外科急診創(chuàng)傷之脊椎損傷

SpinalCordInjuriesL.Barnes,BS,CCEMT-P,NREMT-P“Amongallneurologicdisorders,thecosttosocietyofautomotiveSCIisexceededonlybythecostofmentalretardation.〞 NationalInstitutesofHealth33bonescomprisethespineFunctionSkeletalsupportstructureMajorportionofaxialskeletonProtectivecontainerforspinalcordVertebralBodyMajorweight-bearingcomponentAnteriortoothervertebraecomponentsSpinalAnatomyandPhysiology

VertebralColumnSizeofVertebraeC-1&C-2NovertebralbodySupportheadAllowforturningofheadVertebralbodysizeincreasethemoreinferiortheybecomeLumbarspinehasstrongestandlargestBearweightofthebodySacral&CoccyxvertebraearefusedNovertebralbodySpinalAnatomyandPhysiology

VertebralColumnComponentsofVertebraeSpinalCanalOpeninginthevertebraethatthespinalcordpassesthroughPediclesThick,bonystructuresthatconnectthevertebralbodytothespinousandtransverseprocessesLaminaePosteriorbonesofvertebraethatmakeupforamenTransverseProcessBilateralprojectionsfromvertebraeMuscleattachmentandarticulationlocationwithribsSpinalAnatomyandPhysiology

VertebralColumnComponentsofVertebraeSpinousProcessPosteriorprominenceonvertebraeIntervertebralDisksCartilagenouspadbetweenvertebraeServesasshockabsorberSpinalAnatomyandPhysiology

VertebralColumn(continued)VertebralLigamentsAnteriorLongitudinalAnteriorsurfaceofvertebralbodiesProvidesmajorstabilityofthespinalcolumnResistshyperextensionPosteriorLongitudinalPostersurfaceofvertebralbodiesinspinalcanalPreventshyperflexionSpinalAnatomyandPhysiology

VertebralColumnCervicalSpine7vertebraeSolesupportforheadHeadweighs16-22poundsC-1(Atlas)SupportsHeadSecurelyaffixedtotheocciputPermitsnoddingC-2(Axis)OdontoidProcess(Dens)ProjectsupwardProvidespivotpointsoheadcanrotateC-7Prominentspinousprocess(vertebraprominens)SpinalAnatomyandPhysiology

DivisionsoftheVertebralColumnThoracicSpine12vertebrae1stribarticulateswithT-1AttachestotransverseprocessandvertebralbodyNextnineribsattachtotheinferiorandsuperiorportionofadjacentvertebralbodiesLimitsribmovementandprovidesincreasedrigidityLargerandstrongerthancervicalspineLargermuscleshelptoensurethatthebodystayserectSupportsmovementofthethoraciccageduringrespirationsSpinalAnatomyandPhysiology

DivisionsoftheVertebralColumnLumbarSpine5vertebraeBearforcesofbendingandliftingabovethepelvisLargestandthickestvertebralbodiesandintervertebraldisksSpinalAnatomyandPhysiology

DivisionsoftheVertebralColumnSacralSpine5fusedvertebraeFormposteriorplateofpelvisHelpprotecturinaryandreproductiveorgansAttachespelvisandlowerextremitiestoaxialskeletonCoccygealSpine3-5fusedvertebraeResidualelementsofatailSpinalAnatomyandPhysiology

DivisionsoftheVertebralColumnLayersDuramaterArachnoidPiamaterCoverentirespinalcordandperipheralnerverootsthatexitCSFbathesspinalcordbyfillingthesubarachnoidspaceExchangeofnutrientsandwasteproductsAbsorbsshocksofsuddenmovementSpinalAnatomyandPhysiology

SpinalMeningesFunctionTransmitssensoryinputfrombodytothebrainConductsmotorimpulsesfrombraintomusclesandorgansReflexCenterInterceptssensorysignalsandinitiatesareflexsignalGrowthFetusEntirecordfillsentirespinalforamenAdultBaseofbraintoL-1orL-2levelPeripheralnerverootspulledintospinalforamenatthedistalend(CaudaEquina)SpinalAnatomyandPhysiology

SpinalCordBloodSupplyPairedspinalarteriesBranchoffthevertebral,cervical,thoracic,andlumbararteriesTravelthroughintervertebralforaminaSplitintoanteriorandposteriorarteriesSpinalAnatomyandPhysiology

