
- Glasgow coma scale (8 or less = intubate)

Cervical Spinal Clearance

 Patients must be alert and oriented to person, place and time

 Not clinically intoxicated with alcohol or drugs
 Non-tender at all spinous processes
 No focal neurological deficits
 No distracting injuries
 Painless range of motion of neck

4. Exposure

 Remove all clothing

- Examine for other signs of injury

- Injuries cannot be diagnosed until seen by provider

 Logroll the patient to examine patient’s back

- Maintain cervical spinal immobilization

 - Palpate along thoracic and lumbar spine
- Minimum of 3 people, often more providers required

 Avoid hypothermia

- Apply warm blankets after removing clothes

- Hypothermia = Coagulopathy  Increases risk of hemorrhage

Physical Exam

n Battle Sign (fracture at base of the skull)

n Raccoon's Eyes
n Cullen’s Sign
n Grey-Turner Sign
 SPINAL CORD INJURY (SCI)

2.1 Definition of Spinal Cord Injury

SCI is damage to the spinal cord resulting in loss of function, such as mobility or sensation.

 The cord does not need to be severed.

 Most SCIs involve compression or bruising.
 SCI is different from:
o Ruptured discs
o Spinal stenosis
o Pinched nerves

2.2 Terminology

Quadriplegia (Tetraplegia)

 Dysfunction of arms, legs, bowel, and bladder CANNOT MOVE

 Caused by cervical spinal cord injury

Paraplegia

 Dysfunction of lower body, bowel, and bladder

 Caused by thoracic, lumbar, or sacral injury

Spinal Shock

 Temporary areflexic state

 Loss of autonomic control
 Lasts up to 6 weeks
 Common in cervical & upper thoracic injuries
 Recovery may improve after resolution

Neurogenic Shock

 Hemodynamic triad:
o Hypotension
o Bradycardia
o Peripheral vasodilation
 Caused by interruption of sympathetic control
 Occurs in acute SCI
2.3 Causes and Risk Factors

Causes

Main Mechanisms

 Contusion
 Laceration
 Transection
 Haemorrhage
 Vascular damage

Contributing Events

 Motor vehicle accidents

 Falls
 Gunshot wounds
 Assault
 Industrial accidents
 Sports injuries (especially diving into shallow water)

Risk Factors

 Age
 Gender
 Alcohol & drug abuse
Hyperflexion – Forcible forward bending, may compress vertebral bodies and disrupt
ligaments and intervertebral discs

Hyperextension -Forcible backward bending, disrupts ligaments and causes vertebral

fractures and stretching of the cord

Axial loading – A form of compression, is the application of vertical force to the spinal cold
column e,g falling and landing on the feet or buttocks or by diving into shallow water

Excessive rotation of the head may tear ligaments and cause compression fractures

Forces resulting in spinal cord

A , Flexion injury of the cervical spine

ruptures the posterior ligaments.

B , Hyperextension injury of the cervical

spine ruptures the anterior ligaments.

C , Fractured vertebrae that force bony

fragments into the spinal canal.

D , Flexion–rotation injury of the cervical

spine often results in tearing of
ligamentous structures that normally
stabilise the spine.
6. Pathophysiology of SCI

SCI involves primary and secondary injury.

Primary Injury

 Occurs at time of trauma

 Causes:
o Microscopic haemorrhage (grey matter)
o Oedema (white matter)

Secondary Injury (Hours–Days Later)

Caused by:

 Inflammatory response
 Vascular changes
 Intracellular calcium changes

Results in:

 Oedema
 Ischaemia
 Impaired microcirculation

Neurochemical Release

Injured tissue releases:

 Noradrenaline
 Serotonin
 Dopamine
 Histamine

These cause:

 Vasospasm
 Reduced perfusion
 Decreased oxygen delivery
 Ischaemia

If Ischaemia Prolonged:

 Necrosis within hours

 Nerve function lost within 24 hours
 White matter circulation returns in ~24 hours
  Grey matter circulation remains impaired

Extent of Injury

 Oedema extends 2 segments above and below injury

 Cannot fully assess extent for up to 1 week

Repair Phase

 Tissue repair: 3–4 weeks

 Neurons removed by macrophages (first 10 days)
 RBCs reabsorbed
 Area replaced with collagen
 Meninges thicken

7. Signs & Symptoms of Acute SCI

Below level of injury:

