Injuries — spinal

Related protocol — Assessing trauma — primary and secondary survey

Risk of injury

If alert and sober, no other serious or painful injury, no pain in neck or back, no pins and needles, no numbness, no weakness in arms or legs — spinal fracture or dislocation is extremely unlikely
Unconscious person
  • If trauma — suspect spinal injury, immobilise, urgent medical consult
  • Remember DRS ABC
    • Minimise neck movement
    • Use jaw thrust and chin lift before head tilt
Conscious person

Suspect spinal (neck or back) injury, immobilise and urgent medical consult if

  • Injury caused by (most common mechanisms)
    • Motor vehicle, motorcycle or bicycle accident as occupant, rider or pedestrian
    • An industrial (work) accident or electric shock
    • A sporting accident (eg football)
    • Fall greater than standing height (eg ladder, roof)
    • Kick or fall from horse
    • Hit to head
    • Dived or fell head first into shallow water
    • A severe penetrating wound (eg gunshot)
    • Elderly patient with fall and head/neck injury
  • AND any 
    • Pain or deformity in injured region and/or back of the neck or back
    • Tingling or numbness in the limbs or area below the injury
    • Decreased level of alertness, headache or dizziness
    • Nausea
    • Altered or absent skin sensation
    • Weakness or unable to move limbs
    • Evidence of intoxication (alcohol and/or drugs)
    • Pain that might distract person from pain of spinal injury

Do not

  • Do not allow person to move their neck if it hurts
  • Do not log-roll person with suspected spinal injury unless checking back for penetrating injury or loading on/off a stretcher with a trained team
    • Log-rolling may make spinal cord or chest injuries worse, cause bleeding from pelvic fractures, cause unnecessary pain and anxiety

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
Neurological assessment
  • Can person move their fingers and toes
  • Check for loss of feeling
    • Trapezius (muscle on top of shoulder) (C4)
    • Pads of the index finger (C6), middle finger (C7), little finger (C8)
    • Nipple (T4)
    • Umbilicus (T10)
    • Pubic symphysis pubis (T12)
    • Outside of the foot (lateral) (S1)
  • Check grip strength and foot and ankle power (plantar and dorsiflexion)
  • Check for an erection in males (sign of spinal cord injury) — absence of an erection does not mean there is not a spinal injury

Do 

Immobilise person

  • If unable to clear C-spine (based on mechanism of injury, symptoms/level of consciousness or neurological findings) immobilise the C-spine
    • If cooperative, advise to keep neck still, use headblocks/sandbags, clearly mark as 'C-spine not cleared' — Figure 2.23
    • If uncooperative, use MILS (manual in-line stabilisation), encourage patient with clear instructions, use head blocks/sandbags as tolerated. Clearly document C-spine not cleared and the challenges of immobilisation
    • A collar can be placed according to organisational guidelines if the patient is unconscious with a mechanism of injury suggestive of possible cervical spine involvement OR the patient has neurological symptoms suggestive of spinal cord injury 
  • Immobilise person on spine board/vacuum mattress for transport
  • Use PAT slide/spine board for transfers

Figure 2.23  

After immobilisation

  • Monitor airway
  • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD — 88–92%
  • Put in 2 IV cannula
    • Run normal saline — medical consult about rate
  • If paralysis — systolic BP of 90 is OK (greater than 100 is better) as long as urine output is not less than 0.5mL/kg/hr
    • Also look for and treat other causes of low BP such as haemorrhage
  • Put in indwelling urinary catheter — female, male
  • Give antiemetic to stop vomiting — non-sedating preferred
  • Consider nasogastric tube
  • Medical consult, send to hospital