SpinalCordGeneralCordAnatomyAnteriorMedialFissureDeepcreasealongtheventralsurfaceofthespinalcordthatdividescordintoleft&righthalvesPosteriorMedialFissureShallowlongitudinalgroovealongthedorsalsurfaceGrayMatterAreaoftheCNSdominatedbynervecellbodiesCentralportionofthespinalcordWhiteMatterSurroundsgraymatter.ComprisedofaxonsSpinalAnatomyandPhysiology

SpinalCordGeneralCordAnatomyAxonsTransmitsignalsupwardtothebrainanddowntothebodyAscendingTractsAxonsthattransmitsignalstothebrainSensoryTractsDescendingTractsAxonsthattransmitsignalstothebodyMotortractsVoluntaryandfinemusclemovementSpinalAnatomyandPhysiology

SpinalCord31pairsofnervesthatoriginatealongthespinalcordfromanteriorandposteriornerverootsSensory&motorfunctionsTravelthroughintervertebralforamina1stpairexitbetweentheskullandC-1RemainderofpairsexitbelowthevertebraeEachpairhas2dorsaland2ventralrootsVentralroots:motorimpulsesfromcordtobodyDorsalroots:sensoryimpulsesfrombodytocordC-1&Co-1donothavedorsalrootsSpinalAnatomyandPhysiology

SpinalNervesSpinalAnatomyandPhysiology

SpinalNerves(continued)PlexusNerverootsthatconvergeinaclusterofnervesCervicalPlexus5cervicalnerverootsInnervatestheneckProducesthephrenicnervePeripheralnerverootsC-3thruC-5Responsiblefordiaphragmcontrol“C3,4&5keepsthediaphragmalive〞SpinalAnatomyandPhysiology

SpinalNervesBrachialPlexusC-5thruT-1ControlstheupperextremityLumbar&SacralPlexusInnervationofthelowerextremityReflexPathwaysFunctionSpeedsbody’sresponsetostressorsReducesseriousnessofinjuryBodystabilizationOccurinspecialneuronsInterneuronsExampleTouchhotstoveSeverepainsendsintenseimpulsetobrainStrongsignaltriggersinterneuroninthespinalcordtodirectasignaltotheflexormuscleLimbwithdrawswithoutwaitingforasignalfromthebrainSpinalAnatomyandPhysiology

SpinalNervesSubdivisionofANSParasympathetic“Feed&Breed〞ControlsrestandregenerationPeripheralnerverootsfromthesacralandcranialnervesMajorFunctionsSlowsheartrateIncreasedigestivesystemactivityPlaysaroleinsexualstimulationSpinalAnatomyandPhysiology

SpinalNervesSubdivisionofANSSympathetic“FightorFlight〞IncreasesmetabolicrateBranchesfromnervesinthethoracicandlumbarregionsMajorFunctionsDecreaseorgananddigestivesystemactivityVasoconstrictionReleaseofepinephrineandnorepinephrineSystemicvascularresistanceReducevenousbloodvolumeIncreaseperipheralvascularresistanceIncreasesheartrateIncreasecardiacoutputSpinalAnatomyandPhysiology

SpinalNervesColumnInjuryMovementofvertebraefromnormalpositionSubluxationorDislocationFracturesSpinousprocessandTransverseprocessPedicleandLaminaeVertebralbodyRupturedintervertebraldisksCommonsitesofinjuryC-1/C-2:DelicatevertebraeC-7:TransitionfromflexiblecervicalspinetothoraxT-12/L-1:DifferentflexibilitybetweenthoracicandlumbarregionsPathophysiologyof

SpinalInjuryCordInjuryConcussionSimilartocerebralconcussionTemporaryandtransientdisruptionofcordfunctionContusionBruisingofthecordTissuedamage,vascularleakageandswellingCompressionSecondaryto:displacementofthevertebraeherniationofinterverterbraldiskdisplacementofvertebralbonefragmentswellingfromadjacenttissuePathophysiologyof

SpinalInjuryCordInjuryLacerationCausesBonyfragmentsdrivenintothevertebralforamenCordmaybestretchedtothepointoftearingHemorrhageintocordtissue,swellinganddisruptionofimpulsesHemorrhageAssociatedwithcontusion,laceration,orstretchingPathophysiologyof

