Suspect Spinal Injury: Following any 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. All road traffic accidents. 2. Any fall from a height above six feet. 3. Any impact or crush injuries. 4. Patient with multiple trauma. 5. Loss of consciousness. 6. Penetrating injuries of neck and/or trunk eg. stab wounds, gunshot wounds. 7. Back or neck pain, guarding their back or neck after injury, 8. Sensory changes or loss such as numbness or tingling after injury.

Aim of First aid is Prevent Further Spinal cord injury:

Role of a primary physician is in the field and also at the primary health care centre. He has to prevent further bony dislocation (in the field and prevent), secondary injury to cord (at the primary health centre). We should remember that:
a) 3% to 25% injuries to spine occur after the initial injury.
b) reports of poor outcome due to mishandling are well reported.
c) 20% cases have multiple spinal injuries.

Common causes of bony dislocation:

a) Improper extrication from vehicle.
b) Handling of the patient by non-professionals.
c) Improper lifting of the patient.
d) Improper transport of the patient.

Requirements in field:

a) Spine board.
b) Philadelphia collar.
c) Minimum of four persons.
d) Hard stretcher.
e) Oxygen.
f) Provision for starting IV fluids.

What to do in the field:

a) Don't remove the helmet if patient is wearing one.
b) If patient is stable in the vehicle wait till ambulance arrives.
c) Log roll the patient to turn.
d) Place patient on spinal board.
e) Strap the head to the board.
f) Philadelphia collar to supplement.

Maintain potential SCI patients 'in a neutral position' (for fear of worsening the initial injury 'pithing the frog'. Avoid suspension of neck using proper 'manual neck support' or spine board. 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. In suspected cervical injuries the neck should be immobilised using a stiff neck collar. To ensure that total immobilisation of the spine is maintained when the patient is moved from ground to spine board there are 3 techniques which can be applied.
a) Log roll.
b) Spinal Lift.
c) Sliding.

First Look:
Take an instance from the history. A description of the accident can give an indication of the potential injuries.
A full and quick examination of the patient is essential in order to identify and stabilise possible injuries. Look for other injuries like head injuries, chest injuries, abdominal injuries, pelvic injuries, long bone fractures.
Secondary injuries to spinal cord:
a) Hypoxia
b) Hypotension
c) Hypoglycemia
d) Hyperglycemia
e) Electrolyte disturbance
f) Blood loss
g) Hyperthermia

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:
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 a significant airway compromise are usually those with head injury.
a) Look for evidence of breathing difficulties, obstruction or aspiration.
b) Listen for noisy breathing, strider or gurgling.
c) Feel with finger in the mouth or throat.
d) Use gloved finger to scoop the inside of the mouth.
e) Oral suctioning may be necessary.
f) To protect a threatened airway do not hyperextend the neck instead use the jaw thrust.
g) Plastic airway can be used to keep the airway open.

Breathing:
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 for instance pneumothorax, haemothorax.
a) Presence, rate & depth of respirations.
b) Shallow or abdominal breathing.
c) Asymmetry of the chest.
d) Paradoxical breathing in cervical injuries.
e) Continuously monitor oxygen saturation levels.
f) Maintain SaO₂ at 95% or above.
Administer oxygen via an oxygen mask with a re-breath 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, ascending spinal cord oedema and retained secretions.

Circulation:
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 be alert to a potential problem. Therefore, it is vital that a thorough search for haemorrhage is made. Shock in the multiple trauma patients must not be considered to be caused solely by spinal shock. As haemorrhage is likely aggressive fluid administration is instituted until proven otherwise. This involves screening for haemorrhage into the pelvis abdomen and chest.
Generally speaking, patients suffering from haemorrhagic shock present with:
a) Hypotension.
b) Tachycardia with thready pulse.
c) Poor colour.
d) Skin cold and clammy.
When a patient has a normal pulse but is hypotensive then spinal plus bleeding injury should be suspected.
The patient suffering solely from spinal shock will present:
a) Hypotensive.
b) Bradycardia with pulse of good volume.
c) Colour good.
d) Peripherally warm and dry.
In the casualty who has an isolated spinal cord injury, fluid administration should be done with care. Monitor BP. Maintain a systolic BP of 90-100mmHg.Administer IV fluids. Do not over infuse. This may precipitate cardiac failure and pulmonary oedema.

Bradycardia:
If heart rate drops below and remains below 40 beats per minute, give Atropine 300-600 micrograms, may be given as IV bolus. An abnormal vasovagal response can occur through stimulation such as rapid changes in body positioning - logrolling too quickly, forceful tracheal suctioning, struggling while passing an N.G. tube etc.

Neurological Status:
Examine for both Sensation and Motor Power. Examine by a) Light Touch. b) Blunt pin (pain).
Mark the 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

Skin Care (if patient is with you for more than 2 hours):
The risk of developing pressure sores following spinal cord injury is extremely high due to lack of sensation, lack of muscle activity and poor capillary perfusion reducing tissue oxygenation. These can be prevented by:
a) Checking all the pressure areas for signs of skin breakdown.
b) Removing any objects from patient's clothing (may cause pressure).
c) Logroll patient to ensure there is nothing that could cause pressure - objects in back pockets etc.
d) Placing a small pillow or rolled up towel underneath the ankles to keep heels pressure free.
e) Turning the patient carried out 2 hourly.
f) 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. Due to autonomic dysfunction patient becomes poikilothermic.

a) Monitor temperature frequently.
b) Prevent hypothermia by covering patient with sheet, space blanket then blankets.
c) If hyperthermic cold sponging works well.