 Flaccid paralysis
 Loss of spinal reflexes
 Loss of sensation (pain, touch, temperature, proprioception)
 Loss of sweating
 Loss of sphincter tone
 Bowel & bladder dysfunction

8. Classification of SCI

1. Complete vs Incomplete

Complete SCI
  Total loss of motor & sensory function below injury
 Pathways completely interrupted

Incomplete SCI

 Partial interruption
 Variable function remains
 May move one limb more than another
 May feel but not move

2. Classification by Level of Injury

Cervical Injuries

 Affect arms, legs, trunk

 May affect breathing
 Can cause blood pressure instability

Thoracic Injuries

 Affect legs
 Can affect temperature control
 May cause abnormal sweating

Lumbar/Sacral Injuries

 Affect one or both legs

 Affect bowel & bladder control

9. Vital Signs in SCI

Autonomic dysfunction causes instability.

Heart Rate

 Bradycardia common
 Triggered by suctioning (unopposed vagal activity)

Blood Pressure

 Loss of vasomotor tone

 Vasodilation
 Hypotension
 Neurogenic shock may last weeks
  May require:
o IV fluids
o Vasopressors (e.g., noradrenaline)

Excess fluids → pulmonary oedema

Temperature

 Loss of temperature regulation

 Cannot sweat, shiver, vasoconstrict, or reposition

10. ASIA Impairment Scale

A – Complete

 No motor or sensory function in S4-S5

B – Incomplete

 Sensory preserved, no motor

C – Incomplete

 Motor preserved
 50% muscles < grade 3

D – Incomplete

 Motor preserved
 ≥50% muscles ≥ grade 3

E – Normal

 Normal motor & sensory

11. Breathing in SCI

Respiratory compromise depends on level:

C1–C4

 Diaphragm paralysis
 Requires mechanical ventilation
C5–T6

 Intercostal paralysis
 Diapagm may work
 May require respiratory support

T6–T12

 Abdominal muscle paralysis

 Reduced cough effectiveness

Assessment

 Pattern & effort

 Ability to cough
 Auscultation
 SpO₂
 ETCO₂
 ABG

Intubate if inadequate respiration.

12. Complications of SCI

1. Bladder (Neurogenic Bladder)

 Prevent infection
 Minimise incontinence
 Establish safe emptying

2. Bowel (Neurogenic Bowel)

Risk of:

 Constipation
 Diarrhoea
 Impaction

Affected by:

 Opioids
 Antibiotics
 Immobility
 Poor fluid/fibre
13. Spinal Shock

 Complete loss of neurologic function below injury

 Includes reflexes & rectal tone
 Flaccid paralysis
 Bowel & bladder paralysis
 May have priapism
 Initial hypertension (catecholamine release)
 Followed by hypotension
 Lasts hours to days
 Reflexes return (bulbocavernosus reflex)

Lower thoracic injuries → assume haemorrhagic shock until proven otherwise.

14. Neurogenic Shock

Occurs above T6.

Features:

 Hypotension
 Bradycardia
 Vasodilation
 Hypothermia

Due to:

 Disrupted sympathetic outflow (T1-L2)

 Unopposed vagal tone

Different from hypovolemic shock (which causes tachycardia).

15. Autonomic Dysreflexia

Occurs in injuries at or above T6.

Usually weeks after injury.

Excessive response to noxious stimuli below injury.

Signs & Symptoms

 Severe hypertension (medical emergency)

 Bradycardia
 Severe headache
  Flushed skin
 Sweating
 Goosebumps
 Blurred vision
 Anxiety
 Nasal congestion

Common Causes

 Full bladder
 Bowel impaction
 Pressure sores
 Tight clothing
 Fractures
 Ingrown toenails
 Ejaculation

Management

 Remove stimulus
 Loosen clothing
 Catheterise (with lignocaine gel)
 Bowel disimpaction
 Monitor BP every 5 min
 Antihypertensives if needed

16. Treatment of SCI

SCI is a medical emergency.

Pharmacological

 Methylprednisolone no longer recommended

 Low molecular weight heparin → prevent VTE
 Vasopressors (dopamine)

Surgical

 Decompression laminectomy
 Remove bone fragments/disc fragments
 Spinal fusion
 Bracing

Conservative

 Bed rest
  Spinal traction
 Skull tongs

Spasticity Management

 Baclofen
 Botulinum toxin

Pain Management

 Analgesics
 Muscle relaxants
 Physical therapy