SpinalInjuryClassificationClassifyasoneofcordsyndromesIncompletecordsyndromesmayhavevariableneurologicfindingsSCIsyndromesConcussionComplete<5%recoveryIncompleteMOIAxialloadingFlexion,hyperextension,hyperrotationDistractionLateralbendingAtlasAxisAxialLoadingSpinalcompressionForcestransmitteddirectlythroughspinalcolumnHittotopofhead-divingLandingonfeet/buttocksNarrowingofintervetebralspacesShiftingofIVdisksFracturesCompressionExplodingBurstJeffersonFxUnstableaxialcompressionFxBurstFxC4inxrayJeffersonFx-burstFxC1(TypeIVatlasFx)Flexion,Hyperextension,HyperrotationOfteninvolveligaments,surroundingmusculatureFxWedgeSubluxatonRotationIVdiscdisplacement,ruptureEdema,swellingHemorrhageUsuallyduetorapidacceleration/decelerationShoulderharnesswithlapbeltOdontoidFxTypeITypeIITypeIIISimpleflexion-stableFlexionteardrop-unstableWedgeFxChildwithC6flexionwedgeFxAnteriorsubluxationStablewithextensionPotentiallyunstablewithflexionClayshovelerFxLateralBendingRequirelessmotionthanextension/flexionduetolimitedrangeFx,softtissueinjuriesSideimpactMVCparticularlyelderlyPedestriansvsvehicleContactsportsDistractionShearing,stretchingSofttissueswelling,laceration,tearingligaments,fxvertebralprocesses,severingSCHangingsWeightmaycausefxC2,“hangman’sfracture〞DistractionthoracicspineHangman’sFxLateralviewHangman’sFxC2SpinalprocessFx’sSubluxationWhatlevelisT11?MOIChanceFxCordInjuryConcussionSimilartocerebralconcussionTemporaryandtransientdisruptionofcordfunctionContusionBruisingofthecordTissuedamage,vascularleakageandswellingCompressionSecondaryto:displacementofthevertebraeherniationofinterverterbraldiskdisplacementofvertebralbonefragmentswellingfromadjacenttissuePathophysiologyof

SpinalInjuryTransectionCordInjuryInjurythatpartiallyorcompletelyseversthespinalcordCompleteCervicalSpineQuadriplegiaIncontinenceRespiratoryparalysisBelowT-1IncontinenceParaplegiaIncompletePathophysiologyof

SpinalInjuryCompleteCordLesionFullytransectSCAssociatedwithFx/dislocationsPresentationTotalabsencepain,pressureandpointsensationbelowleveloflesionDependingonlevelinjurymaypresentwithautonomicNSdysfunctionBradycardiaHypotensionVasodilationPriapismDecreasedsweating/shiveringbelowinjuryPoikilothermy–bodytemperatureassumesthatofenvironmentincontenenceSubluxationwithcompletecordsyndromePhysiologyCentralcoreofgreymattersurroundedbymyelinsheathMotor(efferent)neuronsoriginateinanteriorgreymatterSensory(afferent)neuronsoriginateinposteriorgreymatterInterneuronsallowforconnectionThereforepossibletoinjureonetypeofneuronwithoutaffectingtheotherPhysiologySCdividedinto31segmentsEachhasapairofnerverootsAnterior(motor)Dorsal(sensory)AnterioranddorsalcombinetoformthespinalnerveasitexitsthevertebralcolumnSCextendsfrombraintoL1CaudaequinaNotconsideredSCIAutonomicfunctiontransversessympatheticNSfiberswhichexitSCC7-L1/parasympatheticS2-S4Tractsdecussate(crossover)inmedullapriortoenteringSCdorsalcolumnsareascending(sensory)transmitlighttouch,proprioceptionandvibrationcorticospinaltractsaredescending(motor)pathwaysinjurytocorticospinaltract-ipsilateralparalysisorlossofsensationtolighttouch,proprioception,vibrationvascularinjurymaycausecordlesionatalevelhigherthanSCIIncompleteAnteriorcordsyndromeBrown-SequardCentralcordsyndromeConusmedullarissyndromeHornersyndrome/CaudaequinasyndromeCompressionFxincompletecordsyndromeAnteriorCordSyndromePressureonanteriorcordDamagetomainanteriorarteryTypicallyresultsfromhyperflexionPresentationParalyzedbelowlevelinjuryDecreasedpainanddifficultyregulatingtemperaturebelowlesionResponsetolighttouchandproprioception(senseofposition)notaffectedduetoanteriorcordinvolvementonlyBrown-SequardRarelyoccuringPartialcordlesioninvolvingonlyhalfofSCUsuallyduetopenetratingtraumaBonyfragmentintrusionIntervertebralintrusionPresentationParalysisorparesisIpsilateral(injuryside)lossofproprioceptionContralateral(oppositeofinjury)losspain/temperatureonoppoCentralCordSyndromeDirectresultofcontusionwithinSCOftenoccursasaresultofhyperextension/flexionRapidextension/flexioncancausedamagetobloodvesselsHemorrhageincreasespressureonSCHypoxia,ischemiaPresentationCorticospinaltract,centralportionsofposteriorcolumn,lateralspinothalmictractscontainfibersassociatedwithupperarmsSxmorepronouncedinupperextremitiesLossofupperextremityfunctionwhileintactinlowerextremitiesGeneralSigns&SymptomsExtremityparalysisPainwith&withoutmovementTendernessalongspineImpairedbreathingSpinaldeformityPriapismPosturingLossofbowelorbladdercontrolNerveimpairmenttoextremitiesPathophysiologyof