Paralytic illeus:
Paralytic illeus is common in neurogenic shock. There is a risk of vomiting/aspiration.
a) Listen to abdomen for presence of bowel sounds.
b) Observe for abdominal distension.
c) Nil - by - mouth.
d) Pass naso-gastric tube - free drainage. Passing a N-G tube is contra-indicated in those patients who have a suspected head injury (base of skull fracture).

Bladder:
During neurogenic shock bladder control is lost and urinary retention can occur.
a) Avoid over distension of the bladder.
b) Insert Foley catheter and urine volume should be monitored hourly. This gives a good indication for fluid replacement.
c) If the patient has priapism or has pelvic injuries, do not attempt urethral catheterisation as it may cause urethral trauma. Pass supra-pubic catheter in these cases.

Electrolyte imbalance:
Hypotension and hypovolumia causes reflex aldosterone release and this causes hypokalemia. It results in weakness of muscles and T wave flattening in ECG. Potassium can be given 10 Meq Kcl/hr without cardiac monitoring (half an ampoule). Glucose solutions should be avoided as it aggravates hypokalemia.

Specific radiological investigations at peripheral clinic are:
a) X-ray C.Spine- C-V junction to C7-T1, lateral view with collar on (if not visible-with shoulders pulled down, swimmers view or CT scan).

b) X-ray thoracic and lumbar spine AP and lateral view - Thrown from vehicle, fall >6ft, back pain, unconscious, vague pain, suspicion.

Medications:
Steroids: Limits progression of cord damage in spinal trauma. According to the studies.
NASCIS II and III (NEJM 1990, JAMA 1997). Methyl Prednisolone bolus is given in the dosage of 30mg/kg over 15min in 1st hour, then 5.4mg/kg/hr for 23 hours. Only patients who received steroid in the first 8 hours post injury demonstrated a benefit.

Do not give Methyl Prednisolone in:
a) Cauda equina syndrome (saddle anesthesia, bladder retention), Gun shot wounds
b) High morbidity- other injuries.
c) Pregnancy.
d) Narcotic addiction.
e) Less than 13 yrs.
f) Already on steroids.

Other medications:
a) Antibiotics.
b) Acid inhibitors (ranitidine, omiprazole).
c) Analgesics.
d) Avoid sedation.
e) IV fluids- 50-75ml/hr.

Transfer:
Use a spinal board to shift a patient. Stabilise neck with 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. It is advantageous to have a police escort.

Rehabilitation:

The treatment of spine injured doesn't end after discharge from hospital. After discharging him/her from hospital he should be kept in a rehabilitation center, which will try to restore his physical and mental faculties to the maximum possible level. If patients are not rehabilitated after discharge they tend to deteriorate further and becomes a burden for oneself, family and the community. The concept of wholesome rehabilitation has not yet caught up in India. There are a few centres available but not affordable for common man. We should try to develop a chain of rehabilitation centres with help of Government, NGO s, MNCs and vehicle manufacturers. These centres should cater to the following needs of the patients.

1. Physician-Directed Case Management - Provide daily medical care, diagnose and manage the medical problems associated with spinal cord injury..

2. Primary nursing- Skilled nursing for meeting physical and emotional needs of a spine patient. They co-ordinate the treatment of other nursing staff and therapists.

3. Physical Therapy - Individualized treatment program to increase strength and mobility, relieve pain, and restore function of the hands and legs.

4. Occupational Therapy - Trains in self-care (dressing, grooming, bathing, and eating), home management activities, parenting, functional communication, and community activities in a spine injured person.

5. Social Work - Counselling to assist patient and his family in coping with injuries and disabilities.

6. Rehabilitation Engineering - Rehabilitation engineering is the application of technology to increase the functional capabilities of people with disability

7. Rehabilitation Psychology- Psychologists address emotional, cognitive, and behavioural aspects of the patient and prepare for returning home and to his/her community.

8. Therapeutic Recreation - Independence in leisure lifestyle activities by improving patients' physical, cognitive, emotional and social skills.

9. Speech Therapy -Treatment for speech problems and dysphagia (swallowing difficulty).

10. Independent Living - Create opportunities for each person to make choices, participate in community life, make decisions and take responsibility for actions.

11. Discharge Planning - Regular contact after discharge into the community to stay in close touch with the patient and his family members.

References:

a) 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.

b) American College of Surgeons. 1997.Advanced Trauma Life Support Manual. Chicago.

c) NASCIS II,  NEJM 1990 322:1405-11.

d) NASCIS III, JAMA 1997 277:1597-1604.

e) Revisiting NASCIS II & III, J. Trauma 1998 45:6 1088-93.

f) Methylprednisolone for acute spinal injury, J. Neurosurgery (spine 1) 2000:93:1-7.

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