SpinalInjurySCIPrimarymechanicaldisruptiontransectionextraduralpathologydistractionofneuralelementsusuallyoccurswithfxordislocationofspinepenetratinginjuriesbullets,knifebonyfragmentsCompletesubluxationExtraduralmaycauseprimarySCISpinalepiduralhematomaabscessesacutecordcompression/injurylongitudinaldistractionwith/outflexion/extensionmayresultinprimarySCIwithoutfx/dislocationSecondarySCIVascularinjurymajorcausesofsecondarySCIarterialdisruptionarterialthrombushypoperfusionsecondarytoshockanoxicorhypoxiceffectscompoundSCIeffectsSCIdynamicprocessFullextentmaynotbeinitiallyapparentIncompletemayevolvetocompleteInjurylevelmayrise1-2levelsCascadePathophysiologicEventsFreeradicalsvasogenicedemaalteredbloodflowPreventWorseningOxygenationNormalacid/baseSCIWRASpinalcordinjurywithoutradiographicabnormalityprimarilypediatricsspinalcordmorefirmlytetheredthanvertebralcolumnlongitudinaldistractionofvertebralcolumnresultsinprimarySCIwithoutfx/dislocationClinicalEvaluationHx,MOIfocusSxrelatedvertebralcolumnpainmotor/sensorydeficitscompletebilaterallossofsensation/motorfunctionbelowcertainlevelindicatesSCINeurologiclevelofinjuryisthemostcaudallevelwithnormalsensoryandmotorfunctionI.e.ptwithC5quadriplegiahasabnormalmotorandsensoryfunctionfromC6downDifferentiatenerverootinjuryvsSCIPresenceofneurodeficitsthatindicatemultilevelinvolvementsuggestsSCIabsenceofspinalshock,motorweaknesswithintactreflexesindicatesSCImotorweaknesswithabsentreflexesindicatesanerverootlesionDermatomesAreasoftheskinwheresensorynervefibersofaparticularSNinnervateHighlyorganizedvarysizeandshapeUsefulinlocalizinginjurysiteAnterior(ventral)responsibleformotorfunctionDermatomesTopographicalregionofthebodysurfaceinnervatedbyonenerverootKeylocationsCollarregion:C-3Littlefinger:C-7Nippleline:T-4Umbilicus:T-10Smalltoe:S-1SpinalAnatomyandPhysiology

SpinalNervesMyotomesMuscleandtissueofthebodyinnervatedbyspinalnerverootsKeymyotomesArmextension:C-5Elbowextension:C-7Smallfingerabduction:T-1Kneeextension:L-3Ankleflexion:S-1SpinalAnatomyandPhysiology

SpinalNervesPulmonaryFunctionMaybeimpairedlossofventilatorymusclefunctiondenervationchestwallinjurylunginjurydecreasedcentralventilatorydrivedirectrelationshipbetweenlevelofSCIanddegreeofrespiratorydysfunctionC1-C2-vitalcapacity5-10%normalcapacity,nocoughreflexPhrenicnerveC3-C6-vitalcapacity20%,coughweakandineffectiveT2-T4-vitalcapacity30-50%,weakcoughT11-minimalrespiratorydysfunctionFindingsofRespiratoryDysfunctionAnxiety,restlessness,agitationpoorchestwallexpansiondecreasedairentryrales,rhopncipallor,cyanosisincreasedheartrateparadoxicalmovementincreasedaccessorymuscleuseCriticalDeeptendonreflexesperinealevaluationpresence/absenceofsacralsparingiskeyprognosticindicatorTreatmentOxygenateandventilatesuctionintubatefluidresuscitationSBP90-100HR60-100atropineUa30ml/hrdopamine2-5mg/kg/minNGtubeileuscommonantiemeticsSolumedrol30mg/kgover15minutes5.4mg/kg/hr45minutesafterbolusover23hourscoadministeredwithdigoxinmayincreasetoxicitywithin3hrsofinjuryHemorrhagicShockDifficulttodifferentiatedisruptionofautonomicpathwayspreventstachycardiaandperipheralvasoconstrictionoccultinternalinjurywithassociatedhemorrhagemaybemissedallpatientswithSCIandhypotensionsearchforsourceofinjuryHemorrhagicvsNeurogenicShockNeurogenicshockoccursonlyinpresenceofacuteSCI>T6hypotensionwithacuteSCI<T6duetohemorrhagehypotensionwithaspinalfxalonewithoutdeficitsprobablyduetohemprrhagepatientswithSCI>T6maypresentwithautonomicdysfunctionhighincidenceofassociatedinjuryNeurogenicShockUsuallydoesnotoccurbelowSCI@T6ShockbelowT6shouldbeconsideredhemorrhagicuntilprovenotherwiseCharacterizedbysevereautonomicdysfunctionHypotensionRelativebradycardiaPeripheralvasodilationhypothermiaNuerogenicShockTriadDecreasedBPDecreasedHRPeripheralvasodilationResultingfromautonomicdysfunctionandinterruptionofsympatheticNScontrolinacuteSCISpinalShockCompletelossofneurologicalfunctionReflexesRectaltoneFlaccidreflexesbelowspecificlevelSpinalShockTemporaryinsulttothecordAffectsbodybelowthelevelofinjuryAffectedareaFlaccidWithoutfeelingLossofmovement(Flaccidparalysis)Frequentlossofbowel&bladdercontrolPriapismHypotensionsecondarytovasodilationSceneSize-upEvaluateMOIDeterminetypeofspinaltraumaMaintainsuspicionwithsportsinjuriesIfunclearaboutMOItakespinalprecautionsAssessmentofthe

SpinalInjuryPatient(continued)InitialAssessmentConsiderspinalprecautionsHeadinjuryIntoxicatedpatientsInjuriesabovetheshouldersDistractinginjuriesMaintainmanualstabilizationVeststyleversusrapidextricationMaintainneutralalignmentIncreaseofpainorresistance,restrictmovementinpositionfoundAssessmentofthe

SpinalInjuryPatientInitialAssessmentABC’sSuctionConsiderOralorDigitalIntubationifrequiredMaintainin-linemanualc-spinecontrolAssessmentofthe

SpinalInjuryPatientRapidTraumaAssessmentFocusedversusRapidAssessmentRapidAssessmentSuspectedorlikelyspinalcord/columninjuryMulti-systemtraumapatientEvaluateforNeckDeformity,Pain,Crepitus,Warmth,TendernessBilateralExtremitiesFingerAbduction/AdductionPush,Pull,GripsMotor&SensoryFunctionDermatome&MyotomeevaluationBabinskiSignTestHold-UpPositionAssessmentofthe

SpinalInjuryPatientBabinski’sSignTestStrokelateralaspectofthebottomofthefootEvaluateformovementofthetoesFanningandFlexing(lifting)PositivesignInjuryalongthepyramidal(descendingspinal)tractVitalSignsBodyTemperatureAbove&BelowsiteofinjuryPulseBloodPressureRespirationsOngoingAssessmentRecheckelementsofinitialassessmentRecheckvitalsignsRecheckinterventionsRecheckanyneurologicaldeviationsAssessmentofthe

SpinalInjuryPatientSpinalAlignmentMovepatienttoaneutral,in-linepositionPositionoffunctionHipsandkneesshouldbeslightlyflexedformaximumcomfortandminimumstressonmuscles,joints,&spinePlacearolledblanketunderthekneesALWAYSsupporttheheadandneckContraindicationstoneutralpositionMovementcausesanoticeableincreaseinpainNoticeableresistancemetduringprocedureIncreaseinneurologicaldeficitsoccursduringmovementGrossdeformityofspineLESSMOVEMENTISBESTManagementofthe

SpinalInjuryPatientManualCervicalImmobilizationSeatedPatientApproachfromfrontAssignacaregivertoholdGENTLEmanualtractionReduceaxialloadingEvaluateposteriorcervicalspinePositionpatient’sheadslowlytoaneutral,in-linepositionSupinePatientAssignacaregivertoholdGENTLEmanualtractionAdultLiftheadoffground1-2〞:Neutral,in-linepositionChildPositionheadatgroundlevel:AvoidflexionManagementofthe

SpinalInjuryPatientCervicalCollarApplicationApplythec-collarassoonaspossibleAssessneckpriortoplacingC-CollarlimitssomemovementandreducesaxialloadingDOESNOTcompletelypreventmovementoftheneckSizeandApplyaccordingtotheManufacturer’sRecommendationCollarshouldfitsnugCollarshouldNOTimpederespirationsHeadshouldcontinuetobeinneutralpositionSIZEIT,SIZEIT,SIZEIT!!!DONOTRELEASEmanualcontroluntilthepatientisfullysecuredinaspinalrestrictiondeviceManagementofthe

SpinalInjuryPatientStandingTakedownMinimum3rescuersHavepatientremainimmobileRescuerprovidesmanualstabilizationfrombehindAssessneckSizeandplacec-collarPositionboardbehindpatientGraspboardunderpatient’sshouldersLowerboardtogroundSecurepatient

COMMUNICATEWITHPARTNERSANDPATIENTManagementofthe

SpinalInjuryPatientHelmetRemovalWhentoremoveHelmetdoesnotimmobilizethepatient’sheadwithinCannotsecurelyimmobilizethehelmettothelongspineboardHelmetpreventsairwaycareHelmetpreventsassessmentofanticipatedinjuriesPresentorAnticipatedairwayorbreathingproblemsRemovalwillnotcausefurtherinjuryManagementofthe

SpinalInjuryPatientFootballhelmetsMustremoveshoulderpadsifhelmetremovedExcessiveextensionMotorcyclehelmetsMustberemovedorsufficientpaddingunderbodyExcessiveflexionHelmetRemovalTechnique2RescuersHaveaplanRemovefacemaskandchinstrapImmobilizeheadSlideonehandunderbackofneckandheadOtherhandsupportsanteriorneckandjawRemovehelmetGentlyrockheadtoclearocciputAllactionsshouldbeslowanddeliberateTRANSPORTHELMETwithpatientCOMMUNICATIONistheKEYManagementofthe

SpinalInjuryPatientAnymovementMUSTbecoordinatedMovepatientasaunitNOLATERALPUSHINGMovepatientupanddowntopreventlateralbendingRescueratthehead“CALLS〞allmovesALLMOVESMUSTbeslowlyexecutedandwellcoordinatedConsiderthefinalpositioningofthepatientpriortobeginningmoveMovementofthe

SpinalInjuryPatientTypesofmovesLogRollStraddleSlideRope-SlingSlideOrthopedicStretcherVest-TypeImmobilizationRapidExtricationFinalPatientPositioningLongSpineBoardDivingInjuryImmobilizationMovementofthe

SpinalInjuryPatientMedications&SpinalCordinjurySteroidsReducethebody’sresponsetoinjuryReduceswelling&pressureoncordAdministeredwithin1st8hoursofinjuryTypesofMedicationsMethylprednisolone(Solu-Medrol)ReducecapillarydilationandpermeabilityLoadingdose:30mg/kgover15minutesMaintenance:5.4mg/kg/hrover23hrsDexamethasone(Decadron,Hexadrol)Reducecapillarydilationandpermeability5xmorepotentthanSolu-Medrol4-24mg(occasionallyupto100mg)Managementofthe

SpinalInjuryPatientMedications&NeurogenicShockFluidChallengeIsotonicSolution:20ml/kg250mlinitiallyMonitorresponseandrepeatasneededPASGControversialResearchshowsnopositiveoutcomeDopamine2-20mcg/kg/mintitratedtobloodpressureAtropine0.5-1.0mgq3-5min(maximumof2.0mg)Managementofthe

SpinalInjuryPatientMedications&theCombativePatientConsidersedativestoreduceanxietyandcalmpatientPreventsspinalinjuryaggravationMedicationsMeperidine(Demerol)Diazepam(Valium)ConsiderparalyticsManagementofthe

SpinalInjuryPatientNeckTraumaFewemergenciesposeasgreatachallengeasnecktraumaairwayvasculatureneurologicalgastrointestinalVasculatureoftheNeckCarotidArteriesArisefromRIGHT:BrachiocephalicArteryLEFT:AortaArterySplitInternal&ExternalCarotidArteriesUpperborderoftheLarynxCarotidBodies&SinuseslocatedBodies:MonitorCO2andO2levelsSinuses:MonitorBloodPressureAnatomy&Physiology

oftheNeck(continued)JugularVeinsExternalSuperficial,lateraltothetracheaInternalSheathwiththecarotidarteryandvagusnerveAnatomy&Physiology

oftheNeckAirwayStructuresLarynxEpiglottisThyroid&CricoidCartilageTracheaPosteriorborderisanteriorborderofesophagusAnatomy&Physiology

oftheNeckOtherStructuresCervicalSpineMusculoskeletalFunctionExternalSkeletalsupportoftheheadandneckAttachmentpointforspinalcolumnligamentsAttachmentpointfortendonstomoveheadandshouldersNervousFunctionSpinalCordcontainedwithinPeripheralNerveExitbetweenvertebraeAnatomy&Physiology

oftheNeckOtherStructuresEsophagusCranialNervesCN-IX(Glossopharyngeal)CarotidBodies&CarotidSinusesCN-XSpeech,swallowing,cardiac,respiratory&visceralfunctionThoracicDuctDeliverslymphtothevenoussystemAnatomy&Physiology

oftheNeck(continued)GlandsThyroidRateofcellularmetabolismSystemiclevelsofcalciumBrachialPlexusNetworkofnervesinlowerneckandshouldthatcontrolarmandhandfunctionAnatomy&Physiology

oftheNeckCommonMostcommontraumaticinjuriestonecksprainsandstrainsNeckInjuryBloodVesselTraumaBlunttraumaSerioushematomaLacerationSeriousexsanguinationEntrainingofairembolismCoverwithocclusivedressingAirwayTraumaTrachealruptureordissectionfromlarynxAirwayswelling&compromiseNeckInjuryCervicalSpineTraumaVertebralfractureParesthesia,anaesthesia,paresisorparalysisbeneaththeleveloftheinjuryNeurogenicshockmayoccurOtherNeckTraumaSubcutaneousemphysemaTensionpneumothoraxTraumaticasphyxiaPenetratingTraumaEsophagusorTracheaVagusnervedisruptionTachycardia&GIdisturbancesThyroid&ParathyroidglandsHighvascularSceneSize-upInitialAssessmentAirway,Breathing,CirculationRapidTraumaAssessmentHead,Face,NeckGlasgowComaScaleScoreVitalSignsFocusedHistory&PhysicalExamDetailedAssessmentOngoingAssessmentAssessmentof

Head,Facial&NeckInjuriesAsinglepenetratingwoundiscapableofgreatharmseeminglyinocuouswoundsmaynotmanifestclearSxpotentiallylethalinjuriesmaybeoverlookedordiscountedairwayocclusionexsanguinationMuskuloskeletalcspinecervicalm.tendons,ligamnetslaryngealN.CN(IX-XII)VasculaturecarotidA.commoninternalexternalvertebralA.veinsvertebralbrachiocephalicjugularAnteriorandlateralmostexposedVisceralthoracicductsesophaguspharynxlarynxtracheaGlandularthyroidparathyroidsubmandibularparotidZone1subclavianvesselsbrachiocephalicveinscommoncarotidarteryjugularveinaorticarchtracheaesophagusLungapicescspinespinalcordCNrootsThoracicinlettocricoidcartilageZone2Carotidandvertebralart